Sedation Monitoring in ICU

1
Sedation Monitoring in ICU

• 2006/07/31
• ??? Ri???
• ???? ?????

2
Case

• 51y/o ???
• 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
• Wd condition
• 7/05 Wet dressing bid?7/07 q8h
• 7/10
• Turbid wd, Fascial suture tear!
• N/S 500ml irrigation bid suction
• 7/12 N/S 4000ml irrigation qd suction
• 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

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Under- /Over-sedation

• 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

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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)

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• 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

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Assessment? Goal? Therapy
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Goal

• Mechanical ventilation
• Pressure support ventilation, CPAP, SIMV
• good pt 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

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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

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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 pediatric patients.

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Ramsay Scale

• The most commonly scale used today

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SAS, Sedation-Agitation scale

• Stratification of agitation in more categories
  than the Ramsay scale

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RASS, Richmond Agitation and Sedation Scale

• 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

17
Bloomsbury Sedation Scale

• Recommendations for dosing sedatives
• reliability not tested

18
GCSC, Glasgow Coma Scale modified by Cook and
Palma

• useful in mechanically ventilated patients
• Absence of agitation scoring
• Unuseful to monitor sedation in agitated patients

19
ATICE, the Adaptation to the Intensive Care
Environment scale
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• Useful in mechanically ventilated patients
• Delirium is not assessed
• Further studies needed in surgical pt

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Avripas sedation scale

• the predetermined standardized sedation goals
  based on the patients weaning classification.

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The Comfort Scale

• For pediatric ICU patients
• Behavioral and physiologic factors related to
  pediatric distress
• Too Complex

23
Objective methods

• in chemically paralyzed patients
• barbiturate coma
• patients requiring very deep sedation

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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

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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.

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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.

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BIS, Bispectral Index
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BIS

• 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.

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Case

• 51y/o ???
• 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
• Wd condition
• 7/05 Wet dressing bid?7/07 q8h
• 7/10
• Turbid wd, Fascial suture tear!
• N/S 500ml irrigation bid suction
• 7/12 N/S 4000ml irrigation qd suction
• 7/ DC irrigation

32
Sedation condition
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• 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)

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• 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

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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
  20012004 Update, Brian D Watson and Sandra L
  Kane-Gill, Ann Pharmacother 2004381898-906.
• 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