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
• 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
Procedural Sedation
Major Applications
• Surgical
–
–
–
–
–
–
Neurosurgery
Bariatric surgery
Oral
Plastic/reconstructive
Biopsy
CV surgery
• Endoscopic
– Bronchoscopy
– Fiberoptic intubation
– Colonoscopy
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
1.
2.
Pregler JL, et al. Anesthesiol Clin North America. 2003;21(2):207-228.
Bian J, et al. Inquiry. 2009-2010;46(4):433-447.
Common Agents for
Conscious Sedation
Mustoe TA, et al. Plast Reconstr Surg. 2010;126(4):165e-176e.
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 (cardiopulmonary 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.
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.
Endoscopic Procedures
Sedation for Endoscopy
• Desirable qualities
– Permits complete
diagnostic exam
– Safe
– Diminishes memory of
the procedure
– Permits rapid discharge
after procedure
Runza M. Minerva Anestesiol. 2009;75:673-674.
• Risk factors
–
–
–
–
–
–
–
Depth of sedation
ASA status
Medical conditions
Pregnancy
Difficult airway mgt
Extreme age
Rapid discharge time
Drugs for Fiberoptic Intubation
Agent
Class
Example
Advantages
Considerations
GABA
agonist
Benzodiazepine
Midazolam
• Quick onset
• Injection not painful
• Short duration
• Not analgesic
• Airway reflexes persist
GABA
agonist
Benzodiazepine
Propofol
• Quick onset
• Respiratory depression
• Unconsciousness
• Decreased bp, cardiac
output
• Increased HR
Opioid
Fentanyl
Remifentanil
• Analgesic
• Cough suppressive
• Respiratory depression
a2 Agonist
Dexmedetomidine
• Pt easily arousable
• Anxiolytic
• Analgesic
• No respir. depression
• Transient hypertension
• Hypotension
• Bradycardia
Summary courtesy of Pratik Pandharipande, MD.
Propofol vs Combined Sedation
in 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.
Dexmedetomidine vs Midazolam
for Upper Endoscopy
50 adults undergoing upper endoscopy
Dexmedetomidine
• Bolus 1 µg/kg
• Infusion 0.2 µg/kg/hr
( n = 25)
Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.
Midazolam 0.07 mg/kg
• Total dose 5 mg
(n = 25)
Upper Endoscopy Results
• Dexmedetomidine was similar to
midazolam
– Gagging
– Patient satisfaction
– Patient discomfort
– Anxiety scores
– Recovery time
Recovery
Variable
Time to full
recovery,
min
Midazolam
(n = 25)
Dex
(n = 25)
P-value
37.6±11
42±12.5
0.30
Patients fully recovered, n (%)
• Dex was superior to midazolam
– Endoscopist satisfaction
– Retching
– Total number of patients having
any type of side effects
Demiraran Y, et al. Can J Gastroenterol. 2007;21(1):25-29.
15 min
12 (48)
10 (40)
0.56
30 min
20 (80)
18 (72)
0.74
45 min
25 (100)
25 (100)
0.99
Dexmedetomidine Increases Comfort in AFOI
Double-blinded randomized trial
Midazolam +/- dexmedetomidine
Awake fiberoptic intubation (AFOI)
Patient comfort rated by 2 observers
Total Comfort Score (max = 35)
•
•
•
•
n = 24
n = 31
Preoxygenation
Introduction
of scope
Bergese SD, et al. J Clin Anesth. 2010;22(1):35-40.
Introduction of ET tube
Use of Sedation for Colonoscopy
100
Colonoscopies
With Sedation (%)
90
80
70
60
50
40
30
20
10
0
Cohen LB. Gastrointest Endosc Clin N Am. 2010;20(4):615-627.
Sedative Use for Colonoscopy: USA
Propofol
8%
BZD + Opioid
and/or
18%
Propofol
BZD + Opioid
74%
Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.
Endoscopist Choices
for Their Own Colonoscopy
Opiod Alone
1%
BZD Alone
8%
41%
37%
BZD + Opioid
Propofol
14%
No Sedation
* More than one answer was permitted
Cohen LB, et al. Am J Gastroenterol. 2006;101(5):967-974.
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)
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
Fentanyl
0.1-0.2 mg on
demand (n = 24)
Outpatient Colonoscopy: Results
• Study halted after 64 subjects because of AE in the Dex group
• Hb saturation and respiration rate variations not observed
Dex
(n = 19)
Meperidine
(n = 21)
Fentanyl
(n = 24)
Average MAP reduction
26%
14%
3%
Maximum BP reduction
50%
(4 cases)
35%
30%
17%
9%
7%
40 bpm (2 cases)
50 bpm
50 bpm
Vertigo & nausea (n)
5
0
0
Time to discharge readiness (min)
85
39
32
Jaw thrust maneuver
0
6 (29%)
0
Mean HR reduction
Lowest HR
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
Outpatient Colonoscopy:
Hemodynamics
* P < 0.05 after Bonferroni correction
Jalowiecki P, et al. Anesthesiology. 2005;103(2):269-273.
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. Gastrointest Endosc. 2010;72(1):112-117.
• 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
Relative Frequency
Outpatient Colonoscopy:
Respiratory Depression
– AAS: 71.7 P < 0.001
Respiratory Rate (breaths/min)
Mandel JE, et al. Gastrointest Endosc. 2010;72(1):112-117.
Bariatric Surgery
Propofol or BZD/Narcotics for
Pre-Surgical Endoscopy?
•
Endoscopy prior to bariatric surgery
•
Anesthesiologist-monitored sedation
(AMS)
– IV propofol (n = 51)
•
Surgeon-monitored sedation (SMS)
P < 0.02
Nausea after endoscopy
Reported recovery < 1 hour
Remembered gagging
Remembered scope placement
– 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
Madan AK, et al. Obes Surg. 2008;18(5):545-548.
Throat pain after procedure
AMS
Throat pain during procedure
SMS
0
10
20
30
40
50
60
Patient YES responses (%)
Fentanyl vs Dexmedetomidine
Use in Bariatric Surgery
• 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)
Feld JM, et al. J Clin Anesthesia. 2006;18:24-28.
Dexmedetomidine as Desflurane
Adjuvant in Bariatric Surgery
•
•
•
•
80 morbidly obese patients
Gastric banding or bypass surgery
Prospective dose ranging study
Medication
–
–
–
–
–
Celecoxib
Midazolam
Propofol
Desflurane
Dexmedetomidine
400 mg
po
20 µg/kg
IV
1.25 mg/kg
IV
4%
inspired
0, 0.2, 0.4, 0.8 µg/kg/h IV
Tufanogullari B, et al. Anesth Analg. 2008;106:1741-1748.
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.
Oral Surgery
Dental Anesthesia Survey:
Premedication by Specialty
Endodontists
N = 31
Sublingual Triazolam/Halcion (45.2%)
Oral Triazolam/Halcion( 19.5%)
No Premedication Agents Used (19.4%)
MD Anesthesiologists
N = 19
All Agents Identified Are Used (52.6%)
Intramuscular Ketamine (26.3%)
Oral Midazolam (10.5%)
Dental Anesthesiologists
N = 75
All Agents Identified Are Used (32.0%)
Intramuscular Ketamine (22.4%)
Intramuscular Ketamine & Midazolam (14.7%)
General Dentists
N = 144
Oral Triazolam/Halcion (45.1%)
No Premedication Agents Used (25.7%)
Sublingual Triazolam/Halcion (13.9%)
Periodontists
N = 55
Oral Triazolam/Halcion (38.2%)
No Premedication Agents Used (32.7%)
Sublingual Triazolam (14.5%)
Pediatric Dentists
N = 33
Demerol and Hydroxyzine Elixir (36.4%)
Oral Midazolam (27.2%)
No Premedication Agents Used (21.2%)
Oral/Maxillofacial
Surgeons
N = 356
No Premedication Agents Used (54.2%)
Oral Midazolam (9.6%)
Oral Triazolam/Halcion (8.1%)
Public Health Practitioner
N=2
Oral Triazolam/Halcion (50.0%)
No Premedication Agents Used (50.0%)
Prosthodontists
N=2
Oral Triazolam/Halcion (100%)
Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.
Dental Anesthesia Survey:
Sedation/Anesthesia Method by Specialty
Percent
Oral Sedation
IV Conscious Sedation
IV Deep Sedation
GETA
OMFS
N = 356
DENT
ANES
N = 75
PED
DENT
N = 33
Boynes SG, et al. Anesth Prog. 2010;57(2):52-58.
PERIO
N= 55
ENO
N = 31
OMD ANES
N N = 19
GEN DENT
N = 144
Plastic/Reconstructive Surgery
Cosmetic Procedures
• In 2007, 11.7 million procedures in US
–
–
–
–
–
Liposuction
Breast augmentation
Eyelid surgery
Abdominoplasty
Breast reduction
• Site
– Surgeons’ offices
– Ambulatory centers
– Hospitals
54%
29%
17%
Shapiro FE. Curr Opin Anaesthesiol. 2008;21(6):704-710.
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.
Face Lift Surgery:
Hemodynamic Results
SOC+ Dex
SOC
Taghinia AH, et al. Plast Reconstr Surg. 2008;121(1):269-276.
Laparoscopy
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
Salman N, et al. Saudi Med J. 2009;30(1):77-81.
Remifentanil
• 1 µg/kg over 10 mins then
• 0.2 µg/kg/min
Ambulatory Gynecologic Laparoscopy
Group
Remifentanil
Group DEX
Time to eye
opening (mins)
3.5 ±1.1
4.1 ±1.4
Extubation
time (mins)
6.1 ±1.6 *
7.3 ±1.3
Orientation to
person (mins)
9.1 ±2.3 *
10.5 ±1.8
Orientation to
place and time
(mins)
16.1 ±6.3 *
21.2 ±11.7
Discharge time
(mins)
200.3 ±29.5
224.5 ±49.2
Recovery Data
Dexmedetomidine associated with
• Slower recovery
• Less nausea and vomiting
• Lower analgesia requirement
*P < 0.05
Salman N, et al. Saudi Med J. 2009;30(1):77-81.
CV Surgery
What Do Neurointerventionalists
Prefer 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.
General Anesthesia During
AIS Intervention?
McDonagh DL, et al. Front Neurol. 2010;1:118.
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.
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.
Sedation/Analgesia for Traumatic
Brain Injury
Goal: reduce ICP by decreasing pain, agitation
Agent
Advantages
Considerations
Propofol
• Short acting
• Reduces cerebral
metabolism, O2
consumption
• Improves ICP after 3d
• Propofol infusion syndrome
Barbiturates
• Reduce ICP
• Neuroprotection
• Interfere with neuro exam
• Hypotension, reduced CBF
• OCs not improved with severe TBI
Saiki RL. Crit Care Nurs Clin North Am. 2009;21:549-559.
MAC with Dexmedetomidine
• 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 = Monitored anesthesia care
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.
44
Fentanyl, µg
200
150
144.4
Fentanyl Use
*
84.8
100
*
83.6
Midazolam, mg
Dexmedetomidine Reduces Fentanyl and
Midazolam Use During MAC
5
4.1
4
Midazolam Use
3
*
1.4
2
50
1
0
0
Dex 0.5
88.9
75
*
59.0
*
42.6
50
25
0
Placebo
Dex 0.5
Placebo
Dex 1.0
Dex 1.0
Midazolam Treatment, %
Fentanyl Treatment, %
Placebo
100
*
0.9
100
Dex 0.5
Dex 1.0
96.8
*
59.7
75
50
*
45.7
25
0
*P < 0.001 compared with placebo,
MAC = monitored anesthesia care
Candiotti KA, et al; MAC Study Group. Anesth Analg. 2010;110(1):47-56.
Placebo
Dex 0.5
Dex 1.0