Dr Jean-Pierre QUENOT - jivd- .Gestion PARAMÉDICALE de la SÉDATION Dr Jean-Pierre QUENOT jean-...

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  • Gestion PARAMÉDICALE de la SÉDATION

    Dr Jean-Pierre QUENOT jean-pierre.quenot@chu-dijon.fr

    Service de Réanimation Médicale CHU Dijon

    18ème Édition !

    ACTUALITÉS EN RÉANIMATION Réanimation, Surveillance Continue

    et Urgences Graves

  • Prise en charge GLOBALE du patient sous ventilation mécanique

    La SÉDATION est-elle nécessaire ?

    §  Prévention des complications de décubitus §  Prévention des PAVM §  PEC de la douleur §  PEC psychique §  Contention §  ….

  • A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial Thomas Strøm, Torben Martinussen, Palle Toft

    www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9

    No sedation (n=55) Sedation (n=58)

    Age (years) 67 (54–74) 65 (54–74)

    Women 13 (24%) 24 (41%)

    Weight (kg) 80·0 (74·0–92·0) 78·5 (70·0–91·0)

    APACHE II 26 (19–30) 26 (22–31)

    SAPS II 46 (36–56) 50 (43–63)

    SOFA (at day 1) 7·5 (5·0–11·0) 9·0 (5·5–11·0)

    Diagnosis at admission to intensive care unit

    Respiratory disorder* 26 (47%) 27 (47%)

    Sepsis 15 (27%) 19 (33%)

    Pancreatitis 2 (4%) 3 (5%)

    Peritonitis 0 1 (2%)

    Gastro-intestinal bleeding 5 (9%) 0

    Liver and biliary disease 2 (4%) 0

    Trauma 2 (4%) 3 (5%)

    Other 3 (5%) 5 (9%)

    Data are in number (%) or median (IQR). APACHE II=acute physiology and chronic health evaluation. SAPS II=simplifi ed acute physiology score. SOFA=sequential organ-failure assessment. *Pneumonia, chronic obstructive pulmonary disease, and asthma.

    No sedation •  Morphine •  Halopéridol •  Diprivan pour 6 h

    Sedation •  Morphine •  Diprivan •  Hypnovel

    Ramsay

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  • A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial Thomas Strøm, Torben Martinussen, Palle Toft

    www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9

    No sedation (n=55) Sedation (n=58) p value

    Days without mechanical ventilation (from intubation to day 28) 13·8 (11·0); 18·0 (0–24·1) 9·6 (10·0); 6·9 (0–20·5) 0·0191*†

    Length of stay (days)

    Intensive care unit 13·1 (5·7– ··)‡ 22·8 (11·7– ··)‡ 0·0316*§

    Hospital 34 (17–65) 58 (33–85) 0·0039*§¶

    Mortality

    Intensive care unit 12 (22%) 22 (38%) 0·06

    Hospital 20 (36%) 27 (47%) 0·27

    Drug doses (mg/kg) ||

    Propofol (per h of infusion)** 0 (0–0·515) 0·773 (0·154–1·648 ) 0·0001

    Midazolam (per h of infusion) 0 (0–0) 0·0034 (0–0·0240)

  • A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial Thomas Strøm, Torben Martinussen, Palle Toft

    www.thelancet.com Published online January 29, 2010 DOI:10.1016/S0140-6736(09)62072-9

    Ratio IDE/Patients = 1/1

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  • Le sevrage de la VM est-elle possible ?

    Rôle du KINÉSITHÉRAPEUTE

    Rôle du MÉDECIN Rôle de l’IDE/AS

    Ø  Guérison en cours Ø  Antécédents… Ø  Echecs de sevrage

    Ø  Contact avec le patient Ø  Management FiO2, AI,

    antalgie, sédation, nutrition, catécholamines…

    Ø  Contrôle des entrées…

    Ø  Évaluation MRC, toux, déglutition… Ø  Cough assist….

    PATIENT

    Quel NIVEAU de SÉDATION ? L

    a SÉ

    D AT

    IO N

    e st

    -e lle

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  • AMERICAN THORACIC SOCIETY DOCUMENTS

    An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine Scott D. Halpern, Deborah Becker, J. Randall Curtis, Robert Fowler, Robert Hyzy, Lewis J. Kaplan, Nishi Rawat, Curtis N. Sessler, Hannah Wunsch, and Jeremy M. Kahn; on behalf of the Choosing Wisely Taskforce

    THIS OFFICIAL STATEMENT WAS APPROVED BY THE AMERICAN THORACIC SOCIETY (ATS), JUNE 2014; THE AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES (AACN), MARCH 2014; THE AMERICAN COLLEGE OF CHEST PHYSICIANS (ACCP), APRIL 2014; AND THE SOCIETY OF CRITICAL CARE MEDICINE (SCCM), MARCH 2014

    American Journal of Respiratory and Critical Care Medicine Volume 190 Number 7 | October 1 2014

  • AMERICAN THORACIC SOCIETY DOCUMENTS

    An Official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine Policy Statement: The Choosing Wisely® Top 5 List in Critical Care Medicine Scott D. Halpern, Deborah Becker, J. Randall Curtis, Robert Fowler, Robert Hyzy, Lewis J. Kaplan, Nishi Rawat, Curtis N. Sessler, Hannah Wunsch, and Jeremy M. Kahn; on behalf of the Choosing Wisely Taskforce

    THIS OFFICIAL STATEMENT WAS APPROVED BY THE AMERICAN THORACIC SOCIETY (ATS), JUNE 2014; THE AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES (AACN), MARCH 2014; THE AMERICAN COLLEGE OF CHEST PHYSICIANS (ACCP), APRIL 2014; AND THE SOCIETY OF CRITICAL CARE MEDICINE (SCCM), MARCH 2014

    American Journal of Respiratory and Critical Care Medicine Volume 190 Number 7 | October 1 2014

    Table 2. Final Top 5 List Approved by Societies’ Leadership and Included in Choosing Wisely Campaign

    1. Do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. Many diagnostic studies (including chest radiographs, arterial blood gases, blood chemistries and counts, and ECGs) are ordered at regular intervals (e.g., daily). Compared with a practice of ordering tests only to help answer clinical questions, or when doing so will affect management, the routine ordering of tests increases health-care costs, does not benefit patients, and may in fact harm patients. Potential harms include anemia due to unnecessary phlebotomy, which may necessitate risky and costly transfusion, and the aggressive work-up of incidental and nonpathological results found on routine studies.

    2. Do not transfuse RBCs in hemodynamically stable, nonbleeding ICU patients with an Hb concentration greater than 7 mg/dl. Most red blood cell transfusions in the ICU are for benign anemia rather than acute bleeding that causes hemodynamic compromise. For all patient populations in which it has been studied, transfusing RBCs at a threshold of 7 mg/dl is associated with similar or improved survival, fewer complications, and reduced costs compared with higher transfusion triggers. More aggressive transfusion may also limit the availability of a scarce resource. It is possible that different thresholds may be appropriate in patients with acute coronary syndromes, although most observational studies suggest harms of aggressive transfusion even among such patients.

    3. Do not use parenteral nutrition in adequately nourished critically ill patients within the first 7 d of an ICU stay. For patients who are adequately nourished before ICU admission, parenteral nutrition initiated within the first 7 d of an ICU stay has been associated with harm, or at best no benefit, in terms of survival and length of stay in the ICU. Early parenteral nutrition is also associated with unnecessary costs. These findings are true even among patients who cannot tolerate enteral nutrition. Evidence is mixed regarding the effects of early parenteral nutrition on nosocomial infections. For patients who are severely malnourished directly before their ICU admission, there may be benefits to earlier parenteral nutrition.

    4. Do not deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.

    Many mechanically ventilated ICU patients are deeply sedated as a routine practice despite evidence that using less sedation reduces the duration of mechanical ventilation and ICU and hospital length of stay. Several protocol-based approaches can safely limit deep sedation, including the explicit titration of sedation to the lightest effective level, the preferential administration of analgesic medications before initiating anxiolytics, and the performance of daily interruptions of sedation in appropriately selected patients receiving continuous sedative infusions. Although combining these approaches may not improve outcomes compared to one approach alone, each has been shown to improve patient outcomes compared with approaches that provide deeper sedation for ventilated patients.

    5. Do not continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

    Patients and their families often value the avoidance of prolonged dependence on life support. However, man