Controlled Sedation
To prevent the adverse complications of poorly controlled sedation, sedation therapy should be administered in a careful and precise manner. The depth of sedation should be clearly defined and the infusion of sedative drug precisely targeted to this clinical endpoint. If the patient is sedated to an unrousable depth, then unless clinically contraindicated, they should be brought to a level where a neurological assessment can be made every 24 hours [18]. In his manner a cerebral insult will not go undetected. By defining the sedation level and carefully controlling the sedation infusion to meet this endpoint, the dangers of over or under sedation are minimized. It will also provide for continuity of care, as all care-givers understand the required depth of sedation.
To be able to reach this goal the routine use of sedation scales is essential. The scoring system selected for use must be easily understood, used routinely and be part of the regular assessment of the ICU patient In fact sedation scoring systems should be in regular use where ever potent respiratory depressant drugs are being used.
Sedation Scoring Systems.
A sedation scoring system should be an integral component of any sedation protocol. The four most validated scoring systems include: The Ramsay Sedation Scale; The Sedation Agitation Scale; The Motor Activity Assessment Scale and for the pediatric population: The Comfort Scale [19].
The Ramsay Sedation Scale
The Ramsay Sedation Scale (RSS, Table), was the first scale to be defined and was designed as a test of rousability. The RSS scores sedation at six different levels, according to how rousable the patient is. It is an intuitively obvious scale and therefore lends itself to universal use, not only in the ICU, but wherever sedative drugs or narcotics are given. It can be added to the pain score and be considered the sixth vital sign.
Ramsay Sedation Scale
1 Patient is anxious and agitated or restless, or both
2 Patient is co-operative, oriented, and tranquil
3 Patient responds to commands only
4 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
5 Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
6 Patient exhibits no response
The RSS defines the conscious state from a level 1: the patient is anxious, agitated or restless, through the continuum of sedation to a level 6: the patient is completely unresponsive. Therefore when an assessment is to be made, the first decision to be made is to note if the patient is awake. If the patient is awake: are they anxious, agitated or restless (RSS 1) or are they calm, co-operative and communicative (RSS 2)? If the patient is asleep then a test of reusability needs to be made. If the patient responds quickly to a voice command, this is a RSS 3. If the response is slow then the patient is assigned a level 4. If the patient does not respond a stronger stimulus is applied. A louder auditory stimulus or a glabellar (between the eyebrows) tap is enacted. A brisk response to this test of rousabilty places the patient at a RSS 4. A slow or sluggish response categorizes the patient to a RSS 5. No response at all places the patient at a level 6.
The rousability stimulus was specifically designed not to be a painful test and not to startle the patient. In fact it was planned that a sleeping patient would not be roused to a fully awakened state, so that the sleep pattern would not be disturbed.
A disadvantage of the RSS is that it relies on the ability of the patient to respond, therefore the patient who has received neuromuscular blocking drugs cannot be assessed in this manner. Also at a level 1 score, there is no further definition of the degree of agitation, and there are occasions when this may be important to record. The Sedation-Agitation Scale does take this into consideration [20]. At the deep end of the scale, a RSS 6, there is no further information as to whether the patient is in a light plane of general anesthesia or deep coma. This assessment can be made from monitoring the compressed spectral array signal from an electroencephalogram, A bispectral index score of 61.7 correlates well with a RSS of 6.
Conclusion
Despite the ready availability of sedation scales over the last 25 years, a review of ICU practice reveals that many units still do not closely control the level of sedation in their critically ill patients. In those units where sedation scoring systems are used fewer than half the patients are at the prescribed level for more than 50% of the time. Therefore there is still an opportunity to educate the importance of the dynamics of assessment, re-assessment and adjustment in the rate of delivery of sedative. This dynamic is essential to avoid the complications associated with over and under sedation.
References
1.Ramsay MAE, Savege TM, Simpson BRJ & Goodwin R. Controlled sedation with alpaxalone-alphadolone. British Medical Journal 1974; 2: 656 - 659.
2.Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W & Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical Care Medicine 1999; 27: 2609 - 2615.
3.Saich C, Manji M, Dyer I & Rosser D. Effect of introducing a sedation guideline on sedative costs per bed day. British Journal of Anaesthesia 1999; 82: 792 - 793.
4.Griffiths RD, Jones C. Recovery from intensive care. British Medical Journal 1999; 319: 427 -429.
5.Crippen DW. The role of sedation in the ICU patient with pain and agitation. Critical Care Clinics 1990; 6: 369 - 393.
6.Murray K. The need for assessment of sedation in the critically ill. Nurse Critical Care 1997; 2: 297 - 302.
7.Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic sleep in nine patients receiving postoperative care. British Medical Journal 1985; 290: 1029 - 1032.
8.Krachman SL, D'Alonzo GE & Criner GJ. Sleep in the intensive care unit. Chest 1995; 107: 1713 - 1720.
9.Dinges DF, Douglas SD, Hamarman S, Zaugg L & Kapoor S. Sleep deprivation and human immune function. Advances in Neuroimmunology 1995; 5: 97 - 110.
10.Lewis KS, Whipple JK, Michael KA & Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. American Journal of Hospital Pharmacists 1994; 51: 1539 - 1554.
11.Murray MJ, DeRuyter ML & Harrison BA. Opioids and benzodiazepines. Critical Care Clinics 1995; 11: 849 - 874.
12.Glass PS, Gan TJ & Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesthesia and Analgesia 1999; 89: S7 - 14.
13.Rudolph F, Hein HAT, Marcel RJ, Swygert TH, Lynch K Ramsay KJ & Ramsay MAE. End-tidal carbon dioxide does not correlate with arterial carbon dioxide in early recovery from general anesthesia. Anesthesia & Analgesia 1998; 86: S93.
14.Hutton P & Clutton-Brock T. The benefits and pitfalls of pulse oximetry. British Medical Journal; 21: 457 - 458.
15.Coursin DR, Coursin DB. Survivors, beware of posttraumatic stress disorder: What shall we tell the Men in Black? Critical Care Medicine 1998; 26: 634 - 635.
16.Wagner BK, Zavotsky KE, Sweeney JB, Palmeri BA & Hammond JS. Patient recall of therapeutic paralysis in a surgical critical care unit, Pharmacotherapy 1998; 18: 358 - 363.
17.Kress JP, Pohlman AS, O'Connor MF & Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England Journal of Medicine 2000; 342: 1471 - 1477.
18.DeJonghe B, Cook D, Appere-de-Vecchi C, Guyatt G, Meade M, Outin H. Using and understanding sedation scoring systems: a systematic review. Intensive Care Medicine 2000; 26: 275-285.
19.Riker RR, Picard JT & Fraser GL. Prospective evaluation of the sedation -agitation scale for adult critically ill patients. Critical Care Medicine 1999; 27: 1325 - 1329.
20.De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E & Colardyn F. Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients. Intensive Care Medicine 1998; 24: 1294 - 1298.
To prevent the adverse complications of poorly controlled sedation, sedation therapy should be administered in a careful and precise manner. The depth of sedation should be clearly defined and the infusion of sedative drug precisely targeted to this clinical endpoint. If the patient is sedated to an unrousable depth, then unless clinically contraindicated, they should be brought to a level where a neurological assessment can be made every 24 hours [18]. In his manner a cerebral insult will not go undetected. By defining the sedation level and carefully controlling the sedation infusion to meet this endpoint, the dangers of over or under sedation are minimized. It will also provide for continuity of care, as all care-givers understand the required depth of sedation.
To be able to reach this goal the routine use of sedation scales is essential. The scoring system selected for use must be easily understood, used routinely and be part of the regular assessment of the ICU patient In fact sedation scoring systems should be in regular use where ever potent respiratory depressant drugs are being used.
Sedation Scoring Systems.
A sedation scoring system should be an integral component of any sedation protocol. The four most validated scoring systems include: The Ramsay Sedation Scale; The Sedation Agitation Scale; The Motor Activity Assessment Scale and for the pediatric population: The Comfort Scale [19].
The Ramsay Sedation Scale
The Ramsay Sedation Scale (RSS, Table), was the first scale to be defined and was designed as a test of rousability. The RSS scores sedation at six different levels, according to how rousable the patient is. It is an intuitively obvious scale and therefore lends itself to universal use, not only in the ICU, but wherever sedative drugs or narcotics are given. It can be added to the pain score and be considered the sixth vital sign.
Ramsay Sedation Scale
1 Patient is anxious and agitated or restless, or both
2 Patient is co-operative, oriented, and tranquil
3 Patient responds to commands only
4 Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
5 Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
6 Patient exhibits no response
The RSS defines the conscious state from a level 1: the patient is anxious, agitated or restless, through the continuum of sedation to a level 6: the patient is completely unresponsive. Therefore when an assessment is to be made, the first decision to be made is to note if the patient is awake. If the patient is awake: are they anxious, agitated or restless (RSS 1) or are they calm, co-operative and communicative (RSS 2)? If the patient is asleep then a test of reusability needs to be made. If the patient responds quickly to a voice command, this is a RSS 3. If the response is slow then the patient is assigned a level 4. If the patient does not respond a stronger stimulus is applied. A louder auditory stimulus or a glabellar (between the eyebrows) tap is enacted. A brisk response to this test of rousabilty places the patient at a RSS 4. A slow or sluggish response categorizes the patient to a RSS 5. No response at all places the patient at a level 6.
The rousability stimulus was specifically designed not to be a painful test and not to startle the patient. In fact it was planned that a sleeping patient would not be roused to a fully awakened state, so that the sleep pattern would not be disturbed.
A disadvantage of the RSS is that it relies on the ability of the patient to respond, therefore the patient who has received neuromuscular blocking drugs cannot be assessed in this manner. Also at a level 1 score, there is no further definition of the degree of agitation, and there are occasions when this may be important to record. The Sedation-Agitation Scale does take this into consideration [20]. At the deep end of the scale, a RSS 6, there is no further information as to whether the patient is in a light plane of general anesthesia or deep coma. This assessment can be made from monitoring the compressed spectral array signal from an electroencephalogram, A bispectral index score of 61.7 correlates well with a RSS of 6.
Conclusion
Despite the ready availability of sedation scales over the last 25 years, a review of ICU practice reveals that many units still do not closely control the level of sedation in their critically ill patients. In those units where sedation scoring systems are used fewer than half the patients are at the prescribed level for more than 50% of the time. Therefore there is still an opportunity to educate the importance of the dynamics of assessment, re-assessment and adjustment in the rate of delivery of sedative. This dynamic is essential to avoid the complications associated with over and under sedation.
References
1.Ramsay MAE, Savege TM, Simpson BRJ & Goodwin R. Controlled sedation with alpaxalone-alphadolone. British Medical Journal 1974; 2: 656 - 659.
2.Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W & Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical Care Medicine 1999; 27: 2609 - 2615.
3.Saich C, Manji M, Dyer I & Rosser D. Effect of introducing a sedation guideline on sedative costs per bed day. British Journal of Anaesthesia 1999; 82: 792 - 793.
4.Griffiths RD, Jones C. Recovery from intensive care. British Medical Journal 1999; 319: 427 -429.
5.Crippen DW. The role of sedation in the ICU patient with pain and agitation. Critical Care Clinics 1990; 6: 369 - 393.
6.Murray K. The need for assessment of sedation in the critically ill. Nurse Critical Care 1997; 2: 297 - 302.
7.Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic sleep in nine patients receiving postoperative care. British Medical Journal 1985; 290: 1029 - 1032.
8.Krachman SL, D'Alonzo GE & Criner GJ. Sleep in the intensive care unit. Chest 1995; 107: 1713 - 1720.
9.Dinges DF, Douglas SD, Hamarman S, Zaugg L & Kapoor S. Sleep deprivation and human immune function. Advances in Neuroimmunology 1995; 5: 97 - 110.
10.Lewis KS, Whipple JK, Michael KA & Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. American Journal of Hospital Pharmacists 1994; 51: 1539 - 1554.
11.Murray MJ, DeRuyter ML & Harrison BA. Opioids and benzodiazepines. Critical Care Clinics 1995; 11: 849 - 874.
12.Glass PS, Gan TJ & Howell S. A review of the pharmacokinetics and pharmacodynamics of remifentanil. Anesthesia and Analgesia 1999; 89: S7 - 14.
13.Rudolph F, Hein HAT, Marcel RJ, Swygert TH, Lynch K Ramsay KJ & Ramsay MAE. End-tidal carbon dioxide does not correlate with arterial carbon dioxide in early recovery from general anesthesia. Anesthesia & Analgesia 1998; 86: S93.
14.Hutton P & Clutton-Brock T. The benefits and pitfalls of pulse oximetry. British Medical Journal; 21: 457 - 458.
15.Coursin DR, Coursin DB. Survivors, beware of posttraumatic stress disorder: What shall we tell the Men in Black? Critical Care Medicine 1998; 26: 634 - 635.
16.Wagner BK, Zavotsky KE, Sweeney JB, Palmeri BA & Hammond JS. Patient recall of therapeutic paralysis in a surgical critical care unit, Pharmacotherapy 1998; 18: 358 - 363.
17.Kress JP, Pohlman AS, O'Connor MF & Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England Journal of Medicine 2000; 342: 1471 - 1477.
18.DeJonghe B, Cook D, Appere-de-Vecchi C, Guyatt G, Meade M, Outin H. Using and understanding sedation scoring systems: a systematic review. Intensive Care Medicine 2000; 26: 275-285.
19.Riker RR, Picard JT & Fraser GL. Prospective evaluation of the sedation -agitation scale for adult critically ill patients. Critical Care Medicine 1999; 27: 1325 - 1329.
20.De Deyne C, Struys M, Decruyenaere J, Creupelandt J, Hoste E & Colardyn F. Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients. Intensive Care Medicine 1998; 24: 1294 - 1298.
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