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Script for Audio-Visual Training Module for “MANAGEMENT OF PAIN, AGITATION AND DELIRIUM IN ARDS PATIENTS ON INVASIVE MECHANICAL VENTILATION”Associated Documents/Interactions:Pre/post-TestGeneral Guidance: Give a 3 second pause between bullet points. Where the sentence at the end of the slide narrative ends with an ellipsis, transition between slides without pause. Otherwise, give 3-4 second pause between slides. Lay emphasis on words in boldSlide #Script Actions/Demonstrations/Direction etc.1Hello, my name is………and I will be taking you through this module on “Management Of Pain, Agitation And Delirium In Acute Respiratory Distress Syndrome Patients On Invasive Mechanical Ventilation’’Ellipses signify transition 2At the end of this module, you are expected to be able to:Describe the long-term complications associated with the use of sedatives in critically ill patients,Describe the long-term benefits associated with using a management approach protocol to pain, agitation and delirium (PAD), and,Formulate a Pain, Agitation and Delirium protocol adapted to your hospital setting.3The long term complications of intensive care unit survival impacts greatly on the patient’s family, hobbies and work.This because, about 50 –70% of ICU survivors have cognitive impairment while 60–80% are functionally impaired and some end up with psychiatric conditions which can make adjusting back to the work life balance quite difficult.Let’s look at sedation in ARDS patients on invasive mechanical ventilation..Ellipses signify transition 4Deep sedation was historically carried out because it was believed that amnesia was desirable, andEarly generation ventilators were insensitive to patient ventilatory effort.However, for most patients, the current standard of care promotes use of Light/no sedation because;Modern ventilators have sensitive trigger and patients are more synchronousAmnesia may actually contribute to risk of PTSD, andDeep sedation may cause respiratory, cardiovascular, neurological, psychological and immunological complications and may contribute to the risk of death.Emphasize points in highlights5During sedation, the goal should be Patient Comfort by ensuring adequate pain control, anxiolysis, prevention, and treatment of delirium. Although, achieving the appropriate balance of analgesia, and sedation is quite challenging, implementing the Pain, Agitation and Delirium (PAD) guidelines improves patient outcome.Emphasize on points in highlights6These outcomes may be short term, and long term.The Short term outcomes include:fewer days of delirium Quicker extubation time, hence reducing the length of stay in the Intensive Care Unit,Lower hospital costsMore mobilization during ICU admission which effectively increases patient’s chances of survival.Long-term outcomes on the other hand include;better cognitive function and physical mobility,fewer psychiatric conditions such as anxiety, depression or Post Traumatic Stress Disorder (PTSD), andIncreased survival rate.To develop a PAD protocol adapted to your health care facility setting, a stepwise approach is recommended….Ellipses signify transition while the last sentence is still being spoken7We will be considering these seven step approach:Assess and recognize pain, agitation and delirium using standard scalesPain management in terms of prevention and treatmentAnxiety management; choosing targeted sedationDelirium management Recognize special situations (such as severe ARDS) that may need deep sedation and neuromuscular blockadeMonitor, Record, Interpret and Respond appropriately, finally,Deliver quality care: implement as part of ABCDEF bundle.Now, let’s take an in-depth look at each of these steps…Ellipses signify transition while the last sentence is still being spoken8&9To successfully recognize pain, agitation and delirium, in a mechanically ventilated patient,Routinely evaluate the patient once or twice during every nursing shift, and as needed.Ensure using standard tools across board to minimize variation between various caregivers.Note that agitation is a non-specific symptom of pain, anxiety or delirium thus it is important to find and treat the root cause.Emphasize on points in highlights10The cause of pain in patients in the intensive care unit may be due to:The critical illness itself such as pleurisy, injury or surgical sites,Alternatively, it may be due to secondary processes such as endotracheal tube intolerance, joint stiffness, pressure areas or immobility.Non-specific signs of pain such as diaphoresis, hypertension and tachycardia are less reliable indicators to be able to recognize pain. 11A 10-point pain scale, which ranges from no pain to unbearable pain can be used to recognize pain in patients who can self-report.While for non-communicative or sedated patients, a behavioural pain scale which assigns scores based on the patient’sfacial expressionupper limb movements, muscle tension; andCompliance with mechanical ventilation.12The image on the slide (left), is an example of a 10-point pain scale (Visual Analog Scale or Wong Baker Faces) which uses smiley face to indicate the level of pain.While to the right is a Behavioural Pain Scale with the three indicators and appropriate scoring.The BPS score ranges from a score of 3 indicating “no pain” to a maximum score of 12 which indicates the patient is experiencing “extreme form of pain”The lower the score, the higher quality of analgesia.Emphasize on points in highlights13Anxiety in ICU patients may be as a result of exaggerated sense of fear, nervousness or apprehension which can present with agitation or increased motor activity.However, the patient may also present with hypo-activity and be withdrawn, distrustful or have blunted affect.Alternatively, the anxiety may be due to the primary illness such as sepsis or from the care itself (that is, medication related). 14To recognize anxiety in a patient (both adult and paediatric), the Richmond Agitation-Sedation Scale (RASS) can be used. The RASS scoring is based on observing the patient’s response to verbal or painful stimuli such as body movement, eye opening, and duration of eye contact.Although in children, commonly used is the Comfort-B scale in which scoring is based on observing the child’s behaviours - crying, facial tone, muscle tone, movement, alertness, and ventilator compliance.15The Richmond Agitation-Sedation Scale (RASS) is very easy and only takes 20 seconds.The RASS score ranges from +4 (for a patient who is combative) to minus 5 (unarousable despite verbal or physical stimulation) as shown in the table on the slide.For example, a patient who makes frequent non-purposeful movements and fights the ventilator is termed agitated and assigned a score of +2.16ICU patient present with fluctuation in consciousness associated with inattention and disorganized thinking or perceptual disturbance that develops over short period of time.Delirium in this patients may be due to a secondary condition such as pain, hypoxaemia, shock, infection, electrolyte imbalance, or side effect of or withdrawal from some medications.There are three types of delirium - hypoactive, hyperactive and mixed.Of these 3, hyperactive is least common but easiest to diagnose.It is important to note that Delirium is an independent predictor of death.17The Confusion Assessment Method (CAM-ICU) is a well-validated tool that can be used to assess for delirium in adults (CAM-ICU) and children older than 4 years (pCAM-ICU).The assessment is based on the presence of:18Acute change or fluctuation in mental status in the last 24hours. This is assigned a yes, or a no as indicated.Inattention: ability of the patient to pay attention long enough to carry out simple commands. 0 - 2 errors in doing this indicates no delirium.Level of consciousness using the RASS scale; and any score other than zero indicates the presence of deliriumDisorganized thinking by asking series of unrelated questions. If there is 0-1 error, this indicates no delirium while more than 1 error signifies the presence of deliriumNow we have come to the end of Unit 1. Please attempt the mid-section quiz. See you in Unit 2?Ellipses signify transition while the last sentence is still being spoken19&20Welcome Back!Once you recognize the presence of pain, anxiety or delirium in a patient, it is of utmost importance that you manage appropriately..21Pain management must be foremost on the agenda of any managing team. This is because the use of analgesia-based approach may be adequate for most critically ill patients and minimize the need for additional sedatives.Always give pre-emptive analgesia to alleviate pain prior to invasive or potentially painful procedures.Non-neuropathic pain should be treated with opioids such as fentanyl, and morphine.It is best to start with intermittent dosing but continuous infusions may be considered based on intermittent dose requirements or if patient is known to have chronic painAbove all, Avoid over sedation!22Non-opiate analgesics such as acetaminophen, NSAIDs if not contraindicated or oral sucrose for procedural analgesia in neonates, can be used judiciously to minimize the use of opioids and their secondary harmful effects.Neuropathic agents like gabapentin, carbamazepine etc. can be considered for patients with neuropathic painWhile for localized pain, regional anaesthesia or topical local anaesthetics can be used.23&24Next is to manage the patient’s anxiety.Set daily sedation targets based on the clinical condition, and management plans agreed upon by the managing team.For most patients, target light sedation so the patient is awake and calm unless this is clinically contraindicated.Give sedative in order to reach target sedation score.Remember to always use the lowest effective dose.25When possible, choose a short-acting sedative such as :Continuous infusion of propofol in adults but not in children < 16 years of age or dexmedetomidine (if available)Enteral sedatives for example chloral hydrate in childrenIntermittent dosing of short-acting benzodiazepine, because continuous infusion of benzodiazepines is associated with prolonged days on invasive mechanical ventilation and increase in delirium.Alternatively, ketamine or clonidine (if dexmedetomidine not available) can be used.26If the patient is unstable and unable to receive short-acting agents, cautiously use low dose continuous infusions of benzodiazepines and titrate down to lowest dose needed to achieve the target RASS score.However, if the patient is over-sedated from continuous infusions, screen daily for sedation awakening trial (SAT).Discontinue use of narcotics (once pain is controlled) and continuous sedatives in most critically ill patients, except, if the patient has:Active seizures, alcohol withdrawal, severe agitation, ongoing myocardial ischaemia, elevated intracranial pressure or receiving neuromuscular blockade.27&28If Sedation Awakening Trial (SAT) is conducted, monitor the patient closely for agitation, haemodynamic instability or respiratory distress.If any of these occur, then restart infusion at half the previous dose. Although some experts suggest a “no sedation” policy except for morphine 2.5–5mg boli as needed.This policy however, is critically dependent on the nurse : patient ratio as closer monitoring is required.Remember, always coordinate SAT with spontaneous breathing trial (SBT) as patients spend fewer days on invasive mechanical ventilation and are more likely to survive at 1 year when bundled together.29-31Delirium is an independent risk factor for mortality in the intensive care unit and cognitive impairment in survivors. Therefore, early recognition and treatment are of paramount importance.To successfully manage delirium, attention must be paid to the following:Contributing medical conditions must be treated,Discontinue administration of delirium producing medications, especially benzodiazepines.Pain must be adequately controlled.Although, clinical trial data regarding most effective treatments of delirium are lacking, use of non-pharmacologic interventions can be employed. These includes:Sleep hygiene by controlling light, reducing noise and stimuli at night, as well as clustering patient’s activities; Re-orientating patient to surroundings, provide reassurance, encourage family visits and have familiar objects in room provide visual or hearing aids as required, TV and music during the daytime. Ensure early mobilization and exercise.Remove tubes and restrains as soon as possible.32&33In patients with early, severe acute respiratory distress syndrome (ARDS), deep sedation should be targeted to optimize lung protective ventilation (LPV) strategy.This is because, patients with severe ARDS are not good candidates for sedation interruption as they may easily deteriorate with little movement or minor ventilator asynchronyNeuromuscular blockers (NMB) may be added early for short term use (not more than 48 hours) as this has been associated with reduced mortality and more organ-failure free daysNMB must be used in conjunction with continuous sedatives that provide amnesia and analgesics for pain34Finally, implementing quality care delivery in the management of Pain, Agitation and Delirium (PAD) as part of ABCDEF bundle is essential. These includes:Conducting Spontaneous Awakening and Breathing Trials Choice of analgesia and sedationAssess, Prevent, and Manage DeliriumEncourage early mobility and exercise in the patient, andFamily engagement and empowerment.Instituting the ABCDEF bundle has proven to have positive impacton patient’s outcome by reducing the number of days on invasive mechanical ventilation, length of stay in the ICU, occurrence of delirium, long-term cognitive, disability impairments, and mortality.Summarily, here are some important key points:35Implement a protocolized management approach to pain, agitation and delirium (PAD) to improve patient outcomes. Regularly assess patients using standardized, reproducible scales such as the visual analogue scale, Richmond Agitation-Sedation Scale, and Confusion Assessment Method. First, treat pain (with opioids and non-opioids) to minimize the harmful effects of sedatives. Then treat anxiety using non-benzodiazepines sedatives (when possible) and target light sedation in most patients.Use non-pharmacologic interventions to prevent delirium.36 - 38We have come to the end of this module.I hope you can now adapt PAD protocols and effectively manage Pain, Anxiety and delirium in acute respiratory distress syndrome patients on invasive mechanical ventilation.Thank you! ................
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