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Correlation between the Sedation-Agitation Scale and the Bispectral Index in ventilated patients in the intensive care unit. Heart Lung 2009; 38:336-45. [DOI: 10.1016/j.hrtlng.2008.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Revised: 10/12/2008] [Accepted: 10/17/2008] [Indexed: 10/21/2022]
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Cidoncha E, Mencía S, Riaño B, Urbano J, López-Herce J, Carrillo A. Valoración de la sedación en el niño crítico con ventilación mecánica durante la aspiración endotraqueal. An Pediatr (Barc) 2009; 70:218-22. [DOI: 10.1016/j.anpedi.2008.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 10/24/2008] [Indexed: 10/20/2022] Open
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53
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Olson DM, Thoyre SM, Peterson ED, Graffagnino C. A randomized evaluation of bispectral index-augmented sedation assessment in neurological patients. Neurocrit Care 2009; 11:20-7. [PMID: 19184556 DOI: 10.1007/s12028-008-9184-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Accepted: 12/18/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether monitoring sedation status using bispectral index (BIS) as an adjunct to clinical evaluation was associated with a reduction in the total amount of sedative drug used in a 12 h period. DESIGN Prospective randomized controlled clinical trial. SETTING Tertiary care neurocritical care unit. PATIENTS Sixty-seven mechanically ventilated adult patients receiving continuous intravenous sedation with propofol. INTERVENTIONS Sedation monitoring using clinical assessment with the Ramsay scale (Ramsay-alone group) or clinical assessment plus BIS monitoring (BIS-augmentation group). Subjects were randomized to Ramsay-alone (n = 35), or BIS-augmentation (n = 32). Nurses adjusted the dose of propofol to a Ramsay of 4, or a Ramsay of 4 and BIS between 60 and 70. MEASUREMENTS AND MAIN RESULTS Patients in the BIS-augmentation group received significantly less propofol by volume (93.5 ml vs. 157.8 ml, respectively; P < .015), and had lower infusion rates (14.6 vs. 27.9 mcg/kg/min; P = .003). There is a lower risk of propofol infusion exceeding manufacturer's recommended dosing guides in the BIS-augmentation group versus the Ramsay-alone group (0 vs. 23%, P = .0052). The BIS-augmentation group woke up much quicker than those in the Ramsay-alone group (1.2 vs. 7.5 min; P < .0001). CONCLUSIONS BIS-augmented sedation monitoring resulted in a marked reduction in the total dose of sedative used to achieve the same level of clinical sedation resulting in shortened time to wake up without any measurable adverse effects. Physiologic sedation assessment tools may provide a useful means of improving the care of sedated critically ill patients.
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Affiliation(s)
- Daiwai M Olson
- Department of Medicine-Neurology, Duke University Medical Center, Durham, NC 27710, USA.
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Frontal EEG for intensive care unit sedation: treating numbers or patients? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:186. [PMID: 18983711 PMCID: PMC2592758 DOI: 10.1186/cc7029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In this issue of Critical Care, Dr Haenggi and co-workers present a study evaluating bispectral index (BIS), state entropy (SE) and response entropy in 44 patients sedated in the intensive care unit (ICU). As in recent studies attempting to correlate frontal electroencephalogram (EEG) measurements with clinical evaluations of sedative efficacy, there is considerable overlap in numerical EEG values and different clinical levels of sedation. This precludes the use of these monitors for monitoring or titrating sedation in the critically ill. Despite many attempts, no study has yet presented data showing improved outcome with the use of EEG monitors in ICU sedation. Meanwhile, clinical sedation protocols have emerged, improving important endpoints in critically ill patients needing sedation. A major underlying problem in applying EEG monitors in the ICU is that they have been developed for measuring anesthetic depth and the related risk of recall, rather than the acknowledged endpoints of sedation, namely reduction of anxiety and discomfort. Until an 'objective' monitor is developed to measure the degree of such symptoms, physicians should continue treating patients and not numbers.
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Kurtz P, Claassen J. Continuous EEG monitoring in the ICU. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.5.575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Continuous EEG (cEEG) monitoring is one of many available techniques to assess cerebral function in critically ill patients. Detection and treatment of nonconvulsive seizures (NCSZ) and nonconvulsive status epilepticus (NCSE) are the main clinical applications of cEEG. These patterns are common and associated with poor outcome after severe brain injury. Quantitative EEG parameters can be used for early detection of NCSZ and ischemia caused by vasospasm after subarachnoid hemorrhage. Early and aggressive treatment of such complications may prevent secondary brain injury and avoid irreversible damage. Periodic epileptiform discharges (PEDs) are also seen frequently after acute brain injury and may be associated with poor outcome. However, to date, it is uncertain whether NCSZ, NCSE or PEDs cause additional injury or if they are epiphenomena of brain damage. Currently, there are many limitations to the widespread use of cEEG, particularly the lack of high quality studies. In the future, the role of cEEG as part of multimodality neuromonitoring should be further investigated to determine if optimization of neuronal activity, brain metabolism, oxygenation and perfusion profiles can prevent further damage to the brain and thereby improve outcome.
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Affiliation(s)
- Pedro Kurtz
- Columbia University, Division of Critical Care Neurology, Dept of Neurology, Neurological Institute, 710 W 168th Street, NY 10032, USA
| | - Jan Claassen
- Columbia University, Division of Critical Care Neurology & Comprehensive Epilepsy Center, Dept of Neurology, Neurological Institute, Box 91, 710 W 168th Street, NY 10032, USA
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Sessler CN, Grap MJ, Ramsay MA. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care 2008; 12 Suppl 3:S2. [PMID: 18495053 PMCID: PMC2391268 DOI: 10.1186/cc6148] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologic measures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value.
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Virginia Commonwealth University Health System, Richmond, Virginia 23298, USA.
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59
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Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Box 980050, Virginia Commonwealth University Health System, Richmond, VA 23298, USA.
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Abstract
Multiple studies have been undertaken to show that neurofunction monitors can correlate to objective sedation assessments. Showing a correlation between these 2 patient assessments tools may not be the correct approach for validation of neurofunction monitors. Two different methods of assessing 2 different modes of the patient's response to sedation should not be expected to precisely correlate unless the desire is to replace one method with the other. We provide a brief summary of several sedation scales, physiologic measures and neurofunction monitoring tools, and correlations literature for bispectral index monitoring, and the Ramsay Scale and the Sedation Agitation Scale. Neurofunction monitors provide near continuous information about a different domain of the sedation response than intermittent observational assessments. Further research should focus on contributions from this technology to the improvement of patient outcomes when neurofunction monitoring is used as a complement, not a replacement, for observational methods of sedation assessment.
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61
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Scales DC, Laupacis A. Health technology assessment in critical care. Intensive Care Med 2007; 33:2183-91. [PMID: 17952404 DOI: 10.1007/s00134-007-0909-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 09/13/2007] [Indexed: 01/15/2023]
Abstract
BACKGROUND Heath technology assessments (HTAs) evaluate the benefits and costs of devices for monitoring and therapy (and their associated requirements for human resources) which contribute to the high expense associated with ICU admission. DISCUSSION Given the limited resources available for health care and increasing demands, funds spent inefficiently or unnecessarily on technologies in the ICU may threaten the sustainability of the health care system or prevent other potentially cost-effective devices from being introduced into clinical care. We discuss the factors impeding the conducting of HTAs in the ICU and suggest strategies for change. CONCLUSIONS Despite the need for HTAs of ICU devices only few have been conducted. They should be undertaken more frequently, and their results used to influence clinical practice and hospital and regional-level policy decisions.
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Affiliation(s)
- Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, M4N 3M5, Toronto, Canada.
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Pun BT, Dunn J. The sedation of critically ill adults: Part 1: Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs 2007; 107:40-8; quiz 49. [PMID: 17589228 DOI: 10.1097/01.naj.0000279265.66906.2f] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients. The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.
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Affiliation(s)
- Brenda T Pun
- Vanderbilt University Medical Center, Nashville, TN, USA.
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Peeters MYM, Bras LJ, DeJongh J, Wesselink RMJ, Aarts LPHJ, Danhof M, Knibbe CAJ. Disease Severity Is a Major Determinant for the Pharmacodynamics of Propofol in Critically Ill Patients. Clin Pharmacol Ther 2007; 83:443-51. [PMID: 17687274 DOI: 10.1038/sj.clpt.6100309] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As oversedation is still common and significant variability between and within critically ill patients makes empiric dosing difficult, the population pharmacokinetics and pharmacodynamics of propofol upon long-term use are characterized, particularly focused on the varying disease state as determinant of the effect. Twenty-six critically ill patients were evaluated during 0.7-9.5 days (median 1.9 days) using the Ramsay scale and the bispectral index as pharmacodynamic end points. NONMEM V was applied for population pharmacokinetic and pharmacodynamic modeling. Propofol pharmacokinetics was described by a two-compartment model, in which cardiac patients had a 38% lower clearance. Severity of illness, expressed as a Sequential Organ Failure Assessment (SOFA) score, particularly influenced the pharmacodynamics and to a minor degree the pharmacokinetics. Deeper levels of sedation were found with an increasing SOFA score. With severe illness, critically ill patients will need downward titration of propofol. In patients with cardiac failure, the propofol dosages should be reduced by 38%.
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Affiliation(s)
- M Y M Peeters
- Department of Clinical Pharmacy, St Antonius Hospital, Nieuwegein, The Netherlands
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Cho HH, O'Connell JP, Cooney MF, Inchiosa MA. Minimizing tolerance and withdrawal to prolonged pediatric sedation: case report and review of the literature. J Intensive Care Med 2007; 22:173-9. [PMID: 17569173 DOI: 10.1177/0885066607299556] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Midazolam and fentanyl infusions are commonly used for prolonged sedation and analgesia in the pediatric intensive care setting. Tolerance and withdrawal are major concerns when these infusions are used for days or weeks. Here, we review the current approaches to prolonged pediatric sedation using midazolam and fentanyl and discuss newer strategies to avoid tolerance and withdrawal syndromes. We report the case of a pediatric burn patient who developed tolerance syndrome and a movement disorder in our institution. We also review the relevant literature and methods of minimizing tolerance and withdrawal. Prolonged sedation is often necessary in treating critically ill children, and tolerance and abstinence syndrome can complicate a successful recovery. Scoring systems can be used to minimize oversedation and to titrate effectively. "Drug cycling," "wake-up protocols," and weaning regimens, possibly combined with adjuvant drugs, are being implemented successfully. Such novel approaches may decrease the incidence of tolerance and withdrawal associated with prolonged sedative and analgesic use.
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Affiliation(s)
- Hannah H Cho
- Department of Anesthesiology, New York Medical College, Valhalla, NY, USA.
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Pangalos MN, Schechter LE, Hurko O. Drug development for CNS disorders: strategies for balancing risk and reducing attrition. Nat Rev Drug Discov 2007; 6:521-32. [PMID: 17599084 DOI: 10.1038/nrd2094] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Disorders of the central nervous system (CNS) are some of the most prevalent, devastating and yet poorly treated illnesses. The development of new therapies for CNS disorders such as Alzheimer's disease has the potential to provide patients with significant improvements in quality of life, as well as reduce the future economic burden on health-care systems. However, few truly innovative CNS drugs have been approved in recent years, suggesting that there is a considerable need for strategies to enhance the productivity of research and development in this field. In this article, using illustrative examples from neurological and psychiatric disorders, we describe various approaches that are being taken to discover CNS drugs, discuss their relative merits and consider how risk can be balanced and attrition reduced.
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Affiliation(s)
- Menelas N Pangalos
- Wyeth Research, Neuroscience Discovery, CN800, Princeton, New Jersey 08543, USA.
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66
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LeBlanc JM, Kane-Gill SL, Cook CH, Dasta JF. Bispectral index does not correlate with the stress response in critical care patients. Anesth Analg 2007; 104:1616. [PMID: 17513686 DOI: 10.1213/01.ane.0000260311.37607.1a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Depth-of-anesthesia monitoring with EEG or EEG combined with mLAER is becoming widely used in anesthesia practice. Evidence shows that this monitoring improves outcome by reducing the incidence of intra-operative awareness while reducing the average amount of anesthesia that is administered, resulting in faster wake-up and recovery, and perhaps reduced nausea and vomiting. As with any monitoring device, there are limitations in the use of the monitors and the anesthesiologist must be able to interpret the data accordingly. The limitations include the following. The currently available monitoring algorithms do not account for all anesthetic drugs, including ketamine, nitrous oxide and halothane. EMG and other high-frequency electrical artifacts are common and interfere with EEG interpretation. Data processing time produces a lag in the computation of the depth-of-anesthesia monitoring index. Frequently the EEG effects of anesthetic drugs are not good predictors of movement in response to a surgical stimulus because the main site of action for anesthetic drugs to prevent movement is the spinal cord. The use of depth-of-anesthesia monitoring in children is not as well understood as in adults. Several monitoring devices are commercially available. The BIS monitor is the most thoroughly studied and most widely used, but the amount of information about other monitors is growing. In the future, depth-of-anesthesia monitoring will probably help in further refining and better understanding the process of administering anesthesia.
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Affiliation(s)
- T Andrew Bowdle
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Mail Stop 356540, Room AA-117C, University of Washington, Seattle, WA 98195, USA.
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Couchman BA, Wetzig SM, Coyer FM, Wheeler MK. Nursing care of the mechanically ventilated patient: what does the evidence say? Part one. Intensive Crit Care Nurs 2006; 23:4-14. [PMID: 17046259 DOI: 10.1016/j.iccn.2006.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 08/08/2006] [Accepted: 08/08/2006] [Indexed: 11/26/2022]
Abstract
The care of the mechanically ventilated patient is at the core of a nurse's clinical practice in the Intensive Care Unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient is explored with specific focus on patient safety: particularly patient and equipment assessment. Part two of the paper examines the evidence related to the mechanically ventilated patient's comfort, the patient/family unit, patient position, hygiene, management of stressors, pain management and sedation.
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Affiliation(s)
- Bronwyn A Couchman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Butterfield St., Brisbane, Qld 4029, Australia
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69
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MacLaren R, Sullivan PW. Economic evaluation of sustained sedation/analgesia in the intensive care unit. Expert Opin Pharmacother 2006; 7:2047-68. [PMID: 17020432 DOI: 10.1517/14656566.7.15.2047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Lorazepam, midazolam, propofol and opioids are the primary agents that are used for sustained sedation and analgesia of critically ill patients. The choice of agent depends on safety profiles, expected outcomes, cost, patient characteristics and clinical experience. Few studies have comparatively evaluated the sedatives in terms of cost. Many factors, aside from drug costs, influence the total cost of sedation in the intensive care unit. This article reviews the cost parameters of intensive care unit sedation that are specific to the characteristics of commonly used sedatives and analgesics, evaluates economic studies and cost models, summarises alternative methods of sedation and analgesia, and provides practical recommendations for methods of cost containment, including daily sedation interruption, sedation monitoring and protocol implementation.
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Affiliation(s)
- Robert MacLaren
- University of Colorado at Denver and Health Sciences Center, Department of Clinical Pharmacy, School of Pharmacy, 4200 East Ninth Avenue, Denver, CO 80262, USA.
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