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Diminishing Sedation To Enhance Results

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  1. Reducing Sedation To Improve Outcomes Terry P. Clemmer, MD Vicki Spuhler, RN, MSN LSD Hospital Salt Lake City, UT 84143

  2. Tao te Ching # 65 The ancient masters didn’t try to educate the people, but taught them to not know. When they think they know the answers, people are difficult to guide. When they know that they don’t know, people can find their own way.

  3. Current Thinking For Safety Reasons, Patients on Ventilators Need to Be Sedated Heavily

  4. New Thinking Heavy-Sedation Is Harmful !

  5. Heavy-Sedation Is Harmful! • It Predisposes to VAP by • Inhibiting Coughing • Inhibiting Mobilization of the Patient • Decreasing Immune Function • Promoting Aspiration • It Accelerates Patient Deconditioning • It Prolongs Time on Ventilators • It Promotes Skin Breakdown • It Most Likely Promotes Post ICU-PTSD

  6. Awake and Cooperative Is The Goal • Reflexes Return • cough, sigh, deglutition. • Mobility Starts • Ventilator Time Is Reduced • Reduces Skin Problems • Reduces Long Term Psychological Problems

  7. Stoppers – Unjustified Fears • Patient will Harm Self If Not Heavily Sedated • Better If Patient Does Not Remember This Experience • Care Will Be Compromised If Patient Is Not Controlled and Moves Around

  8. SEDATION METARULES • Set “Necessity Criteria for Sedation”. Provider’s Fear Is Is Not A Just Reason • Titrate to a Sedation Score to Avoid Over Sedating Patient • Remove Sedation at Least Once a Day to Make Sure Patient Still Requires Sedation • After Sedation Interruption Restart Sedation at a Fraction of the Prior Dose (½ or ¾)

  9. Eligibility for Daily Sedation Vacation • All Ventilated Patients Receiving IV Drip Sedation (Fentanyl, Propofol, Midazolam, or Lorazepam) and • Have a GCS of < 13 or • Who Retain CO2 When the Ventilator Support Is Reduced.

  10. Exceptions to Daily Sedation Vacation: • Open Abdominal Wound in Which Fascia Is Not Closed Unless Okayed by Surgeon • Intracranial Pressure > 20 Unless Okayed by a Physician. • Severe O2 Desaturation While on FiO2> 90% Unless Ordered by a Physician.

  11. Procedure for Daily VacationFrom Fentanyl: • If Patient Has Significant Pain Make Sure Analgesia Is Ordered. Enteral Route Preferred • Stop the Fentanyl Drip • If Patient Becomes Agitated or Delirious and Needs to Return to IV Drip, Give a 50-100 Microgram Bolus of Fentanyl and Restart the Drip at ½ the Rate. • Titrate the Rate As Necessary to Obtain a MAAS Score of 2-3

  12. Procedure for Daily VacationFrom Propofol: • If Patient Has Significant Pain, Make Sure an Analgesic Is Ordered • Reduce Propofol Rate in Half. • If After 30 Minutes Patient Is Still Not Overly Agitated or Delirious Stop the Propofol Drip. • If Patient Becomes Agitated or Delirious After Reducing or Stopping the Drip Give a Bolus of Propofol As Needed • Resume Titration at ½ the Last Rate to a Level That Results in a Maas Score of 2-3.

  13. Procedure for Daily VacationFrom Benzodiazepines: • If Patient Has Significant Pain Make Sure Patient Has Analgesia Ordered. • Stop the Benzodiazepines Drip • If Patient Becomes Agitated or Delirious and Needs to Return to IV Drip, Give Small Bolus of Benzodiazepines and Restart the Drip at ½ the Rate. • Titrate the Rate As Necessary to Obtain a MAAS Score of 2-3

  14. If Patient Fails a Daily Vacation Trial Try a New Strategy: • If Patient Is Delirious or Severely Agitated a Trial of Quetiapine Fumarate(Seroquel®),Olanzapine(Zyprexa®),or Haloperidol(Haldol®)Can Be Tried • If Patient Is Very Anxious, Try Clonazepam(Klonopin®)or Low Dose Lorazepam(Ativan®) • If Patient Very Restless, Try Valporic Acid(Depacon®)

  15. Clarify the Reason for Sedation Need and Severity of Problem • Pain • Agitation • Delirium • ETOH Withdrawal • Anxiety • Sleep Deprivation

  16. Scoring Tools • Pain Scales ------------ Verbal, FLACC Face, Legs, Activity, Cry, Consolability • Agitation ---------------- MAAS, SAS, RASS Motor Activity Assessment Scale Sedation-Agitation Scale Richmond Agitation and Sedation Score • Delirium ---------------- CAM-ICU Score Confusion Assessment Method for the Intensive Care Unit • ETOH Withdrawal ---- CIWA Clinical Institute Withdrawal Assessment • Anxiety ------------------ GAD 7 General Anxiety Disorder Score • Sleep

  17. Therapy for These Disorders • Pain ------------------ Analgesics • Agitation ------------ Valporic Acid • Delirium ------------- Atypical Antipsychotics • ETOH Withdrawal - Low Dose Benzodiazepines • Anxiety --------------- Low Dose Benzodiazepines • Sleep --------------------- Trazodone and/or Zolpidem

  18. AnalgesiaGoal: Tolerable Pain Relief with Minimal Sedation • Use Enteral Route Whenever Possible • Scheduled Versus PRN • Intermittent Parenteral Versus Continuous • Selection of Narcotic Agents • Long Acting Versus Short Acting • Side Effects (BP, HR, Renal Function, CNS) • Alternative to Narcotic Agents

  19. AgitationGoal: Calm with Minimal Sedation • Valporic Acid • Comes both Parenteral and Enteral Forms • Use smaller doses than for Anti-convulsant or Anti-psychotic indications (250 mg – 1000mg daily in divided doses) • Contraindicated in Liver Failure • Benzodiazepine • Lorazepam 1 mg PRN not to exceed 4 mg per day • Clonazepam 0.5 – 1 mg daily

  20. Delirium Goal: Non-delirious with Minimal Sedation • Quetiapine Fumarate (Seroquel) • Enteral Administration Only • 50 to 100 mg enterally once or twice per day • Olanzapine (Zyprexa) • Enteral, Sublingual, IM Administration • 5 to 10 mg bid • Haloperidol (Haldol) • Low Dose Lorazepam for ETOH Withdrawal

  21. Anxiety Goal: Non-anxious with Minimal Sedation • Benzodiazepine • Clonazepam 0.5 – 1 mg daily • Only Available in Enteral Form • Lorazepam 0.5 - 1 mg PRN not to exceed 4 mg per day

  22. Sleep Goal: Rested For Daily Activity • Control the Night Time Environment • Interruptions, Noise, Lighting • Increase Daytime Activities • Dangling, Standing by Bed, Transferring to Chair, Sitting in Chair, Walking • Sedation • Trazodone 100 mg at 8 PM. May Repeat at 10 PM as needed • Zolpidem 5 mg at 8 PM

  23. References to Scoring Tools References to Agitation Scores • Devlin JW, Boleski G, Mlvnarek M, Nerenz DR, Peterson E, Jankowski M, Horst HM, Zarewitz BJ.Motor Activity Assessment Scale: a valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Crit Care Med. 1999 Jul;27(7):1271-5. • Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients.Crit Care Med. 1999 Jul;27(7):1325-9. • Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK.The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44.

  24. References to Scoring Tools References to Delirium Scores • Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med. 2001 Jul;29(7):1370-9. • Reoux JP, Oreskovich MR.A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-AD.Am J Addict. 2006 Jan-Feb;15(1):85-93. References to Anxiety Score • Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092-7.

  25. References to Scoring Tools Reference to Pain Scoring • Voepel-Lewis T, Merkel s, Tait AR, Trzcinka A, Malviva S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9 • Paven JF, Bru O, Bosson JL, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001 Dec;29(12):2258-63. Reference to Ambulating Vent Dependent Patients • Bailey, RN, APRN; George E. Thomsen, MD; Vicki J. Spuhler, RN, MS; Robert Blair, PT; James Jewkes, PT; Louise Bezdjian, RN, BSN; Kristy Veale, RN, BSN; Larissa Rodriquez, AS; Ramona O. Hopkins, PhD. Early activity is feasible and safe in respiratory failure patients *.Polly. Crit Care Med January 2007; 35(1):139-145