ICU PATIENT CARE: SERIES OF BASICS
Being a clinical pharmacist have you ever imagined the emotional status of a patient? Critical illness can be a frightening experience for a variety of reasons, and adequate sedation may reduce this. Pain is a common problem and may be worsened by invasive and unpleasant procedures. Agitation is thought to occur at least once in 71% of patients in a medical-surgical ICU. Let’s have a brief about the significance of checking the sedative status of an ICU patient.
There are many scoring systems to evaluate such as Ramsay, Addenbrookes and Bloomsberry scale.
Sedation score as per Bloomsberry scale:
SEDATION SCORE 3 - Agitated and restless 2 - Awake and comfortable 1 - Aware but calm 0 - Roused by voice -1 - Roused by touch -2 - Roused by painful stimuli -3 - Unrousable A - Natural sleep P - Paralysed
IMPORTANCE OF MONITORING SEDATION:
How much sedation is given, and for how long, is important in determining patient outcome as both over and under-sedation can have potentially deleterious consequences. Over-sedation can increase time on ventilatory support and prolong ICU duration of stay. Under-sedation can cause hyper-catabolism, immunosupression, hypercoagulability, and increased sympathetic activity. Haemodynamic responses as a measure of sedation are unreliable in the critically ill patient, hence the need for formal sedation scoring.
Instrumental measures of sedation:
(i) Electroencephalograms (EEG): This requires specifically trained personnel and equipment and is thus not practical in the intensive care environment.
(ii)Bispectral index (BIS): This technique is mostly used to monitor depth of surgical anaesthesia in the operating theatre; it provides a quantitative value between 0 and 99. A BIS value of 0 equals EEG silence, near 100 is the expected value in a fully awake adult, and between 40 and 60 indicates a level recommended for general anaesthesia.
A sedation holiday involves stopping the sedative infusions and allowing the patient to wake. The infusion should only be restarted once the patient is fully awake and obeying commands or until they became uncomfortable or agitated and deemed to require the resumption of sedation. Ideally, this should be performed on a daily basis. This strategy has been shown to decrease the duration of mechanical ventilation and the length of stay in ICU, without increasing adverse events such as self-extubation.
Sedation protocols should be standard in every critical care, and followed by nursing and medical staff. Such protocols should be regularly updated. Titration of individual patients’ sedation throughout their ICU admission should reduce over-sedation and side-effects, and contribute to reduced duration of mechanical ventilation and length of stay.