Showing posts with label sedation. Show all posts
Showing posts with label sedation. Show all posts

Saturday, February 22, 2020

Guidelines for Pain, Agitation/Sedation, Delirium in the ICU

I am currently working on a lecture where I discuss reducing the utilization of opioids in the ICU for our critically ill patients. The sources of pain are plentiful, unfortunately. Truth is, opioids are the best option for our patients at the time of this writing but we also need to work hard to try to minimize the exposure to this family of medications via alternatives. Which alternatives might you ask? In particular, I have taken deep dives into the utilization of ketamine, magnesium, gabapentin/pregabalin, NSAIDS, nefopam, acetaminophen, dexmedetomidine, as well as regional blocks performed by our anesthesia colleagues. 


The PADIS (pain, agitation/sedation, delirium, immobility, and sleep disruption) guidelines linked here, and are completely FREE to download, provide some direction as to how to better take care of our patients. When I write these lectures, and this may seem counterintuitive to some, I leave the guidelines for last and attempt to read everything under the sun on the topic so that it does not cloud my interpretation. I had read these guidelines in 2018 when they initially came out but now I have even more respect for the section on pain management bc the quality of the studies just aren't as good as we want them to be. Hence the "very low quality of evidence" tied to many of the recommendations made. I surprised that they even made a dosing recommendation for ketamine as the dosing behind most of the articles are pretty scattered.  
These guidelines are a monumental undertaking and I send a definite hat tip to the authors.

Devlin JW, Skrobik Y, GĂ©linas 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:e825–e873.

-EJ




Link to FULL FREE Article



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Tuesday, August 27, 2019

Benzodiazepine use should be minimized for sedation in the ICU

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Team, I'll get to making this whole post prettier in the AM when I have some rest under my belt. I saw everyone chiming in on bedsideroundz’ page how they provide versed/midazolam for sedation in their critically ill patients and I had no choice but to put off my bedtime for a few hours and work on this post instead. A đŸŽ© tip to bedsideroundz for shining some indirect light to this conversation. Here are the official 2018 guideline statements regarding utilizing benzodiazepines such as midazolam/versed.
"The 2013 guidelines suggested targeting light levels of sedation or using daily awakening trials, and minimizing benzodiazepines to improve short-term outcomes (e.g., duration of mechanical ventilation and ICU LOS)."
"...sedation with benzodiazepines, which are no longer recommended for sedation in critically ill patients"
"The 2013 PAD guidelines suggest (in a conditional recommendation) that nonbenzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults because of improved short-term outcomes such as ICU LOS, duration of mechanical ventilation, and delirium"
"We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery"
"...shorter time to extubation with propofol versus a benzodiazepine"
"Overall, the panel judged that the desirable consequences of using propofol probably outweigh the undesirable consequences, and thus issued a conditional recommendation favoring propofol over a benzodiazepine."
"We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults"
"the study by Xu et al also showed reduced delirium with dexmedetomidine use"
"the Dexmedetomidine Versus Midazolam for Continuous Sedation in the ICU (MIDEX) study demonstrated a shorter duration of mechanical ventilation with dexmedetomidine over a benzodiazepine infusion"

I'll post some more later. Please read the article for yourself. Don’t trust what I post.

-EJ.




Link to abstract

Link to PDF

Devlin JW, Skrobik Y, GĂ©linas 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:e825–73.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Wednesday, May 22, 2019

Dexmedetomidine for Sedation



Link to Article

Link to full FREE PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Tuesday, April 23, 2019

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort



https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2394-9
https://ccforum.biomedcentral.com/track/pdf/10.1186/s13054-019-2394-9

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.