Sedation in the Surgery Patient

1
Sedation in the Surgery Patient

• Colby Miller Pharm.D., BCPS
• Critical Care Specialist
• Sinai Hosptial

2
Case 1

• JS is a73 year old female admitted to SICU after
  tumor debulking surgery for stage IV ovarian
  cancer (omentectomy, TAH/BSO, SBR) EBL 700 ml,
  PRBCs 2 units, 2.7 L IVF
• Patient extubated in the PACU but reintubated for
  respiratory distress and transferred to the SICU.
  She is unable to be extubated and on day 4 is
  diagnosed with a pseudomonal VAP. She is started
  on piperacillin/tazobactam and tobramycin.

• PMH
• Right mastectomy for breast cancer
• HLD
• HTN
• OA
• Depression
• Chronic back pain
• Home medications
• exemestane 25mg qd
• diltiazem 240mg qd
• rosuvastatin 2.5mg qd
• paroxetine 30mg qd
• risedronate 35mg qweek
• oxycodone CR 40mg bid

JS is very agitated, what has caused her
increasing agitation?
3
(No Transcript)
4
Complications of UnderSedation

• ?

5
Complications of UnderSedation

• Patient recall (PTSD)
• Device removal
• Ineffectual mechanical ventilation
• Initiation of neuromuscular blocker therapy
• Myocardial or cerebral ischemia
• Decreased family satisfaction with care

6
Complications of OverSedation

• ?

7
COMPLICATIONS OF OVER SEDATION

• Prolonged mechanical ventilation
• Need for additional diagnostic testing
• Increased length of ICU and hospital stay
• Increased risk of complications
• Ventilator-associated pneumonia
• Thromboembolic events
• Drug withdrawal

8
Incidence of Inadequate Sedation
Kaplan L, et al. Crit Care 20004(suppl 1)S110.
9
Goals of sedation and analgesia

• Relieve pain and anxiety
• Improve compliance with care
• Optimize safety
• Avoid or reduce delirium

10
How do we assess sedation?
11
Desirable features of sedation scales

• Easy to administer, recall and interpret
• Clear definitions of each level
• Discretion between each level of scale
• Proven validity
• Inter-rater reliability (including in different
  settings)

12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
Crit Care Med 2006 3416911699.
16
Crit Care Med 2006 3416911699.
17
Key Points

• Use validated tools
• Monitor patients frequently
• Target
• Tolerance of ICU environment
• Pain and anxiety control
• Patient/ventilator synchrony
• Avoid under-sedation
• Avoid excess or prolonged sedation

18
PATIENT FOCUSED SEDATION
19
CASE 2

• TC is a 21 year old male s/p multiple GSW to
  abdomen. Patient is taken to OR for ex-lap. He
  undergoes SBR, repair of liver laceration,
  exploration of retroperitoneal hematoma and
  washout of abdomen. He is transferred to the
  SICU after the OR with an open abdomen. He is
  returning to the OR in 3 days for
  washout/reexploration.
• His pain is being treated appropriately with
  fentanyl
• RASS Score assessed on admission to SICU is 3
  and nonpharmacological interventions have been
  implemented. The RASS score is now 2.
• Goal RASS? Which sedative medication should be
  ordered?

20
Non-pharmacological measures

• Minimize
• Blood draws
• X-rays
• Blood pressure measurements
• Blood glucose measurements
• Dimming lights at night (sleep-wake cycle)
• Massage, therapeutic touch and music therapy

21
Selection of Sedatives

• Benzodiazepines
• Diazepam
• Lorazepam
• Midazolam
• Propofol
• Dexmedetomidine
• Haloperidol, other neuroleptics

22
Medication Selection

• Pharmacokinetic / dynamic properties of
  medications
• Patient-specific characteristics
• SCCM Guidelines (last updated in 2002)
• Clinical trials since 2002

23
PROPERTIES OF MEDICATIONS

• Onset and offset of effect
• Duration
• Drug metabolism
• Presence of active metabolites
• Effectiveness of medication

• Adverse effects
• Costs related to drug acquisition
• Costs related to duration of therapy

24
(No Transcript)
25
Dexmedetomidine

• Alpha2-adrenoceptor agonist
• Produces sedation and analgesia but no
  respiratory depression
• Side effects should be anticipated
• blood pressure reduction
• heart rate reduction
• Bradycardia and sinus arrest have been reported
• Caution should be exercised when administering
  Precedex to patients with advanced heart block
  and/or severe ventricular dysfunction

26

• Hyperosmolarity, elevated anion and osmol gaps,
  metabolic and lactic acidosis, acute renal
  failure, contact dermatitis, seizures, mental
  status changes, cardiac arrhythmias, and
  asystole.
• Osmolar gap can be used as a surrogate marker for
  serum propylene glycol concentration.
• (2 x serum sodium mEq/L) (glucose mg/dl/18)
  
• (BUN mg/dl/2.8).
• In critically ill patients, receiving lorazepam
  for sedation, an osmol gap above 10 was
  associated with concentrations previously
  reported to cause toxicity.

Pharmacotherapy 20062623-33.
27
Propofol-related infusion syndrome (PRIS)

• Propofol infusion syndrome
• (1) the sudden, or relatively sudden, onset of
  marked bradycardia resistant to treatment, with
  progression to asystole
• Bradycardia required plus one of the following
• (2) the presence of lipemia
• (3) a clinically enlarged liver secondary to
  fatty infiltration
• (4) the presence of severe metabolic acidosis
• (5) the presence of muscle involvement with
  evidence of rhabdomyolysis or myoglobinuria

28
Jacobi J et al. Crit Care Med 200230119-141.
29
Key Points

• Choose medications best suited to the patients
  characteristics
• Organ function
• Drug metabolism
• Risk of side effects
• Sedation needs differ among patients
• Patients needs vary over time

Important note remember medication
reconciliation
30
CASE 2

• TC is a 21 year old male s/p multiple GSW to
  abdomen. Patient is taken to OR for ex-lap. He
  undergoes SBR, repair of liver laceration,
  exploration of retroperitoneal hematoma and
  washout of abdomen. He is transferred to the
  SICU after the OR with an open abdomen. He is
  returning to the OR in 3 days for
  washout/reexploration.
• His pain is being treated appropriately with
  fentanyl
• RASS Score assessed on admission to SICU is 3
  and nonpharmacological interventions have been
  implemented. The RASS score is now 2.
• Goal RASS? Which sedative medication should be
  ordered?

31
TIPS AND TRICKS TO MINIMIZE SEDATION
32
Tip 1
Use a sedation protocol
33
Crit Care Med 2000282300-2306.
34
Duration of mechanical ventilation 10.3 d
(control) vs 4.4 d (algorithm)
Crit Care Med 200533120-127.
35
Tip 2
Incorporate Daily Interruption of Sedation (DIS)
36
N Engl J Med 20003421471-7.

• RCT comparing daily interruption of sedatives
  (midazolam/propofol and analgesia) until patient
  able to follow 3 of 4 simple commands or became
  agitated vs usual care. Sedation restarted at
  half of previous rate when reinitiated.
• Outcomes
• Duration of mechanical ventilation
• ICU length of stay
• Length of hospital stay
• Need for diagnostic tests for unexplained altered
  mental status

37
Kress et al. N Engl J Med 20003421471-7.
38
Kress et al. N Engl J Med 20003421471-7.
39
Kress et al. N Engl J Med 20003421471-7.
40
Am J Respir Crit Care Med 200316814571461

• Patients randomized to daily interruption of
  sedation (DIS) have fewer symptoms of PTSD
  compared to control patients

Important Note Do not provide DIS for patients
receiving paralysis, or patients with HTN crisis,
severe status asthmaticus or severe ETOH
withdrawal
41

• VAP Bundle

Jt Comm J Qual Patient Saf 200531243-248
42
Tip 3
Provide Analgesia Management First
43
Crit Care 20059R200-R210

• RCT comparing a remifentanil-based sedation
  regimen titrated to response before the addition
  of midazolam for further sedation vs.
  midazolam-based sedation regimen with fentanyl or
  morphine added for analgesia

44
Tip 4
Use Newer Medications With Different Properties
45
JAMA 2007298(22)2644-2653
Not published, presented at SCCM 2008
46
Tip 5
Use Other Nonpharmacologic Interventions
47
Lancet 2008 371 12634

• RCT comparing DIS followed by spontaneous
  breathing trials (SBT) with sedation per usual
  care (no DIS) plus a daily SBT
• Outcomes
• More ventilator-free days (14.7d vs 11.6d)
• Shorter ICU length of stay (9.1d vs 12.9d)
• Shorter hospital length of stay (14.9d vs 19.2d)
• More self-extubations (16 vs 6) with similar
  reintubation rates

48
Key Points

• Use protocols to optimize sedation
• Use titration strategies to minimize sedation
• Daily interruption of sedation (with SBT)
• Intermittent vs. continuous therapy
• Bolus doses before increasing infusion rates
• Analgesic-based therapy
• Consider dexmedetomidine

Important Note Incorporate careful
de-escalation of therapy to prevent withdrawal
after prolonged sedation