2.  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. ‘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. 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.  ANXIOLYSIS  SLEEP  ANALGESIA  MUSCLE RELAXATION

10.  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.  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.  DVT prophylaxis  Gastric ulcer prophylaxis  Sedation 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.  HUMANE? OVER OR UNDER SEDATED  PATIENT PHYSIOLOGICAL SAFETY  PATIENT PHYSICAL SAFETY  PARALYZING AGENTS – STOP!!  WHICH TOOL???

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

16.  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.  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. Old sedation scoring method: Adaptation of Addenbrookes Sedation Score 0Agitated 1 Awake 2 Roused by voice 3 Roused by pain/coughs on suction 4 No response/unrousable Pparalysed

20. 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.

30.  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