Understanding Sedation in Critical Care

All right you guys, welcome back to another video lesson from ICU Advantage. And in this lesson we're going to continue our collection of lessons on ICU drips and we're going to be talking about sedation. This is going to be broken up into two parts, so make sure you guys stay tuned for both of those lessons. But, before we begin, if this is your first time to our channel here and watching one of our videos, we do invite you to subscribe to our channel below. Make sure you guys hit that bell icon and select all notifications, that way you'll be notified as soon as our new lessons are released to you guys. We do truly value the subscriptions, the likes, and the comments that you guys leave for us. and they really go a long way to help support our channel, and for that, I do want to thank you guys. And for those of you who don't know me, my name is Eddie Watson, and this is ICU Advantage. Alright, so let's go ahead and get into our lesson here talking about sedation. So let's really begin things off and really talk about what is sedation. So when we take a look at our patients who are in the critical care environment, they're often dealing with two problems. They're either uncomfortable or they're anxious. And oftentimes we're wanting to deal with this discomfort and this anxiety that these patients are having. And one really important thing is that we want to make sure that we provide pain relief to them first. So it's really important that we ensure that our patients are either pain-free or that we've addressed their pain with some sort of intervention or analgesia. And so once we've done that, then we start to talk about a group of medications that we call sedatives. And so essentially sedatives are a group of medications that... can either reduce a patient's anxiety, reduce their awareness to noxious stimuli, or induce sleep. But one very important thing to remember with our sedatives is that they do not address pain, at least for a majority of them. And so we know that these medications are going to have these benefits, and so we're going to primarily use them to ensure tolerance to interventions that we're doing and treatments that we're trying to provide for our patients. We can be using them for clinical stability or to just protect the patient from inadvertent self-harm. And unfortunately, using these medications can have either negative effects to outcomes or risk for delirium. So we really want to attempt to either reduce or eliminate the use of sedatives if possible. So now that we've talked about that, let's really move on and begin to talk about why exactly we would be using sedation on our patients. And there's six primary reasons that we would be doing that, and I'm going to list those out here, and we're going to go through and talk about each one of these here. And so the first of these is going to be amnesia, and this is going to be something that's really useful for procedures, surgeries, or invasive interventions that we're doing. And so we really don't want our patients aware or remembering some of this stuff, and so that's one of the benefits of these medications. Although it's not recommended to be... using this if this is our sole reason to extend the use of sedation to our patients. One of the major exceptions to this is if we have patients who are on paralytics. So now if we move on and talk about our ventilator tolerance, here if we have either ineffective, dyssynchronous, or even an excessive respiratory effort, that this can all increase our patient's work of breathing and ultimately increase our O2 consumption. And so really, we want to make sure that we're attempting to identify the cause of this and try to improve the patient's tolerance before we move into the world of sedation. And once we do make that cross into needing to use sedation, we can either use it in frequent boluses or continuous IV. So now as we talk about anxiety and fear, this is one thing that it might be difficult to really identify and assess for this in the critically ill patient. Because the patients may really have difficulty in expressing themselves. So we really want to be assessing for signs or behaviors that we're typically going to associate with anxiety and fear. And so these are going to be things like nonspecific distress, agitation, thrashing, diaphoresis, that facial grimacing, or even an elevated blood pressure and heart rate. And oftentimes for patients, oral anxiolytics may be more beneficial to them, but certainly at times sedation is going to be needed. So now when it comes to our patient's safety and agitation, We can really see this agitation manifest with things that are unhelpful or potentially harmful to the patient. And so our patients may be aware, but just unable to communicate the source of agitation, or they might even be completely unaware. But typically, we're going to see this manifest itself as those like episodic, non-purposeful movements that they can do, severe thrashing, attempting to remove lines. tubes, trying to get out of bed, or other things that might just bring harm to themselves. And so in cases like these, sedation is going to really be of benefit to preventing or reducing this agitation and ultimately keeping our patients safe. So now when we talk about sleep deprivation, this is one thing that is very common in the critically ill. And this is especially common with patients who have pain, discomfort, or anxiety. And so... our patients may appear rested, but they may never achieve that physiological stages of deep sleep that they really need. And so here, obviously, we want to try non-pharmacological interventions and other sleep aid medications before we're trying to use sedation for this type of purpose. And so the last thing I want to talk about here is delirium. And this is really important because it's said to occur in 50 to 80 percent of critically ill patients. And this can really have long-term cognitive effects on our patients. And one thing that's especially important to know is that really only about 5% of our patients that have delirium are going to present with that agitated delirium. The vast majority are going to present with either a hypoactive, which means that they're calm and quiet, or some sort of mixed presentation. So you can't rely on that as our sole indicator for determining if our patients might have delirium. And so because of that, routine assessment for delirium is absolutely important. And so when it comes to delirium, we really don't want to be using sedatives to induce sedation for our patients because this can actually potentially make things worse. There are some of the medications which we're going to talk about in the next lesson that get classified into this group that are actually quite beneficial for patients with delirium. All right, so hopefully that gives you guys a good understanding of why we'd be using these medications. purpose of sedation in our patients. The next thing that I want to talk about are our goals for monitoring our patients on sedation. So the most important thing is that we want to ensure that we're using the appropriate drug and the appropriate dose. And ultimately, our goal is to provide those positive outcomes for our patients. And so having this goal in mind, it is important to know that if we have appropriately dosed sedation, that this is not going to interfere with clinical progress. And so what we want to be doing is adjusting the doses of the drugs to really avoid drowsiness and respiratory depression. And ideally, we want to maintain either a calm awake state or a patient who's easily arousable in most cases. And so in order to really do this for our patients, we have to use some sort of sedation scale to help us select the dose that's going to achieve the most appropriate effect for our patient. And so we do actually have a scale that's pretty widely used, and it's something that's called the Richmond Agitation Sedation Scale, or as we commonly refer to it, our RAS. And so we're going to go over the scale here in just a second, but this is something that we're going to want to determine this level frequently with our patients, and then make dose adjustments to our sedation in accordance with the score that we get. And so it's pretty simple. We have a scale that goes from negative five all the way up to four. And on this scale, for most of our patients, our goal is usually going to be either a 0 or a negative 1. And you will see why here in just a minute. And so the way this scale works is you want to attempt to interact with your patient and see what sort of responses that you get. And based on the responses that you get, you find where that lines up on this scale, and that would be your patient's RAS score. So the first one here at negative 5 is going to be what we call unresponsive. And so... despite voice or even physical stimulation, you get no response from your patient. Now a score of negative four is what we refer to as deep sedation. And so here again, they're still going to have no response to voice, but any kind of movement that you see in response to physical stimulation would meet this criteria. Now a score of negative three is going to be what we call moderate sedation. And so here you're going to have any kind of movement resulting from stimulation from your voice, but you're not going to have eye contact. So now moving down to negative two, this is what we refer to as light sedation. And here we're going to see brief, but less than 10 seconds that our patients are awake with eye contact to stimulation. to voice. Now a score of negative one is going to be what we call drowsy. And here the patient's not fully alert, but they're going to sustain more than 10 seconds of being awake, and they are going to have that eye contact to voice. Now a score of zero is what we refer to as alert and calm, and I think this one's pretty self-explanatory. And then the score of one is what we refer to as restless. And here your patient's going to be anxious or apprehensive, but they're not aggressive or having any vigorous movements. Now a score of two is what we refer to as agitated, and this is where you're going to see those frequent non-purposeful movements or that patient vent dyssynchrony. Now a score of three is going to be very agitated, and this is where you're going to have them pulling on their lines and tubes, or they're going to have that aggressive behavior towards the staff. And then finally the fourth and final score is going to be a four, which is going to be combative. And here the patient is just overtly combative or violent and they're an immediate danger to the staff. So this is our Richmond Agitation Sedation Scale or our RAS scale. As you can see, it gives you a quantifiable score, a method in which you can assess your patient and determine where they fall on this sedation versus agitation in order to appropriately adjust your sedation medication to fine tune and get them into that. ideal range. Again, normally for most patients, we're typically going to be shooting for 0 or negative 1, but this obviously can change on a patient-to-patient basis, and some providers may also have more of a preference than others. All right, so that's going to wrap things up for this lesson here. We covered a good little bit of information starting out here talking about sedation, what it is, why we use it, and most importantly, how we monitor and assess our patients on sedation. And so with all that said, I do want to thank you guys so much for watching. I really want to say a special thank you to our subscribers that are out there who continue to come back and watch our videos and support our channel. Really do appreciate you guys. If you guys did find this lesson to be useful, please go down below, hit the like button, leave us a comment. All of this is really beneficial for the YouTube algorithm to help promote our channel and get the word out there. So we really appreciate your support there. And part. two of this lesson we're going to look at the actual medications that we use in order to appropriately sedate our patients. So make sure you guys keep an eye out for that lesson. In the meantime feel free to check out the last series of lessons that we just completed where we took a look at the endocrine system. As always thank you guys so much for watching and you have a great day.

But, before we begin, if this is your first time to our channel here and watching one of our videos, we do invite you to subscribe to our channel below. Make sure you guys hit that bell icon and select all notifications, that way you'll be notified as soon as our new lessons are released to you guys. We do truly value the subscriptions, the likes, and the comments that you guys leave for us. and they really go a long way to help support our channel, and for that, I do want to thank you guys.

And for those of you who don't know me, my name is Eddie Watson, and this is ICU Advantage. Alright, so let's go ahead and get into our lesson here talking about sedation. So let's really begin things off and really talk about what is sedation. So when we take a look at our patients who are in the critical care environment, they're often dealing with two problems. They're either uncomfortable or they're anxious.

And oftentimes we're wanting to deal with this discomfort and this anxiety that these patients are having. And one really important thing is that we want to make sure that we provide pain relief to them first. So it's really important that we ensure that our patients are either pain-free or that we've addressed their pain with some sort of intervention or analgesia.

And so once we've done that, then we start to talk about a group of medications that we call sedatives. And so essentially sedatives are a group of medications that... can either reduce a patient's anxiety, reduce their awareness to noxious stimuli, or induce sleep.

But one very important thing to remember with our sedatives is that they do not address pain, at least for a majority of them. And so we know that these medications are going to have these benefits, and so we're going to primarily use them to ensure tolerance to interventions that we're doing and treatments that we're trying to provide for our patients. We can be using them for clinical stability or to just protect the patient from inadvertent self-harm. And unfortunately, using these medications can have either negative effects to outcomes or risk for delirium. So we really want to attempt to either reduce or eliminate the use of sedatives if possible.

So now that we've talked about that, let's really move on and begin to talk about why exactly we would be using sedation on our patients. And there's six primary reasons that we would be doing that, and I'm going to list those out here, and we're going to go through and talk about each one of these here. And so the first of these is going to be amnesia, and this is going to be something that's really useful for procedures, surgeries, or invasive interventions that we're doing.

And so we really don't want our patients aware or remembering some of this stuff, and so that's one of the benefits of these medications. Although it's not recommended to be... using this if this is our sole reason to extend the use of sedation to our patients.

One of the major exceptions to this is if we have patients who are on paralytics. So now if we move on and talk about our ventilator tolerance, here if we have either ineffective, dyssynchronous, or even an excessive respiratory effort, that this can all increase our patient's work of breathing and ultimately increase our O2 consumption. And so really, we want to make sure that we're attempting to identify the cause of this and try to improve the patient's tolerance before we move into the world of sedation.

And once we do make that cross into needing to use sedation, we can either use it in frequent boluses or continuous IV. So now as we talk about anxiety and fear, this is one thing that it might be difficult to really identify and assess for this in the critically ill patient. Because the patients may really have difficulty in expressing themselves. So we really want to be assessing for signs or behaviors that we're typically going to associate with anxiety and fear. And so these are going to be things like nonspecific distress, agitation, thrashing, diaphoresis, that facial grimacing, or even an elevated blood pressure and heart rate.

And oftentimes for patients, oral anxiolytics may be more beneficial to them, but certainly at times sedation is going to be needed. So now when it comes to our patient's safety and agitation, We can really see this agitation manifest with things that are unhelpful or potentially harmful to the patient. And so our patients may be aware, but just unable to communicate the source of agitation, or they might even be completely unaware.

But typically, we're going to see this manifest itself as those like episodic, non-purposeful movements that they can do, severe thrashing, attempting to remove lines. tubes, trying to get out of bed, or other things that might just bring harm to themselves. And so in cases like these, sedation is going to really be of benefit to preventing or reducing this agitation and ultimately keeping our patients safe. So now when we talk about sleep deprivation, this is one thing that is very common in the critically ill. And this is especially common with patients who have pain, discomfort, or anxiety.

And so... our patients may appear rested, but they may never achieve that physiological stages of deep sleep that they really need. And so here, obviously, we want to try non-pharmacological interventions and other sleep aid medications before we're trying to use sedation for this type of purpose.

And so the last thing I want to talk about here is delirium. And this is really important because it's said to occur in 50 to 80 percent of critically ill patients. And this can really have long-term cognitive effects on our patients. And one thing that's especially important to know is that really only about 5% of our patients that have delirium are going to present with that agitated delirium. The vast majority are going to present with either a hypoactive, which means that they're calm and quiet, or some sort of mixed presentation.

So you can't rely on that as our sole indicator for determining if our patients might have delirium. And so because of that, routine assessment for delirium is absolutely important. And so when it comes to delirium, we really don't want to be using sedatives to induce sedation for our patients because this can actually potentially make things worse.

There are some of the medications which we're going to talk about in the next lesson that get classified into this group that are actually quite beneficial for patients with delirium. All right, so hopefully that gives you guys a good understanding of why we'd be using these medications. purpose of sedation in our patients.

The next thing that I want to talk about are our goals for monitoring our patients on sedation. So the most important thing is that we want to ensure that we're using the appropriate drug and the appropriate dose. And ultimately, our goal is to provide those positive outcomes for our patients.

And so having this goal in mind, it is important to know that if we have appropriately dosed sedation, that this is not going to interfere with clinical progress. And so what we want to be doing is adjusting the doses of the drugs to really avoid drowsiness and respiratory depression. And ideally, we want to maintain either a calm awake state or a patient who's easily arousable in most cases.

And so in order to really do this for our patients, we have to use some sort of sedation scale to help us select the dose that's going to achieve the most appropriate effect for our patient. And so we do actually have a scale that's pretty widely used, and it's something that's called the Richmond Agitation Sedation Scale, or as we commonly refer to it, our RAS. And so we're going to go over the scale here in just a second, but this is something that we're going to want to determine this level frequently with our patients, and then make dose adjustments to our sedation in accordance with the score that we get. And so it's pretty simple. We have a scale that goes from negative five all the way up to four.

And on this scale, for most of our patients, our goal is usually going to be either a 0 or a negative 1. And you will see why here in just a minute. And so the way this scale works is you want to attempt to interact with your patient and see what sort of responses that you get. And based on the responses that you get, you find where that lines up on this scale, and that would be your patient's RAS score.

So the first one here at negative 5 is going to be what we call unresponsive. And so... despite voice or even physical stimulation, you get no response from your patient. Now a score of negative four is what we refer to as deep sedation.

And so here again, they're still going to have no response to voice, but any kind of movement that you see in response to physical stimulation would meet this criteria. Now a score of negative three is going to be what we call moderate sedation. And so here you're going to have any kind of movement resulting from stimulation from your voice, but you're not going to have eye contact. So now moving down to negative two, this is what we refer to as light sedation.

And here we're going to see brief, but less than 10 seconds that our patients are awake with eye contact to stimulation. to voice. Now a score of negative one is going to be what we call drowsy. And here the patient's not fully alert, but they're going to sustain more than 10 seconds of being awake, and they are going to have that eye contact to voice. Now a score of zero is what we refer to as alert and calm, and I think this one's pretty self-explanatory.

And then the score of one is what we refer to as restless. And here your patient's going to be anxious or apprehensive, but they're not aggressive or having any vigorous movements. Now a score of two is what we refer to as agitated, and this is where you're going to see those frequent non-purposeful movements or that patient vent dyssynchrony.

Now a score of three is going to be very agitated, and this is where you're going to have them pulling on their lines and tubes, or they're going to have that aggressive behavior towards the staff. And then finally the fourth and final score is going to be a four, which is going to be combative. And here the patient is just overtly combative or violent and they're an immediate danger to the staff. So this is our Richmond Agitation Sedation Scale or our RAS scale. As you can see, it gives you a quantifiable score, a method in which you can assess your patient and determine where they fall on this sedation versus agitation in order to appropriately adjust your sedation medication to fine tune and get them into that.

ideal range. Again, normally for most patients, we're typically going to be shooting for 0 or negative 1, but this obviously can change on a patient-to-patient basis, and some providers may also have more of a preference than others. All right, so that's going to wrap things up for this lesson here. We covered a good little bit of information starting out here talking about sedation, what it is, why we use it, and most importantly, how we monitor and assess our patients on sedation. And so with all that said, I do want to thank you guys so much for watching.

I really want to say a special thank you to our subscribers that are out there who continue to come back and watch our videos and support our channel. Really do appreciate you guys. If you guys did find this lesson to be useful, please go down below, hit the like button, leave us a comment.

All of this is really beneficial for the YouTube algorithm to help promote our channel and get the word out there. So we really appreciate your support there. And part.

two of this lesson we're going to look at the actual medications that we use in order to appropriately sedate our patients. So make sure you guys keep an eye out for that lesson. In the meantime feel free to check out the last series of lessons that we just completed where we took a look at the endocrine system. As always thank you guys so much for watching and you have a great day.

Transcript for:Understanding Sedation in Critical Care

Transcript for:
Understanding Sedation in Critical Care