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 care population? Describe assessment tools available for Pain CPOT Agitation/sedation RASS Delirium CAM-ICU Guidelines & Bundle(s) Specific management for PAD (IS). 2
WHY IS THIS IMPORTANT? 3
Pain Pain is a common memory for most ICU patients (Reade & Finfer, 2014) Critical care population may not be able to self-report their experience of pain so it may go undetected Consequences of uncontrolled pain Immunosuppression PTSD Delayed wound healing 4
Agitation & Sedation Early mechanical ventilation required deep sedation due to problems with patient synchrony & comfort Advances in vent technology & medications means this isn t always necessary now But common feature of ICU patients as they experience a frightening & stressful stimuli during their stay with us 5
Delirium Affects up to 80% of mechanically ventilated adult ICU patients Acute onset of cerebral dysfunction Characterised by Change/fluctuation from baseline mental status Inattention Either disorganised thinking or altered level of consciousness Barr(2013) 6
Barr(2013) 7
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Causes & Interactions of PAD N Engl J Med 2014; 370:444-454
ASSESSMENT TOOLS 10
Assessing pain at SGH: 1. Self Report (gold standard) Pain Assessment chart used by whole trust for patients able to tell us if it hurts 2. Continuous Pain Observation Tool (CPOT) Adult ICU patients who are unable to self report 3. Abbey Pain Scale Pain assessment chart used in trust for patients unable to self report such as LD 11
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Assessing agitation at SGH: Richmond Agitation Sedation Score 17
Assessing delirium at SGH: Confusion assessment Method for the ICU CAM-ICU 18
Valeria Page cam icu assessment: https://www.youtube.com/wa tch?v=6wyj0zl7vki 3mins 30 secs 20
GUIDELINES & BUNDLES 21
PAD guidelines (Barr 2013) 22
PADIS guidelines (Devlin et al 2018) 24
ABCDEF Bundle 25
ecash: 26 Vincent et al (2016) Comfort & patient centred care without excessive sedation: the ecash concept Intensive care Medicine
SPECIFIC MANAGEMENT FOR PAD (IS). 27
Pain management in ICU: Consistent approach to pain assessment Analgesia first sedation or a analgesia based sedation IV opioids 1 st line BUT important considerations include: Sedation, Delirium, Resp despression, Ileus, immunosuppression SO.. Think about adjuncts to spare/minimise opioid use IV PARACETAMOL, low dose ketamine, Massage, music Gabapentin, Carbamazepine, Pregablin neuropathic pain Remember reduced morphine clearance in renal failure -?switch to Fentanyl Relative potency to morphine 28
Agitation management: Agitation is a feature of ICU admission Traditionally managed with deep sedation Paradigm shift to light sedation.. Titrated to Sedation Score Daily Sedation Hold (unless contraindicated) Sedation strategy that avoids benzo: Alfentenyl Propofol Dexdor Lorazepam Midazolam Haloperidol 29
Delirium management: Routine screening for delirium CAM-ICU Reduce modifiable risk factors Hearing aids & spectacles easy fix & quick win Re-orientation (Clocks), Cognitive stimulation Improve Sleep Increase wakefulness (reduce sedation) Early rehab/mobilsation ABCDEF Bundle Pharmacology? Restraint? 30
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Immobility Management Early Mobilisation & rehabilitation Even on intubated patients! In bed activities eg Motomed 32
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Sleep Management Ear Plugs & Eye Shades Relaxing music Reduction in night time light, noise, intervention? Melatonin,?dexdor 34
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Summary Pain Agitation Delirium Immobility Sleep Disruption CAN ALL BE IMPROVED BY COMMITTED, HOLISTIC, PATIENT FOCUSED CARE 36