Episode 89: Dropping the Grenade On the ICU
https://anchor.fm/restoringlife/episodes/Episode-89-Dropping-the-Grenade-On-the-ICU-e19p8h5
What role does choice of sedation in the field or ED play in the delirium that unfolds in the ICU?
How can inter-departmental collaboration improve sedation practices and patient outcomes?
How can the ICU better understand delirium and respond appropriately to new admissions from the other facilities and the ED?
Jeff Polland, BS, NRP, FP-C, shares with us his work to avoid benzodiazepine abuse to improve patient outcomes.
Jeff’s References:
https://journals.lww.com/anesthesia-analgesia/Abstract/1989/08000/Midazolam_Alfentanil_Synergism_for_Anesthetic.13.aspx — ASA I and II patients, ED95 95% CI of 0.15–0.5 mg/kg- Using loss of response to verbal commands as an endpoint- So not exactly what I would consider suitable anesthetic depth for ETI.
https://journals.lww.com/anesthesia-analgesia/Abstract/1985/08000/Induction_Dose_Response_Curves_for_Midazolam_and.9.aspx — ASA III/IV patients. Not quite as high as I had remembered but look at how wide the 95% CIs are for ED95, especially to trap pinch… Which is significantly milder than ETI. Significant limitations but the key takeaway is the wide, wide variability in ED95.
https://journals.lww.com/anesthesia-analgesia/Citation/1990/02001/MIDAZOLAM_INDUCED_AMNESIA__DOSE_RESPONSE_CURVE_AND.417.aspx — wide dose-response variability with midazolam and amnesia.
http://www.nearstudy.net/wp-content/uploads/general/2014-09/Underdosing-of-Midazolam-in-Emergency-Endotracheal-Intubation.pdf — older study but the doses used in this are pretty common to what I have seen even in current practice… And they use 0.1–0.3 mg/kg as the standard induction dose, because that is what is ‘recommended’ by major societies… That have clearly never looked at the dose-response curves and ED95. …. Again, shit drug!
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095819/ — peds, benzos as an independant predictor for development of delirium.
https://pubs.asahq.org/anesthesiology/article/104/1/21/7483/Lorazepam-Is-an-Independent-Risk-Factor-for — lorazapam as an independent risk factor for delirium.
https://www.atsjournals.org/doi/full/10.1164/rccm.201312-2291oc — propofol better than benzos
Editorial, but well cited. https://journal.chestnet.org/article/S0012-3692(12)60436-X/fulltext
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316795/ — systematic review, fairly well conducted IMO,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391269/ — another review article.
https://pubmed.ncbi.nlm.nih.gov/16394685/ — lorazapam as an independant predictor for delirium
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232258/ — survey, not hard data, but really interesting nonetheless. 82% of ICUs treat delirium with benzos only.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028734/ — no duh
https://www.sciencedirect.com/science/article/abs/pii/S0883944119304319?via%3Dihub — feasibility study on analgesia-first sedation, I’m trying to find my favorite study on analgesia first sedation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237378/ — not addressing delirium in AFS, but a great bit about the feasibility and efficacy of an analgesia first approach.
Pandharipande, P., et al. (2006). Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 104(1). https://pubmed.ncbi.nlm.nih.gov/16394685/
Taipale, P., et al. (2012). The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study. International Journal Nursing Student, 49(9). https://pubmed.ncbi.nlm.nih.gov/22542266/
Yang, et al. (2017). Risk factors of delirium in sequential sedation patients in intensive care units. Biomed Research International. https://www.hindawi.co
