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Pain, Agitation, dan Delirium
l
e S
pada Pasien dengan MV

p l CPD Ventilasi Mekanis

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Keseminatan Intensive Care

a
2017

Tujuan kursus

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Setelah mengikuti topik ini, peserta akan:

li
• Mengetahui dan menjelaskan patofisiologi nyeri, agitasi dan

S
delirium dalam kaitan dengan ventilasi mekanis

e
• Mengetahui dan menjelaskan akibat dari nyeri, agitasi dan

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delirium pada outcome pasien sakit kritis
• Mengenali, mengukur dan mengelola nyeri, agitasi dan

m
delirium pada pasien sakit kritis

S a
• Melakukan evaluasi harian terhadap penggunaan obat-
obatan untuk nyeri, agitasi dan delirium dalam rangka
percobaan weaning harian
 e s
•
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April 1st to June 30th , 1996, 50 ICU patients during the first

S
week of their ICU stay, 50 of their respective relatives and 50

e
members of the professional team

p l
Stressors ranking comparison table by patients, relatives and professionals (1 - 4 scale)

Patient Relatives Team

m
Stressor
Rank Mean±SD Rank Mean±SD Rank Mean±SD

a
Being in pain 1 3.36 ± 1.01 1 3.66 ± 0.75 1 3.66 ± 0.75

S
Being unable to sleep 2 3.34 ± 0.98 4 3.34 ± 0.92 4 3.58 ± 0.57

Having tubes in the nose and/or mouth 3 3.26 ± 1.01 2 3.58 ± 0.7 19 3.62 ± 0.81

Having no control on oneself 4 3.10 ± 1.11 3 3.24 ± 1.06 3 3.00 ± 0.95

Being tied down by tubes 5 3.02 ± 1.22 11 3.4 ± 0.78 9 3.58 ± 0.78

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DeliriumS
p l e
am
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 ICU Delirium Facts

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• US: 55,000 pasien dirawat di 6000 Critical illness

li
ICUs setiap hari, kebanyakan di-
ventilasi

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Mechanical ventilation
• 60% - 80% pasien yang di-ventilasi

e
mengalami delirium

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Psychoactive medications
• 20% - 50% pasien di ICU dengan

p
kategori ringan mengalami delirium
Sleep alterations ICU
• 3 kali lebih besar resiko kematian in the ICU Delirium

m
dalam 6 bulan

a
• 5 hari lebih sedikit bebas dari

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Functional Cognitive
• 9 kali lebih tinggi insidens gangguan PTSD
impairment impairment
Death
cognitive pada waktu dekuar dari RS
• $15k - $25k lebi tinggi biaya RS nya
• Di-estimasi menghabiskan biaya $4 - Ely EW et al. JAMA 2004; 291: 1753-1762
$16 milyard per tahun Milbrandt EB, et al. Crit Care Med 2004; 32:955–962
Barr J, et al. Crit Care Med 2013; 41:263–306

Cardinal Symptoms of Delirium and Coma

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AROUSABLE
TO VOICE

li d UNAROUSABLE
TO VOICE

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Acute mental Fluctuating

e
status change mental status

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DELIRIUM COMA

p
Disorganized
Inattention
thinking

am
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Hallucinations, Altered level of
Delusions, consciousness
Illusions

Morandi A, et al. Intensive Care Med (2008) 34:1907–1915

 Subtypes of Delirium

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• Hyperactive delirium - paranoid, delusions, agitated
•

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Mudah dikenali, prognosis terbaik

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• Murni hiperaktif: 1.6% dari episode delirium
•

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Hypoactive delirium - menarik diri, diam, paranoid

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• “Quiet delirium”, penurunan tingkah laku reduced psycho-motor dan

p
lethargy
• Sering tidak mudah dikenali, misdiagnosis

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• Murni hipoaktif: 43.5% episodes

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• Mixed - kombinasi, fluktuasi antara kedua subtipe

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• Tersering di pasien ICU 54.9%
• Prognosis terjelek

Morandi A, et al. Intensive Care Med (2008) 34:1907–1915

Peterson JF, et al. J Am Geriatr Soc 2006;54: 479-484

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Pasien usia 65 dan lebih tua mengalami delirium hipoaktif pada laju yang lebih tinggi
dibandingkan pasien yang lebih muda (41.0% vs 21.6%, P .001) dan mereka tidak pernah
mengalami delirium hiperaktif

Peterson JF, et al. J Am Geriatr Soc 2006;54: 479-484

 Predisposing and Causative Conditions

s
Invasive

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Acute medical medical & Hospital
Mechanical nursing
or surgical Medications acquire
ventilation

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illness interventions d illness

Underlying
medical
conditions

Sli ICU
environmental
influences

Management of predisposing
Anxiety

p l e
Pain Delirium

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Sedative analgesic,
& causative conditions Intervention Antipsychotic medications

Dangerous
agitation
S a
Agitation, Vent
dyssynchrony
Pain,
anxiety
Calm, alert
free of pain
& anxiety
Lightly
sedated
Deeply
sedated
Unresponsive

Spectrum of Distress / Comfort / Sedations

Sessler CN, Varney K. Chest 2008;133:552-565

Risk of Delirium with Commonly

Administered Drugs

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• High Risk

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• Opioids (particularly meperidine & morphine)

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• Antiparkinsonian agents
• Antidepressants (particularly anticholinergic agents)

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• Benzodiazepines
• Corticosteroids

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• Medium Risk

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• Alpha- and beta-blockers
• NSAIDS
•
a
Low Risk

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• ACE-I
• H2 antagonists
• Calcium channel blockers
• Anticonvulsants

Maldonado JR. Crit Care Clin 2008;24:789-856.

Relationship between ICU-acquired delirium
and weakness in a patient with sepsis

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Patient with Sepsis

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Mechanical
Ventilation

p l e Sedation

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Cognitive and Functional Impairment, Institutionalization, Mortality

Vasilevskis EE, et al. Chest 2010; 138(5):1224–1233

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Pengenalan dini P-A-D

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Pain-Agitation-Delirium (PAD) Screening
• Pain

i d e
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• Self-reporting: Numerical Rating Scale or Wong-Baker Faces Pain

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Rating Scale
• Non-verbal:

l e
• Behavioral Pain Scale (BPS)

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• Critical Care Pain Observation Tool (CPOT)
• Agitation

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• Richmond Agitation Sedation Scale (RASS)

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• Riker Sedation Agitation Scale (SAS)

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• Delirium
• Confusion Assessment Method in the ICU (CAM-ICU)
• Intensive Care Delirium Screening Checklist (ICDSC)

Barr J, et al. Crit Care Med 2013; 41:263–306

s
Pain assessment

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(for patient with no impaired communication)

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Numerical Rating Scale (NRS)

Untuk anak sekitarusia

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l
8 tahun keatas

m p
S a
Untuk anak sekitarusia
3 tahun keatas

Nyeri bermakna bila NRS ≥ 4

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Behavioral Pain Scale
Item

d
Description

i e Score

l
Relaxed 1

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Partially tightened (e.g., brow 2
Facial expression lowering)

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Fully tightened (e.g., eyelid closing) 3

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Grimacing 4

p
No movement 1
Upper limb Partially bent 2

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movements Fully bent with finger flexion 3
Permanently retracted 4

a
Tolerating movement 1

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Coughing but tolerating ventilation for 2
Compliance with
the most of time
mechanical ventilation
Fighting ventilator 3
Score: 3 - 12 Unable to control ventilation 4
Significant Pain if BPS > 5
Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated
patients by using a behavioral pain scale. Crit Care Med 2001;29:2258–63

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Significant Pain if CPOT ≥ 3
 s
Richmond Agitation Sedation Scale (RASS)

i d e
Sl
p l e
am
S

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Richmond Agitation Sedation Scale (RASS)

i d e
Sl
p l e
am
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 e s
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Confusion Assessment Method

(CAM-ICU)
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1. Acute onset of mental status changes or a

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fluctuating course

p l e
and

2. Inattention

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3. Altered level of or 4. Disorganized

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consciousness thinking

= Delirium
 Confusion Assessment Method in the ICU

Delirium Assessment (CAM-ICU): 1 AND 2 AND (Either 3 OR 4)

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RASS is above - 4
1 Acute Onset or Fluctuating Course Stop

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(-3Proceed
through +4 An acute change from mental status baseline? No No delirium

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to next step Or Patient’s mental status fluctuating during the past 24 hours

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Yes

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2 Inattention

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Please read the following ten letter: S A V E A H A A R T Stop
Scoring: Error: when patient fails to squeeze on the letter “A” < 3 Errors No delirium
If RASS is above - 4 or - 5 Error: when the patient squeeze on any letter than “A”

p
Stop ≥3
Errors

m
Reassess patient at a later time
3 Altered Level of Consciousness (actual “RASS”)
If RASS is zero, Proceed to next step Stop

a
If RASS is other than zero Patients is
Delirious
0

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RASS

4 Disorganized Thinking
Dx Delirium: 1. Will a stone float on water? (Or: Will a leaf float on water?)
≥ 2 Errors Patient is Delirious

Feature 1 & 2: positive 2.

3.
Are there fish in the sea? (Or: Are there elephants in the sea?
Does one pound weigh more than two pounds? (Or: Do two pounds weigh more than one?)
Plus 4.
5.
Can you use a hammer to pound a nail? (Or: Can you use a hammer to cut wood?)
Command:
Either Feature 3 or 4 Say to patient: “Hold up this many fingers” (Examiner holds two fingers in front of patient) Stop
“Now do the same thing with the other hand” (Not repeating the number of finger). < 2 Errors No delirium
If patient is unable to move booth arms for the second part, ask patient “add one more finger”

www.icudelirium.org

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Pengelolaan
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Pain-Agitation-Delirium

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Tujuan pengelolaan pasien (dgn ventilator)

di ICU

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• Indikasi, pengelolaan,komplikasi pemberian:
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• nyeri → analgesia

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• kegelisahan (agitasi) → sedasi

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• delirium → tranquilizer
a
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• obat pelumpuh otot
 Tujuan sedasi

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• Mengurangi kecemasan dan stres pada tindakan,
terapi, pemantauan non invasif

Sli
• Mencegah ekstubasi dan pencabutan kateter
yang tidak disengaja

p
• Sinkronisasi ventilatorl e
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• Mengurangi kebutuhan bantuan ventilasi mekanik

S a
• Mengurangi konsumsi O2 dan work of breathing
• Mengurangi kebutuhan obat pelumpuh otot

Pengendalian sedasi

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• Terapi sedasi harus diberikan dengan hati-hati dan dosis
tepat
• Tujuan sedasi harus jelas
Sli
e
• Kedalaman sedasi harus ditentukan

p l
• Tingkat sedasi dinilai dan dicatat secara teratur
• Penggunaan sistem skoring sedasi merupakan keharusan

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• Penggunaan protokol sedasi mengurangi durasi ventilasi

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mekanik, rawat ICU
 Sedasi

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p l
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* Laboratory data only

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Pain-Agitation-Delirium (PAD) Screening
• Pain

i d e
l
• Self-reporting: Numerical Rating Scale or Wong-Baker Faces Pain Rating

S
Scale
• Non-verbal:

l e
• Behavioral Pain Scale (BPS)
• Critical Care Pain Observation Tool (CPOT)

p
• Agitation

m
• Richmond Agitation Sedation Scale (RASS)

a
• Riker Sedation Agitation Scale (SAS)
•

S
Delirium
• Confusion Assessment Method in the ICU (CAM-ICU)
• Intensive Care Delirium Screening Checklist (ICDSC)

Barr J, et al. Crit Care Med 2013; 41:263–306

 Confusion Assessment Method – ICU

(CAM – ICU)
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Feature 1: Perubahan status mental akut atau berfluktuasi

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l
dan

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Feature 2: Tidak ada perhatian

am dan

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Feature 3: Disorganized Thinking atau

= Delirium
Feature 4: Altered Level of Consciousness

Confusion Assessment Method – ICU


(CAM – ICU)
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Langkah 1: Penilaian sedasi: RASS Langkah 2: Penilaian Delirium

l e
Feature 1:Perubahan status mental akut atau
perjalanannya ber-fluktuasi

p
Dan

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Feature 2: Tidak ada
perhatian

a
Dan

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Feature 3: Disorganized Feature 4: Gangguan
Thinking ATAU level kesadaran

= Delirium

Bila RASS - 4 atau - 5, Stop dan Bila RASS > - 4 (- ~ + 4) teruskan ke

Evaluasi ulang lagi lain waktu Langkah 2
 s
Langkah-langkah pemberian sedatif-analgesik

i d e
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Agitasi

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Koreksi Penyebab yg Reversibel

Terapi non-
farmacologik

p l e
m
Kendalikan
Analgesik Sedatif Delirium

S a
Hemodinamika
Tidak Stabil
stabil

• Fentanyl • Morphine • Midazolam • Lorazepam • Haloperidol

25 ~ 100μgIV 2 ~ 5 mgIV 2 ~ 5 mgIV 1~4mg IV 2 ~ 10 mgIV

• Ketamine • Propofol
0.5 ~ 1.0 mg/kgIV 5 μg/kg/min

Obat-obat ideal yang diharapkan

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Obat-obat ideal

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Obat-obat yang tersedia
• Onset cepat
• Efek analgesia dan sedasi baik
• Benzodiazepine
• Midazolam
Sl
l e
• Mudah di-titrasi • Lorazepam
• Propofol

p
• Akumulasi obat dan metabolit:
minimum • Butyrophenones

m
• Efek samping pd C-V, resp, • Haloperidol

a •
hepato-renal: minimum Dexmedetomidine
• Cepat bangun
S
• Cost effective
 s
AMNESIA ‘SEDATION’ SLEEP PAIN RELIEF

e
PROPOFOL

BENZODIAZEPINES

li d
S
CHLORMETHIAZOLE

p l e
THIOPENTONE

- 2 AGONISTS

am NSAIDs

Sedasi Dosis Bolus

S
Dosis Infus
OPIOIDS

KETAMINE

olam 2,5 – 5 mg 2 – 5 mg/jam

fol 1 – 3 mg/kg 1 -3 mg/kg/jam
edetomidin 0,2–0,6 mg/kg/jam

eridol 1 – 5 mg
ental 5 – 10 mg/kg 4 – 6 mg/kg/jam
in 0,2–0,5 mg/kg

Obat-obat sedasi
s
date 9,5mg 60mg/jam

i d e
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Obat sedasi Dosis bolus Dosis infus

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2.5 - 5 mg 2 - 5 mg/jam
Midazolam

e
1 - 3 mg/kg 1 - 3 mg/kg/jam
Propofol

l
0.2 - 0.6 mg/kg/jam

p
Dexmedetomidin
1 - 5 mg/jam
Haloperidol

am
5 - 10 mg/kg 4 - 6 mg/kg/jam
Thiopental

S
0.2 - 0.5 mg/kg
Ketamin
9.5 - 60 mg/jam
Etomidate
 e s
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S
Paralysis
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p l
am
S

Indikasi obat pelumpuh otot

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• Memudahkan intubasi trakhea
e
intrakranial
p l
• Mengendalikan peningkatan tekanan

m
• Mengurangi tonus otot pd kondisi ttt
a
S
• Memudahkan melakukan tindakan
 s
Komplikasi penggunaan obat pelumpuh otot di ICU

• Sedasi dan analgesia tidak adekuat

i d e
l
• Ventilasi tidak adekuat bila ada diskoneksi ventilator

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• Kesulitan penilalian klinis pasien

e
l
• Takipilaksis

p
• Tidak mampu batuk, retensi sputum, atelektasis

m
• Gangguan hemodinamik

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• Tidak bergerak : komplikasi tromboembolik, pressure ulcer,

S
trauma syaraf perifer
• Kelemahan otot berkepanjangan

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Penyebab kelemahan otot berkepanjangan
• Perubahan farmakokinetik

i d e
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• Interaksi obat dengan obat pelumpuh otot

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• Penumpukan obat pelumpuh otot

e
l
• Gangguan metabolik dan elektrolit

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• Hipotermi

m
• Perubahan fungsi pada otot (motor unit)

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• Miopati

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• Neuropati
• Defek fungsi neuromuscular junction
Obat-obat yang berpotensiasi dengan obat
pelumpuh otot

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d
• Antibiotik • Calsium Channel
•
•
Aminoglikosida
Polymyxin B

Sli
blockers
• Beta-adrenergic
e
blockers

l
• Tetracyclin

• Cyclosparin
p
• Clindamycin

• Antiaritmia • Furosemod
• Quinidin
am • Magnesium
S
• Procainamid
• Bretylium
• Anestetika lokal

Pertanyaan-pertanyaan sebelum
menggunakan obat pelumpuh otot

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• Apakah indikasinya jelas?

li d
S
• Apakah ada gangguan nerologi?
• Bagaimana status metabolik dan elektrolit?
• Apakah normotermik?

p l e
• Apakah sedasi dan analgesi sudah optimal

a
berpotensiasi?
m
• Apakah pasien mendapat obat-bat yg dapat

S
• Apakah ps sedang mendapat steroid dosis tinggi?
 e s
d
Daily Awakeningliand
Yang dilakukan di ICU:

e S
l
Breathing Controlled

m p
(ABC) trial

S a

Daily Awakening and Breathing Controlled (ABC) trial atau Wake Up and Breathe Protocol

s
SAT safety screen
tiap 24 jam SAT Safety
Screen

e
Tidak ada kejang
Tdk dlm alcohol withdrawal
gagal Tidak ada agitasi

d
Tidak lumpuh/dilumpuhkan
lolos
Tidak ada iskemia miokard

i
Tek. intrakranial normal

l
Lakukan SAT
SAT failure

S
Anxietas, agitasi, atau nyeri
Respiratory rate > 35/min

e
SpO2 < 88%
gagal
Mulai sedative lagi Respiratory distress

l
dgn 1/2 dosis Acute cardiac arrhythmia

p
lolos

SBT safety screen

SBT Safety

m
Tidak ada agitasi
Screen
Oxygen saturation ≥ 88%
FiO2 ≤ 50%

a
gagal PEEP ≤ 7.5 cm H2O
Tidak ada iskemia miokard
Tidak pakai vasopressor

S
lolos
Inspiratory effort cukup

Lakukan SBT

SBT failure
gagal
Tunjangan ventilasi
Respiratory rate > 35/min
penuh lolos
Respiratory rate < 8/min
SpO2 < 88%
Pertimbangkan Respiratory distress
ekstubasi Perubahan status mental
Acute cardiac arrhythmia

SAT: Spontaneous Awakening Trial SBT: Spontaneous Breathing Trial

ABC Trial - wahju - Jan
2011
 ABCDE is an ICU-acquired delirium and
weakness mitigation strategy
e s
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• Reduce Sedation by 1/2
the Current Dose and
Titrate as Needed

e
• Continue Sedation and Unsuccessful SAT, SBT, or

l
Daily Exercise Delirium Monitoring Extubation

ICU
Asses for

m
Daily
p Daily
PASS Consider
• Extubate

a
Sedation and Spontaneous PASS Spontaneous
` Trial Extubation
PASS • Exercise
Patient Awakening Trial Breathing • Continue Sedation and
Delirium

S
(SAT) (SBT) Delirium Monitoring

Morning
Time

ABC: Awakening & Breathing Coordination

D: Delirium Nonpharm Interventions
E: Early Exercise & Mobility
Vasilevskis EE, et al. Chest 2010; 138(5):1224–1233

e s
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Yang sering
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l
dilupakan

m p
S a
Patient Factors Predisposing Disease
Increased age Cardiac disease

s
Alcohol use
Male gender
Less Modifiable Cognitive impairment
(eg, dementia)

e
Living alone Pulmonary disease
Smoking

d
Renal disease

Sli Acute Illness

e
Length of stay

l
Fever
Medicine service

p
Lack of nutrition
Hypotension
Sepsis

m
Environment Metabolic disorders
Tubes/catheters

a
Admission via ED or Delirium Pain
through transfer
Medications:

S
Isolation
No clock - Anticholinergics
No daylight - Corticosteroids
- Benzodiazepines
No visitors
Noise
Use of physical restraints
More Modifiable

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S
m p?l e
S a