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Sedation and pain control
筆記整理: 奇美醫院住院醫師 盧致穎 Introduction:
The quality of evidence for each statement and recommendation was ranked as high The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (–) a intervention. Concept of perfusion: 血管截面積大: Adequate volume, analgesics, sedatives 血管截面積小: Volume deficiency, pain, agitation/delirium, ventilator fighting Intestine with well perfusion: Normal digestion Intestine with poor perfusion: Autodigestion, bacterial translocation ↑circulation catecholamines : Ileus/stress ulcer Catabolic hypermetabolism: hyperglycemia, lipolysis, breakdown of muscle ↓Cytotoxic T cells/ Neutrophil phagocytic activity: Immunosuppression Hypoperfusion → Intestine ischemia → Inflammation/SIRS → Organ failure Assessment of pain
Assess pain : Visual Analogue Scale(VAS) and Numrical Rating Scale(NRS) are gold The Behavioral Pain Scale (BPS) and the Critical- Care Pain Observation Tool (CPOT) for adult patients who are unable to self-report (B) Use vital signs alone to assess pain (-2C) Vital signs may be used as a cue to begin further assessment(+2C) Monitor agitation and depth of sedation
The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) RASS: -1~-3(light to moderate sedation) -4~-5(Deep sedation) Maintaining light levels of sedation in adult ICU patients improved clinical outcomes (B) ;Use painkiller in patients after surgery Maintaining light levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B) Detecting and Monitoring Delirium
Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools in adult ICU patients (A). Routine monitoring of delirium in adult ICU patients is feasible in clinical practice Feature 1 : acute change or fluctuating course of mental status Feature 3 : Altered level of consciousness Treat Pain, Agitation and Delirium
Pain management can be facilitated by identifying and treating pain early rather than
Use intravenous (IV) opioids as the first-line drug class of choice to treat All available IV opioids, are equally effective (C). Use non-opioid analgesics to decrease the amount of opioids administered and Thoracic epidural anesthesia/analgesia for postoperative analgesia in patients with - abdominal aortic aneurysm surgery(+1B) Pain management for abdominal surgery:
Compare epidural, IVPCA and continuous wound infiltration for postoperative pain management after open abdominal surgery. Epidural analgesia reduced incidence of chronic pain after abdominal surgery. Perioperative IV lidocaine infusion reduce pain and analgesic requirements Choice of Sedatives
Identification and treatment of possible underlying causes of agitation Propofol or dexmedetomidine may be preferred over BZDs to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B) BZDs may increase ICU LOS by approximately 0.5 days Use either daily sedation interruption or light target level of sedation in mechanically If RASS goal < -3, daily interruption if feasible Drug shifting strategy for long term sedation: Do not suggest either haloperidol or atypical antipsychotics (-2C) Reduces the duration of delirium in adult ICU patient - continuous IV infusions of dexmedetomidine (+2B) - Atypical antipsychotics: quetiapine(Seroquel) (C) Choice of sedatives and decrease delirium
- Dexmedetomidine: ↓ICU cost compare to midazolam infusions (↓ICU stay and Early Mobility and Exercise
ICU-acquired weakness: 25-60%: Prolongs mechanical ventilation, hospital LOS and Early mobility↓ incidence/duration of delirium(+1B) Acute respiratory failure pts with early mobility - Out of bed 6 days earlier - Discharged from ICU 1.5 days earlier Interdisciplinary ICU team approach (+1B) - Education - Protocols and order forms - Checklists Pain Management and Sedation for Critical Obese Patients: sleep apnea - Continues IV infiltration instead of bolus - Dexmedetomidine - Bipap/CPAP - Sit up 45。 Q & A:
Q: 請問 IV infiltration Lidocaine 是否會容易有 CNS side effect ? A: 劑量上控制在 240mg/hr 以內,依照研究的 protocol 來使用 Q: 在使用呼吸器狀況下讓病人使用助行器來達到 early mobilization 是否可行? A: 若有大量的人力支援的情況下是可行的,一般情況的人力配置無法達到 Q: 使用 Morphine or Fentanyl 的部分患者有主動吐氣和呼吸器 fighting 的情況是 A: 除了呼吸器的調整外,或許稍為加重 sedation 即可改善此情況。

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