Early Goal Directed Sedation In Critically Ill Patients
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1 Early Goal Directed Sedation In Critically Ill Patients Yahya Shehabi, FCICM, FANZCA, EMBA Professor, Intensive Care Medicine Clinical School of Medicine, University New South Wales School of Epidemiology and Preventive Medicine, Monash University Medical Director Acute & Complex Clinical Services Program Director Intensive Care Research, Prince of Wales Hospitals Early Goal Directed Sedation in Critically Ill Patients CCCF Nov
2 Disclosure Unrestricted Grant-In-Aid Hospira Inc. Investigator initiated trial Granting body had no involvement in the study concept, design, data management, analysis or publication. Endorsed by ANZICS Clinical Trials Group Complied with endorsement guidelines Managed by the ANZIC RC Monash University School of Epidemiology and Preventive Medicine EGDS RCT is funded by NHMRC Grant
3 Incidence of mechanical ventilation 217/100,000 69% Increase in number mechanical ventilation days 30% Increase in proportion of in-patients days with mechanical ventilation / total adult inpatient days Ventilated patients showed increased 30 day crude mortality 27% to 32% over the 8 years period Age, Charlson score, Year In contrast to lower mortality trends seen in sepsis and in ICU patients over the last 20 years Crit Care Med 2013
4 The 2013 SCCM Guidelines
5 2013 SCCM PAD 2 main Recommendations Analgesia First Light sedation Didn t specify when to deliver light sedation? 5
6 How often is light sedation achieved? 6
7 How often is light sedation achieved? 7
8 How often and When is light sedation NOT achieved? 712 patients 8500 ICU days 4 countries 43 ICUs 8
9 Light sedation is NOT achieved for up to 72 hours after ventilation Common Unrecognized Unjustified? Shehabi et al, AJRCCM 2012 Shehabi et al, Int Care Med Feb
10 Early Deep Sedation Can be Harmful Independently predicts time to extubation Shehabi et al, AJRCCM Oct 2012 Shehabi et al, Int Care Med Jan. 2013
11 Early Deep Sedation Can be Harmful Independent predictor of 6 month mortality Shehabi et al, Int Care Med Jan Shehabi et al, AJRCCM Oct 2012
12 EGDS, Rationale Light sedation is desirable Median ventilation time is usually 5-7 days Deep sedation is common in the early phase after initiating mechanical ventilation 79% deeply sedated soon after > 50% still deeply sedated at day 4 Previous sedation trials ignored the first hours after starting ventilation
13 Early Goal Directed Sedation Principles Delivered early within less than 6 hours of initiation of sedation and mechanical ventilation; Rely on an integrated process of targeting light sedation through frequent assessment of sedation levels and Incorporates the use of sedative agents known to promote wakefulness and arousal and/or agents with favorable pharmacokinetic profile such as short onset and offset time 13
14 Early Goal Directed Sedation Key Elements 1. Early effective analgesia titrated to effect according to standardized pain assessment; 2. Early delivery of sedative agents including dexmedetomidine as a primary sedative 3. Tight targeting of light sedation early, from the time of initiation, with regular and frequent assessment of patient wakefulness/sedative state and titration of sedative infusions; 4. Avoidance of benzodiazepines 5. Reduced overall sedation depth with targeted light sedation. 14
15 EGDS Algorithm Patient is mechanically ventilated Sedation assessment Pain assessment Clinicians choice Opioid, other On-going Sedation Adequate analgesia RASS -3 Dexmedetomidine infusion 1 mcg/kg/hr. (No Loading) RASS 2 Stop propofol first dexmedetomidine 0.2 mcg/kg/hr every 30 minute RASS -3 2 RASS -2 to +1 Sedation no longer needed Stop Infusion RASS -2 to +1 Propofol mg/hr. RASS -3 2 Dexmedetomidine mcg/kg/hr. Propofol 0 70 mg/hr.
16 Is EGDS Feasible? First, How soon can EGDS be effectively delivered? Second, how effective is EGDS in providing optimal sedation and preventing early deep sedation? Third, is EGDS only effective with a dexmedetomidine based algorithm? Fourth, is EGDS achievable outside high intensity bedside nursing? Finally, is EGDS feasible in the context of randomized clinical trials? 16
17 Is Early Goal Directed Sedation Feasible? Is Early Deep Sedation Modifiable? Randomized control trial 17
18 EGDS ANZ Pilot RCT Crit Care Med Aug 2013
19 Time spent in light sedation first 48 hours EGDS vs. STDS Light sedation 203/307(66%) vs. 74/197(38%) (P=0.01) Deep sedation 93/307(30%) vs.112/197(57%) (P=0.02) 19
20 Patients achieving light sedation during the first 7 study days P=0.011 P=0.036 P=
21 EGDS Malaysian Pilot RCT Objectives: The feasibility of EGDS outside a high intensity ANZ ICU model of care The feasibility of achieving EGDS with standard sedatives Outcomes of combined ANZ and MY cohorts
22 Inclusion Criteria Patient is mechanically ventilated in the previous 12 hours, and the treating clinician believes that: 1. The patient requires ongoing sedative medication for comfort, safety, and to facilitate the delivery of life support measures 2. The patient is expected to remain intubated the day after tomorrow. (> 24 hours). 22
23 Exclusion Criteria Age < 18 years. Pregnant and/or lactating. Proven or suspected acute primary brain lesion that may result in global impairment of conscious level or cognition, such as traumatic brain injury, intracranial haemorrhage, stroke, or hypoxic brain injury. Proven or suspected cervical spinal cord injury or pathology that may result in permanent or prolonged weakness of upper and lower limbs. Proven or suspected primary neurological pathology associated with prolonged weakness, such as Guillain-Barré syndrome Admitted as a consequence of a drug overdose Recent burn injuries Receiving or expected to need ongoing neuromuscular blockade Allergy to propofol or dexmedetomidine 23
24 Exclusion II Cardiovascular parameters A mean arterial blood (MAP) pressure is less than 55 mmhg either with or without resuscitation and vasopressor therapy A heart rate (HR) less than 55/min unless being treated with a blocker A high grade atrio-ventricular block in the absence of a functioning pacemaker Patient has end stage liver failure or acute fulminant hepatic failure Patient does not communicate in English Death is deemed imminent and inevitable Patient is a full time nursing home or hostel resident Patient has an underlying disease that makes survival to 90 days unlikely. 24
25 EGDS Total Cohort ANZ & MY Pilot RCT
26 Patients' Demographics 26
27 Sedative and Analgesic Agents Cummulative dose and Time Rx Drugs given Median {IQR] per patient EGDS N=52 STDS N=45 %. Rx EGDS vs. STDS P value Dexmedetomidine ug 1559 # % vs < ( ) ( ) 4% 0.34 # Time on Dexmed D 3 (2-5) 0[0-0] < Midazolam mg 4.5 # 56 19% vs (2-9) ( ) 80% < # Time on Midazolam D 0 [0-0] 2 (2-3) < Propofol mg 535 # % vs 0.65 ( ) ( ) 47% 0.06 # Time on Propofol D 1.23 (2.15) 1.42 (2.03) 0.65 Morphine mg # (24-279) Fentanyl ug 420 # ( ) 110 (21-199) 1340 ( ) 27% vs 51% 58% vs 62% # #
28 RASS achieved in First 48 hours 28
29 16 90% EGDS Stand P= % P< P< % P= P=0.05 P< P< P=0.04 0% MY RASS CAM ICU +ve CAM Ph Rest Dex MDZ Prop Mor Fent Nil Sed ICU -ve 29
30 EGDS Pilots Main outcomes Clinical outcome Time to randomization hrs. Median [IQR] RASS --2 to +1 first 48 h % Light sedation range RASS -3 to -5 first 48 h % Deep sedation range Physical restraints % (n) Ventilation time Med (IQR) hrs ICU Length of Stay Med (IQR) D Hospital Length of Stay Med (IQR) Days Hospital mortality N (%) 90 day mortality N (%) EGDS Pilot Combined EGDS N= ( ) 71% 517/732 26% 187/732 STDS N= ( ) 5% (1) 31% (5) 61.8 ( ) 4.3 ( ) 11.7 ( ) 7 (13%) 11 (21%) P value % 312/606 < % 278/606 < ( ) 5.04 ( ) ( ) 5 (11%) 7 (16%) EGDS Pilot MY sites EGDS N= (0.17-6)] 74% 314/425 22% 94/425 STDS N= ( ) 7 (23%) 14 (48%) ( ) 3.55 ( ) ( ) 4 (13%) 6 (19%) P value % 238/409 < % 166/409 < ( ) 4.84 ( ) ( ) 4 (14%) 5 (17%)
31 Conclusions EGDS is feasible and can be delivered: Early in the context of RCT Effectively with Reduced Early Deep Sedation Light sedation targets Reduced use of traditional sedative Safely with Reduced physical restraints use No other safety issues External validity of EGDS algorithm 31
32 Should EGDS be tested in a large scale RCT? EGDS is aligned with current actual practice and in line with international guidelines; EGDS mimics clinical reality and deliver an intervention that combines potentially safer drugs and beneficial light sedation targets; EGDS mandates frequent monitoring of patient responsiveness ( wakefulness ), sedation depth, and delirium; All interventions are delivered soon after initiation of mechanical ventilation maximising their potential benefits; Primary outcomes will be patient centered and long-term. Therapy is delivered by bedside nurses, EGDS will be applicable to currently practiced ICU model of care. 32
33 33
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