Transcript Guidelines for the Diagnosis and Management of Asthma

Teamwork and Multidisciplinary Approach to
“Wake Up and Walk
Implementation of the ABCs of good
sedation practices in the ICU
Pratik Pandharipande, MD, MSCI
Department of Anesthesiology
Vanderbilt University School of Medicine
VA TN Valley Health Care System
Need for Sedation and Analgesia
1. Prevention of pain and anxiety
2. Decrease oxygen consumption
3. Decrease the stress response
4. Patient-ventilator synchrony
5. ? Prevention of psychiatric illnesses–
depression, PTSD
Rotondi AJ, et al. Crit Care Med. 2002;30:746-52A.
Weinert C, et al. Curr Opin in Crit Care. 2005;11(4):376-380.
Kress JP, et al. J Respir Crit Care Med. 1996;153:1012-1018.
Pitfalls of Sedatives and Analgesics
Sedatives and analgesics may contribute to
• Increased duration of mechanical ventilation
• Length of intensive care requirement
• Impede neurological examination
• May predispose to delirium
Kollef M, et al. Chest. 114:541-548.
Pandharipande et al. Anesthesiology. 2006;124:21-26.
The ABCDE approach of good
sedation and delirium management
• AB- Awakening and Breathing
Coordination
• C- Choice of Sedative
• D- Delirium monitoring and management
• E- Early mobility
AB
•Awakening and Breathing
Daily Interruption of Sedatives
Patients Receiving
Mechanical Ventilation (%)
100
80
Ventilator time reduced by 2.5 days
Adjusted P<.001
60
40
Control (n=60)
20
Protocol (n=68)
0
0
5
10
15
20
25
30
Time (Days)
Kress JP, et al. NEJM. 2000;342:1471-1477.
The ABC Trial
(Both groups get patient targeted sedation)
Medical ICU on Ventilator
Surrogate Informed Consent
Control
Intervention
Spontaneous Breathing Trial (SBT)
Spontaneous Awakening Trial (SAT)
ventilator off
safely monitored
turn sedation/narcotics off
monitor safely
OUTCOMES
Spontaneous Breathing Trial (SBT)
delirium, LOS, 12-mo NPS testing, QOL
ventilator off
safely monitored
OUTCOMES
delirium, LOS, 12-mo NPS testing, QOL
Girard TD, et al. Lancet. 2008;371:126-134.
Benzodiazepines
Daily Dose of Benzodiazepines
70
Usual Care + SBT
SBT + SAT
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21
Study Day
Successful Extubation
Patients Successfully Extubated (%)
100
80
SAT + SBT (n=167)
SBT (n=168)
60
40
20
Mean ventilator-free days, 14.7 versus 11.6 days
95% CI for the difference, 0.7 to 5.6 days; P=.02
0
0
7
14
21
28
Days
Girard TD, et al. Lancet. 2008;371:126-134.
Improved 1-Year Survival in ABC Trial
100
Patients Alive (%)
80
SAT+SBT (n=167)
60
40
SBT (n=168)
20
Hazard Ratio=0.68 (0.50-0.92), P=.01
0
0
60
120
180
240
300
360
Days
Girard TD, et al. Lancet. 2008;371:126-134.
Implementation challenges and
multidisciplinary approach to
overcome barriers
Components of the Awakening and
Breathing Coordination
Sedation Safety Screen
FAIL
PASS- Sedation Cessation
SBT
SAT Trial FAIL
Sedative Restarting Criteria
Safety Screening Criteria
• Why have a safety screen?
• Does it have to be tailored to different
populations/ICU or can you have one?
• Key Question:
When is it not safe to stop sedatives?
Spontaneous Awakening Trial Screen
Key players to get involved
• Approvals from unit specific physician and
nursing leadership
• ICU Director or designee
• Nurse educators and charge nurses in each ICU
• Respiratory therapists in each ICU
• Champions in each unit (nurses, NPs…)
• ICU Team for reinforcement
Allay Concerns
“I think that, to get nursing staff buy-in
(especially in the CVICU where hemodynamic swings
can be devastating), it is important to clearly define
hemodynamic instability.”
“If we start with what all consider to be
reasonable, then we have more likelihood of additional
patients included later. If we start with criteria that
the nurses consider to be “dangerous”, we will not get
buy-in.”
Allay Concerns
“Is there any more specific definition for
hemodynamically unstable – including a timeframe from a
last major intervention to get them stable?
(Example: If
the patient is now at target for their blood pressure, PA
pressures, or heart rate, but they have only been there for two
hours after a raucous 12 hour chase, are they now
hemodynamically stable and eligible for SAT?)”
“Do you want a nurse to determine hemodynamic
instability or cardiac ischemia. We have some new nurses in
our ICU”
“Surgical patients have pain. I don’t want to stop
analgesic infusions.”
Responsiveness to concerns:
modified SAT screen
1. Active seizures?
2. Active ETOH withdrawal?
3. Ongoing agitation (RASS ≥ +2 in last 4 hours)?
4. Paralytics or a RASS order of -4 or -5?
5. SpO2 ≤ 88% and FiO2 ≥ 0.70 ?
6. Myocardial ischemia (troponin ≥ 0.2 µ/L) ?
7. Hemodynamic instability in previous 4 hours?*
8. Abnormal ICP (≥ 20 mm Hg)?
9. Open abdomen or similar contraindications for wake up ?
•*Use of 2 concurrent vasopressors/inotropes, or > 7.5 µg/min of norepinephrine or
epinephrine or > 7.5 µg/kg/min of dopamine or dobutamine
C
•Coordination of Awakening and
Breathing
Timing of SATs/SBTs
• Night shift?
• Day Shift?
RN Staff (email from educator):
We understand the reluctance to discontinue sedation on a ventilated
patient first thing in the morning, when you haven’t seen your other patient.
So, here is the compromise in step-by-step format after discussion with a large
group of your peer nurses and physicians.
1. Complete your bedside shift report on all patients in your assignment
(645-7 am)
2. Complete your assessments including SAT safety screen on both
patients (7 am -730 am).
3. Start the SAT trial if the patient passes the safety screen. This should
happen sometime around 730-8am. Notify RT
4. When the team rounds, you should address your progress on the
SAT trial. Even if you haven’t started the actual trial, the team wants to know
during rounds whether or not the patient is eligible for the trial. In short,
communicate with the team about the status of the SAT.
5. Notify the team that the patient of the results of the SAT/SBT
Components of the Awakening and
Breathing Coordination
Sedation Safety Screen
FAIL
Sedation Cessation
SBT
SAT Trial FAIL
Sedative Restarting Criteria
Sedation cessation-practical aspects
• Once safety screen is passed, discontinue ALL
sedative and analgesic infusions; prn analgesics OK
• We stop dexmedetomidine UNLESS to treat delirium
• Inform respiratory therapist to coordinate SBT
• Sedative/Analgesics stay off until
– Pass SAT/SBT and move towards extubation
– Need for some sedation based on RASS target
– Fail SAT (SAT duration >4hrs not a failure criteria)
• Restart at lowest dose needed to maintain RASS target
Involve Nursing in Morning Report:
Mandatory Documentation
Neuro Status
Sedation
RASS/CAM:
SAT screen Passed/Failed
If failed why?
SAT trial
7am
7pm
____/____ _____/____
In progress/Passed/Failed
If failed why?
Pain Management
PO IV
PO IV
PCA Epid PCA Epid
Feedback and Auditing
• Daily during rounds- attending or
designated champions. We are using our
NPs and pharmacists who are constants in
the ICU
• Weekly reports
• Focus on education and not being punitive
• Feedback from users
• Electronic prompts/reminders
C
•Choice of sedation (after analgesia
and if needed)
First Author
Year
Population
Outcome(s) improved
Benzodiazepines vs. propofol
Trials finding better outcomes with propofol
Grounds RM
1987
Cardiac surgery Faster awakening
Aitkenhead AR
1989
McMurray TJ
1990
Carrasco G
1993
Roekaerts PM
1993
Ronan KP
1995
Sherry KM
1996
Chamorro C
1996
General ICU
Better ventilator synchrony, faster awakening
Barrientos-Vega R
1997
General ICU
Earlier extubation
Weinbroum AA
1997
General ICU
Faster awakening
Sanchez-Izquierdo-Riera
JA
McCollam JS
1998
Trauma ICU
Faster awakening
1999
Trauma ICU
Less oversedation
Hall RI
2001
Mixed ICU
More accurate sedation, earlier extubation
Carson SS
2006
Medical ICU
General ICU
More consistent awakening, faster weaning
Cardiac surgery Faster awakening
General ICU
More accurate sedation, faster awakening, lower costs
Cardiac surgery Faster awakening, earlier extubation
Surgical ICU
Faster awakening
Cardiac surgery Lower costs
Fewer ventilator days
Trials finding no differences in outcomes
Searle NR
1997
Kress JP
2000
Huey-Ling L
2008
Cardiac surgery None
Medical ICU
Cardiac surgery None
Trials finding better outcomes with the benzodiazepine
None
None
First Author
Year
Population
Outcome(s) improved
Benzodiazepines vs. remifentanil
Trials finding better outcomes with remifentanil
Breen D
2005
Mixed ICU
Shorter duration of mechanical ventilation
Muellejans B
2006 Cardiac surgery Earlier extubation and ICU discharge
Rozendaal FW
2009
Mixed ICU
Lighter sedation, shorter weaning time
Trials finding no differences in outcomes
None
Trials finding better outcomes with the benzodiazepine
None
Benzodiazepines vs. dexmedetomidine
Trials finding better outcomes with dexmedetomidine
Pandharipande PP
2007
Mixed ICU
More accurate sedation, more delirium/coma-free days
Riker RR
2009
Mixed ICU
Lower prevalence of delirium, earlier extubation
Ruokonen E
2009
Mixed ICU
Shorter duration of mechanical ventilation*
Maldonado JR
2009 Cardiac surgery Lower incidence and duration of delirium
Esmaoglu A
2009
Eclampsia
Shorter ICU length of stay
Dasta JF
2010
Mixed ICU
Lower ICU costs
Jakob SM
2012
General ICU Lighter sedation, fewer ventilation days
Trials finding no differences in outcomes
None
Trials finding better outcomes with the benzodiazepine
None
Analgesia/Sedation Protocol for Mechanically Ventilated Patients
1
In pain?
Bolus dosing prn with either
•Fentanyl 50-100 mcg
•Hydromorphone 0.1-0.3 mg
•Morphine 2-5 mg
Yes
No
Reassess often
Yes
Controlled or anticipated control with < 3
bolus doses/hr
No
Analgesia may be
adequate to reach RASS
target
•Fentanyl 50- 300 mcg/hr gtt
• Fentanyl 25-100 mcg prn pain
2 At RASS target?
No
No
Yes
Under-sedated
• Propofol 5-30 mcg/kg/min
• Dexmed 0.2-1.5 mcg/kg/hr
(if delirious†/weaning)
• Midazolam 1-3 mg prn‡
(ETOH withdrawal or
intolerance*).
CAM-ICU negative
Reassess q 6-12 hrs
‡ Midazolam
* Propofol
Reassess often
Over-sedated
Hold sedative/ analgesics to
achieve RASS target. Restart at 50%
if clinically indicated
SAT+SBT daily
propofol
Physical therapy
3
CAM-ICU positive
Delirium ?
-Non pharm management
- Pharm management
1-3 mg/hr gtt rarely if > 2 midaz boluses/hr and propofol intolerance
intolerance refers to propofol infusion syndrome, hemodynamic instability , increasing CPK >5000 IU/L, triglycerides >500 mg/dl or use >96
PRECEDE Model for
Improvement
• Predispose
• Enable
• Reinforce
Predispose for Success
• Must identify and understand current needs and
barriers to adoption
– Knowledge
– Needs
– Skills
– Values
Address Knowledge Gaps
• Address Knowledge Barriers Explicitly
– Physician / Nurse / RT education
•
•
•
•
•
•
•
Multidisciplinary Educational Seminar
In Service Training
Grand Rounds
Journal Clubs
Posters
Readily Accessible Materials
Web-site development / Access
Barrier: Knowledge Gaps
• Barriers to Sedation Protocol
–
–
–
–
Use may cause oversedation
Not appropriate for select patients
Possibility for undersedation
No proven benefit
• Barriers to Sedation and Ventilation Interruption
–
–
–
–
–
Concerns about device removal
Compromising patient comfort
Lead to respiratory compromise
No proven benefit
Leads to PTSD
Tanios MA, et al. J Crit Care. 2009;24:66-73
Devlin JW, et al. Crit Care Med 2006;34(2):556–7
Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446
Barrier: Unmet Needs
Sedation Protocol and Sedation / Ventilation Interruption
•Lack of physician order
•Protocol not accessible when needed
•Inconvenient to coordinate
Tanios MA, et al. J Crit Care. 2009;24:66-73
Ely EW, et al. Am J Respir Crit Care Med 1999;159:439–446
Addressing Unmet Needs
Make Protocol Accessible When Needed
• Integrate with electronic medical record
• Make available at charting area, bedside, and common
gathering areas
– Attach to charting areas
– Attach to ventilators
• Use pocket cards
• Bedside reference book
Enable Success
Optimize your environment: Resource support
• Engage hospital and unit level leadership
• Seek and provide administrative, financial, and
professional support
• Engage informatics and data management support for
evaluation
Reinforce: Data audit and
feedback
• Critical to measure performance
– Quantitative and Qualitative
– Qualitative
• Informal
• Formal
– Interviews
– Focus Groups
– Observation of processes
– Process mapping
Reinforce: Reward and
Recognize
• Reward excellent performance
• Display pride in job well done
– Public display of performance improvement
• Posters
• Website / Blog
• Newsletter
– Recognition of leadership and quality improvement
Conclusions
• Implementation must be
– Interdisciplinary
– Automated
– Integrated
– Monitored and Assessed with Data