2013 SCCM Guidelines
(Crit Care Med 2013;41:263)
- 10 myths re icu sedation (crit care med 2013;41:s46)
- Alcohol and nicotine withdrawal in the icu (crit care med 2013;41s57)
STATEMENTS AND RECOMMENDATIONS
i. We recommend that pain be routinely monitored in all adult ICU patients (+1B).
ii. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for monitoring pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report and in whom motor function is intact and behaviors are observable. Using these scales in other ICU patient populations and translating them into foreign languages other than French or English require further validation testing (B).
iii. We do not suggest that vital signs (or observational pain scales that include vital signs) be used alone for pain assessment in adult ICU patients (–2C).
iv. We suggest that vital signs may be used as a cue to begin further assessment of pain in these patients, however (+2C).
c. Treatment of pain
i. We recommend that preemptive analgesia and/or nonpharmacologic interventions (e.g., relaxation) be administered to alleviate pain in adult ICU patients prior to chest tube removal (+1C).
ii. We suggest that for other types of invasive and potentially painful procedures in adult ICU patients, preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered to alleviate pain (+2C).
iii. We recommend that intravenous (IV) opioids be considered as the first-line drug class of choice to treat non-neuropathic pain in critically ill patients (+1C).
iv. All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective (C).
v. We suggest that nonopioid analgesics be considered to decrease the amount of opioids administered (or to eliminate the need for IV opioids altogether) and to decrease opioid-related side effects (+2C).
vi. We recommend that either enterally administered gabapentin or carbamazepine, in addition to IV opioids, be considered for treatment of neuropathic pain (+1A).
vii. We recommend that thoracic epidural anesthesia/analgesia be considered for postoperative analgesia in patients undergoing abdominal aortic aneurysm surgery (+1B).
viii. We provide no recommendation for using a lumbar epidural over parenteral opioids for postoperative analgesia in patients undergoing abdominal aortic aneurysm surgery, due to a lack of benefit of epidural over parenteral opioids in this patient population (0,A).
ix. We provide no recommendation for the use of thoracic epidural analgesia in patients undergoing either intrathoracic or nonvascular abdominal surgical procedures, due to insufficient and conflicting evidence for this mode of analgesic delivery in these patients (0,B).
x. We suggest that thoracic epidural analgesia be considered for patients with traumatic rib fractures (+2B).
xi. We provide no recommendation for neuraxial/regional analgesia over systemic analgesia in medical ICU patients, due to lack of evidence in this patient population (0, No Evidence).
2. Agitation and Sedation
a. Depth of sedation vs. clinical outcomes
i. Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay [LOS]) (B).
ii. Maintaining light levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B).
iii. The association between depth of sedation and psychological stress in these patients remains unclear (C).
iv. We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated (+1B).
b. Monitoring depth of sedation and brain function
i. The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients (B).
ii. We do not recommend that objective measures of brain function (e.g., auditory evoked potentials [AEPs], Bispectral Index [BIS], Narcotrend Index [NI], Patient State Index [PSI], or state entropy [SE]) be used as the primary method to monitor depth of sedation in noncomatose, nonparalyzed critically ill adult patients, as these monitors are inadequate substitutes for subjective sedation scoring systems (–1B).
iii. We suggest that objective measures of brain function (e.g., AEPs, BIS, NI, PSI, or SE) be used as an adjunct to subjective sedation assessments in adult ICU patients who are receiving neuromuscular blocking agents, as subjective sedation assessments may be unobtainable in these patients (+2B).
iv. We recommend that EEG monitoring be used to monitor nonconvulsive seizure activity in adult ICU patients with either known or suspected seizures, or to titrate electrosuppressive medication to achieve burst suppression in adult ICU patients with elevated intracranial pressure (+1A).
c. Choice of sedative
i. 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).
a. Outcomes associated with delirium
i. Delirium is associated with increased mortality in adult ICU patients (A).
ii. Delirium is associated with prolonged ICU and hospital LOS in adult ICU patients (A).
iii. Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B).
b. Detecting and monitoring delirium
i. We recommend routine monitoring of delirium in adult ICU patients (+1B).
ii. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools in adult ICU patients (A).
iii. Routine monitoring of delirium in adult ICU patients is feasible in clinical practice (B).
c. Delirium risk factors
i. Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU: preexisting dementia, history of hypertension and/or alcoholism, and a high severity of illness at admission (B).
ii. Coma is an independent risk factor for the development of delirium in ICU patients (B).
iii. Conflicting data surround the relationship between opioid use and the development of delirium in adult ICU patients (B).
iv. Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients (B).
v. There are insufficient data to determine the relationship between propofol use and the development of delirium in adult ICU patients (C).
vi. In mechanically ventilated adult ICU patients at risk of developing delirium, dexmedetomidine infusions administered for sedation may be associated with a lower prevalence of delirium compared to benzodiazepine infusions (B).
d. Delirium prevention
i. We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B).
ii. We provide no recommendation for using a pharmacologic delirium prevention protocol in adult ICU patients, as no compelling data demonstrate that this reduces the incidence or duration of delirium in these patients (0,C).
iii. We provide no recommendation for using a combined nonpharmacologic and pharmacologic delirium prevention protocol in adult ICU patients, as this has not been shown to reduce the incidence of delirium in these patients (0,C).
iv. We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adult ICU patients (–2C).
v. We provide no recommendation for the use of dexmedetomidine to prevent delirium in adult ICU patients, as there is no compelling evidence regarding its effectiveness in these patients (0,C).
e. Delirium treatment
i. There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (No Evidence).
ii. Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C).
iii. We do not recommend administering rivastigmine to reduce the duration of delirium in ICU patients (–1B).
iv. We do not suggest using antipsychotics in patients at significant risk for torsades de pointes (i.e., patients with baseline prolongation of QTc interval, patients receiving concomitant medications known to prolong the QTc interval, or patients with a history of this arrhythmia) (–2C).
v. 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).
4. Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes
a. We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients (+1B).
b. We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B).
c. We recommend promoting sleep in adult ICU patients by optimizing patients’ environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patients’ sleep cycles (+1C).
d. We provide no recommendation for using specific modes of mechanical ventilation to promote sleep in mechanically ventilated adult ICU patients, as insufficient evidence exists for the efficacy of these interventions (0, No Evidence).
e. We recommend using an interdisciplinary ICU team approach that includes provider education, preprinted and/or computerized protocols and order forms, and quality ICU rounds checklists to facilitate the use of pain, agitation, and delirium management guidelines or protocols in adult ICUs (+1B).
Best Review Article (Am J Resp Crit Care 2012;185:486)
Large recently published trial shows sedation holidays unnecessary when compared to protocolized sedation, multi-center, Sangeeta Mehta, Lisa Burry, Paul Hébert, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol. A Randomized Controlled Trial. JAMA 2012; ePub online October 17, 2012.
Most ED patients receive inadequate sedation and pain control (Am J Emerg Med 2008;26:469)
Am J Emerg Med. 2012 Jul 4. Estimates of sedation in patients undergoing endotracheal intubation in US EDs.
New article shows no sedation (but of course analgesia) got pts off the vent quicker. (Lancet 2010;375:475)
C.N. Sessler, K. Varney Patient-focused sedation and analgesia in the ICU Chest, 133 (2008), pp. 552–565
P.S. Richman, D. Baram Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combination Crit Care Med, 34 (5) (2006 May), pp. 1395–1401
D. Breen, A. Karabinis, M. Malbrain et al. Decreased duration of mechanical ventilation when comparing when comparing analgesia based sedation using remifentanil with standard hypnotic based sedation for up to 10 days in intensive care unit patients: a randomised trial Crit Care, 9 (3) (2005), pp. R200–R210
benzodiazepenes are the most potent amnestics
Sedation is amnesia, hypnosis, and anxiolysis
Opioids can provide analgesia and some anxiolysis and hypnosis but not amnesia
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)
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
from SCANCRIT guys:
Ketamine i.v. drip infusion
Mix 500mg of Ketamine in a bag of 500 mL saline, to get ketamine 1 mg/ml. Get the patient’s weight in kilograms. Let the starting point for your maintanence dose of ketamine i.v. drip infusion be [the patient’s weight i kg] drops per minute. This will equal around 4 mg/kg/hr. Adjust to effect.
Ketamine induction cocktail
You will still need an induction dose of ketamine 1-2 mg/kg i.v. For children (or grown-ups) where you can’t easily get i.v. access while they’re awake, you can use a dose of ketamine 5-8 mg/kg i.m. for induction. You can also mix in atropin and a little midazolam in the same i.m. syringe to give them the full cocktail i.m. induction.
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
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:email@example.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: firstname.lastname@example.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)
Delirium: •1590s, from L. delirium “madness,” from deliriare “be crazy, rave,” lit. “go off the furrow,” a plowing metaphor, from phrase de lire (de “off, away” + lira “furrow”).
Importance of dx and managing ICU delerium (Chest 2007;132:624) use CAM-ICU RASS > 0 include flowchart in pics
How to prevent delirium
orient the patient
keep hearing aids glasses, etc.
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) and then
Haldol didn’t work in RCT for delirium prevention (The Lancet Respiratory Medicine 2013;1(7):515)
send ck and lipids q24 after 24 hours of propofol
Best review for the ICU (Drugs 2006;66(3):365)
Midazolam and its metabolites can last a long, long time and may cause coma and false prognostication for ICU patients (Lancet 1995;346:145)