Best Review Article (Am J Resp Crit Care 2012;185:486)
Most ED patients receive inadequate sedation and pain control (Am J Emerg Med 2008;26:469)
New article shows no sedation (but of course analgesia) got pts off the vent quicker. (Lancet 2010;375:475)
The agents
benzodiazepenes are the most potent amnestics
Sedation is amnesia, hypnosis, and anxiolysis
Opioids can provide analgesia and some anxiolysis and hypnosis but not amnesia
Valium:Ativan:Versed 5:0.5:2
pH<4, imidazole ring of midaloam is open making it water soluble
at >4 it closes and the drug becomes lipid soluble
propofol’s offset is by lipid solubility not metabolism
dexmed dries the mouth
Another Protocol (J Trauma 2008;65:517)
J Trauma puts forth a not so bad sedation protocol (J Trauma 2007;63:945)
Awakening and Breathing Controlled trial (Lancet 2008;371:126) Interrupt sedation and then let the patient wake up and spont. breath; duh??? 
Ketamine
SCCM Critical Connections Article in Feb/Mar 2012 recommends ketamine infusion dose of
0.05-0.4 mg/kg/hr adjusted every 5-20 minutes
dilute to 1-2 mg/ml by adding 500 mg to 500 or 250 of NS or D5W
Back to topDexmedetomidine
3 patients with non-dt withdrawl syndromes (J of Inten Care Med 2005;20(2):118
Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients The MENDS Randomized Controlled Trial (JAMA. 2007;298(22):2644-2653. )
Large trial of dex vs. midaz, notable for doses up to 1.4 mcg/kg/hr and duration up to 30 days (JAMA 2009;301(5):489)
New trial on the long-term use of infusion doses of up to 2.5 mcg/kg/hr show no additional side effects (crit care 2011;15:R257)
- I haven’t needed to use a bolus, just started the drip at 0.5 to 0.7 mcg/kg/hr. – Once patient extubated wean it over couple of hours or faster. - Expensive so we use it judiciously. - Used to try the usuals (fentanyl, propofol, haldol, benzos, etc)before trying precedex but now moving quicker to it. - I believe FDA approved for 48 hrs but have heard multiple anecdotes by anesthesia colleagues using it for periods of up to 2 weeks. Have never had to use it for more than 24hrs. - Not had ever any problems with bradycardia or hypotension, but never used a bolus.
Back in the early 90s, there was a big push to use a lot of lorazepam in the ICU because it was off patent and cheap and the others were on patent and expensive. Many of the papers extoling the virtues of lorazepam in Critical Care Medicine were thinly veiled advertisements. “Gee….we used a lot of it in the ICU and it worked just swell…..lets use more!!”. then look down at the bottom of the page and see “This advertisement brought to you by a grant from Wyeth, makers of lorazepam”. Delirium occurs when pattern recognition is lost in the ICU. Elderly people start running on pattern recognition at some point in their lives. They simply get used to their shrinking environment. Like a blind dog in your house. You never know the dog is blind. He knows the house and never bumps into anything. Then they land in an ICU and all that pattern recognition evaporates. And they might as well be on mars. Mild or incipient dementia takes over and they become confused and confounded and try to escape, following which they are quickly restrained and the race is on. Giving lorazepam simply decreases their ability to discern the thin grasp of reality, paradoxically increasing the delirium. Use a sedative you can titrate to effect. Propofol or midazolam.JAMA study higher incidence of delerium when benzos and inadequate pain regiemn compared to dexmed (JAMA 2009;301(5):489)industry supported study states dex may be cheaper than midaz (Critical Care Medicine Issue: Volume 38(2), February 2010, pp 497-503)
Ramsay Sedation Scale Awake 1 Anxious, agitated, restless 2 Cooperative, orientated, tranquil 3 Responds to commands only Asleep 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
Crit Care Med 2006;34(6):1668 Permissive hypercapnia patients required more propofol but same amount of midazolam
List of sedation and pain meds
Have I got the cure for you Lou: Start Risperdal 1mg bid, and valproate 500 bid. Can double both if you need. Should begin to work pretty quickly. We have had dramatic success with these drugs. Made a big difference in my life (taking care of pts). Leo PS. We do not use morphine by infusion b/o rapid development of tolerance. Substitute fentanyl instead. I’ve posted the reference mult times.
Dose of Risperdal ranges from 0.25 mg daily for a frail 80 yo, to 2 mg bid for a healthy robust young guy. I gave 1 mg bid to my 50 yo polysubstance abuser. Dose of valproate that I use is either 500 or 750 bid. Most pts actually only get the Risperdal. Only the really agitated and more robust pts get the Valproate. Typical pt who gets both is your alcohol withdrawal pt. If put virtually all my pts with DTs on both of these drugs, and encourage the hospitalists to do that too, as soon as the pts are admitted. I believe it’s saved quite a number from needing transfers to the ICU, but I don’t have rigorous data. I know for sure that pts in DTs are now a relative rarity for us in the unit, whereas a few years ago they were much more common. Leo ________________________________ From: prasannasimha [mailto:prasannasimha@gmail.com] Sent: Friday, August 25, 2006 5:54 AM To: Leo I. Stemp, MD Cc: ‘International Critical Care Internet Group’ Subject: Re: ccml sedation management in SICU Trauma Patient Can you give me the doses of Risperidone an Sodium Valproate. Prasanna Leo I. Stemp, MD wrote: NMB?! Crazy. And by the way, like you said, avoid the NMBs with steroid nucleus. Doesn’t that mean avoiding the ‘-curonium’ drugs (panc, vec, roc)? We use only cis-atracurium here. We see these pts routinely, have had huge reduction in problems since we started using the new antipsychotics combined with valproate. At the suggestion of a member of this List, I might add. One of the most impt new developments in my practice in years. Just had a success with it this week. Pt about 6 days post-esophagectomy, agitated, not handling secretions. Intubated him for airway protection, got him on Risperdal and valproate, extubated two days later fully awake and oriented, looking great. In the old days, reintubating such a pt would have been a calamity. No problem here. Had another recent dramatic success: a 49 yo multi-substance abuser looser, came in with ischemic bowel. E-lap, etc. Recurrent abdom sepsis necessitated him going back to OR two more times, open abdomen, resulting in the contents of his abdominal cavity being one large, scarred in, soccer-ball sized lump of cement. Not a candidate for another operation bec there would have been no tissue planes. Following that had mult radiologic cavity drainage procedures. The guy was septic for a long time, but never developed MOSF, only resp failure. So trached. No peg, had to be on TPN. Once we started Risperdal (the orally disintegrating tabs) and valproate, his general and resp course really smoothed out. Got him onto trach collar, then out of the unit after two months or so, looking like a champ — and acting like the nicest guy in the world. Leo —-Original Message—- From: David Crippen Sent: Thursday, August 24, 2006 5:24 PM To: ccm-l@ccm-l.org Subject: ccml sedation management in SICU Trauma Patient He is on industrial strength doses of meds and I can’t seem to get them down. He is on Morphine 25 mg/hr, Lorazepam 10 mg/hr, and haloperidol 15 mg/hr via constant infusion. Even with this, he occasionally gets agitated This is strong evidence for antecedent recreational drug dependence, not matter what he or his family tells you. All those medications are cross dependent to and cross tolerant to ethanol and many of the recreational feel-goods. This will put you into a very big kink trying to sedate him, as you have already found out. Like it or not, “partial” neuromuscular blockade is the only way you are going to get control of this without depleting the Eastern USA supply of sedatives, and suffering all the side effects thereof. Not total paralysis, neuromuscular blocker in a titrated dose only to slow him down, not make him completely flaccid. After all, it is the musculoskeletal hyperactivity that is the problem, not just the subjective aspects of “discomfort”. You need to stop the untoward effect of hypermetabolism. Making him more “comfortable” is more optional at this point. Get an EEG and make sure he isn’t seizing in the temporal lobe. If you start a continuous infusion of (my recommendation) Rocuronium, and simply have the nurse titrate it to the point where you can get on propofol and fentanyl in somewhere reasonable doses. Morphine is not potent enough to work. Haloperidol will do little as it isn’t a sedative. Lorazepam is like water. The combo of Propofol and Fentanyl is the least cross tolerant combo and will give you the most bang for your buck in the presence of loosening his ass up with Rocuronium. Vecuronium a second choice. Don’t use anything with a steroid nucleus. Forget giving anything enterally. If you have a cerebral (recreational) drug toxicity encephalopathy, you’re in for a rough ride as it can last for a month or longer. Usually they loosen up eventually. Seems like Mike Hansen had a Similar patient recently. Maybe he can comment on what happened to that one. — David Crippen, MD
review of propofol deaths (anesthesiology Volume 105(5), November 2006, pp 1047-1051)
Analgesics beat out hypnotics; use fentanyl (Br J Anaesth 2007;98(1):76)
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Delirium
http://icudelirium.org/delirium/
CAM-ICU scoring
Importance of dx and managing ICU delerium (Chest 2007;132:624) use CAM-ICU RASS > 0 include flowchart in pics
Memorial Delirium Assesment Scale
How to prevent delerium
allow sleep
orient the patient
keep hearing aids glasses, etc.
reduce pain
avoid dopaminergic, anti-cholinergic, or GABA agents
hyperactive, treat dopamine with typical or atypical antipsych
hypoactive or mixed, use atypical, followed by ACHase inhibitor (donepezil) and serotonin antagonist (ondansetron)
Haldol prophylaxis (0.5 mg IV and then 0.1 mg/h) prevented post-delirium (CCM 2012;40:731)
Back to topPropofol
send ck and lipids q24 after 24 hours of propofol