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 sedated, comfortable and safe in bed Plenty of time to rehab once cured of their critical illness Early mobility is unsafe New teaching: Sedation/delirium/lack of mobility contributes to long term poor outcome Sedation leads to delirium, prolonged mechanical ventilation, increased tracheostomies and death Early mobility is associated with improved patient outcomes 2
Pain in the Critically Ill May be sole cause of agitation Probably underdiagnosed Endotracheal tube may be cause Narcotics are drugs of choice
Non-Verbal Pain Scale
A Protocol of No Sedation for Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Trial Single center non-blinded trial comparing no sedation with daily interruption of sedation (140 patients with 1:1 nursing) No sedation had significantly more days without ventilation (13.8 vs. 9.6), shorter length of ICU stay (13.1 vs. 22.8), and hospital LOS (34 vs 58). Mortality in ICU 22% vs 38% P=0.06. No difference in complications but higher incidence of delirium Need multicenter trial to confirm Lancet 2010;375:475-480.
Decreased Duration of Mechanical Ventilation when Comparing Analgesia-based Sedation Using Remifentanyl with Standard Hypnotic-based Sedation for up to 10 Days in Intensive Care Unit Patients: A Randomised Trial Randomized 105 patients comparing remifentanyl based sedation with addition of midazolam vs midazolam based sedation with addition of morphine or fentanyl Both titrated to SAS and pain scale Remifentanyl based regime significantly reduced duration of mechanical ventilation by 2 days Trend toward reduction in ICU LOS No sedation interruption Breen et al Crit Care 9:R200, 2005
Assessing the Level of Sedation Clinical Methods (ie Ramsay Scale, sedation-agitation scale) Associated with 33% reduction in dangerous agitation and 66% reduction in significant pain Neurophysiologic Methods (ie Processed EEG and AEP)
Sedation-Agitation Scale 7 Dangerously agitated 6 Very Agitated 5 Agitated 4 Calm and cooperative 3 Sedated 2 Very Sedated 1 Unarousable
A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients MICU patients ventilated for more than 48 hours randomized to receive lorazepam intermittent bolus administration vs continuous infusion propofol with daily interruption Results: Median ventilator days for propofol (5.8 days) vs lorazepam (8.4 days) p= 0.04 Carson, et al, 2006;34:1326-1332. 9
Efficacy and Safety of a Paired Sedation and Ventilator Weaning Protocol for Mechanically Ventilated Patients in Intensive Care (Awakening and Breathing Controlled Trial): A Randomised Controlled Trial Randomly assigned 336 patients comparing SBTs vs paired SATs and SBTs Endpoint time breathing without assistance Intervention group spent 15 days of unassisted breathing vs 12 days in the control group LOS in ICU 9 vs 13 days and Hosp 15 vs 19 days favoring intervention group For every 7 patients treated with intervention, one life was saved Girard et al Lancet 371:126-134, 2008
Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients Compare safety and efficacy of prolonged sedation in 375 med/surg ICU ventialted patients expected to be ventilated 24 hours or more Dexmedetomidine vs midazolam Results: Delirium prevalence 54% in dexmedetomidine group and 75.1% for midazolam group Time to extubation 3.7 days in dex group vs 5.6 in midazolam group Riker, et al, JAMA, 2009;301:489-499 11
Delirium Transient reversible brain dysfunction of rapid onset Marked by rapid fluctuations in mental status, disorientation, agitation or lethargy and reduced cognition Etiology multifactorial (closely linked with benzodiazepines)
Incidence, Risk Factors and Consequences of ICU Delirium Prospective observational study of 820 patients assessing risk factors for delirium Delirium occurred in 32% of patients Delirium associated with HTN, alcoholism, severity of illness and with sedatives and analgesics used to induce coma Delirium linked with longer length of ICU stay (11 vs 5 days) and mortality (26% vs 21%) Ouimet et al Int Care Med 33:66-73 (2007)
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial 104 patients on mech vent less than 72 hours but predicted to be on at least another 24 hours PT/OT during sedation interruption vs. sedation interruption Return to independent function in 59% (rx) vs 35% controls 2 days less delirium and 2.5 more vent free days. Lancet 2009, 373:1874-1881.
URMC Mobility Protocol 16
Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study Quiapentine (50-200 mg BID) vs placebo for delirium in 36 ICU patients Haloperidol used as prn Results: Reduced duration of delirium with quiapentine, 36 hours vs 120 hours (p=0.006) Reduced agitation with quiapenine 6 vs 36 hours (p= 0.002) Reduced need for prn haloperidol withh quiapenine 3 days vs 4 days (p=0.05) Quiapentine treated patients were were more likely to be discharged home or to rehab 89% vs 56% (p=0.06) Devlin et al, Crit Care Med 2010;38:419-427 17
SCCM Practice Guidelines Recommend pre-emptive pain management with opiods Use lightest levels of sedation possible Suggest non-benzodiazepine sedation strategies Recommend early mobilization to limit risk for delirium Routinely assess level of pain, depth of sedation, and monitoring for delirium Barr et al, Crit Care Med 2013;41:263-306 18
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