Minimize Sedation, Optimize Mechanical Ventilation
Tammy L Uhl, RN, MSN, CCRN, CCNS
Duke Children’s Hospital
Durham, NC
Historically……………..
VERSED
FENTANYL
KETAMINE
DEX
The Need for Analgesia (and Sedation?)
 Most critically ill patients experience pain
 ETT painful, especially suctioning
 Minimize delirium
 Decrease stress response
 Prevent anxiety
 Decrease O2 consumption/metabolic demand
 Patient‐ventilator synchrony
Burr J, et al. Crit Care Med 2013;41:263‐306.
Arroyo‐Novoa CM, et al. Crit Care Nurs 2008; Feb; 24(1):20‐7. Potential Drawbacks of Sedatives (and to a lesser extent, Analgesics)
• Over‐sedation
 Increased duration of mechanical ventilation
FDA, 2016, Drug Safety Communication:
 Failed ERTs
Label warning: Sedation drugs used for more than 3  Longer ICU LOS consecutive hours or repeated use, specifically • Impedes neurologic assessment/function
propofol, ketamine, barbiturates and • Impedes ability to communicate
benzodiazepines, may effect the development of • Numerous agent‐specific adverse events
– Hemodynamic instability
brains in children less than 3 years of age.
– Paradoxical reactions
– Delirium
– Dependence
• Neuronal apoptosis
Andropoulos, et. al., 2017, NEJM.
Johnson, et. al., 2012, Adv Crit Care, 23(4).
Tobias, 2005, Pediat Annuals, 34(8).
Burr, J., et. al., 2013, Crit Care Med, 41.
Playfor, et. al., 2006, Intens Care Med, 32(8).
Too little?
• Under‐sedation and inadequate pain relief
– Hyperactive stress response
• Tachycardia, increased O2 consumption, hyper‐metabolism, increased endogenous catecholamines
– Adverse events
– Delirium
– PTSD
Wolf, et., al., 2010, Pediat Anes, 21.
Sorce, L., 2005, Crit Care Nurs Clin N Am, 17.
^
DON’T
Depth of Sedation: the dilemma of too much or too little
What we knew…
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Multitude of problems with over‐sedation Provider variations in practice
High incidence of withdrawal
Use of a pain/sedation practice guideline contributes to decrease in bolus administrations, improves communication and standardizes care
Larson et al., 2013, Aus Crit Care, 26.
Tobias, J., 2000, Peds Crit Care, 28(6).
Tobias, J., 1999, Paediatr Drugs, 1(2).
Kudchadkar, et. al., 2014, Crit Care Med, 42(7).
Amigoni, et., al., 2014, Acta Pediat, 103.
Hypothesis 1: use of a standardized approach to pain and sedation management could be successful in a high percentage of mechanically ventilated kids.
Hypothesis 2: some kids can tolerate intubation and mechanical ventilation without the need for additional sedatives (polypharmacy) if pain is adequately addressed. Hypothesis 3: A reduction in sedative use would decrease time on mechanical ventilation and length of ICU stay.
Davies, et. al., 2006, Peds Crit Care Med, 7(4), 409.
Deeter, et. al., 2011, Crit Care Med, 39(4).
Thomas, et. al., 2010, Dynamics, 21(4).
So what did we want to achieve?
Calm and easily arousable state while minimizing pain, anxiety, or agitation unless contraindicated
• Easy transition from sleep to wakefulness and task performance when aroused
• Able to resume rest when not stimulated
• Allows for interaction • Reduces risk of drug‐induced complications
 It’s a trial!
 Your feedback will be listened to.
 It is a work in progress, not a mandate in stone.
 Optimal goal is what we are all trying to achieve: improve care and patient outcomes!
Let’s make this simple
Adequate analgesia should be provided to all intubated critically ill children as unrelieved pain associated with poor cognitive outcomes, thus:
 Intravenous opiates first line
 Bolus prn to steady state
 Non‐opioid options Playfor, S. Contin Educ Anaesth Crit Care Pain (2008) 8 (3): 90‐94.
Pain controlled but still anxious/agitated?
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Full bladder
Correct other etiologies for agitation*
Temp abnormality
Minimize noxious stimuli
Noise
Sleep deprivation
Developmentally appropriate interactions
Delirium
Familiar objects Disorientation
Inability to communicate
Delirium preventative strategies
Inadequate ventilator flow rates
Uncomfortable position Hypoxia
Withdrawal
ETC...
Agitation continues?
• Dexmedetomidine – Anxiolysis and some analgesia effect
FY15‐FY16
ICU LOS
ICU median down 21% (1.59 v 1.26)
Time on Mechanical Ventilation
Median ventilator days down 25% (4 v 3)
Total hospital median LOS is down 11%.
Percentage of patients receiving methadone on the general peds floor after transfer from PICU is down 72% from 2015 to 2016.
Lessons learned……..
FENTANYL