FULFILLING THE NEED OF ICU PATIENTS

Mazen kherallah, MD, FCCP

Stress in ICU?

Psychological Stress

Environmental Stress

Spiritual Strees

Physical Stress

Psychological Stress in ICU

Psychological Stress in ICU Loss of control Fear of death or serious illness Fear of pain Overwhelming isolation Feelings of helplessness Loss of normal circadian rhythms The disruption of normal sleep patterns Sleep deprivation Disorientation and panic

Can the patient whom we thing is sedated on the ventilator hear and think?

Listen to this…

Alien, sensory rich environment

Environmental Stress in ICU

Environmental Stress in ICU Foreign environments Room temperature Continuous ambient lighting Family not continuously available for

comfort Significant noise from personnel and

medical equipment

12

12

Physical Stress in ICU Attached to equipments with tubes

or wires Intubated and ventilated Treatment or diagnostic procedures Confined (restricted) to bed Uncomfortable bed and pillow Unable to control stool habit

+ Inability to communicate

Frustration and Anger

Excessive stimulation in ICU• Monitoring• Cleaning• Suctioning• Dressing changes• Mobilization• Physical therapy

Anxiety, sleep deprivation 71% of patients in a medical surgical ICU get agitated at

least once (46% severe agitation)Pharmacotherapy 2000; 20: 75-82

Delirium in 87% with fluctuating mental status,

inattention, disorganized thinking with or without

agitationJAMA 2001; 286: 2703-2710

Recall in the ICU• Questionnaire to 80 survivors of ARDS• 80% remembered an adverse experience e.g.

nightmares, anxiety, pain, respiratory distress• 28% met criteria for PTSD

- 41% with recall of 2 frightening experiences

• Other reports suggest 4-15% PTSD in ICU survivors

Crit Care Med 2000; 28: 86-92

Crit Care Med 1998;18:651-659

Sedation Goal

ICU Sedation Goal• Stabilize hemodynamics & modulate

stress response• Reduce motor activity – tolerance of

procedures, facilitate nursing managment

• Facilitate mechanical ventilation• Facilitate sleep patterns

UndersedationUnderdosing ToleranceWithdrawal

OversedationOverdosingDrug accumulationImpaired elimination

Drug interactions Adverse side effects

Incidence of Inappropriate Sedation

Over-sedation

On Target

Under-sedation

54%

15.4%

30.6%

Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.Olson D et al. NTI Proceedings. 2003; CS82:196.

10%20%

70%

Kaplan L. and Bailey H. 2000

Olson D. et al.2003

Sedation

SedativesCauses for Agitation

Undersedation

SedationCauses for Agitation

Agitation & anxietyPain and discomfortCatheter displacementInadequate ventilationHypertensionTachycardiaArrhythmiasMyocardial ischemiaWound disruptionPatient injury

Oversedation

Sedation

Causes for Agitation

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

So, we want appropriate sedation, but how?

Sedation Depth

ComplicationsCostsAdverse Outcomes

Complications Adverse Outcomes

BEST OUTCOMES

ADEQUATE/OPTIMALOVERDOSING UNDERDOSING

Is Your Patient Comfortable and at Goal ?

Pain Assessment by Family?

• Surrogates were able to assess presence or absence of pain in 73.5% of patients

• Degree of pain correctly assessed in only 53% of patients

*Crit Care Med 2002;30:119-141

Signs of Pain

Hypertension Tachycardia Lacrimation Sweating Pupillary dilation

Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial

expression, and posturing) and physiological indicators (HR, BP, RR) and the change in these parameters following analgesic therapy

Grade B recommendation

Motor Activity Assessment Scale (MAAS)*

Seven categories to describe the patient’s reaction to stimulation

*Devlin et al. Crit Care Med 1999;27:1271-1275

Score Description Definition

0 Unresponsive Does not move with noxious stimulus*

1 Responsive only to Open eyes OR raises eyebrows OR turns noxious stimuli head toward stimulus OR moves limbs

with noxious stimuli

2 Response to touch Opens eyes OR raises eyebrows OR turns or namehead towards stimulus OR moves limbs when touched or name is loudly spoken

3 Calm and cooperative No external stimulus is required to elicit movement AND patient is adjustingsheets or clothes purposefully andfollows commands

*Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, or nail bed pressure

Score Description Definition

4 Restless and No external stimulus is required to elicit cooperative movement AND patient is picking at sheets

or tubes or uncovering self and follows commands

5 Agitated No external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g. will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed

6 Dangerously agitated No external stimulus is required to elicit Uncooperative movement AND patient is pulling at tubes

or catheters OR thrashing side to side or striking at staff OR trying to climb out of bed AND does not calm down when asked

Objective assessment of sedation during:

BIS in the ICU: Key Applications

? Mechanical Ventilation

Neuromuscular Blockade

Bedside Procedures

Drug Induced Coma

GE BIS Display / BIS Sensor

GE BIS Display

BIS Sensor

BIS converts the “raw” EEG

signal to a number 0-100

BIS = 95

BIS = 70

BIS = 50

BIS = 30

Responds to normal voice

Responds to loud commands or mild prodding/shaking

100BIS

80

60

40

20

0

Low probability of explicit recall

Unresponsive to verbal stimulus

Burst suppression

BIS in Deep Sedation

Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67.

• Titration to maximal Ramsay Score of 6 (unarousable)• Blinded BIS monitoring

Results:• Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation.

0

10

20

30

40

50

60

70

80

90

100

Day 1 Day 3 Day 5

BIS

Val

ue

BIS

Ram

say Score*

68

4531

6 6 6

23

4

56

* Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.

Ramsay

BIS in Deep Sedation

Riker. AJRCCM 1999De Deyne. Int Care Med 1998

Unarousable

0102030405060708090

100B

ispe

ctra

l Ind

ex (B

IS)

SAS 1 Ramsay 6

• Titration to unarousable state by subjective scale• Blinded BIS monitoring

Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in

sedation level as measured objectively with BIS monitoring.

Ruling Out Reversible Causes

Sedation of agitated patients should start only after providing adequate analgesia and treating

reversible physiological causesGrade C recommendation

Pain, hypoxemia, hypoglycemia, hypotension, withdrawal from alcohol and other drugs

Correctable Causes of Agitation

Full bladder

Uncomfortable bed position

Inadequate ventilator flow rates

Mental illness

Uremia Drug side effects

Disorientation

Sleep deprivation

NoiseInability to communica

teCold room

Uncomfortable

mattress or pillow

Traction on endotrache

al tube

Sedation

SedativesCauses for Agitation

Sedation Analgesia

“ICU Sedation”

Amnesia Hypnosis Anxiolysis

Patient Comfort