TopicsImproving critically ill outcome is not just a matter of how and when administering a particular drug.
Wwe need to revise the entire clinical approach in the intensive care setting to reach this important target.
Sedation and Analgesia
... are two highly connected items that need to be delt with separately.
Trying to sedate patients using opiates could be a fascinating approach with the risk of abusing them. In the contest of a painful patient it’s correct to threat this condition using opiates; anxiety, restlessness and aggressiveness need a different approach using other pharmacologic categories with relatively less collateral effects from opiates.The A.O. San Paolo ten years old experience in sedating critical ill patients is found on the enteral approach of sedation using, in particular, lorazepam and idrossizina. This kind of administration means a slower absorption and elimination of drugs with a superficial level of sedation reached. In this setting, adding oral melatonin could re-establish patients’ sleeping-awake rhythm.
Acute cerebral disfunction (delirium) among critically ill is a widespread and worrying matter.Newly developed instruments to correctly investigate patients’ neurological status are nowadays available giving the operators the possibility to diagnose also those types of delirium characterized by the hypokinetic pattern. Not diagnose or misdiagnose delirium means not treating this condition!
The acute cerebral disfunction is strenghtly associated whit increased morbility and mortality unregarding those other severity scores such as APACHE, SAPS II and physiologic evaluation parameters (age, associated morbidity etc..).Morbility and mortality improve with the days a patient experience delirium.
Health operators’ training in precociously detecting delirium appears to be crucial; everyday targets should be aimed at:
- preventing delirium by maintenance of stable vital parameters, correct use of drugs, rationale organization of operators and patients spaces;
- monitoring delirium using international validated instruments by health operators trained to use them;
treating delirium: first solving physiologic problems than trying to treat the condition with non-pharmacologic strategies and only at the end using targeted drugs.
Considering cerebral health as important as any other vital parameter is the first step in improving critically ill quality and quantity of life ... learn more on SedaICUConsult the internationa literature about Delirium
Conscious Critically ill
The most important new in intensive care is the possibility to keep patient awake: from deep sedation is suitable to pass to a conscious sedation, consisting in use of analgesic and sedative drugs in minimal amount, with the aim of a good adaptation to critical disease and to invasive treatment, achieving as soon as possible the conscious state.
Obviously to succeed in keeping awake a critical high risk patient (SAPS > 32 and mechanical ventilation > 2 days ), it’s necessary a deep change in the culture of approach to these patients. It should modify many common practices, such as:
- Mechanical ventilation patterns which second patient respiratory trigger: Pressure Support instead of Pressure Control, NAVA, frequent SIGH instead of prolonged recruitment maneuvers, …
- Tracheal respiratory prosthesis management: naso-tracheal intubation instead of oro-tracheal, early tracheostomy in patient with predicted mechanical ventilation in second day longer than 8/10 days, …
- Monitoring pain through validate instruments and early successful analgesic therapy;
- Hygiene practices with some precautions: analgesic and/or sedative bolus before painful or worrying to the patient procedures, early mobilization to physiotherapy, physical restraint if risk of removing catheters and prosthesis;
- Early orientation of the patient: talks between operators and patient, calling him with his name, get him able to see and heard with his own prosthesis, exhortation to psychophysical activity, …
- Get early enteral nutrition, accurate metabolic control, restore as soon as possible diet per os;
- Improve collaboration between operators and with patient relatives, especially in Units with prolonged times of relatives access to patients (“open” ICUs).
These are only some of the tricks needed to keep conscious, awake, critically ill patients. This aim is the last strong ring in a weak chain: if one of the above element is fragile, patient will show his intolerance to “wakefulness”, inducing little motivated operators to increase sedation rather than solve discomfort causes in that patient, in that moment… Learn more about this item with SedaICU lessons
Un reparto di Terapia Intensiva è un unico organismo… Non si può curare gli ammalati senza prendersi cura anche degli operatori.
Gestire il doloreFlowchart dolore
Gestire la sedazioneFlowchart sedaz/agitaz
Gestire il deliriumFlowchart Delirium
Scheda di lavoro CAM-ICU
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Finanziamento per la Ricerca Indipendente
(Decreto DGS 13456 del 22 dicembre 2010)