ICU PADIS guidelines

Jared Larson

updates to the 2018 PADIS guidelines from 2013

added recommendations about immobility and sleep

pain

unpleasant sensory and emotional experience associated with actual or potential tissue damage

short and long term consequences of unrelieved acute pain

stress response can be deleterious … impaired tissue perfusion, hyperglycemia, lipolysis, muscle breakdown, impaired wound healing, increased risk of wound infection, and suppressed natural killer cell activity

greatest risk factor for developing debilitating chronic, persistent, and neuropathic pain

acute pain

NEED TO TREAT _____ because antibiotics alone will not always work

pain

analgosedation

pain should be treated before a sedative agent is considered

use sedatives only if agitation or anxiety persists despite adequate pain control

gold standard of pain assessment

self-report (VAS)

other options for pain assessment tools in patients who have limited communication

behavioral pain scale (BPS) and critical care pain observation tool (CPOT)

analgesia-first sedation

analgesic used before a sedative

analgesia based sedation

analgesia used instead of a sedative

sedation assessment tools

richmond agitation-sedation scale (RASS) or sedation-agitation scale (SAS)

stepwise protocol for analgesia

nurse-driven protocolized algorithms

start with intermittent, as needed doses before using continuous infusions

minimize deep sedation

primary medication for managing pain in critically ill patients

opioids

2 main opiates used in ICU

fentanyl

hydromorphone

fentanyl

lipophilic (very rapid onset of action)

synthetic opioid

good quick on / quick off

accumulates in patients with hepatic impariment

AE: tachyphylaxis and chest wall rigidity

most commonly used opioid in adult ICU patients

fentanyl

hydromorphone

semi-synthetic and binds mu-receptors

accumulates in organ failure (hepatic and renal)

hydrophilic

therapeutic option in patients tolerant to morphine/fentanyl

hydromorphone

which is not a preferred opioid analgesic for IV infusion

morphine

why should morphine not be used IV for analgesia

it has active metabolites (M3G and M6G) that contribute to SE and analgesia, respectively

accumulates in hepatic/renal impairment

histamine release → pruritis and bronchospasm

important regimen to implement when on opioid

bowel regimen

opioid adverse effects

constipation/ileus, somnolence, respiratory depression, N/V

fentanyl specific AE

skeletal muscle regidity

morphine specific AE

hypotension and pruritis

multimodal analgesia

balanced analgesia

combines different analgesic agents that act by different mechanisms at different sites in the nervous system

benefits of multimodal analgesia

improves pain control, reduces opioid consumption, and improves patient-centered outcomes

pharmacologic adjuvants to opioid therapy

acetaminophen, ketamine, neuropathic pain medications, lidocaine, and NSAIDs

non-pharm interventions for analgesia

cybertherapy/hypnosis, music, massage, cold therapy, and relaxation techniques

acetaminophen

use as an adjunct to an opioid to decrease pain intensity and opioid consumption

ketamine

suggest using low dose as an adjunct to opioid therapy

water soluble phencyclidine derivative

ketamine MOA

NMDA antagonist, AMPA agonist, opioid agonist, 5-HT2 agonist, dopa agonist, and anti-inflammatory

ketamine dose recommendation for adjunct therapy

0.5 mg/kg IV push x 1

1-2 mcg/kg/min infusion

neuropathic pain medication

recommended with opioids!!

ex. gabapentin, carbamazepine, and pregabalin

neuraxial analgesia

intrathecal or epidural catheters to deliver opioids or local anesthetics to the spinal cord or subarachnoid space

benefits of neuraxial analgesia

avoids sedative or respirator SE of systemic medications

contraindications to catheter placement

coagulopathy

uncontrolled infection

unstable spinal skeletal structures

purpose of sedatives in ICU

relieve anxiety, reduce stress of mechanical ventilation, and prevent agitation-related harm

key considerations for sedatives

they may predispose patients to increased morbidity

critically ill patients have increased risk of AEs from sedatives

goal of sedation

go as light as possible

goal RASS score

between +1 (restless) and -1 (drowsy)

sedation recommendations in critically ill, mechanically ventilated adults

suggest using propofol or dexmedetomidine over benzodiazepines

why to avoid benzodiazepines in ICU patients for sedation

shown increased risk of ICU delirium

sedation recommendations in mechanically ventilated patient in ICU where light sedation and/or a reduction in delirium are highest priorities

suggest using dexmedetomidine over propofol

if worried about light sedation and reduction in delirium for sedation which is the better treatment choice

dexmedetomidine

dexmedetomidine (Precedex)

centrally acting alpha 2 adrenoreceptor agonist

minimal respiratory depression

should only be used in patients requiring a light level of sedation

AE: Bradycardia and hypotension

avoid using loading/bolus doses

only sedative approved in US for non-intubated patients

dexmedetomidine

don’t use _____ in patients who need deep sedation

dexmedetomidine

propofol

causes global CNS depression

can accumulate in adipose tissue

sedative of choice if the patient can tolerate

causes hypotension

can be a useful agent in RSI

favorable PK/PD

propofol MOA

GABA-A receptor agonist and NMDA inhibitor

sedative and amnestic, no analgesia

propofol infusion syndrome

rare, but potentially lethal

associated with prolonged infusions at higher doses

need to discontinue propofol immediately if suspected

S/S: hypotension, arrhthmias, AKI, urine discoloration, liver dysfunction, rhabdomyolysis, hypertriglyceridemia

benzodiazepines

GABA-A receptor agonists

anxiolytic/amnestic at lower doses

hypnotic at higher doses

can cause respiratory depression when administered with opioids

Paradoxical reactions can be seen (elderly patients and those with CNS disease)

one of the most critical steps in pain management

follow-up and reassessment

signs of oversedation

respiratory depression, hypotension, GI tract paralysis, renal failure, immobility delirium, PTSD

signs of undersedation

pain, anxiety, hypertension, tahcycardia, hypoxia, hypercarbia, ventilator asynchrony, agitation, PTSD

adequate sedation signs

tolerance of mechanical ventilation, calm and cooperative patient, communicative, avoidance of pain, and promotion of normal sleep-wake cycle

what controls ventilation and CO₂

RR and VT

what controls oxygenation

PEEP and FiO₂

PEEP

keeps alveoli open at end-expiration and improves oxygenation

higher ventilator support may increase ____

discomfort and the need for sedation

volume control

gives a set tidal volume

pressure control

gives a set pressure

pressure support

patient triggered

commonly used for weaning

ARDS (acute respiratory distress syndrome)

uses P/F ratio to assess severity

mild: 201-300

moderate: 101-200

severe: ≤100

assist control

ventilator provides the preset minimum rate, but the patient can trigger additional supported breaths above that rate

the most important ventilator setting

PEEP (positive end expiratory pressure)

PEEP and effect on oxygenation

PEEP keeps alveoli open → prevents collapse → improves oxygenation

daily sedative interruption (DSI) and spontaneous awakening trial (SAT)

every day pause or greatly reduce sedative medication to achieve arousal and/or increase alertness (RASS to -1 to +1)

when to avoid DSI/SAT

sedation for seizures or alcohol withdrawal

recieving rapidly escalating doses due to acute agitation episodes

myocardial ischemia within past 24 hours

elevated ICP

paralyzed with NMBs

patient requiring prone positioning

prone positioning

associated with reduction in mortality

should be utilized in patients with severe ARDS

may require deep sedation and/or paralysis

neuromuscular blockade

paralysis without sedation or analgesia

may be used in severe ARDS

still need to SEDATE/ANALGESIZE first

delirium

characterized by acute onset of cerebral dysfunction

associated with change or fluctuation in mental status from baseline

cardinal features of delirium

disturbed level of consciousness

change in cognition

development of perceptual disturbance

modifiable delirium risk factors

benzodiazepine use and blood trasnfusions

non-modifiable delirium risk factors

advanced age, dementia, prior coma, pre-ICU emergency surgery, trauma, APACHE and ADA physical status scores

what is an independent risk factor for development of delirium in ICU patients

coma

how to prevent delirium

no medication or protocol has been shown to prevent it

early mobilization is crucial

delirium assessment

CAM-ICU and ICDSC

delirium prevention recommendation

suggest NOT using haloperidol, dexmedetomidine, statins, or ketamine to prevent delirium

suggest using non-pharm interventions

nonpharm delirium prevention

allow sleep, orient patient, keep hearing aids and glasses, try to minimize pain when possible, music therapy, cognitive stimulation

early exercise and mobility

avoid dopaminergic, anticholinergic, and GABA agents

delirium management

suggest against using haloperidol or statin to treat routinely

ABCDEF bundle elements

assess, prevent, and manage pain

both SAT and SBT

choice of analgesia and sedation

delirium: assess, prevent, and manage

early mobility and exercise

family engagement and empowerment

metrics of assessment

measure every 4 hours

self report with 0-10 numeric rating scale

unable to self report: use CPOT

role of pharmacists

opioid analgesics

multimodal analgesia

monitor medication effects/side effects

education about orders/dosing

spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT)

should be attempted daily on appropriate patients

role of pharmacists in choice of analgesia/sedation

help guide therapy to maintain most patients at a light level of sedation

reduce use of continuous sedatives

transition from IV to enteral/PO

daily reassessment of all psychoactive medication use

delirium prevention main points

non-pharm interventions (sleep improvement and better mobility)

sleep improvement

suggest administering melatonin

early mobility and exercise

rehab and mobilization

regular, early and often