H O ME

IN DEX

CONT A CT

EMC R IT BL O G A N D P O DC A S T

OLD TOC

Analgesia and Sedation of the Intubated Patient

SI T E SEA R C H

Back to top
Sea r ch

2013 SCCM Guidelines

TOP I CS 201 3 SCCM Guidelines Sedation Only A1 Sedation Ketamine Dex medetomidine Delirium Propofol Remifentanil Midazolam

(Crit Care Med 2013;41:263) ST AT EMENT S AND RECOMMENDAT IONS

i. We recommend that pain be routinely monitored in all adult ICU patients (+1 B).

ii. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and relia behavioral pain scales for monitoring pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report and in whom motor function is intact and behaviors are observable. Using th scales in other ICU patient populations and translating them into foreign languages other than French or English re further validation testing (B). iii. We do not suggest that vital signs (or observational pain scales that include vital signs) be used alone for pain assessment in adult ICU patients (2C). iv. We suggest that vital signs may be used as a cue to begin further assessment of pain in these patients, however (+ c. Treatment of pain i. We recommend that preemptive analgesia and/or nonpharmacologic interventions (e.g., relaxation) be administe to alleviate pain in adult ICU patients prior to chest tube removal (+1C). ii. We suggest that for other types of invasive and potentially painful procedures in adult ICU patients, preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered to alleviate pain (+2C). iii. We recommend that intravenous (IV) opioids be considered as the first-line drug class of choice to treat nonneuropathic pain in critically ill patients (+1C). iv. All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective (C). v. We suggest that nonopioid analgesics be considered to decrease the amount of opioids administered (or to elimin the need for IV opioids altogether) and to decrease opioid-related side effects (+2C). vi. We recommend that either enterally administered gabapentin or carbamazepine, in addition to IV opioids, be considered for treatment of neuropathic pain (+1A). vii. We recommend that thoracic epidural anesthesia/analgesia be considered for postoperative analgesia in patien undergoing abdominal aortic aneurysm surgery (+1B). viii. We provide no recommendation for using a lumbar epidural over parenteral opioids for postoperative analges patients undergoing abdominal aortic aneurysm surgery, due to a lack of benefit of epidural over parenteral opioid this patient population (0,A). ix. We provide no recommendation for the use of thoracic epidural analgesia in patients undergoing either intratho or nonvascular abdominal surgical procedures, due to insufficient and conflicting evidence for this mode of analges delivery in these patients (0,B). x. We suggest that thoracic epidural analgesia be considered for patients with traumatic rib fractures (+2B). xi. We provide no recommendation for neuraxial/regional analgesia over systemic analgesia in medical ICU patien due to lack of evidence in this patient population (0, No Evidence). 2. Agitation and Sedation a. Depth of sedation vs. clinical outcomes

i. Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shor duration of mechanical ventilation and a shorter ICU length of stay [LOS]) (B). ii. Maintaining light levels of sedation increases the physiologic stress response, but is not associated with an increa incidence of myocardial ischemia (B). iii. The association between depth of sedation and psychological stress in these patients remains unclear (C). iv. We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in ad ICU patients, unless clinically contraindicated (+1B). b. Monitoring depth of sedation and brain function i. The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliab sedation assessment tools for measuring quality and depth of sedation in adult ICU patients (B). ii. We do not recommend that objective measures of brain function (e.g., auditory evoked potentials [AEPs], Bispec Index [BIS], Narcotrend Index [NI], Patient State Index [PSI], or state entropy [SE]) be used as the primary metho monitor depth of sedation in noncomatose, nonparalyzed critically ill adult patients, as these monitors are inadequ substitutes for subjective sedation scoring systems (1B). iii. We suggest that objective measures of brain function (e.g., AEPs, BIS, NI, PSI, or SE) be used as an adjunct to subjective sedation assessments in adult ICU patients who are receiving neuromuscular blocking agents, as subject sedation assessments may be unobtainable in these patients (+2B). iv. We recommend that EEG monitoring be used to monitor nonconvulsive seizure activity in adult ICU patients wi either known or suspected seizures, or to titrate electrosuppressive medication to achieve burst suppression in adu patients with elevated intracranial pressure (+1A). c. Choice of sedative i. We suggest that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) ma preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B). 3. Delirium a. Outcomes associated with delirium i. Delirium is associated with increased mortality in adult ICU patients (A). ii. Delirium is associated with prolonged ICU and hospital LOS in adult ICU patients (A). iii. Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B). b. Detecting and monitoring delirium i. We recommend routine monitoring of delirium in adult ICU patients (+1B). ii. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools in adult ICU patients (A). iii. Routine monitoring of delirium in adult ICU patients is feasible in clinical practice (B). c. Delirium risk factors i. Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU: preexisting dementia, history of hypertension and/or alcoholism, and a high severity of illness at admission (B). ii. Coma is an independent risk factor for the development of delirium in ICU patients (B). iii. Conflicting data surround the relationship between opioid use and the development of delirium in adult ICU pat (B). iv. Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients (B). v. There are insufficient data to determine the relationship between propofol use and the development of delirium adult ICU patients (C). vi. In mechanically ventilated adult ICU patients at risk of developing delirium, dexmedetomidine infusions administered for sedation may be associated with a lower prevalence of delirium compared to benzodiazepine infus (B).

d. Delirium prevention i. We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence an duration of delirium (+1B). ii. We provide no recommendation for using a pharmacologic delirium prevention protocol in adult ICU patients, a compelling data demonstrate that this reduces the incidence or duration of delirium in these patients (0,C). iii. We provide no recommendation for using a combined nonpharmacologic and pharmacologic delirium preventio protocol in adult ICU patients, as this has not been shown to reduce the incidence of delirium in these patients (0,C iv. We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adul patients (2C). v. We provide no recommendation for the use of dexmedetomidine to prevent delirium in adult ICU patients, as th no compelling evidence regarding its effectiveness in these patients (0,C). e. Delirium treatment i. There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU pati (No Evidence). ii. Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C). iii. We do not recommend administering rivastigmine to reduce the duration of delirium in ICU patients (1B). iv. We do not suggest using antipsychotics in patients at significant risk for torsades de pointes (i.e., patients with baseline prolongation of QTc interval, patients receiving concomitant medications known to prolong the QTc inter or patients with a history of this arrhythmia) (2C). v. We suggest that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuo infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the dur of delirium in these patients (+2B). 4. Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes a. We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanic ventilated adult ICU patients (+1B). b. We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B). c. We recommend promoting sleep in adult ICU patients by optimizing patients environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patients sleep cy (+1C). d. We provide no recommendation for using specific modes of mechanical ventilation to promote sleep in mechani ventilated adult ICU patients, as insufficient evidence exists for the efficacy of these interventions (0, No Evidence e. We recommend using an interdisciplinary ICU team approach that includes provider education, preprinted and/ computerized protocols and order forms, and quality ICU rounds checklists to facilitate the use of pain, agitation, a delirium management guidelines or protocols in adult ICUs (+1B).

Best Review Article (Am J Resp Crit Care 2012;185:486) Good review article Large recently published trial shows sedation holidays unnecessary when compared to protocolized sedation, multi center, Sangeeta Mehta, Lisa Burry, Paul Hbert, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol. A Randomized Controlled T r JAMA 2012; ePub online October 17, 2012. Most ED patients receive inadequate sedation and pain control (Am J Emerg Med 2008;26:469) and another Am J Emerg Med. 2012 Jul 4. Estimates of sedation in patients undergoing endotracheal intubation in US EDs. Back to top

Sedation Only
New article shows no sedation (but of course analgesia) got pts off the vent quicker. (Lancet 2010;375:475)

Back to top

A1 Sedation
C.N. Sessler, K. Varney Patient-focused sedation and analgesia in the ICU Chest, 133 (2008), pp. 552565 P.S. Richman, D. Baram Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combinatio Crit Care Med, 34 (5) (2006 May), pp. 13951401 D. Breen, A. Karabinis, M. Malbrain et al. Decreased duration of mechanical ventilation when comparing when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial Crit Care, 9 (3) (2005), pp. R200R210

The agents
Talk from Sladen at NCC 2009 benzodiazepenes are the most potent amnestics Sedation is amnesia, hypnosis, and anxiolysis Opioids can provide analgesia and some anxiolysis and hypnosis but not amnesia Valium:Ativan:Versed 5:0.5:2 pH<4, imidazole ring of midaloam is open making it water soluble at >4 it closes and the drug becomes lipid soluble propofols offset is by lipid solubility not metabolism dexmed dries the mouth

Another Protocol (J Trauma 2008;65:517)

RASS

Review Article

J Trauma puts forth a not so bad sedation protocol (J Trauma 2007;63:945)

Awakening and Breathing Controlled trial (Lancet 2008;371:126) Interrupt sedation and then let the patient wake u

spont. breath; duh???

Back to top

Ketamine
SCCM Critical Connections Article in Feb/Mar 2012 recommends ketamine infusion dose of 0.05-0.4 mg/kg/hr adjusted every 5-20 minutes dilute to 1-2 mg/ml by adding 500 mg to 500 or 250 of NS or D5W

from SCANCRIT guys:

Ketamine i.v. drip infusion Mix 500mg of Ketamine in a bag of 500 mL saline, to get ketamine 1 mg/ml. Get the patients weight in kilograms. L starting point for your maintanence dose of ketamine i.v. drip infusion be [the patient's weight i kg] drops per minu This will equal around 4 mg/kg/hr. Adjust to effect. Ketamine induction cocktail Y ou will still need an induction dose of ketamine 1-2 mg/kg i.v. For children (or grown-ups) where you cant easily g i.v. access while theyre awake, you can use a dose of ketamine 5-8 mg/kg i.m. for induction. Y ou can also mix in at and a little midazolam in the same i.m. syringe to give them the full cocktail i.m. induction. Back to top

Dexmedetomidine
Best Review

3 patients with non-dt withdrawl syndromes (J of Inten Care Med 2005;20(2):118

Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients The MENDS Randomized Controlled Trial (JAMA. 2007;298(22):2644-2653. )

Large trial of dex vs. midaz, notable for doses up to 1.4 mcg/kg/hr and duration up to 30 days (JAMA 2009;301(5) New trial on the long-term use of infusion doses of up to 2.5 mcg/kg/hr show no additional side effects (crit care 2011;15:R257) - I havent needed to use a bolus, just started the drip at 0.5 to 0.7 mcg/kg/hr. Once patient extubated wean it ov couple of hours or faster. - Expensive so we use it judiciously. - Used to try the usuals (fentanyl, propofol, haldol, benzos, etc)before trying precedex but now moving quicker to it. - I believe FDA approved for 48 hrs but have hea multiple anecdotes by anesthesia colleagues using it for periods of up to 2 weeks. Have never had to use it for mor than 24hrs. - Not had ever any problems with bradycardia or hypotension, but never used a bolus.

Back in the early 90s, there was a big push to use a lot of lorazepam in the ICU because it was off patent and cheap a the others were on patent and expensive. Many of the papers extoling the virtues of lorazepam in Critical Care Med were thinly veiled advertisements. Gee.we used a lot of it in the ICU and it worked just swell..lets use more!!. t look down at the bottom of the page and see This advertisement brought to you by a grant from Wyeth, makers of lorazepam. Delirium occurs when pattern recognition is lost in the ICU. Elderly people start running on pattern recognition at some point in their lives. They simply get used to their shrinking environment. Like a blind dog in yo house. Y ou never know the dog is blind. He knows the house and never bumps into anything. Then they land in an

and all that pattern recognition evaporates. And they might as well be on mars. Mild or incipient dementia takes ov they become confused and confounded and try to escape, following which they are quickly restrained and the race Giving lorazepam simply decreases their ability to discern the thin grasp of reality, paradoxically increasing the del Use a sedative you can titrate to effect. Propofol or midazolam.JAMA study higher incidence of delerium when be and inadequate pain regiemn compared to dexmed (JAMA 2009;301(5):489)industry supported study states dex m cheaper than midaz (Critical Care Medicine Issue: Volume 38(2), February 2010, pp 497-503)

Ramsay Sedation Scale Awake 1 Anxious, agitated, restless 2 Cooperative, orientated, tranquil 3 Responds to commands only Asleep 4 Brisk response to light glabellar tap or loud auditory stimulus 5 Sluggish response to light glabellar tap or loud auditory stimulus 6 No response to light glabellar tap or loud auditory stimulus

Crit Care Med 2006;34(6):1668 Permissive hypercapnia patients required more propofol but same amount of midazolam

List of sedation and pain meds

Have I got the cure for you Lou: Start Risperdal 1mg bid, and valproate 500 bid. Can double both if you need. Sho begin to work pretty quickly. We have had dramatic success with these drugs. Made a big difference in my life (tak care of pts). Leo PS. We do not use morphine by infusion b/o rapid development of tolerance. Substitute fentany instead. Ive posted the reference mult times.

Dose of Risperdal ranges from 0.25 mg daily for a frail 80 yo, to 2 mg bid for a healthy robust young guy. I gave 1 m to my 50 yo polysubstance abuser. Dose of valproate that I use is either 500 or 750 bid. Most pts actually only get Risperdal. Only the really agitated and more robust pts get the Valproate. Typical pt who gets both is your alcohol withdrawal pt. If put virtually all my pts with DTs on both of these drugs, and encourage the hospitalists to do that t soon as the pts are admitted. I believe its saved quite a number from needing transfers to the ICU, but I dont have rigorous data. I know for sure that pts in DTs are now a relative rarity for us in the unit, whereas a few years ago the were much more common. Leo ________________________________ From: prasannasimha [mailto:prasannasimha@gmail.com] Sent: Friday, August 25, 2006 5:54 AM To: Leo I. Stemp, MD Cc: Internation Critical Care Internet Group Subject: Re: ccml sedation management in SICU Trauma Patient Can you give me the of Risperidone an Sodium Valproate. Prasanna Leo I. Stemp, MD wrote: NMB?! Crazy. And by the way, like you sai avoid the NMBs with steroid nucleus. Doesnt that mean avoiding the -curonium drugs (panc, vec, roc)? We use on cis-atracurium here. We see these pts routinely, have had huge reduction in problems since we started using the new antipsychotics combined with valproate. At the suggestion of a member of this List, I might add. One of the most im new developments in my practice in years. Just had a success with it this week. Pt about 6 days post-esophagectomy agitated, not handling secretions. Intubated him for airway protection, got him on Risperdal and valproate, extubat two days later fully awake and oriented, looking great. In the old days, reintubating such a pt would have been a calamity. No problem here. Had another recent dramatic success: a 49 yo multi-substance abuser looser, came in w ischemic bowel. E-lap, etc. Recurrent abdom sepsis necessitated him going back to OR two more times, open abdom resulting in the contents of his abdominal cavity being one large, scarred in, soccer-ball sized lump of cement. Not a candidate for another operation bec there would have been no tissue planes. Following that had mult radiologic cav drainage procedures. The guy was septic for a long time, but never developed MOSF, only resp failure. So trached. peg, had to be on TPN. Once we started Risperdal (the orally disintegrating tabs) and valproate, his general and resp course really smoothed out. Got him onto trach collar, then out of the unit after two months or so, looking like a ch and acting like the nicest guy in the world. Leo -Original Message- From: David Crippen Sent: Thursday, Augu 24, 2006 5:24 PM To: ccm-l@ccm-l.org Subject: ccml sedation management in SICU Trauma Patient He is on indu strength doses of meds and I cant seem to get them down. He is on Morphine 25 mg/hr, Lorazepam 10 mg/hr, and haloperidol 15 mg/hr via constant infusion. Even with this, he occasionally gets agitated This is strong evidence for antecedent recreational drug dependence, not matter what he or his family tells you. All those medications are cros dependent to and cross tolerant to ethanol and many of the recreational feel-goods. This will put you into a very big trying to sedate him, as you have already found out. Like it or not, partial neuromuscular blockade is the only way are going to get control of this without depleting the Eastern USA supply of sedatives, and suffering all the side effe thereof. Not total paralysis, neuromuscular blocker in a titrated dose only to slow him down, not make him comple flaccid. After all, it is the musculoskeletal hyperactivity that is the problem, not just the subjective aspects of discomfort. You need to stop the untoward effect of hypermetabolism. Making him more comfortable is more optional at this point. Get an EEG and make sure he isnt seizing in the temporal lobe. If you start a continuous infus (my recommendation) Rocuronium, and simply have the nurse titrate it to the point where you can get on propofol fentanyl in somewhere reasonable doses. Morphine is not potent enough to work. Haloperidol will do little as it isn sedative. Lorazepam is like water. The combo of Propofol and Fentanyl is the least cross tolerant combo and will giv you the most bang for your buck in the presence of loosening his ass up with Rocuronium. Vecuronium a second ch

Dont use anything with a steroid nucleus. Forget giving anything enterally. If you have a cerebral (recreational) dru toxicity encephalopathy, youre in for a rough ride as it can last for a month or longer. Usually they loosen up even Seems like Mike Hansen had a Similar patient recently. Maybe he can comment on what happened to that one. D Crippen, MD

review of propofol deaths (anesthesiology Volume 105(5), November 2006, pp 1047-1051)

Analgesics beat out hypnotics; use fentanyl (Br J Anaesth 2007;98(1):76)

Back to top

Delirium
Delirium: 1590s, from L. delirium madness, from deliriare be crazy, rave, lit. go off the furrow, a plowing metaphor, from phrase de lire (de off, away + lira furrow). http://icudelirium.org/delirium/

CAM-ICU scoring

Importance of dx and managing ICU delerium (Chest 2007;132:624) use CAM-ICU RASS > 0 include flowchart in

Memorial Delirium Assesment Scale

How to prevent delirium allow sleep orient the patient keep hearing aids glasses, etc. reduce pain avoid dopaminergic, anti-cholinergic, or GABA agents hyperactive, treat dopamine with typical or atypical antipsych hypoactive or mixed, use atypical, followed by ACHase inhibitor (donepezil) and serotonin antagonist (ondansetro

Haldol prophylaxis (0.5 mg IV and then 0.1 mg/h) prevented post-delirium (CCM 2012;40:731) Back to top

Propofol
send ck and lipids q24 after 24 hours of propofol Back to top

Remifentanil

Best review for the ICU (Drugs 2006;66(3):365) Back to top

Midazolam
Midazolam and its metabolites can last a long, long time and may cause coma and false prognostication for ICU pati (Lancet 1995;346:145)

Share this:

Back to top

P R E V I OU S P OS T: N E X T P OS T:

ICU Literature

Catheter Bloodstream Infection

Creati v e Com m on s Li cen se 2012. Th i s si te represen ts th e opi n i on s of Crash i n g Pati en t LLC. See h ere for fu l l di scl ai m er.