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Oversedation in ICU REcap

Using ABCDE Bundle to Tackle Oversedation
by

Glenn Siy

on 18 September 2013

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Transcript of Oversedation in ICU REcap

A B C D E Bundle
Delirium is an acute disturbance of consciousness with inattention accompanied by a change in cognition or perceptual distubance that may linger or fluctuate in time.
History: We have quite a few patients who were delirious after they have been extubated. The goal of this EBP project is to understand these patients and address the underlying cause to prevent it from reoccurring?

EBP= the searched for evidence based practices lead as to ABCDE bundle
Our main focus: Sedative and Narcotics (Problem of Oversedation leading to prolonged mechanical ventilation)
Risk factors for Delirium
Spontaneous Awakening Trial
Spontaneous Breathing Trial
Choice of Sedation
Delirium Monitoring and Management
Early Progressive Mobility
ABCDE Bundle
Establish an ICU where all patients undergoing mechanical ventilation are alert, calm, and delirium free.
A facility wherein nonverbal patients can effectively express their need for better pain control, repositioning, or psychosocial support.
We have gone a long way
with

medical
science and technology in saving lives
A bridge towards a better bedside care
Respiratory-therapist-driven weaning protocol that included SBTs significantly shortened time to extubation compared with physician-driven weaning.
Reference: Ely et. al. (1996)
SBT strategy was associated with reduced time to successful weaning off mechanical ventilator.
(Hooper & Girard, 2009)
Sedation interruption in mechanically ventilated patients led to a shorter duration of mechanical ventilation and ICU stay, as well as a reduction in the number of diagnostic imaging tests for altered mental status (Kress, Pohlman, O'Connor, & Hall, 2000)
Protocol-driven sedation during mechanical ventilation reduced the duration of mechanical ventilation, decreased ICU and hospital lengths of stay, shortened the duration of continuous infusion of sedatives, and lowered tracheostomy rates of patients compared with patients treated with non-protocol-directed sedation (Brook, et al., 1999)
Note the verbal stimulation
Detection is the key!
Evidence have shown that without a tool, clinicians oftentimes miss delirium cases in critically ill patients. (Devlin, et al., 2007)
A mobilization and an early exercise intervention in ICU patients reduce the incidence and shorter duration of ICU delirium (Schweickert, et al., 2009)
For now, we'll limit it to passive range of motion and sitting position.
Delirium Management will be handled by Doctors. Nurses will focus on delirium detection first.
Preliminary Workflow
"Feeling of persecution"

"nurses were trying to kill me for the knowledge that I have"

"ICU was like a torture chamber for me"

"I was ashamed to think like that considering I owed my life to them"
Prof. Nancy Andrews
It is a multicomponent, multidisciplinary, interdependent tool that aligns and supports the people, processes, and technology and designed to:
- Improve clinical team collaboration
- Standardize care processes
- Break the cycle of oversedation and prolonged ventilation
ABCDE bundle Positive Outcomes:
This year's Goals are...
Paired SAT/SBT
- Passive range of motion
- Sitting position
- Decrease length of hospital stay
- Decrease ICU length of stay
- Decrease tracheostomy cases
- Discharges directly to home
- Decrease days on mechanical ventilator
REFERENCES
Awissi, D. K., Bégin, C., Moisan, J., Lachaine, J., & Skrobik, Y. (2012). I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation. Annals of Pharmacotherapy, 46(1), 21-28.

Balas, M. C., Happ, M. B., Yang, W., Chelluri, L., & Richmond, T. (2009). Outcomes Associated With Delirium in Older Patients in Surgical ICUs. CHEST, 135(1), 18-25.

Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., ...Jaeschke, R. (2013). Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine, 41(1), 263-306. doi: 10.1097/CCM.0b013e3182783b72

Boot, R. (2012). Delirium: A review of the nurses role in the intensive care unit. Intensive & critical care nursing : the official journal of the British Association of Critical Care Nurses, 28(3), 185-189.

Brook, A. D., Ahrens, T. S., Schaiff, R., Prentice, D., Sherman, G., Shannon, W., & Kollef, M. H. (1999). Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical Care Medicine, 27(12), 2609-2615.

Chanques, G., Jaber, S., Barbotte, E., Violet, S., Sebbane, M., Perrigault, P., ...Eledjam, J. (2006). Impact of systematic evaluation of pain and agitation in an intensive care unit. Critical Care Medicine, 34(6), 1691-1699.

Devlin, J. W., Fong, J. J., Schumaker, G., O'Conner, H., Ruthazer, R., & Garpestad, E. (2007). Use of a validated delirium assessment tool improves the ability of physicians to identify delirium in medical intensive care unit patients. Critical Care Medicine, 35(12), 2721-2724.

Ely, E. W., Baker, A. M., Dunagan, D. P., Burke, H. L., Smith, A. C., Kelly, P. T., ...Haponik, E. F. (1996). Effect on the Duration of Mechanical Ventilation of Identifying Patients Capable of Breathing Spontaneously. New England Journal of Medicine, 335(25), 1864-1869.

Ely, E. W., Gautam, S., Margolin, R., Francis, J., May, L., Speroff, T., ...Inouye, S. K. (2001). The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Medicine, 27(12), 1892-1900.

Ely, E. W., Shintani, A., Truman, B., Speroff, T., Gordon, S. M., Harrell, F. E., Jr., ...Dittus, R. S. (2004). Caring for the critically ill patient. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA: Journal of the American Medical Association, 291(14), 1753-1762.

Ely, E. W., Truman, B., Shintani, A., Thomason, J. W. W., Wheeler, A. P., Gordon, S., ...Bernard, G. R. (2003). Caring for the critically ill patient. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA: Journal of the American Medical Association, 289(22), 2983-2991.

Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., ...Ely, E. W. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513-1520.

Hipp, D., & Ely, E. W. (2012). Pharmacological and Nonpharmacological Management of Delirium in Critically Ill Patients. Neurotherapeutics, 9(1), 158-175. doi: 10.1007/s13311-011-0102-9

Hooper, M. H., & Girard, T. D. (2009). Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Critical Care Clinics, 25(3), 515-525.

Inouye, S. K., Bogardus, S. T., Jr., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M., Jr. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients.: New England Journal of Medicine March 4, 1999;340(9):669-676.

King, M. S., Render, M. L., Ely, E. W., & Watson, P. L. (2010). Liberation and animation: strategies to minimize brain dysfunction in critically ill patients. Seminars in Respiratory & Critical Care Medicine, 31(1), 87-96.

Kress, J. P., Pohlman, A. S., O'Connor, M. F., & Hall, J. B. (2000). Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation. New England Journal of Medicine, 342(20), 1471-1477.

Lat, I., McMillian, W., Taylor, S., Janzen, J. M., Papadopoulos, S., Korth, L., ...Burke, P. (2009). The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Critical Care Medicine, 37(6), 1898-1905. doi: http://dx.doi.org/10.1097/CCM.0b013e31819ffe38

Maniou, M. (2012). Delirium: a distressing and disturbing clinical event in a Intensive Care Unit. Health Science Journal, 6(4), 587-597.

Mascia, M. F., Koch, M., & Medicis, J. J. (2000). Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care. Critical Care Medicine, 28(7), 2300-2306.

McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Belzile, E. (2002). Delirium predicts 12-month mortality. Archives of Internal Medicine, 162(4), 457-463.

Milbrandt, E. B., Deppen, S., Harrison, P. L., Shintani, A. K., Speroff, T., Stiles, R. A., ...Ely, E. W. (2004). Costs associated with delirium in mechanically ventilated patients. Critical Care Medicine, 32(4), 955-962.

Morandi, A., Brummel, N. E., & Ely, E. W. (2011). Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Current Opinion in Critical Care, 17(1), 43-49.

Olsen, K., Burke, W., Peitz, G., Gannon, D., Stothert, J., Jawa, R., ...Balas, M. (2012). 5: THE ABCDE Bundle Reduces the Incidence of Delirium in non-mechanically ventilated Patients. Critical Care Medicine, 40(12) Supplement(1), 1-328.

Pandharipande, P., Cotton, B. A., Shintani, A., Thompson, J. L., Pun, B. T., Morris, J. A. J., ...Ely, E. W. (2008). Prevalence and Risk Factors for Development of Delirium in Surgical and Trauma Intensive Care Unit Patients. Journal of Trauma-Injury Infection & Critical Care, 65(1), 34-41.

Pohlman, M. C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ...Kress, J. P. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine, 38(11), 2089-2094.

Quenot, J.-P., Ladoire, S., Devoucoux, F., Doise, J.-M., Cailliod, R., Cunin, N., ...Charles, P. E. (2007). Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Critical Care Medicine, 35(9), 2031-2036.

Richman, P. S., Baram, D., Varela, M., & Glass, P. S. (2006). Sedation during mechanical ventilation: a trial of benzodiazepine and opiate in combination. Critical Care Medicine, 34(5), 1395-1401.

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ...Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet, 373(9678), 1874-1882.

Strom, T., Stylsvig, M., & Toft, P. (2011). Long-term psychological effects of a no-sedation protocol in critically ill patients. Critical Care (London, England), 15(6), R293. doi: http://dx.doi.org/10.1186/cc10586

Van Rompaey, B., Schuurmans, M. J., Shortridge-Baggett, L. M., Truijen, S., Elseviers, M., & Bossaert, L. (2009). Long term outcome after delirium in the intensive care unit. Journal of Clinical Nursing, 18(23), 3349-3357. doi: http://dx.doi.org/10.1111/j.1365-2702.2009.02933.x

Vasilevskis, E. E., Morandi, A., Boehm, L., Pandharipande, P. P., Girard, T. D., Jackson, J. C., ...Ely, E. W. (2011). Delirium and Sedation Recognition Using Validated Instruments: Reliability of Bedside Intensive Care Unit Nursing Assessments from 2007 to 2010. Journal of the American Geriatrics Society, S249-255. doi: http://dx.doi.org/10.1111/j.1532-5415.2011.03673.x

Wong, C. L., Holroyd-Leduc, J., Simel, D. L., & Straus, S. E. (2010). Does this patient have delirium?: value of bedside instruments. JAMA: Journal of the American Medical Association, 304(7), 779-786. doi: http://dx.doi.org/10.1001/jama.2010.1182

Zaal, I. J., & C. (2012). Delirium in Critically Ill Patients: Epidemiology, Pathophysiology, Diagnosis and Management. Drugs, 72(11), 1457-1471.

Patients who received daily interruption of their continuous sedative-analgesic infusion did not experience adverse psychological outcomes and were less likely to have symptoms of PTSD than those who received conventional management.

Kress et.al, Am J Res Crit Care Med. 2003; 168(12):1457

- Oversedation in the ICU is common; associated with negative outcomes.
- Analgosedation (A-1) has been shown to improve outcomes; consider sedation only if necessary.
- Use the ABCDE protocol to eliminate oversedation.
- Use of benzodiazepines should be minimized (benzosparing sedation)
- Use the Pulmonary Vent Bundle and start vent weaning protocol on Day 1.
- Choos from (3) Anesthesia Care Plans and click the daily sedation vacation.

SUMMARY
KEY STUDY PERSONNEL:

Evidence-Based Practice (EBP) Fellow: Glennard Siy
Clinical Consultants:
Dr. Maqbool Ahmed, Beth Gladney, Amy Ziegler, Becky Prenton

Opinion Leaders:
Kalsang Dorji, Michaela Davis, Maureen Allain, Minette Rillon, Elisa Jang

Change Champion:
Kalsang Dorji, Michaela Davis, Carol Brower, Maureen Allain, Steve Lowe

Core Group:
Doug Dado, Arlene Cabanero, Raquel Aguirre
Lourdes Balomadres, Ivan Dasig, Catherine Gorry, Susan Latka
Jennifer Tudor, Joshua Mefford Brenda Blair, Cathy Carrasco, Marilou Lucero, Wendy Volponi, Laura Corson, Chelestina Patzer,
Debra MacNeil, Melissa Hines, Deb Whittington
Darrell Waite, Andrea Gonzalez, Micheline Ceccatti
Neeta Bhasin

Quality Control Coordinator: Cecilia David
Data Manager: Glennard Siy
Statistician: Denis Waldron

Sedation in ICU
Van Rompaey B, et al. Crit Care. 2009;13:R77.
Inouye SK, et al. JAMA.1996;275:852-857.
Skrobik Y. Crit Care Clin. 2009;25:585-591.

DELIRIUM

More Modifiable

Less Modifiable


Cardiac disease
Cognitive impairment
(eg, dementia)
Pulmonary disease


Admission via ED or
through transfer
Isolation
No clock
No daylight
No visitors
Noise
Physical restraints


Increased age
Alcohol use
Male gender
Living alone
Smoking
Renal disease

DELIRIUM
Acute Illness
Predisposing Disease
Patient Factors
Environment

Develops in 60-80% of mechanically ventilated ICU patients
Hypoactive or mixed forms most common
Increased risk
Benzodiazepines
Extended ventilation
Immobility
Associated with weakness
Undiagnosed in up to 72% of cases

ICU Delirium
Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.

Neurotransmitter imbalance
Neuroinflammation
Blood brain barrier permeability
Impaired oxidative metabolism
Microglial activation
Abnormal levels of large neutral amino acids
Mechanisms for Delirium are not clearly understood
Maldonado JR. Crit Care Clin. 2008;24(4):789-856.
Pandharipande PP. Intensive Care Med. 2009;35(11):1886-1892.
Adams-Wilson JR, et al. Crit Care Med. 2012 (in press)

Length of stay
Fever
Medicine service
Lack of nutrition
Hypotension
Sepsis
Metabolic disorders
Tubes/catheters
Medications:
- Anticholinergics
- Corticosteroids
- Benzodiazepines
- Narcotics
Oversedation


Vasilevskis et al Chest 2010; 138;1224-1233

Cognitive and Functional Impairment, Institutionalization, Mortality

Patient with Sepsis

Weakness

Delirium

Mechanical
Ventilation

Sedation

Day 1: 84 y.o. woman with H1N1 no sedation
- Oversedation in the ICU is common; associated with negative outcomes.
- Analgosedation (A-1) has been shown to improve outcomes; consider sedation only if necessary.
- Use the ABCDE protocol to eliminate oversedation.
- Titrate all sedative medications using proper RASS scoring to keep patients comfortable and arousable if possible.
- Use of benzodiazepines should be minimized (benzosparing sedation)
- The workflow involves paired SAT/SBT every shift.

Document RASS score every two hours and adjust sedation drips accordingly
Types of Delirium
Risks of Mechanical Ventilation
Precedex
Precedex
Focus on treating the reversible causes of delirium such as:
- Sleep deprivation
- Pain
- Dis-Orientation
- Sensory deprivation (eyes/ears)
Sitting upright facilitates extubation process
This is more problematic
Four Interrelated Major Problems in ICU
Estimated End time
Take note of inclusion and exclusion criteria
This is where you keep track of the ABCDE bundle!
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