SARI CLINICAL CARE TRAINING

INVASIVE MECHANICAL VENTILATION FOR

ACUTE RESPIRATORY DISTRESS SYNDROME
MANAGE PAIN, AGITATION AND DELIRIUM

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Learning objectives

At the end of this lecture, you will be able to:

• Describe the long-term complications associated with use of
sedatives in critically ill patients (firstly do no harm).
• Describe the long-term benefits associated with using a
protocolized management approach to pain, agitation and
delirium (PAD).
• Formulate a PAD protocol adapted to your hospital setting.

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 ICU survivors: long term complications

50–70% cognitively impaired

60–80% functionally impaired
?% psychiatric conditions
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Slide use with permission from www.icudelirium.org EMERGENCIES
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The history of sedation
• Historically patients were deeply sedated because:
– early generation ventilators were insensitive to patient ventilatory effort,
leading to patient discomfort and asynchrony
– belief that amnesia was desirable.

• Light/no sedation is the current standard of care for most

patients:
– modern ventilators have sensitive trigger and patients are more
synchronous
– amnesia may actually contribute to risk of PTSD
– deep sedation may cause respiratory, CVS, neurological, psychological
and immunological complications and contribute to risk of death.

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 Patient COMFORT should be the goal, and
includes adequate pain control, anxiolysis and
prevention and treatment of delirium.
Achieving the appropriate balance of analgesia,
and sedation is challenging.

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Implementation of PAD guidelines improves patient outcomes

• Short-term outcomes: • Long-term outcomes:

– fewer days of delirium – better cognitive function
– fewer days of IMV (quicker time – better physical mobility
to extubation) – fewer psychiatric conditions
– fewer days in the ICU (e.g. PTSD, depression,
– lower hospital costs anxiety)
– more mobilization during ICU – increased survival.
stay
– increased survival.

Develop a PAD protocol that is adapted to your hospital.

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Formulate a
PAD protocol
Step 1: Assess and recognize pain, agitation and delirium using standardized
scales
Step 2: Manage pain first: prevent and treat
Step 3: Manage anxiety: choose targeted sedation
Step 4: Manage delirium: prevent and treat
Step 5: Recognize special situations that may need deep sedation and
neuromuscular blockade (i.e. severe ARDS)
Step 6: Monitor-record-interpret-respond
Step 7: Deliver quality care: implement as part of ABCDEF bundle.

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Step 1

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Recognize pain, agitation and delirium

• Routinely evaluate mechanically ventilated patients

for pain, agitation and delirium:
– i.e. once or twice a nursing shift, and as needed.

• Use standardized tools to minimize variation between

various caregivers.

• Agitation is a non-specific symptom of pain, anxiety or

delirium:
– find and treat the root cause.

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Why do ICU patients experience pain?

Pain Patients can experience pain for may reasons:

• due to critical illness itself:
i.e. pleurisy, injury or surgical sites
• due to secondary processes:
i.e. endotracheal tube intolerance, joint stiffness, wound
care, pressure areas or immobility.

Non-specific signs of pain include diaphoresis,

hypertension and tachycardia. These signs are less
reliable.

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Step 1a. Recognize pain
• In patients who can self-report, use a 10-point pain
scale:
– reliable and accurate (gold standard):
• Visual Analog Scale (VAS)
• Wong Baker Faces

● In patients that are noncommunicative or sedated,

use a behavioural pain scale:
– score based on facial expression, limb movement, muscle
tension and ventilator compliance:
• Behavioural Pain Scale (BPS) and Critical-Care Pain Observation
Tool (CPOT)
• Comfort-B scale.
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Pain scales

The lower the score, the higher quality of analgesia.

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Why do ICU patients experience
anxiety?

Anxiety Patients may feel an exaggerated sense of fear, nervousness or

apprehension and can present with agitation or increased motor
activity.

Patient may also manifest with hypo-activity and be withdrawn,

distrustful or have blunted affect.

Due to the primary illness (i.e. sepsis) or from the care itself (i.e.
medication related).

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Step 1b. Recognize anxiety

• In adults and children, the Richmond Agitation-Sedation Scale

(RASS) is easy to use (next slide):
– scoring based on observing patient’s response to verbal or painful
stimuli:
• body movement, eye opening, duration of eye contact.

• In children, the Comfort-B scale is commonly used:

– scoring based on observing patient behaviours:
• crying, facial tone, muscle tone, movement, alertness, ventilator compliance.

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RASS scale (takes only 20 seconds)

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Why do ICU patients experience
delirium?

Delirium Patients present with fluctuation in consciousness associated with

inattention and disorganized thinking or perceptual disturbance that
develops over short period of time.

Three types: hypoactive, hyperactive and mixed. Hyperactive is least

common but easiest to diagnose.

Due to a secondary condition (i.e. pain, primary intracranial process,

hypoxaemia, shock, infection, electrolyte abnormalities, metabolic
disturbances, medications). Benzodiazepines are a common culprit or
drug withdrawal.

Delirium is an independent predictor of death.

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Step 1c. Recognize delirium

• The Confusion Assessment Method (CAM-ICU) is well validated

tool to assess for delirium in adults (CAM-ICU) and children
older than 4 years (pCAM-ICU).
– Based on presence of:
• mental status fluctuation
• inattention
• level of consciousness
• disorganized thinking.

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Step 2

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 Manage pain first (1/2)
• Use of analgesia-based approach may be adequate for most
critically ill patients and minimize the need for additional sedatives:
– give pre-emptive analgesia to alleviate pain prior to invasive or potentially
painful procedures.

• Use opioids to treat non-neuropathic pain:

– common agents:
• fentanyl, morphine, hydromorphone.
– dosing:
• start with intermittent dosing
• consider continuous infusions based on intermittent dose requirements or if patient is known to
have chronic pain
• avoid oversedation.
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 Manage pain first (2/2)
• Optimize simple non-opiate analgesics to minimize opioid
use and their secondary harmful effects:
– acetaminophen (paracetomol)
– nonsteroidal anti-inflammatory drugs (e.g. ibuprofen) in
selected patients, but not routinely in children < 1 month old
– oral sucrose for procedural analgesia in neonates.

• For patients with neuropathic pain, also consider

neuropathic agents:
– i.e. gabapentin, carbamezapine, amitryptiline.

• For localized pain, consider regional anesthesia or topical local

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Step 3

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Manage anxiety (1/4)
• Set daily sedation targets:
– based on the patient’s clinical condition, management plans
– agreed upon by the health care team.

• For most patients, target light sedation so the patient

is awake (0), calm (-1):
– unless this is clinically contraindicated.

• Give a sedative based to reach target sedation score:

– always use the lowest dose necessary to reach target and
reduce secondary harmful effects.

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Manage anxiety (2/4)
• Choose a short-acting sedative when possible:
– continuous infusion of very short-acting agents:
• propofol in adults but not in children < 16 years of age
• dexmedetomidine (if available)
– Enteral sedatives are commonly used in children:
• chloral hydrate
• triclofos
– Intermittent dosing of short-acting benzodiazepine (i.e.
midazolam)
• Alternative options:
– ketamine (where available)
– clonidine (if dexmedetomidine not available).
Avoid continuous infusion of benzodiazepines because associated
with prolonged days on IMV and increase in delirium.
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Manage anxiety (3/4)
• Cautiously use continuous infusions of benzodiazepines in
patients unable to receive short-acting agents.

• Preferably, use low-dose infusions and titrate down to lowest dose

needed to achieve target RASS.

• If patient is oversedated from continuous infusions, then screen

daily for sedation awakening trial (SAT).

• It is safe to stop narcotics (as long as pain is controlled) and

continuous sedatives in most critically ill patients, except those
with:
– active seizures, alcohol withdrawal, severe agitation, ongoing myocardial ischaemia,
elevated intracranial pressure or those receiving NMB.

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Manage anxiety (4/4)

• If SAT conducted:
– monitor patient closely for agitation, haemodynamic instability or respiratory
distress
– if these occur, then restart infusion at ½ previous dose.

• Some experts suggest a “no sedation” policy except for

morphine 2.5–5mg boli as needed:
– may be associated with shorter duration of ventilation, shorter ICU and hospital stay, less
delirium
– no increased in self extubation or other complications
– critically dependent on nurse : patient ratio.

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 Coordinate the SAT with spontaneous breathing
trial (SBT). When bundled together, patients spend
fewer days on IMV and are more likely to survive at
1 year.

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Step 4

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Manage delirium (1/4)

• Treat the contributing medical conditions.

• Stop delirium producing drugs (i.e. benzodiazepines).

• Provide adequate pain control.

Delirium is an independent risk factor for mortality in the ICU and

cognitive impairment in survivors.
Early recognition and treatment are appropriate.
However, clinical trial data regarding most effective treatments are
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Manage delirium (2/4)
• Use non-pharmacologic interventions:
– sleep hygiene:
• protect patient sleep cycles by controlling light, reducing noise and
stimuli at night, eye shades, ear plugs
• cluster patient activities.

– Orientation:
• re-orient patient to surroundings, provide reassurance and
encourage family visits, have familiar objects in room
• provide visual aids, hearing aids, TV during the daytime, music.

– Early mobilization and exercise.

– Remove tubes and restrains as soon as possible.

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Step 5

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Special considerations
for patients with severe ARDS
• In patients with early, severe ARDS, target deep sedation
(RASS -4, -3) to optimize LPV strategy:
– patients with severe ARDS may easily deteriorate with little
movement or minor ventilator asynchrony
– not good candidates for sedation interruption.

• Addition of early NMB for the short term (up to 48 hours):

– associated with reduced mortality and more organ-failure free days
– and not with prolonged weakness.

• NMB must be used in conjunction with continuous

sedatives that provide amnesia and analgesics for pain:
– NMB does not provide sedation, amnesia or analgesia.
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PAD as part of the ABCDEF bundle

Delirium
Awake and
Choose light monitoring Early mobility
Breathing Family
sedation and and exercise
Coordination
management

Days IMV, length of stay, delirium,

long-term cognitive and disability
impairments and mortality (more next
slide show).
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Useful websites
To access the PAD guidelines and additional training materials
and videos, including information about the ABCDE bundles,
please visit: www.icudelirium.org

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Summary
• Implement a protocolized management approach to pain,
agitation and delirium (PAD) to improve patient outcomes.

• Regularly assess patients using standardized, reproducible

scales (i.e. VAS, RASS, CAM-ICU).

• First, treat pain (with opioids and non-opioids) to minimize the

harmful effects of sedatives.

• Then treat anxiety using non-benzodiazepines sedatives (when

possible) and target light sedation in most patients.

• Use non-pharmacologic interventions to prevent delirium.

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Acknowledgements

• Contributors
Dr Charles David Gomersall, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong, SAR, China
Dr Janet V Diaz, WHO Consultant, San Francisco CA, USA
Dr Neill Adhikari, Sunnybrook Health Sciences Centre, Toronto, Canada
Dr Steve Webb, Royal Perth Hospital, Australia
Dr Satish Bhagwanjee, University of Washington, USA
Dr Kobus Preller Addenbrooke’s Hospital, Cambridge, UK
Dr Paula Lister, Great Ormond Street Hospital, London, UK
Dr Wes Ely Vanderbilt University School of Medicine, Nashville, USA

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