Sedation Monitoring in ICU

1. Sedation Monitoring in ICU 2006/07/31 報告者: Ri楊育絜 指導老師: 韓吟宜老師

2. Case • 51y/o 林先生 • PHx: • Gout, chronic alcoholic hepatitis for 20yrs • 2005/11: advanced esophageal ca • Neoadjuvant CCRT • 2006/03/06 subtotal esophagectomy+ gastric tube reconstruction + jejunostomy

3. Present Illness • 2006/07/04: Ischemic bowel and intestinal strangulation + septic shock • Emergent OP: perforation repair + jejunostomy • W’d condition: • 7/05 Wet dressing bid7/07 q8h • 7/10 • Turbid w’d, Fascial suture tear! • N/S 500ml irrigation bid + sucction • 7/12 N/S 4000ml irrigation qd + sucction • 7/20 DC irrigation

4. Distress and agitation in ICU • Factors: • Sleep deprivation, environment, extreme anxiety, delirium, adverse drug effect, and pain • Hormonal effects: increase catecholamines, growth hormone, prolactin, vasopressin, cortisol, glucagons, fatty acids, protein catabolism, and sympathetic tone. ischemia, fluid and electrolyte disturbances, and decreased wound healing.

5. Stress response: • tachycardia • increased myocardial oxygen consumption, • hypercoagulability, • immunosuppression • persistent catabolism • Agitation: deleterious effect on patients • Ventilator dysynchrony, • an increase in oxygen consumption, • and inadvertent removal of devices and catheters

6. Under: ventilator asynchrony, increase in oxygen consumption, unwanted removal of devices and catheters, resource waste, and posttraumatic stress disorder. Over: excessive mechanical ventilation, pneumonia, lung injury, neuromuscular irregularities. Dyssynchronized melatonin secretion sleep pattern derangement delirium Under- /Over-sedation

7. 2002 SCCM Guideline for Sedation in ICU • Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult, Society of Critical Care Medicine, Crit Care Med 2002 Vol. 30, No. 1 • The use of sedation guidelines, an algorithm,or a protocol is recommended. (Grade B) • The titration of the sedative dose to a defined endpoint is recommended with systematic tapering of the dose or daily interruption with retitration to minimize prolonged sedative effects. (Grade A)

8. Multidisciplinary development and implementation of sedation guidelines a defined sedation goal and a protocol-driven sedation plan •  direct drug costs (from $81.54 to $18.12 per patient per day), •  ventilator time (317 to 167 hours), and •  the lengths of ICU stay (19.1 to 9.9 days) and total stay • without a change in mortality

10. Assessment Goal Therapy

11. Goal • Mechanical ventilation • Pressure support ventilation, CPAP, SIMV • good p’t cooperation • Ramsay 2, GCSC 13-15, SAS 4, RASS 0 • Assisted controlled • Ramsay 3, GCSC 8-12, SAS 3, RASS -1~-3 • Pressure controlled • Ramsay 4-5, GCSC 8-12, SAS 2, RASS -4 • Agitation and delirium • Ramsay 2-3, SAS 3-4, RASS 0~-2 • IICP • Ramsay 5, SAS 1, RASS -5

12. An ideal sedation scale • Good reliability and validity • determination of the degree of sedation and agitation, • behavioral descriptors, • Applicability • require minimal training • easy to score • For diverse patient population • guide the titration of therapy to a defined sedation endpoint

13. Subjective methods • The Ramsay Scale • The Glasgow Coma Scale modified by Cook and Palma, GCSC • The Sedation Agitation Scale, SAS • The Richmond Agitation and Sedation Scale, RASS • The Bloomsbury sedation scale • the Adaptation to the Intensive Care Environment (ATICE) scale • The Avripas sedation scale • the Comfort scale for paediatric patients.

14. The most commonly scale used today Ramsay Scale

15. Stratification of agitation in more categories than the Ramsay scale SAS, Sedation-Agitation scale

16. studied in diverse pt. population (different ICUs, ventilated and non-ventilated) Stratification of agitation and sedation in more categories than the Ramsay scale and the SAS RASS, Richmond Agitation and Sedation Scale

17. Recommendations for dosing sedatives reliability not tested Bloomsbury Sedation Scale

18. useful in mechanically ventilated patients Absence of agitation scoring Unuseful to monitor sedation in agitated patients GCSC, Glasgow Coma Scale modified by Cook and Palma

19. ATICE, the Adaptation to the Intensive Care Environment scale

20. Useful in mechanically ventilated patients • Delirium is not assessed • Further studies needed in surgical p’t

21. the predetermined standardized sedation goals based on the patient’s weaning classification. Avripas sedation scale

22. For pediatric ICU patients Behavioral and physiologic factors related to pediatric distress Too Complex The Comfort Scale

23. Objective methods • in chemically paralyzed patients • barbiturate coma • “patients requiring very deep sedation”

24. Objective methods • Pharmacokinetic methods • Physiologic parameters • lower oesophageal sphincter contractility measurement • heart rate variability measurement • Neurophysiologic methods • Frontalis muscle electromyograms • auditory evoked potentials, AEP • Electroencephalography, EEG • Bispectral Index, BIS • Patient State Index, PSI • Entropy • Narcotrend

25. AEP • the latency of the early cortical responseindicator of depth of anesthesia and awareness. • Increasing iv anesthetics: latencies  and amplitudes  • Previous experience in OR • 95 medical and/or surgical ICU patients • AEP: closest correlation with the Ramsay than Cohen, Cambridge, Bloomsbury, and Newcastle sedation scores

26. EEG analysis 3 predominant methods • time domain analysis methods: analyse the changes in the EEG signal in respect to time, • frequency domain analysis methods: analyse the changes in the EEG potentials in respect to frequency • bispectral analysis methods: analyse EEG signal in respect to its amplitude, its frequency and its correlation between phase angle and the frequency range of the included waves.

27. PSI • 4-channel EEG Patient State Analyzer: self-norming technique values: 0 to 100 • Previous experience in OR • useful in assessing patients receiving a combination of propofol and sufentanil. • the influence of muscle activity: uncertain.

28. BSI, Bispectral Index

29. BSI • Recommending results • good relationship with subjective monitoring tools • a decreased use of opioids and analgesics using BIS-guided sedation therapy • Conflicting results • poor correlation with subjective monitoring tools • intra-individual variation in BIS values even in chemically paralyzed patients • underestimation of sedation in non-chemically paralyzed patients. • the use of the BIS monitor in the ICU is still unclear.

30. Case • 51y/o 林先生 • PHx: • Gout, chronic alcoholic hepatitis for 20yrs • 2005/11: advanced esophageal ca • Neoadjuvant CCRT • 2006/03/06 subtotal esophagectomy+ gastric tube reconstruction + jejunostomy

31. Present Illness • 2006/07/04: Ischemic bowel and intestinal strangulation + septic shock • Emergent OP: perforation repair + jejunostomy • W’d condition: • 7/05 Wet dressing bid7/07 q8h • 7/10 • Turbid w’d, Fascial suture tear! • N/S 500ml irrigation bid + sucction • 7/12 N/S 4000ml irrigation qd + sucction • 7/ DC irrigation

32. Sedation condition

33. When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat any underlying physiological disturbances, such as hypoxemia, hypoglycemia, hypotension, pain, and withdrawal from alcohol and other drugs. • Sedation of agitated critically ill patients should be started only after providing adequate analgesia and treating reversible physiological causes. (Grade C)

35. Better match between analgesic and psychoactive drugs administered and patients’ requirements. • Improvement process in quality and safety • a decrease in duration of sedation • decrease duration of ventilation • decrease nosocomial infections rate’

36. Thank you for your participation! • References: • Sedation monitoring in ICU, S. Rinaldi et al, Current Anaesthesia & Critical Care (2006)article in press • Sedation Assessment in Critically Ill Adults: 2001–2004 Update, Brian D Watson and Sandra L Kane-Gill, Ann Pharmacother 2004;38:1898-906. • Impact of systematic evaluation of pain and agitation in an intensive care unit, G. Chanques et al, Crit Care Med 2006 Vol. 34, No. 6