Pain, Agitation/Sedation, Delirium, Immobility, Sleep Flashcards
Pain
unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
Agitation
condition characterized by apprehension, increased motor activity, and autonomic arousal; may also be manifested by fearful withdrawal
agitation - state of anxiety accompanied by motor restlessness
Delirium
syndrome characterized by acute cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or altered level of consciousness
Delirium cardinal features
disturbed level of consciousness (decreased clarity of awareness of environment) with a reduced ability to focus, sustain, or shift attention
either a change in cognition (memory/disorientation/language) or development of a perceptual disturbance (hallucinations/delusions)
Pain and analgesia
pain is poorly treated in hospitalized pts
most (>/=50%) ICU pts experience pain: report as a significant source of stress, many unable to self report pain, may be procedural (intubation, surgery, changing wounds) and at rest
associated with physiologic + psychological consequences: agitation, chronic pain (potentially debilitating), health-related QOL
Pain related stress response
increases sympathetic nervous system activation, raises catcholamine levels
vasoconstriction, impaired tissue perfusion
catabolism/hypermetabolism
impaired wound healing/increased wound infection
immunosuppression
can alter breathing patterns and mechanics, can contribute to hypermetabolic response to trauma
Pain assessment
needs to be routinely monitored in ICU (not all pts will be able to speak/assess pain)
gold standard - avoid stigma
If unable to self report pain assessment
behavioral pain scale
critical care pain observation tool
proxy report
Behavioral pain scale (BPS)
facial expression, upper limb movements, compliance with mechanical ventilation
Critical care pain observation tool (CPOT)
facial expression, body movements, muscle tension, compliance with mechanical ventilation OR vocalization
Analgesia
preemptive analgesia should generally be used in advance of painful procedures
in general, IV opioids preferred for non-neuropathic pain in critically ill pts: all available IV opioids are equally effective when titrated to similar endpoints; opioids may have sedative effects
Non-opoiod analgesics may be used to
decrease opioid requirements (multi-modal approach)
acetaminophen, neuropathic pain meds (gabapentin, pregabalin, carbamazepine), potentially NSAIDs (routine use not recommended, may be used for procedural analgesia, drawback is bleeding risk), ketamine (post surgery)
Opioid pharmacology
fentanyl and morphine are most common
also have hydromorphone, methadone, and remifentanil
respiratory depression is dependent factor on how aggressive tx is
can administer as bolus dosing or continuous infusion
Agitation/sedation
agitation = state of anxiety accompanied by motor restlessness
frequent in critically ill pts, associated with adverse clinical outcomes: ventilatory dysynchrony, inappropriate verbal behavior, physical aggression, increased motor activity, increases in oxygen consumption, inadvertent removal of devices and indwelling lines and catheters
Agitation/sedation may lead to
harm of pts and/orcaregivers
up to 70% of ICU pts, 40% may exhibit severe or dangerous agitation
Agitation/sedation underlying causes
pain (one of the big causes), mechanical ventilation, delirium, hypoxia, hypotension, withdrawal (ETOH, drugs)
Treatment of agitation
nonpharmacologic efforts: maintenance of pt comfort, provision of adequate analgesia, frequent reorientation, optimization of environment to maintain normal sleep pattern (to decrease other consequences), many pts requiring mechanical ventilation will require some pharmacological sedation
pharmacologic treatment to supplement our non-pharmacologic efforts
Sedation
act of calming, especially by the administration of a sedative drug; mainstain for treatment of agitation/anxiety in ICU
Hypnosis
state of minimal motor activity that is physically similar to sleep; state of altered consciousness, artifically induced
Anxiolysis
reduction of emotional and physical responses to real/perceived danger
Indications for sedatives poorly defined
adjuncts for anxiety and agitation
nonpharmacologic efforts to reduce anxiety may be supplemented with sedatives
many pts requiring mechanical ventilation will require some pharmacological sedation
Sedatives may reduce
the stress of mechanical ventilation, relieve anxiety, and prevent agitation-related harm
pharmacologic sedation should be started after providing adequate analgesia and treating reversible physiological causes
should NOT be used as a method of restraint, coercion, discipline, convenience, or retaliation
Over sedation is problematic
leads to increase time on mechanical ventilation, increase ICU and hospital length of stay, obscure neurological function testing, and neurotrauma/neurologic disorders
Goal of treating agitation-sedation
adequate sedation, but not over sedatino
LESS is BEST –> light sedation
calm arousable pt, able to purposefully follow simple commands; potential benefits: decrease duration of mechanical ventilation, decrease ICU length of stay, possible decrease in mortality
efforts to achieve light sedation should be employed - daily sedation interruption (spontaneous awakening trial), nursing-protocolized targeted sedation
Assessment of sedation - subjective
assessment facilitates titration of sedatives to pre-determined endpoints
subjective assessment is difficult in pts with altered level of mentation or inability to outwardly express anxiety; scales used - richmond-agitation-sedation scale (RASS) and sedation-agitation scale (SAS); both used to assess agitation and titrate the sedation
Assessment of sedation - objective
objective assessment: tools/algorithms using quantifiable parameters; ex. bispectral index, autidory evoked potentials
Bisprectral index (BIS)
EEG assessment
digital scale from 100 (completely awake) to 0 (isoelectric EEG)
guidelines suggest using in pts in whom other measures are not feasible (ex. deep sedation, neuromuscular blockade)
do NOT recommend BIS monitoring in all sedation ICU pts
recommend EEG monitoring for non-convulsive seizure activity in ICU pts with known/suspected seizures or to titrate meds to achieve burst suppression
Properties of the ideal sedative agent
rapid onset and offset; minimal respiratory depression; lack of cardiovascular effects; inactive or absent metabolites; no drug interactions; consistent PK; no tolerance or withdrawal; analgesic sparing; inexpensive; does not contribute to delirium or long term impairments in cognition
Sedative drugs used in the ICU
benzodiazepines: lorazepam, midazolam, diazepam
propofol
dexmedetomidine
Benzodiazepines MOA
bind and activate a specific site on GABA receptor –> facilitate inhibitory action of GABA on neuronal impulse transmission –> hyperpolarizes cells, more resistant to excitation
Benzodiazepines have ideal properties
anxiolysis; hypnosis; amnesia –> antegrade amnestic effects; anticonvulsant and muscle relaxant effects; elderly more sensitive; tolerance may be seen with chronic administration; drugs primarily used in ICU: lorazepam, midazolam
Benzodiazepine AEs
respiratory depression (dose dependent; @ high doses)
cardiovascular effects (usually minimal, may include hypotension, tachycardia)
withdrawal possible, esp following large doses, prolonged duration, and abrupt discontinuation: may be severe, risk of seizures (more careful with underlying seizure disorder), gradual tapering of doses is required
delayed emergence from sedation: prolonged infusion –> saturation of peripheral tissues, advanced age, hepatic/renal insufficiency (midazolam)
may be associated with longer duration of mechanical ventilation compared to propofol or dexmedetomidine
potential association with delirium
Benzodiazepines dosing
can be used as continuous or bolus dosing