Guidelines for Pain, Agitation/Sedation, Delirium in the ICU

I am currently working on a lecture where I discuss reducing the utilization of opioids in the ICU for our critically ill patients. The sources of pain are plentiful, unfortunately. Truth is, opioids are the best option for our patients at the time of this writing but we also need to work hard to try to minimize the exposure to this family of medications via alternatives. Which alternatives might you ask? In particular, I have taken deep dives into the utilization of ketamine, magnesium, gabapentin/pregabalin, NSAIDS, nefopam, acetaminophen, dexmedetomidine, as well as regional blocks performed by our anesthesia colleagues. 

The PADIS (pain, agitation/sedation, delirium, immobility, and sleep disruption) guidelines linked here, and are completely FREE to download, provide some direction as to how to better take care of our patients. When I write these lectures, and this may seem counterintuitive to some, I leave the guidelines for last and attempt to read everything under the sun on the topic so that it does not cloud my interpretation. I had read these guidelines in 2018 when they initially came out but now I have even more respect for the section on pain management bc the quality of the studies just aren't as good as we want them to be. Hence the "very low quality of evidence" tied to many of the recommendations made. I surprised that they even made a dosing recommendation for ketamine as the dosing behind most of the articles are pretty scattered.  

These guidelines are a monumental undertaking and I send a definite hat tip to the authors.

Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825–e873.

-EJ

Link to FULL FREE Article



Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Continuous Infusion of Lidocaine

I covered the 2015 version of meta-analysis back in April when I couldn't get my hands on this one, the 2018 version. I appreciate the Cochrane Library for making this free. You could get to it from my website. The last time I posted about Lidocaine was in April when I had fewer than 1500 followers and this community is extremely helpful in shaping how we all practice. Not to mention that my posts at that time were even harder to read than they are now!

At that time, a follower named @ameliahlaws commented on how her shop uses lidocaine for their trauma patients and have seen great results. That was definitely encouraging. I do not have experience with this in my practice because it cannot be used in patients with renal nor heart failure due to the active metabolites which can cause accumulation and toxicity respectively. As I primarily take care of medical ICU patients at the moment, using this medication would not be helpful.

This meta-analysis was one heck of an endeavor. Let me summarize the 285 pages in several words: we need more data. That was the conclusion that these authors came to as well because ultimately the quality of the data is so poor, or how they described it "very low quality". It hurts to write that because, as many of you know, I do not do research myself, and that seems like a kick in the face to those out there who work so hard doing the necessary research that ultimately improves patient care.

I have added the Forest Plots to my slides because they look pretty and make it seem like it's of substantial impact but in reality it's not. Sigh.

As mentioned, many of the findings were "very low quality". That doesn't mean that it doesn't work, nor that future studies won't prove that it does work, but rather that we just don't know YET.

The authors are recommending someone, anyone, conduct a study with more than 200 patients. I guess that's why this is "cutting edge" stuff at the time of this post. They also cannot make any recommendations regarding dosing, duration, timing, and the type of surgery where this would benefit the most.

-EJ


Link to Article (FREE)

Link to PDF

Weibel S, Jelting Y, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database of Systematic Reviews 2018; 6: CD009642.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Be careful with Ketamine and Catecholamine-dependent Heart Failure

The Ketamine kick continues! I am not going to pretend I knew everything about everything as I've created this page over the last several months. People who walk around saying things like they were born with that knowledge sometimes need to be checked. We all had that one eye-opening day where it was like, "(explicative) I should have known that!"

I had some basic knowledge on ketamine but fortunately I have expanded that substantially over the course of working on my lectures. The whole "negative ionotrope" concept was something I was familiar with, but I never actually looked up in depth until colleagues such as the great Seiha Kim, David Convissar, and other great anesthesia colleagues who have more experience on the matter than I do. Not to mention that Seiha is both a pharmacist and an anesthesiologist.

A healthy heart should not have any issues with ketamine for sedation nor rapid sequence intubation, but, as mentioned in the Christ article linked, you can find a 21% decrease in cardiac index. This also brings me to the point where many clinicians focus on the blood pressure while ignoring the patients cardiac index/cardiac output. It makes us feel all warm and fuzzy inside to see the MAP > 65 as we keep on increasing our pressors but at the same time we have NO IDEA what this afterload increase is doing to the LV. We feel self-reassured but really our patients are going on a downward spiral. That's a discussion for another day. We really need more than a BP cuff or an a-line to get a true grasp of what's going on with our critically ill patient who is otherwise hemodynamically unstable.

-EJ

Link to Abstract

Christ G, Mundigler G, Merhaut C, Zehetgruber M, Kratochwill C, Heinz G, et al. Adverse cardiovascular effects of ketamine infusion in patients with catecholamine-dependent heart failure. Anaesth Intensive Care. 1997;25:255–259.

Link to Abstract

Bovill JG (2006). Intravenous anesthesia for the patient with left ventricular dysfunction. Semin Cardiothorac Vasc Anesth 10: 43–48.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Ketamine: Mechanism of Action

Link to Abstract

Link to FULL FREE Article

K Hirota, D G Lambert, Ketamine: its mechanism(s) of action and unusual clinical uses., BJA: British Journal of Anaesthesia, Volume 77, Issue 4, Oct 1996, Pages 441–444.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Magnesium for Sedation in Mechanically Ventilated Patients?

This is cool, really cool. We need more data, but this is a great start. I learned a lot of basic science from reading the introduction as well as discussion on this article and it all makes sense. I don't see myself using this anytime soon until there's a study where they add magnesium to a different agent that's not midazolam because I do not use benzodiazepines in my practice for sedation unless there are extreme cases.

I encourage you read this article yourself as it's interesting and I don't want to divulge too much out of respect for the authors.

-EJ



Link to Abstract

Link to FREE FULL PDF

Altun, Dilek. (2019). Can we use Magnesium for sedation in Intensive Care Unit for critically ill patients; Is it as effective as other sedatives?. Ağrı - The Journal of The Turkish Society of Algology. 31.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Ketamine Continuous Infusions for Sedation in the ICU

One of the lectures I’m working on is regarding minimizing opioid utilization in the ICU on our critically ill patients on mechanical ventilation.

I honestly do not use ketamine as often as I’d like and I have been reviewing all the data behind continuous infusions over the last two days.

Unfortunately, the data isn’t incredibly robust (small sample sizes, mostly retrospective, heterogenous non-MICU patient populations) and there is a wide variation in the doses used in the different studies. This study published earlier this year used ketamine in conjunction with other agents, mostly propofol or fentanyl. The authors found that using ketamine decreases the doses the other agents with no changes in all the other outcomes. Most clinicians are looking for miracle drugs rather than incremental (albeit small) improvements here and there.

One of the problems I have with ketamine is, depending on how it’s mixed, is the sheer volume of the drip. I try to keep my patients potato chip dry and if the ketamine is basically a maintenance fluid, I’m not going to be as excited about it. 

Do you all use ketamine in your ICU for continuous sedation? Do you use it as monotherapy or with other infusions?



Link to Abstract

Garber, P. M., Droege, C. A., Carter, K. E., Harger, N. J. and Mueller, E. W. (2019), Continuous Infusion Ketamine for Adjunctive Analgosedation in Mechanically Ventilated, Critically Ill Patients. Pharmacotherapy, 39: 288-296.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Analgesia and Sedation in the ICU

Link to Abstract

Sessler, C. N., Grap, M. J., & Brophy, G. M. (2001). Multidisciplinary Management of Sedation and Analgesia in Critical Care. Seminars in Respiratory and Critical Care Medicine, 22(02), 211–226.

Continuous Lidocaine Infusion as Adjunctive Analgesia in Intensive Care Unit Patients

Link to Article

Link to full FREE PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.