All the way back on Podcast 21, I advocated for better post-intubation sedation in the ED. Well, now it turns out that if you are still using just lorazepam and vecuronium you are now even further from the ideal.
It is all about Sleep and Orientation
Bad sedation strategies destroy sleep architecture and orientation, then patients become crazy.
- The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892–1900
- Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762
- Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009; 35:1276–1280
- Delirium leads to long-term cognitive impairment (N Engl J Med 2013; 369:1306-1316) HT to @icudelirium
- Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180:1092–1097
- Deep sedation associated with higher mortality (Critical Care 2015, 19:197 )
It doesn't matter if we screw it up Downstairs, they can Fix it in the ICU
Ummm, not so much if you believe the SPICE Study-In 251 critically ill patients at multiple centers, we identified deep sedation within 4 hours of commencing ventilation as an independent negative predictor of the time to extubation, hospital death, and 180-day mortality. The early phase of ICU sedation is usually unaccounted for in randomized controlled trials due to late randomization. (Am J Respir Crit Care Med Vol 2012;186(8):724–731)[cite source='doi']10.1164/rccm.201203-0522OC[/cite]
A1 Sedation – Analgesia First
Stick your finger down your throat–now leave it there
Strom et al. evaluated this: RCT of 140 patients-analgesia vs. analgesia+sedation. Analgesia only showed shorter vent time and ICU LOS.[cite source='pubmed']20116842[/cite]
Analgosedation: a paradigm shift in intensive care unit sedation practice,[cite source='doi']10.1345/aph.1Q525[/cite].
Just put patients on a fentanyl drip. If not go with dilaudad IV. When remifentanil is cheap, we'll switch to that in a bunch of patient categories.[cite]15329588[/cite]
Then evaluate pain and decide if the patient needs additional pushes of pain meds.
Consider using the Behavioral Pain Scale (Crit Care Med 2001;29(12):2258) HT to Nikolay Yusupov
Myth – We can prevent PTSD if we Black Out the ICU Experience
just the other way around
Myth – Benzos are just Swell
Not so much-Benzos lead to longer length of stay, longer vent time, and increased delirium.
Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials,[cite source='doi']10.1097/CCM.0b013e3182a16898[/cite].
Myth – Short-Acting Sedatives and Analgesics Go Away Quickly
You need a goal, like RASS
Myth-Pain is a Great Pressor
Patients should never be undersedated due to hemodynamics
Standard Critically Ill Patients
Fentanyl and Dexmedetomidine (or Propofol)
If you have ICP issues, propofol and fentanyl
Hemodynamically Compromised Patients
Fentanyl and then,
Ketamine drip or intermittent boluses
What are they doing in the ICU?
In patients with protocolized sedation, daily sedation interruptions (holidays) did not lead to demonstrable benefit. The SLEAP Study (JAMA 2012;308(19):1985)[cite source='doi']10.1097/CCM.0b013e3182a168c5[/cite]
The SCCM Guidelines
ICU Delirium Site Protocol
A Lecture on the SCCM Guidelines
Here is the Protocol
Dr. Herr created for the STC Center (STC Pain Sedation and Delirium Protocol)
Must Read Reviews
- Top 10 myths regarding sedation and delirium in the ICU,[cite source='doi']10.1097/CCM.0b013e3182a168f5[/cite]
- Sedation and analgesia in the mechanically ventilated patient,[cite source='doi']10.1164/rccm.201102-0273CI[/cite]
- Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies,[cite source='doi']10.1055/s-0033-1342983[/cite]
- An economic review of dexmedetomidine (Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care – an economic evaluation [cite source='doi']10.1186/s13054-015-0787-y[/cite]
- Ketamine for Analgosedation
- Propofol doesn't seem to increase pressor requirements in this pilot study (prop and vasopressor use)
- Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the emergency department: a cohort study. Chest. 2017 Jun 20. pii: S0012-3692(17)31076-0. doi: 10.1016/j.chest.2017.05.041. [Epub ahead of print] More on oversedation leading to badness in the ED
- ED-SED – A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients doi: 10.1097/CCM.0000000000003928
Now, On to the Podcast…
- COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD - April 6, 2020
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020