Objectives. Important Principles

(1)

Management of the Intubated

Patient

Christopher J Edwards PharmD BCPS Christopher J. Edwards, PharmD, BCPS Clinical Pharmacist - Emergency Medicine March 19th_{, 2013}

REPS EC SAG 2

Objectives

Describe the rationale for post intubation

analgesia and sedation

Compare and contrast various sedatives

commonly used in mechanically ventilated

patients

Design the optimum regimen of sedation and

analgesia for the recently intubated patient

Important Principles

Events prior to intubation can be painful

Intubation is painful

Procedures done after intubation are painful

Analgesia is the cornerstone of post intubation

care

(2)

Pain from Endotracheal Intubation

Rotondi AJ, et al. Patient’s recollections of

stressful experiences while receiving prolonged

mechanical ventilation in an intensive care unit.

Crit Care Med 2002



Endotracheal tube pain , 0–10 scale (25

th

_{and 75}

th

percentile)

ETT pain at its worst = 8 (6, 10) ETT pain at its least = 5 (3, 7)

Negative Effects of Poor Pain Control

Patients who recalled pain had higher

incidence of chronic pain, PTSD symptoms,

and lower health related quality of life

 Schelling et al. CCM. 1998

Pain response increases catecholamine release,

impairs tissue perfusion

Deleterious effects on immune response

Post-Intubation Analgesia and Sedation in

the Emergency Department

Weingart GS et al. Estimates of sedation in patients

undergoing intubation in US EDs. 2013. Am J of EM

1,071,000 patients included, 46.4% received sedatives and/or opiates

Jordan, B et al. Inadequate provision of postintubation

anxiolysis and analgesia in the ED. 2008. Am J of EM

117 patients, 33% received no anxiolysis, 53% received no analgesia

Of 70 patients who received vecuronium, 4% received adequate anxiolysis or analgesia

(3)

Paralytic Choice and Time to Sedation

Early initiation of analgesia and sedation is

particularly important when long acting

paralytics are used

Watt JM, et al. Effect of paralytic type on time

to post-intubation sedative use in the ED. EMJ.

2012.

Significantly greater time between intubation and initiation of sedation in patients receiving rocuronium compared to succinylcholine

Emergency Pharmacists Can Help!

Endpoint

Before EPh After EPh

p – value

Rate of post

intubation analgesia

8 (20%)

20 (49%)

p = 0.005

Sedative or anxiolytic 30 (73%)

y

21 (51%)

p = 0.04

without analgesia

(

)

(

)

p

Time to analgesia

after intubation

98 minutes

45 minutes

N/A

Robey-Gavin, E and Abukar, L. Impact of clinical pharmacists on initiation of post-intubation analgesia in the emergency department. Poster presented at ASHP’s Midyear Clinical Meeting. 2012

SCCM Guidelines for Management of

Pain, Agitation, and Delirium in ICU

Barr J, et al. Critical Care Medicine. 2013.

Preemptive analgesia

Opiate based regimens

Light level sedation

Non-benzodiazapines first line

(4)

The ED is not the ICU

Procedures often performed immediately after

intubation

Central line placement

R di l i l i i

Radiological imaging

Lumbar puncture

Orthopedic reduction

Etc, etc, etc…

Higher nurse to patient ratios

Much shorter length of stay

Pain Assessment in Mechanically

Ventilated Patients

Pain Scales

BPS – Behavioral Pain Scale

CPOT – Critical Care Pain Observation Tool

Vit l i

h ld

t f th

l ti

Vital signs should prompt further evaluation

Respiratory rate

Tachycardia

Hypertension

Diaphoresis

Richmond Agitation Sedation Scale

(RASS)

Score Term Description

+ 4 Combative Overtly combative, violent, immediate danger to staff + 3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive + 2 Agitated Frequent non-purposeful movement, fights ventilator + 1 Restless Anxious but movements not aggressive vigorous 0 Alert and Calm

-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) -2 Light sedation Briefly awakens with eye contact to voice (<10 seconds) -3 Moderate sedation Movement or eye opening to voice (but no eye contact) -4 Deep sedation No response to voice, but movement or eye opening

to physical stimulation

(5)

Important Concept

Bolus when patient acutely agitated

Titrating drip without bolus leads to slow resolution of agitation

Leads to aggressive titration

Leads to over sedation\adverse effects

Leads to discontinuation of sedation

Leads to acute agitation

Rinse and repeat

Analgesia

Opiates

Who should receive

Almost anyone who is currently intubated

Who should not receive

Patients currently on naloxone

Certain patients intubated for oversedation/intoxication

Precautions

(6)

Fentanyl

Onset: 30 - 60 seconds with bolus dosing

Elimination Half-Life

0.5 - 1 hour for bolus doses

Extended with prolonged infusion, hepatic impairment

Dosing

Bolus dosing: 0.5 – 1 mcg/kg

Continuous infusion starting rate: 0.5-1 mcg/kg/hr

Less hypotension compared to morphine

Potential for chest wall rigidity

Hydromorphone

Onset: 5 - 15 minutes with bolus dosing

Elimination Half-Life

2 – 3 hours for bolus doses

Dosing

Intermittent bolus dosing: 0.2 – 1 mg every 1 - 2 hours

Continuous infusion rate: 0.5 – 3 mg/hr

Less hypotension compared to morphine

Morphine

Onset: 5 - 10 minutes with bolus dosing

Elimination Half-Life

3 - 4 hours for bolus doses

D i

Dosing

Intermittent bolus dosing: 2 - 4 mg every 1 - 2 hours

Continuous infusion rate: 2 – 30 mg/hr

Accumulation of active metabolite in renal

failure

(7)

Opiates

Opiate Equi-Analgesic Dose Onset Elimination Half-Life

Bolus Dose Initial Infusion Rate Fentanyl 0.1 mg (100 mcg) 30 – 60 sec 0.5 – 1 hr 0.5-1 mcg/kg q 0.5 – 1 hr 0.5-1 mcg/kg/hr H d h 1 5 5 15 i 2 3 h 0 5 1 0 5 3 /h Hydromorphone 1.5 mg 5 – 15 min 2 – 3 hr 0.5 – 1 mg q 1 – 2 hr 0.5 – 3 mg/hr Morphine 10 mg 5 – 10 min 3 – 4 hr 2 – 4 mg q 1 – 2 hr 2 – 30 mg/hr

Sedatives

Propofol

Non-benzodiazepine sedative

Sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant properties

NO analgesic effects

Who should get it

Patients requiring frequent neurologic examinations

Patients with traumatic brain injury

Precautions/contraindications

(8)

Propofol

Onset: 30-60 seconds with bolus dosing

Elimination Half-Life

3-12 hours with continuous infusion

Duration extended with prolonged infusion, higher rate of infusion, excessive lipid stores, older patients

Duration decreased in younger patients

Dosing

Bolus dosing: 0.5 – 1 mg/kg

Continuous infusion: 5 – 70 mcg/kg/min Typical starting rate: 20 mcg/kg/min

Benzodiazepines

GABA-A activation leading to sedative effects

Anxiolytic, amnestic, hypnotic, and anticonvulsant properties

NO analgesic effect

Who should receive

Patients who cannot tolerate propofol

Patients who do not require frequent awakening

Precautions

Patients with hepatic failure (prolonged duration)

Chronic alcohol/benzo users may require higher doses

Midazolam

Onset: 2 – 5 minutes after bolus

Elimination Half-Life

3 – 11 hours

Extended with prolonged infusion, higher rate of infusion, older patients, hepatic failure, renal insufficiencyp , p , y

Dosing

Bolus dosing: 0.05 – 0.1 mg/kg

Initial infusion rate: 0.02 – 0.1 mg/kg/hr

Concerns

Accumulation of active metabolite in renal insufficiency

(9)

Lorazepam

Onset: 3 – 10 minutes after bolus

Elimination Half-Life

8-15 hours

Duration extended with prolonged infusion, higher rate of infusion, older patients, hepatic failure, renal insufficiency

Dosing

Bolus dosing: 0.02 – 0.04 mg/kg q 6 hrs prn

Infusion rate: 0.01 – 0.1 mg/kg/hr

Preferred benzodiazepine in hepatic failure

Concern for propylene glycol toxicity

Dexmedetomidine

Selective

α

2-receptor agonist

Sedative, analgesic, sympatholytic properties

Lacks amnestic and anticonvulsant properties

Wh

h ld

i

Who should receive

Patients requiring short term, low level sedation

Patients who are difficult to wean off of mechanical ventilation

Precautions

Hemodynamic instability (bradycardia, hypotension)

No amnestic effects

Dexmedetomidine

Onset: 15 minutes after initiation of infusion

Elimination Half-Life

1.8-3.1 hours

Extended in hepatic insufficiency

Dosing

Bolus not recommended due to adverse hemodynamic effects

(10)

Sedatives

Agent Onset After Bolus Elimination Half-Life

Bolus Dose Maintenance

Dosing Propofol 0.5 - 1min 3 - 12 hr

(Short term use)

0.5 – 1 mg/kg 5 – 70 mcg/kg/ min

Dexmedetomidine N/A 1 8 – 3 1 hr Not recommended 0 2-0 7 mcg/kg/hr Dexmedetomidine N/A 1.8 3.1 hr Not recommended 0.2 0.7 mcg/kg/hr

Midazolam 2 – 5 min 3 – 11 hr 0.05 -0.1 mg/kg 0.02-0.1 mg/kg/hr Lorazepam 3 – 10 min 8 – 15 hr 0.02 – 0.04 mg/kg (2 mg max) 0.01 – 0.1 mg/kg/hr (max 10 mg/hr)

Ketamine

NMDA receptor antagonist

Dissociative anesthetic with analgesic, sympathomimetic, and brochodilatory effects