Sedation in the Critical Care Setting

Introduction

• Purpose: Introduce the concept of sedation in critical care.
• Topics: Define purposes and reasons for sedation, nursing roles, and considerations for medications.

Reasons for Sedation

• **Establish Calm: ** Decreases level of consciousness.
• Maintain Patient Safety: Helps in cases where patients may interfere with critical interventions.
• Minimize Discomfort: Both physiological and psychological.
• Control Behavior: Necessary for some patients to accept interventions like mechanical ventilation.

Situational Use

• Conscious Sedation: Brief, for bedside procedures.
• Continuous Sedation: For ongoing need, often titratable.

Key Points on Sedation

• Not Equivalent to Analgesia: Sedation ≠ pain control.
• Sedation and Amnesia: Some sedatives cause memory loss, which can be beneficial.
• Tolerance & Dependence: Patients can develop these over time and experience withdrawal.
• Impact on REM Sleep: Continuous sedation can reduce quality of REM, affecting memory and cognition.
• Balance is Essential: Avoid over and under sedation to minimize complications and facilitate recovery.

Assessment and Management

• Frequent Nursing Assessment Required: Ensure sedation levels are appropriate.
• Common Scales: Richmond Agitation Sedation Scale (RASS) and Ramsey Scale.
• Goal: Achieve calm, but easily arousable state at the lowest effective dose.

Common Sedatives in ICU

• Fentanyl: Rapid onset, analgesic and sedative properties.
  • Side effects: Respiratory depression, tolerance, dependence, withdrawal, serotonin syndrome.
• Midazolam (Versed): Benzodiazepine used for sedation and procedures.
  • Side effects: Respiratory depression, dependence, memory loss.
• Propofol (Dipravan): Lipid-based, rapid onset and offset.
  • Side effects: Respiratory depression, hypotension, metabolic acidosis, cardiac/renal failure.
• Dexmedetomidine (Precedex): Alpha-adrenergic agonist, less likely to cause respiratory depression.
  • Usable in intubated and non-intubated patients.

Nursing Considerations

• Protocols & Dosing: Familiarize with medication protocols and specific orders.
• Alternatives to Sedation: Lighting, noise control, and other non-pharmacological interventions.
• Breaks: Sedation vacations are recommended.
• Pain Management: Treat pain before sedation.

Knowledge Check Examples

• Appropriate Sedation Use: Case scenarios to determine correct sedation use.
  • Example: 51-year-old female with rib fractures and intubation needs sedation.
• Nursing Actions: Decision-making based on patient vitals and medication protocols.
  • Example: Alternative medication choice when propofol causes hypotension.