Sedation , Analgesia & Paralysis in ICU

Dr.Venugopalan.P.PDA,DNB,MNAMS

Chief, Emergency Medicine –MIMS Site Director ,Masters program in EM

Executive director ,Angels international foundation

Objectives

Guidelines for sedation, analgesia, and chemical paralysisBenefits of daily awakening/lightening and sedation titration programsRational pharmacologic strategy based on treatment goals and co morbidities

What We Know About ICU Agitation/Discomfort?

Prevalence• 50% incidence in those with length of stay > 24 hours

Primary causes• Unrelieved pain• Delirium • Anxiety • Sleep deprivation.

ICU Agitation/Discomfort sequelae

Immediate• Patient-ventilator

dyssynchrony• Increased oxygen

consumption • Self (and health care

provider) injury• Family anxiety

Late• chronic anxiety

disorders • post-traumatic

stress disorder (PTSD)

Recall in the ICU

Some degree of recall occurs in up to 70% of ICU patients.• Anxiety, fear, pain, panic, agony, or nightmares reported in 90% of those who

did have recall.

Potentially cruel:• Up to 36% recalled some aspect of paralysis.

Associated with PTSD in ARDS? • 41% risk of recall of two or more traumatic experiences.

Associated with PTSD in cardiac surgery

Appropriate Recall May be Important

Factual memories help to put ICU experience into perspective

Delusional memories cause panic attacks and PTSD

The optimal level of sedation for most patients - Offers comfort while allowing for interaction with the environment.

Why sedation in ICU?

• Anxiety• Pain• Acute confusional status• Mechanical ventilation• Treatment or diagnostic procedures• Psychological response to stress

Sedation Goal

• Patient comfort • Control of pain• Anxiolysis and

amnesia• Blunting adverse

autonomic and hemodynamic responses

• Facilitate nursing management

• Facilitate mechanical ventilation

• Avoid self-extubation• Reduce oxygen

consumption

Ideal sedation agents

• No respiratory depression

• Analgesia• Rapid onset,

titratable, with a short elimination half-time

• Sedation with ease of orientation and arousability

• Anxiolytic• Hemodynamic

stability

The Challenges

• Assessment of sedation• Altered pharmacology• Tolerance• Delayed emergence• Withdrawal• Drug interaction

Sedation

SedativesCauses for Agitation

UndersedationSedatives

Causes for AgitationAgitation & anxietyPain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury

Oversedation

Sedatives

Causes for Agitation

Prolonged sedationDelayed emergenceRespiratory depressionHypotensionBradycardiaIncreased protein breakdownMuscle atrophyVenous stasisPressure injuryLoss of patient-staff interactionIncreased cost

Reversible Causes of Agitation

• Full bladder• Uncomfortable

bed position• Inadequate

ventilator flow rates

• Mental illness• Uremia

• Drug side effects• Disorientation• Sleep

deprivation• Noise• Inability to

communicate

Life threatening Causes

• Hypoxia• Hypercarbia• Hypoglycemia• Endotracheal tube

malposition

• Pneumothorax• Myocardial

ischemia• Abdominal pain• Drug and alcohol

withdrawal

Daily Goal is Arousable, Comfortable Sedation

Effect of this strategy on outcomes:• One- to seven-day reduction in

length of sedation and mechanical ventilation needs

• 50% reduction in tracheostomies• Three-fold reduction in the need

for diagnostic evaluation of CNS

Sedation needs to be protocolized and titrated to goal:

•Lighten sedation to appropriate wakefulness daily.

Protocols and Assessment Tools

Sedation

o Validated sedation assessment tools (Ramsay Sedation Scale [RSS],

o Sedation-Agitation Scale [SAS]

o Richmond Sedation-agitation Scale [RSAS]

No evidence that one is preferred over another

Pain

o Numeric rating scale [NRS]

o Visual analogue scale [VAS]

Pain assessment tools - none validated in ICU

Sedation/Analgesia ICU

Rule out reversible causes of discomfort/anxiety such as hypoxemia, hypercarbia, and toxic/drug side effect.

Assess co-morbidities and potential side effects of drugs chosen.

Target irreversible etiologies of pain and agitation.

Strategies for Patient Comfort

• Set treatment goal• Quantitate

sedation and pain• Choose the right

medication

• Use combined infusion

• Reevaluate need• Treat withdrawal

Yes

Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal

No

Set Goalfor

Analgesia

Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min

Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min

Repeat until pain controlled, then scheduled doses + prn

Set Goalfor

Sedation

Acute Agitation #

Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled

Ongoing Sedation #

Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal

Set Goalfor Controlof Delirium

Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper

IVP Dosesmore often than Q

2hr?

Consider continuousinfusion opiate or

sedative

> 3 Days Propofol?(except neuro pt.)

Convert toLorazepam

Yes

Benzodiazepine or Opioid:Taper Infusion Rate by

10-25% Per Day

Yes

Dosesapproximate for

70kg adult

Rule out and Correct Reversible Causes

Use Non-pharmacologic Treament,Optimize the Environment

ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS

Use Pain Scale * toAssess for Pain

Use Sedation Scale **

to Assess forAgitation/Anxiety

Use Delirium Scale *** toAssess for Delirium

Is the Patient Comfortable & at Goal?

Lorazepam viainfusion?

Use a low rate and IVPloading doses

1

2

3

4

Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

Pain

Assess Pain Separately

Visual Pain Scales

0 1 2 3 4 5 6 7 8 9 10

No pain Worst possible pain

Signs of Pain

• Hypertension• Tachycardia• Lacrimation• Sweating• Pupillary dilation

Pain Management

• Anticipate • Recognize • Quantify

RecognizePain

Ask

FindLo

ok

Treat Pain

oQuantify the pain perception oCorrect the correctable causes oUse appropriate analgesics

• Remember- most sedative agents do not provide analgesia

• Reassess

Non-pharmacologicalMethods

• Proper position of the patient• Stabilization of fractures• Elimination of irritating stimulation• Proper positioning of the ventilator

tubing to avoid traction on endotracheal tube

Yes

Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal

No

Set Goalfor

Analgesia

Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min

Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min

Repeat until pain controlled, then scheduled doses + prn

Set Goalfor

Sedation

Acute Agitation #

Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled

Ongoing Sedation #

Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal

Set Goalfor Controlof Delirium

Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper

IVP Dosesmore often than Q

2hr?

Consider continuousinfusion opiate or

sedative

> 3 Days Propofol?(except neuro pt.)

Convert toLorazepam

Yes

Benzodiazepine or Opioid:Taper Infusion Rate by

10-25% Per Day

Yes

Dosesapproximate for

70kg adult

Rule out and Correct Reversible Causes

Use Non-pharmacologic Treament,Optimize the Environment

ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS

Use Pain Scale * toAssess for Pain

Use Sedation Scale **

to Assess forAgitation/Anxiety

Use Delirium Scale *** toAssess for Delirium

Is the Patient Comfortable & at Goal?

Lorazepam viainfusion?

Use a low rate and IVPloading doses

1

2

3

4

Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

Address Pain

Set G oalfor

Analgesia

Hem odynam ically UnstableFentanyl 25 - 100 m cg IVP Q 5-15 m in, orHydromorphone 0.25 - 0.75 m g IVP Q 5 - 15 m in

Hem odynam ically stableMorphine 2 - 5 m g IVP Q 5 - 15 m in

Repeat until pain controlled, then scheduled doses + prn

Use Pain Scale * toAssess for Pain

Reassess goal daily,T itrate and taper therapy to m aintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & m onitorfor withdrawal

Is the Patient Com fortable & at Goal?

Opiates

Benefits• Relieve pain or the sensibility to

noxious stimuli• Sedation trending toward a

change in sensorium

Opiates - Risks

• Respiratory depression• NO amnesia• Pruritus• Ileus• Urinary retention

Opiates- Risks

• Histamine release - morphine

• Morphine metabolites which accumulate in renal failure .

• Meperidine should be avoided due to neurotoxic metabolites which accumulate in renal failure

Agent Dose (iv) Half-life Metabolic pathway Active metabolites

Fentanyl 200 g 1.5-6 hr Oxidation None

Hydromorphone 1.5 mg 2-3 hr Glucuronidation None

Morphine 10 mg 3-7 hr Glucuronidation Yes (Sedation in RF)

Meperidine 75-100 mg 3-4 hr Demethylation & hydroxylation

Yes (neuroexcitation in RF)

Codeine 120 mg 3 hr Demethylation & Glucuronidation

Yes ( analgesia, sedation)

Remifentanil 3-10 min Plasma esterase None

Keterolac 2.4-8.6 hr Renal None

Pharmacology of Selected Analgesics

Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone

Fentanyl Hydromorphone Morphine

Rapid onset X

Rapid offset X*

Avoid in renal disease X**

Preload reduction X

Avoid in hemodynamic instability

X

Equivalent doses 100 mcg 1.5 mg 10 mg

* Offset prolonged after long-term use

** Active metabolite accumulation causes excessive narcosis

Sam

ple

Anal

gesi

a Pr

otoc

olNumeric Rating Scale

ICU

SEDAT

ION

Sedation- Assessment

• Ramsay Sedation Scale (RSS)

• Sedation-agitation Scale (SAS)

• Observers Assessment of Alertness/Sedation Scale (OAASS)

• Motor Activity Assessment Scale (MAAS)

BMJ 1974;2:656-659Crit Care Med 1999;27:1325-1329J Clin Psychopharmacol 1990;10:244-251Crit Care Med 1999;27:1271-1275

Scale Description

1 Anxious and agitated or restless, or both

2 Cooperative, oriented, and tranquil

3 Response to commands only

4 Brisk response to light glabellar tap or loud auditory stimulus

5 Sluggish response to light glabellar tap or loud auditory stimulus

6 No response to light glabellar tap or loud auditory stimulus

The Ramsay Scale

Score Description Definition

7 Dangerous agitation

Pulling at endotracheal tube, trying to strike at staff, thrashing side to side

6 Very agitated Does not calm despite frequent verbal commands, biting ETT

5 Agitated Anxious or mildly agitated, attempting to sit

4 Calm and cooperative

Calm, awakens easily, follows commands

3 Sedated Difficult to arouse, awakens to verbal stimuli, follows simple commands

2 Very sedated Arouse to physical stimuli, but does not communicate spontaneously

1 Unarousable Minimal or no response to noxious stimuli

The Riker Sedation-Agitation Scale

The Motor Activity Assessment Scale

Score Description Definition

6 Dangerous agitation

Pulling at endotracheal tube, trying to strike at staff, thrashing side to side

5 Agitated Does not calm despite frequent verbal commands, biting ETT

4 Restless and cooperative

Anxious or mildly agitated, attempting to sit

3 Calm and cooperative

Calm, awakens easily, follows commands

2 Responsive to touch or name

Opens eyes or raises eyebrows or turns head when touched or name is loudly spoken

1 Responsive only to noxious stimuli

Opens eyes or raises eyebrows or turns head with noxious stimuli

0 Unresponsive Does not move with noxious stimuli

What sedation Scale do?

•Provide a semi quantitative “score”•Standardize treatment endpoints•Allow review of efficacy of sedation•Facilitate sedation studies•Help to avoid over sedation

But scales Do not ....

• Assess anxiety• Assess pain• Assess sedation in paralyzed patients• Predict outcome• Agree with each other

BIS Monitoring

Used to asses Sedation levels

BIS Range GuidelinesAwake

Responds to loud commands or mild prodding/shaking

Low probability to explicit recallsUnresponsive to verbal stimuli

Burst suppression

Flat line EEG

Responds to normal voice Axiolysis

Moderatesedation

Deep Sedation

100

80

60

40

20

0

BIS

Yes

Reassess goal daily,Titrate and taper therapy to maintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & monitorfor withdrawal

No

Set Goalfor

Analgesia

Hemodynamically UnstableFentanyl 25 - 100 mcg IVP Q 5-15 min, orHydromorphone 0.25 - 0.75 mg IVP Q 5 - 15 min

Hemodynamically stableMorphine 2 - 5 mg IVP Q 5 - 15 min

Repeat until pain controlled, then scheduled doses + prn

Set Goalfor

Sedation

Acute Agitation #

Midazolam 2 - 5 mg IVP Q 5 - 15 min untilacute event controlled

Ongoing Sedation #

Lorazepam 1 - 4 mg IVP Q 10-20 min untilat goal then Q 2 - 6 hr scheduled + prn , orPropofol start 5 mcg/kg/min, titrate Q 5 minuntil at goal

Set Goalfor Controlof Delirium

Haloperidol 2 - 10 mg IVP Q 20 - 30 min,then 25% of loading dose Q 6hr x 2-3 days,then taper

IVP Dosesmore often than Q

2hr?

Consider continuousinfusion opiate or

sedative

> 3 Days Propofol?(except neuro pt.)

Convert toLorazepam

Yes

Benzodiazepine or Opioid:Taper Infusion Rate by

10-25% Per Day

Yes

Dosesapproximate for

70kg adult

Rule out and Correct Reversible Causes

Use Non-pharmacologic Treament,Optimize the Environment

ALGORITHM FOR SEDATION AND ANALGESIA OF MECHANICALLY VENTILATED PATIENTS

Use Pain Scale * toAssess for Pain

Use Sedation Scale **

to Assess forAgitation/Anxiety

Use Delirium Scale *** toAssess for Delirium

Is the Patient Comfortable & at Goal?

Lorazepam viainfusion?

Use a low rate and IVPloading doses

1

2

3

4

Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

Set G oalfor

Sedation

Acute Agitation #

Midazolam 2 - 5 m g IVP Q 5 - 15 m in untilacute event controlled

Ongoing Sedation #

Lorazepam 1 - 4 m g IVP Q 10-20 m in untilat goal then Q 2 - 6 hr scheduled + prn, orPropofol start 5 m cg/kg/m in, titrate Q 5 m inuntil at goal

IVP Dosesm ore often than Q

2hr?

Consider continuousinfusion opiate or

sedative

> 3 Days Propofol?(except neuro pt.)

Convert toLorazepam

Benzodiazepine or Opioid:Taper Infusion Rate by

10-25% Per Day

Use Sedation Scale **

to Assess forAgitation/Anxiety

Lorazepam viainfusion?

Use a low rate and IVPloading doses

Yes

Reassess goal daily,T itrate and taper therapy to m aintain goal,Consider daily wake-up,Taper if > 1 week high-dose therapy & m onitorfor withdrawal

Is the Patient Com fortable & at Goal?

Address Sedation

How to Sedate ?

• Benzodiazepines• Propofol• -2 agonists

Sedatives-

Options

Benzodiazepines (Midazolam & Lorazepam) Anxiolysis

Amnesia

Sedation

Pharmacokinetics/dynamics•Lorazepam: onset 5 - 10 minutes, half-life 10 hours, glucuronidated

•Midazolam: onset 1 - 2 minutes, half-life 3 hours, metabolized by cytochrome P450, active metabolite (1-OH) accumulates in renal disease

Benefits

Option1

Benzodiazepines (Midazolam & Lorazepam)

• Delirium• NO analgesia• Excessive sedation: especially after long-

term sustained use• Propylene glycol toxicity (parenteral

lorazepam) - Significance uncertain

- Evaluate when a patient has unexplained acidosis

- In alcoholics (due to doses used) and renal failure

• Respiratory failure (concurrent opiate use)

• Withdrawal

PROBLEMS

Propofol

Pharmacology: GABA agonistPharmacokinetics/dynamics: onset 1 - 2 minutes, terminal half-life 6 hours, duration 10 minutes, hepatic metabolism

Benefits

Rapid onset

&Offset

Hypnotic and

Antiemetic Reduce ICP

OPTION 2

Propofol • No amnesia- especially at low doses

• NO analgesia!• Hypotension• Hypertriglyceridemia;

lipid source (1.1 kcal/ml)• Respiratory depression• Propofol Infusion

Syndrome

PROBLEMS

• Cardiac failure, rhabdomyolysis, severe metabolic acidosis, and renal failure

• Caution : at a doses > 80 mcg/kg/min for more than 48 hours

• Problematic when used simultaneously in patient receiving catecholamines and/or steroids

POPOFOL

INFUSION

Syndrome

Propofol Dosing

• 3-5 g/kg/min antiemetic• 5-20 g/kg/min anxiolytic• 20-50 g/kg/min sedative hypnotic• >100 g/kg/min anesthetic

DexmedetomidineAlpha-2-

adrenergic agonist Decrease the

need for other sedation

Useful while decreasing other sedatives to prevent withdrawal

Rapid onset

No Respiratory depression

Sympatholytic action

Benefits

Option -3

Dexmedetomidine

No Amnesia

Excessive awareness

Bradycardia ,Hypotension

PROBLEMS

Alpha-2 Receptors

Brain(locus ceruleus)

Spinal Cord

Peripheral vasculature

SedationAnxiolysis

Sympatholysis

Analgesia

Vasoconstriction

DEX: Dosing

Loading infusion0.25-1 g/kg(10-20 min)

Maintenance infusion0.2-0.7 g/kg/hr

Sedation-agitation Scale

Riker RR et al. Crit Care Med. 1999;27:1325.

Sample Sedation Protocol

Use Continuous and Combined Infusion

Plasma Level

Load

Maintenance

Repeated Bolus

Plasma levels

Choose the Right Drug

Sedation Analgesia

Amnesia AnxiolysisHypnosis

Propofol

Patient ComfortBenzodiazepines

-2 agonists

Opioids

ICUChemical Paralysis

Neuromuscular Blockade (NMB) Caution

• NO ANALGESIC or SEDATIVE properties

• Add sedation with amnestic effect .

• Analgesic as needed• Never use without the ability

to establish and/or maintain a definitive airway with ventilation

• If administering for prolonged period (> 6 - 12 hours), use an objective monitor to assess degree of paralysis.

Used most often acutely (single dose) to facilitate intubation or selected procedures

NMBLimited use because of risk of prolonged weakness and other complications

Maximize sedative/analgesic infusions as much as possible prior to adding neuromuscular blockade

Current concepts

NMB • Facilitate mechanical ventilation [abdominal compartment syndrome, high airway pressures, and dyssynchrony]

• High Frequency Ventilation, Prone ventilation

• Elevated intracranial pressures

• Reduce oxygen consumption• Prevent muscle spasm

[neuroleptic malignant syndrome, tetanus, etc.]

• Protect surgical wounds or medical device placement

When to Use it?

NMB agents

• Depolarizers• Non depolarizersTwo classes

NMB agents • Succhinylcholine is the only drug in this class

• Depolarization (fasciculations) and desensitization of the motor endplate

• Motor Paralysis

Depolarizers Prolonged binding to acetylcholine receptor

NMB Agents • Benzylisoquinoliniums• Curare Atracurium,

Cisatracurium, Mivacurium, Doxacuronium

• Aminosteroids• Pancuronium,

Vecuronium, Rococuronium

Non depolarizersCompetitive inhibitors of postsynaptic receptors

NMB Agents for intubation

Rocuronium• Onset -45 seconds• Nondepolarizer with about an hour

duration and 10% renal elimination• Dose is 1.2 mg/kg

Succinylcholine• Onset 30 seconds• Duration of 10 minutes • All or none train of four after

administration due to desensitization• prolonged in patients with abnormal

plasma cholinesterase• Dose is 1 - 2 mg/kg

Need rapid onset paralysis

Not usually used for continuous maintenance infusions

Succinylcholine Severe K+ releases• Denervation injury• Stroke• Trauma• Burns of more than 24

hours

Problems•Potassium release- 0.5 to 1 meq/liter

•Bradycardia•Increases intra gastric, ocular and cranial pressures •Anaphylaxis •Muscle pain

NDMR • Pancuronium -

tachycardia• Vecuronium -

renally excreted active metabolites

• Elimination of cisatracurium is not affected by organ dysfunction

Infusion doses•Pancuronium 0.05 - 0.1 mg/kg/h•Vecuronium 0.05 - 0.1 mg/kg/h•Cisatracurium 0.03 - 0.6 mg/kg/h

Agents Are Very

Special

Monitoring NMBAs

Methods:

• NMBA dose reduction or cessation once daily if possible

• Clinical evaluation: Assess skeletal muscle movement and respiratory effort

• Peripheral nerve stimulation

To prevent prolonged weakness associated with excessive NMBA administration

Monitoring NMBAs • Train of four response consists of four stimulae of 2 Hz, 0.2 msec in duration, and 500 msec apart.

• Comparison of T4 (4th twitch) and T1 with a fade in strength means that 75% of receptors are blocked.

• Only T1 or T1 and 2 is used for goal in ICU and indicates up to 90% of receptors are blocked.

Peripheral nerve stimulation

Complications of NMB Agents

Associated with inactivity:• Muscle wasting, deconditioning, decubitus

ulcers, corneal drying

Associated with inability to assess patient:• Recall, unrelieved pain, acute neurologic

event, anxiety

Complications of NMB Agents

Associated with loss of respiratory function:• Asphyxiation from ventilator malfunction or accidental

extubation, atelectasis, pneumonia

Other:• Prolonged paralysis or acute NMBA related myopathy

- Related to decreased membrane excitability or even muscle necrosis

- Risk can be compounded by concurrent use of steroids.

Monitoring Sedation During Paralysis

• Bispectral index• Titrating to appropriate sedation to the least

amount required, not proven to achieve the goal.

• Potential for baseline neurologic deficit and EEG interference in ICU patients

Monitoring Sedation During Paralysis…

No randomized controlled studies to support reliable use in ICU.

Other neuromonitoring (awareness) modalities are likely to be developed.

Cessation of NMB as soon as safe in conjunction with other patient parameters should be a daily consideration.

Sample NMBA Protocol

ICU Delirium

ICU Delirium

Seen in > 50% of ICU patients

Three times higher risk of death by six months

Four times greater frequency of medical device removal

Nine times higher incidence of cognitive impairment at hospital discharge

Delirium

1.Acute onset of mental status changes or a fluctuating course

&2. Inattention

&

or

Courtesy of W Ely, MD

3. Disorganized Thinking

4. Altered level of consciousness

Risk Factors for Delirium

Primary CNS Dx

Infection

Metabolic derangement

Pain

Sleep deprivation

Age

Substances including tobacco (withdrawal as well as direct effect)

Diagnostic Tools: ICURoutine monitoring recommended

• Confusion Assessment Method (CAM-ICU) or Delirium Screening Checklist (DSC)

Requires Patient Participation• Cognitive Test for Delirium• Abbreviated Cognitive Test for Delirium• CAM-ICU

Ely. JAMA. 2001;286: 2703-2710.

Delirium Screening Checklist

No Patient Participation• Delirium Screening Checklist

Bergeron. Intensive Care Med. 2001;27:859.

Treatment of Delirium

Correct inciting factor

Control symptoms?• No evidence that treatment reduces duration and severity

of symptoms• Typical and atypical antipsychotic agents• Sedatives?

- Particularly in combination with antipsychotic and for drug/alcohol withdrawal delirium

No treatment FDA approved

HaloperidolThe good:

• Hemodynamic neutrality• No effect on respiratory drive

The bad:• QTc prolongation and torsades de pointes• Neuoroleptic malignant syndrome • Extrapyramidal side effects

Atypical Antipsychotics: Mechanism of action

unknownLess movement disorders than haloperidolEnhanced effects on both positive (agitation) and negative (quiet) symptoms

Quetiapine OlanzapineRisperidoneZiprasidone

Efficacy = haloperidol?

• Lack of available IV formulation

• Troublesome reports of CVAs, hyperglycemia, NMS

• Titratability hampered

QTc prolongation with ziprasidone IM

- Hypotension with olanzapine IM

Atypical Antipsychotics:

Issue

s

Summary

• Patient discomfort in ICU should be addressed appropriately and seriously

• Protocol based practice will bring up excellent results.

• Assess and Manage Sedation and Analgesia • Paralysis should be restricted to indicated

cases• Address delirium and withdrawals

Thank you for your patient listening

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