A new Era in the Care of the critically ill patient, by Miguel Ángel Romera

It is not uncommon to observe that, for some professionals involved in the care of the critically ill patient, sedation remains a low priority over other aspects of treatment such as respiratory, cardiac or renal function. 

Concepts as early resuscitation in sepsis or the strategy of lung protection in patients with respiratory distress syndrome are assumed, but with analgesia or sedation is another question.

Multiple studies have shown an insufficient monitoring of analgesia, sedation and delirium, inadequate analgesia in many patientes and how oversedation is still a problem in many ICU. However, the strategy of analgesia and sedation used will influence the evolution of the patient and growing evidence shows the relationship between unnecessary excessive sedation and adverse effects such as cognitive disorders, neuromuscular complications or increased mortality.

In the same path that SCCM recommendations (1) or the most recent made in Germany (2), Intensive Care Medicine has just published a review, proposing a new approach to the topic, called “eCASH concept” (early Comfort using Analgesia, minimal Sedatives and maximal Human care) (3). This concept perfectly summarizes what the current focus of any strategy of sedoanalgesia in the critical patient should be, and basically consists of the early implementation of a bundle in order to keep the patient comfortable, calm and cooperative.



1. The first priority is to achieve effective analgesia for the patient, using a multimodal strategy on which opioids are the mainstay of treatment. The choice of the drug will depend on factors such as the pharmacokinetic and pharmacodynamic properties, pain intensity or concomitant sedation regime.

2. Starting from this point, the next step is to establish a sedation protocol based on objectives, according to the patient's clinical situation. These objectives must be clearly defined at the beginning of the treatment and daily revised, considering that most of patients can be kept, from the first moments, with a superficial sedation (RASS 0, - 1). When this is not feasible, as for example, patients with neuromuscular blockers, some cases with severe respiratory failure, intracranial hypertension, or status epilepticus, consider minimizing sedation as early as possible as soon as the clinical situation allows it. 

We can´t justify a deep sedation due to enough staff. In this context, the role of the interruption of sedation would be limited to a rescue measure in cases of drug accumulation. "Goodbye daily sedation stops: hello frequent titration protocols".

In this strategy, it is essential to make an adequate choice of the sedative and evidence goes in favour of the use of drugs non-benzodiazepine (propofol, remifentanil, dexmedetomidine). Probably, benzodiazepines should be limited to selected cases as some patients requiring deep sedation, abstinence, or seizures.


Routine and frequent monitoring of pain, sedation and delirium with validated tools is required to achieve these objectives. Because of the interpersonal variability in the dosage of sedatives and analgesics for a same effect, it is mandatory to maintain a strict monitoring to manage the minimum effective dose to achieve the desired objective.

3. Patient-centered care. In this approach, even when the aim is to maintain a superficial sedation, not all are drugs. It is important to establish care based on the needs of the patient, and probably also of the family. Emotional support to the patient and the family are a fundamental part.

The inability to speak is stressful and inefficient communication impacts negatively on the patient, generating sensations such as helplessness, frustration, anxiety, or fear. It is important to try to optimize communication and work to find alternative methods to improve it.

We have to apply measures of reorientation and environmental stimulation, including clear explanations about the disease and the actions that will be performed, allowing the availability of familiar objects, etc.

In addition, it is important to adapt the environment, trying to make it more comfortable. Reducing noises, lights or unnecessary manoeuvres, especially during rest periods, to facilitate sleep. Improving the privacy and comfort of patients. Limiting the use of physical restraint and promote the early mobilization and collaboration of the patient in rehabilitation. Facilitating the family presence and their participation in care, always under adequate supervision.

Recently, the results of a study conducted in seven ICU in California has been published, including more than 6,000 patients: the application of similar measures, the “ABCDEF bundle”, is associated with an increase in the free days of delirium or coma, and an increase in survival, related to the degree of fulfilment of the same (4).

There are no excuses, it is time to change. Time to evaluate in every ICU, not only the analgesia and sedation practices, also other measures that imply that our units are no longer a hostile place. There is sufficient evidence to improve care, implementing strategies as the concept eCASH concept of the ABCDEF bundle. This is a challenge but the result can be very positive for the patient, improving not only the evolution, but also making their ICU experience more human and less traumatic.

To succeed, attitude and commitment of the whole team of professionals involved in the care is essential.

Dr. Miguel Ángel Romera
Hospital Universitario Puerta de Hierro-Majadahonda ICU


References

1.- Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306.

2.- Baron R, Binder A, Biniek R, Braune S, Buerkle H et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) -short version. Ger Med Sci 2015; 13: Doc19.

3.- Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med 2016 Apr 13

4.- Barnes-Daly MA, Phillips G, Ely EW. ICU liberation: using the ABCDEF bundle to improve outcomes in 7 California community ICUS. Crit Care Med 2015; 43 (Suppl): A41

Trick of the Trade: Securing the intraosseous needle

intraosseous needle IO-secure So much attention is appropriately focused on the anatomy and technique for intraosseous needle placement. In contrast, very little attention is paid to securing the needle. Often this involves a make-shift setup which involves gauze, wraps, and/or tape. This becomes especially important in the prehospital setting where these can be easily dislodged. The following trick stems from a Twitter discussion in 2015 amongst prehospital providers, lamenting this fact.

Trick of the Trade

Use a mask from a bag valve mask (BVM) setup

Place the padded mask over the IO needle. The IV tubing can be threaded through the hole at the top of the mask. Secure the mask by wrapping circumferential tape around the extremity and mask as a unit. This mask trick works whether the IO needle is in the tibia, femur, or humerus. If available, you can use a pediatric mask for a less obtrusive setup – great tip by Ireland paramedic Eoghan Connolly (@EoghanCon11).

intraosseous needle

Image and trick courtesy of Scott Long (@FlightNurse30)

 

The mask also works for humeral IO lines and seems pretty secure with a prototype that Dr. Jonathan Fu and I tested on shift.

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco

The post Trick of the Trade: Securing the intraosseous needle appeared first on ALiEM.

Siguiendo con el uso de opioides en el dolor crónico


Hace relativamente poco publicamos otra entrada sobre este tema. Ahora se trata de la actualización de una guía de la CDC Guideline for Prescribing Opioids for Chronic Pain que hemos conocido a través una entrada del blog Hemos leído. En la entrada podéis encontrar datos interesantes de consumo y de su aumento tanto de EEUU como de España. En ella se resalta también el valor añadido del material adicional de la guía y especialmente el que resume en 12 puntos las indicaciones de la guía que Carlos Fernández, autor del blog, se ha tomado el trabajo de traducir. Las copio y pego aquí, pero os aconsejo que leáis su entrada porque lo merece.


1.- El tratamiento no farmacológico y los analgésicos no opioides son de elección en el abordaje del dolor crónico. Los opioides deben utilizarse sólo si los beneficios esperados en términos de dolor y funcionalidad compensan los riesgos para el paciente. En caso de utilizar los opioides, deben asociarse -de forma adecuada- con medidas no farmacológicas y fármacos no opioides. 

2.- Antes de comenzar el tratamiento con opioides deben establecerse los objetivos del mismo con los pacientes (incluyendo el dolor y la funcionalidad) y debe preverse cómo interrumpirlo si los beneficios no superan los riesgos. El tratamiento con opioides debe continuarse sólo si hay una mejoría clínica significativa en los términos señalados.

3.- Antes de comenzar y luego, periódicamente durante el tratamiento con opioides se debe discutir con los pacientes los riesgos conocidos y los beneficios reales, así como las responsabilidades de unos y otros en el tratamiento.

4.- Al comenzar el tratamiento con opioides para el dolor crónico se deben prescribir formulaciones de liberación inmediata en vez de liberación modificada.

5.- Tras comenzar el tratamiento, debe prescribirse la mínima dosis eficaz. Así mismo, deben reevaluarse los beneficios y riesgos al incrementar la dosis equivalente de morfina por encima de 50 mg/día o justificar minuciosamente la decisión de aumentarla por encima de 90 mg/día de equivalente a morfina. 


6.- El tratamiento crónico con opioides comienza a menudo con el tratamiento del dolor agudo. En este caso, debe prescribirse la mínima dosis eficaz de un opioide de liberación inmediata en una cantidad no superia la necesaria para la gravedad del episodio que requiere de estos medicamentos. A menudo, 3 días -o menos- son suficientes y rara vez más de 7.

7.- Se deben evaluar los beneficios y daños a las 1-4 semanas del inicio el tratamiento o del aumento de la dosis Y posteriormente cada 3 meses, o con más frecuencia. Si los beneficios no superan los riesgos, se deben optimizar otros abordajes y trabajar con los pacientes para reducir la dosis de opoides o deprescribirlos.


8.- Antes de comenzar el tratamiento y, luego periódicamente, deben evaluarse los factores de riesgo de los daños asociados a los opioides. Se deben implementar estrategias para mitigar el riesgo que incluyan prescribir naloxona cuando dichos factores, tales como antecedentes de sobredosis, de consumo de sustancias de abuso, dosis altas (≥50 mg/día equivalentes de morfina) o el consumo concomitante de benzodiacepinas, incrementen el riesgo de sobredosificación.


9.- Se debe revisar el historial farmacoterapéutico del paciente para comprobar que no toma dosis de opiáceos o combinaciones peligrosas que provoquen una sobredosis.


10.- Cuando se prescriban opioides en dolor crónico, debe utilizarse una prueba de detección en orina antes de comenzar el tratamiento y luego al menos anualmente, para detectar el consumo de otros medicamentos peligrosos y drogas ilegales.


11.- Siempre que sea posible se debe evitar la prescripción conjunta de opioides y benzodiacepinas


12.- En pacientes con problemas relacionados con el tratamiento con opioides se debe utilizar o planificar un tratamiento basado en la evidencia (generalmente con buprenorfina o metadona en combinación con terapias conductuales).

Blog Birthday? Nearly missed it!

So, I still have the blog, though those of you in the know are following me over on Twitter where my writing and attention span really shine in 140 characters.

Still in a weird place professionally, in that ‘things are happening’ and yet writing about it is Verboten.

So, 14 years of a blog. Yeah, i have shoes older, but I’m enjoying having it even if I’m not busy here.

Thanks to the seven of you.

Know your A-lines!

Arterial lines can provide accurate, real-time information on your patient’s blood pressure.  They can be vital in cases where you want to trend precise blood pressure goals or where BP cuffs are producing incongruous measurements in a critically ill patient.  However, as with all tools the information they yield is only as good as the assay you use to measure it.  As with all tests, arterial line measurements can be prone to error.  In order to optimize your arterial line and receive accurate data it helps to know how it works.
The line itself is composed of hydraulic and electrical systems that work together to produce a pressure waveform on your monitor.  The hydraulic system is composed of the vascular catheter itself, hollow  fluid filled IV tubing, stopcocks to permit flow to be diverted, a continuous flush device to provide constant low grade flow to keep the line clear, and a pressure transducer.  A series of fluid (typically saline) filled tubed connects from the arterial catheter to the pressure transducer forming an unbroken column of fluid contiguous with your patient’s arterial vasculature.  The pressure transducer is typically a silicone diaphragm and operates in conjunction with a system of 4 resistors known as a wheatstone bridge.  In this system three resistors generate pre-determined resistance to an electrical current while the fourth is “zeroed” at this value and subsequently varies according to the deviation in resistance from this set zero point.  The variable resistance is provided by the silicone diaphragm and the resistance of the circuit varies proportionally to pressure applied to this diaphragm.  The change in voltage is measured and reported by a voltmeter within the circuit.  You should know how to set this system up prior to starting critical care shifts: for an excellent tutorial on how to set such a system up see the linked videos below on ECHED.org.  The pressure transducer will typically come pre-assembled for you.  Some elements of these videos are specific to Elmhurst hospital and to the emergency departments’ website on which they are hosted.
http://emcrit.org/pressure-set-up/ :courtesy of Scott Weingart, MD
A Wheatstone Bridge.  The variable resistor is indicated by the arrow at R2.
The electrical system for the line consists of an amplifier, a monitor/oscilloscope, a processor, and a recorder.  The amplifier will take the voltage reported by the pressure transducer and convert it into a visible signal.  The monitor or oscilloscope displays this signal for your review.  The processor will take this data and calculate hemodynamic parameters.  Your recorder will store and print this data.  Of the two systems, the hydraulic system is more likely to suffer errors that your are able to fix or optimize than the electrical system.
The relative altitude of your pressure transducer and the stopcock to your patient’s heart when the system is zeroed can affect the values reported by the transducer.  Changes in altitude lead to common errors in measurement.  When the transducer/stopcock is placed properly it is said to be aligned with the body’s “phlebostatic axis.”  The appropriate point can be determined by drawing a line through the 4th intercostal space and locating the spot at which it intersects with the mid axillary line which will zero the system to the level of the right atrium.  The stopcock that you use to set the “zero” point for the system is the actual determinant for the zero pressure experienced by the transducer.  Some transducers will come with a stopcock attached at the end, however if this is not the case or if you choose to use a different stopcock then this point will determine the altitude experienced by the transducer and should be taped to the patient’s chest at the phlebostatic axis to ensure its accuracy.  The system is zeroed by turning the stopcock open to air (and closed to the patient) and then hitting the zero button on your monitor.  This location of the phlebostatic axis (as an approximation of the right atrium) is chosen because this describes cardiac pre-load.  Positioning the transducer lower than this point will report falsely elevated pressures due to increased pressure applied to the hydraulic tubing.  If the transducer is positioned above the phlebostatic axis then the pressure applied to the tubing will be lower and will yield falsely low blood pressure readings.  Depending on the indication for invasive monitoring, you may be most interested in different reference points and the transducer altitude may be adjusted accordingly.  For example, in a patient in whom intracranial arterial pressures are of chief interest the pressure transducer may be set at the level of the eternal auditory meatus and will reports pressure with reference to that point.
The phlebostatic axis.
Tomorrow’s pearl will continue to explore optimization of your arterial line and troubleshooting more complex errors.
Cheatham ML. Hemodynamic Monitoring: Principles to practice.  http://sinaiem.org/wp-content/uploads/2016/05/ABP-photo.jpghttp://www.surgicalcriticalcare.net/Lectures/PDF/hemodynamic%20monitoring%20principles%20to%20practice.pdf. Updated 1/13/2009.  Accessed 5/2/15.
Rhdv – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=2888809