Improving the Management of Pain, Agitation, and Delirium (PAD) in the Intensive Care Unit: Translating Evidence Into Practice
|
|
|
- Ada Barnett
- 5 years ago
- Views:
Transcription
1 Improving the Management of Pain, Agitation, and Delirium (PAD) in the Intensive Care Unit: Translating Evidence Into Practice Christine M. Groth, Pharm.D., BCCCP NYS Partnership for Patients September 2017
2 Objectives Apply strategies for operationalizing pain and agitation guidelines into clinical practice Select appropriate sedative medications using validated scales for pain, agitation, and delirium in the intensive care unit Define the pharmacist s role in optimizing the management of pain, agitation, and delirium in critically ill patients 2
3 University of Rochester Medical Center 850-bed tertiary care hospital 120-bed emergency department (ED) Level 1 trauma Comprehensive stroke center Adult ICUs (~100 beds) MICU SICU Burn/Trauma ICU Neuro ICU CVICU Progressive care units MICU, SICU, trauma
4 Traditional PAD Practices at SMH NVPS: Nonverbal Pain Scale SAS: Riker Sedation-Agitation Scale 4
5 Traditional PAD Practices at SMH Original pain and sedation guideline Fentanyl and lorazepam continuous infusions as first-line Propofol as second-line agent Revised pain and agitation guideline (~2007) Attempted intermittent sedation first Changed to midazolam infusions over lorazepam Complicated with multiple algorithms 5
6 Traditional PAD Practices at SMH Trialed an intermittent pain and agitation protocol that failed Complexity in implementing without electronic medical record Regulations around handling controlled substances Delirium not addressed Treated like an expected occurrence Assumed it would resolve with time 6
7 Quality Improvement Process for PAD management Summarize the evidence Identify local barriers Measure performance Ensure all patients receive the strategy 7 Pronovost, et al. HSR: Health Services Research 41:4, Part II, Pronovost, et al. BMJ 2008; 337.
8 Ensure all Patients Receive the Strategy Pronovost, et al. HSR: Health Services Research 41:4, Part II, Pronovost, et al. BMJ 2008;
9 Summarize the Evidence 9 Barr, et al. CCM 2013; 41:
10 Identify Local Barriers Lack of awareness that sedative agents can cause harm Outdated and complex pain and sedation guideline Physician order entry process No process for delirium detection and management Choose a tool for monitoring delirium Nursing by-in to monitor for delirium Increase provider awareness Develop a guideline for management 10
11 Engaging and Educating Health-care Professionals on the Harm in Oversedation Sedative medication error patient cases Interactive Open for discussion Discussions on patient care rounds Point out what we do well Point out what we could ve done better Use of Validated Scales Treating pain first Trial intermittent sedation first Bolus prior to increasing infusions Sedation holidays/reductions One-on-one discussions at the bedside Empowering nurses on their ability to improve patient outcomes 11
12 Effect of a Nursing-Implemented Sedation Protocol on the Duration of Mechanical Ventilation The protocol: Assessed pain first Corrected other etiologies for agitation Used sedation score to titrate sedatives Used intermittent sedation first Actively down-titrated sedation even when patient was at goal Brook, et al. Crit Care Med 1999; 27(12):
13 Impact of Delirium and Coma on Mortality Ouimet S et al. Intensive Care Med 2007; 33 (1):
14 Risk of Delirium with Benzodiazepines Pandharipande P, et al. Anesthesiol. 2006:104:21-26.; Pandharipande P, et al. J Trauma 2008; 65:34
15 Engaging and Educating on the Importance of Monitoring for and Minimizing Delirium Choosing a delirium screening tool Trialed ICU-DSC and CAM-ICU Formal education Nursing symposium Demonstrated how to use screening tool Educational flyers ICU-DSC: Intensive care unit delirium screening checklist CAM-ICU: Confusion assessment method for the intensive care unit 15
16 Formal PAD Education Plan Across Multiple Disciplines Multi-Disciplinary Educational Retreats in June 2013 ABCDEF bundle Pros and cons of medications used to treat pain and agitation Harms of oversedation Importance of using validated scales to assess PAD Impact of sedation holidays/reductions on patient outcomes Rolled out our new intermittent dose protocol Importance of delirium monitoring Risks associated with delirium Demonstrated how to use the ICU-DSC Discussed our delirium guideline Pros and cons of antipsychotic therapy 16
17 Formal PAD Education Plan Across Multiple Disciplines Nursing in-service/education Live and computer-based PAD guidelines Intermittent dose protocol Delirium monitoring Provider in-service/education General PAD management Propofol infusion syndrome Ketamine 17
18 SMH Adult Pain/Sedation Guideline for Mechanically Ventilated Patients GENERAL PRINCIPLES Intermittent bolus doses trialed before continuous infusions Hold continuous infusions on admission to the unit Optimize analgesia before initiating sedatives Promotes bolus doses Anticipate and treat breakthrough pain/agitation Prior to any increase in infusion rate Use of validated scales Goal Non-verbal pain score 0-3 or numerical rating 5 on 0-10 scale Goal SAS 3-4 unless specified different/paralyzed Reassess and document the level of sedation and analgesia every hour 18
19 SMH Adult Pain/Sedation Guideline for Mechanically Ventilated Patients INTERMITTENT PAIN/SEDATION PROTOCOL Hydromorphone 1 mg IV every 5-15 min up to 3 doses for NVPS > 3 If NVPS 3 start 1mg IV q2h prn If NVPS> 3 after 3 doses initiate fentanyl infusion 50 mcg/hr Midazolam 2 mg IV every 5-15 min up to 3 doses for SAS > 4 If SAS 4 start 1mg IV q1h prn If SAS>4 after 3 doses then initiate midazolam infusion at 2 mg/hr or if hemodynamically stable propofol infusion at 20 mcg/kg/min *Provider can change doses based on individual patient needs 19
20 Use of Computerized Provider Order Entry to Improve the Management of Pain/Agitation 20
21 Use of Computerized Provider Order Entry to Improve the Management of Pain/Agitation 21
22 Use of Computerized Provider Order Entry to Improve the Management of Pain and Agitation 22
23 Use of Computerized Provider Order Entry to Improve the Management of Pain and Agitation NYS Regulation does not allow nurses to bolus propofol URMC uses rapid titration strategy Small doses of mg are given every 5 minutes until SAS of 3-4 achieved then infusion rate is increased 23
24 Impact of an Analgesia-Based Sedation Protocol on Mechanically Ventilated Patients in a Medical Intensive Care Unit Retrospective Pre- and Post-Analgosedation guideline implementation study n=144 Pre: Propofol infusion/prn narcotics morphine infusion/midazolam Post: Fentanyl PRN or continuous/prn midazolam propofol/dexmedetomidine 24 Faust, et al. Anesthesia and Analgesia 2016; 123:903-9
25 Optimizing Non-Benzodiazepine Sedation Sedative Indications Monitoring Propofol mcg/kg/min Hemodynamically stable patients Synergy with midazolam Transition off of midazolam BP and HR Propofol Infusion Syndrome -CK and TG 2-3x weekly -AGMA (lactate) Dexmedetomidine mcg/kg/hr Ketamine mg/kg/hr Light sedation Poor amnestic properties Analgesic sparing Facilitate extubation Hemodynamically unstable Opioid tolerance Bronchospasm Analgesic effects BP and HR Tachyphylaxis BP and HR Secretions Delirium/psychosis BP=blood pressure; HR=heart rate; CK=creatine kinase; TG:Triglycerides; AGMA=anion gap metabolic acidosis Erstad, et al. J Crit Care 2016; 35:145-9 Barr, et al. CCM 2013; 41:
26 Pharmacist s Role in Optimizing PAD Management 26 Marshall, et al. Crit Care Med 2008; 36: ; Reinaker, et al. J Trauma Nursing 2015; 22: Louzon, et al. AJHP 2017; 74:
27 Pharmacist s Role in Optimizing PAD Management SAT: Sedation Awakening Trial 27 Stollings, et al. Ann Pharmacotherapy 2015; 49: ; Louzon, et al. AJHP 2017; 74:
28 Pharmacist s Role in Using Validated PAD Scales to Reduce Continuous Sedation Is my patient on continuous infusions of sedatives and analgesics? What have the SAS scores been over the last hours? If SAS <4 why (vent dyssynchrony, extreme agitation, no reason) Can we decrease the rate? Has a sedation holiday been done? Can we change to intermittent sedation? Can we change to a non-benzodiazepine sedative? 28
29 Pharmacist s Role in Using Validated PAD Scales to Reduce Continuous Sedation If SAS >4 why (pain, delirium, withdrawal) Is the NVPS > 3? Can we increase fentanyl, change to sedative with analgesic effects, what were they on at home? Is the CAM-ICU positive? Can we change to dexmedetomidine? Should we add an antipsychotic? Remove deliriogenic meds/restraints/catheters Non-pharmacologic therapy Correct metabolic disturbances Are there any home medications we should restart? Have we tried coming down to quickly on the rates? 29
30 TREATMENT ALGORITHM
31 50 Continuous Sedation Use Over Time on Our 12-Bed MICU Number of Encounters Receiving Continuous Sedation (n=381) 2013 (n=381) 2014 (n=357) 2015 (n=343) 2016 (n=311) Fentanyl Midazolam Propofol Dexmedetomidine 45-55% of all admitted patients are mechanically ventilated; 14% of mechanically ventilated patients receive continuous sedation 31
32 Snapshot of Current Sedation Practices in Our Adult ICUs :2017 All Adult ICUs 32
33 Snapshot of Current Sedation Practices in Our Adult ICUs One Day Random Sample of ICU Patients Percentage With One Assessment Completed in 24 hours 33
34 NEXT STEPS.. Continuous Improvement is Better Than Delayed Perfection Mark Twain Pharmacist coordination of ABCDEF Bundle Use of clinical decision support in the electronic medical record Standardizing provider note template Treat PAD scores as vital signs Revitalize delirium awareness, monitoring, and management Fall of 2017 retreats 34
35
Ventilator-Associated Event Prevention: Innovations
Ventilator-Associated Event Prevention: Innovations Michael J. Apostolakos, MD Professor of Medicine Director, Adult Critical Care University of Rochester Mobility/Sedation in the ICU Old teaching: Keep
ICU Liberation for the Pharmacist. A. Kendall Gross, PharmD, BCPS, BCCCP Critical Care Pharmacist UCSF Medical Center
ICU Liberation for the Pharmacist A. Kendall Gross, PharmD, BCPS, BCCCP Critical Care Pharmacist UCSF Medical Center Disclosure No conflicts of interest to disclose Objectives o Outline the elements of
Appendix 1. University of Minnesota Amplatz Children s Hospital Opioid Weaning Guideline
Appendix 1. University of Minnesota Amplatz Children s Hospital Opioid Weaning Guideline 1. Pharmacist to order Narcotic Withdrawal Scores QH X 4 hours, then per table below: Narcotic Withdrawal Score
From the Department of Pharmacy (JM, CAF) and Department of Pulmonary and Critical
PrintClose Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay * Author(s): Marshall, John PharmD; Finn, Christine A.
Critical Care Strategic Clinical Network Provincial ICU Delirium Framework
Pain assessed and documentation using validated tool (CPOT and NRS) Assess and document q4h and prn 100% of patients assessed for pain and documented q4h A: Assess, Prevent & Manage Pain Self Reporting
Sedation and delirium- drugs and clinical management
Sedation and delirium- drugs and clinical management Shannon S. Carson, MD Associate Professor and Chief Division of Pulmonary and Critical Care Medicine University of North Carolina Probability of transitioning
Goals for sedation during mechanical ventilation
New Uses of Old Medications Gina Riggi, PharmD, BCCCP, BCPS Clinical Pharmacist Trauma ICU Jackson Memorial Hospital Disclosure I do not have anything to disclose Objectives Describe the use of ketamine
Disclosure. Hospira Pharmaceuticals. Unrestricted research funding Honoraria for CME education administered via France Foundation
Disclosure Hospira Pharmaceuticals Unrestricted research funding Honoraria for CME education administered via France Foundation Economics in Sedation: Responsible Use of the ICU Budget John W. Devlin,
Interaction between Sedation and Weaning: How to Balance Them? Guillermo Castorena MD Fundacion Clinica Medica Sur Mexico
Interaction between Sedation and Weaning: How to Balance Them? Guillermo Castorena MD Fundacion Clinica Medica Sur Mexico Balance is not that easy! Weaning Weaning is the liberation of a patient from
Early Goal Directed Sedation In Critically Ill Patients
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
Jennifer Mando-Vandrick, PharmD, BCPS Clinical Pharmacist, Emergency Department Director, PGY2 Critical Care Pharmacy Residency Duke University
Jennifer Mando-Vandrick, PharmD, BCPS Clinical Pharmacist, Emergency Department Director, PGY2 Critical Care Pharmacy Residency Duke University Hospital Objectives Review pertinent pharmacotherapy common
KICU Spontaneous Awakening Trial (SAT) Questionnaire
KICU Spontaneous Awakening Trial (SAT) Questionnaire Please select your best answer(s): 1. What is your professional role? 1 Staff Nurse 2 Nurse Manager 3 Nurse Educator 4 Physician 5 Medical Director
7/6/ ANNUAL MEETING BRINGING THE ABC(DEF) S TO THE ICU ICU TRIAD DISCLOSURE ICU TRIAD SEDATION AND ANALGESIA OBJECTIVES
ICU TRIAD BRINGING THE ABC(DEF) S TO THE ICU GINA RIGGI, PHARMD, BCPS, BCCCP CLINICAL HOSPITAL PHARMACIST- TRAUMA INTENSIVE CARE UNIT JACKSON MEMORIAL HOSPITAL MIAMI, FLORIDA Figure 1. Reade M and Finfer
STARSHIP WITHDRAWAL OF ANALGESIA AND SEDATION
STARSHIP WITHDRAWAL OF ANALGESIA AND SEDATION Patients receiving analgesia and/or sedation for longer than 5-7 days may suffer withdrawal if these drugs are suddenly stopped. To prevent this happening
Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure. Supplement 2 Table of Contents
Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure Supplement 2 Table of Contents RESTORE Algorithm and Box-by-Box Instructions Page 1 of 2
ICU LIBERATION: IMPLEMENTING THE ABCDEF BUNDLE AND IMPROVING THE LIVES OF ICU PATIENTS
ICU LIBERATION: IMPLEMENTING THE ABCDEF BUNDLE AND IMPROVING THE LIVES OF ICU PATIENTS J. MATTHEW ALDRICH, MD ASSOCIATE CLINICAL PROFESSOR OF ANESTHESIA AND PERIOPERATIVE CARE UNIVERSITY OF CALIFORNIA
Fighting the Fog A Collaborative Approach to Decreasing ICU Delirium
Fighting the Fog A Collaborative Approach to Decreasing ICU Delirium Kimberly Scherr NP Jennifer Barker RN Misericordia Hospital ICU Edmonton, AB CACCN Dynamics Sept 21, 2014 Delirium Delirium is an acute
PHYSICIAN'S ORDERS Mark in for desired orders. If is blank, order is inactive. VENTILATOR SEDATION / ANALGESIC / DELIRIUM ORDER
Nursing Daily awakenings PHYSICIAN'S ORDERS Mark in for desired orders. If is blank, order is inactive. VENTILATOR SEDATION / ANALGESIC / DELIRIUM ORDER Do not perform daily awakenings: Rationale: Daily
POST-INTUBATION ANALGESIA AND SEDATION. August 2012 J Pelletier
POST-INTUBATION ANALGESIA AND SEDATION August 2012 J Pelletier Intubated patients experience pain and anxiety Mechanical ventilation, endotracheal tube Blood draws, positioning, suctioning Surgical procedures,
Can Goal Directed Sedation Improve Outcomes?
Can Goal Directed Sedation Improve Outcomes? Yahya SHEHABI, FANZCA, FCICM, EMBA Professor and Program Director Critical care Monash Health and Monash University - Melbourne School of Medicine, University
Managing Delirium: The best way to achieve clarity (of mind) Tim Walsh. Professor of Critical Care, Edinburgh University
Managing Delirium: The best way to achieve clarity (of mind) Tim Walsh Professor of Critical Care, Edinburgh University Lecture Plan: a route to clarity What is delirium? Why is delirium important? Step
Kendiss Olafson MD FRCPC MPH Section of Critical Care University of Manitoba
Kendiss Olafson MD FRCPC MPH Section of Critical Care University of Manitoba Outline Sedation in ICU Purpose/Goals Common Drugs Sedation delivery strategies Mobility in the ICU Weakness with critical illness
+ Change in baseline mental status, inattention, and either disorganized thinking or altered level of consciousness. Delirium. Disclosure.
47 th Annual Meeting August 2-4, 2013 Orlando, FL Identification, Prevention and Treatment of Delirium: The Role of the Health System Pharmacist Jennifer Cortes, PharmD, BCPS Medical ICU Clinical Pharmacy
DELIRIUM IN ICU: Prevention and Management. Milind Baldi
DELIRIUM IN ICU: Prevention and Management Milind Baldi Contents Introduction Risk factors Assessment Prevention Management Introduction Delirium is a syndrome characterized by acute cerebral dysfunction
Do benzos, opioids, or strong anticholinergics cause delirium? Lisa Burry
Do benzos, opioids, or strong anticholinergics cause delirium? Lisa Burry Delirium in the ICU Occurs in up to 85% of MICU/SICU MV patients 20-50% of lower severity ICU patients develop delirium Hypoactive
The Difficult to Sedate ICU Patient
The Difficult to Sedate ICU Patient Dan Burkhardt, M.D. Associate Professor Department of Anesthesia and Perioperative Care University of California San Francisco burkhard@anesthesia.ucsf.edu Richmond
Sedation and Delirium Questions
Sedation and Delirium Questions TLC Curriculum William J. Ehlenbach, MD MSc Assistant Professor of Medicine Pulmonary & Critical Care Medicine Question 1 Deep sedation in ventilated critically patients
ANALGESIA AND SEDATION IN MECHANICAL VENTILATION
ANALGESIA AND SEDATION IN MECHANICAL VENTILATION Erik Stoltenberg, MD Abbott Northwestern Hospital February 27, 2018 DISCLOSURE Nothing to disclose AllinaHealthSystem 1 OBJECTIVE To apply knowledge of
Therapeutic Hypothermia for Post Cardiac Arrest Plan Initial Orders
Arrest Plan Initial Orders Weight Allergies Therapeutic Hypothermia Guidelines ***Required to continue with ordering Plan.*** Strict Intake and Output q1h, throughout cooling and re warming. Set Up for
Sedation of the Critically Ill Patient
Buffalo theory of sedation It s a well known fact that a herd of buffalo can only move as fast as the slowest buffalo. And when the herd is hunted, it s the slowest and weakest ones at the back that are
Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe )
PROTOCOL Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe ) Page 1 of 6 Scope: Population: Outcome: Critical care clinicians and providers. All ICU patients intubated or mechanically
Pain, Agitation & Delirium (2013) Immobility & Sleep (2018) Catherine Jones Practice Educator GICU October 2018
Pain, Agitation & Delirium (2013) Immobility & Sleep (2018) Catherine Jones Practice Educator GICU October 2018 1 Plan for session Why Pain Agitation & Delirium are important considerations in critical
SEDATION, AGITATION, DELIRIUM Daniel Lollar, MD
SEDATION, AGITATION, DELIRIUM Daniel Lollar, MD OVERVIEW Correctable causes of agitation Pain assessment opioids Agitation assessment BZNs, propofol, precedex comparisons Delirium haldol, antipsychotics
Overview of Presentation. Delirium Definition. Assessing & Managing ICU Delirium: What is the Evidence?
Assessing & Managing ICU Delirium: What is the Evidence? Dale Needham, MD, PhD Professor Pulmonary & Critical Care Medicine, and Physical Medicine & Rehabilitation Medical Director, Critical Care Physical
Dexmedetomidine: the various roles and utilization strategies. Julie Belfer, PharmD September 2014
Dexmedetomidine: the various roles and utilization strategies Julie Belfer, PharmD September 2014 Disclosure No disclosures concerning possible financial or personal relationships with commercial entities
NYSPFP HIIN: VAE/Delirium Prevention. Operationalizing Prevention Strategies in the ICU
NYSPFP HIIN: VAE/Delirium Prevention Operationalizing Prevention Strategies in the ICU 1 Agenda Time Topic Speakers 9:00 a.m.-9:10 a.m. Welcome & Introductions NYSPFP Staff 9:10 a.m.-10:40 am Why Prevent
Pathway to Pain Control
Pathway to Pain Control Assessing, Preventing, and Managing Pain in the Intensive Care Unit Caitlin S. Brown, PharmD Brianne M. Ritchie, PharmD, MBA, BCCCP, BCPS Pharmacy Grand Rounds November 21, 2017
Doug Paul, D.O. FACOS Medical Director, Trauma Services Kettering Health Network
Doug Paul, D.O. FACOS Medical Director, Trauma Services Kettering Health Network A paradigm shift (or revolutionary science) is, a change in the basic assumptions, or paradigms, within the ruling theory
Collaborative Regional Benchmarking Group (North of England, North Yorkshire & Humber and West Yorkshire)
Best Practice Guidance Sedation These recommendations are bound by the current evidence and best practice at the time of writing and so will be subject to change as further developments are made in this
PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
Available ONLY at: BMC-B BMC-D BMC-N BMC-S Intubation Phase Notify Therapy for STAT intubation SUB Rapid Sequence Induction(SUB)* ***The above subphase is available at the end of the powerplan under the
NYSPFP HIIN: VAE/Delirium Prevention. Operationalizing the Pain, Agitation and Delirium Assessments
NYSPFP HIIN: VAE/Delirium Prevention Operationalizing the Pain, Agitation and Delirium Assessments March 28, 2017 1 Agenda Topic Welcome and Introductions A Guide for Success: Implementing the Confusion
Sedation and Analgesia in the Critically Ill
12th Congress of the World Federation of Societies of Intensive and Critical Care Medicine August 29 (Sat.) September 1 (Tue.), 2015 COEX, Seoul, Korea ONE STEP FURTHER: THE PURSUIT OF EXCELLENCE IN CRITICAL
PRESCRIBING PRACTICE IN DELIRIUM. John Warburton Critical Care Pharmacist
PRESCRIBING PRACTICE IN DELIRIUM John Warburton Critical Care Pharmacist Learning outcomes Modifiable medication risk factors for delirium An appreciation of contributing factors modifiable with medicines
WAKE UP AND TREAT DELIRIUM : PITFALLS OF THE PAD GUIDELINES
WAKE UP AND TREAT DELIRIUM : PITFALLS OF THE PAD GUIDELINES Tudy Hodgman, Pharm D, FCCM, BCPS The goal of this discussion will be to review the literature published since the PAD guidelines were released
Summary of Delirium Clinical Practice Guideline Recommendations Post Operative
Summary of Delirium Clinical Practice Guideline Recommendations Post Operative Intensive Care Unit Clinical Practice Guideline for Postoperative Clinical Practice Guidelines for the Delirium in Older Adults;
Update on the Management and Monitoring of Deep Analgesia and Sedation in the Intensive Care Unit
AACN Advanced Critical Care Volume 24, Number 2, pp.101 107 2013, AACN ECG Challenges Earnest Alexander, PharmD, and Gregory M. Susla, PharmD Department Editors Update on the Management and Monitoring
Analgosedation: What Strategy is Best? Guillermo Castorena MD Fundación Clínica Médica Sur México
Analgosedation: What Strategy is Best? Guillermo Castorena MD Fundación Clínica Médica Sur México The facts Despite the efforts to optimize sedation and comfort of ICU s patients: More than 50% of patients
Sedation Pearls. Topics
Sedation Pearls Lundy J. Campbell Department of Anesthesia and Perioperative Care University of California San Francisco Topics Why sedate patients How to sedate patients Goals of sedation What to sedate
Canadian Practices for the Treatment of Delirium. Lisa Burry, BScPharm, PharmD
Canadian Practices for the Treatment of Delirium Lisa Burry, BScPharm, PharmD Disclosures & Acknowledgements Conflicts of interest: None Acknowledgements: our patients and the clinical staff that supported
Delirium Screening and Prevention Faculty Disclosures
Delirium Screening and Prevention Faculty Disclosures I have nothing to disclose Kathleen Puntillo RN, PhD, FAAN, FCCM Professor Emeritus School of Nursing, UCSF Objectives Discuss prevalence, risk factors
Supplementary appendix
Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Page VJ, Casarin A, Ely EW, et al. Evaluation
Analgesia and Sedation Guidelines for Paediatric Intensive Care Unit
These clinical guidelines have been developed by a multidisciplinary working group in an attempt to achieve consistency in the choice and application of analgesic and sedative drugs in the PICU/CICU including
ABCs of ICU Delirium Marian Maxwell, Pharm.D., BCCCP January 6, 2018
ABCs of ICU Delirium Marian Maxwell, Pharm.D., BCCCP January 6, 2018 Disclosures I do not have any financial/non-financial relationships to disclose. Learning Objectives Define delirium and discuss the
KEY REFERENCES Laying the foundation for D of ABCDEF bundle
KEY REFERENCES Laying the foundation for D of ABCDEF bundle Ely E. JAMA. 2001;286:2703-2710 (CAM-ICU) Bergeron N. Intensive Care Med. 2001;27:859-864 (ICDSC) Dubois M. Intensive Care Med. 2001;27:1297-1304
Sarah V. Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn University Harrison School of Pharmacy Auburn, AL ALSHP Annual Clinical Meeting
Sarah V. Cogle, PharmD, BCCCP Assistant Clinical Professor Auburn University Harrison School of Pharmacy Auburn, AL ALSHP Annual Clinical Meeting 2018 I have no actual or potential conflict of interest
SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT TITLE: PROPOFOL SEDATION PROTOCOL Job Title of Reviewer: Director, ICU :#: EFFECTIVE DATE: REVISED DATE: TYPE: 1/95 8/06, 5/09 DEPARTMENTAL INTERDEPARTMENTAL
Pain and Sedation in the ICU
Pain and Sedation in the ICU Dan Burkhardt, M.D. Medical Director of Inpatient Pain Services Associate Professor Department of Anesthesia and Perioperative Care University of California San Francisco burkhard@anesthesia.ucsf.edu
Conflict of Interest. Patient Case. Objectives. The Balancing Act. Why We Need Sedation
Agitation in the ICU Have we swung the pendulum too far from benzodiazepines? Conflict of Interest The author of this presentation has no conflicts of interest to disclose Nina Vadiei, PharmD PGY1 Pharmacy
Monday, October 17 3:45 p.m. 5:45 p.m. Convention Center: Spirit of Pittsburgh Ballroom A
Critical Care PRN and Society of Critical Care Medicine Focus Session Sedation and Delirium in the ICU: Update on the Status of the 2011 SCCM Guidelines Activity No. 0217-0000-11-079-L01-P (Application-Based
New approaches of sedation in critically ill patients.
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,
Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients
Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit January 2013 Volume 41 Number 1 Society of Critical Care Medicine 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時,
Prolonged opioid therapy in the Critically Ill Pediatric Patient
PBLD Table #22 Prolonged opioid therapy in the Critically Ill Pediatric Patient Arlyne K. Thung, M.D. Assistant Professor, Anesthesiology & Shu-Ming Wang, M.D. Associate Professor, Anesthesiology Yale
Analgesia, Sedation and Delirium The Latest Evidence in Assessment & Treatment
Analgesia, Sedation and Delirium The Latest Evidence in Assessment & Treatment Julie Miller, RN, BSN, CCRN How many of you routinely assess for delirium in your patients? 2013 SCCM Guidelines Pain Recommend
Delirium Screening and Prevention. Faculty Disclosures. Objectives 5/13/2014. I have nothing to disclose
Delirium Screening and Prevention Kathleen Puntillo RN, PhD, FAAN, FCCM Professor Emeritus School of Nursing, UCSF Faculty Disclosures I have nothing to disclose Objectives Discuss prevalence, risk factors
Disclosures. Learning Objectives. Updates in Critical Care Pharmacy: Reviewing Pain, Agitation, and Delirium in the Adult Critically Ill 5/15/2016
Updates in Critical Care Pharmacy: Reviewing Pain, Agitation, and Delirium in the Adult Critically Ill Chris Oswald, PharmD, BCPS, BCCCP Clinical Pharmacist Saint Alphonsus Regional Medical Center (Boise,
Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium
Online Data Supplement Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE) Bundle Authors-Michele C. Balas, Eduard
Delirium in the ICU: Prevention and Treatment. Delirium Defined Officially. Delirium: Really Defined. S. Andrew Josephson, MD
Delirium in the ICU: Prevention and Treatment S. Andrew Josephson, MD Director, Neurohospitalist Service Medical Director, Inpatient Neurology June 2, 2011 Delirium Defined Officially (DSM-IV-TR) criteria
ALL orders are active unless: 1. Order is manually lined through to inactivate 2. Orders with check boxes ( ) are unchecked DRUG AND TREATMENT ORDERS
DRUG AND TREATMENT Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine
Conducting Delirium Research
Optimizing Clinical Trials When Conducting Research Research funding: Disclosure NHLBI, NIA, AstraZeneca John W. Devlin, PharmD, FCCP, FCCM, Professor of Pharmacy, Northeastern University Scientific Staff,
Successful implementation of a pediatric sedation protocol for mechanically ventilated patients*
Successful implementation of a pediatric sedation protocol for mechanically ventilated patients* Kristina H. Deeter, MD; Mary A. King, MD, MPH; Debra Ridling, CCRN; Gretchen L. Irby, PharmD; Anne M. Lynn,
Executive Sponsorship of Delirium Initiatives Lessons from ICU Liberation
Executive Sponsorship of Delirium Initiatives Lessons from ICU Liberation J. Matthew Aldrich, MD Co-Chair, SCCM ICU Liberation Committee Associate Professor Medical Director, Critical Care Medicine UCSF
Pain & Sedation Management in PICU. Marut Chantra, M.D.
Pain & Sedation Management in PICU Marut Chantra, M.D. Pain Diseases Trauma Procedures Rogers Textbook of Pediatric Intensive Care, 5 th ed, 2015 Emotional Distress Separation from parents Unfamiliar
Extreme arousal, irritability, excess motor activity driven by internal sense of discomfort such as disease, pain, anxiety and delirium
Agitated patient in ICUapproach & management Arjun Srinivasan Agitation Extreme arousal, irritability, excess motor activity driven by internal sense of discomfort such as disease, pain, anxiety and delirium
NURSING DEPARTMENT CRITICAL CARE POLICY MANUAL CRITICAL CARE PROTOCOL USE OF PROPOFOL (DIPRIVAN) FOR VENTILATOR MANAGEMENT
NURSING DEPARTMENT CRITICAL CARE POLICY MANUAL CRITICAL CARE PROTOCOL I. PURPOSE: To provide guidelines for the administration of Propofol, which is an anesthetic agent, indicated for the continuous intravenous
Management of Delirium in the ICU. Yahya Shehabi
Management of Delirium in the ICU Yahya Shehabi Hello! Doctor, your patient is CAM + ve Good morning Dr, Am one of the RC, Just examined Mr XXX he is CAM +ve Positive what? Sir replied RC: I meant he is
Naeem Ali, MD Medical Director. The Ohio State University Wexner Medical Center
Update in Critical Care, 2012: Teamwork in the ICU Naeem Ali, MD Medical Director Medical Intensive Care Unit The Ohio State University Wexner Medical Center 1 Many developments in Critical Care Emergence
Delirium in Critical Care. Recognition, Management, Research tasters. Dr Valerie Page Watford General Hospital
Delirium in Critical Care. Recognition, Management, Research tasters Dr Valerie Page Watford General Hospital What does it look like? Diagnosing delirium CAM-ICU CAM-ICU Feature 1: Acute onset of mental
CUSP 4 MVP-VAP Patient Care Bundle
Spontaneous Awakening and Spontaneous Breathing Trials, Literature Synopsis CUSP 4 MVP-VAP Patient Care Bundle Spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) reduce the length
Responding to The Joint Commission Alert on Safe Use of Opioids in Hospitals
Responding to The Joint Commission Alert on Safe Use of Opioids in Hospitals Suzanne A Nesbit, PharmD, CPE Clinical Pharmacy Specialist, Pain Management The Johns Hopkins Hospital Objectives and Disclosures
Sedation For Cardiac Procedures A Review of
Sedation For Cardiac Procedures A Review of Sedative Agents Dr Simon Chan Consultant Anaesthesiologist Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong 21 February 2009 Aims
(31189) Hypothermia Initiation Phase One
Hypothermia Initiation Phase One Diagnosis Allergies For hypothermia tracking purposes only. Please do not uncheck.- Required Cardiac Emergency Tracking For hypothermia tracking purposes only. Consults
Refractory Status Epilepticus in Children: What are the Options?
Refractory Status Epilepticus in Children: What are the Options? Weng Man Lam, PharmD, BCPS, BCPPS PICU Clinical Pharmacy Specialist Memorial Hermann Texas Medical Center November 11, 2017 Objectives 1.
ICU Delirium in Infants & Children: Cause for Concern or False Alarm. Objectives
ICU Delirium in Infants & Children: Cause for Concern or False Alarm Peter (Pete) N. Johnson, Pharm.D., BCPS, BCPPS, FPPAG Associate Professor of Pharmacy Practice University of Oklahoma College of Pharmacy
4/3/2018. Management of Acute Pain Crises. Five Mistakes I ve made and why you shouldn t
Management of Acute Pain Crises Maggie O Connor, M.D. Retired Palliative Care Physician Hope is not the conviction that something will turn out well, but the certainty that something makes sense, regardless
Delirium in the ICU Pamela L. Smithburger, PharmD, MS, BCPS, BCCCP, FCCP Associate Professor, University of School of Pharmacy
Delirium in the ICU Pamela L. Smithburger, PharmD, MS, BCPS, BCCCP, FCCP Associate Professor, University of Pi@sburgh School of Pharmacy Pa2ent Case JJ is 75 Yo male admi@ed to the MICU on 12/10 with acute
Status Epilepticus: Implications Outside the Neuro-ICU
Status Epilepticus: Implications Outside the Neuro-ICU Jeffrey M Singh MD Critical Care and Neurocritical Care Toronto Western Hospital October 31 st, 2014 Disclosures I (unfortunately) have no disclosures
PICU Sedation Holidays. Jorge G. Sainz MD FAAP Medical Director PICU Medical Director Transport
Jorge G. Sainz MD FAAP Medical Director PICU Medical Director Transport jsainz@elpasochildrens.org 1. Define sedation holiday. Objectives 2. Review differences between adult and pediatric sedation in ICU
ABCDEF Bundle Breakout
ABCDEF Bundle Breakout Andrew Masica, MD, MSCI VP, Chief Clinical Effectiveness Officer Baylor Scott & White Health andrew.masica@bswhealth.org Disclosures/Funding Support Grant R18-HS021459 from the Agency
Pain management. Coleman Palliative Care Conference: February 2016 Josh Baru MD Stacie Levine MD
Pain management Coleman Palliative Care Conference: February 2016 Josh Baru MD Stacie Levine MD Case #1 61 yo man with history of Stage 3 colon cancer, s/p resection and adjuvant chemotherapy with FOLFOX
Objectives. History of Ketamine First synthesized at Parke Davis Alternative to phencyclidine Veterinary medicine. Mechanism. Mechanism 9/13/2016
Objectives Keeping Things Calm and Cool: A Pharmacotherapy Update Describe the pharmacology and recognize the adverse effects of ketamine Select an appropriate patient to sedate with ketamine to facilitate
Physician Orders ADULT: Vascular Surgery AAA Repair Open Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: AAA Repair Open Postop Phase, When to Initiate: Initiate Powerplan Phase Phase: Mechanically Ventilated Patients Phase,
High-Alert Medications: A Look at the Safe Use of Narcotics. Allen Vaida, BSc, PharmD Institute for Safe Medication Practices (ISMP)
High-Alert Medications: A Look at the Safe Use of Narcotics Allen Vaida, BSc, PharmD Institute for Safe Medication Practices (ISMP) Risk Identification in Healthcare The detection of a potential or actual
North Wales Critical Care Network
North Wales Critical Care Network SEDATION GUIDELINES FOR ADULTS IN CRITICAL CARE Approved 6.9.12 1 Sedation guidelines for intensive care Betsi Cadwaladr University Health Board (Adapted from guidelines
Assessment Algorithm for Sedated Adult ICU Patients
Assessment Algorithm for Sedated Adult ICU Patients ICU Sedation Guidelines of Care No Rule out/correct reversible causes Use nonpharmacologic treatment Optimize the environment Is patient comfortable
9/28/2016. Sedation Strategies in the ICU. Outline. ICU sedation. Recent clinical practice guidelines Top 10 myths A practical approach
Sedation Strategies in the ICU UW Medicine EMS and Trauma Conference Seattle, Washington September 26 th, 2016 C. Terri Hough, MD MSc Associate Professor of Medicine Division of Pulmonary and Critical
Drug induced delirium
Drug induced delirium Knut Erik Hovda, MD, PhD, FACMT, FEAPCCT The Norwegian CBRNe Centre of Medicine Department of Acute Medicine Oslo University hospital Content 1. Introduction 2. Risk factors 3. Prevalence
Optimal sedation and management of anxiety in patients undergoing endobronchial ultrasound (EBUS)
Optimal sedation and management of anxiety in patients undergoing endobronchial ultrasound (EBUS) Georgios Dadoudis Anesthesiologist ICU DIRECTOR INTERBALKAN MEDICAL CENTER Optimal performance requires:
Implementing the 2013 PAD Guidelines
1 of 20 8/11/2013 10:25 PM www.medscape.com Implementing the 2013 PAD Guidelines Top Ten Points to Consider Brenda T. Pun, MSN, RN, ACNP, Michele C. Balas, PhD, RN, APRN-NP, CCRN, Judy Davidson, DNP, RN,
LUNCH AND LEARN. November 13, 2015
LUNCH AND LEARN Sterile Products Used in the Critical Care Practice Setting November 13, 2015 Featured Speaker: Jeremy P. Hampton, PharmD, BCPS Clinical Assistant Professor University of Missouri Kansas