Use of Sedation and Neuromuscular Blockers in Critically Ill Adults Receiving High-Frequency Oscillatory Ventilation.

Burry LD, Seto K, Rose L, Lapinsky SC, Mehta S.

Ann Pharmacother. 2013 Sep;47(9):1122-1129.

Source

Department of Pharmacy, Mount Sinai Hospital, New York, NY.

Abstract

BACKGROUND:

Nearly all patients receive sedation and neuromuscular blockers (NMBs) during high-frequency oscillatory ventilation (HFOV).

OBJECTIVE:

To describe analgo-sedation and NMB use prior to and during HFOV in adults with acute respiratory distress syndrome.

METHODS:

Retrospective single-center study of 131 consecutive adults whose care was managed with HFOV from 2002 to 2011.

RESULTS:

During the first 4 days of HFOV, 89% and 95% of patients received sedation and opioids, respectively. Upon HFOV initiation, 119 (90.8%) patients received fentanyl doses higher than 200 µg/h; of these, 48 also received more than 20 mg/h of midazolam. Analgo-sedation doses increased significantly over time such that doses were double by day 3. Factors independently associated with fentanyl doses higher than 200 µg/h were NMB ever used (OR 4.43; 95% CI 1.26-15.65, p = 0.02), pH less than 7.15 (OR 2.08; 95% CI 1.22-3.5, p = 0.007), worsening partial pressure of oxygen/fraction of inspired oxygen (OR 1.05; 95% CI 1.00-1.10, p = 0.04), and Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR 0.87; 95% CI 0.79-0.97, p = 0.009). Deep sedation was commonly administered when NMBs were not being used, with 99.2% of sedation-agitation scores of 1 or 2. Eighty-six patients (65.6%) received NMBs and use was greatest on day 1 (59.5%). Train-of-Four was measured every hour for 53.4% of patients; 29.2% of the measurements were 0 of 4. NMB use declined over the 10-year study period.

CONCLUSIONS:

High analgo-sedation doses were associated with APACHE II scores, worsening gas exchange, and NMB use. Two thirds of patients received NMBs; use was highest on day 1 and subsequently declined. The percentage of patients who received NMB during HFOV in our study was lower than that previously reported. Future research should evaluate patient outcomes with and without use of NMBs, as well as the potential to manage patients with less sedation.

KEYWORDS:

high frequency oscillatory ventilation, intensive care unit, neuromuscular blockers, sedation

The effect of ketamine on hypoventilation during deep sedation with midazolam and propofol: A randomised, double-blind, placebo-controlled trial.

De Oliveira GS Jr, Fitzgerald PC, Hansen N, Ahmad S, McCarthy RJ.

Eur J Anaesthesiol. 2013 Nov 14. 

Source

From the Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Abstract

BACKGROUND:

Hypoventilation is a major cause of morbidity and mortality in patients having procedures under sedation. Few clinical strategies have been evaluated to reduce intraoperative hypoventilation during surgical procedures under deep sedation.

OBJECTIVE:

The primary objective of this investigation was to examine the effect of ketamine on hypoventilation in patients receiving deep sedation for surgery with midazolam and propofol.

DESIGN:

The study was a randomised, placebo-controlled, double-blind clinical trial.

SETTING:

Intraoperative.

PATIENTS:

Healthy women undergoing breast surgery.

INTERVENTION:

Randomised to receive ketamine (0.5 mg kg bolus, followed by an infusion of 1.5 μg kg min) or isotonic saline.

MAIN OUTCOME MEASURE:

Duration of hypercapnia measured continuously with a transcutaneous carbon dioxide (TCO2) monitor.

RESULTS:

Fifty-four participants were recruited. Patient and surgical characteristics were similar between the study groups. The median percentage of the sedation time with TCO2 more than 6.7 kPa in participants in the ketamine group, 1.2% (95% confidence interval, CI, 0 to 83), was less than that in the isotonic saline group (65%, 95% CI, 0 to 88; P = 0.01). Severe hypoventilation (TCO2 >8.0 kPa) was also less in the ketamine group, median 0% (95% CI, 0 to 11.7) compared with 28% (95% CI, 0 to 79.3; P = 0.0002) for the isotonic saline group. The ketamine group required less airway manoeuvres (chin lift) to keep the SaO2 greater than 95% median (95% CI) [0 (0 to 3) compared with 3 (0 to 16) in the isotonic saline group] (P = 0.004).

CONCLUSION:

Ketamine decreased the duration and severity of hypercapnia in patients undergoing deep sedation with propofol. The addition of ketamine may reduce hypoventilation and adverse effects in patients having procedures under sedation.

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https://sites.google.com/a/paldoc.com/all-things-palliative

Algies pelvipérinéales

 

 Eléments clés de la prise en charge des algies pelvipérinéales chroniques rebelles

Même s'il n'existe pas encore, à ce jour, de recommandations internationales de prise en charge consensuelles validées, certains éléments clés de la prise en charge actuelle des algies pelvipérinéales peuvent être soulignés.

Comme pour tous les syndromes douloureux, il est nécessaire d'effectuer un bilan lésionnel rigoureux (le plus souvent négatif), à la recherche de pathologies organiques régionales (infectieuses, tumorales, malformatives, lithiasiques...) pouvant faire l'objet d'un traitement spécifique.

Il faut également comprendre les mécanismes favorisants et d'entretien des algies pelvipérinéales, communs aux autres syndromes douloureux chroniques.

• Terrain favorisant : histoire de vie marquée par des événements traumatiques physiques et/ou psychologiques, notamment des abus sexuels (quatre fois plus que dans la population générale [Hu JC et al. 2007]), carences affectives précoces).
• Facteurs déclenchants : physiques, comme une intervention chirurgicale, ou psychologiques, comme un deuil, un divorce, un licenciement (Schaeffer AJ et al. 2002).
• Facteurs d'entretien : iatrogénie, examens complémentaires inutiles, gestes techniques ou chirurgicaux inappropriés et/ou répétitifs, nomadisme médical voire éléments contentieux.
• Fréquence des comorbidités douloureuses et psychologiques : syndromes douloureux abdomino-pelviens chroniques entre eux (syndrome de vessie douloureuse, syndrome de l'intestin irritable, névralgie pudendale, vestibulite vulvaire), syndrome fibromyalgique associé, antécédents de syndrome douloureux régional complexe (SDRC) ; troubles psychologiques : syndrome dépressif, anxiété organique (Clemens JQ et al. 2008).

Une démarche diagnostique est nécessaire et doit être basée sur une approche par symptômes, à partir de l'interrogatoire qui, lorsqu'il est bien conduit, peut être très contributif : la douleur prédomine souvent dans un territoire donné (périnéal notamment, mais aussi testiculaire ou pénien, urétral ou vésical) ; à partir de là, la douleur peut être attribuée à un territoire d'innervation d'origine thoraco-lombaire (sympathique participant à la sensibilité viscérale) ou à un territoire sacré (somatique, périnéal).

L'association de la douleur à des troubles fonctionnels urinaires, digestifs ou sexuels justifie un traitement associé et d'une coopération entre spécialistes des pathologies d'organe et algologues. Il faut aussi prendre en compte, au plan thérapeutique, des phénomènes d'hypersensibilisation centrale (communs à d'autres syndromes douloureux chroniques comme le SDRC ou la fibromyalgie), expliquant le caractère neuropathique des douleurs. Une approche pluridisciplinaire, médico-chirurgicale et psychologique des patients permet d'éviter le piège d'une approche exclusivement lésionnelle.

Une prise en charge pluridisciplinaire stratifiée est recommandée, nous la détaillerons le mois prochain. 

Hu JC et al. J Gen Intern Med. 2007 Nov; 22(11): 1532-7

Schaeffer AJ et al. J Urol. 2002 Aug; 168(2): 593-8

Clemens JQ et al. J Urol. 2008 Oct; 180(4): 1378-82
http://link.springer.com/article/10.1007/s11606-007-0341-y
http://www.sciencedirect.com/science/article/pii/S0022534705646861
http://www.sciencedirect.com/science/article/pii/S0022534708015644

American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.

Jarzyna D, Jungquist CR, Pasero C, Willens JS, Nisbet A, Oakes L, Dempsey SJ, Santangelo D, Polomano RC.

Pain Manag Nurs. 2011 Sep;12(3):118-145

.e10. doi: 10.1016/j.pmn.2011.06.008.Source

University Medical Center, Tucson, Arizona 85724, USA.

Abstract

As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events. Multiple factors, including opioid dosage, route of administration, duration of therapy, patient-specific factors, and desired goals of therapy, can influence the occurrence of these adverse events. Furthermore, there is an urgent need to educate all members of the health care team about the dangers and potential attributes of administration of sedating medications concomitant with opioid analgesia and the importance of initiating rational multimodal analgesic plans to help avoid adverse events. 

Nurses play an important role in:

 1) identifying patients at risk for unintended advancing sedation and respiratory depression from opioid therapy; 

2) implementing plans of care to assess and monitor patients; and

 3) intervening to prevent the worsening of adverse events. 

Despite the frequency of opioid-induced sedation, there are no universally accepted guidelines to direct effective and safe assessment and monitoring practices for patients receiving opioid analgesia. Moreover, there is a paucity of information and no consensus about the benefits of technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy. To date, there have not been any randomized clinical trials to establish the value of technologic monitoring in preventing adverse respiratory events. Additionally, the use of technology-supported monitoring is costly, with far-reaching implications for hospital and nursing practices. As a result, there are considerable variations in screening for risk and monitoring practices. All of these factors prompted the American Society for Pain Management Nursing to approve the formation of an expert consensus panel to examine the scientific basis and state of practice for assessment and monitoring practices for adult hospitalized patients receiving opioid analgesics for pain control and to propose recommendations for patient care, education, and systems-level changes that promote quality care and patient safety.

Copyright © 2011 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserve