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ABCDE implementation at BHCS Susan Smith, MS, RN, ACNS-BC Clinical Nurse Specialist Baylor University Medical Center Critical Care Services 1 2 SEDATION VACATION AND SPONTANEOUS BREATHING TRIALS 3 4 5 Awakening Trial Safety Screen (BUMC criteria) • • • • • • NO FiO2 ≥ 0.6 NO PEEP > 7.5 cm NO neurosurgical pts. NO ICP > 10 cm H2O NO HR > 140 bpm NO neuromuscular blocker • • • • • NO open surgical abdomen/chest NO active seizures NO active ETOH withdrawal NO active agitation NO myocardial ischemia within the past 24 hours Hold analgesic / sedation for continuous infusion 2 times daily. May supplement with prn analgesic / sedative if ordered. 6 Sedation Restarting Criteria • If patient develops any of the symptoms below, resume infusion at HALF of the previous rate prior to sedation vacation – – – – Agitated or combative O2 saturation falls below 90% Respiratory Rate is 40 or above Worsening dyspnea • If these symptoms persist, contact the physician • Be sure to have prn bolus orders for pain and sedation before beginning SAT/sedation vacation 7 Spontaneous Breathing Trial Safety Screen (BUMC) Breathing Trial Breathing Trial • Patient awake and able to • No vasopressors, HD follow 3 of 4 commands: stable – Opens eyes with verbal command • No active agitation – Points 2 fingers upon • No FiO2 ≥ 0.6 instruction – Tracks caregiver • No RR ≥ 40 – Sticks tongue out on • No worsening dyspnea command If these symptoms Place patient on present contact CPAP 5 + 5 cm H2O physician 8 Spontaneous Breathing Trial • Discontinue SBT and resume prior vent settings for: – – – – – – – – RR > 35 or < 8 x 5 minutes or longer SpO2 < 90% x 5 minutes or longer Acute cardiac arrhythmia HR > 130 or < 60 Accessory muscle use Abdominal paradoxical breathing Diaphoresis Marked dyspnea 9 Spontaneous Breathing Trial • If SBT successful measure: – RR and TV (more parameters may be requested) – Call physician after 30 minutes of the trial 10 Critical Care Flowsheet 11 Patient Care Viewer 12 Improvement Strategies • People – RN, RT, MD – Others: Pharmacist • Process – Adult Ventilator Orderset – Multidisciplinary Rounds – Daily Vent Mortality Data collection • How do we get this data to match up with our documentation? • Technology – EHR – DART reports 13 CHOICE OF SEDATIVE 14 Treatment of Pain Opiate IV PO IV Onset (min) Half-life (hours) Fentanyl 0.1 -- 1-2 2-4 Hydromorphone 1.5 7.5 5-15 2-3 Morphine 10 30 5-10 3-4 15 Treatment of pain with IV medications Opiate Intermittent dosing IV infusion rate 0.35-5 mcg/kg 0.7-10 mcg/kg/hr 25-100mcg 25-250mcg/hr Fentanyl Other information Most lipophillic, accumulation w/ liver dysfunction Hydromorphone 0.2-0.6 mg 0.5-3 mg/hr May be better in patients tolerant to other agents Morphine 2-4 mg 2-30 mg/hr Active metabolites, histamine release 16 Opioid related side effects • • • • • • • Sedation Muscle rigidity Respiratory depression Decrease GI mucus secretion and increase fluid absorption Nausea, vomiting Pruritus CONSTIPATION 17 Adjunctive pain agents • • • • • • • Local and regional anesthetics Ketamine Acetaminophen NSAIDS Gabapentin or pregabalin Carbamazepine Non-pharmacological management strategies 18 Indications for sedation • Treat agitation • Promptly identify underlying causes – Delirium, pain, hypoxemia, hypoglycemia, hypotension, alcohol withdrawal • Titration of sedation to light and arousable • Sedation scales and protocols have reduced the amount of sedation patients receive and improve outcomes 19 Benzodiazepines • • • • • • • Activate GABA-A receptors in the brain Anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects Potency: Lorazepam > Midazolam > Diazepam Lipophilicity: Midazolam and Diazepam > Lorazepam All BDZs are metabolized hepatically Caution in elderly patients Lorazepam, oxazepam, and temazepam are renally cleared 20 Benzodiazepines Agent Onset (min) Half life (hours) Active metabolites IV infusion rate Midazolam 2-3 3-11 Yes 1-7 mg/hr Lorazepam 15-20 8-15 No 1-10 mg/hr Diazepam 2-5 20-120 Yes Not used 21 Propofol • Exact mechanism is not known • Binds to GABA-A, glycine, nicotinic, and muscarinic receptors • Sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant • No analgesic properties • Highly lipid soluble • Best for patients who need frequent awakenings • Caution with egg and soybean allergies 22 Propofol Agent Onset (min) Half life (hours) Active metabolites IV infusion rate Propofol 1-2 3-12 No 5-50 mcg/kg/min • Adverse effects: hypertriglyceridemia, acute pancreatitis, myoclonus, hypotension • Propofol infusion syndrome: metabolic acidosis, hypertriglyceridemia, hypotension with vasopressor use, arrhythmias, acute kidney injury, hyperkalemia, rhadbomyolysis 23 Dexmedetomidine • Selective alpha 2 receptor agonist • Sedative, sympatholytic, and questionable analgesic properties • Generally patients are more easily arousable with minimal respiratory depression • Hepatically cleared • Adverse effects: hypotension, bradycardia Agent Onset (min) Half life (hours) Active metabolites IV infusion rate Dexmedetomidine 5-10 1-3 No 0.2-0.7 mcg/kg/min 24 What should I do to prepare for a sedation vacation? • Evaluate your flowsheet checklist • If patient doesn’t meet requirement, ask for clarification on multidisciplinary rounds • The most important tool you can have for a sedation vacation is PRN pain and sedative agents. Why??? – If a patient fails vacation and patient isn’t going to be extubated you will need PRN agents to get them under control and to prevent dose titrations beyond their requirements. 25 What about precedex? • This agent is typically ordered when preparing for extubation • Purpose of precedex is to allow the pt to remain calm and compliant with the ventilator without lowering respiratory drive • Allow the patient to prove that he/she needs the agent when the other sedatives are stopped 26 How do I handle a sedation vacation when the patient is already on precedex? • • • • • • 90 percent of the time, it is appropriate to keep this agent going If the patient is only on precedex and they are overly drowsy, they may not require this agent to remain calm for extubation, consider stopping It is not wrong to pause this agent, in fact, the ideal patient would remain calm with no agent on board. If patient has had a h/o agitation and this was the reason for starting the agent, another appropriate method would be to titrate down to minimal requirements during the “sedation vacation” Once the patient is extubated, stop the agent. If agitation occurs after extubation, clarify with MD what agent to use. In general we will use other agents after extubation to assist the patient in remaining calm 27 The patient failed the trial, how do I proceed • • • Is the patient acutely in pain? – Give PRN Pain agent (fentanyl, dilaudid, morphine, norco, etc) Is the patient acutely agitated? – Give PRN Sedative agent (ativan, versed) – If patient was on propofol gtt What rate to I set my drips at? – Regardless of agitation or not, restart at half the rate! – Utilize PRN pushes to support the patient through the agitation/pain period – If more than one push is required, then titrate up the agent – Let the patient prove they need more agent – Always titrate to calmness, while trying to maintain the highest level of alertness unless MD order specifies otherwise 28 What if my patient is fully alert on their sedation? • Stop the agent and do a sedation vacation. • Let them prove they need the agent to remain calm • The agent may be frivolous at that point…why give something they do not need? • It is never wrong to ask for clarification, but the majority of the time your answer will be to stop the agent • Remember, the ideal patient is the one tolerating the ventilator without any continuous infusion on board. Ideally we would have no gtts and utilize PRN agents to support them through acute pain and agitation 29 What if my patient is complaining of pain, should I stop the agent? • If your pt is alert and complaining of pain, then get a clarification from the MD. • We do not want to cause pain that would increase respirations and thus negatively impact their ability to be extubated. • The patient may qualify for a transition to longer acting oral agents to control pain • If they aren’t alert and unable to verbalize their pain, then stop the agent. – Let them prove to you they need the pain medication 30 HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation so Sally stops the Versed. Has she done the correct thing? What recommendations would you make? 31 • HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation. After your brilliant education, Sally stops both the fentanyl and versed. However an hour later the patient starts fighting the ventilator and requires reinitiating the patient’s pain and sedation regimen. • How should she proceed with reinitiating the pain and sedation on this patient? 32 • MM is a 50 yoM on a ventilator for 7 days. He was initiated on precedex 0.5mcg/kg/hour yesterday after his propofol was stopped and he became agitated. He is also on fentanyl at 1mcg/kg/hr. He meets requirements for a sedation vacation. • What other information do you need before deciding how to proceed? • If he is in pain how would you proceed? • If he is drowsy how would you proceed 33 Improvement Strategies • Provide more in depth drug information to super trainers to be able to better support staff nurses during the SAT/SBT process – Encourage use of pharmacists to help with guidance • Encourage good communication • Daily multidisciplinary rounds to discuss patient progress • Review of documentation daily • Daily vent mortality data collection – Does this match your documentation? 34 DELIRIUM SCREENING AND MANAGEMENT 35 …seems like it was in a huge, empty gray space, sort of like a monstrous underground parking garage with no cars, only me, floating or seeming to float, on something… -SB Travis Smith via Flickr 36 37 Sarah Beth tells her story 38 Confusion Assessment Method for the ICU (CAM-ICU) Feature 1: Acute change or fluctuating course of mental status And Feature 2: Inattention And Feature 3: Altered level of consciousness Or Feature 4: Disorganized thinking Inouye, et. al. Ann Intern Med 1990; 113:941-948.1 Ely, et. al. CCM 2001; 29:1370-1379.4 Ely, et. al. JAMA 2001; 286:2703-2710.5 39 Step 1: Sedation Assessment (RASS) Sessler CN, AJRCCM 2002;166:1338-1344 Ely EW, AJRCCM 2001;163:A954 40 Step 2: Content Assessment Assess For Delirium With the CAM-ICU 41 42 Feature 1: Alteration/Fluctuation in Mental Status • Is the pt different than his/her baseline mental status? or • Has the patient had any fluctuation in mental status in the past 24 hours (e.g. fluctuating RASS, GCS, previous delirium assessments, etc) The Feature is Present if either question is YES. 43 Feature 2: Inattention Screening for Attention– two options Inattention Present: If >2 errors Letter “A” test Letters: S A V E A H A A R T Say 10 letters and instruct the patient to squeeze on the letter “A” Pictures Similar test with pictures (instructions are in picture packets) 44 Feature 3: Altered Level of Consciousness You already did this assessment when you did the RASS. It was the first thing you did when you walked in the room! If the Actual RASS score is anything other than “0” (zero) and alert, then altered LOC is Present 45 Teaching Point • It is only necessary to proceed to Disorganized Thinking when a patient is Feature 2 positive (Inattentive) and Awake and Alert (RASS 0) at the time of CAM-ICU evaluation. 46 Feature 4: Disorganized Thinking Yes/No Questions (Use either Set A or Set B) : Set A 1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two pounds? 4. Can you use a hammer to pound a nail? wood? Set B 1. Will a leaf float on water? 2. Are there elephants in the sea? 3. Does two pounds weigh more than one pound? 4. Can you use a hammer to cut Note: Use whatever form of communication that works (nodding, hand squeezing, blinking, etc). 47 Feature 4: Disorganized Thinking Command Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) “Now do the same thing with the other hand” (Not repeating the number of fingers). Patient gets credit only if able to successfully complete the entire command. 48 CAM-ICU FAQs • Patient with severe depression: – May result in a false positive—consult psych • Patient with dementia: – CAM-ICU reliable in both groups of patients – Patients can have both – Assessment is more difficult, must know the baseline 49 CAM-ICU FAQs • Neuro patients e.g. stroke, TBI, disease, SDH, SAH – – – – This may represent the patient’s new baseline Look for fluctuation Are there structural neurologic changes? Are there reversible causes of delirium? • Use last know baseline and adjust as more info is obtained • Alterations and fluctuations include those caused by us from sedatives etc. 50 CAM-ICU FAQs • ETOH withdrawal – Can be CAM-ICU ⊕ – Also do CIWA-Ar • Tetraplegia or Blind – Score Feature 4 on just the questions – Cannot make more than 1 error 51 Delirium Management 52 SCCM recommended approach to management of delirium 1. Identify etiology 2. Identify risk factors 3. Consider pharmacologic treatment So: STOP & THINK before you medicate Jacobi J, et al. Crit Care Med 2002;30:119-141 53 Risk Factors for Developing Delirium • Age • Sensory impairment • History of dementia, ETOH, smoking, depression • Malnutrition • Disease processes • Polypharmacy and psychotropic meds • Renal/liver impairment • • • • • Dehydration Sleep deprivation Restraints/lines/tubes Excessive noise Day/night disorientation • Constipation Any patient with these problems should be flagged as high risk for delirium 54 Ambien Consult pharmacy for patients with these drugs who are at high risk for delirium or patients who have delirium. 55 Stop and THINK Do any meds need to be stopped or lowered? • Especially consider sedatives • Is patient on minimal amount necessary? – Daily sedation cessation – Targeted sedation plan – Assess target daily • Do sedatives need to be changed? • Remember to assess for pain! Toxic Situations • CHF, shock, dehydration • New organ failure (liver/kidney) Hypoxemia Infection/sepsis (nosocomial), Immobilization Nonpharmacologic interventions • Hearing aids, glasses, reorient, sleep protocols, music, noise control, ambulation K+ or electrolyte problems Consider antipsychotics after evaluating etiology & risk factors 56 Elder Life Program Targeted Risk Factor Standardized Intervention Cognitive impairment Orientation & therapeutic activity protocol (discuss current events, word games, reorient, etc) Sleep deprivation Sleep enhancement & nonpharm sleep protocol (noise reduction, back massages, schedule adjustment) Visual impairment Early mobilization protocol (active ROM, reduce restraint use, ambulation, remove catheters) Vision protocol (glasses, adaptive equipment, reinforce use) Hearing impairment Hearing protocol (amplification devices, hearing aids, earwax disimpaction) Dehydration Dehydration protocol (early recognition of dehydration & volume repletion) Immobility Inouye, et al. NEJM. 1999;340:669-676. 57 Nonpharmacologic interventions • Early Mobility*—the only nonpharmacologic intervention shown to reduce ICU delirium • Other Interventions: – Environmental changes (e.g., noise reduction) – Sensory aids (e.g., glasses) – Reorientation and cognitive stimulation – Sleep preservation and enhancement *Schweickert WD, et al. Lancet. 2009;373:1874-1882. 58 Nonpharmacologic interventions Pain: • Monitor and manage pain using an objective scale (e.g., FACES, BPS, VAS, CPOT, etc.) Orientation: • Convey the day, date, place, and reason for hospitalization • Update the whiteboards with caregiver names • Request placement of a clock and calendar in room • Discuss current events 59 Nonpharmacologic interventions Sensory: • Determine need for hearing aids and/or eye glasses • If needed, request surrogate provide these for patient when appropriate Sleep: • Noise reduction strategies (e.g. minimize noise outside the room, offer white noise or earplugs) • Normal day-night variation in illumination • Use “time out” strategy to minimize interruptions in sleep • Maintain ventilator synchrony • Promote comfort and relaxation (e.g., back care, oral care, washing face/hands, daytime bath, and massage) 60 61 All ICU CAM-ICU Documentation 100% 90% 80% 67% 70% 60% 50% 56% 47% 40% 29% 30% 26% 22% 18% 20% 11% 10% 0% CAM SN CAM SN CAM-ICU Correct CAM-ICU Correct CAM-ICU Incorrect CAM-ICU Incorrect CAM-ICU Not Done CAM-ICU Not Done Oct-13 Dec-13 Oct-13 Dec-13 Oct-13 Dec-13 Oct-13 Dec-13 62 Oct-13 RASS RASS vs Ramsay Use Dec-13 RASS Oct-13 Ramsay Dec-13 Ramsay 100% 100% 100% 100% 100% 100% 100% 100% 100% 94% 89% 90% 80% 80% 76% 73% 70% 60% 60% 55% 48% 50% 40% 60% 35% 32% 30% 25% 18% 20% 14% 11% 10% 0% 0% 0% 0% 0% 0% All ICU 2 South 3 North 4West 4 North 3 Truett 4 Truett 63 Documentation Issues • In many cases, the nurse had documented on both CAM and CAM-ICU. This is problematic for several studies that depend on data collection through chart review. It is also unnecessary documentation. • In the majority of cases, the CAM-ICU was incorrect because the RASS or Ramsay was in the correct range, but the nurse documented CAM-ICU not indicated. • In many cases, the CAM-ICU was considered incorrect because at some point during the shift the patient progressed to a RASS or Ramsay in the correct range, but the nurse never attempted a CAM-ICU during these times. 64 Improvement Strategies • People/Process – Super trainers demo correct use of the CAM-ICU • Provide scenarios • Allow nurses to demo to each other and rate each others performance – Competency tool for all staff – Pizza party! • Technology – Demonstrate correct documentation 65 66 EARLY MOBILITY 67 “Look at the patient lying long in bed. What a pathetic picture he makes. The blood clotting in his veins, The lime draining from his bones, The scybala stacking up in his colon, The flesh rotting from his seat, The urine leaking from his distended bladder, And the spirit evaporating from his soul.” Dr. Richard Asher, British Medical Journal, 1947 68 "Teach us to live that we may dread Unnecessary time in bed. Get people up and we may save Our patients from an early grave” Dr. Richard Asher, British Medical Journal, 1947 69 http://www.youtube.com/watch?v=0jycOFVE 624 Gary’s story 70 Mobility safety screen first • Responds to verbal stimuli – RASS> (-4) or Ramsay <5 • • • • • FiO2 <0.6 PEEP <7.5 cmH2O No increased dose of vasopressor No evidence of AMI in past 24 hours No arrhythmia requiring new anti-arrhythmic in past 24 hours 71 Mobility safety screen Pass Exercise/Mobility Therapy Active ROM Dangle Chair Ambulate Fail Too Ill for Exercise/Mobility Passive ROM Nursing: Consult PT to evaluate and treat if patient unable to perform any of the above activities. Consult OT if patient is unable to perform ADLs once able to dangle safely. 72 73 74 75 76 77 Improvement Strategies • People – Who gets patients up? – Do your nurses know how to do this? Do they want to do this? – What are your MDs ordering? • Processes – When does PT get involved? – What about other therapies? • Technology – Do you have gait belts? Chairs? Lift equipment? – Is this being documented? 78