logo sedation in the icu prof. bahaa ewees ain shams university
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LOGO
Sedation in the ICU
Prof. Bahaa EweesAin Shams University
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Contents
Definition of Sedation1
Importance of Sedation in the ICU2
Monitoring of Sedation3
Mode of Sedation4
Examples of Sedation Protocol5
Delivery of Sedation5
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Sedation: depression of awareness and reduction of the response to external stimuli
Definition of Sedation1
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Plays a vital role in the care of critically-ill patients and encompasses wide spectrum of symptom management.
Heavy sedation is used to facilitate ETT insertion and M.V. (replacing NMBA)
Importance of Sedation2
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Monitoring of Sedation3
Done HourlyTo avoid:
Under-Sedation
Heavy Sedation
↑ catecholamines Coagulopathy and Immune Suppression
* ↑ duration of ICU stay and M.V.* Side Effects of sedationdrug
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Monitoring of Sedation3
1. Scoring Systems
2. Instrumental
BIS
EEG
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Mode of Sedation4
Non Pharmacological
Pharmacological
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Mode of Sedation4
Non Pharmacological
1. Continuous communication with the patient
2. Good Hydration
3. Good Nutritional Support
4. Physiotherapy Ve………..ry Important
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Mode of Sedation4
Pharmacological
A. Drugs used for Induction of Anaesthesia
B. Benzodiazepines
C. Neuroleptic Agents
D. Opioids
E. Clonidine and Dexmedetomedine
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Pharmacological
A. Drugs used for Induction of AnaesthesiaA. Propofol
Widely used due to high clearance and metabolism. Dose: 0.5 – 4 mg/kg/h. Problems
↓ HR ↓ BP Propofol Infusion Syndrome
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Pharmacological
Propofol Infusion Syndrome Rare Manifestations
↓ pH Arrhythmias Cardiovacular collapse Acute renal Failure Hyperkalaemia
Risk factors Sepsis Severe Cerebrovascular Stroke High propofol doses (> 5 mg/kg/h.)
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Pharmacological
Propofol Infusion Syndrome (cont.) Recommendations
Once suspected, stop infusion Dose should be < 4mg/kg/h. Duration should be less than 24 h. Daily monitoring of triglyceride levels and renal
function.
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Pharmacological
A. Drugs used for Induction of AnaesthesiaB. Thiopental used by infusion (for status epilepticus to
control convulsions) Problems:
Low clearance Metabolized by redistribution Myocardial depression Accumulation
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Pharmacological
A. Drugs used for Induction of AnaesthesiaC. Etomidate Infusion Only BUT, ↓↓↓↓ adrenocortical
function
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Pharmacological
A. Drugs used for Induction of AnaesthesiaD. Ketamine Can be used for intubation in the ICU Sedation especially in asthmatic patient
BUT, ↑↑ CMRO2, Delirium, and hallucination
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Pharmacological
B. Benzodiazepines Acting on GABA receptors (the main inhibitory
neurotransmitter in CNS)
1. Midazolam Metabolized in liver to active metabolite Highest clearance among BZs Suitable for infusion (0.04 – 0.2 mg/kg/h.)
2. Diazepam Metabolized to active metabolite by liver Lowest clearance among BZs Suitable for oral use or bolus injection (2- 10 mg)
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Pharmacological
C. Neuroleptic Agents Haloperidol or Chloropromazine Used for delirium and psychosis in the ICU Can cause:
Respiratory depression Prolonged QT interval Arrhythmias
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Pharmacological
D. Opioids Provide analgesia and anxiolysis Better used by infusion Remifentanil (ultrashort acting opioid)
0.1 – 0.15 ug/kg/min.
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Pharmacological
E. Clonidine and Dexmedetomedine Alpha 2 Agonists
Can be used for sedation in both spontaneous and mechanically ventilated patients.
Dexmedetomedine is more potent than clonidine Shorter elimination t1/2
So, it is widely used nowadays for sedation
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Delivery of Sedation5
Intermittent Injection
Bolus Injection
Infusion
ConstantLevel ofsedation
1
Less chanceOf
Intermittentagitation
2
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Delivery of Sedation5
Sedation Holiday
Stopping the sedation infusion and allowing the patient to awake.
Restarted once: Patient fully awake and obeying commands, or Patient becoming agitated or uncomfortable
Should be done on a daily basis!This strategy ↓ duration of MV and Length of
stay in ICU.
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Example of Sedation Protocols6
Short term therapy< 72 h.
Hemodynamically stable?
YES
* Propofol infusion
* Opioid
- Remifentanil
- Fentanil
NO
* Alfentanil infusion
If necessary consider propofol infusion.
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Example of Sedation Protocols6
Long-term therapy> 72 h.
CONSIDER
1. Opioid
- morphine infusion
- Alfentanil infsion (if Renal failure)
2. Benzodiazepine
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