1. Mazen kherallah, MD, FCCP

2. Stress in ICU? Psychological Stress Environmenta l Stress Spiritual Strees Physical Stress

4. Psychological Stress in ICU

5.  Loss of control  Fear of death or serious illness  Fear of pain  Overwhelming isolation  Feelings of helplessness  Loss of normal circadian rhythms  The disruption of normal sleep patterns  Sleep deprivation  Disorientation and panic

6. Can the patient whom we thing is sedated on the ventilator hear and think?

7. Listen to this…

8. Alien, sensory rich environment

10. Environmental Stress in ICU

11.  Foreign environments  Room temperature  Continuous ambient lighting  Family not continuously available for comfort  Significant noise from personnel and medical equipment

12. 12

13. Physical Stress in ICU  Attached to equipments with tubes or wires  Intubated and ventilated  Treatment or diagnostic procedures  Confined (restricted) to bed  Uncomfortable bed and pillow  Unable to control stool habit

15. + Inability to communicate

16. Frustration and Anger

17. Excessive stimulation Excessive stimulation in ICU Monitoring Monitoring Cleaning Cleaning Suctioning Suctioning Dressing changes Dressing changes Mobilization Mobilization Physical therapy Physical therapy

18. Anxiety, sleep deprivation 71% of patients in a medical surgical ICU get agitated at least once (46% severe agitation) 71% of patients in a medical surgical ICU get agitated at least once (46% severe agitation) Pharmacotherapy 2000; 20: 75-82

19. Delirium in 87% Delirium in 87% with fluctuating mental status, with fluctuating mental status, inattention, disorganized inattention, disorganized thinking with or without thinking with or without agitation agitation JAMA 2001; 286: 2703-2710

20. Recall in the ICU Questionnaire to 80 survivors of ARDSQuestionnaire to 80 survivors of ARDS 80% remembered an adverse experience e.g. nightmares, anxiety, pain, respiratory distress80% remembered an adverse experience e.g. nightmares, anxiety, pain, respiratory distress 28% met criteria for PTSD28% met criteria for PTSD - 41% with recall of  2 frightening experiences Other reports suggest 4-15% PTSD in ICU survivorsOther reports suggest 4-15% PTSD in ICU survivors Crit Care Med 2000; 28: 86-92 Crit Care Med 1998;18:651-659 Crit Care Med 2000; 28: 86-92 Crit Care Med 1998;18:651-659

21. Sedation Goal

22. ICU Sedation Goal Stabilize hemodynamics & modulate stress responseStabilize hemodynamics & modulate stress response Reduce motor activity – tolerance of procedures, facilitate nursing managmentReduce motor activity – tolerance of procedures, facilitate nursing managment Facilitate mechanical ventilationFacilitate mechanical ventilation Facilitate sleep patternsFacilitate sleep patterns

23. UndersedationUnderdosingToleranceWithdrawal OversedationOverdosing Drug accumulation Impaired elimination Drug interactions Adverse side effects

24. Incidence of Inappropriate Sedation Over-sedation On Target Under-sedation 54% 15.4% 30.6% Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. Olson D et al. NTI Proceedings. 2003; CS82:196. 10% 20% 70% Kaplan L. and Bailey H. 2000 Olson D. et al. 2003

25. Sedation Sedatives Causes for Agitation

26. Undersedation Sedation Causes for Agitation Agitation & anxiety Pain and discomfort Catheter displacement Inadequate ventilation Hypertension Tachycardia Arrhythmias Myocardial ischemia Wound disruption Patient injury

27. Oversedation Sedation Causes for Agitation Prolonged sedation Delayed emergence Respiratory depression Hypotension Bradycardia Increased protein breakdown Muscle atrophy Venous stasis Pressure injury Loss of patient-staff interaction Increased cost

28. So, we want appropriate sedation, but how? Sedation Depth Complications Costs Adverse Outcomes Complications Adverse Outcomes BEST OUTCOMES ADEQUATE/OPTIMALOVERDOSING UNDERDOSING

29. Is Your Patient Comfortable and at Goal ?

31. Pain Assessment by Family? Pain Assessment by Family? Surrogates were able to assess presence or absence of pain in 73.5% of patientsSurrogates were able to assess presence or absence of pain in 73.5% of patients Degree of pain correctly assessed in only 53% of patientsDegree of pain correctly assessed in only 53% of patients *Crit Care Med 2002;30:119-141 *Crit Care Med 2002;30:119-141

32. Signs of Pain  Hypertension  Tachycardia  Lacrimation  Sweating  Pupillary dilation Patients who cannot communicate should be assessed through subjective observation of pain-related behaviors (movement, facial expression, and posturing) and physiological indicators (HR, BP, RR) and the change in these parameters following analgesic therapy Grade B recommendation

33. Motor Activity Assessment Scale (MAAS)* Seven categories to describe the patient’s reaction to stimulation *Devlin et al. Crit Care Med 1999;27:1271-1275

34. ScoreDescriptionDefinition 0 UnresponsiveDoes not move with noxious stimulus* 1 Responsive only toOpen eyes OR raises eyebrows OR turns noxious stimuli head toward stimulus OR moves limbs with noxious stimuli 2 Response to touchOpens eyes OR raises eyebrows OR turns or namehead towards stimulus OR moves limbs when touched or name is loudly spoken 3 Calm and cooperativeNo external stimulus is required to elicit movement AND patient is adjusting sheets or clothes purposefully and follows commands *Noxious stimuli = Suctioning OR 5 sec of vigorous orbital, sternal, or nail bed pressure

35. ScoreDescriptionDefinition 4 Restless andNo external stimulus is required to elicit cooperativemovement AND patient is picking at sheets or tubes or uncovering self and follows commands 5 AgitatedNo external stimulus is required to elicit movement AND attempting to sit up OR moves limbs out of bed AND does not consistently follow commands (e.g. will lie down when asked but soon reverts back to attempts to sit up or move limbs out of bed 6 Dangerously agitatedNo external stimulus is required to elicit Uncooperativemovement AND patient is pulling at tubes or catheters OR thrashing side to side or striking at staff OR trying to climb out of bed AND does not calm down when asked

36. Objective assessment of sedation during: BIS in the ICU: Key Applications ? Mechanical Ventilation Neuromuscular Blockade Bedside Procedures Drug Induced Coma

37. GE BIS Display / BIS Sensor GE BIS Display BIS Sensor

38. BIS converts the “raw” EEG signal to a number 0-100 BIS = 95 BIS = 70 BIS = 50 BIS = 30

39. Responds to normal voice Responds to loud commands or mild prodding/shaking 100 BIS 80 60 40 20 0 Low probability of explicit recall Unresponsive to verbal stimulus Burst suppression

40. BIS in Deep Sedation Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67. Titration to maximal Ramsay Score of 6 (unarousable) Blinded BIS monitoring Results: Ramsay Score remains the same, with significant decrease of BIS values over time. Data suggest possible accumulation of sedatives and inherent risks of over-sedation. BIS Value BIS Ramsay Score* 68 45 31 6 6 6 2 3 4 5 6 * Mondello et al. Minerva Anestesiology. 2002;68(102):37-43. Ramsay

41. BIS in Deep Sedation Riker. AJRCCM 1999 De Deyne. Int Care Med 1998 Unarousable SAS 1 Ramsay 6 Titration to unarousable state by subjective scale Blinded BIS monitoring Results: Patients were unarousable at maximal sedation score. All patients appeared similar clinically, but displayed wide variation in sedation level as measured objectively with BIS monitoring.

42. BIS Reduces Sedative Cost & Improves Patient Experience Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. SICU patients (n=57): Infusions of sedatives & paralytics Control: Sedatives titrated to vital signs and comfort BIS: Sedatives titrated to BIS 70-80 (post-stimulation) BIS-Guided Titration Results: Average sedative savings of $150 per patient Unpleasant recall reduced from 18% to 4% (p<0.05) BIS Titrated Control Sedative Cost / patient ($) 18% Decrease $819 $669 BIS Titrated Control Patient Recall: Frightened / Painful (%) 78% Decrease 18% 4%

43. Ruling Out Reversible Causes

44. Sedation of agitated patients should start only after providing adequate analgesia and treating reversible physiological causes Grade C recommendation  Pain, hypoxemia, hypoglycemia, hypotension, withdrawal from alcohol and other drugs

45. Correctable Causes of Agitation Full bladder Uncomfortable bed position Inadequate ventilator flow rates Mental illness Uremia Drug side effects Disorientation Sleep deprivation Noise Inability to communicate Cold room Uncomfortable mattress or pillow Traction on endotracheal tube

46. Sedation Sedatives Causes for Agitation

47. SedationAnalgesia “ICU Sedation” AmnesiaHypnosisAnxiolysis Patient Comfort