PAD Launch Day - Yoanna Skrobik

Download PAD Launch Day - Yoanna Skrobik

Post on 15-Jul-2015

263 views

Category:

Healthcare

0 download

Embed Size (px)

TRANSCRIPT

<p>Prsentation PowerPoint</p> <p>The ICU challenge translating the evidence into everyday practice: managing Pain, Agitation and DeliriumYoanna Skrobik MD FRCP(c) MSc.</p> <p>11Conflicts of interestMember, SCCM Pain, Agitation and Delirium guidelines writing committeeVice-chair, SCCM Pain, Agitation, Delirium, Early Mobility and Sleep guidelinesMember, SCCM family-centered care guideline writing committeeInvestigator initiated research funding, HospiraAcademic chair, Universit de Montral</p> <p>22Academic chair</p> <p>AstellasMerckPfizerBaxterHospiraOtsukaNovartisLilly</p> <p>Why would you evaluate pain, agitation, delirium?PainlessnessReassuranceFeeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000 Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May</p> <p>planPain assessment and managementSedation and level of consciousness alterations in the ICUDeliriumAdding mobility and sleepWhy assessing pain, sedation and delirium mattersWhy are we not all doing it</p> <p>pain</p> <p>6painIncidence of pain:Adult M&amp;S ICU patients consistently experience pain, at rest and with routine ICU care (mobilization, suctioning).Pain in adult cardiac surgery patients, especially women, (i.e., incisional pain due to coughing, respiratory care procedures, and mobilization) remains prevalent and poorly treated .Procedural pain is common in adult ICU patients .</p> <p>7Memories and perceptions in ICU survivors: a multidimensional questionnaire G Hernandez, R de la Fuente, C Romero, ME Naranjo, M Zanolli, N Barticevic, L Castillo, G Bugedo </p> <p>Thirst (76%), sleep deprivation (66%) and isolated pain (52%) predominated in factual memories</p> <p>8Pain assessmentShould be routine, right?</p> <p>9Evaluation of pain in my ICUEven though assessment was done 90% of the timeNo severity scale used in 17% of patients Evaluations were not done according to the pain reported by the patient when scales were used 20% of the time </p> <p>Correlation between gold standard adjudicators and nurses was excellent R= 1,000 (0,88 when using all evaluations)</p> <p>Obstacles to the use of the NRS: Assumption that the patient has no painNurses relying on their own evaluation of the patients pain10painRoutine pain assessments in adult ICU patients are associated with improved clinical outcomes. 11Assessing Pain Improves OutcomesPayen JF, et al. Anesthesiology. 2009;111:1308-1316.</p> <p>Outcome Day 2 Pain Assessment?Unadj. ORP-valueAdjusted ORP-valueNoYesICU Mortality22%19%0.910.691.060.71ICU LOS18 d13 d1.70&lt; 0.011.430.04MV duration11 d8 d1.87&lt; 0.011.400.05Vent-acquired pneumonia 24%16%0.61&lt; 0.010.750.21</p> <p>1212Correlation between pain assessments and analgesic administration in critical careLess patients evaluated and more treated with analgesics without protocolPain evaluation done routinely in 21% units surveyed in 20060255010075Patients (%)ProtocolNo Protocol**AssessedTreated1. Payen JF, et al. Anesthesiol. 2007;106:687-695.2. Martin J, et al. Crit Care. 2007;11:R124. * P &lt; 0.01 vs. ICUs using a protocol</p> <p>13Measuring painSelf-reporting of pain remains the gold standard </p> <p>14</p> <p>Patient-directed pain control. Patient assessment</p> <p>16And this is what it looks like</p> <p>And in the patient unable to self-report18Keep in mindRoutine pain assessments in adult ICU patients are associated with improved clinical outcomes. Self-reporting of pain remains the gold standard. For medical, postoperative or trauma adult ICU patients unable to self-report, the BPS and CCPOT (French/ English) pain scales are considered to be the most valid and reliable. vital signs (or observational pain scales that include vital signs) are unreliable in pain assessment in adult ICU patients.</p> <p>19Pain assessment valueCompliance and documentation of pain assessments Impact of pain assessment on analgesic and other medications Impact of pain assessment on level of pain Impact of pain assessment on duration of mechanical ventilation Impact of pain assessment on occurrence of adverse events and complications Impact of pain assessment on patient satisfaction Impact of pain assessment on ICU length of stay (LOS) Impact of pain assessment on mortality </p> <p>sedation</p> <p>21sedationNo text</p> <p>Monitoring sedationThe RASS and SAS scales are valid and reliable for measuring quality and depth of sedation in adult ICU patients .</p> <p>23Sedation-Agitation Scale (SAS)Riker RR, et al. Crit Care Med. 1999;27:1325-1329.Brandl K, et al. Pharmacotherapy. 2001;21:431-436.Score StateBehaviors7Dangerous AgitationPulling at ET tube, climbing over bedrail, striking at staff, thrashing side-to-side6Very AgitatedDoes not calm despite frequent verbal reminding, requires physical restraints5AgitatedAnxious or mildly agitated, attempting to sit up, calms down to verbal instructions4Calm and CooperativeCalm, awakens easily, follows commands3SedatedDifficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off2Very SedatedArouses to physical stimuli but does not communicate or follow commands1UnarousableMinimal or no response to noxious stimuli, does not communicate or follow commands2424Richmond Agitation Sedation Scale (RASS)ScoreState+ 4Combative+ 3Very agitated+ 2Agitated+ 1Restless0Alert and calm-1Drowsyeye contact &gt; 10 sec-2Light sedationeye contact &lt; 10 sec-3Moderate sedationno eye contact-4Deep sedationphysical stimulation-5Unarousableno response even with physicalVerbal StimulusPhysical Stimulus25sedationDepth of sedation vs. clinical outcomes:Maintaining lighter levels of sedation in adult ICU patients is associated improved clinical outcomes ( duration of mechanical ventilation and length of stay).Maintaining lighter sedation levels increases physiologic stress response, but not incidence of myocardial ischemia .The relationship between depth of sedation and psychological stress in these patients is unclear .sedative medications titrated to maintain light (vs. deep) levels of sedation in adult ICU patients are associated with better outcomes .26consciousness</p> <p>Alteration of consciousness and outcomeComa is bad for you</p> <p>In my ICU the baseline RASS is -0.4wake up and breathe</p> <p>Why is it that when an ICU caregiver digs himself into a hole he talks about the light at the end of the tunnel?</p> <p>Who benefits the most?adjustment vs. interruption</p> <p>Outcomes related to sedationsedation strategies using non-benzodiazepine sedatives have better outcomes than benzodiazepine infusions in mechanically ventilated adult ICU patients.</p> <p>analgesia should be evaluated prior to sedation in adult ICU patients who are mechanically ventilated .</p> <p>38delirium</p> <p>Van der Mast. PhD Thesis, Delirium After Cardiac Surgery, Erasmus University, Rotterdam, 1994</p> <p>39Delirium and outcomesDelirium is strongly associated with increased mortality and LOS in adult ICU patients.</p> <p>40</p> <p>41delirium and distress</p> <p>Breitbart W et al. Psychosomatics 2002;43:183</p> <p>42</p> <p>CAM-ICU(Confusion Assessment Method-ICU) Delirium scales ICDSC(Intensive Care Delirium Screening Checklist)http://www.icudelirium.co.uk/www.icudelirium.org</p> <p>43Delirium nomenclature</p> <p>Delirium and its consequences44Delirium preventionearly mobilization of adult ICU patients reduces the incidence and duration of delirium.</p> <p>45Protocol to address patient views on what is important in the ICUPainlessnessReassuranceFeeling safe Journal of Nursing Scholarship. 32(4):361-7, 2000 Information, orientation, cognitive abnormalities American Journal of Critical Care. 9(3):192-8, 2000 May</p> <p>46</p> <p>47Analgesia Sedation Delirium ProtocolANALGESIASubjective Pain Scale Short acting narcotics SEDATIONSubjective Sedation Scale (ex RASS)Avoidance of oversedation and caution with benzodiazepinesDELIRUMSubjective Delirium Scale (ICDSC or CAM-ICU)Agitation</p> <p>BeforeAfterGoing home45.2%52.2%P=0.024Patient-driven analgesia, sedation and delirium management in 1200 patients</p> <p>50Delirium symptoms</p> <p>Specifically, level of consciousnesswakefulness</p> <p>Does it influence delirium assessment?</p> <p>CAM-ICU(Confusion Assessment Method-ICU) Delirium scales ICDSC(Intensive Care Delirium Screening Checklist)http://www.icudelirium.co.uk/www.icudelirium.org</p> <p>5353</p> <p>Assessment of Delirium Relative to Daily Sedative Interruption</p> <p>JT Poston MD, MW Sjoding MD, AS Pohlman RN MSN, BK Gehlbach MD, JB Hall MD, JP Kress MD</p> <p>Daily Assessment Schematic DiagramCAM-ICURASS4-VCACAM-ICU4-VCADaily Sedative Interruptionif 2 VC, repeat in 15 minutesif 3 VC or 2 hours after DSI start 30 minutes after DSI startDaily AssessmentSecond Assessment after DSIRASSDaily Assessment Schematic DiagramCAM-ICURASS4-VCACAM-ICU4-VCADaily Sedative Interruptionif 2 VC, repeat in 15 minutesif 3 VC or 2 hours after DSI start 30 minutes after DSI startDaily AssessmentSecond Assessment after DSIRASS</p> <p>Assessment of Delirium Relative to Daily Sedative Interruption</p> <p>JT Poston MD, MW Sjoding MD, AS Pohlman RN MSN, BK Gehlbach MD, JB Hall MD, JP Kress MD</p> <p>48%higher delirium identification during sedation administration when compared to assessments made in the same patients after sedation was lightened to the point of wakefulness. This difference persisted for analysis of MV days, ICU days, and total hospital days </p> <p>wakefulnessDelirium assessment is sensitive to the timing of evaluation relative to sedative/analgesic infusion and interruption This robust effect can significantly impact assessed days of delirium well beyond the administration of sedatives/analgesics</p> <p> ImplicationsA standardized assessment accounting for sedatives/analgesics and daily interruption should be part of future investigationsDelirium due solely to sedative/analgesic infusion may portend a different prognosis than delirium that persists in its absence</p> <p>Awake patients mean</p> <p>Pain can be assessedSedation is adjustedDelirium is minimizedMobility can be implementedSleep can be optimizedHow can optimal patient care be provided?a multidisciplinary ICU team approach, that includes provider education, preprinted and/or computerized sedation protocols and order forms, and a quality rounds checklist, can be used to facilitate analgesia, sedation and delirium management in adult ICUs...</p> <p>58But we all know. it takes an average of 17 years for new knowledge to have an impact on bedside standards of practicechange</p> <p>Canadian collaborative</p> <p>Measuring and implemening changeChampionsRealistic plan and follow throughObjective measures</p> <p>alternativesWeb-based teachingWeb-based benchmark comparisonsEngaging staffEngaging patients and families</p> <p>Engaging staff</p> <p>Engaging patients:Mrs Ms taking stick</p> <p>recapPain assessment and managementSedation and level of consciousness alterations in the ICUDeliriumAdding mobility and sleepWhy combining pain, sedation and delirium mattersWhy are we not all doing it</p> <p>Making patient care better</p> <p>71Thank you</p> <p>Grfico347.828.5194.71515106025403053814.29.514.5</p> <p>neverfewmostalwayssensorial memories%</p> <p>Tabla ResultadosS1S2S3S4S5S6S7S8S9S10S11S12S13S14C1C2C3C4C5C6C7C8C9C10C11C12C13C14C15C16C17D1D2D3D4D5D6D7D8D9D10D11D12D13D14D15D16D17D18D19D20D21D22D23D24D25P1P2P3P4P5P6F1F2F3F4F5F6F7R1R2n4241424242424242424242424242424242424242424242414242424242424242424242424240404040403942424241414142404242424242414141414141424240423940SI14%7%7%10%5%14%31%26%29%2%38%38%38%12%45%31%36%40%19%26%74%81%54%31%10%29%17%38%60%33%5%36%14%12%35%10%10%12%56%44%39%57%57%33%40%24%46%41%12%22%29%62%40%23%NO74%78%79%76%81%71%55%60%60%81%48%48%48%74%40%57%52%48%69%62%10%5%22%45%74%57%69%48%26%52%79%50%71%74%28%71%74%71%27%39%44%29%29%50%45%56%34%39%68%59%51%36%57%70%Siempre43%5%38%5%3%5%18%10%75%La mayora17%10%5%0%0%18%18%10%Ocasionalmente10%24%18%3%8%25%5%7%Nunca0%48%25%78%75%38%10%29%5%no poda expresarlas5%no los expreso12%Agrado5%Desagrado17%No siente dolor23%33%Ritmo normal10%Rpido13%Lento25%Muy lento38%Ruido0%Luces3%Posicin8%Angustia3%Dolor0%Otra13%poda dormir35%Depende18%Ms optimista43%Igual que siempre48%Ms pesimista7%No Recuerda12%15%14%14%14%14%14%14%12%17%14%14%14%14%14%12%12%12%12%12%17%14%14%24%24%17%14%14%14%14%14%14%14%17%14%14%14%15%15%15%15%15%15%19%17%17%17%17%17%14%15%14%17%17%14%45%20%20%20%20%20%20%2%2%3%2%3%8%total100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%14%100%100%100%100%100%100%100%100%121%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%100%77%100%100%100%100%100%100%100%100%100%100%100%100%100%</p> <p>Paso del tiempocambio visin del mundocambio visin de Diosmundo post UTI</p> <p>TotalNNombreApellido1Apellido2RUTSexoEdadDireccinTelfono1Telefono2F. IngresoF. EgresoD. UTID. HosptIngresoMotivo ingresoDiagnsticoPatologa Cr. AgragadaD. VMMotivo VMFalla desteteDVA1DVA1 dosisDVA2DVA2 dosisDVA3DVA3 dosisSedacinD. sedacinAPACHESOFAPa/FibilirrubinPlaquetasCrat plGlascowPCRLactatoCostosComentariosFecha entEntrevistadorLugar entComentario entS1S2S3S4S5S6S7S8S9S10S11S12S13S14C1C2C3C4C5C6C7C8C9C10C11C12C13C14C15C16C17D1D2D3D4D5D6D7D8D9D10D11D12D13D14D15D16D17D18D19D20D21D22D23D24D25P1P2P3P4P5P6F1F2F3F4F5F6F7R1R21EnriqueDelgeonManieu3869242-9161San Pascual 49002-22888649874810108/11/0213/11/02611A, 1By pass gstricoObesidad mrbidaHTA, DM4220000001, 23941551.11590001.6315211.95215787InternetinternetNada222222222222221112221112222210202122422211110117222222222221La verdad es que estuve 3 das dormido o casi, de tal modo que no recuerdo mucho y los dolores que seguramente tuve por la operacin no los sent. Dira que lo ms desagradable de todo fue la sed de lquido tanto de da como de noche. Respecto a la conex2GerardoVillablanca8069346-k143Los Olmos 2568, la pintana, RM02-852124902/12/0217/01/032345A,2Shock spticoSepsis origen abdominal. Falla orgnica mltipleHTA95210.242.50038117710.4630007.1810.8122391439310/01/03G.H, R.F2Nada222221221222121211111111212212120222100102422211112223182112222201102Angustia3DarioVillalon5508385-1157Paradero7 pajaritos altura 1900, RM02-741314730/10/0203/12/0250612, BSDRASDRA post revascularizacin IAM masivoHTA, DM, ACxFA, valvulopata mitral y tricuspidea, enf coronaria 3 vasos261, 4244.200001, 219213265.66340001.731317.51.33694884101/04/03G.H1Muy cristiano y con fe22222212221112212222113, 41122221120222210012422211122223282122222201102NecesariaExperiencia necesaria4VictoriaAlvaradoBarrientos4954635-k263San Martn 745, Castro065-6324429774403809/05/0217/07/0238602, AShock spticoPeritonitis, LNHEsplenectoma, DHCr, TVP vena porta, coleccin abdominal21521000001, 2212772002.11550001.541518.87.73133278516/07/02G.H, R.F2Nada122212221112122222211151221212511222200012012111221188131122122221102Buena atencin, pensar en morir lejos de su casaSensacin de atencin ptima, UTI es initimisante, no tener claro los lmites5MariaFuentesCanales7817728-4240El retorno 2304, las condes, RM02-214310109/06/0204/05/0219191, APeritonitisBy pass gastrco, filtracin anastomosisObesidad mrbida, HTA, hipotiroidea, T. Bipolar123210.0500001, 2101252501, 213700001.021524.61.42113506327/08/02G.H1Nada222222212222121222221138822221021222200002222212113121, 4202222221100...</p>