4-25-07 Delirium draft 3

4-25-07 Delirium draft 3 - Management of Sedation and...

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Management of Sedation and Delirium in Ventilated ICU Patients Gabriel Tsao Stanford University School of Medicine
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Introduction In the United States, 55,000 patients are cared for daily in 6000 ICUs. The most common reason for admission is respiratory failure and the need for mechanical ventilator. The vast majority of patients on ventilators require sedation 60-80% of ventilated patients develop delirium at some point during their hospital course Ely EW et al. Delirium as a predictor of mortality in mechanically ventilated patients in the ICU. JAMA 2004; 291: 1753-62
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Presentation Outline Sedation in the ICU Drug overview Sedation assessment Drug selection Delirium in the ICU Incidence and mortality Delirium assessment Management of delirium (Serotonin Syndrome on Friday? Sorry, Dr. Spain)
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Sedation in Ventilated Patients Mechanical ventilation is uncomfortable and anxiety provoking Sedation is often necessary for comfort and airway, line, foley, nursing protection >85% of ventilated patients receive sedation Weinert CR, et al. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med 2007. 35(2): 393-401
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Commonly Used Sedatives “Standard” sedation Benzodiazepines - midazolam, lorazepam, diazepam Anesthetics - propofol Special circumstance sedation Central alpha-agonists - clonidine, dexmedetomidine High-dose opioids Haloperidol
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Benzodiazepines Sedative-hypnotic agents Sedative (anxiolytic): blocks acquisition and processing of new information Hypnotic: produces drowsiness and encourages onset and maintenance of sleep. Lacks analgesia effects Issues: CNS depression (additive) Hypotension Respiratory depression Tolerance Withdrawal Midazolam
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Benzodiazepines Diazepam not used extensively in ICU, metabolites and renal excretion Use of BZD in liver dz: LOT - L orazepam O xazepam T emazepam Flumazenil reversal for BZD overdose Competitive antagonist Short half-life, heavy sedation may resume Concern for withdrawal especially after prolonged BZD use Use low dose (0.15 mg dose x1), second dose if some response observed.
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Propofol IV general anesthetic agent Sedative/hypnotic properties at lower doses Rapid onset and rapid recovery (ambulate sooner) “Milk of amnesia” Similar degree of amnesia as BZDs No analgesic properties Requires dedicated line for infusion Stored in lipid emulsion --> hypertriglyceridemia 1.1 kcal/ml from fat, adjust tube feeds Pancreatitis, particularly in prolonged or high-dose Check triglyceride levels after 2 days Adverse Effects Marked hypotension during induction, respiratory depression (apnea), bradycardia, arrhythmias, propofol infusion syndrome
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Central alpha-agonists Unlike other sedatives, α 2 -agonists do not cause respiratory depression or hemodynamic instability
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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4-25-07 Delirium draft 3 - Management of Sedation and...

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