Sedation Use in the Critical Care Environment

Lisa Notley LP in Critical Care Royal Bournemouth Hospital & Christchurch NHS Foundation Trust Bournemouth University

Aims
To review sedation use in critically ill Draw upon clinical experience of changing a sedation scoring tool Discuss sedations holds in relation to care bundles and patient outcomes.

Why use sedation?

Sedation is an essential component of the management of intensive care patients. It is required to relieve the discomfort and anxiety caused by procedures such as tracheal intubation, ventilation, suction and physiotherapy. It can also minimise agitation yet maximise rest and appropriate sleep (Werrett, 2003)

Agitation.
complicates management in the ITU leads to further complications is characterised by abnormal vital signs Characteristics continual movement, fidgeting, pulling at dressings & sheets, attempting to remove catheters or tubes, shouting, calling out, moaning, unable to follow requests

General aims of sedation

Allows sleep minimises discomfort abolishes pain alleviates anxiety facilitates organ support facilitates nursing care allows communication expediates weaning

Two Extremes
Over-sedated Hypotension Prolonged recovery Delayed weaning Gut ileus DVT Nausea & vomiting Immunosuppression Under sedation Hypertension Tachycardia Increased O2 consumption Myocardial ischaemia Atelectasis Tracheal tube intolerance Infection

COMPONENTS OF SEDATION REGIME

ANXIOLYSIS SLEEP ANALGESIA MUSCLE RELAXATION

Ideal sedative ...

Analgesia Hypnotic Amnesic short onset and offset of action no effect on cardiovascular or respiratory function Allow natural sleep Metabolic pathways independent of hepatic and renal function Non-cumulative Inactive metabolites Modest cost

Back to reality

...

Cardiovascular compromise Respiratory depression Dependence Increased tolerance (down regulation of receptors) Prolonged ventilator time Increased risk of nosocomial pneumonia Muscle wasting Increased risk of DVT Prevention of REM sleep Amnesia / Delirium Increased need for tracheotomy

Drugs used
typically drug combinations
Benzodiazepines Propofol Barbituates Phenothiazines Clonidine chlormethiazole ?Ketamine Chloral hydrate Volatile agents Morphine Fentanyl Alfentanil Remifentanil

??muscle relaxation
Early resuscitation Refractory hypoxaemia Raised ICP Status epilepticus and tetanus Pateint transfer and inverse ratios Prone ventilation

Ventilation Care Bundle & Sedation

Started in the USA and introduced in UK in 2002 Group of evidenced based elements which have been shown to improve patient outcomes & collectively audited review standards of treatment (Berenholtz 2002) DOH, NICE & Modernisation Agency protocol based care

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery (NICE )

Ventilation Care Bundle

DVT prophylaxis Gastric ulcer prophylaxis Sedation holds Head of bed elevation (30 degrees) Also BM control Use of steroids in catecholamine dependent septic shock Audit & monitoring compliance is a key aspect i.e. sedation costs, time on ventilator, ICU LOS

Whats the score?

HUMANE? OVER OR UNDER SEDATED PATIENT PHYSIOLOGICAL SAFETY PATIENT PHYSICAL SAFETY PARALYZING AGENTS STOP!! WHICH TOOL???

TOOLS/SCALES
RAMSEY SCALE COHEN AND KELLY SCALE THE NEWCASTLE SCALE ADDENBROOKES/CAMBRIDGE SCALE NEW SHEFFIELD SCALE BLOOMSBURY SCALE Intensive Care Society EEG (Bispectral Index)

The benefits of a sedation protocol

Removes the effects of external influences All nurses aware of common goal Sedation level will be much lighter (+/- sedation vacation) Aim to reduce ventilator time Reduced need for tracheotomy Reduced rate of complications Increase patient throughput Cost savings

A little about my unit

The Critical Care Unit consists of the Intensive Care Unit (ICU) and High Dependency Unit (HDU), together comprising a total of 10 critical care beds. The ICU & HDU admit over 800 patients a year, with a wide variety of conditions. 20% are routine admissions for post-operative care following major surgery, the remaining 80% are emergency admissions. The critical care unit receives patients from all specialities and has particular expertise in the care of patients following oesophageal and vascular surgery.

RBH Critical Care Adopted System for Sedation Scoring

Old sedation scoring method: Adaptation of Addenbrookes Sedation Score 0 Agitated 1 Awake 2 Roused by voice 3 Roused by pain/coughs on suction 4 No response/unrousable P paralysed

Sedation scoring flow chart 2004

A suggested time for this is 08:00, however please always confirm with nurse in charge before making any alterations

Is patient receiving intravenous sedation?

YES
Unless directed otherwise by anaesthetist, transfer over to correct infusions after confirming with Nurse In Charge (NIC)

Is patient receiving sedation as per protocol?

NO

YES Review when 6 hours of continuous sedation has been reached or at a time agreed with NIC / anaesthetist.

Has patient received continuous intravenous sedation for 6 hours or more? YES

NO

If appropriate consider stopping infusions until patient rouses to satisfactory level or sedation score 14 plus

N.B. Please note that the sedation protocol guidelines state the following: Morphine infusion 1-8mgs/hr (bolus of 2-5mg IV). Propofol 1% 1-50mls/hr. Midazolam infusion 1-10mgs/hr (bolus of 1-2.5mg IV).

SEDATION SCORING TOOL ADAPTED FROM NEWCASTLE SCALE RESPONSE TO NURSING PROCEDURES OBEYS COMMANDS PURPOSEFUL MOVEMENT NON-PURPOSEFUL MOVEMENT NONE RESPIR TION EXTUBATED SPONT. BREATHS INTUBATED/TRACHE BiPAP AND BREATHS RESPS AGAINST VENTILATOR FULLY VENTILATED GR DES OF SED TION FORM THE AWAKE ASLEEP LIGHT SEDATION MODERATE SEDATION DEEP SEDATION ANAESTHETISED 5 4 3 2 1 4 3 2 1

COOK

ND P LM

EYES OPEN

COUGH SPONTANEOUS STRONG SPONTANEOUS WEAK ON SUCTION ONLY NONE 4 3 2 1

SSESSMENT 17-19 15-17 12-14 8-11 5-7 4

FOR SPONTANEOUS COMMUNICATION ADD

IF YOUR P TIENT IS REQUIRING BOLUSES OF SED TION ON TOP OF N INFUSION PLE SE DD B ON YOUR CH RT T THE TIME GI EN FOLLO ED BY THE MOUNT

DS/PB/RR

Continue reviewing sedation score PRN

On recommencement use boluses as stated below and run infusions at a reduced rate until sedation score of 11-14 is reached or patient comfortable and compliant. Review sedation score prn (hourly if necessary) and repeat daily to ensure consistant sedation levels.

1989 4 3 2 1

SPONTANEOUSLY TO SPEECH TO PAIN NONE

New Sedation Score with Holiday

3 Agitated and restless 2 Awake and uncomfortable 1 Aware but calm 0 roused by voice -1 roused by touch -2 roused by painful stimuli -3 unrousable A natural asleep P paralysed Give bolus or start infusion Reduce infusion rate No change Stop infusions Recommence at lower rate when sedation score reaches desired level 3 2 1 0 -1 -2 -3 Hourly sedation score

If your patient meets with the protocol for stopping sedation, please stop at 11.00 and access using the above tool. If the patient scores 2 on assessment consider analgesia or re-sedation

If patient score 3 and is unable to settle sedation may be recommended If your patient does not meet the protocol and therefore sedation is not stopped, please document that it was considered.

BED N : KEY: Y-Yes N No C N/A Cons dered but not appropr ate

Date

Sedat on Bed DVT Pept c Co ents S gnature Ho d e evat on Prophy ax s U cer and >30 Prophy ax s Quer es degrees

Sedation Holds/Holiday/Interruption!!

Guideline: Objective:

Sedation scoring with holiday Break of all sedation

Sedation must be identified by multi disciplinary team on admission then subsequently on daily ward round or with any significant change in patients condition. All patients receiving sedation / analgesic drugs will have a sedation score assessment hourly. All patients to have their sedation stopped following physiotherapy in order to assess depth of sedation and neurological status. Timing between 11.00am and 12.00 midday. Sedation will not be withheld in patients receiving muscle relaxants. If sedation is assessed as being required recommence at 50% of previous dose and titrate to achieve a level acceptable for the patient. Boluses of sedation required prior to procedures or therapeutic interventions must be documented on the ITU observation chart. Sedation scoring is inappropriate when patient receives paralysing agents. However it is essential to assess patients sedation level prior to commencing muscle relaxants. The patient must be constantly observed for autonomic signs of under-sedation, i.e. unexplained tachycardia, hypertension or sweating. Where there are no complications and on consultation with the anaesthetist, paralysing agents should be discontinued daily for assessment or neuromuscular blockade. Airway pressure will be observed for signs of increase and the patient observed for signs of fighting the ventilator. The patients sedation score will be recorded and sedation adjusted accordingly once paralysis is reversed. Patients not being sedated should have a documented Glasgow Coma Scale score at least once per shift. This Unit uses propofol in short term ventilation. Longer periods of ventilation may require midazolam and morphine, although this should be discussed with the anaesthetic team and reviewed on daily ward round.

PROTOCOL FOR SEDATION HOLIDAY

SEDATION HOLIDAY 11am 12pm Patient sedated only Patient sedated and paralysed

Yes

No

No

Yes

Fi02 < 60% PEEP < 10CM

ASSESS GCS

Follow sedation Only flow chart

Fi02 < 60% PEEP <10CM

No

Yes

No

Yes

Maintain sedtion for further 6 hours

Patient neurologically intact

Patient Neurologically intact

RE-ASSESS

No

Yes

Yes

No

Maintain sedation for further 6 hours

Stop sedation

Stop paralysing agent

Maintain sedation & paralysing agent

RE-ASSESS

ASSESS

Assess if stable 1 hour stop sedation

REASSESS IN 6 HOURS

N.B. Neurologically intact = no history of head injury / #C spine injury

RE-ASSESS

Monthly Audit Results .v. recently published report

100 90 80 70 60 50 40 30 20 10 0 M y-05 Jun-05 Jul-05 Aug-05

ed hold bed elev V G

East Surrey Hospital

Cruden, E. 2005 an evaluation of the impact of the ventilator care bundle. Nursing in Critical Care. 10 (3) 242246.
100 90 80 70 60 50 40 30 20 10 0 2002 2003

top he d elev DV G

Sedati

and Anal esia in Sepsis

 Sedati n pr t l f r echanicall entilated patients ith standardized subjecti e sedati n scale tar et.
Inter ittent bolus Continuous infusion ith dail awakening/retitration Grade
Kollef, et al. Chest rook, et al. CCM Kress, et al. M ; ; ; : : : -

Conclusion

Sedati i i tensi e care means caring for the physical and psychological comfort of critically ill patients recei ing organ support Competence, compassion and communication are basic elements; drugs only provide part of the care (oh 2003)

Other approaches are just as important

Good communication with regular reassurance Environmental control such as humidity, lighting, temperature, noise Explanation prior to procedure Management of thirst, hunger, constipation, full bladder Variety for the patient radio, visits from relatives, washing Appropriate diurnal variation

References
ansen-Flaschen J, easure f edating 7 . Jacobi J, Fraser , and nalgesics in the wen J, lo ano : eyond the a sey ale: eed f r alidated rug fficiency in the Intensive are nit. ritical are ed 97 ; :7 -

ursin , et al: . linical ractice uidelines f r the use f edatives ritically ill. ritical are ed.; : 9-141. ntinuous i.v. sedation is associated with 48.

llef , evy T, hrens TS, et al: 199 . The use f prolongation f echanical ventilation. hest, 114: 41 4

ress J , hl an S, nnor F, all J : . aily interruption f sedative infusions in ritically ill patients undergoing echanical ventilation. ngl.J ed; 42:1471-7. a sey , Savage TM, Si pson alphadolone. MJ; 2:256-259. J, et al: 1974 ntrolled Sedation with lphalax ne-

iker , icard JT, Fraser ; 1999. rospective valuation f the Sedation-agitation Scale f r dult ritically Ill atients. rit. are Med; 27: 25-1329. errett, . 2003. Sedation in Intensive are atients. pdate in naesthesia, issue 16 article 5. n-line, available at http://www.nda. x.ac.uk/wfsa/ht l/u16/u1605_01.ht essed n 30/10/05.