Connee Sloman CRNA, MSN

Connee L. Sloman, CRNA 

Certified Registered Nurse Anesthetist

Associated Anesthesiologist

Springfield, Illinois

Assessing and Managing Sedation

Faculty DisclosureIt is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Connee Sloman, CRNA, has received grant/research support from the AANA.

Learning Objectives• Manage adult patients who need sedation and

analgesia while receiving ventilator support according to current standards and guidelines

• Use validated scales for sedation, pain, agitation and delirium in the management of these critically ill patients

• Assess recent clinical findings in pain, agitation, and delirium management and incorporate them into the management of ICU patients

Need for Sedation and Analgesia• Prevent pain and anxiety• Decrease oxygen consumption• Decrease the stress response• Patient-ventilator synchrony• Avoid adverse neurocognitive sequelae

– Depression– PTSD– Delirium– Anxiety

• Avoid post-intensive care syndrome Rotondi AJ, et al. Crit Care Med. 2002;30:746-752.Weinert C. Curr Opin in Crit Care. 2005;11:376-380.Kress JP, et al. Am J Respir Crit Care Med. 1996;153:1012-1018.

Characteristics of an Ideal Sedative

• Rapid onset of action allows rapid recovery after discontinuation

• Effective at providing adequate sedation with predictable dose response

• Easy to administer• Lack of drug accumulation• Few adverse effects• Minimal adverse interactions with other drugs• Cost-effective• Promotes natural sleep

1. Ostermann ME, et al. JAMA. 2000;283:1451-1459.2. Jacobi J, et al. Crit Care Med. 2002;30:119-141.3. Dasta JF, et al. Pharmacother. 2006;26:798-805.4. Nelson LE, et al. Anesthesiol. 2003;98:428-436.

Consider Patient Comorbidities When Choosing a Sedation Regimen

• Chronic pain• Organ dysfunction• CV instability• Substance abuse/withdrawal• Respiratory insufficiency• Obesity • Obstructive sleep apnea

Potential Drawbacks of Sedative and Analgesic Therapy

• Impede assessment of neurologic function• Increase risk for delirium• Numerous agent-specific adverse events• Vital signs alone do not tell the amount of pain• Need for objective measures of brain function to

adjunctively monitor level of consciousness especially with NDNMB (BIS)

Kollef MH, et al. Chest. 1998;114:541-548.Pandharipande PP, et al. Anesthesiology. 2006;104:21-26.

A Word About the 2013 PAD Guidelines(Evidence-based)

• Supporting organizations– American College of Critical Care Medicine (ACCM) – Society of Critical Care Medicine (SCCM)– American Society of Health-System Pharmacists (ASHP)

• Suggest preemptively treating pain with analgesics and/or non-pharmacologic treatment

• Use opioids as first-line therapy for treatment of non-neuropathic pain

• Use non-opioid analgesics in conjunction with opioids to decrease opioid requirements and side effects

Improper Sedation

• Continuous sedation carries the risks associated with oversedation and may increase the duration of mechanical ventilation (MV)1

• MV patients accrue significantly more cost during their ICU stay than non-MV patients2

– $31,574 versus $12,931, P < 0.001

• Sedation should be titrated to achieve a cooperative patient and daily wake-up, a JC requirement1,2

1. Kress JP, et al. N Engl J Med. 2000;342:1471-1477.2. Dasta JF, et al. Crit Care Med. 2005;33:1266-1271.3. Kaplan LJ, Bailey H. Crit Care. 2000;4(suppl 1):P190.

Undersedated3

Oversedated

On Target

15.4%

54.0%

30.6%

Pain, Agitation, and Delirium Are Interrelated

Barr J, et al. Crit Care Med. 2013;41:263-306.

AgitationPai

n

Delirium

ICU Delirium

Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.

• Develops in ~2/3 of critically ill patients • Hypoactive or mixed forms most common• Increased risk

– Benzodiazepines– Extended ventilation– Immobility

• Associated with weakness• Undiagnosed in up to 72% of cases

After Hospital Discharge

During the ICU/Hospital Stay

Sequelae of Delirium

• Increased mortality• Longer intubation time• Average 10 additional days in hospital• Higher costs of care

• Increased mortality• Development of dementia • Long-term cognitive impairment• Requirement for care in chronic care facility• Decreased functional status at 6 months

Bruno JJ, Warren ML. Crit Care Nurs Clin North Am. 2010;22(2):161-178.Shehabi Y, et al. Crit Care Med. 2010;38(12):2311-2318.Rockwood K, et al. Age Ageing. 1999;28(6):551-556.Jackson JC, et al. Neuropsychol Rev. 2004;14:87-98.Nelson JE, et al. Arch Intern Med. 2006;166:1993-1999.

Worse Long-term Cognitive Performance

• Duration of delirium was an independent predictor of cognitive impairment – An increase from 1 day of delirium to 5 days was

associated with nearly a 5-point decline in cognitive battery scores

• Patient testimony“One quite literally loses one’s grip on what is true and what is false because the true and the false are mixed together in a mess of experience.”

Girard TD, et al. Crit Care Med. 2010;38:1513-1520.Misak CJ. Am J Respir Crit Care Med. 2004;170(4):357-359.

Consequences of Delirium After Cardiac Operations

• Delirium after cardiac procedures is associated with – Increased mortality (13.5% vs 2.0% in patients without)

– More hospital readmissions (45.7% vs 26.5%)

– Reduced quality of life

– Reduced cognitive functioning, including failures in attention, memory, perception, and motor function, and with functional dysfunction such as independency in activities of daily living and mobility

• Suggests we need new treatment strategies

Koster S, et al. Ann Thorac Sur. 2012;93:705-711.

• To determine the efficacy and safety of a protocol linking:

spontaneous awakening trials (SATs) &

spontaneous breathing trials (SBTs)– Ventilator-free days– Duration of mechanical ventilation– ICU and hospital length of stay– Duration of coma and delirium– Long-term neuropsychological outcomes

ABC Trial: Objectives

Girard TD, et al. Lancet. 2008;371:126-134.

A Clinical Approach to Improve Outcomes in Critically Ill Patients

• More than half of patients on MV in the United States receive continuous sedation– Risks (delirium, prolonged MV, ↑ stay ICU/hospital)– Benzodiazepines and propofol

• DIS (daily interruption of sedation) • Evidence suggests DIS used with assessment tools can

lead to improved outcomes• Despite recommendations less than 33% of Medical

ICUs in the US use a sedation protocol

Berry E, Zecca H. Crit Care Nurse. 2012;32(1):43-51.

Despite Proven Benefits, Spontaneous Awakening/Daily Interruption Trials

Are Not Standard of Practice at Most Institutions

• Canada – 40% get SATs (273 physicians in 2005)1

• US – 40% get SATs (2004-05)2

• Germany – 34% get SATs (214 ICUs in 2006)3

• France – 40–50% deeply sedated with 90% on continuous infusion of sedative/opiate4

1. Mehta S, et al. Crit Care Med. 2006;34:374-380.2. Devlin J. Crit Care Med. 2006;34:556-557.3. Martin J, et al. Crit Care. 2007;11:R124.4. Payen JF, et al. Anesthesiology. 2007;106:687-695.

Correlating Pain Assessment WithAnalgesic Administration in the ICU

• Fewer patients assessed for pain, more treated with analgesics in ICUs without analgesia protocols compared with ICUs with protocols1

• Pain scoring used in 21% of surveyed ICUs in 20062

1. Payen JF, et al. Anesthesiol. 2007;106:687-695.2. Martin J, et al. Crit Care. 2007;11:R124.

Pat

ien

ts (

%)

Protocol No Protocol

Assessed Treated

*P < 0.01 vs ICUs using a protocol

0102030405060708090

100

60

25

8792*

*

Common Agents for Conscious Sedation

Mustoe TA, et al. Plast Reconstr Surg. 2010;126(4):165e-176e.

Agent Classification Dose Guidelines

Side Effects

Midazolam BZD 0.5-1 mg every 5-10 min

Respiratory depression, somnolence

Ketamine Dissociative Anesthetic

200-750 mcg/kg bolus, 5-20 mcg/kg/min

Hallucinations, delirium, intracranial HTN,

↑ secretions

Fentanyl Opioid agonist 25-50 mcg Respiratory depression, Nausea/vomiting

Sedation-Agitation Scale (SAS)

Riker RR, et al. Crit Care Med. 1999;27:1325-1329.Brandl K, et al. Pharmacotherapy. 2001;21:431-436.

Score State Behaviors

7 Dangerous Agitation

Pulling at ET tube, climbing over bedrail, striking at staff, thrashing side-to-side

6 Very AgitatedDoes not calm despite frequent verbal reminding, requires physical restraints

5 AgitatedAnxious or mildly agitated, attempting to sit up, calms down to verbal instructions

4 Calm and Cooperative

Calm, awakens easily, follows commands

3 SedatedDifficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off

2 Very SedatedArouses to physical stimuli but does not communicate or follow commands

1 UnarousableMinimal or no response to noxious stimuli, does not communicate or follow commands

PAD Choice of SedativeRecommendations

• We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B)

• We suggest that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B)

• We suggest that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients (+2B)

Barr J, et al. Crit Care Med. 2013;41:263-306.

Ramsay Sedation Scale

1 - Awake and anxious, agitated, or restless

2 - Awake, cooperative, accepting ventilation, oriented, tranquil

3 - Awake; responds only to commands

4 - Asleep; brisk response to light glabellar tap or loud noise

5 - Asleep; sluggish response to light glabellar tap or loud noise stimulus but does not respond to painful stimulus

6 - Asleep; no response to light glabellar tap or loud noise

Ramsay MA, et al. Br Med J. 1974;2(5920):656-659.

GABA AgonistBenzodiazepine (Midazolam)

• May accumulate with hepatic and/or renal failure

• Anterograde amnesia• Long recovery time• Synergy with opioids • Respiratory depression• Delirium

• Sedation, anxiolysis, and amnesia

• Rapid onset of action (IV)

Adverse EffectsClinical Effects

Olkkola KT, Ahonen J. Handb Exp Pharmacol. 2008;(182):335-360.Riker RR, et al; SEDCOM Study Group. JAMA. 2009;301(5):489-499.

Propofol

• Sedation• Hypnosis• Anxiolysis• Muscle relaxation• Mild bronchodilation• Decreased ICP• Decreased cerebral metabolic rate• Antiemetic

Ellett ML. Gastroenterol Nurs. 2010;33(4):284-925.Lundström S, et al. J Pain Symptom Manage. 2010;40(3):466-470.

Clinical Effects Adverse Effects

• Pain on injection• Respiratory depression• Hypotension• Decreased myocardial contractility• Increased serum triglycerides• Tolerance• Propofol infusion syndrome• Prolonged effect with high adiposity• Seizures (rare)

a2 Agonist Dexmedetomidine

•Hypotension•Hypertension•Nausea•Bradycardia •Dry mouth

• Peripheral vasoconstriction at high doses

•Antihypertensive•Sedation•Analgesia•Decreased shivering•Anxiolysis•Patient arousability•Potentiate effects of opioids,

sedatives, and anesthetics

•Decrease sympathetic activity

Adverse EffectsClinical Effects

Kamibayashi T, et al. Anesthesiol. 2000;93:1345-1349.Bhana N, et al. Drugs. 2000;59(2):263-268.

Benzodiazepines vs PropofolBetter Outcomes With Propofol

Study/Year Population Outcome Improved

Grounds et al 1987 Cardiac surgery Faster awakening

Aitkenhead et al 1989 General ICU More consistent awakening, faster weaning

McMurray et al 1990 Cardiac surgery Faster awakening

Carrasco et al 1993 General ICUMore accurate sedation, faster awakening,

lower costs

Roekaerts et al 1993 Cardiac surgery Faster awakening, earlier extubation

Ronan et al 1995 Surgical ICU Faster awakening

Sherry et al 1996 Cardiac surgery Lower costs

Chamorro et al 1996 General ICUBetter ventilator synchrony, faster

awakening

Barrientos-Vega et al 1997 General ICU Earlier extubation

Weinbroum et al 1997 General ICU Faster awakening

Sanchez-Izquierdo-Riera et al 1998 Trauma ICU Faster awakening

McCollam et al 1999 Trauma ICU Less oversedation

Hall et al 2001 Mixed ICU More accurate sedation, earlier extubation

Carson et al 2006 Medical ICU Fewer ventilator days

Ely EW, et al. Chest. 2012;142(2);287-289.

Benzodiazepines vs Propofol

Study/Year Population Outcome Improved Trials finding no differences in outcomes    

  Searle et al, 1997 Cardiac surgery None

  Kress et al, 2000 Medical ICU None

  Huey-Ling et al, 2008 Cardiac surgery None

Trials finding better outcomes with benzodiazepine: None

   

Ely EW, et al. Chest. 2012;142(2);287-289.

Benzodiazepines vs Dexmedetomidine

Study/Year Population Outcome Improved  Trials finding better outcomes with dex    

  Pandharipande et al, 2007 Mixed ICU More accurate sedation, more delirium/coma-free days

  Riker et al, 2009 Mixed ICU Lower prevalence of delirium, earlier extubation

  Ruokonen et al, 2009 Mixed ICU Shorter duration of mechanical ventilation

  Maldonado et al, 2009 Cardiac surgery Lower incidence and duration of delirium

  Esmaoglu et al, 2009 Eclampsia Shorter ICU length of stay

  Dasta et al, 2010 Mixed ICU Lower ICU costs

  Jakob et al, 2012 General ICU Lighter sedation, fewer ventilation days

 Trials finding no differences in outcomes: None    

 Trials finding better outcomes with the BZD: None    

Ely EW, et al. Chest. 2012;142(2);287-289.

MENDS: Dexmedetomidine vs Lorazepam

Pandharipande PP, et al. JAMA. 2007;298(22):2644-2653.

• Double-blind RCT of dex (0.15–1.5 mcg/kg/hr) vs lorazepam (1–10 mg/hr)

• Titrated to sedation goal (using RASS) established by ICU team

• Dexmedetomidine resulted in more time spent within sedation goals than lorazepam (P = 0.04). Differences in 28-day mortality and delirium-free days were not significant

• While incidence of HR ≤ 60 was greater with Dex (17 vs 4%, P = 0.03, the incidence of HR ≤ 40 was not different (2 vs 2%)

• Double-blind, randomized, multicenter trial comparing long-term (> 24 hr) dexmedetomidine (n = 244) with midazolam (n = 122)

• Sedatives (DEX 0.2-1.4 μg/kg/hr or MDZ 0.02-0.1 mg/kg/hr) titrated for light sedation (RASS -2 to +1), administered up to 30 days

• All patients underwent daily arousal assessments and drug titration Q 4 hours

Riker RR, et al. JAMA. 2009;301(5):489-499.

OutcomeMidazolam(N = 122)

DEX(N = 244)

P-Value

Time in target sedation range, % 75.1 77.3 0.18

Duration of sedation, days 4.1 3.5 0.01

Time to extubation, days 5.6 3.7 0.01

Patients receiving open-label, % midazolam

49 63 0.02

Bradycardia, % 18.9 42.2 0.001

Bradycardia requiring intervention, % 0.8 4.9 0.07

SEDCOM: Dexmedetomidine vs Midazolam

?

a2A

a2C

a2A

a2A

Anxiolysis

? a2B

a2B

X

a2B

X

Adapted from Kamibayashi T, Maze M. Anesthesiology. 2000;93:1346-1349.

Physiology of a2 Adrenoceptors

a2A

Applications for a2 Agonist

• Surgical– Bariatric surgery– CV surgery– Neurosurgery

• Endoscopic– Bronchoscopy– Fiberoptic intubation– Colonoscopy

35

• Randomized, prospective, double-blind, placebo-controlled, multicenter

• 326 pts undergoing MAC for surgery (orthopedic, ophthalmic, vascular, excision of lesions, others < 10%)

• All patients sedated – Observer’s Assessment of Alertness/Sedation Scale (OAA/S ) to < 4

• Sedation with – Dexmedetomidine ± rescue midazolam– Placebo + rescue midazolam

• Fentanyl PRN for pain

MAC with Dexmedetomidine

Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.

MAC = Monitored anesthesia care

Placebo Dex 0.5 Dex 1.00

25

50

75

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45.7

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144.4

84.8 83.6

0

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100

150

200

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Fe

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Dexmedetomidine Reduces Fentanyl and Midazolam Use During MAC

*P < 0.001 compared with placebo, MAC = monitored anesthesia care

**

Placebo Dex 0.5 Dex 1.00

25

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Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.

Drugs for Fiberoptic Intubation

Agent Class

Example Advantages Considerations

GABA agonist

Benzodiazepine Midazolam

•Quick onset• Injection not painful•Short duration

• Not analgesic• Airway reflexes persist

GABA agonist

Benzodiazepine Propofol

•Quick onset • Respiratory depression• Unconsciousness• Decreased blood

pressure & CO• Increased HR

Opioid FentanylRemifentanil

•Analgesic•Cough suppressive

• Respiratory depression

a2 Agonist Dexmedetomidine •Pt easily arousable•Anxiolytic •Analgesic•No resp depression

• Transient hypertension• Hypotension • Bradycardia

Summary courtesy of Pratik Pandharipande, MD.

Dexmedetomidine Increases Comfort in AFOI • Double-blinded randomized trial• Midazolam +/- dexmedetomidine• Awake fiberoptic intubation (AFOI)• Patient comfort rated by 2 observers

Bergese SD, et al. J Clin Anesth. 2010;22(1):35-40.

Tota

l C

om

fort

Sco

re (

max

= 3

5)

Pre-oxygenation

Introduction of scope

Introduction of ET tube

n = 24n = 31

Sedation for AFOIConclusions

• Compared to placebo, dexmedetomidine reduces the amount of BZD in patients with high risk airway compromise in AFOI

• Dexmedetomidine in combination with low doses of midazolam is more effective than midazolam alone for sedation in AFOI

Fentanyl vs Dexmedetomidine in Bariatric Surgery

• 20 morbidly obese patients• Roux-en-Y gastric bypass surgery• All received midazolam, desflurane to maintain BIS at

45–50, and intraoperative analgesics– Fentanyl (n = 10) 0.5 µg/kg bolus, 0.5 µg/kg/h (group 1)– Dexmedetomidine (n = 10) 0.5 µg/kg bolus, 0.4 µg/kg/h (group 2)

• Dexmedetomidine associated with – Lower desflurane requirement for BIS maintenance– Decreased surgical BP and HR – Lower postoperative pain and morphine use (up to 2 h)

Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.

Dexmedetomidine in Bariatric Surgery

• 80 morbidly obese patients• Gastric banding or gastric bypass surgery• Prospective dose ranging study• Medication

– Celecoxib 400 mg po

– Midazolam 20 µg/kg IV– Propofol 1.25 mg/kg IV– Desflurane 4% inspired– Dexmedetomidine 0, 0.2, 0.4, 0.8 µg/kg/h IV

Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.

Dexmedetomidine in Bariatric Surgery: Results

• More dex 0.8 patients required rescue phenylephrine for hypotension than control pts (50% vs 20%, P < 0.05)

• All dex groups – Required less desflurane (19–22%)– Had lower MAP for 45’ post-op– Required less fentanyl after awakening (36–42%)– Had less emetic symptoms post-op

• No clinical difference – Emergence from anesthesia– Post-op self-administered morphine and pain scores – Length of stay in post-anesthesia care unit– Length of stay in hospital

Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.

Neurological Surgery Desirable Properties for Sedatives

• Preservation of intracranial hemodynamics• Hemodynamic stability• Noninterference with neurophysiologic monitoring• Cooperative sedation (for functional

neurosurgery)• Controllability (rapid onset and offset of effect)• Neuroprotection• Decreased awareness (by the patient)• Decrease oxygen consumption

Characteristics of Cooperative Sedation for Neurosurgery

• Patients easily transition from sleep to wakefulness and task performance when aroused

• Patients can resume rest when not stimulated• Most useful during procedures in which

communication with the patient must be maintained, facilitates patient participation in therapeutic maneuvers

• Reduces risk of drug-induced complications

Bekker A, et al. Neurosurgery. 2005;57(1 Suppl):1-10.

Current Sedatives for Awake Craniotomy

Bonhomme V, et al. Eur J Anaesthesiol. 2009;26(11):906-912.

Sedation During Awake CraniotomyIs Dex Compatible With Neurocognitive Testing?

Bekker 2001 Bustillo 2002 Lotto 2003 Ard 2003 Ard 2005

Patient Number 1 5 11 2 17

Indication Neoplasm AVMTumor, epilepsy,

aneurysmPediatric epilepsy Tumor, epilepsy

Dex Load, μg/kg 1 0 or 1 1 0.5

Dex Infusion, μg/kg.h 0.4, 0.2, 0.1 0.2–0.7 0.6 0.5, 0.2, 0.1 0.1–0.4

Mean MDZ, mg 2.8 1 1.7 (in 6 pts)

Mean Fentanyl, μg 100 160 100 191 (in 16 pts)

Other Anesthesia Prop, N2O, Sevo (flumazenil) Prop Prop, N2O, sevo Prop, N2O, sevo

Cognitive Test Language Wada Language Language Language

Test successful? 1/1 0/5 10/11 2/2 17/17

Bekker AY, et al. Anesth Analg. 2001;92(5):1251-1253.Bustillo MA, et al. J Neurosurg Anesthesiol. 2002;14(3):209-212.Lotto M, et al. Anesthesiology. 2003; 99: A356.Ard J, et al. J Neurosurg Anesthesiol. 2003;15(3):263-266.Ard JL, et al. Surg Neurol. 2005;63(2):114-116.

AVM = arteriovenous malformationProp = propofolSevo = sevoflurane

Implanting Deep Brain Stimulator for Parkinson’s Disease

• Sedation is demanding– Recordings of movement-related neurons– Preservation of Parkinson’s symptoms for DBS localization– Patient cooperation– Halo restricts movement, respiratory depression problematic

• GABAergic sedatives (MDZ, propofol) not useful– Ameliorate tremor and rigidity (precludes mapping & testing)– Impair consciousness– May cause respiratory depression

Rozet I, et al. Anesth Analg. 2006;103(5):1224-1228.

Implanting Deep Brain Stimulator for Parkinson’s Disease

• Retrospective study with dexmedetomidine– Control (no sedative) n = 8 patients

– Dex (0.1-0.3 mcg/kg.h, more to goal [OAA/S = 4]) n = 11 patients

• Results– Microelectrode recordings unimpaired by dex

– Surgical time shorter with dex (4 vs 6 h, P = 0.05)

– Less intraoperative use of antihypertensives (100% vs 54%, P = 0.048)

– Dex preserved clinical signs of Parkinson’s disease Tremor

Rigidity

Bradykinesia

• Study limitations– Small

– Observational

– Only perioperative outcomes presented

Rozet I, et al. Anesth Analg. 2006;103(5):1224-1228.

Implanting Deep Brain Stimulator for Parkinson’s Disease

• Retrospective analysis of 258 procedures (250 patients)• Patients with motor disorders, 68% PD• Propofol most common sedative, 91%• Propofol used almost exclusively in the first 30 to 45 minutes to

facilitate head-frame placement

Khatib R, et al. J Neurosurg Anesthesiol. 2008;20:36-40.

Neurosurgery Summary

• Neurosurgery presents special challenges for sedation– Preserve cerebral hemodynamic stability– Maintain patient consciousness for some procedures

• Oversedation presents risks– Delirium

– Increased ICU LOS

– Lack of patient interaction during procedure

• Emerging combinations of anesthetic and sedative compounds have attractive properties for addressing these unique requirements

Case Presentation

• 64-year-old female with pulsatile mass left shoulder

• 67-year-old severe pump failure with poor prognosis

• 71-year-old BZD and opioid dependent female for MVR

Penney R. AANA J. 2010;78(6):446-450.

Questions?

Thank You!