In this episode, I’ll discuss using analgosedation in critically ill patients.
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Before we begin, I’d like to share a pearl from my book, A Pharmacist’s Guide to Inpatient Medical Emergencies:
“Typical features of shock: AMS, high HR, low BP, oliguria, cool & clammy skin, acidosis” #pharmacists https://t.co/w0tP1mmQW7
— Pharmacy Joe (@PharmacyJoe) September 17, 2016
Background
Acceptance of using analgosedation, or “analgesia-first sedation” for critically ill patients is steadily growing.
Pain is common in critical illness and is not addressed by common sedative agents like benzodiazepines and propofol.
The 2013 SCCM Pain, Agitation & Delirium guidelines give a positive recommendation for using analgosedation for mechanically ventilated ICU patients. The recommendation is graded evidence level 2B.
Pain and discomfort are often primary causes of agitation.
One moderate-quality study suggested that analgosedation is associated with longer ventilator-free time and shorter ICU LOS.
Unfortunately, this study did not mimic real-life practice. The nurse to patient ratio was 1:1 and patient sitters were available.
The SCCM guideline authors made the familiar “call for more research.”
Recent research
Recently, a group of researchers at Texas Health Presbyterian Hospital in Dallas published a retrospective review comparing the before and after period of implementation of an analgosedation protocol. Analgosedation was effective and resulted in a shorter ventilator duration, lighter sedation, better pain management, and lower use of sedative infusions. The review did not demonstrate an impact of the protocol on the development of ICU delirium.
Perhaps the most significant part of this study is that it was performed in a medical ICU. The research referenced in the SCCM guidelines was taken from surgical ICU patients.
I have not yet seen the sedation protocol used at Texas Health Presbyterian Hospital in Dallas. Analgosedation protocol information is available at icudelirium.org, a resource that has been discussed on this podcast several times in the past.
Adapting a protocol to the real-world
Finding an analgosedation protocol that fits a real-world scenario is challenging. Existing protocols such as the one at icudelirium.org are the product of years of institution-specific efforts changing the culture, knowledge, and practice habits of critical care nurses and providers.
Copy-pasting such a protocol into a community hospital ICU is not likely to be successful or even safe. The reasons for this are many including:
1. Nurses in the real-world don’t always have low 1:1 patient ratios and patient sitters available.
2. Practitioners that are used to continuous sedative infusions need to receive significant education to switch to other methods of providing sedation.
3. Different providers in the real-world are not always consistent in their approach or agreement with protocols compared to how they would be in a clinical trial.
In my opinion anyone interested in beginning an analgosedation protocol in their ICU should compare and contrast current practice with the ideal practice represented by these published protocols. Ideally, this comparison will be done with a multidisciplinary group. This group can then come up with a “bridge protocol” to cross the gap between current practice and the eventual goal of an analgosedation protocol.
Example “bridge protocol”
For example, in an ICU that uses continuous infusions of sedatives without analgesia, a “bridge protocol” would look like this after mechanical ventilation is started:
- Fentanyl infusion at 1 mcg/kg/hr
- Frequent fentanyl boluses as needed for pain or agitation with a RASS of +1
- Frequent midazolam boluses as needed for agitation with a RASS of +2 or higher
- Increase fentanyl infusion rate when multiple fentanyl boluses are needed within a short period
- Add a continuous sedative infusion (propofol, dexmedetomidine, or midazolam) when multiple midazolam boluses are needed within a short period
The exact medication choices, dosages, and frequencies should be tailored to the needs identified by the multidisciplinary group. This “bridge protocol” can then be continuously refined and iterated upon until it morphs into a true analgosedation protocol similar to what is used in published studies.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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