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Sedation and Delirium Management Medical Surgical Nursing II Urden Chapter 9 Goals of Sedation and Delirium Management “The goal is to find a balance between providing compassionate patient care and avoiding the perils of over-sedation” (Urden, 2012, p. 95). Sedation Scales Scoring systems to assess sedation are strongly recommended. Why ◦ Individuals do not metabolize sedative medications at the same rate. ◦ Use of a standardized scale can ensure that continuous infusions such as proprofol or lorazepam are titrated to a specific goal. ◦ Use of scales can be used for medications given prn to assess response and patient comfort. Complications of sedation “State of unintended patient unresponsiveness in which the patient resides in a state of suspended animation similar to general anesthesia” Prolonged deep sedation is associated with complications of ◦ Pressure ulcers ◦ Thromboemboli ◦ Gastric ileus Nosocomial pneumonia Delayed weaning from mechanical ventilation Levels of Sedation Light sedation – Drug induced state in which patients respond ________ to ___________commands. Impaired function includes: Unaffected functions: Moderate Sedation Also used as another name for: Defined: Patients respond to _______commands. Or will respond to _______ ________ Commands. No interventions are required to maintain: Deep Sedation and Analgesia Drug induced depression of consciousness during which the patients cannot be _______ _______________. Respond purposefully after repeated or ____________stimulation. Independent ventilatory function is: Assistance is required to maintain: General anesthesia Drug induced loss of consciousness Not arousable even w/painful stimulation Airway and ventilation are impaired Assistance is required, usually intubation is required with ventilation Total loss of protection Patient is total care Perils of Undersedation Self extubation with complications of : ◦ Bronchospasm, aspiration, dysrhythmias, bradycardia and death related to the inability to establish a patent airway. Pharmacological Management with sedation Sedation must always be preceded or accompanied by analgesia if there is a mechanism of pain or suspicion of pain being experienced. Benzodiazepines Powerful amnesic properties Inhibit reception of new sensory information Do not give pain relief Most frequently used are: Which one is used for acute, short term agitation? Benzodiazepines Which drug is used for long term sedation? Why is it preferred over the other? What are the major side effects of these medications? The antidote is: What must be considered before an antidote is given? Sedative-Hypnotics Propofol – sedative/hypnotic and general anesthetic agent. In the critical area and in the emergency room it is used as a method to ensure sedation after intubation. Delivered as a continuous infusion at the rates of 5 to 80 mcg/kg/min. Benefit to remember: Propofol does not Provide amnesia Pain relief So it must be given along with other medications to provide the patient with these medication actions. Other medications to give with this drug are fentynl, morphine, versed ( amnesia). Side effects to manage with Propofol Hypotension – How would you manage this problem Hyperlipidemia in long term use Infection related to high fat content Pancreatitis Propofol Related infusion syndrome PRIS ◦ ◦ ◦ ◦ ◦ Most common in children Metabolic acidosis Rhabodmyolysis Acute kidney failure Dysrhythymias Propofol Infusion Things to remember ◦ Dedicated line ◦ Do not mix with other drugs if possible otherwise check compatibility ◦ Certain IV fluids cannot be given with proprofol ◦ Monitor serum triglyceride levels ◦ Calories from propofol are calculated into daily calorie counts. Central Alpha Agonists Dexmedetomidine or Precedex Approved for continuous infusion for less than 24 hours in mechanically ventilated patients. Confers sedation and analgesic effects without respiratory depression. Loading dose is 1.0 mcg/kg over 10 minutes Continuous infusion is range 0.2 to 0.7 mcg/kg/hour. Central Alpha Agonists Precedex Onset of action: Elimination from the body: What condition decreases Precedex elimination from the body? Things to Remember Choice of sedative is highly specific to the patient and the situation Short term sedation - < 24 hours most frequently used sedatives are _______ & Propofol. Both drugs should or may be combined with a short-acting opiod analgesic which is ____________ or ______________. Things to remember For long term sedation the recommended agent is? Precedex Versed Lorazepam Morphine Fentynl Preventing sedative dependence and withdrawal Why this occurs? Critically ill patients are often sedated and mechanically ventilated are seriously ill for weeks or months. With time physical and psychological dependence occurs. What are the symptoms of sedative dependence and withdrawal? Sedation vacation Strategy to avoid the pitfalls of sedative dependence and withdrawal is a planned strategy to turn off the sedation infusion once a day. Shortens time to extubation Back up plan is needed for patients who do not tolerate the procedure. The goal is to allow the stable patient to regain consciousness for clinical assessment – what would you use? Nursing Care Responsibility Ongoing assessment of the patient’s level of consciousness to avert complications. If the patient is severely agitated, consult with the physician it is vital to consult with the physician and pharmacist to establish and effective treatment plan. Often the sedation is restarted at 50% of the previous morning dose and titrated upward for patient comfort. Delirium Global impairment of cognitive processes Sudden onset Coupled with disorientation Impaired short-term memory Altered sensory perception(manifests as?) Inappropriate behavior Delirium Occurs in 60% to 85% among mechanically ventilated patients. Delirium is often identified in the patient who is agitated and pulling at tubes. Delirium can occur in patients who are physically calm. Provision of adequate _________is an essential component of delirium prevention. Management of Delirium with Medication Priority – medication selection of drugs that provide sedation without withdrawal associated agitation. Which drug is discussed by Urden as a plausible choice? What type of delirium is this medication used for? Monitoring Requirements Use of this drug requires _____ monitoring due to the prolongation of the QT interval which increases the risk of ventricular dysrhythmias. Stabilizes cerebral function by blocking transmission of ______mediated neurotransmitters at the cerebral synapses and in the basal ganglia. Nonpharmacological interventions to prevent delirium These methods are similar to those used to relieve pain Back massage Music therapy Noise reduction Decreasing lights at night Clustering nursing care interventions Uninterrupted rest Speaking in a calm and gentle voice. AWS & Delirium Tremens Patients w/alcohol dependency & critically ill are at risk for alcohol withdrawal syndrome and DT’s. AWS assoc w/increased risk of delirium, hallucinations, seizures, need for mechanical ventilation and death Delirium Tremens- when hyperactive agitated delirium is caused by alcohol withdrawal
