Sangeeta Mehta MD, FRCPC

CCCF

Nov 9, 2018

Comfort without sedation

Disclosures

• I have no disclosures or conflicts of interest

To review…

• Why should we avoid sedation?

• Is it possible?

• How? What are the alternatives?

361 ICUs, 20 countries

5183 receiving MV > 12 h

68% received sedative for >3 hrs within 24 hrs

Use of sedatives associated with

Longer duration of MV

Longer weaning time

Longer ICU stay

CHEST 2005;128:496

Observational study, 242 mechanically ventilated adults

Duration of MV:

- infusion 185 190h

- intermittent 56 76h p<0.001

Infusion group:

- more patients tracheostomized

- ICU and hospital LOS

CHEST 1998;114:541

AJRCCM 2012

Time to extubation Survival

Deep sedation = RASS -3 (movement/eye opening to voice but no eye contact) to -5 (unarousable)

Crit Care Medicine June 2018

Sedation Index – calculated over 48H

Sum of negative RASS scores

# of RASS measurements

Agitation component

Sedation component

Probability of Extubation

Probability of survival

Every 1-point ↑ in SI• Delayed extubation by one day• ↑ risk of dying in 6 months by 30%

The Ideal

Scenario

PADIS GuidelinesCCM Sept 2018

• We suggest using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults (conditional recommendation, low quality of evidence)

• In critically ill, intubated adults, DSI protocols and NP-targeted sedation can achieve and maintain a light level of sedation (ungraded)

• We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery (conditional recommendation, low quality of evidence)

• We suggest either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults (conditional recommendation, low quality of evidence)

Symptom based management

Pain

Fear

Anxiety

Agitation

Sleep

ALWAYS

• Non-pharmacologic management

ONLY IF NEEDED

• Pharmacologic management

• Sedative adjuncts

• (Physical restraint)

All patients managed

with RN driven

sedation/analgesia protocol

Daily interruptionSedation/analgesia

No daily interruption

randomized

N=430

16 centers

Surgical and medical pts

JAMA 2012

Crit Care Med 2015

ICU Memory ToolDay 28

I remember…. N=121

Admission to hospital 47%

Being in ICU 74%

getting enough sleep in ICU 66%

breathing tube 53%

having my trachea suctioned 36%

Pain 29%

Panic 32%

Feeling confused 47%

Feeling anxious/frightened 54%

Hallucinations 40%

Nightmares 34%

Remember feeling fearful

Yes - bothered none or little 19%

Yes - bothered moderately - extremely 81%

Remember feeling something bad will happen

Yes - bothered none or little 16%

Yes - bothered moderately - extremely 84%

Remember not being able to sleep

Yes - bothered none or little 16%

Yes - bothered moderately - extremely 84%

Remember being in pain

Yes - bothered none or little 14%

Yes - bothered moderately - extremely 86%

CCM 2002;30:746

Questions to ask yourself daily…

• Does my patient need sedation?

• Why does my patient need sedation?

140 MV patients

morphine prn

Propofol x 48 h then midazolam infusion

morphine prn

DI in both groupsLocal weaning protocol, no SBT

Ramsay 3-4

No sedation group

• 4.2 fewer MV days

• shorter ICU and hospital LOS

• more agitated delirium – 20% vs 7%

• more haldol

• Sedative infusions in 18%, mainly ARDS

Lancet Resp Med Oct 2017

Time to successful extubation (h)

8 hours vs 50 hours

Can we avoid sedation?

Can we avoid sedation?

Not in all patients

When sedation is necessary….

• Use lowest doses

necessary to achieve

your clinical goals

• Stop sedation as

quickly as possible

When sedation is necessary….

• Intermittent sedation

• Sedation protocols

• Sedation scales

• Daily sedation interruption

• Propofol/Dexmedetomidine

• Multi-modal approach

• Use lowest doses

necessary to achieve

your clinical goals

• Stop sedation as

quickly as possible

Avoid benzodiazepines IndicationsPalliationSeizuresSevere anxietyProcedural amnesia

Project IMPACT 2003-2009. Propensity matching AJRCCM 2014

Co-operation and communication

• 4 multicentre trials (N=1461) compared dex with midazolam or propofol

• Secondary outcomes: nurses’ assessment of arousal, co-operation and ability to

communicate pain using VAS

• In all 4 trials patients who received dex were significantly more arousable, more co-

operative and better able to communicate their pain than those who received propofol or

midazolam (p ≤ 0.001 in all cases)

Pharmacologic options for agitated patients...

Short duration…

• Sedative infusions

• (Physical restraint)

Longer duration…

• Antipsychotics– Haldol, risperidone, quetiapine, loxapine

• Clonidine

• Propranolol

• Benzodiazepines– Clonazepam, lorazepam

• Non-opioid analgesics

• Sleep aids

Non pharmacologic multi-component interventions

• Individualised care

• Reorientation

• Attention to sensory

deprivation

• Familiar objects

• Nutrition/ hydration

• Mobilisation

• Sleep hygiene

• Comprehensive Geriatric

Assessment

• Mood: assessment for

depression/anxiety

• Family presence

• Cognitive stimulation

• Fresh Air

Day 3

N=155

Day 28

N=121

Day 90

N=100

Had enough sleep in the ICU 51% 66% 71%

Reasons for inadequate sleep

Noise

Bright lights

Loud speaking

People entering room

47%

31%

41%

45%

50%

40%

45%

26%

41%

33%

33%

37%

Crit Care Med 2016

Minerva Anesthesiol 2012

Very poor

27%

Poor

41%

Good

17%

Very Good

13%

Excellent

2% Very poor

25%

Poor

32%

Good

17%

Very Good

13%

Excellent

13%

Quality Quantity

Patient assessment of sleep in the ICU

Possible Improvements for the ICU % Patients

Closing Doors/Blinds at Night 42

No Unnecessary Interruptions 40

Use of Sleeping Pills 33

Dimmed Lights in the Entire Unit 27

Visible Clock in room 25

Removal of Monitors and Alarms Overnight 25

Patients’ perceptions of Intensive care

• 76 patients, Lucca, Italy

• Patients reported

– Insufficient sleep (61%)

– Uncomfortably hot (37%) and cold (28%)

– Lonely or isolated (46%)

Simini, The Lancet 1999

Experience Remember with stress

Noise from ventilators 32%

Noisy and bad sleeping nights 54%

Lack of privacy in hygiene 43%

Communication difficulties 59%

Brightness from artificial lights 33%

Losing time orientation 37%

Crit Care 2005

464 patients

Urner, Ferreyro, Doufle, Mehta. Resp Care 2018 – In press

Essentials of comfort management - 1

• Keep your patients awake and engaged

• Symptom based management

• Pain, anxiety, agitation, sleep

• Intermittent/prn rather than continuous

• Analgesia-first strategy

– Objective assessment of pain

– Minimal or no sedation

Essentials of comfort management - 2

• De-medicalize/mobilize

• Non-pharmacologic support

• Family presence

• If sedation is needed

– Favour propofol/dexmedetomidine

– Use adjunctive agents

• Be vigilant for iatrogenic withdrawal

• Sleep promotion

geeta.mehta@utoronto.ca

Vincent JL et al. Int Care Med 2016;42:962

• Anxiety because I felt I needed to get my restraints off

• A nurse - a man - he came and tied my hands really tight

• When in restraints thought an electronic [slruder] treatment was

coming

• I was terrified for my life. I felt restrained.

• Dream that someone was hand cuffing pt to a table/chair

• Pt remembers being restrained & pleading to have restraints

removed

• A male nurse tied my hand very tight after I called him over to help

me turn as I was very uncomfortable

• The feeling of restraint was upsetting and made him feel violated.

Felt he was yelled at

• Saw images of vampires who tied her arms down in order to suck

blood from her central line

SLEAP StudyMemories of Physical Restraint