Rethinking Critical Care Sedation

Rethinking Critical Care SedationSharon Warden MSN MHA RN CCRNNOVEMBER 10TH, 2015

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But what I see these days are paralyzed, sedated patients, lying without motion, appearing to be dead, except for the monitor that tell me otherwiseThomas Petty, 1998

First and foremost Do no Harm, this is our motto, for years we as health care professional thought we were doing just that. We quickly sedated patients and started the fentanyl drips in an attempt to make our patients comfortable and wiping this awful experience from their memory. But now we ask, is this the best practice? The best we can do? In light of recent research, we now know we can and should do better. Thank you for allowing me to come today and share some new developments in critical care sedation management. In this presentation I will review the current research and recommendations in critical care sedation as well as a quick review of the current perceptions and opinions of the staff in both MICU and SSICU from earlier this year. The sedation practices in the adult critical care units are changing, this presentation includes the new algorithm and Pain/ Agitation/ Delirium recommendations that we are implementing. Additionally, included is a short review of delirium and CAM ICU. 2

Learning ObjectivesAfter participating in this educational offering the critical care nurse will be able to:Discuss the rationale and evidence for changing sedation practicesDiscuss the physiological and psychological effects of too much and too little sedation and analgesiaIdentify the differences between personal beliefs and evidence-based researchExplain the pain, anxiety, delirium management plan and the benefits to the patientExplain the importance of correctly performing the CAM-ICU and identify treatment options

Actual patient account of eventsI WAS MADE TO RUN DRUGS FOR SMUGGLERS BY SWIMMING UNDER WATER FOR AN EXTENDED PERIOD OF TIME HOLDING THEIR BREATHE TO GET INTO THIS UNDERGROUND MALL AFTER HOURS AND LOCKED UP FOR TRAINING DRUG DEALERS. I ACTUALLY SEEN BODY BAGS WITH MY CHILDRENS NAMES ON THEM. I TRIED TO HELP THEM AND TRIED TO COMMUNICATE THIS BUT WITH THE TRACE I WAS UNABLE .

This is DELIRIUM JUST IMAGINEInstitute for Improvement (2013)

This excerpt from a patients account of their critical illness was shared with me in a conference I attended in 2013. As you can see the thoughts are disjointed , but it was this unimaginable personal recount that convinced me to look further at the evidence. 4

Research and EvidenceBrooks and colleagues found that nursing implemented protocol-directed sedation during mechanical sedation:Reduced duration of ventilator daysDecreased ICU and hospital LOSShortened number of sedation daysDecreased tracheostomy ratesDecrease in delirium incidenceImproved long and short-term patient outcomes

(Balas, et al., 2012)

The evidence to support protocol directed sedation is overwhelming, but the conclusions are the same less is better, controlled is better, nursing-directed protocols including sedation awakening trials (SAT) effectively improve long and short-term outcomes. 5

Research and EvidenceWHY CHANGE?One of four patients suffer permanent cognitive impairment 12 months after critical illness (Pandharipande, et al., 2013)Longer duration of delirium associated with worsening cognitive impairments (Pandharipande, et al., 2013)PTSD symptoms experienced by 12% of patients who survived a critical illness and long-term ventilator support (Jubran, et al., 2010)Real memories of intensive care have been shown to reduce the severity of post traumatic stress disorder (Strem, Martinussen, & Taft, 2010)Each day a patient is delirious increases the risk of death by 10% (Peitz, Balas, Olsen, Pun, & Wesley, 2013)

A large multi-center research study conducted at Vanderbult University Medical Center and Saint Thomas Hospital in Nashville the BRAIN-ICU study revealed cognitive impairment in one of four patients extending 12 months after critical illness. The impairments resembled impairments expected after a moderate traumatic brain injury. In addition to cognitive impairments the research identifies Post-traumatic stress disorders (PTSD) as a significant problem after critical illness. The findings support that real memories as opposed to delirium memories decrease the severity of PTSD. This thinking is directly contradictory to the thinking of just ten years ago. The mounting research is overwhelming in support of decreasing the amounts and duration of sedation in critically ill patients; however, this presents new dilemmas of decision-making. Walking that fine line between not enough sedation and too much sedation. 6

Too little sedationPsychological sequeleaAnxietyAccidental extubationPhysical harmPhysiological responses to anxietyChanges in autonomic toneIncreased myocardial workloadIncreased coagulopathyIncreased metabolism (O2 requirements)Immunocompromised

(Aitken, Marshall, Elliott, & McKinley, 2008)

Now we tread down that fine line of the affects of not enough sedation for the critically ill patients and the psychological and physiological results of not enough sedation or pain medication. The real component of not enough is analgesic relieve and assessing the patient for pain versus anxiety and treating the appropriate symptoms. Additionally, treating the patient with medication dosages appropriate for the identified problem. 7

Too much sedationProlonged mechanical supportDeliriumComplications with reduced mobilityPatient comfortLong-term neuropsychological deficitsLong-term cognitive deficitsPTSD

The balancing between too much and too little sedation and analgesic requires a nurse driven protocol that encompasses nursing assessments of both anxiety and pain. The critical care nurse must incorporate appropriate patient assessments together with the physiological factors that influence the patients sedation needs such as weight, metabolism, age, and home medication prior to illness. 8

Too little analgesiaIncreased anxietyIncreased catacholamine release and sympathetic stress responseTachycardiaHypertensionIncreased oxygen consumption and demandHypermetabolismPTSD

The critical care nurses pain assessments occur at a minimum of every two hours regardless of the method of analgesic administration and within one hour of administration of a bolus dose in any form. The frequency of the pain assessments is important in ensuring the analgesic needs of the patient are met with appropriate assessment and administration. 9

Sedation decisionsNurse related factors effecting medication administrationKnowledgeEducationAttitudes and beliefsPrevious experienceAbility to assess and respondEffective communication strategies(Aitken, Marshall, Elliott, & McKinley, 2008)

Managing a fine line between keeping our patients comfortable and preventing harm. The critical care nurse draws on personal experiences, knowledge base, education level, and personal attitudes and beliefs regarding sedation for decision-making at the bedside. Additionally, a compelling component of sedation and analgesic decision-making is the nurses ability to rely on effective communication strategies to reduce the patients anxiety level, anticipate the patients needs, and clustering care to allow for rest periods (Aitken, Marshall, Elliott, & McKinley, 2008).

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Current BeliefsMICU 15/36SSICU 22/44

Long and short term patient outcomes are improved when we use evidence-based research to guide our practice. SSICU agrees MICU mostly agrees but a few are undecided.Delirium is a major concern in the adult critical care environment.Most staff agree in both units, MICU 1-2 that disagreeFor ventilated patients sedation should be managed with infusion versus medication boluses. MICU MOST staff either disagree or have no opinion, in SSICU the majority believe infusions are better although there are wide variations here.Our current sedation practices in the adult ICU are effective for optimal patient outcomes.Majority of responders in both units believe that current sedation practices are not effective for our patient populations, although there a significant number that believe otherwise. Our current analgesic practices in the adult ICU are effective for optimal patient outcomes.Most responders believe that our analgesic practices are effective for optimal patient outcomes.

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Personal beliefs vs. EBPMyth: All mechanically ventilated patients require sedationMyth: It is easier to care for a deeply sedated ICU patientMyth: Only surgical ICU patients experience painMyth: Sedatives help to facilitate sleep in ICU patientsMyth: Delirium is benign and an expected side effect of being in the ICUMyth: Daily interruptions of sedation are unsafe(Peitz, Balas, Olsen, Pun, & Wesley, 2013)

These misconceptions directly reflect the perceptions and beliefs of critical care practitioners and reflect the decision-making concepts of the past. Changing our thinking and practices means identifying and recognizing the myths and improving critical care practice by relying on evidence instead of myths. 12

Pain or SedationPain assessment toolsCritical care pain assessment toolNumerical rating scalesPicture rating scalesCAM-ICUProven accuracy when used correctlyRegular accurate use leads to faster resolutionRASSAssess for appropriate sedation levelsEnsure RASS goal is documented

The accurate use of the assessment tools leads to accurate use of appropriate medications, which leads to improved patient outcomes. At our disposable in documentation is the numeric pain assessment tool, critical care assessment tool, and picture assessment tool. Additionally, the CAM-ICU is a requirement currently every four hours in the ICU setting for identifying delirium symptoms such as disorganized thinking, and inattentiveness. The every four hours schedule encourages a compressive assessment with the required nursing assessment. Included in the guidelines are the required RASS goal for sedation in ICU patients.13

Pain, Agitation, Delirium (PAD) ManagementPain AssessmentPain TreatmentRoutinely monitoredBehavioral pain scale and critical care pain scale proven most reliable for ICU populationVital signs used as a cue to begin further assessmentsPreemptive medication prior to potentially painful proceduresIntravenous opioids first-line drug choiceNon-opiod analgesic considered as an adjunctNeuropathic pain treated with enteral gabapentin or carbamazepine (Barr, et al., 2013)(Barr & Pandharipandle, 2013)

The fist recommendation is to assess and treat pain first! Most important is a regular pain assessment. Our standard is pain assessment every two hours and within 1 hour of administering pain intervention. Although the self-reporting of pain is the gold-standard for pain, the ICU patient many times cannot tell us when they are having pain. Therefore, the second highest reliability is the behavioral and the critical care pain assessment tool. A critical care pain assessment score of 3 or greater are considered to be in significant pain. 14

PAD MANAGEMENTAgitation assessmentAgitation treatmentRASS and SAS most reliable sedation scoring assessmentsCompleted and documented every 2 hoursRecommendation is to maintain light levels of sedationSedate to maintain light levels and use bolus as needed Assess for cause of agitationUse non-benzodiazepines such as propofol or dexmedetomidine Bolus dosing preferred Use environmental interventionsSedation choices should be based upon using sedatives that minimize side effects and improve patient outcomesKeep the outcome in mind

(Barr & Pandharipandle, 2013)(Barr, et al., 2013)

Maintaining light sedation is linked with improved patient clinical outcomes. Assess for cause of agitation such as pain, ventilator mode, delirium, hot/cold etc. and treat cause prior to administering sedation medication. Focus on treating pain first then sedate, if needed. Choose sedation based on individualized patient goals and the pharmacologic profile of the medication using non benzodiazepines preferentially. Use both pharmacologic and non pharmacologic treatments to manage ICU patients. 15

RASS-Richmond Agitation sedation SCALE+4= COMBATIVE,VIOLENT, IMMEDIATE DAGER TO STAFF+3=VERY AGIATATED,PULLS TO REMOVE TUBES OR CATHETERS, AGGRESSIVE+2=AGITATED FREQUENT NON-PURPOSED MOVEMENT, FIGHTS VENTIALTOR+1=RESTLESS, ANXIOUS, APPREHENSIVE, MOVEMENTS NOT AGGRESSIVE0=ALERT AND CALM,SPONTANEOUSLY PAYS ATTENION TO THE CAREGIVER-1=DROWSY, NOT FULLY ALERT BUT HAS SUSTAINED AWAKENING TO VOICE (EYE OPENING AND CONTACT>10 SEC)-2=LIGHT SEDATION, BREIFLY AWAKENES TO VOICE (EYES OPEN AND CONTACT,10SEC)-3MODERATE SEDATION, MOVEMENT OR EYE OPENING TO VOICE (NO EYE CONTACT)If RASS IS >+-3 proceed to CAM-ICU (is patient CAM-ICU positive or negative)-4= deep sedation no response to voice but movement or eye opening to physical stimuli-5 unarousable no response to voice or physical stimulationIf RASS is _4 or 5 STOP (patient is unconscious) recheck your RASS goal and act accordingly

PAD MANAGEMENTDelirium AssessmentDelirium TreatmentCAM-ICU most reliable toolRoutine monitoring and PRN effective in clinical practiceIdentify and eliminate potential contributing factorsAtypical antipsychotics may decrease duration of delirium

Identify and eliminate potential contributing factors such as pain, drug withdrawal, abrupt discontinue of psychiatric medications, exposure to deleriogenic medications such as benzodiazepines, and environmental factors. 17

On the topic of Delirium

Hypoactive stateHyperactive stateMixed state (Gorman, 2014)

The three states of delirium are hypoactive, hyperactive, and mixed delirium. Hypo delirium often goes unrecognized the patient is quietly looking around the room, yet not verbalizing or acting on the fear, hallucinations, or delusions. Hyper delirium is very recognizable and most often sends nurse to the PYXIS to access medication. Clearly the patient needs sedation of some sort. Mixed state is a delirium that fluctuates between the two. Delirium of any variety os associated with increased mortality, prolonged ICU stay, post-ICU cognitive impairments. 18

Delirium PreventionSleepDaytime versus nighttimeEncourage scheduleWhiteboards for documenting pending scheduleCollaboration with PT/OT/RTMedicationsAppropriate medications and dosagesReality orientationFrequentFamily involvementEarly and progressive mobility

http://www.heartbrain.com/delirium/

The importance of a proactive approach to delirium prevention cannot be stressed enough. We should be beginning to think of patient care with the outcome in the front of our vision. 19

CAM-ICU ReviewIs your patient different from baseline?Has your patient fluctuated in the past 24 hours?Inattentive thinking (Save-a-Heart)Disorganized thinking (Does a rock float)

For the CAM to be positive for delirium, it requires the presence of both features 1 and 2, AND either 3 or 4.

Quick pointsConfusion and delirium are not the sameA patient can be confused and not deliriousCAM-ICU is required for any ICU patient unless RASS IS -4 or -5A full patient assessment includes assessing mentation CAM-ICU is an important part of our role to keep our patients safe

A quick review of the CAM-ICU. If you do not have a CAM-ICU pocket guide please see myself or Jane after the presentation. It is important to know where your patient failed the CAM-ICU in order to help them. For example, is you patient having trouble with inattentive thinking and the inability to focus or is your patient having issues with disorganized thinking and scrambled thought patterns. Furthermore, your patient can be lethargic and have hypoactive delirium and the CAM-ICU can help you identify this problem nad treat appropriately. 20

CAm-ICU 101Mr Jones is in the ICU after an emergency intubation in the ER. He has been here several days, and Nancy nurse performs his CAM-ICU on day four.Is your patient different from his baseline? YESIs your patient had mentation fluctuations in the past 24 hours? YESNancy Nurse asks Mr Jones to squeeze her hand every time she says the letter A, and recites the save-a-heart letters. Mr Jones gets all letters correctNancy nurse asks Mr. Jones the disorganized thinking questions. Mr. Jones answers all correctly.

Is Mr. Jones suffering from delirium?No because you must have two yesses AND either three or four failed.

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New Sedation Algorithm

Double click to enlarge for viewing. 22

Whats up in the Future?The future of critical care is an awake patient involved in his or her own care and decision-making throughout the critical illnessThe future promises a patient-centered focus for health care and modifying nursing practice to accommodate patients and familys need for participative health careThe future of critical care includes the implementation of team concepts and a multidisciplinary approach to patient-centered care

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ConclusionObviously there are some patients who really need sedation in the short-term momentSedate if you need to, but consider this a short-term solution and the goal is to awaken quicklyLess is best!!

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Questions

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ReferencesAitken, L. M., Marshall, A. P., Elliott, R., & McKinley, S. (2008). Critical care nurses decision making: Sedation assessment and management in intensive care. Journal of Clinical Nursing, 18(1), 36-45. doi:10.1111/j.1365-2702.2008.02318.xBarr, J., & Pandharipandle, P. P. (2013). The pain, agitation, and delirium care bundle: Synergistic benefits of implementing the 2013 pain, agitation, and delirium guidelines in an integrated and interdisciplinary fashion. Critical Care Medicine, 41(9), S99-S115. doi:10:1097/ccm.0bo13e3182a16ff0Barr, J., Fraser, G. L., Puntillo, K., Ely, W. E., Gelinas, C., Dasta, J. F., . . . Jaeschke, R. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: Executive summary. American Journal of Health Systems-Pharmacology, 70(1), 53-58.

ReferencesGorman, S. (2014). Delirium in the hospitalized elderly. Retrieved from Texas website for Training Excellence in Aging Studies: http://www.uth.tmc.edu/reynolds/soundbytes/delirium.htmlJubran, A., Lawm, G., Duffner, L. A., Collins, E. G., Lanuza, D. M., Hoffman, L. A., & Tobin, M. J. (2010). Post-traumatic stress disorder after weaning from prolonged mechanical ventilation. Intensive Care Medicine, 36, 2030-2037. doi:10.1007/s00134-101-1972-8Pandharipande, P. P., Girard, T. D., Jackson, J. C., Morandi, A., Thompson, J. L., Pun, B. T., . . . Ely, E. W. (2013). Long-term cognitive impairment after critical illness. The New England Journal of Medicine, 369(14), 1306-1316. doi:10.1056/NEJMoe1301372

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referencesPeitz, G. J., Balas, M. C., Olsen, K. M., Pun, B. T., & Wesley, E. E. (2013). Top ten myths regarding sedation and delirium in the ICU. Critical Care Medicine, 41(9), S46-S56. doi:10.1087/ccm.0bo13e3182a16815Strem, T., Martinussen, T., & Taft, P. (2010). A protocol of no sedation for critically ill patients receiving mechanical ventilation: A randomized trial. The Lancet, 375(9713), 475-480.

Is patient comfortable and at

goal?

Rule out reversible causes

NO

Reassess goals daily

Perform Daily Awakening Trial (includes narcotics)

YES

TREAT PAIN FIRST BEFORE SEDATION!!

Is Patient in pain?

Assess pain using CPOT if non-verbalAsses Q 2 hr. and PRN, reassess in 30-60 minutesInclude non-pharmacological interventionsInclude non-narcotic medicationsAdminister pre-procedural analgesiaConsider epidural analgesia

INTERMITTANT DOSING FIRST AND PREFERREDFentanylHydromorphoneOxycodone

CONTINUOUSConsider using if PRN doses not effectively manage pain

DilaudidFentanyl

NON-NARCOTIC ANALGESICSTylenolKetorolac

DAILY AWAKENING TRIALStop all sedation and narcotic infusions early in a.m. (if no contraindications or per MD order)Allow to awaken to at least RAAS-2If necessary to restart infusions, restart at 50% of previous dose

Is Patient agitated or anxious?

Assess agitation and sedation level Q 4 hr. and PRNTarget RASS Goal 2Daily Awakening trial including narcotic infusionsIf under-sedated, assess/treat pain first; may need to re-bolus and/or increase doseIf over-sedated, hold sedative until at target RASS, then restart at 50% previous doseAssess for and initiate Early Mobility, exercise

Potential compromised

ICP/CPP?Propofol

INTERMITTANT DOSING FIRST AND PREFERREDClonazepamValproic acidMidazolamLorazepam 0.

Consider continuous infusion if PRN doses given > Q 1 hr. x 6 doses

IF CONTINUOUS INFUSION NEEDEDPrecedex (prefer for cardiac patientsMidazolamPropofol

If on propofol > 3 days, consider midazolam unless ICP compromised

YES YES

NO

NO

Is Patient delirious?

FOR PATIENTS ON NEUROMUSCULAR BLOCKADE, NEVER HOLD SEDATIVES OR ANALGESICS UNTIL NMB STOPPED

Assess by CAM-ICU Q shift and PRNAssess/treat painRe-orient, use visual/hearing aids if neededMobilize/exercises patients regularly during dayPromote sleepAvoid benzodiazepines

Use Delirium Order Set #3445

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