Post on 04-Jan-2016
LOGO
Sedation in the ICU
Prof. Bahaa EweesAin Shams University
Contents
Definition of Sedation1
Importance of Sedation in the ICU2
Monitoring of Sedation3
Mode of Sedation4
Examples of Sedation Protocol5
Delivery of Sedation5
Sedation: depression of awareness and reduction of the response to external stimuli
Definition of Sedation1
Plays a vital role in the care of critically-ill patients and encompasses wide spectrum of symptom management.
Heavy sedation is used to facilitate ETT insertion and M.V. (replacing NMBA)
Importance of Sedation2
Monitoring of Sedation3
Done HourlyTo avoid:
Under-Sedation
Heavy Sedation
↑ catecholamines Coagulopathy and Immune Suppression
* ↑ duration of ICU stay and M.V.* Side Effects of sedationdrug
Monitoring of Sedation3
1. Scoring Systems
2. Instrumental
BIS
EEG
Mode of Sedation4
Non Pharmacological
Pharmacological
Mode of Sedation4
Non Pharmacological
1. Continuous communication with the patient
2. Good Hydration
3. Good Nutritional Support
4. Physiotherapy Ve………..ry Important
Mode of Sedation4
Pharmacological
A. Drugs used for Induction of Anaesthesia
B. Benzodiazepines
C. Neuroleptic Agents
D. Opioids
E. Clonidine and Dexmedetomedine
Pharmacological
A. Drugs used for Induction of AnaesthesiaA. Propofol
Widely used due to high clearance and metabolism. Dose: 0.5 – 4 mg/kg/h. Problems
↓ HR ↓ BP Propofol Infusion Syndrome
Pharmacological
Propofol Infusion Syndrome Rare Manifestations
↓ pH Arrhythmias Cardiovacular collapse Acute renal Failure Hyperkalaemia
Risk factors Sepsis Severe Cerebrovascular Stroke High propofol doses (> 5 mg/kg/h.)
Pharmacological
Propofol Infusion Syndrome (cont.) Recommendations
Once suspected, stop infusion Dose should be < 4mg/kg/h. Duration should be less than 24 h. Daily monitoring of triglyceride levels and renal
function.
Pharmacological
A. Drugs used for Induction of AnaesthesiaB. Thiopental used by infusion (for status epilepticus to
control convulsions) Problems:
Low clearance Metabolized by redistribution Myocardial depression Accumulation
Pharmacological
A. Drugs used for Induction of AnaesthesiaC. Etomidate Infusion Only BUT, ↓↓↓↓ adrenocortical
function
Pharmacological
A. Drugs used for Induction of AnaesthesiaD. Ketamine Can be used for intubation in the ICU Sedation especially in asthmatic patient
BUT, ↑↑ CMRO2, Delirium, and hallucination
Pharmacological
B. Benzodiazepines Acting on GABA receptors (the main inhibitory
neurotransmitter in CNS)
1. Midazolam Metabolized in liver to active metabolite Highest clearance among BZs Suitable for infusion (0.04 – 0.2 mg/kg/h.)
2. Diazepam Metabolized to active metabolite by liver Lowest clearance among BZs Suitable for oral use or bolus injection (2- 10 mg)
Pharmacological
C. Neuroleptic Agents Haloperidol or Chloropromazine Used for delirium and psychosis in the ICU Can cause:
Respiratory depression Prolonged QT interval Arrhythmias
Pharmacological
D. Opioids Provide analgesia and anxiolysis Better used by infusion Remifentanil (ultrashort acting opioid)
0.1 – 0.15 ug/kg/min.
Pharmacological
E. Clonidine and Dexmedetomedine Alpha 2 Agonists
Can be used for sedation in both spontaneous and mechanically ventilated patients.
Dexmedetomedine is more potent than clonidine Shorter elimination t1/2
So, it is widely used nowadays for sedation
Delivery of Sedation5
Intermittent Injection
Bolus Injection
Infusion
ConstantLevel ofsedation
1
Less chanceOf
Intermittentagitation
2
Delivery of Sedation5
Sedation Holiday
Stopping the sedation infusion and allowing the patient to awake.
Restarted once: Patient fully awake and obeying commands, or Patient becoming agitated or uncomfortable
Should be done on a daily basis!This strategy ↓ duration of MV and Length of
stay in ICU.
Example of Sedation Protocols6
Short term therapy< 72 h.
Hemodynamically stable?
YES
* Propofol infusion
* Opioid
- Remifentanil
- Fentanil
NO
* Alfentanil infusion
If necessary consider propofol infusion.
Example of Sedation Protocols6
Long-term therapy> 72 h.
CONSIDER
1. Opioid
- morphine infusion
- Alfentanil infsion (if Renal failure)
2. Benzodiazepine
LOGO