Sedation in the Intensive Care Unit

Educational Objectives

The goal of this program is to improve sedation in the intensive care unit (ICU). After hearing and assimilating this program, the clinician will be better able to:

1. Manage sedated patients using the recommendations in the Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) guidelines (2018).
2. Select appropriate medications for inducing light sedation and for prevention of delirium.

Summary

Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) Guidelines (2018)

Light sedation: light sedation (≥-2 on the Richmond Agitation Sedation Scale [RASS]) is preferred over deep sedation; light sedation is associated with shorter time to extubation and a lower tracheostomy rate; no differences have been observed in rates of 90-day mortality, delirium, post-traumatic stress disorder, depression, or self-extubation compared with deep sedation

Daily interruption of sedation: spontaneous awakening trial or nursing-protocolized (NP)-targeted sedation can achieve light sedation; however, patients should not be deeply sedated and awakened every 12 hr; sedation assessment by nursing staff and modality of sedative administration varies among institutions

Choice of sedative: nonbenzodiazepine sedatives are preferred over benzodiazepines because they are associated with improvement in short- and long-term outcomes; trials of medical and surgical patients in the intensive care unit (ICU) show that time to light sedation and extubation were shorter with propofol compared with benzodiazepines; propofol is preferable to benzodiazepine for sedation; Riker et al (2009) found that time to extubation improved by 1.9 days and the risk for delirium was lower with dexmedetomidine compared with midazolam; use of dexmedetomidine was associated with bradycardia, but no clinical treatment was required; dexmedetomidine is preferred over benzodiazepine; no difference in time to extubation was observed with propofol compared with dexmedetomidine; dexmedetomidine is associated with a decreased incidence of delirium and has some benefit for extubation of patients with agitation; for light sedation, propofol or dexmedetomidine may be used

Monitoring of sedation: bispectral index monitoring is better for titration during deep sedation

Physical restraints: risk for use include older age, delirium, and nurse-to-patient ratio; early mobility can reduce use of restraints; frequently used and prevalence rates vary

Pharmacologic considerations: midazolam is least preferred for pain

Propofol vs dexmedetomidine for sedation: ventilator asynchrony was better with dexmedetomidine; no other differences were found; incidence of delirium is lower with dexmedetomidine; incidence of hypotension is higher with propofol in some studies; propofol is preferred for deep sedation; propofol infusion syndrome (ie, metabolic acidosis, rhabdomyolysis, kidney failure) may occur with high doses

Prevention of delirium: Skrobik et al (2018) found that fewer patients on dexmedetomidine developed delirium compared with placebo

Treatment of delirium: no difference between haloperidol and olanzapine was observed; a study found less agitation with haloperidol vs placebo; quetiapine was associated with shorter time to resolution and less agitation compared with placebo; the MIND-USA trial (Girard et al [2018]) that compared haloperidol or ziprasidone with placebo found no benefit for hypoactive delirium; Reade et al (2016) showed that dexmedetomidine increased ventilator-free hours and accelerated the resolution of delirium

Sleep: no recommendations for use of melatonin or dexmedetomidine; propofol should not be used for sleep; ramelteon improves sleep with some decrease in delirium; dexmedetomidine increases non-rapid eye movement stage 1 and 2 sleep and may cause bradycardia

Readings

Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. doi:10.1097/CCM.0000000000003299; Girard TD, Exline MC, Carson SS, et al. Haloperidol and ziprasidone for treatment of delirium in critical illness. N Engl J Med. 2018;379(26):2506-2516. doi:10.1056/NEJMoa1808217; Reade MC, Eastwood GM, Bellomo R, et al. Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: A randomized clinical trial [published correction appears in JAMA. 2016 Aug 16;316(7):775]. JAMA. 2016;315(14):1460-1468. doi:10.1001/jama.2016.2707; Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):489-499. doi:10.1001/jama.2009.56; Skrobik Y, Duprey MS, Hill NS, et al. Low-dose nocturnal dexmedetomidine prevents icu delirium. A randomized, placebo-controlled trial. Am J Respir Crit Care Med. 2018;197(9):1147-1156. doi:10.1164/rccm.201710-1995OC.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Smith is a consultant for Intuitive Surgical. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Smith was recorded at Trauma, Critical Care and Acute Care Surgery 2022, held March 28-30, 2022, in Las Vegas, NV, and presented by Trauma and Critical Care Foundation. For more information about upcoming CME activities from this presenter, please visit Trauma-criticalcare.com. Audio Digest thanks the speakers and Trauma and Critical Care Foundation for their cooperation in the production of this program.

ABS Continuous Certification

Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit/s toward the CME [and Self-Assessment] requirements of the American Board of Surgery’s Continuous Certification pro

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.25 CE contact hours.

Lecture ID:

GS691603

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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