Intensive Care Procedures 351

Analgosedation

The use of analgetics and sedatives for the treatment of pain, anxiety, and agitation is a daily challenge in the intensive care environment. It is usually needed for the mechanically ventilated patient. To achieve a sufficient level of patient shielding while minimizing side effects and a short and cost-effective weaning period, the algorithm for analgosedation (AS) is an important task for the clinician. Emphasis should be placed on the consequent and correct implementation of a concept while the details ofthe concept are not as important. Another key aspect is the regular documentation of the indication for continuing AS, the definition of a therapeutic goal, the assessment of the patient's degree of agitation and pain, and finally the adjustments in the drug therapy. If the underlying diseases permit, a regular daily suspension of the AS is advisable to evaluate the patient neurologically and discover a prolonged effect of the AS (Martin et al. 2005).

There are manifold causes of pain in the intensive care environment: preexisting disease, invasive procedures, trauma, monitoring and therapeutic devices (such as catheters, drains, noninvasive ventilating devices, endotracheal tubes), routine nursing care (airway suctioning, physical therapy, dressing changes, patient mobilization), and prolonged immobility. Unrelieved pain leads to inadequate sleep, causing exhaustion, disorientation, agitation, stress response (tachycardia, increased myocardial oxygen consumption, hy-percoagulability, immunosuppression, persistent ca-tabolism), pulmonary dysfunction through localized guarding of muscles around the area of pain and a generalized muscle rigidity or spasm that restricts movement of the chest wall and diaphragm.

The causes for anxiety in the intensive care unit can be secondary to an inability to communicate due to continuous noise (alarms, personnel, and equipment), continuous ambiguous lighting, excessive stimulation (inadequate analgesia, frequent measurements of vital signs, repositioning, lack of mobility, room temperature, sleep deprivation, and the underlying disease that led to ICU admission. Causes for agitation include extreme anxiety, delirium, adverse drug effects, and pain. If agitation is present, it is important to identify and treat any underlying physiological disturbances: hyp-oxemia, hypoglycemia, hypotension, pain, withdrawal from alcohol, and other drug effects. Special attention should be paid to the treatment of agitation, because it can pose a serious threat to patients by contributing to ventilator dyssynchrony, increase in oxygen consumption, or inadvertent removal of devices and catheters (Jacobi et al. 2002).

3.5.1.1 Algorithm

Before the start of analgosedation, it is important to assess the indication and define a therapeutic goal. Today the patients in the intensive care unit should react adequately to verbal stimulation, perceive their environment, communicate their needs, and tolerate the diagnostic and therapeutic measures.

The next step is to assess the degree of agitation and pain. A good approach is the concept by Martin and Messelken (1998), which implements the Richmond Agitation-Sedation Scale (RASS) (Sessler et al. 2002) at the outset and continues depending on the RASS score with an adequate pain score. For the unresponsive to lightly sedated patient, the behavioral pain scale (BPS) by Payen et al. (2001) is applicable, for the sleepy to

Behavioral Pain Scale Payen
Fig. 3.7. Algorithm of analgosedation. Assembled from Jacobi et al. (2002); Martin et al. (2005); Martin andMesselken (1998)

restless patient the numeric rating scale (NRS: 0 = no pain to 10 = highest pain possible) assessed by the patient himself is applicable, and for the agitated to fighting patient the NRS rated by a medical professional (physician or nurse) is applicable. For details of the assessment of agitation and pain, please refer to Tables 3.6 and 3.7.

The last step is to schedule the duration of the AS and choose the appropriate drug accordingly. The SeSAM concept (Martin and Messelken 1998) provides four duration categories: up to 24 h, up to 72 h, more than 72 h, and ultrashort analgosedation (e.g., for short painful diagnostic procedures). The drugs were chosen such that the length of the context-sensitive half-life meets the requirements of the duration of AS needed and prolonged action is unlikely. For dosages of the drugs, please refer to Tables 3.8 and 3.9. Co-medication such as nonopioids should be considered to support the AS in an additive way, but strict adherence to the contraindications of these drugs is mandatory. Another therapeutic option is continuous regional anesthetic techniques such as epidural catheter analgesia

Table 3.6. Richmond agitation-sedation scale (RASS)

Score

Term

Description

Procedure

+4

Com

Overtly combative or violent; immediate dan-

1. Observe patient. Is patient alert and calm (score 0)?

bative

ger to staff

Does patient have behavior that is consistent with

+3

Very agitated

Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff

restlessness or agitation (score +1 to +4 using the criteria listed above, under "description")?

+2

Agitated

Frequent nonpurposeful movement or patientventilator dyssynchrony

2. If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can

+1

Restless

Anxious or apprehensive but movements not aggressive or vigorous

prompt patient to continue looking at speaker. Patient has eye opening and eye contact, which is

G

Alert and calm

sustained for more than 10 s (score -1).

Patient has eye opening and eye contact, but this is

not sustained for 10 seconds (score -2).

-1

Drowsy

Not fully awake, but has sustained (more than 10 s) awakening, with eye contact, to voice

Patient has any movement in response to voice, excluding eye contact (score -3).

-2

Light

Briefly (less than 10 s) awakens with eye con-

3. If patient does not respond to voice, physically

sedation

tact to voice

stimulate patient by shaking shoulder and then

-3

Moderate sedation

Any movement (but not eye contact) to voice

rubbing sternum if there is no response to shaking shoulder.

Patient has any movement to physical stimulation

-4

Deep

No response to voice, but any movement to

(score-4).

sedation

physical stimulation

Patient has no response to voice or physical stimu

-5

Unarou-sable

No response to voice or physical stimulation

lation (score -5).

From Sessler et al. (2002)

From Sessler et al. (2002)

Table 3.7. Behavioral pain scale (BPS)

Item Description Score

Facial Relaxed 1 expression Partially tightened (e.g., brow lowering) 2

Fully tightened (e.g., eyelid closing) 3

Grimacing 4

Upper No movement 1

limbs Partially bent 2

Fully bent with finger flexion 3

Permanently retracted 4

Compliance Tolerating movement 1

with Coughing but tolerating ventilation 2 ventilation most of the time

Fighting ventilator 3

Unable to control ventilation 4

or continuous femoral nerve block. With the use of regional anesthesia techniques, a dose reduction of opioids and their side effects can be achieved. Spinal-applied local anesthetics provide sympathicolysis with improved bowel function and less postoperative ileus. A drawback of the continuous regional anesthesia techniques is the risk of infection at the puncture site and the risk of spinal hematoma formation, when a hypocoagulatory state is caused by disease or treatment with antithrombotic agents (therapeutic anticoagulation).

From Payen et al. (2001)

Table 3.8. Drugs for analgesia, sedation and vegetative attenuation. On usage of Ketamin-S cut dosages in half. All dosages refer to a middle aged adult of 60 - 80 kg.

Drug Loading Dosage Application Metabolism Active Daily

(mg/50 ml) [mg(^g)/kg/h] speed (ml/h) metabolites costs

Low High Low High (Germany)

Table 3.8. Drugs for analgesia, sedation and vegetative attenuation. On usage of Ketamin-S cut dosages in half. All dosages refer to a middle aged adult of 60 - 80 kg.

Drug Loading Dosage Application Metabolism Active Daily

(mg/50 ml) [mg(^g)/kg/h] speed (ml/h) metabolites costs

Low High Low High (Germany)

Propofol 2%

1,000

0.8 mg

4mg

3.0

14

Oxidation

No

+++

Midazolam

90

0.01 mg

0.18 mg

0.5

6.9

Oxidation

Yes (prolonged sedation)

++

Remifentanil

5

1.5 |g

18 |g

1

12

Serum esterase

No

+++

Fentanyl

1.5

0.9 |g

3.5 |g

2.0

8.0

Oxidation

No Accumulation

+

Sufentanil

0.5

0.15 |g

0.7 |g

2.0

10.0

Oxidation

No

++

Ketamine

2,500

0.4 mg

3.0 mg

0.6

4.0

Glucuronidized

Yes

+++

Clonidine

2.25

0.32 |g

1.3 |g

0.6

2.0

Hydroxylized

No

+

Modified from Martin et al. (2005)

Modified from Martin et al. (2005)

Drug Dosage Terminal Metabolism Active Cost per half-life meta- applica-

bolites tion

Table 3.9. Co-medication to analgosedation.

Please be aware of contraindications

Modified from Martin et al. (2005)

CEA continuous epidural anesthesia

Piritramide Pethidine Paracetamol Metamizol

Diclofenac CEA

Block of femoral

50-100 mg supp, max 150-200 mg/day

Ropivacaine 0.2% 10-20 mg/h, or in combination with an opioid (sufentanil or fenta-nyl)

Or 15mlbupivacaine 0.25% 3-4/day

Ropivacaine 0.2 % 20-30 ml Or bupivacaine 0.25% 20-30 ml

1-2h 3h

Oxidation No

Demethyl. No

Conjugation No

Hydroxyliz. Yes

Hydroxy-

liz.+Conju-

gation

Hydroxyliz

Assessment of Agitation and Pain

See Tables 3.6 and 3.7 for the assessment of agitation and pain.

At regular intervals (e.g., once every 8-h shift), the algorithm for assessing sedation, pain, and agitation should be followed again.

function and its determinants are uncertain and have not responded to treatment.

• Class IIa (weight of evidence/opinion is in favor of usefulness/efficacy): surgical procedures in patients at increased risk of myocardial ischemia, myocardial infarction, or hemodynamic disturbances.

Drug Adjustment

Monitoring 3.5.2.1

Transesophageal Echocardiography

Transesophageal echocardiography (TEE) enables the experienced examiner to evaluate online the morphology of the anatomic structures of the heart and the large vessels, contractility of the ventricles, and blood flow.

The ACC/AHA/ASE 2003 guidelines (Cheitlin et al. 2003) state the following indication for an intraoperative TEE. Only the indications that apply to the urologic environment are stated:

Class I (evidence or general agreement that a given procedure or treatment is useful and effective): evaluation of acute, persistent, and life-threatening hemodynamic disturbances in which ventricular

With the PiCCO-system, cardiac output, the stroke volume index, the heart rate, the mean arterial pressure, the systemic vascular resistance, stroke volume variation (indicator of volume deficit), and left ventricular contractility can be measured continuously with a relatively noninvasive device. First a special arterial catheter must be placed in a large arteria (e.g., the femoral artery). This catheter has two functions: it has a transducer to measure the arterial pressure and a thermistor for the registration ofchanges in blood temperature for calibration. Second, a regular central venous catheter is needed to calibrate the system. After the setup, it should be calibrated at regular intervals (e.g., every 8 h), and changes in central venous pressure should be entered into the monitor to allow calculation of additional parameters. Please refer to Fig. 3.8 for the configuration of the PiCCO-system, to Table 3.10 for the overview of the complete parameters of the PiCCO-system, and to Fig. 3.9 for the decision tree and the therapeutic suggestions.

Picco Monitor
Fig. 3.8. Configuration of the PiCCO-System (Pulsion Technology 2006)
Table 3.10. Parameters and normal values of the PiCCO system

Category

Parameter

Abbr.

Value

Unit

Flow/afterload

Cardiac Index

CI

3.0-5.0

l/min/m2

Stroke Volume Index

SVI

40-60

ml/m2

Heart rate

HR

60 - 100

1/min

Mean arterial pressure

MAP

70-90

mm Hg

Systemic Vascular Resistance Index

SVRI

1700-2,400

dyn*s*cm-5m2

Volume management

Global End-Diastolic Volume Index

GEDI

680 - 800

ml/m2

Intrathoracic Blood Volume Index

ITBI

850-1,000

ml/m2

Stroke volume variation

SVV

10

%

Pulse pressure variation

PPV

10

%

Lungs

Extravascular Lung Water Index

ELWI

3.0-7.0

ml/kg

Pulmonary Vascular Permeability Index

PVPI

1.0-3.0

Contractility

Global ejection fraction

GEF

25-35

%

Cardiac Function Index

CFI

4.5-6.5

1/min

Left ventricular contractility

dP/mx

Continuous parameters/discontinuous parameters Modified from Pulsion Technology (2006)

Continuous parameters/discontinuous parameters Modified from Pulsion Technology (2006)

3.6 Intraoperative and Postoperative Procedures

Fig. 3.9. PiCCO Decision Tree (Pulsion Technology 2006)

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