Drugs and weaning: a brief overview of pain, sedation, and ... › presentations › 2016 ›...
Transcript of Drugs and weaning: a brief overview of pain, sedation, and ... › presentations › 2016 ›...
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Drugs and weaning: a brief
overview of pain, sedation,
and agitation management
Lisa Burry, PharmD
Mount Sinai Hospital
University of Toronto
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Disclaimer
No financial disclosures
This is my interpretation of the literature
Personal mission: to stop polypharmacy
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Weaning
Definition: liberation from mechanical
ventilatory support
Process should start with intubation
◦ Readiness for weaning should be monitored daily,
with consideration of both clinical trends and
stability
Boles JM Eur Respir J 2007 29:1033-1056
Estaban A NEJM 1995;332:345-350
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Weaning criteria
Resolution of underlying cause of acute
respiratory failure
Haemodynamic stability, defined as no need for
vasoactive/inotropic drugs
Absence of fever (preferable)
Adequate gas exchange
◦ (Pa02:Fi02 > 200 with a PEEP=5)
Adequate neurological status or cooperative
sedationDrive,
Endurance,
Energy consumption,
Psychological wellbeing
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G – Get some sleep
H – Home meds & withdrawalwww.iculiberation.org
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SAT
SAT
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Dale CR Ann Am Thor Soc 2014;11:367-74
PAD Protocol + SATs + SBTs
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How can we minimize sedation?
Sedation protocols
Daily sedation interruption
No sedation
Choice of drug or the method of administration (infusion vs. bolus)
Combination(s) of the above
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Strategies endorsed by SCCM PAD
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Any route: OR 1.04 (per 5 mg midazolam, 1.02-1.05)
Infusions: OR 1.04 (1.03-1.06) vs. bolus 0.97 (0.88-1.05)
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In all 4 trials patients who received dexmedetomidine were
significantly more arousable, more co-operative and better able to
communicate their pain than those who received propofol or
midazolam (p ≤ 0.001 in all cases)
Ventilator Free Days – mean diff 3.28 days
Time to extubation - Mean diff 1.85 days favouring dexmedetomidine
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Eligibility
Adults who continue to require MV only because their degree of agitation is so severe sedation could not be lessened
Required to meet all 3 criteria during the 4 h prior to randomization:
(1) need for mechanical restraint, antipsychotic or sedative medication, or both
(2) CAM-ICU + for delirium
(3) MAAS score ≥ 5, confirming psychomotor agitation
Primary OutcomeMedian difference 19.5 hours (95% CI 5.3 to 31.1 h, P<0.001)
LimitationsN = 72Stopped earlyBaseline imbalancesNo weaning/extubation protocol
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What about Sleep? Now patients
are awake...
Higher night time doses
independently associated with
failure to…
1. Meet SBT screen
2. Pass SBT
3. Be extubated
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What about sleep? Now patients
are awake...
Promote sleep: control light, noise, cluster patient-care
activities, reduce nocturnal stimuli
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H: Home medication and withdrawal
Consider withdrawal
from home
medications (e.g.
SSRI), nicotine &
alcohol.
Consider withdrawal
of sedatives &
opioids used during
the ICU stay
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Summary
• It is very important to consider pain, sedation,
& agitation in the weaning process.
• Use ABCDEFGH to support the weaning
process
• Consider the pharmcokinetics-dynamics of
the drugs you select
– Consider this at minimum daily as requirements
will vary