New approaches of sedation in critically ill patients.

Transcription

1 New approaches of sedation in critically ill patients. Jean Mantz, MD, PhD Professor and Chair, Department of Anesthesia and Critical Care F- Paris Val de Seine University Hospitals Univ Paris Diderot, Paris Sorbonne Cité INSERM U 676, Pharmacological Neuroprotection

2 Disclosures Orionpharma Hospira Baxter

3 Goals of the lecture To review the changes in goals and practices of ICU sedation and analgesia over the last decades. To focus on the detrimental role of the ICU environment (including sedation) on brain function (delirium, sleep disorders, PTSD, cognitive impairment) To discuss the cornerstone principles for future research in ICU sedation and analgesia

4 Goals of the lecture To review the changes in goals and practices of ICU sedation and analgesia over the last decades. To focus on the detrimental role of the ICU environment (including sedation) on brain function (delirium, sleep disorders, PTSD, cognitive impairment) To discuss the cornerstone principles for future research in ICU sedation and analgesia

5 The moving landscape of ICU sedation : to provide sedation is beneficial to the ICU mechanically ventilated patient 2000: to alleviate sedation improves patient outcome (except specific situations) : to protocolize, monitor and titrate sedation by nurses-driven algorithms allows to improve pain control and avoid oversedation : to develop cooperative sedation and physiotherapy still improves outcome, during and after the ICU stay.

6 Principles of sedation in the non braininjured ICU patient Prevention and treatment of pain Calm, cooperative state No anxiety

7 Goals of the lecture To review the recent changes in goals and practices of ICU sedation and analgesia. To focus on the detrimental role of the ICU environment (including sedation) on brain function (delirium, sleep disorders, PTSD, cognitive impairment) To discuss the cornerstone principles for future research in ICU sedation and analgesia

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10 Pitfalls with sedatives and analgesics Sedatives and analgesics contribute to increased duration of mechanical ventilation and mortality They may impede neurological examination and favor delirium. They may have detrimental consequences on cognitive function after ICU.

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12 Ely EW Crit Care Med 2002

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18 Sleep disorders

19 Hypnogram in a young and healthy subject Anaesthesia, 2004; 59:

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22 Goals of the lecture To review the changes in goals and practices of ICU sedation and analgesia over the last decades. To focus on the detrimental role of the ICU environment (including sedation) on brain function (delirium, sleep disorders, PTSD, cognitive impairment) To discuss the cornerstone principles for future research in ICU sedation and analgesia

23 The future of research in ICU sedation: translational research Basic research: To better understand the consequences of ICU environment on short- and long-term brain function Clinical research:to design top-level clinical trials that validate and/or generate new hypotheses.

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27 et al

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33 -Early sedation -Protocolized sedation as a control group -Integrated care process targeting light sedation (brain rehabilitation programs) - New drugs (dexmedetomidine)

34 Early Goal-Directed Sedation Compared With Standard Care in Mechanically Ventilated Critically Ill Patients (SPICE III RCT) patients ClinicalTrials.gov Identifier: NCT Goal-directed dexmedetomidine-based sedation in mechanically ventilated patients vs standard care - Primary goal: Mortality at Day 90

35 Conclusion The brain is particularly sensitive to agressions in the mechanically ventilated ICU patient. Future research dedicated to Icu patients should be Translational Outcome-targeted With top-level methodology

36 Thank you for your kind attention! Thank you for your kind attention

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