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Critical care training

Critical care training. Learning sequence 9 Invasive mechanical ventilation for acute respiratory distress syndrome Deliver targeted sedation and prevent delirium. Learning objectives. At the end of this lecture, you will be able to: Distinguish among pain, anxiety, and delirium

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Critical care training

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  1. Critical care training Learning sequence 9Invasive mechanical ventilation for acute respiratory distress syndromeDeliver targeted sedation and prevent delirium

  2. Learning objectives At the end of this lecture, you will be able to: • Distinguish among pain, anxiety, and delirium • Formulate a sedation and delirium treatment plan • Describe the potential complications associated with sedatives and delirium |

  3. Recognize (1/2) • Evaluate mechanically ventilated patients for pain, anxiety, and delirium routinely • Anxiety • exaggerated sense of fear, nervousness or apprehension • can present with agitation or increased motor activity • these symptoms CAN be treated with sedatives • Delirium • presents with inattention, disorganized thinking, altered consciousness, or agitation • hallmark is fluctuation in mental status • these symptoms should not be treated with sedatives alone |

  4. Recognize (2/2) • Pain • associated with the condition leading to IMV or a secondary process • treat with pain medications, NOT sedatives • may also present with agitation, diaphoresis, and facial grimacing Agitation is a non-specific symptom of pain, anxiety, and delirium!

  5. Formulate a daily sedation plan Step 1: Recognize the presence of anxiety, delirium and pain using standardised scales Step 2: Set sedation target Step 3: Give sedatives to achieve target Step 4: Screen for sedation interruption if continuous infusions used Step 5: Recognize special situations that may need neuromuscular blockade Step 6: Treat delirium and pain if present Step 7: Monitor-record-respond Step 8:Deliver quality care |

  6. Step 1: Assess using standardized scales • Assessments can vary between observers • Sedation scales • e.g. Richmond agitation sedation scale (RASS) • assess level of consciousness by the patient’s response to external stimuli (e.g. voice or touch ) • can be used for children and adults • Delirium scales • e.g. Confusion assessment method of the ICU (CAM-ICU) and pCAM-ICU in children >5years. • assess for signs of delirium such as inattentiveness or presence of disorganized thinking • Pain scales • e.g. Visual analog scale (VAS) • COMFORT-B and FLACC scores

  7. Step 2: Set a sedation target • Set daily sedation targets • based on the patient’s clinical condition, management plans • agreed upon by the health care team • For most patients, target sedation so the patient is awake (0), calm (-1) or slight drowsy (-2) • the presence of agitation should not be a target • Certain clinical conditions may require deeper sedation targets • e.g. a patient with severe ARDS may need deeper sedation to provide LPV • target sedation so patient is arousable to voice (-3) or movement (-4) |

  8. Step 3: Give sedatives to achieve target • Choose a sedative based on availability, pharmacology and risk profile. • use lowest dose necessary to reach target • 1st line • intermittent doses of benzodiazepines (midazolam or lorazepam) or propofol infusion • Propofol is contraindicated as sedative in children < 16 years • 2nd line • if intermittent doses fail to achieve target, then consider continuous infusion of lorazepam or propofol if not already used Caution: continuous infusion of benzodiazepines is associated with prolonged days on IMV and delirium. Use the minimal sedation necessary to reach target |

  9. Step 4: Screen all patients on continuous infusions for sedation interruption • Perform a safety screen • in most patients, it is safe to discontinue the infusion • do not interrupt sedation in patients with • active seizures, alcohol withdrawal, severe agitation, ongoing myocardial ischemia, elevated intracranial pressure, or receiving neuromuscular blockade • If patient passes safety screen • then stop continuous sedative infusion • Monitor patient closely for agitation, hemodynamic instability or respiratory distress • if these occur, then restart infusion at ½ previous dose Daily sedation interruption alone or in coordination with daily spontaneous breathing trial (SBT) is associated with fewer days of IMV |

  10. Use a sedation protocol • Using a protocol to deliver targeted sedation is associated with following benefits for patients on IMV • reduced days of IMV (quicker time to extubation) • ensures regular sedation assessment schedule • ensures appropriate sedative administration • e.g. guide titration of continuous infusions up and down based on sedation assessment to reach sedation target • Performs as as well as sedation interruption Develop a sedation protocol that is adapted to your local hospital setting |

  11. Step 5: Special considerations for neuromuscular blockade (NMB) • Consider early, short term use in patients with severe ARDS (up to 48 hours) • associated with reduced mortality and more organ-failure free days AND not with prolonged weakness • NMB use must be used in conjunction with continuous sedatives that provides amnesia • NMB does NOT provide sedation, amnesia or analgesia • Avoid use in patients without severe ARDS unless there is clear indication that cannot be achieved with with sedation • If used, then monitor depth of blockade with train-of-four peripheral nerve stimulation • Discontinue promptly when no longer necessary • Risks include: • Prolonged neuromuscular weakness • Reduce dose in renal failure

  12. Step 6: Treat delirium if present (1/2) • 1st line: Find the cause and treat • delirium is usually a manifestation of a medical problem, such as sepsis or electrolyte abnormality, or side effect of benzodiazepines or narcotics • 2nd line: Use non-pharmacologic interventions • re-orient patient to surroundings • provide reassurance • encourage family visits • maximize sleep time • normalize sleep-wake cycle • discontinue tubes and restraints In children: • provide access for parents • encourage parental involvement in child’s care • age-appropriate positioning, e.g. swaddling infants • restraints fixed to immobile objects NOT recommended |

  13. Step 6: Treat delirium if present (2/2) • 3rd line • if above not effective, consider antipsychotics • haloperidol, quetiapine, risperidone • dexmedetomidine is a newer sedative that has been associated with fewer days with delirium Delirium is an independent risk factor for mortality in the ICU and cognitive impairment in survivors. Early recognition and treatment are appropriate.

  14. Step 6: Treat pain if present • Assess regularly using a standardized scale • e.g. VAS scale • in patients unable to participate, signs of pain include agitation, hypertension, and tachycardia without other underlying physiological causes • Adequate treatment of pain may decrease need for continuous sedation • Common agents: fentanyl, morphine, hydromorphone • 1st line: intermittent dosing • 2nd line: continuous infusions based on intermittent dose requirements • Common adjuncts • acetaminophen (paracetomol) • nonsteroidal anti-inflammatory drugs (e.g. ibuprofen) in selected patients • NO aspirin in children (<18 years) with viral infection

  15. Sedation for patients with severe ARDS • Patients with severe ARDS may easily deteriorate • with little movement or minor ventilator asynchrony • not good candidates for sedation interruption • Set initial sedation target deep (e.g. RASS -4, -3) • until LPV targets are met • Consider early use of short-term NMB if patient has severe ARDS or is unstable at target sedation and LPV targets not met • discontinue NMB within 48 hrs to minimize risk, then lighten sedation gradually • It is reasonable to consider sedation interruption and/or lighter sedation targets once PEEP is 12 cmH2O or less • closely monitor for early deterioration |

  16. Summary (1/2) • In all intubated patients on IMV, use a systematic protocol-based approach to manage pain, anxiety, and delirium. • Evaluate the patient regularly for pain, anxiety, and delirium using standardized scales. • Set a daily target for depth of sedation • use intermittent benzodiazepines or propofol (if > 16 years age) continuous infusion as first line sedatives to reach sedation target • minimize the use of continuous benzodiazepine infusions

  17. Summary (2/2) • Evaluate patients on continuous sedative infusions daily for sedation interruption readiness. • When ready, discontinue sedative and monitor closely. • If no signs of failure, then perform SBT if eligible • If signs of failure, resume infusion at ½ rate. • Regularly assess for delirium • if present, look for and treat the underlying cause • use non-pharmacologic interventions preferentially • use antipsychotic agents when necessary • Regularly assess for pain • try to prevent rather than treat • use non-opioid and opioid medications

  18. Acknowledgement • Authors • Dr. Charles David Gomersall, The Chinese University of Honk Kong, Prince of Whales Hospital, Hong Kong • Dr. Janet V. Diaz, WHO Geneva, Switzerland • Dr. Neill Adhikari, Sunnybrook Health Sciences Centre, Toronto, Canada • Reviewers • Dr. Steve Webb, Royal Perth Hospital, Australia • Dr. Satish Bhagwanjee, University of Washington, USA

  19. Critical care training Thank you for your attention!

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