ABCDE Education Slides

7/27/2019 ABCDE Education Slides

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Need for Sedation and Analgesia

Prevent pain and anxiety

Decrease oxygen consumption

Decrease the stress response

Patient-ventilator synchrony

Avoid adverse neurocognitive sequelae

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.

- Depression,

PTSD


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Potential Drawbacks of Sedativeand Analgesic Therapy

Oversedation:

Failure to initiate spontaneous breathing trials (SBT) leads to increased duration ofmechanical ventilation (MV)

Longer duration of ICU stay

Impede assessment of neurologic function

Increase risk for delirium

Numerous agent-specific adverse events

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


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SedationMechanicalVentilation

DeliriumWeakness

Patient withSepsis

Cognitive and Functional Impairment, Institutionalization,MortalityVasilevskis et al Chest 2010; 138;1224-


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We Need Coordinated Care

Many tasks and demands on critical care staff

Great need to align and supporting the people,

processes, and technology already existing in ICUs

ABCDE protocol is multiple components,

interdependent, and designed to:

Improve collaboration among clinical team members

Standardize care processes

Break the cycle of oversedation and prolonged ventilation

Vasilevskis et al Chest 2010; 138;1224-


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What is the MIND-USAABCDE Protocol?

Awakening and Breathing

Coordination

Delirium Identification and

Management

Early Exercise and Mobility

ABC

D

E


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Awakening and Breathing

Coordination

ABC


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Oversedatio

n

PatientComfortand

Ventilatory

Optimization

ICU Sedation: Its a Balancing Act


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Consequences of SuboptimalSedation

Inadequatesedation/analgesia

Anxiety

Pain

Patient-ventilatordyssynchrony

Agitation

Self-removal oftubes/catheters

Care provider assault

Myocardial ischemia

Family dissatisfaction

Excessive sedation

Prolonged mechanicalventilation, ICU LOS

Tracheostomy DVT, VAP

Additional testing

Added cost

Inability to communicate

Cannot evaluate fordelirium


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Structured Approaches to Sedation& Analgesia in the ICU

1. Multidisciplinary development, implementation

2. Establish goals/targets, frequently re-evaluate

3. Measure key components using validated scales

4. Select medications based on characteristics, evidence

5. Incorporate key patient considerations

6. Prevent oversedation, yet control pain and agitation

7. Promote multidisciplinary acceptance and integration into

routine care

ler & Pedram. Crit Care Clinics 2009; 25:489-513


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Validated ICU Sedation Scales

Richmond agitation-sedation scale (RASS)

Sedation agitation scale (SAS)

Ramsay sedation scale

Motor activity assessment scale (MAAS) Vancouver interactive and calmness scale (VICS)

Adaptation to intensive care environment (ATICE)

Minnesota sedation assessment tool (MSAT)


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Setting Targets

Provide for agitation/anxiety free,amnesia, comfort

Trying to achieve a balance

TIGHT TITRATION

Adjust target depending on current need

Per patient Different over the course of Illness/Treatment


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Use Protocols to Achieve Goals, Minimize DrugAccumulation, Maximize Alertness

Patient-focused drug selection

Preference for analgesia > sedation

Intermittent therapy via boluses

Frequent evaluation of sedation, pain,ICU therapy tolerance

Titrate therapy for lowest effective dose

Daily interruption of sedation


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RCT: 2x2 factorial design

Midazolam vs propofol

Daily interruption of sedation vs routine

Discontinue all sedative and analgesic medications Monitor patient closely until awake or agitated,

i.e., can perform at least 3 of 4 on command: Open eyes

Squeeze hand

Lift head

Stick out tongue

Restart medications at half dosage (if necessary)

Kress et al. N Engl J Med 2000; 342:1471-7


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Shorter durationof mechanical

ventilation Shorter ICU LOS

Fewer tests foraltered mentalstatus

Kress et al. N Engl J Med 2000; 342:1471-7

Daily Awakening Trial Results


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Why Is Interruption of SedationEffective?

Less accumulation of sedative drug andmetabolites

Significantly less midazolam and morphine with DIS

in midazolam subgroup

But no difference in amount of propofol andmorphine with DIS in propofol subgroup

Opportunity for more effective weaning from

mechanical ventilation?

Sessler CN. Crit Care Med 2004 Kress et al. NEJM. 2000

Wake Up andBreathe


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Multicenter RCT:

168 patients with spontaneousawakening trial (SAT)

i.e., daily interruption of sedation (SAT)+ spontaneous breathing trial (SBT)

168 patients with standard sedation +

SBT

Click to edit Master text styles


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Click to edit Master text stylesSecond level

Third levelFourth level

Fifth level


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SAT + SBT Was Superior toConventional Sedation + SBT

Intervention (SAT) group = Less benzodiazepine

Girard et al. Lancet 2008; 371:126-34

P = 0.02

P = 0.01

Extubated faster Discharged from ICU sooner


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SAT + SBT Was Superior toConventional Sedation + SBT

Intervention (SAT) group = More unplannedextubation, but not more reintubation

P = 0.02

P = 0.01

Discharged from hospitalsooner

Better survival at 1 yr

Aliv

eP = 0.01

P = 0.04

ard et al. Lancet 2008; 371:126-34


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Awakening & BreathingCoordination

Synergy of daily awakening viainterruption of sedation plusspontaneous breathing trial

Less medication accumulation, lessexcessive sedation

Opportunity for more effective

independent breathing (SBT) Perform safety screens for SAT and

for SBT


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ABC Safety Screens

Wake Up Safety Screen

No active seizures

No active alcoholwithdrawal

No active agitation

No active paralytic use

No myocardial ischemia

(24h) Normal intracranial

pressure

Breathe Safety Screen

No active agitation

Oxygen saturation >88%

FiO2 < 50%

PEEP < 7.5 cm H2O

No active myocardial

ischemia (24h)

No significant vasopressoruse

Girard et al. Lancet 2008; 371:126-34.

Kress et al. Crit Care Med 2004; 32(6):1272-6

-


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ABCAwakening & Breathing Coordination

Eligibility = On the ventilator

1. SAT Safety Screen - pass/fail

2. If pass safety screen, perform SAT

If fail; restart sedatives if necessary (1/2 dose)

If pass; continue to SBT safety screen

5. SBT Safety Screen - pass/fail

6. If pass safety screen, perform SBT

If fail; return to previous ventilatory support

If pass; consider extubation


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D

Delirium Monitoring and

Management


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Delirium: Key Features

1. Disturbance ofconsciousness with reduced ability tofocus, sustain or shift attention

2. A change in cognition or the development of aperceptual disturbance that is not better accounted for

by pre-existing, established or evolving dementia

3. Develops over a short period of time and tends tofluctuate over the course of the day

4.There is evidence from the H&P and/or labs that thedisturbance is caused by a medical condition, substanceintoxication or medication side effect


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Delirium Subtypes

Alert &Calm

CombativeAgitatedRestless

LethargicSedatedStupor

Hyperactive Delirium

Hypoactive Delirium

MixedDelirium


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ICU Delirium Increased ICU length of stay (8 vs 5 days)

Increased hospital length of stay (21 vs 11 days)

Increased time on ventilator (9 vs 4 days)

Higher ICU costs ($22,000 vs $13,000)

Higher ICU mortality (19.7% vs 10.3%)

Higher hospital mortality (26.7% vs 21.4%)

3-fold increased risk of death at 6 months

Ely, et al. ICM2001; 27, 1892-1900Ely, et al, JAMA 2004; 291: 1753-1762Lin, SM CCM 2004; 32: 2254-2259

Milbrandt E, et al, Crit Care Med 2004; 32:955-962.

-


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Confusion Assessment Method forthe ICU (CAM-ICU)

Feature 1: Acute changeor fluctuating course of

mental status

And

Feature 2:Inattention

And

Feature 3: Alteredlevel of consciousness

Feature 4:Disorganized thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-

948.1Ely, et. al. CCM 2001; 29:1370-1379.4


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Delirium Management

1. Identify etiology

2. Identify risk factors

3. Consider pharmacologictreatment

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


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Stop and THINK

Do any meds need to be stoppedor lowered?

Especially consider sedatives

Is patient on minimal amount

necessary?

Daily sedation cessation

Targeted sedation plan

Assess target daily

Do sedatives need to be changed?

Remember to assess for pain!

Toxic SituationsCHF, shock, dehydrationNew organ failure

(liver/kidney)

Hypoxemia Infection/sepsis

(nosocomial),

Immobilization

Nonpharmacologicinterventions

Hearing aids, glasses,reorient,sleep protocols, music, noise

control, ambulation

Consider antipsychotics after evaluating etiology &

risk factors


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Eligibility = RASS -3

DeliriumNonpharmacologic Interventions

+4 COMBATIVE Combative, violent, immediate danger to staff

+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive

+2 AGITATED Frequent non-purposeful movement, fights ventilator

+1 RESTLESS Anxious, apprehensive, movements not aggressive

0 ALERT & CALM Spontaneously pays attention to caregiver

-1 DROWSY Not fully alert, but has sustained awakening to voice

(eye opening & contact >10 sec)

-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact


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DeliriumNonpharmacologic Interventions

Pain:

Monitor and manage pain using an objective scale (e.g.,FACES, BPS, VAS, CPOT, etc.)

Orientation: Convey the day, date, place, and reason for hospitalization

Update the whiteboards with caregiver names

Request placement of a clock and calendar in room

Discuss current events


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Nonpharmacologic Interventions

Sensory: Determine need for hearing aids and/or eye glasses

If needed, request surrogate provide these for patient whenappropriate

Sleep: Noise reduction strategies (e.g. minimize noise outside the

room, offer white noise or earplugs)

Normal day-night variation in illumination

Use time out strategy to minimize interruptions in sleep

Maintain ventilator synchrony

Promote comfort and relaxation (e.g., back care, oral care,washing face/hands, and daytime bath, massage)


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Early Exercise and

Mobility

E


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Early Exercise in the ICU

Early exercise = progressive mobility

Study design: paired SAT/SBT protocolwith PT/OT from earliest days of

mechanical ventilation

eickert WD, et al. Lancet. 2009;373:1874-1882.

Wake Up, Breathe, andMove


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Early Exercise Study Results

OutcomeIntervention

(n=49)Control(n=50) P

Functionally independent atdischarge

29 (59%) 19 (35%) 0.02

ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03

Time in ICU with delirium (%) 33 (0-58) 57 (33-69) 0.02

Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) 0.02

Hospital days with delirium (%) 28 (26) 41 (27) 0.01

Barthel index score atdischarge

75 (7.5-95) 55 (0-85) 0.05

ICU-acquired paresis atdischarge

15 (31%) 27 (49%) 0.09

Ventilator-free days 23.5 (7.4-25.6)

21.1 (0.0-23.8)

0.05

Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08

Length of stay in hospital(days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93eickert WD, et al. Lancet. 2009;373:1874-1882.


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Early Exercise and Mobility

Eligibility = All patients are

eligible for Early Exercise andMobility


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Perform Safety Screen First

Safety Screen

Patient responds to verbal stimulation (i.e., RASS > -3)

FIO2


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1. Active range of motion in bed and sittingposition in bed

2. Dangling

3. Transfer to chair (active), includes standingwithout marching in place

4. Ambulation (marching in place, walking inroom or hall)

*All may be done with assistance.

Early Exercise & MobilityLevels of Therapy*

E l E i d M bili


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Early Exercise and MobilityProtocol Progression

Active ROM (in bed)

Sit/ Dangle

March/ Walk

Transfer

No Exercises,but Passive

Range ofMotion allowed

Progre

ss

as

tolerated

I

CUD

ischarge

Ex

ercise

screen

RASS -3RASS -5 / -4

Benefits of ABCDE Protocol


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Morandi A et al. Curr Opin Crit Care,2011;17:43-9

Benefits of ABCDE Protocol


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