Niki Hester Maureen Clifford Heather Woodard Jennifer Stephens

 Define delirium and how delirium impacts the patient.  State the purpose of daily interruption of sedation (DIS).  Describe RASS and explain range.  Accurately rate the hypothetical patient using the RASS scale.  Answer questions about the RASS.  Commit to using the RASS.

 The ICU is an environment with alarms, constant light and frequent interruptions, causing sleep deprivation. The patients have many tubes, pain and anxiety.  Delirium, or “ICU psychosis” develops in 60 to 80% of ventilated ICU patients and 20 to 50% of non- ventilated patients.  Delirium is a global impairment of the cognitive processes, usually of sudden onset, with disorientation, impaired memory, altered sensory perceptions, and, at times, inappropriate behavior. Delirium is reversible.

 Common causes of delirium include medical conditions, substance intoxification or withdrawal, and medications. PAIN is also a cause of delirium.  Consequences of delirium include increased re- intubation rates, prolonged hospital length of stay, increased cost, prolonged neurocognitive impairment, and an increased risk of death.  Analgesics and sedatives are needed to maintain patient safety and comfort, and are used in treatment of delirium. Oversedating or undersedating these patients can have significant adverse affects.

 Also known as “sedation vacation”  The purpose is to interrupt the patient’s sedation by turning their sedation off once daily.  This helps to avoid sedative dependence and withdrawls, and has been shown to decrease the patient’s duration of mechanical ventilation and length of stay (LOS).  The patient awakens, and assessment of level of consciousness and neurologic function are performed utilizing the Richmond Agitation and Sedation Scale.  DIS is also used as an adjunct intervention for the reduction of ventilator associated pneumonia (VAP).

 Active seizures  Alcohol withdrawl or delirium tremors  Increased intracranial pressure  Neuromuscular blockade  Uncontrolled arrhythmias  Myocardial infarction within previous 24 hours  Palliative care patients  MD order

Is a DIS contraindicated ? Is analgesia being used for pain? Manage pain prior to turning off sedation Turn off sedation DIS = Turn sedation & analgesia off Did the patient tolerate DIS RCP to perform SBT Able to extubate patient Consider bolus dose, prn dosing or restart sedation at 50% of previous level Reevaluate SAS score for appropriateness Is patient at ordered level ? Consult Sedation Mangement Job Aid Consider PRN dosing Consider delirium Continue present treatment and attempt DIS in 24 hours Collaborate with MD & RCP Does patient require sedation? YES NO YES NO STOP YES NO DO NOT restart sedation, continue to monitor pt YES NO

 Richmond Agitation and Sedation Scale  Research has shown that excessive sedation can prolong the use of mechanical ventilation, create physical and psychological dependence, and increase the length of the hospital stay.  The RASS scale is an assessment tool that measures the sedation or agitation of ICU patients, which assists healthcare providers in titrating sedative medications.  The RASS is a ten-point scale with zero as the neutral position. Positive numbers measure agitation, while negative numbers measure sedation.

 The significance of RASS is to maintain a balance between patient comfort and interaction with the environment, ensuring that patients are maintained on the least amount of sedation as possible. The goal is a zero or negative one on the RASS scale.  Literature supports notion that inadequate and/or excessive sedation and analgesia are still common in Intensive Care Units despite Joint Commission mandating use of sedation scales.

 Failure to meet goals of proper sedation and analgesia can have detrimental effects including an increase in adverse events, poor outcomes, longer ICU stays and financial burdens.  Studies have shown better outcomes and cost savings with the implementation of sedation protocols.  Patients who were aroused/woken up on a daily basis during their ICU stay were shown to have a shorter LOS and a shorter duration of mechanical ventilation.

Optimal sedation level that provides comfort while maintaining patient interaction with the environment. Daily goal = arousable, comfortable sedation RASS goal = 0 or -1

 Aim of Study: Examine and compare the reliability and validity of three scales (Sedation and Agitation Scale, Richmond Agitation and Sedation Scale & Visual Analog Scale) used for measuring sedation and agitation levels and determine which one was the most reliable and accurate for use in the ICU  Study Population: Observations were conducted on 79 patients by a total of 25 nurses and four physicians who were unfamiliar with the scales.  Results: RASS had an excellent reliability (r>0.86) with high coefficients noted between the research team nurse and unit physician (r=0.91). The RASS also had higher correlations when compared to the SAS and VAS which means the RASS is a reliable and valid tool for measuring states of sedation and agitation in general ICUs

 Objective: Look at the current literature regarding daily sedation interruption (DSI) and determine its pros and cons.  Findings: DIS patients were extubated quicker than conventional sedation management, discharged from the ICU quicker, and had fewer expensive neurological investigations (CT, EEG). It is also suggested that pain and anxiety are the predictable adverse effects of DIS as patients wake from coma.

 Aim of Study: Determine the validity and reliability of the Richmond agitation and sedation scale in relation to ease of use as well as accuracy of determining an appropriate level of sedation for the patient.  Study Population: Sample size included 172 patients of various conditions in different types of intensive care units.  Results: Indicated that the RASS had a high correlation of inter-rater reliability, with all five raters having the RASS score within 1 point of each other in more than 95% of cases. The study suggests that the Richmond Agitation and Sedation Scale is not only easy to use, but is accurate, and has a high inter- rater reliability across a wide variety of intensive care unit patients, further enhancing generalizability.

 That’s Right! It’s Time For…

Delirium and DISRASSResearch

Delirium and DIS - 10 Name 3 consequences of delirium.

Delirium and DIS Answer – 10 - increased reintubation rates - prolonged hospital stay - increased cost - increased risk of death - prolonged neuro-cognitive impairment after discharge

Delirium and DIS - 20 Name 3 contraindications for Daily Interruption of Sedation (DIS)?

Delirium and DIS Answer – 20 - active seizures -alcohol withdrawal/ detox - increased intracranial pressure -neuromuscular block -uncontrolled arrhythmias - MI within previous 24hours - high frequency oscillating ventilation - hypothermia protocol - palliative care - MD Order

RASS - 10 What are some advantages of the Richmond Agitation and Sedation Scale compared with other sedation assessments?

RASS Answer – 10 ease of use, accuracy, and high inter-rater reliability

RASS - 20 What is the goal of sedation?

RASS Answer – 20 - arousable, yet comfortable sedation - a score of -1 to 0 on the RASS - a balance between sedation and pain management

Research - 10 Positive ratings on Richmond agitation & sedation scale indicate ___________while negative ratings indicate ___________.

Research Answer – 10 agitation; sedation

Research - 20 Why is the Richmond Agitation and Sedation Scale the best scale for measuring agitation and sedation?

Research Answer – 20 High validity and reliability

Research - 30 What are some of the benefits of using DIS?

Research Answer – 30 DIS patients were extubated quicker than conventional sedation management, discharged from the ICU quicker, and had fewer expensive neurological investigations (CT, EEG)

You All Win!!

 It is possible to wean from sedation, even if the patient can not be weaned from the ventilator.  RN & RCP should collaborate on timing of DIS & SBT  Goal is to maintain the patient on the least amount of sedation that is medically appropriate  Lighten sedation to appropriate wakefulness daily.  Assess sedation using RASS per hospital protocol (usually q4h and prn).  RASS goal should be reevaluated daily.

 Discuss the significance of using a standardized tool to assess the ICU patient.  Discuss the value of using the RASS tool to benefit the patient.

In our presentation we…  Defined delirium and its impact on ICU patients.  Stated the purpose of the daily interruption of sedation (DIS).  Described RASS scale and explained its continuum/range.  Demonstrated use of RASS scale using hypothetical patient scenario.  Encouraged commitment to using RASS when determining patients level of agitation or sedation.

Bastable, S. B. (2008). Nurse as educator: Principle of teaching and learning for nursing practice (3 rd ed.). Boston, MA: Jones and Bartlett Publishers. Delirium Committee, Sentara Norfolk General Hospital. (2011). Detecting and managing delirium in the ICU. Norfolk, VA. O’Connor, M., Bucknall, T., & Manias, E. (2008). A critical review of daily sedation interruption in the intensive care unit. Journal of Clinical Nursing, 18,

 Rassin, M., Sruyah, R., Kahalon, A., Naveh, R., Nicar, I. & Silner, D. (2007) Between the fixed and changing: examining and comparing reliability and validity of three sedation-agitation measuring scales. Dimensions of Critical Care Nursing, 26,  Robinson, B. R., Mueller, E. W., Henson, K., Branson, R. D., Barsoum, S., & Tsuei, B. J. (2008). An analgesia- delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. Journal of Trauma, Injury, Infection, and Critical Care, 65, doi: /TA.0b013e318181b8f6

 Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O’Neal, P. V., Keane, K. A.,…Elswick, R.K. (2002). The richmond agitation-sedation scale: Validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine, 166, Retrieved from  Urden, L. D., Stacy, K. M., Lough, M. E. (2010). Critical care nursing (6 th ed.). St. Louis, MO: Mosby Elsevier.

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