Escalas de sedación / Sedation scales

Mayo 29, 2016. No. 2341

Comparación de dos herramientas de evaluación del dolor, "Expresión facial" y "Herramienta de cuidado crítico de observación del dolor" en pacientes intubados después de cirugía cardiaca. Comparison of Two Pain Assessment Tools, "Facial Expression" and "Critical Care Pain Observation Tool" in Intubated Patients After Cardiac Surgery. Kiavar M1, Azarfarin R2, Totonchi Z2, Tavakoli F2, Alizadehasl A1, Teymouri M1. Anesth Pain Med. 2016 Jan 18;6(1):e33434. doi: 10.5812/aapm.33434. eCollection 2016. Abstract BACKGROUND: Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation. OBJECTIVES: This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were "critical-care pain observation tool (CPOT)" and "facial expression (FE)". PATIENTS AND METHODS: This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools' scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously. RESULTS: At the first period, the frequency of "severe" pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient's position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was "severe" (κ = 0.787, P < 0.001) and "mild" (κ = 0.851, P < 0.001). CONCLUSIONS: The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with "Facial Expression". Best agreement between these tools was observed in two extremes of pain intensity. KEYWORDS: Cardiac Surgery; Intensive Care Unit; Pain Assessment PDF  Utilidad de RASS en la valoración de la disfunción neurológica aguda en UCI Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit. Trivedi V1, Iyer VN1. J Thorac Dis. 2016 May;8(5):E292-4. doi: 10.21037/jtd.2016.03.71. PDF Una evaluación modificada secuencial de valoración en falla orgánica utilizando RASS en UCI. A modified Sequential Organ Failure Assessment score using the Richmond Agitation-Sedation Scale in critically ill patients. J Thorac Dis. 2016 Mar;8(3):311-3. doi: 10.21037/jtd.2016.02.61. Viglino D1, Maignan M1, Debaty G1. PDF Evaluación y monitoreo de la analgesia y sedación en UCI Evaluating and monitoring analgesia and sedation in the intensive care unit. Sessler CN1, Grap MJ, Ramsay MA. Crit Care. 2008;12 Suppl 3:S2. doi: 10.1186/cc6148. Epub 2008 May 14. Abstract Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologicmeasures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value. PDF VIII Foro Internacional de Medicina del Dolor y Paliativa  Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Junio 9-11, Ciudad de México Dra. Argelia Lara Solares Tel. 5513 3782  www.dolorypaliativos.org  Cursos de Anestesiología en Chile, 2016 Facultad de Medicina. Pontificia Universidad Católica de Chile Información

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Escalas de sedación / Sedation scales

Mayo 29, 2016. No. 2341

Comparación de dos herramientas de evaluación del dolor, "Expresión facial" y "Herramienta de cuidado crítico de observación del dolor" en pacientes intubados después de cirugía cardiaca. Comparison of Two Pain Assessment Tools, "Facial Expression" and "Critical Care Pain Observation Tool" in Intubated Patients After Cardiac Surgery. Kiavar M1, Azarfarin R2, Totonchi Z2, Tavakoli F2, Alizadehasl A1, Teymouri M1. Anesth Pain Med. 2016 Jan 18;6(1):e33434. doi: 10.5812/aapm.33434. eCollection 2016. Abstract BACKGROUND: Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation. OBJECTIVES: This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were "critical-care pain observation tool (CPOT)" and "facial expression (FE)". PATIENTS AND METHODS: This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools' scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously. RESULTS: At the first period, the frequency of "severe" pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient's position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was "severe" (κ = 0.787, P < 0.001) and "mild" (κ = 0.851, P < 0.001). CONCLUSIONS: The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with "Facial Expression". Best agreement between these tools was observed in two extremes of pain intensity. KEYWORDS: Cardiac Surgery; Intensive Care Unit; Pain Assessment PDF  Utilidad de RASS en la valoración de la disfunción neurológica aguda en UCI Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit. Trivedi V1, Iyer VN1. J Thorac Dis. 2016 May;8(5):E292-4. doi: 10.21037/jtd.2016.03.71. PDF Una evaluación modificada secuencial de valoración en falla orgánica utilizando RASS en UCI. A modified Sequential Organ Failure Assessment score using the Richmond Agitation-Sedation Scale in critically ill patients. J Thorac Dis. 2016 Mar;8(3):311-3. doi: 10.21037/jtd.2016.02.61. Viglino D1, Maignan M1, Debaty G1. PDF Evaluación y monitoreo de la analgesia y sedación en UCI Evaluating and monitoring analgesia and sedation in the intensive care unit. Sessler CN1, Grap MJ, Ramsay MA. Crit Care. 2008;12 Suppl 3:S2. doi: 10.1186/cc6148. Epub 2008 May 14. Abstract Management of analgesia and sedation in the intensive care unit requires evaluation and monitoring of key parameters in order to detect and quantify pain and agitation, and to quantify sedation. The routine use of subjective scales for pain, agitation, and sedation promotes more effective management, including patient-focused titration of medications to specific end-points. The need for frequent measurement reflects the dynamic nature of pain, agitation, and sedation, which change constantly in critically ill patients. Further, close monitoring promotes repeated evaluation of response to therapy, thus helping to avoid over-sedation and to eliminate pain and agitation. Pain assessment tools include self-report (often using a numeric pain scale) for communicative patients and pain scales that incorporate observed behaviors and physiologicmeasures for noncommunicative patients. Some of these tools have undergone validity testing but more work is needed. Sedation-agitation scales can be used to identify and quantify agitation, and to grade the depth of sedation. Some scales incorporate a step-wise assessment of response to increasingly noxious stimuli and a brief assessment of cognition to define levels of consciousness; these tools can often be quickly performed and easily recalled. Many of the sedation-agitation scales have been extensively tested for inter-rater reliability and validated against a variety of parameters. Objective measurement of indicators of consciousness and brain function, such as with processed electroencephalography signals, holds considerable promise, but has not achieved widespread implementation. Further clarification of the roles of these tools, particularly within the context of patient safety, is needed, as is further technology development to eliminate artifacts and investigation to demonstrate added value. PDF VIII Foro Internacional de Medicina del Dolor y Paliativa  Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Junio 9-11, Ciudad de México Dra. Argelia Lara Solares Tel. 5513 3782  www.dolorypaliativos.org  Cursos de Anestesiología en Chile, 2016 Facultad de Medicina. Pontificia Universidad Católica de Chile Información

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Dexmedetomidina en UCI / Dexmedetomidine in ICU

Abril 6, 2016. No. 2288

Efecto de dosis diferentes de dexmedetomidina sobre la frecuencia cardiaca y presión arterial en pacientes de UCI Effects of different doses of dexmedetomidine on heart rate and blood pressure in intensive care unit patients. Zhang X, Wang R, Lu J, Jin W, Qian Y, Huang P, Tian R, Li Y. Exp Ther Med. 2016 Jan;11(1):360-366. Epub 2015 Nov 17. Abstract The aim of the present study was to observe and compare the sedative effect of different doses of DEX on heart rate (HR) and blood pressure (BP) in critically ill patients admitted to intensive care units (ICUs). The study included patients that were retained in ICUs and required sedation between January and March 2014. Patients were excluded if they had a BP of >200 mmHg, a HR of <60 bpm or were in a state of shock. The included patients were randomized into three groups: Group A, 1.0 µg/kg/10 min DEX; group B, 0.5 µg/kg/10 min DEX; and group C, 0.4 µg/kg/h DEX. After receiving these initial designated doses of DEX via an intravenous (IV) infusion pump for 10 min, the patients were maintained continuously at an identical dose of 0.4 µg/kg/h DEX. Ramsay score, HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), breathing rate (BR) and peripheral capillary oxygen saturation (SpO2) were recorded prior to the IV pump infusion and at 2, 4, 6, 8, 10, 60, 120, 180 and 240 min following infusion. Patients in groups A and B achieved sedation more rapidly compared with those in group C (P<0.05). HR decreased more significantly at 8 and 60 min after the initial IV pump infusion with DEX in groups A and B compared with group C (P<0.05). SBP decreased significantly at 10 min after IV pump infusion in group A compared with groups B and C (P<0.05). No significant difference existed in the SBP reduction trend between the three groups during the maintenance period. Therefore, the routine dose of DEX (0.4 µg/kg/h) provides an ideal sedative effect in ICU patients. The recommended loading dose for a more rapid sedation is 0.5 µg/kg/h. High loading doses of DEX via IV pump infusion should be avoided in elderly individuals, patients with acute exacerbation of chronic obstructive pulmonary disease and anemic patients, in whom combination medication, such as midazolam or propofol, may be considered when necessary. KEYWORDS: bradycardia; dexmedetomidine; intensive care; sedation PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015