1. Sedation Use in the Critical Care Environment Lisa Notley LP in Critical Care Royal Bournemouth Hospital & Christchurch NHS Foundation Trust Bournemouth University

2. Aims To review sedation use in critically ill Draw upon clinical experience of changing a sedation scoring tool Discuss sedations holds in relation to care bundles and patient outcomes.

3. Why use sedation? ‘Sedation is an essential component of the management of intensive care patients. It is required to relieve the discomfort and anxiety caused by procedures such as tracheal intubation, ventilation, suction and physiotherapy. It can also minimise agitation yet maximise rest and appropriate sleep’ ( Werrett, 2003)

6. Two Extremes Over-sedated Hypotension Prolonged recovery Delayed weaning Gut ileus DVT Nausea & vomiting Immunosuppression Under sedation Hypertension Tachycardia Increased O 2 consumption Myocardial ischaemia Atelectasis Tracheal tube intolerance Infection

7. COMPONENTS OF SEDATION REGIME ANXIOLYSIS SLEEP ANALGESIA MUSCLE RELAXATION

10. Drugs used typically drug combinations Benzodiazepines Propofol Barbituates Phenothiazines Clonidine chlormethiazole ?Ketamine Chloral hydrate Volatile agents Morphine Fentanyl Alfentanil Remifentanil ??muscle relaxation Early resuscitation Refractory hypoxaemia Raised ICP Status epilepticus and tetanus Pateint transfer and inverse ratio’s Prone ventilation

11. Ventilation Care Bundle & Sedation Started in the USA and introduced in UK in 2002 Group of evidenced based elements which have been shown to improve patient outcomes & collectively audited review standards of treatment (Berenholtz 2002) DOH, NICE & Modernisation Agency – protocol based care

12. ‘Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery’ ( NICE )

13. Ventilation Care Bundle DVT prophylaxis Gastric ulcer prophylaxis Sedation holdsSedation holds Head of bed elevation (30 degrees) Also BM control Use of steroids in catecholamine dependent septic shock Audit & monitoring compliance is a key aspect i.e. sedation costs, time on ventilator, ICU LOS

14. What’s the score? HUMANE? OVER OR UNDER SEDATED PATIENT PHYSIOLOGICAL SAFETY PATIENT PHYSICAL SAFETY PARALYZING AGENTS – STOP!! WHICH TOOL???

15. TOOLS/SCALES RAMSEY SCALE COHEN AND KELLY SCALE THE NEWCASTLE SCALE ADDENBROOKES/CAMBRIDGE SCALE NEW SHEFFIELD SCALE BLOOMSBURY SCALE Intensive Care Society EEG (Bispectral Index)

16. The benefits of a sedation protocol Removes the effects of external influences All nurses aware of common goal Sedation level will be much ‘lighter’ (+/- sedation vacation) Aim to reduce ventilator time Reduced need for tracheotomy Reduced rate of complications Increase patient throughput Cost savings

17. A little about my unit The Critical Care Unit consists of the Intensive Care Unit (ICU) and High Dependency Unit (HDU), together comprising a total of 10 critical care beds. The ICU & HDU admit over 800 patients a year, with a wide variety of conditions. 20% are routine admissions for post-operative care following major surgery, the remaining 80% are emergency admissions. The critical care unit receives patients from all specialities and has particular expertise in the care of patients following oesophageal and vascular surgery.

18. RBH Critical Care Adopted System for Sedation Scoring Old sedation scoring method: Adaptation of Addenbrookes Sedation Score 0Agitated 1Awake 2Roused by voice 3Roused by pain/coughs on suction 4No response/unrousable Pparalysed

20. New Sedation Score with Holiday 3Agitated and restless 2Awake and uncomfortable 1Aware but calm 0roused by voice -1roused by touch -2roused by painful stimuli -3unrousable Anatural asleep P paralysed Hourly sedation score 3210-2-3 Give bolus or start infusion No change Reduce infusion rate Stop infusions Recommence at lower rate when sedation score reaches desired level If your patient meets with the protocol for stopping sedation, please stop at 11.00 and access using the above tool. If the patient scores 2 on assessment consider analgesia or re-sedation If patient score 3 and is unable to settle sedation may be recommended If your patient does not meet the protocol and therefore sedation is not stopped, please document that it was considered.

22. Sedation Holds/Holiday/Interruption!!

25. Monthly Audit Results.v. recently published report

26. East Surrey Hospital Cruden, E. 2005 an evaluation of the impact of the ventilator care bundle. Nursing in Critical Care. 10 (3) 242- 246.

28. Conclusion

30. Other approaches are just as important Good communication with regular reassurance Environmental control such as humidity, lighting, temperature, noise Explanation prior to procedure Management of thirst, hunger, constipation, full bladder Variety for the patient – radio, visits from relatives, washing Appropriate diurnal variation