Sedation & Paralytic Therapy in the ICU

1
Sedation Paralytic Therapy in the ICU

• Leanna R. Miller, RN, MN, CCRN-CSC, PCCN-CMC,
  CEN, CNRN, NP
• Education Specialist
• LRM Consulting
• Nashville, TN

2
Objectives

• Identify the purpose for pain, sedation,
  paralysis management in the ICU patient
• Analyze and compare assessment methods for
  determining appropriate pain, sedation
  paralysis management.
• Recognize and apply the different
  pharmacotherapeutics used in the ICU for pain,
  sedation, paralysis.

3
Goals of Critical Care Management

• Save the salvageable and relieve suffering
• Peaceful dignified death without prolonging
  life
• Curative therapy should not supplant palliation
  of pain
• Use of state-of-the-art interventions
• Aggressive fast paced therapy according to need
• Quality pain management mandatory for all patients

4
Consciousness/Sedation
The Balance of Analgesia, Sedation, and
Paralytics to promote comfort
5
What is Sedation?

• Several Clinical Definitions
• process of establishing a state of calm
• promoting a sense of well-being
• reduction of anxiety and agitation through the
  use of pharmacotherapy
• Sedation is NOT analgesia
• 80 of Doctors and 40 of ICU nurses answered
  that benzodiazepines provided analgesia (1990s)

6
Pathophysiology Response of Stress and Anxiety

• Cardiovascular
• Release of systemic epinephrine and
  norepinephrine
• Elevated HR and BP
• Increased cardiac O2 demand
• Decrease end-organ perfusion
• Endocrine
• Release of Cortisol, Glucagon, Glucose
• Hyperglycemia

7
Pathophysiology Response of Stress and Anxiety

• Neurological
• Increased response and activation of peripheral
  pain fibers
• Increased sensation to pain
• Release of neurotransmitters in the brain
• Pain
• Agitation
• Delirium

8
Pathophysiology Response of Stress and Anxiety

• Immune
• Increased levels of prostaglandins, cortisol,
  glucose, cytokines,
• Increase anti-inflammatory response
• Decrease wound healing

SIGNIFICANT STRESS IN THE ICU PATIENT OVERALL
CAUSES ORGAN ISCHEMIA AND DECREASED HEALING
9
Analgesia

• Clinical Definition
• The absence of pain through the use of
  pharmacotherapy
• Acute and chronic pain in the ICU activates the
  stress response
• Patients with analgesia can still experience
  anxiety

10
PAIN THERAPY - Myth One size fits all or Set
and forget therapy. Its essentially a maintenance
therapy
11
Truths

• Majority of ICU patents suffer moderate/severe
  pain
• 40 are delirious cannot communicate
• 50 are either physically/emotionally distressed
• 10-20 have no hopes of cure --- end-of-life in
  ICU
• Balance between pain relief maintaining
  alertness
• Multidisciplinary team for multimodal therapies.

12
Pain in ICU

• Repeated episodes of acute pain? localized
• Surgery/tissue inflammation immobility
• catheter/ apparatus discomfort/ nasogastric
  orogastric tubes
• endotracheal intubation/ suctioning/ chest tubes
• phlebotomy/vascular access/physiotherapy
• routine turning positioning the patient

13
Types of pain in ICU

• Somatic most common localized ? opiates
• Visceral cramping colicky ? anticholinergics
• Neuropathic burning / shooting ?
  antidepressants
• Mixed type ? combination therapy
• Sustained or chronic pain of varying degrees

14
Inherent Problems

• difficult to differentiate due to lack of
  communication
• untreated pain affects all body systems
• synergistic effect of pain on anxiety,
  depression, sleep
• all modalities are unpredictable have adverse
  effects
• pain therapy to be tailored to individual needs.

15
Assessment of pain in ICU

• Pain as the 5th vital sign- requires frequent
  evaluation
• Cognitive impairment/delirium markers
• Behavioral (facial, FACS)
• Physiological (BP, HR, RR)
• Creative assessments (teaching hand movements,
  blinking
• Subjective quantification (numeric/graphic scales
  W-B faces)

16
Assessment of pain in ICU
17
(No Transcript)
18
Treatment of Pain

• treatment of perceived prevention of
  anticipated pain
• Opiates principal agents in ICU
• - potent / lack ceiling effects
• - mild anxiolytic sedative
• - relieves air hunger suppresses cough in
• respiratory failure
• - improved patient ventilator synchrony
• - effective antagonist naloxone
• lack amnesic effects /additional sedatives
  required

19
Treatment of Pain

• adjuvant / non-pharmacological / multimodal
  therapies
• Simple Relaxation must begin preoperatively
• Jaw relaxation
• Progressive muscle relaxation
• Simple imagery
• Music (either patient preferred or easy
  listening are effective in reducing mild to
  moderate pain
• Complex Relaxation must begin preoperatively
• Biofeedback
• imagery

20
Causes of Pain in the ICU?
21
The Messengers of Pain

• Direct tissue damage stimulates pain fibers
• Local Inflammatory mediators
• Bradykinin, Prostaglandins, Cytokines
• Tissue Injury
• Histamine
• Serotonin
• TNF

22
WHY IS THIS IMPORTANT?
23
Common Analgesic Drugs in the CVICU
Drug Dose Onset Peak Duration
Morphine Renal 1 - 4 mg 5 min 20 min 4 - 5 hrs
Fentanyl Liver 25 100 mcg 1 - 2 min 3 - 5 min 30 - 60 min
Remifentanil Plasma .5 40 mcg/kg/h lt1 min lt1 min 3 - 10 min
Dilaudid Liver .25 2 mg 10 - 15 min 15 - 30 min 2 - 3 hrs
Toradol Liver 15 30 mg Immediate 1 - 3 min 6 - 8 hrs
24
A Focus on Morphine

• First narcotic to be used
• Narcotic standard
• Relies on good kidney function for excretion
• Stimulates mast cells to release histamine
• Itching
• Rash
• Hypotension
• Acute Asthma episode
• No longer used frequently due to newer drugs

25
A Focus on Fentanyl

• 100x stronger then Morphine
• Fastest metabolizing narcotic used in the CVICU
• Chest Wall Rigidity
• can cause shortness of breath and difficulty
  weaning
• occurs most often with high IV bolus doses
• Decreases BP and HR

26
A Focus on Remifentanil

• Newest synthetic narcotic derived from Fentanyl
• Eliminated by plasma esterases
• Metabolism not dependent on liver or kidney
  function
• Elimination not dose dependent
• Advantages
• Organ independent metabolism
• Lack of accumulation
• Provides analgesia and sedation in ventilated
  patient
• Disadvantages
• Expensive
• Severe withdrawal
• Rebound hyperalgesia

27
A Focus on Toradol

• Is a potent IV/IM NSAID
• Decreases sternal incision pain and inflammation
• Like many NSAIDs can be nephrotoxic
• Know your patients BNP and Creatinine
• Can cause GI bleeding
• Usually not given if the patient is
• Age gt75
• Elevated creatinine
• Chest tube bleeding
• Low platelets

28
Sedation in ICU

• used in the agitated, ventilated for procedure
  discomfort
• to avoid self extubation removal of catheters
• NM blockade mandates analgesia sedation
• control of pain before sedation
• all have side effects dose dependent
• analgesics are not sedatives/ Sedatives are not
  analgesics

29
Common Sedatives in the ICU
Drug Dose Onset Peak Duration
Ativan Liver .5 - 2mg 5 min. 60-90 min 6 - 8 hrs
Versed Liver 1 - 2mg 1.5 - 5 min Rapid 2 - 6 hrs
Propofol Liver Starts at 25 mcg/kg/min lt40 sec. 3-5 min 10 - 15 min
Precedex Plasma .2-.7 mcg/kg/hr (3mcg/kg/hr) 15 - 30 min 30 min 60 - 120 min
Ketamine 2 7 mcg/kg/min 30 s 1 min 5 - 10 min
30
A Focus on Precedex

• Only sedative used that does not cause
  respiratory depression
• Patients can be weaned and extubated while on
  Precedex
• Usual titration range 0.2 0.7mcg/kg/hr
• MD order gt0.7mcg/kg/hr
• Titrate by 0.1-0.2mcg/kg/hr q30-45min
• Can cause SEVERE bradycardia and hypotension
• Very expensive!

31
A Focus on Ketamine

• dissociative anesthetic ? light sedation
  amnesia
• used as an adjunct for patients with uncontrolled
  pain or inadequately sedated
• rarely used in the CVICU due to myocardial
  depressant properties
• monitor for hallucinations and vivid dreams

32
Assessment of Pain and Sedation
33
Sedation scoring systems

• Assess levels to vary according to course of ICU
  stay
• Observational scales - 4 levels min, mod, deep,
  GA
• Addenbrooke sedation scale 0-7 (vocal, tracheal
  suction)
• Ramsay sedation scale 1-6 (vocal, glabellar
  tap)--aim for 3-4
• Direct information- ideal to assess analgesia
  sedation
• BIS for deep sedated paralyzed

34
RASS ASSESSMENT

• 4 Combative, violent, danger to self/staff
• 3 Very agitated, pulls lines, tubes, aggressive
• 2 Agitated frequent non-purposeful movement,
  fights the vent
• 1 Restless / Anxious but not aggressive or
  vigorous
• 0 Alert and calm
• -1 Drowsy, not fully alert but can stay awake,
  eyes open to voice for gt10sec
• -2 Light sedation, wake and makes eye contact for
  lt 10 sec
• -3 Moderate sedation, moves/opens eyes to voice
  but no eye contact
• -4 Deep sedation, no response to voice but moves
  or opens eyes to physical stimulation
• -5 Unarousable, no response to stimuli

35
BIS monitor
36
BIS Monitoring
37
BIS Monitor

• BIS monitor utilizes EEG waveforms.
• reading is monitored from the patients forehead.
• excessive muscle activity can interfere with EEG
  detection

38
Bispectral Index

• BIS an attempt to objectively monitor patients
  sedation
• processed EEG measurement that gives a score to
  help determine the patients response to sedation
• useful to help titrate medication
• proper sensor placement is key to accurate
  monitoring

39
Sensor Application
Apply sensor on forehead at angle Circle 1
Centered, 2 inches above nose Circle 4
Directly above eyebrow Circle 3 On temple,
between corner of eye and
hairline
Press around the edges of each circle to assure
adhesion
Press each circle for 5 seconds
40
BIS Placement

• Make sure the forehead is clean and dry!
• Label the sensor with date/time
• Replace sensor every 24 hours and PRN

41
BIS Monitor

• implement BIS monitoring on all patients with
  paralytic drips infusing
• purpose of BIS monitor is to provide a direct
  measurement of the SEDATIVE effects on the brain.
• goal for BIS Monitoring will be 40 60.
• studies have indicated that this is a safe range
  for no memory recall.

42
BIS Monitoring
43
Troubleshooting the BIS

• If the BIS increases suddenly or is higher than
  expected
• Consider
• Is the sedative dose sufficient?
• Is there an increase in stimulation?
• When was the last analgesic given?
• Is the patient adequately paralyzed? TOF?
• Is the patient having a seizure

44
Troubleshooting the BIS

• If the BIS decreases suddenly or is lower than
  expected
• Consider
• Has there been a decrease in stimulation or
  increase in sedation/analgesia?
• Is the patient significantly hypothermic?
• Has there been a sudden significant drop in BP?

45
BIS Monitoring

• Always consider the overall picture of the
  patient
• Ex if nothing significant has changed with
  patient and BIS number suddenly reflects very
  different readings then fall back to your overall
  assessment of the patient

46
REMEMBER!

• Look at the BIG PICTURE!
• Do Not Forget
• You are treating a patient not just the number

47
(No Transcript)
48
Sedation Vacation

• Assess for daily awakening
• Exclusions
• Increased ICP
• Neuromuscular blockade
• Significant ventilation support
• CABG, immediate post-op

49
Sedation Vacation

• Is patient awake and calm?
• SAS 3 4
• RASS 0 to -1
• If no, restart sedation _at_ ½ previous dose
• If yes, proceed to spontaneous breathing trial
  (SBT)

50
Sedation Vacation

• Assess for SBT
• Calm co-operative
• Hemodynamically stable
• PEEP lt 8
• FiO2 lt 0.60
• pH gt 7.34
• SpO2 gt 90

51
Sedation Vacation

• SBT Termination Criteria
• RR gt 35/min for gt 5 minutes
• SpO2 lt 90 for gt 2 minutes
• New ectopy
• HR change 20 from baseline
• BP change 20 from baseline
• Accessory muscle use
• Increased anxiety/diaphoresis

52
Sedation Vacation

• Conduct SBT for 1 minute
• Mode CPAP
• PEEP 0
• PS _at_ least 5 10
• FiO2 unchanged

53
Paralytics in the ICU

• Paralysis the loss of voluntary muscular
  function due to the administration of a paralytic
• Neuromuscular Blockade Agent (NMB) Drugs that
  obstruct transmission of nerve impulses to the
  muscle
• Neuromuscular Blockade agents DO NOT BLOCK THE
  TRANSMISSION OF PAIN!!!!

54
Paralytics in the CVICU

• Sedation and Analgesics must always be given
  FIRST
• Must use sedatives with an Amnesic affect
• Benzodiazepines (VERSED)
• High dose Propofol
• Paralytics are always given LAST

55
Why Do We Paralyze?

• Decreases O2 demand
• ARDS
• Prevent Patient-Ventilator dysynchrony
• VDR ventilators
• BiVent
• Prevents Shivering in hypothermia patients
• Shivering increases O2 demand
• Raises patients temperature
• Open chest

56
Checklist for chemical paralysis

• Must be adequately sedated first before paralytic
  administered
• Must have anxiolytic drip that has amnesic
  properties
• Must have analgesic drip infusing
• Must have lubrication for eyes/eye bubbles

57
Common CVICU Paralytics
Drug Dose Onset Peak Duration
Vecuronium .08 - .1 mg/kg 1 min 3-5 min 15-25 min
Pancuronium .04 -.1 mg/kg 30-45 sec 3-4 min 35-65 min
Succinylcholine .6 mg/kg 30-60 sec 1-2 min 4-10min
Nimbex 3 mcg/kg/min 1-2 min 2-5 min 25-44 min
58
A Focus on Vecuronium

• A non-depolarizing NMB
• Will NOT increase K
• Full recovery from paralytic 25-40min
• Frequently used in the CVICU for intubation or as
  a bolus drug before Nimbex
• Rarely used as a drip in the absence of Nimbex
• 0.8-1.2mck/kg/min

59
A Focus on Succinylcholine

• A depolarizing NMB
• Can increase K 0.5-1mEq/L
• KNOW YOUR PATIENTS K before administering
• Does your patient have any renal disease?
• Metabolized by plasma cholinesterase
• Very rapid metabolism 5min
• Does not rely on kidney or liver function

60
A Focus on Nimbex

• Is our primary titrating NMB used in the CVICU
• Is also metabolized in the blood
• Standard dose is 3mcg/kg/min
• Titrate range 0.5-5mcg/kg/min
• Metabolism 45min
• Changes with hypothermia?

61
Successful Paralysis How do we know?

• Assessment
• Movement
• Spontaneous Breaths
• Peripheral Nerve Stimulator

62
Peripheral Nerve Stimulators

• Peripheral Nerve Stimulator A device that
  delivers a determine electrical current to create
  a muscular contraction
• Used to determine the amount of neuromuscular
  blockade a patient has
• An increase in NMB will show a decrease response
  to a peripheral nerve stimulator at a set current

63
Train of Four

• Train of Four 4 consecutive impulses generated
  from the peripheral nerve stimulator resulting in
  4 muscular twitches
• of twitches seen degree of NMB
• No blockade 4 twitches
• Total blockade 0 twitches
• GOAL IS 1-2 TWITCHES
• Increase drip by 10 if gt2 twitches
• Decrease drip by 10 if lt1 twitch

64
Train of Four Facial Nerve

• Place one electrode on the face at the outer
  canthus of the eye (positive/red electrode)
• Place the second electrode 2 cm below and
  parallel with the tragus of the ear
  (negative/black electrode)
• Watch and feel for facial nerve contraction

65
Train of Four Ulnar Nerve
66
Train of Four

• Must have 2x baseline TOFs before starting NMBs
• Ulnar nerve is more preferred but facial nerve is
  easier to see/assess
• Use alcohol pad to wipe clean and dry the skin
  before applying electrode
• Electrodes must be changed 24 hrs
• Possibly inaccurate in hypothermia patients

67
Helpful tips for TOF

• If checking the thumb ensure the leads are
  placed on the ulnar side of the arm(this is where
  the nerve lies)
• Be careful with applying maximum MAs when leads
  are placed on the face this can lead to
  burns/scarring
• Check your battery
• Change your electrodes q24h

68
Putting it all Together

1. start BIS Monitoring
2. get a Baseline TOF on two locations
3. start Sedation and Analgesic Drips
4. titrate medication up until BIS 40-60
5. bolus paralytic
6. start paralytic drip
7. check TOF q30min until 1-2 twitches
8. monitor TOF and BIS and titrate drips to endpoints

69
CRUCIAL POINT

• Prior to the administration of any paralytic
  agent - sedation MUST be administered first. If
  paralytic will be continued as an infusion,
  sedation MUST also be continued.
• Sedation MUST be a drug that has amnesic
  properties.

70
Drugs that have amnesic effects

• Benzodiazepine class
• Examples
• Versed
• Propofol (in high doses) dose will be individual
  to patient

71
Intravenous Medicines commonly used in CVICU

• SEDATION
• Ativan
• Versed
• Propofol
• Precedex
• Amnesic properties
• Amnesic in high doses only
• DOES NOT have amnesic properties

• ANALGESIA
• Morphine
• Fentanyl
• Dilaudid
• Toradol

72
Case Study

• You are caring for a patient that has an open
  chest, they are on a Nimbex, Fentanyl Versed
  gtts
• VSs
• BP 160/90
• HR 128
• Vent Settings SIMV 12, TV 450, PEEP 5, PS 10,
  Spontaneous RR 12, 02 saturation 98, TOF 2/4
• Is anything wrong here?

73
Case Study

• Patient has open chest, Nimbex, Fentanyl Versed
  gtts
• VSs
• 105/68
• HR 80 Paced
• Vent settings SIMV 12, TV 600, PEEP 5, PS 10,
  Spontaneous RR 16
• TOF 2/4
• Is anything wrong here?

74
Case Study

• Patient has open chest, has experienced excessive
  blood loss through chest tubes, Nimbex
  Propofol gtts(5 mcg/kg/hr)
• VSs
• BP labile 70s to 100s systolic
• HR 80s paced
• Vent settings SIMV 12, TV 400, PEEP 5, PS 5,
  Spontaneous RR 14, 02 saturation 98
• TOF 0/4
• Is anything wrong here?

75
SCCM task force recommendations

• Benzodiazepines most popular for sedation
• Short term sedation
• Midazolam lt3h (amnesic/ hypotension)
• propofol infusion syndrome/ pancreatitis
• Long term lorazepam lt20h /diazepamgt96h (not for
  infusion)
• Delirium haloperidol - neuroleptic syndrome/
  torsade pointes
• Antagonist- flumazenil 0.2mg-1mg (withdrawal
  seizures)

76
ReCap of Key Points

• Sedation
• Patient may still experience pain, goal is
  anti-anxiety/ relaxation, goal is usually to
  give amnesia
• Analgesia
• Used to treat pain, no anti-anxiety properties
• Paralytics
• Used to decrease skeletal muscle movement,
  imperative that amnesic drugs be used in
  combination with analgesic meds, MUST sedate
  before paralyzing

77
ReCap of Key Points

• BIS Monitor
• Used to strictly assess patients sedation level
• Goal is 40-60
• Peripheral Nerve Stimulator
• Used to strictly assess patients paralytic state
• TOF goal is 1-2/4

78
Putting it all Together

1. start BIS Monitoring
2. get a Baseline TOF on two locations
3. start Sedation and Analgesic Drips
4. titrate medication up until BIS 40-60
5. bolus paralytic
6. start paralytic drip
7. check TOF q30min until 1-2 twitches
8. monitor TOF and BIS and titrate drips to endpoints

79
Final Thoughts

• give sedation/analgesia before paralytics
• BIS assess for sedation
• TOF assess for adequate NMB
• If in doubt it never hurts to ask!

80
References

• Gelinas C. Management of pain in cardiac surgery
  ICU patients have we improved over time?
  Intensive Crit Care Nurs. 200723(5)298-303.
• Girard TD, Shintani AK, Jackson JC, et al. Risk
  factors for post-traumatic stress disorder
  symptoms following critical illness requiring
  mechanical ventilation a prospective cohort
  study. Crit Care. 200711(1)R28.
• Jacobi J, Fraser GL, Coursin DB, et al. Clinical
  practice guidelines for the sustained use of
  sedatives and analgesics in the critically ill
  adult. Crit Care Med. 200230(1)119-141.
• Pandharipande PP, Pun BT, Herr DL, et al. Effect
  of sedation with dexmedetomidine vs lorazepam on
  acute brain dysfunction in mechanically
  ventilated patients the MENDS randomized
  controlled trial. JAMA. 2007298(22)2644-2653.