00:00
So we're now going
to step away from
SIRS and sepsis, and we're going to talk about General
Management of the patient in the ICU, including
sedation, pain control, and muscle
relaxation. Muscle
relaxants should be used with great care in the ICU.
It is very easy to produce immobility in the
presence of awareness and pain. If they are used at all,
a peripheral nerve stimulator must be utilized
to assess the degree of paralysis.
The major reason for using paralysis
is to minimize the body's oxygen demands.
When the muscles are all paralyzed,
the oxygen demands in the body
drop dramatically. So it's worth
doing in some cases, but you have to be careful with it. And you have
to remember that muscle relaxants produce no amnesia,
and they produce no analgesia.
Pain management
is usually done by the Continuous
Opioid Infusion, but this has
to be carefully done, particularly in the presence of renal
failure, because complications can occur because
the metabolites of the opioids
are not removed by the kidney.
01:14
Sedation drugs range from Benzodiazepines
such as Midazolam, Lorazepam, the old Valium;
anesthetic drugs such as Propofol,
sometimes Ketamine; and central alpha2
agonists, drugs such as clonidine, which has been
around for a long long time, and
dexmetedomidine, which is a very, currently
very aggressively marketed drug, which seems
to be an excellent drug in some situations
for sedation. Patients in the ICU require
sedation pauses on a regular basis. And the reason
for the sedation pauses is to give them a chance
to wake up. Give them a chance for the nurses
and doctors to assess their ability to recover
and to see what level they're at with
recovery. No sedation mode has been
shown to be superior than others but some, as I
mentioned dexmetedomidine, are very aggressively
marketed. So sedation in the ICU
is titrated to the Richmond Agitation
Sedation Scale or RASS, Richmond Agitation
Sedation Scale, throughout the time
that they are in the ICU. So I'm
going to let you look at the slide
and go through the various numbers. I'm not going
to read it to you, it's easy to see how
the scale is calculated. And,
by reading through this and understanding it, you'll
have a better idea of how sedation is managed
and what level of sedation is considered
to be a normal level. Patients often spend
extended periods of time in the ICU.
And they can't eat.
02:56
They're usually unconscious,
or paralyzed, or heavily sedated,
so nutrition becomes a major issue.
And it's a very complex topic and
we can't cover it in detail in these
talks. But the bottom line is that
the nutrition is given enteraly, through the gut
if possible. And this can be either by
an oral gastric tube that goes through the mouth down into
the stomach or even out, preferably out into the duodenum
or a nasogastric tube. And fats, carbohydrates
and protein can be delivered
this way. And the normal digestive
factors of the human being
are utilized to absorb and use these agents.
This is far and away the best way to
feed patients in the ICU. Early
enteral nutrition improves
outcome in critically ill patients. And we've only known
that for a few years. So it's part of the normal
treatment in the ICU now. Treatment,
nutritional treatment can
be given intravenously by a central line directly into the circular
system, circulation system, but this is a complex
process and is often complicated
by infection and inadequate calorie
delivery. It is not the first choice. This is
a very controversial topic. We
basically don't do a great job of nutrition
support for patients in critically ill situations.