1What is the A, B, C, D, E, F Bundle?
A - Assess, prevent, manage pain
B - Both spontaneous awakening and breathing trials
C - Choice of analgesia and sedative
D - Delirium
E - Early mobilization
F - Family engagement
2What has the bundled approach been shown to do?
- Improve survival
- Reduce length of stay
- Improve post-ICU quality of life
3A - ASSESS, PREVENT, AND TREAT PAIN
Why is pain the first thing we should treat?
Untreated or undertreated pain can lead to agitation, delirium, PTSD
4A - ASSESS, PREVENT, AND TREAT PAIN
What are the two tools used to assess pain in non-verbal patients?
- Behavioral pain scale (BPS)
- Critical-care Pain Observation Tool (CPOT)
5A - ASSESS, PREVENT, AND TREAT PAIN
Treat ICU patients with a ________-centered approach
Pain
6A - ASSESS, PREVENT, AND TREAT PAIN
Use _________-based pain assessment and management
Protocol
7A - ASSESS, PREVENT, AND TREAT PAIN
Utilize __________ pain relief and ______________ analgeisa.
- Multimodal pain relief: Opioids + Non-opioids + Local anesthetics + Non-pharmacologic
- Pre-emptive analgesia
8A - ASSESS, PREVENT, AND TREAT PAIN
What is the gold standard of pain treatment in the ICU?
What agents are most commonly used?
IV opioids
- Fentanyl
- Hydromorphone
- Morphine
9A - ASSESS, PREVENT, AND TREAT PAIN
Which IV opioid should be reserved for intubated patients?
Fentanyl
10B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
Sedatives are frequently administered to ICU patients in order to ...? (3)
- Relieve anxiety
- Reduce the stress of being mechanically ventilated
- Prevent agitation-related harm
11B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
T/F: Sedation usually treats the underlying cause of agitation.
FALSE -- Usually dose not treat underlying cause of agitation. This is why we treat pain first!!
12B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
How do we limit the morbidity associated with sedation?
- Light sedation is preferred
- Utilize spontaneous awakening trials
13B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
What is the tool used to measure agitation and sedation?
RASS scale
14B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
Goal RASS in the ICU?
0 to -1
- More negative = More sedation
- More positive = more agitated
15B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
What are the exceptions to when heavy sedation is preferred over light sedation? (3)
- Severe dyssynchrony with ventilator
- Neuromuscular blockade
- Intracranial pressure increases
16B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
What is the objective measure of brain function used during NM blockade?
Bispectral index (BIS)
17B - BOTH SPONTANEOUS AWAKENING & BREATHING TRIALS
Performing both SATs and SBTs daily in ICU patients has been shown to have what two benefits?
- Reduce mortality
- Reduce length of stay
18C - CHOICE OF ANALGESIA AND SEDATION
What type of sedatives are preferred?
Non-benzodiazepines preferred to benzodiazepines
- Propofol
- Dexmedetomidine
19C - CHOICE OF ANALGESIA AND SEDATION
What situations are benzodiazepines preferred over non-benzodiazepines?
- Alcohol withdrawal
- Seizures/status epilepticus
- Chronic benzodiazepine dependence
- Failure of other agents
20C - CHOICE OF ANALGESIA AND SEDATION
Which sedative should only be used in intubated patients and has amnesic properties?
Propofol
21C - CHOICE OF ANALGESIA AND SEDATION
Which sedative can be used in non-intubated patients and is an alpha-2 agonist?
Dexmedetomidine
22C - CHOICE OF ANALGESIA AND SEDATION
Main two concerns with the non-benzo sedatives?
Hypotension and bradycardia
23C - CHOICE OF ANALGESIA AND SEDATION
What are the three benzos used in the ICU for sedation?
- Midazolam: Most common
- Lorazepam
- Diazepam
24D - DELIRIUM: PREVENT, ASSESS, TREAT
What are the requirements for a delirium dx?
- Disturbance of consciousness
- Change in cognition
- Develops over a short period of time (hours to days) + symptoms fluctuate throughout the day
- Disturbances are NOT better explained by a preexisting, established or evolving neurocognitive disorder
25D - DELIRIUM: PREVENT, ASSESS, TREAT
What is the tool used to assess for delirium in the ICU?
CAM-ICU
26D - DELIRIUM: PREVENT, ASSESS, TREAT
What are the three presentations of delirium?
- Hypoactive Presentation (45.5%): Lethargy / Reduced psychomotor function
- Hyperactive Presentation (1.6%): Agitation / Increased vigilance / Hallucinations
- Mixed Presentation (51.4%): Alternates between hypo- and hyperactive behaviors
27D - DELIRIUM: PREVENT, ASSESS, TREAT
T/F: Delirium is an independent marker for increased mortality during the 12 months after hospital admission
TRUE
28D - DELIRIUM: PREVENT, ASSESS, TREAT
Delirium in the ICU is associated with ...? (4)
- Longer length of hospital stay
- Increased hospital-acquired complications
- Persistent cognitive deficits
- Increased discharge rates to long-term care
29D - DELIRIUM: PREVENT, ASSESS, TREAT
What are the evidence based medications used to prevent delirium?
What are the evidence based medications used to treat delirium?
NO MEDICATION HAS EVIDENCE TO PREVENT OR TREAT DELIRIUM
30D - DELIRIUM: PREVENT, ASSESS, TREAT
When is dexmedetomidine recommended for delirium?
For delirium in mechanically ventilated adults where agitation is precluding weaning/extubation
31D - DELIRIUM: PREVENT, ASSESS, TREAT
What are the guidelines recommendations for managing delirium in the ICU?
Multicomponent, nonpharmacologic intervention that is focused on (but not limited to):
- Reducing modifiable risk factors for delirium
- Improving cognition
- Optimizing sleep, mobility, hearing, and vision in critically ill adults.
**NO medications**
32D - DELIRIUM: PREVENT, ASSESS, TREAT
What is a basic approach to managing delirium?
STOP
- Stop unnecessary medications (particularly benzodiazepines)
- Reduce doses when possible
THINK
- Toxic Situation
- Hypoxemia
- Infection/sepsis (nosocomial), Immobilization
- Nonpharmacological interventions
- K+ or electrolyte problems
LASTLY MEDICATE
33Delirium - Prevention
Avoid unnecessary _______________ medications
Anticholinergic
34Delirium - Prevention
Minimize the use of _____________ and other sedatives
Benzodiazepines
35Delirium - Prevention
Assess _______________ and ________________ medications regularly.
Sedative and analgesic
36Delirium - Treatment
What are some of the ways to treat delirium?
- Discontinue all unnecessary medications
- Maximize non-pharmacological interventions
- Consider the use of neuroleptic medications: CI in patients with Parkinson's Disease or dementia with Lewy bodies
- Consider restarting home psychiatric medications
37Delirium - Treatment
Despite neuroleptic medications not being approved for delirium or having evidence of improved outcomes, when may they be useful?
- Decrease abnormal hallucinations, delusions, unstructured thought patterns
- Have sedative effect
38Delirium - Treatment
T/F: ODT neuroleptic drugs are absorbed sublingually which are useful for ventilated patients.
FALSE -- NOT absorbed sublingually = Have to be able to swallow
39Delirium - Treatment
If a patient is taking is taking a neuroleptic agent, what should be monitored?
Cardiac function and electrolytes
40Delirium - Treatment
What are the nonpharmacologic strategies?
- Re-orientation
- Visitation by loved ones
- Sleep-wake cycle normalization
- Mobilization
- Physical restraint limitation
- Replacement of eyeglasses and hearing aids
**ALL evidence based**
41Delirium - Treatment
What strategy has the strongest evidence for preventing or treating delirium?
Early mobilization
42E - EARLY MOBILIZATION
Benefits of mobilization?
- Reduced incidence of delirium = Most evidence based thing you can do for delirium
- Fewer ventilator-dependent days
- Shorter ICU and hospital stays
- Better functional outcomes + Less nursing home placement
43ICU Sleep Disruption
Sleep deprivation in the ICU contributes to...? (4)
- ICU delirium
- Prolonged mechanical ventilation
- Deranged immune function
- Neurocognitive dysfunction
44ICU Sleep Disruption
Interventions to improve sleep?
- Ventilatory mode
- Noise and light reduction
- No recommendations for pharmacologic therapies