7/6/2016
ICU TRIAD
2016 ANNUAL MEETING
BRINGING THE ABC(DEF)’S
TO THE ICU
GINA RIGGI, PHARMD, BCPS, BCCCP
CLINICAL HOSPITAL PHARMACIST- TRAUMA INTENSIVE CARE UNIT
JACKSON MEMORIAL HOSPITAL
MIAMI, FLORIDA
2016 ANNUAL MEETING
Figure 1. Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.
DISCLOSURE
I, Gina Riggi, have nothing to disclose concerning possible financial
or personal relationships with commercial entities that may have a
direct or indirect interest in the subject matter of this presentation.
ICU TRIAD
• Approaches to management of pain, agitation and delirium are linked
• Assess patient’s pain status first before initiating sedation
• Minimize the use of analgesics and sedatives to keep the patient calm and
cooperative with their care and to reduce the incidence of delirium
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Figure 1. Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.
OBJECTIVES
SEDATION AND ANALGESIA
• Identify the potential adverse outcomes of an ICU stay
NEED FOR SEDATION AND
ANALGESIA
• Prevent pain and anxiety
POTENTIAL ADVERSE EFFECTS
FROM SEDATION AND ANALGESIA
• Over sedation
• Improve ventilator synchrony
• Reduced neurological exam
• Decrease oxygen consumption
• Increased risk for delirium
• Decrease the stress response
• Adverse medication effect
• Describe the components of ICU liberation
• Evaluate pharmacologic interventions used to treat pain, agitation, and
delirium
• Discuss the pharmacist’s role in ABCDEF
2016 ANNUAL MEETING
• Avoid adverse neurocognitive events
2016 ANNUAL MEETING
1
7/6/2016
ICU SEDATION:
THE BALANCING ACT
Oversedation
ABCDEF BUNDLE
Undersedation
GOAL: Patient Comfort and Ventilator Synchrony
2016 ANNUAL MEETING
ICU LIBERATION
• The ABCDEF care bundle elements individually and collectively can help
• Reduce delirium
• Improve pain management
• Reduce long-term consequences
• The interdisciplinary ICU team should reevaluate regimen DAILY
• Check for appropriateness of the regimen
• Pain and sedation requirements change over time
A
• Assess, prevent and manage pain
B
• Both Spontaneous Awakening Trial and Spontaneous
Breathing Trial
C
• Choice of Analgesia and Sedation
D
• Delirium: Assess, prevent and manage pain
EF
2016 ANNUAL MEETING
ABCDEF BUNDLE
A
• Assess, prevent and manage pain
B
• Both Spontaneous Awakening Trial and Spontaneous
Breathing Trial
C
• Choice of Analgesia and Sedation
D
• Delirium: Assess, prevent and manage pain
EF
2016 ANNUAL MEETING
• E: Early mobility and exercise
• F: Family Engagement and empowerment
• E: Early mobility and exercise
• F: Family Engagement and empowerment
2016 ANNUAL MEETING
2013 SCCM PAIN, AGITATION AND DELIRIUM (PAD)
GUIDELINES: ANALGESIA RECOMMENDATIONS
• Valid and reliable tool for monitoring pain in medical, postoperative or trauma patients
• Pain should be assessed first before the addition of sedation therapy using an
analgosedation approach
• Vital signs should not be used alone for pain assessment, should be used as a cue for
further assessment
• Recommend preemptive analgesia and/or nonpharmacological interventions to alleviate
pain in the ICU prior to chest tube removal
• IV opioids are first line drugs choice to treat nonneuropathic pain in the ICU
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Barr J, Fraser G, Puntillo K, et. al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41: 264-306.
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7/6/2016
COMMON CAUSES OF
PAIN AND AGITATION
SCCM PAIN CARE BUNDLE
• Identify these causes of pain and agitation during the patient assessment
• Assess
• Assess pain four times per shift and PRN
• Hypoxemia
• Significant pain with BPS >5, or CPOT>2
• Full bladder
• Treat
• Treat pain within 30 minutes of detecting significant pain & REASSESS:
• Noise
• Non-pharmacological treatment
• Pharmacological treatment
• Frequent ICU procedures
• Prevent
• Administer pre-procedural analgesia and/or non-pharmacological interventions
• Treat pain first, then sedate
2016 ANNUAL MEETING
2016 ANNUAL MEETING
www.iculiberation.org ICU-Liberation-ABCDEF-Bundle-Implementation-Assess-Prevent-Manage-Pain
CRITICAL CARE OBSERVATION TOOL (CPOT)
ABCDEF BUNDLE
CPOT
Indicator
Facial
Expression
Body
movement
Muscle
tension
Compliance
with the
ventilator
(intubated
patients)
Description
No muscle tension observed
Presence of frowning, brow lowering, orbit tightening and levator contraction or any other
change (e.g. opening eyes or tearing during nociceptive procedures)
All previous facial movements plus eyelid tightly closed (the patient may present with mouth
open or biting the endotracheal tube)
Does not move at all (doesn’t necessarily mean absence of pain) or normal position
(movements not aimed toward the pain site or not made for the purpose of protection)
Slow, cautious movements, touching or rubbing the
pain site, seeking attention through movements
Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at
staff, trying to climb out of bed
No resistance to passive movements
Resistance to passive movements
Strong resistance to passive movements or incapacity to complete them
Alarms not activated, easy ventilation
Coughing, alarms may be activated but stop spontaneously
Asynchrony: blocking ventilation, alarms frequently activated
Score
0, relaxed neutral
1, tense
2, grimacing
0, Absence of movements
or normal position
1, protection
2, restlessness/agitation
0, relaxed
1, tense/rigid
2, very tense/rigid
0, Tolerating ventilator or
movement
1, Coughing but tolerating
2, Fighting ventilator
A
• Assess, prevent and manage pain
B
• Both Spontaneous Awakening Trial and Spontaneous
Breathing Trial
C
• Choice of Analgesia and Sedation
D
• Delirium: Assess, prevent and manage pain
EF
• E: Early mobility and exercise
• F: Family Engagement and empowerment
2016 ANNUAL MEETING
Table 1. Gelinas C, Fillion L, Puntillo K, et al. Validation of the Critical-Care Pain Observation Tool in Adult Patients. Am J Crit Care. 2006; 15:420-427.
BEHAVIORAL PAIN SCORE (BPS)
SEDATION INTERRUPTION
BPS
Item
Facial Expression
Upper Limb
Movement
Compliance with
mechanical
ventilation
Description
Relaxed
Partially tightened (ex: brow lowering)
Fully Tightened (ex: eyelid closing)
Grimacing
No movement
Partially Bent
Fully Bent with finger flexion
Permanently retracted
Tolerating movement
Coughing but tolerating ventilation most of the time
Score
1
2
3
4
1
2
3
4
1
2
Fighting ventilator
Unable to control ventilation
3
4
2016 ANNUAL MEETING
Table 1. Aissaoui Y, Zeggwagh A, Zekraoui A, et al. Validation of a Behavioral Pain Scale in Critically Ill, Sedated and Mechanically Ventilated Patients. Anesth Analg. 2005; 101:1470-1476
• Benefit of a sedation interruption
• Evidence for a sedation vacation in conjunction with a spontaneous breathing trial and early
mobility results in decreased adverse outcomes associated with delirium and weakness
• Length of sedation interruption
• A sedation interruption is considered successful if the patient responds to verbal stimulation but
does not display any failure criteria in a 4 hour period
• Potential adverse effects
• Self-extubation, removal of access
• Agitation or pain
2016 ANNUAL MEETING
3
7/6/2016
DAILY SEDATION INTERRUPTION
Title
Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation
Objective
Determine if daily interruption of sedative infusion in mechanically ventilated critically ill patients decreases the
duration of mechanical ventilation and the length of hospital/ICU stay
Study Design
Prospective randomized control trial conducted in the MICU of a single center
Population
Patients that were mechanically ventilated and intubated requiring continuous intravenous infusion of sedatives
•
Protocol
Primary Outcome
•
•
Daily interruption of sedative infusion beginning 48 hours after enrollment (by an investigator not directly
involved in patient care)
Continuous infusion of sedatives with interruption at the treating team’s discretion
Within each group, patients were randomized to receive propofol or midazolam. All patients received IV
morphine for analgesia
Determine if daily interruption of sedative infusion in mechanically ventilated critically ill patients decreases the
duration of mechanical ventilation and the length of hospital/ICU stay.
2016 ANNUAL MEETING
Kress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.
DAILY SEDATION INTERRUPTION
2016 ANNUAL MEETING
Kress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.
DAILY SEDATION INTERRUPTION
2016 ANNUAL MEETING
Kress JP, Pohlman AS, O’Connor MF, et al. Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. NEJM 2000; 342 (20): 1471- 1477.
DAILY SEDATION INTERRUPTION
Title
Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for with a Sedation
Protocol
Adult patients managed with protocolized sedation and daily sedation interruption would receive less sedation
and have a shorter duration of mechanical ventilation than patients that receive protocolized sedation alone
Multi-centered, randomized controlled trial, not blinded
· Study period: January 2008-July 2011
· Study sites: 16 centers (14 in Canada and 2 in the US)
· Critically ill adults in the intensive care unit (ICU)
· Expected mechanical ventilation for more than 48 hours
· Continuous infusion of sedatives or opioids
· Protocolized sedation plus daily interruption (interruption groups)
· Protocolized sedation alone (control group)
Objective
Study Design
Population
Study Groups
Primary Outcome
· Time to successful extubation, defined as time from randomization to extubation for 48 hours
Secondary Outcomes
· Unintended device removal, Physical restraint use, Delirium, Neuroimaging in the ICU, Tracheostomy,
Barotrauma, Total doses of sedatives and analgesics while intubated, Organ dysfunction, ICU and hospital
length of stay, Death
2016 ANNUAL MEETING
Mehta S, Burry L, Fergusson D, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Pateints Cared for With a Sedation Protocol A Randomized Controlled Trial. JAMA 2012; 308 (19): E1-E8.
DAILY SEDATION INTERRUPTION
2016 ANNUAL MEETING
Mehta S, Burry L, Fergusson D, et al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Pateints Cared for With a Sedation Protocol A Randomized Controlled Trial. JAMA 2012; 308 (19): E1-E8.
“WAKE UP AND BREATHE” PROTOCOL
2016 ANNUAL MEETING
4
7/6/2016
SEDATION INTERRUPTION
SEDATION INTERRUPTION
• Sedation interruption should be performed in ALL patients except the following:
FAILURE CRITERIA
INDICATIONS TO RESTART CONTINUOUS INFUSION MEDICATIONS
• Pressure control or inverse ratio ventilation
• PEEP greater than or equal to 10 cm
• Neuromuscular blockade
• FiO2 greater than or equal to 60%
• SpO2 less than 93%
• Becomes unstable
• RASS reaches >+2 for more than 5 minutes
• Two or more of the following:
• Respiratory rate >35 breaths/min for >5 minutes
• Heart rate increase of ≥ 20 BPM
• Pulse oximetry reading <88% for >5 minutes
• Heart rate less than 55 BPM
• Use of accessory muscles
• Acute cardiac arrhythmia
• Abdominal paradox
• ICP > 20 mmHg
• Diaphoresis
• Active ICP management
• Dyspnea
• Hypothermia management
• Actively having seizures or in status epilepticus
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Balas M, et al. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/ Management, and Early Exercise/Mobility Bundle. Crit Care Med 2014.
SEDATION INTERRUPTION
If the patient does not meet any of the exclusion criteria then
perform the sedation vacation
Stop ALL of the continuous infusion medications including
Fentanyl drip daily with your AM assessment
Look for signs that the patient does or does not tolerate a
sedation vacation
SEDATION VACATION PEARLS
• What if your patient did not tolerate a sedation vacation yesterday?
• KEEP TRYING EACH DAY ON EVERYONE
• Analgesia and sedation needs in the ICU are dynamic
• A failed sedation vacation only indicates that we have successfully minimized
our sedation
If the patient meets the criteria to restart continuous infusion
medications, then restart the rate at HALF of the previous dose
2016 ANNUAL MEETING
“WAKE UP AND BREATHE” PROTOCOL
2016 ANNUAL MEETING
ABCDEF BUNDLE
A
• Assess, prevent and manage pain
B
• Both Spontaneous Awakening Trial and Spontaneous
Breathing Trial
C
• Choice of Analgesia and Sedation
D
• Delirium: Assess, prevent and manage pain
EF
2016 ANNUAL MEETING
• E: Early mobility and exercise
• F: Family Engagement and empowerment
2016 ANNUAL MEETING
5
7/6/2016
2013 PAD GUIDELINES:
SEDATION RECOMMENDATIONS
CHOICE OF ANALGESIA
• Non-pharmacologic strategies play an important role in managing pain and
agitation
• IV opioids should be considered first line
• Valid and reliable sedation assessment tool for measuring quality and depth of sedation in
adult ICU patients
• Optimize opioid regimens by assessing the following:
• Non-benzodiazepine sedatives should be used when possible over benzodiazepines in
mechanically ventilated patients
• Is the pain acute, chronic or both?
• Route of administration
• Hemodynamic instability
Situation
Preferred Intervention
Acute pain
Fentanyl IV Push until pain resolves
Acute pain that persists/recurs
Fentanyl infusion plus fentanyl IV Push for
breakthrough
Acute pain in chronic opioid user
Account for previous opioid use when using IV
opioid
Planned transition out of ICU and
patient on IV opioid infusion
Start scheduled oral/enteral opioid therapy plus
intermittent IV opioid
2016 ANNUAL MEETING
Fentanyl
Hydromorphone
• Analgesia should always be assessed first before adding sedation
2016 ANNUAL MEETING
www.iculiberation.org/Bundles/Pages/Choice-of-Medication.aspx
Barr J, Fraser G, Puntillo K, et. al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41: 264-306.
ANALGESIA MEDICATION OPTIONS
Morphine
• Non-benzodiazepines are associated with improved clinical outcomes including shorter length of
stay in the ICU and shorter days of mechanical ventilation
• Histamine release upon administration
• Hypotension
• Accumulation of metabolite in renal failure
• Sedative properties
• Adverse Effect: Constipation (Always start a bowel regimen unless
contraindicated)
• Preferred agent when rapid control is needed
• Good agent for hemodynamically unstable patients
• Rare adverse effect: chest wall rigidity
• Sedative properties
• Adverse Effect: Constipation (Always start a bowel regimen unless
contraindicated)
• Approximately 7.5 times more potent than morphine
• Good agent for hemodynamically unstable patients
• Sedative properties
• Adverse Effect: Constipation (Always start a bowel regimen unless
contraindicated)
2016 ANNUAL MEETING
SEDATION
Title
Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical
ventilation. Two randomized controlled trials
Objective
To determine the efficacy of dexmedetomidine vs. midazolam or propofol in maintaining sedation,
reducing duration of mechanical ventilation and improving patient interaction with nursing
Selection Criteria
Patients were included if they met the following criteria:
• 18 years or older
• Invasive mechanical ventilation for greater than 24 hours
• Clinical need for light to moderate sedation (RASS -3 to 0)
Randomization within 72 hours of ICU admission and within 48 hours of starting continuous sedation
Population
Two prospective randomized, double-blinded controlled trials (MIDEX and PRODEX) conducted in
the ICU’s of 44 different medical centers
•
•
MIDEX: randomized to continue current sedation with midazolam or switched to
dexmedetomidine
PRODEX: randomized to continue current sedation with propofol or switched to
dexmedetomidine
Study medications were titrated in a stepwise fashion by nursing
Primary Outcome
•
•
Proportion of time in target sedation range (RASS 0 to -3) without the use of rescue therapy
Duration of mechanical ventilation
Secondary Outcomes
•
•
•
Length of ICU stay
Ability to cooperate with care
Ability to communicate pain
Intervention
•
2016 ANNUAL MEETING
Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. Two randomized controlled trials. JAMA 2012; 307 (11): 1151-1160.
SEDATION
CONVERSION BETWEEN OPIOIDS
Generic name
Route
Equivalent Dose
Morphine
IV
10mg
Hydromorphone
IV
1.5mg
Fentanyl
IV
100mcg
Morphine
PO
30mg
Hydromorphone
PO
7.5mg
2016 ANNUAL MEETING
2016 ANNUAL MEETING
6
7/6/2016
SEDATION
SEDATION
• Maintaining light levels of sedation in adult ICU patients is associated with
improved clinical outcomes
• Shorter length of stay in the ICU
• Shorter duration of mechanical ventilation
• Goal is light sedation (awake and cooperative)
• Want the least amount of medication to achieve the desired effect
• Historical concerns with light sedation are not supported by current evidence
• Patient will harm self if not heavily sedated
• It is better if patient does not remember this experience
• Care will be compromised if patient moves around and is not controlled
• Patients are in less pain if they are more deeply sedated
2016 ANNUAL MEETING
SEDATION
Title
Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically
ventilated patients. The MENDS randomized controlled trial.
Objective
Determine if dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU
patients in comparison to benzodiazepines.
Selection Criteria
Medical and surgical ICU patients requiring mechanical ventilation for longer than 24 hours.
Excluded patients: Neurological disease, Liver disease, AMI, Heart block, Severe dementia
BDZ dependence
Study Design
Prospective, double-blinded, randomized trial conducted in the medical and surgical ICU’s of 2 tertiary
care centers
•
•
•
Intervention
•
Patients were randomized to receive dexmedetomidine or lorazepam infusions
Infusion rates were titrated by the nurse to achieve a RASS goal set by the medical team.
Maximum infusion doses:
• Dexmedetomidine: 1.5 ug/kg/hr
• Lorazepam: 10 mg/hr
Infusions were allowed for a maximum duration of 120 hours and patients were then switched to the
standard sedation medications used in the particular ICU.
Primary Outcome
•
•
Days alive without delirium or coma
Percentage of days spent within 1 RASS point of sedation goal
Secondary Outcomes
•
•
•
•
Length of stay with ventilation, in the ICU and in the hospital
Neuropsychological testing after ICU discharge
28 day mortality
12 month survival
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Barr J, Fraser G, Puntillo K, et. al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41: 264-306.
SEDATION
• Evidence from randomized, controlled trials consistently supports the use of the
minimum possible sedation
• A minority of patients have an indication for deep continuous sedation
• Intracranial hypertension
• Severe respiratory failure (example: acute respiratory distress syndrome)
• Refractory status epilepticus
• Prevention of awareness for patients receiving neuromuscular blockers
• Deep sedation is only appropriate for the patients mentioned above
• When used inappropriately deep levels of sedation result in increased ventilator associated
pneumonia, accelerated deconditioning, promotion of skin breakdown, may increase
incidence of post traumatic stress disorder, prolonged time on mechanical ventilation
2016 ANNUAL MEETING
Reade M and Finfer S. Sedation and Delirium in the Intensive Care Unit. NEJM. 2014. 370:440-454.
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.
SEDATION
PROPERTIES OF AN IDEAL SEDATIVE
2016 ANNUAL MEETING
Rapid onset
and rapid
offset
Predictable
dose-response
relationship
Ease of
administration
Lack of drug
accumulation
Few side
effects
Minimal drug
interactions
Costeffectiveness
Promotion of
natural sleep
2016 ANNUAL MEETING
www.iculiberation.org/Bundles/Pages/Choice-of-Medication.aspx
7
7/6/2016
SEDATIVE AGENTS
Dexmedetomidine
Propofol
•
•
•
•
Sedative, analgesic and sympatholytic properties (NO amnestic properties)
Adverse effects: bradycardia and hypotension
Does not produce respiratory depression
Decreased incidence of delirium, shorter length of mechanical ventilation, and the ability to
assess cognitive function
• Anesthetic agent with hypnotic, anxiolytic and amnestic properties
• Neuroprotective and antiepileptic properties
• Adverse effects: hypotension, respiratory depression, hypertriglyceridemia, and acute
pancreatitis, propofol related infusion syndrome
Midazolam
• Sedative, amnestic, anxiolytic properties
• Accumulate in obese patients due to increased adipose tissue and in patients with liver
dysfunction (cirrhosis)
• May accumulate the metabolite of midazolam in patients with renal dysfunction and elderly
• Good agent for deeper levels of sedation
Lorazepam
•
•
•
•
MEDICATION EFFECTS
Drug
Blood Pressure
Heart Rate
Respiration
Opioids
↓
↓
↓↓
Benzodiazepines
↓
--
↓
Propofol
↓↓
↓
↓↓
Dexmedetomidine
↓↓
↓
--
Sedative, amnestic, anxiolytic properties
Increased effect in renal failure and elderly patients
Adverse effect: propylene glycol toxicity
Good agent for deeper levels of sedation
2016 ANNUAL MEETING
2016 ANNUAL MEETING
RICHMOND AGITATION SEDATION SCALE (RASS)
MEDICATION EFFECTS
RASS
Term
Combative
Very Agitated
Agitated
Restless
Alert and Calm
Drowsy
Light Sedation
Moderate Sedation
Deep Sedation
Unarousable
Description
Overly combative, violent, immediate danger to staff
Pulls or removes tubes or catheter; aggressive
Frequent non-purposeful movement; fights ventilator
Anxious but movements not aggressive vigorous
Not fully alert, but has sustained awakening
Briefly awakens with eye contact to voice
Movement or eye opening to voice
No response to voice, but movement or eye opening to
physical stimulation
No response to voice or physical stimulation
Score
+4
+3
+2
+1
0
-1
-2
-3
-4
-5
2016 ANNUAL MEETING
Drug
Analgesia
Anxiolysis
Amnesia
Hypnosis
Opioids
+++
--
--
+
Benzodiazepines
--
++
+++
+++
Propofol
--
-
++
+++
Dexmedetomidine
+
+
+
++
2016 ANNUAL MEETING
Table 1. Sessler C, Gosnell M, Grap M, et al. The Richmond Agitation-Sedation Scale: Validity and Reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002; 166:1338-1344.
RIKER’S SEDATION-AGITATION SCALE (SAS)
MEDICATION WITHDRAWAL
SAS
Term
Dangerous agitation
Very agitated
Agitated
Calm and
Cooperative
Sedated
Very Sedated
Unarousable
Description
Pulling at ET tube, trying to remove catheters, climbing over bed rail, striking
at staff, thrashing side to side
Does not calm, despite frequent verbal reminding of limits; requires physical
restraints, biting ET tube
Anxious or mildly agitated, attempting to sit up, calms down to verbal
instruction
Calm, awakens easily, follows commands
Score
7
Difficult to arouse, awakens to verbal stimuli or gentle shaking but drifts off
again, follow simple commands
Arouses to physical stimuli but does not communicate or follow commands,
may move spontaneously
Minimal or no response to noxious stimuli, does not communicate or follow
commands
3
2016 ANNUAL MEETING
Table 1. Bandl K, Langley K, Riker R et al. Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use. Pharmacotherapy. 2001; 21:431-436.
6
• Risk factors for opioid and benzodiazepine withdrawal
• Frequency associated with dose and duration
• Typically associated with one week or more of high dose therapy
• Signs and Symptoms
5
• Seizures, hallucinations, GI disturbances, fever, sweating, increased heart rate, tachypnea,
increased blood pressure
4
• There is not a standard weaning protocol
• Consider a daily reduction of medications 10-20%
2
1
• Make sure that PRN medications are ordered when the continuous infusion
medications are discontinued
2016 ANNUAL MEETING
8
7/6/2016
ABCDEF BUNDLE
DELIRIUM
A
• Assess, prevent and manage pain
B
• Both Spontaneous Awakening Trial and Spontaneous
Breathing Trial
C
• Choice of Analgesia and Sedation
• Disturbance not better explained by a preexisting, established or evolving neurocognitive
disorder
D
• Delirium: Assess, prevent and manage pain
• Evidence from patient’s history, physical examination and/or laboratory results that the
disturbance is caused by a medical condition, substance intoxication or withdrawal, or
medication/toxin side effect
• Identified by the following Key Features
• Disturbance in attention and awareness
EF
• Disturbance in cognition
• Development over a short period of time and tendency to fluctuate during the day
• Associated but nondiagnostic symptoms of ICU delirium include: Hallucinations and delusions
• E: Early mobility and exercise
• F: Family Engagement and empowerment
• Abnormal psychometric activity
• Emotional disturbances
• Sleep disturbances
2016 ANNUAL MEETING
2016 ANNUAL MEETING
http://www.iculiberation.org/Bundles/Pages/Delirium.aspx
DELIRIUM
DELIRIUM
• Delirium is experienced by 50%–80% of mechanically ventilated patients
• Medications have the potential to contribute to delirium
• Delirium is experienced by 20%–50% of patients with illness of lower severity
• The ABCDEF bundle suggests the following approach to delirium management:
• Stop
• Delirium results in:
• Review medications
• Prolonged hospitalization
• Plan to reduce drug exposure
• Increased mortality
• Consider sedatives
• Increased cost
• Long-term effects on the patient include long-term cognitive impairment
• THINK
• Medicate
• SCCM guideline suggests nonbenzodiazepine sedatives
2016 ANNUAL MEETING
http://www.iculiberation.org/Bundles/Pages/Delirium.aspx
2013 PAD GUIDELINES:
ANALGESIA RECOMMENDATIONS
• Perform early mobilization of adult ICU patients whenever feasible to reduce the incidence
and duration of delirium
• Pharmacologic delirium prevention protocol is not recommended
• Recommend using a combined nonpharmacologic and pharmacologic delirium prevention
protocol
• Medication management is not recommended to prevent delirium in adult ICU patients
• Dexmedetomidine is not recommended to prevent delirium in adult ICU patients
2016 ANNUAL MEETING
Barr J, Fraser G, Puntillo K, et. al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine 2013; 41: 264-306.
2016 ANNUAL MEETING
http://www.iculiberation.org/Bundles/Pages/Delirium.aspx
DELIRIUM
T
• Toxic situations and medications: Congestive Heart Failure, shock,
dehydration, new onset organ failure (e.g. liver or kidney), deliriogenic
medications (e.g. benzodiazepines, anticholinergics, and steroids)
H
• Hypoxemia
I
• Infection/ sepsis (nosocomial), inflammation, immobilization
N
• Non-pharmacologic delirium mitigation strategies
K
• K+ or other electrolyte imbalances
2016 ANNUAL MEETING
9
7/6/2016
DELIRIUM
DELIRIUM
• Non-pharmacologic management
Title
• Pain: Monitor and/or manage pain using an objective scale
Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium
Monitoring/Management and Early Exercise Mobility Bundle
Determine if implementing an ABCDE components as a bundle would prove safe and effective if applied to
every critically ill patient, every day, regardless of mechanical ventilation status
Objective
Study Design
• Orientation: Talk about a day, date, place; discuss current events; provide
caregivers names; use clock and calendar in room
Population
• Sensory: Determine need for hearing aids and/or eyeglasses
Primary Outcome
• Sleep: Noise reduction, day-night variation, “time-out” to minimize
interruptions of sleep, promoting comfort and relaxation
Secondary Outcomes
2016 ANNUAL MEETING
Protocol Intervention
18 month prospective, cohort before-after study conducted between November 2010 and May 2012
Adult patients ≥19
Medical or surgical ICU
RASS score of -3 or higher underwent the delirium screening with CAM-ICU
CAM-ICU and RASS assessments recorded every 8 hours
Ventilator free days
• Prevalence, duration, and percent of ICU days of delirium/coma
• 28-day ICU and total hospital mortality
• Time to discharge from ICU and hospital
• Number of patients who experienced a change in residence
• Percent of ICU time in physical restraints
2016 ANNUAL MEETING
www.ICUdelirium.org
Balas M, et al. Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/ Management, and Early Exercise/Mobility Bundle. Crit Care Med 2014.
DELIRIUM
DELIRIUM
2016 ANNUAL MEETING
2016 ANNUAL MEETING
www.ICUdelirium.org
INTENSIVE CARE DELIRIUM SCREENING
CHECKLIST (ICDSC)
DELIRIUM
ISDSC
Altered Level of Consciousness
Exaggerated response to normal stimulation
Normal wakefulness
Response to mild or moderate stimulation
Response only to intense and repeated stimulation
No response
Inattention
Difficulty in following commands
Easily distracted by external stimuli
Difficulty in shifting focus
1 point if any present
Disorientation
Mistake in either time, person or place
1 point for any abnormality
Hallucination
Evidence of hallucinations
Delusions or gross impairment of reality
1 point for either
Psychomotor agitation or
retardation
Hyperactive
Hypoactive
1 point for either
Inappropriate speech or mood
Inappropriate, disorganized, or incoherent speech
Inappropriate mood related to events or situation
1 point for any abnormality
Sleep/wake cycle disturbance
Sleeping < 4 hours/night
Waking frequently at night
Sleeping more than 4 hours during the day
1 point for any
Symptom fluctuation
Fluctuation of any of the above items over a 24 hour period
1 point for any
2016 ANNUAL MEETING
1 point
0 points
1 point
Stop assessment
Stop assessment
http://www.iculiberation.org/Bundles/Pages/Delirium.aspx
2016 ANNUAL MEETING
10
7/6/2016
THE CURRENT DEBATE
• No longer centers on the importance of SAT and SBT
THE PHARMACIST’S ROLE
• Create a protocol for how and when to titrate sedation
• Create education for the nursing staff
• How to sustain the process daily
• Who should be the champion?
• Educate and empower your nursing colleagues
• Make ‘sedation rounds’ each day with the physicians, nurse manager and
bedside nurse
2016 ANNUAL MEETING
THE PHARMACIST’S ROLE
Title
Pharmacist Leadership in ICU Quality Improvement: Coordinating Spontaneous Awakening
and Breathing Trial
Objective
Determine the feasibility and sustainability of a rounds-based, non-nurse, non-RT driven
interdisciplinary QI program to improve the process measures resulting in conduction and
coordination of our SAT/SBT protocol
Methods
•
•
•
Population
MICU patients at a single center
Intervention
Pharmacist provided 4 separate education sessions during shift change on Tuesdays/Thursdays to
the nursing staff
Primary Outcome
Number of SAT
Secondary Outcomes
•
•
•
•
•
Pharmacist led education
Daily discussion on rounds
Weekly performance reports to staff
2016 ANNUAL MEETING
JHS ANALGESIA AND SEDATION
PROTOCOL
Continuous analgesia/sedation protocol
SAT safety screen
SBT safety screens
SBTs
Analgesia and sedation use
Sustainability of the program for an 8 month period
2016 ANNUAL MEETING
2016 ANNUAL MEETING
Stolllings J, et al. Pharmacist Leadership in ICU Quality Improvement: Coordinating Spontaneous Awakening and Breathing Trials. Annals of Pharmacotherapy. 2015. 49(8) 883–891.
THE PHARMACIST’S ROLE
SAMPLE TITRATION PARAMETERS
Fentanyl
Initiate infusion at 50 mcg/hour (usual dose 50-300 mcg/hour), to maintain CPOT goal less than or equal
to 2 or to control shivering or ICP above 20 mmHg. Assess CPOT score in 30 minutes and in 4 hours.
Titrate infusion rate every 4 hours per protocol below:
2016 ANNUAL MEETING
CPOT: 3 to 8
Give bolus, if ordered and increase rate by 25 mcg/hour. Reassess in 30 minutes
and in 4 hours.
CPOT: 0 to 2
Reassess every 4 hours. Once CPOT is maintained at 0 to 2 for 8 hours, decrease
rate by 25 mcg/hour every 4 hours
2016 ANNUAL MEETING
11
7/6/2016
SEDATION/DELIRIUM ASSESSMENT
SAMPLE TITRATION PARAMETERS
Propofol
Initiate infusion at 5 mcg/kg/min (Usual dose 5-50 mcg/kg/min), to maintain RASS goal 0 to -2 or to
control shivering or ICP above 20 mmHg. Assess RASS score in 5 minutes. Titrate infusion per protocol
below:
RASS: +4 to +1
Increase rate by 5 mcg/kg/min. Reassess in 5 minutes
RASS: 0 to -2
Reassess every 4 hours. Once RASS is maintained at 0 to -2 for 8 hours,
decrease rate by 2.5 mcg/kg/min every 4 hours
RASS: -3 to -5
Decrease by 5 mcg/kg/min and reassess in 30 minutes and in 4 hours
2016 ANNUAL MEETING
2016 ANNUAL MEETING
DELIRIUM
SEDATION INTERRUPTION
Dose Initiation
Haloperidol
2.5 – 5 mg q6hr
PRN
Dose Initiation
2016 ANNUAL MEETING
Quetiapine
25 mg BID
Olanzapine
5 mg daily
Chlorpromazine
25 mg QID
Risperidone
0.5 mg BID
Benztropine
1 mg BID
Titration
Initiatie or ↑ dose of standing antipsychotic
and continue same PRN dose
Titration
↑ by 25-50 mg BID
every other day
↑ by 5 mg daily
every other day
↑ by 25-50 mg QID
every other day
↑ by 0.5-1 mg BID
every other day
Drug Initiation & Titration
Max
Administration
Dose
35 mg
PO – tabs
IM – short-acting injection
IV
Scheduled Antipsychotic Initiation & Titration
Wean
Max
Administration
Dose
↓ by 25 – 50 mg
400 mg
PO – immediate release (IR) tabs
every other day or
by 25 – 50% every
20 mg
PO – tabs
other day
IM – short-acting injection
400 mg
PO – tabs, solution
IV – administer in NS bag over 30 min
6 mg
PO – tabs, solution
Order solution if patient cannot
swallow – DO NOT CRUSH TABS
Cogentin Initiation & Titration (if needed)
↑ by 0.5 mg BID if patient experiencing EPS
6 mg
PO – tabs
Monitoring



QTc interval at BASELINE and with every dose
change or addition of other QTc prolonging agents
Extrapyramidal symptoms
Anticholinergic effects
Monitoring



QTc interval at BASELINE and with every dose
change or addition of other QTc prolonging agents
Extrapyramidal symptoms (dystonia, dyskinesia,
akathesia, etc.)
Anticholinergic effects
Somnolence

Anticholinergic effects

2016 ANNUAL MEETING
THE PHARMACIST’S ROLE
Perform your own assessments!
• Example: Procedure for RASS Assessment
• Observe patient
• Patient is alert, restless or agitated (score 0 to +4)
• If not alert, state patient’s name and say to open eyes and look at speaker.
• Patient awakens with sustained eye opening and eye contact
(score −1)
• Patient awakens with eye opening and eye contact, but not sustained
(score −2)
• Patient has any movement in response to voice but no eye contact.
(score −3)
• When no response to verbal stimulation, physically stimulate patient by shaking shoulder
and/or rubbing sternum.
• Patient has movement to physical stimulation.
(score −4)
• Patient has no response to any stimulation
(score −5)
2016 ANNUAL MEETING
BRINGING THE ABC(DEF)’S
TO THE ICU
GINA RIGGI, PHARMD, BCPS, BCCCP
CLINICAL HOSPITAL PHARMACIST- TRAUMA INTENSIVE CARE UNIT
JACKSON MEMORIAL HOSPITAL
MIAMI, FLORIDA
2016 ANNUAL MEETING
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