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Assessing and Managing Sedation in the Intensive Care and the Perioperative Settings

Assessing and Managing Sedation in the Intensive Care and the Perioperative Settings. SEDATION Curriculum Learning Objectives. Manage adult patients who need sedation and analgesia while receiving ventilator support according to current standards and guidelines

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Assessing and Managing Sedation in the Intensive Care and the Perioperative Settings

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  1. Assessing and Managing Sedation in the Intensive Care and the Perioperative Settings

  2. SEDATION Curriculum Learning Objectives • Manage adult patients who need sedation and analgesia while receiving ventilator support according to current standards and guidelines • Use validated scales for sedation, pain, agitation, and delirium in the management of these critically ill patients • Assess recent clinical findings in sedation and analgesia management and incorporate them into the management of patients in the acute care, procedural, and surgical sedation settings

  3. Procedural SedationMajor Applications • Surgical • Neurosurgery • Bariatric surgery • Oral • Plastic/reconstructive • Biopsy • CV surgery • Endoscopic • Bronchoscopy • Fiberoptic intubation • Colonoscopy

  4. Growth of Ambulatory Surgery Centers (ASC) • ASCs increased outpatient operations from < 10% in 1979 to 50% in 19901 • From 1993 to 20012 • ASCs in metropolitan areas increased by 150% • Hospital outpatient surgeries increased 28% • Inpatient surgeries decreased by 4.5% • 70% of surgical interventions in the United States are outpatient procedures1 Pregler JL, et al. Anesthesiol Clin North America. 2003;21(2):207-228. Bian J, et al. Inquiry. 2009-2010;46(4):433-447.

  5. Common Agents for Conscious Sedation Mustoe TA, et al. Plast Reconstr Surg. 2010;126(4):165e-176e.

  6. Factors Jeopardizing Safety • Risk of major blood loss • Extended duration of surgery (> 6 h) • Critically ill patients (evaluate and document prior to procedure) • Need for specialized expertise or equipment (cardio-pulmonary bypass, thoracic or intracranial surgery) • Supply and support functions or resources are limited • Inadequate postprocedural care • Physical plant is inappropriate or fails to meet regulatory standards Eichhorn V, et al. Curr Opin Anaesthesiol. 2010;23(4):494-499.

  7. Standardized Monitoring • Hemodynamic • ECG • Blood pressure • Respiration • Oxygenation (SpO2 by pulse oximetry, supplemental oxygen) • Ventilation (end tidal CO2, EtCO2) • Temperature (risk of hypothermia) • Higher risk at remote locations • Inadequate oxygenation/ventilation • Oversedation • Inadequate monitoring Eichhorn V, et al. Curr Opin Anaesthesiol. 2010;23(4):494-499.

  8. Endoscopic Procedures

  9. Sedation for Endoscopy • Desirable qualities • Permits complete diagnostic exam • Safe • Diminishes memory of the procedure • Permits rapid discharge after procedure • Risk factors • Depth of sedation • ASA status • Medical conditions • Pregnancy • Difficult airway mgt • Extreme age • Rapid discharge time Runza M. Minerva Anestesiol. 2009;75:673-674.

  10. Drugs for Fiberoptic Intubation Summary courtesy of Pratik Pandharipande, MD.

  11. Propofol vs Combined Sedationin Flexible Bronchoscopy • Randomized non-inferiority trial • 200 diverse patients received propofol or midazolam/hydrocodone • 1o endpoints • Mean lowest SaO2 • Readiness for discharge at 1h • Result • No difference in mean lowest SaO2 • Propofol group had • Higher readiness for discharge score (P = 0.035) • Less tachycardia • Higher cough scores • Conclusion: Propofol is a viable alternative to midazolam/hydrocodone for FB Stolz D, et al. Eur Respir J. 2009;34:1024-1030.

  12. Dexmedetomidine vs Midazolamfor Upper Endoscopy 50 adults undergoing upper endoscopy • Dexmedetomidine • Bolus 1 µg/kg • Infusion 0.2 µg/kg/hr • ( n = 25) • Midazolam 0.07 mg/kg • Total dose 5 mg • (n = 25) Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.

  13. Upper Endoscopy Results Dexmedetomidine was similar to midazolam Gagging Patient satisfaction Patient discomfort Anxiety scores Recovery time Dex was superior to midazolam Endoscopist satisfaction Retching Total number of patients having any type of side effects Recovery Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.

  14. Dexmedetomidine Increases Comfort in AFOI Double-blinded randomized trial Midazolam +/- dexmedetomidine Awake fiberoptic intubation (AFOI) Patient comfort rated by 2 observers n = 24 n = 31 Total Comfort Score (max = 35) Pre- oxygenation Introduction of ET tube Introduction of scope Bergese SD, et al. J Clin Anesth. 2010;22(1):35-40.

  15. Use of Sedation for Colonoscopy Colonoscopies With Sedation (%) Cohen LB. GastrointestEndoscClin N Am. 2010;20(4):615-627.

  16. Sedative Use for Colonoscopy: USA Propofol BZD + Opioid and/or Propofol BZD + Opioid Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.

  17. Endoscopist Choices for Their OwnColonoscopy BZD Alone Opiod Alone 8% 41% Propofol 14% No Sedation * More than one answer was permitted Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.

  18. Outpatient Colonoscopy: Study Design 90 colonoscopy patients Dex 1 µg/kg over 15 mins, then 0.2 µg/kg/hr (n = 19) Meperidine 1 mg/kg with midazolam 0.05 mg/kg (n = 21) Fentanyl 0.1-0.2 mg on demand (n = 24) Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.

  19. Study halted after 64 subjects because of AE in the Dex group Hb saturation and respiration rate variations not observed Outpatient Colonoscopy: Results Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.

  20. Outpatient Colonoscopy: Hemodynamics * P < 0.05 after Bonferroni correction Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.

  21. Elective Colonoscopy: Can the Patient Control Sedation? • Patient-controlled sedation (PCS) with propofol-remifentanil (PR) • Rapid sedation • Rapid recovery • More airway rescue needed with PR than with MDZ-fentanyl • Prospective, randomized, open-label trial • n = 25 Patient-controlled sedation (PCS) • n = 25 Anesthesiologist-administered sedation (AAS) • Procedure • Outpatient colonoscopy • All patients received propofol-remifentanil • 100% oxygen via an anesthesia mask • Continuous spirometry and bispectral index (BIS) monitoring • Primary endpoint: oversedation • Respiratory rate • BIS Mandel JE, et al. GastrointestEndosc. 2010;72(1):112-117.

  22. Outpatient Colonoscopy: Respiratory Depression • AAS group used more mean total drug • Safety interventions • Criterion: 30s of SaO2 < 90% • PCS: 0/25 • AAS: 5/25 • Median BIS values • PCS: 88.1 • AAS: 71.7 P < 0.001 Relative Frequency Respiratory Rate (breaths/min) Mandel JE, et al. GastrointestEndosc. 2010;72(1):112-117.

  23. Bariatric Surgery

  24. Propofol or BZD/Narcotics forPre-Surgical Endoscopy? P < 0.02 • Endoscopy prior to bariatric surgery • Anesthesiologist-monitored sedation (AMS) • IV propofol (n = 51) • Surgeon-monitored sedation (SMS) • IV narcotics and benzodiazepines • Study design • Observational study • Data from patient survey • Doses/regimens not reported • Results • Generally no difference between methods • Trend toward amnesia in AMS group Patient YES responses (%) Madan AK, et al. Obes Surg. 2008;18(5):545-548.

  25. 20 morbidly obese patients Roux-en-Y gastric bypass surgery All received midazolam, desflurane to maintain BIS at 45–50, and intraoperative analgesics Fentanyl (n = 10) 0.5 µg/kg bolus, 0.5 µg/kg/h Dexmedetomidine (n = 10) 0.5 µg/kg bolus, 0.4 µg/kg/h Dexmedetomidine associated with Lower desflurane requirement for BIS maintenance Decreased surgical BP and HR Lower postoperative pain and morphine use (up to 2 h) Fentanyl vs Dexmedetomidine Use in Bariatric Surgery • Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.

  26. Dexmedetomidine as Desflurane Adjuvant in Bariatric Surgery • 80 morbidly obese patients • Gastric banding or bypass surgery • Prospective dose ranging study • Medication • Celecoxib 400 mg po • Midazolam 20 µg/kg IV • Propofol 1.25 mg/kg IV • Desflurane 4% inspired • Dexmedetomidine 0, 0.2, 0.4, 0.8 µg/kg/h IV Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.

  27. Dexmedetomidine as Desflurane Adjuvant in Bariatric Surgery: Results • More dex 0.8 patients required rescue phenylephrine for hypotension than control pts (50% vs 20%, P < 0.05) • All dex groups • Required less desflurane (19%–22%) • Had lower MAP for 45’ post-op • Required less fentanyl after awakening (36%–42%) • Had less emetic symptoms post-op • No clinical difference • Emergence from anesthesia • Post-op self-administered morphine and pain scores • Length of stay in post-anesthesia care unit • Length of stay in hospital Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.

  28. Oral Surgery

  29. Dental Anesthesia Survey:Premedication by Specialty Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.

  30. Dental Anesthesia Survey:Sedation/Anesthesia Method by Specialty Oral Sedation IV Conscious Sedation IV Deep Sedation GETA Percent OMFSN = 356 DENT ANESN = 75 PED DENT N = 33 PERIO N= 55 ENO N = 31 OMD ANESN N = 19 GEN DENT N = 144 Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.

  31. Plastic/Reconstructive Surgery

  32. Cosmetic Procedures • In 2007, 11.7 million procedures in US • Liposuction • Breast augmentation • Eyelid surgery • Abdominoplasty • Breast reduction • Site • Surgeons’ offices 54% • Ambulatory centers 29% • Hospitals 17% Shapiro FE. Curr Opin Anaesthesiol. 2008;21(6):704-710.

  33. Face Lift Surgery • Retrospective study • Single surgeon • Multiple anesthetists • Groups • N = 77 Standard of care (mainly propofol, ketamine, fentanyl, and midazolam) • N = 78 SOC plus dexmedetomidine • Not randomized, treated per anesthetist choice • All patients in deep sedation Taghinia AH, et al. Plast Reconstr Surg. 2008;121(1):269-276.

  34. Face Lift Surgery:Hemodynamic Results SOC+ Dex SOC Taghinia AH, et al. Plast Reconstr Surg. 2008;121(1):269-276.

  35. Laparoscopy

  36. Ambulatory Gynecologic Laparoscopy • ASA I-II patients • N = 60 • Prospective • Randomized • Double blind • Dex • 1 µg/kg over 10 mins then • 0.4 µg/kg/hr • Remifentanil • 1 µg/kg over 10 mins then • 0.2 µg/kg/min Salman N, et al. Saudi Med J. 2009;30(1):77-81.

  37. Ambulatory Gynecologic Laparoscopy • Dexmedetomidine associated with • Slower recovery • Less nausea and vomiting • Lower analgesia requirement Salman N, et al. Saudi Med J. 2009;30(1):77-81.

  38. CV Surgery

  39. What Do NeurointerventionalistsPrefer for AIS Interventions? *Treated as ordinal 4 = Most frequent 3 = Frequent 2 = Least frequent 1 = Never McDonagh DL, et al. Front Neurol. 2010;1:118.

  40. General Anesthesia During AIS Intervention? McDonagh DL, et al. Front Neurol. 2010;1:118.

  41. Trial of Dexmedetomidine for CV Procedure: Design • Prospective, randomized, double-blinded, placebo-controlled multicenter trial • Procedure • AV fistula creation and peripheral vascular stent placement • Local anesthesia or peripheral nerve block • Patients randomized 2:2:1 • Dex 1.0 mg/kg load, then infusion of 0.6 mg/kg/h • Dex 0.5 mg/kg load, then infusion of 0.6 mg/kg/h • Normal saline 0.9% infusion • Drug titrated to achieve a target OAA/S of ≤ 4 • Fentanyl in 25 μg increments IV for pain • 1o EP: % patients not requiring MDZ during infusions Huncke TK, et al. Vasc Endovascular Surg. 2010;44(4):257-261.

  42. Trial of Dexmedetomidine for CV Procedure: Results Number (%) of Patients Not Requiring Rescue Midazolam (MDZ) The Perioperative Use of MDZ and Fentanyl Huncke TK, et al. Vasc Endovascular Surg. 2010;44(4):257-261.

  43. Sedation/Analgesia for Traumatic Brain Injury Goal: reduce ICP by decreasing pain, agitation Saiki RL. Crit Care Nurs Clin North Am. 2009;21:549-559.

  44. Randomized, double-blind, placebo-controlled, multicenter 326 pts undergoing MAC for surgery (orthopedic, ophthalmic, vascular, excision of lesions, others < 10%) All patients sedated Observer’s Assessment of Alertness/Sedation Scale (OAA/S ) to < 4 Sedation with Dex ± rescue midazolam, or Placebo + rescue midazolam Fentanyl PRN for pain MAC with Dexmedetomidine MAC = Monitored anesthesia care Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56. 44

  45. Dexmedetomidine Reduces Fentanyl and Midazolam Use During MAC 200 144.4 150 Fentanyl, µg 84.8 83.6 100 50 0 Placebo Dex 0.5 Dex 1.0 Fentanyl Use Midazolam Use * * * * * * * * *P < 0.001 compared with placebo, MAC = monitored anesthesia care Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.

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