UNA EXPERIENCIA SENSORIAL Y EMOCIONAL DESAGRADABLE, ASOCIADA CON UNA LESIÓN HÍSTICA, PRESENTE O POTENCIAL”. IASP 1979 <Pie de Página> Se edita por el menú Insertar, Número de Diapositiva... 1

EN CUIDADOS INTENSIVOS ANALGESIA EN CUIDADOS INTENSIVOS

30-70% DE LOS PACIENTES EN UCI PRESENTAN DOLOR DURANTE SU ESTANCIA REFERIDO EN MÁS DE LA MITAD DE LOS CASOS COMO MODERADO A SEVERO

“ LOS PACIENTES QUE SON DADOS DE ALTA DE LA UCI RECUERDAN EL DOLOR COMO SU PEOR EXPERIENCIA

“ El dolor que mejor se soporta es el dolor ajeno” Renè Leriche ( 1875-1955)

DOLOR EN EL PACIENTE EN ESTADO CRITICO TUBO OT - SONDAS ASPIRACION VIA AEREA PROCEDIMIENTOS Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002 MOVILIZACION - TERAPIA FISICA Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

Trombosis venosa profunda Atelectasias - Sobreinfección pulmonar Consumo de oxígeno - IAM Ileo Aumento del catabolismo Inmunosupresión Síndromes de dolor crónico Morbi - Mortalidad SL Spencer. Effect of Postoperative Analgesia on Major Postoperative Complications: A Systematic Update of the Evidence. Anesth Analg 2007

DOLOR EN EL PACIENTE EN ESTADO CRITICO Sleep in the Intensive Care Unit Pharmacotherapy 2005

DEBE SER EVALUADO REGULARMENTE Y DOCUMENTADO EL DOLOR DEBE SER EVALUADO REGULARMENTE Y DOCUMENTADO Ventilado, sedado, relajado PACIENTE INCONSCIENTE TAQUICARDIA - HTA – DESADAPTACION VM MOVIMIENTOS - EXPRESION FACIAL - POSTURA SUDORACION - LAGRIMAS Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

OPIOIDES ANALGESICOS DE ELECCION FARMACOS RECOMENDADOS IV MORFINA , FENTANIL , HIDROMORFONA SI REQUIERE RAPIDO INICIO DE ACCION FENTANIL 30 SEGUNDOS PARA MANEJO INTERMITENTE MORFINA – HIDROMORFONA MEDIDAS NO FARMACOLOGICAS Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

ES EL ANALGESICO DE ELECCION EN PACIENTES CON ESTABILIDAD HEMODINAMICA LA MORFINA ES EL ANALGESICO DE ELECCION EN PACIENTES CON ESTABILIDAD HEMODINAMICA EN LA UNIDAD DE CUIDADOS INTENSIVOS EL FENTANILO ES EL ANALGESICO DE ELECCION EN PACIENTES INESTABLES HEMODINAMICAMENTE MEDIDAS NO FARMACOLOGICAS Freid, E.: Sedation management and role of restraints in the intensive care unit.Critical Care Refresher Course, 2001; 97-107

insuficiencia renal es el causante de la depresión res- MORFINA LIBERA HISTAMINA HIPOTENSION BRONCOESPASMO MORFINA 6 GLUCURONIDO TITULAR IRC FALLA HEPATICA ANCIANOS Sedación 0.4 – 2% desarrollan tolerancia para el efecto sedante < 10% metilfenidato 10 mg Insuficiencia renal I3. Se recomienda no usar morfina en el paciente crítico con insuficiencia renal y en diálisis. Grado de recomendación fuerte. Nivel de eviden- cia moderado (1B). Justificación. La morfina sufre una biotransforma- ción hepática por glucoronización a productos acti- vos M6G y M3G, dializables que se excretan por el riñón. El metabolito M6G que se acumula durante la insuficiencia renal es el causante de la depresión res- piratoria que se ha observado en pacientes con insu- ficiencia renal. A pesar de la diálisis, el efecto es pro- longado, probablemente por la disminución de la difusión desde el SNC. En pacientes crónicos se ha demostrado que la morfina es menos tolerada que la hidromorfona211,214,216,217. Dependiendo del grado de la insuficiencia renal se pueden ajustar las dosis según el aclaramiento de creatinina: entre 20-50 ml/minuto, 75% de la dosis; entre 10-20 ml/minuto, 50% de la dosis. Depresión respiratoria <1% antes de que haya depresión respiratoria los pacientes presentan primero sedación vía aérea y ventilacion ampollas de 1 mL con 400 μg. 1 - 2 μg/kg cada 3 minutos la respuesta se produce en 3 minutos duración 30 – 45 minutos según vida media del opioide implicado 5 ampollas de Naloxona de 0,4 mg/ml (2 mg) en 500 ml, se obtiene una concentración de 4 μg/ml. : 30 cc/h Infusión 2 mcg/kg/hora ACCP Critical Care Board Review 2008

MORFINA 5 minutos efecto pico 20 minutos duración 4 horas TITULACION RAPIDA 0.05 mg/kg/dosis 3 mg cada 10 minutos hasta control 0.3 mg/kg/ día 18 mg 3 mg cada 4 horas INFUSION 2 - 4 mg/hora 0.07 mg/kg/h ( 0.5 ) 1 % 10mg/cc 3 % 30 mg/cc TOLERANCIA Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007 ACCP Critical Care Board Review 2008

HIDROMORFONA Amp 2 mg 5 VECES MAS POTENTE QUE LA MORFINA ESTABILIDAD HEMODINAMICA NO LIBERA HISTAMINA < SEDACION < NAUSEA Y VOMITO UTIL EN FALLA RENAL NO METABOLITOS inicio acción 5 minutos 1. 5 mg cada 4 horas dosis 0.03 mg/kg/ dosis infusión: 0.5 mg/ hora 8 mcg/kg/hora Amp 2 mg ACCP Critical Care Board Review 2008 Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007

FENTANIL 100 VECES MAS POTENTE QUE LA MORFINA ESTABILIDAD HEMODINAMICA NO AFECTA EL INOTROPISMO CARDIACO LA FARMACOCINETICA NO SE ALTERA EN PRESENCIA DE DISFUNCION HEPATICA O RENAL ADMINISTRACION RAPIDA BRADICARDIA Y TORAX LEÑOSO ACCP Critical Care Board Review 2008

FENTANIL 25 – 100 mcg CADA 5 - 15 MINUTOS 0.4 – 1.5 mcg/kg SI EL DOLOR NO ES CONTROLADO INFUSION 50 mcg/hora 0.7 MCG/KG/HORA > 25 MC/HORA CADA HORA ( 10 mcg/kg/hora) Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007 Guidelines for Sedation and Analgesia During Mechanical Ventilation General Overview. J Trauma. 2007 Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007

REMIFENTANIL INICIO DE ACCIÓN (1 ½ MINUTO) ELIMINACIÓN MENOR A 10 MINUTOS ESTERASAS PLASMÁTICAS EXTUBACION MAS RAPIDA INDEPENDIENTE DURACIÓN DE LA INFUSIÓN Ó DE LA DOSIS Fx DE LOS ÓRGANOS (HÍGADO, RIÑÓN) ESTABILIDAD HEMODINÁMICA NO TOLERANCIA DOSIS : 800 mcg/ hora 0.1-0.2 MCG/KG/MIN  

MEPERIDINA ACUMULACIÓN NORMEPERIDINA VM: 30H CONVULSIONES ANTICOLINÉRGICAS TAQUICARDIA NO EN INSUFICIENCIA RENAL Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

ANALGESIA CONTROLADA POR EL PACIENTE PCA ANALGESIA CONTROLADA POR EL PACIENTE CIRUGIA MAYOR TORACICA O ABDOMINAL CONTROL MAS ADECUADO DEL DOLOR MANTENIMIENTO CONCENTRACION ANALGESICA DE ACUERDO A LOS REQUERIMIENTOS DOSIS TOTALES MENORES MENOS EFECTOS SECUNDARIOS EXCLUSION ALTERACION CONCIENCIA

DEPENDENCIA FISICA EXPOSICION 7 DIAS SUSPENSION ABRUPTA – RAPIDA REDUCCION DE LA DOSIS AGITACION TAQUICARDIA TAQUIPNEA NAUSEA VOMITO < DOSIS 20% DE LA DOSIS DIARIA ROTAR EL OPIOIDE ANTES DE LA SUSPENSION

EFECTOS SECUNDARIOS

OPIOFOBIA barrera al control adecuado del dolor agudo COMBATIR LA OPIOFOBIA OPIOFOBIA barrera al control adecuado del dolor agudo falta de formación de los profesionales de la salud EN PACIENTES HOSPITALIZADOS NO ADICCION

AINES HEMORRAGIA GASTROINTESTINAL FUNCION INHIBICION PLAQUETARIA TENSION ARTERIAL EXACERBACION FALLA CARDIACA NO VENTAJA ANALGESICA POTENCIAN EFECTO ADEVERSO FALLA RENAL

SEDACION EN LA UCI “ seudo analgesia “ SENSACION DE CALMA BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety chologic and physical sources and may be more com- Anxiety and agitation may arise from innumerable psy- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

INDICACIONES DE SEDACION EN UCI Agitación Exploraciones y técnicas invasivas Facilitar el cuidado del paciente Adaptación al ventilador Amnesia paciente BNM BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety chologic and physical sources and may be more com- Anxiety and agitation may arise from innumerable psy- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002

Medicamento ideal UCI . ansiolisis analgesia hipnosis amnesia BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety chologic and physical sources and may be more com- Anxiety and agitation may arise from innumerable psy- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

FORMAS DE ADMINISTRACION BOLOS INTERMITENTES Sobre sedación vs no adecuada Tiempo de enfermería INFUSION CONTINUA Dosing regimens Drugs can be administered by either intermittent bolus dosing or continuous infusion. Bolus dosing may result in periods of oversedation and undersedation and may in- crease demands on nursing time. This may distract nurs- ing attention away from other areas of patient care. Con- ceivably, continuous infusion may result in a more consistent level of sedation, but this approach is more likely to result in drug accumulation, which may delay recovery. Nivel de sedación adecuado Acumulación BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002

CUAL ES LA BDZ DE ELECCION EN LA UCI? SEDACION RAPIDA PACIENTE AGITADO MIDAZOLAM INFUSION CONTINUA LORAZEPAM INICIO RAPIDO Y CORTA DURACION DE ACCION LORA NO METABOLITOS NO INTERACCIONES

MIDAZOLAM ANSIOLITICO AMNESIA ANTEROGRADA SIN ANALGESIA ANTICONVULSIVANTE INICIO DE ACCION 2 MINUTOS Vm: 2H - > 12 h Benzodiazepines are the most commonly used agents to sedate mechanically ventilated patients [40]. They act by potentiating gamma amino-butyric acid receptor com- plex–mediated inhibition of the central nervous system. The gamma amino-butyric acid receptor complex regu- lates a chloride channel on the cell membrane, and, by increasing the intracellular flow of chloride ions, neurons become hyperpolarized, with a higher threshold for ex- citability. Flumazenil is a synthetic antagonist of the benzodiazepine receptor that may reverse many of the clinical effects of benzodiazepines Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

MIDAZOLAM EFECTOS PROLONGADOS ANCIANO - OBESOS ENF. HEPATICA - RENAL ACUMULACION METABOLITO ALFA - HIDROXIMIDAZOLAM TOLERANCIA – DEPENDENCIA FISICA SE ACUMULA EN LA GRASA TOLERANCIA EN HORAS involving 26 patients who were slow to awaken (> 36 hrs after sedation was stopped).56 The investigators found detectable levels of midazolam or 1-hydroxymidazolam glucuronide an average of 67 hours after midazolam infusion was discontinued in 13 patients. T Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

MIDAZOLAM ES RECOMENDADO SOLAMENTE PARA USO A CORTO PLAZO > 48 – 72 HORAS PROLONGA EXTUBACION DESPERTAR NO PREDECIBLE he kinetics of midazolam change considerably when it is administered by continuous infusion to critically ill patients. After continuous infusion for extended time periods (>1 d), this lipid-soluble drug accumulates in peripheral tissues as well as in the blood stream rather than being metabolized. When the drug is stopped, pe- ripheral tissue stores release midazolam back into theplasma, and the duration of clinical effect can be pro- longed (clinical recovery may take hours to days) [30]. Obese patients with larger volumes of distribution and elderly patients with decreased hepatic and renal func- tion may be even more prone to prolonged sedation. involving 26 patients who were slow to awaken (> 36 hrs after sedation was stopped).56 The investigators found detectable levels of midazolam or 1-hydroxymidazolam glucuronide an average of 67 hours after midazolam infusion was discontinued in 13 patients. T Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002 Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

MIDAZOLAM AGITACION AGUDA 2 mg – 5 mg cada 5 – 15 min 0.03 – 0.08 mg/kg infusión 8 mg/hora 0.05 – 0.2 mg/kg/ hora Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

MIDAZOLAM LORAZEPAM Después de infusiones prolongadas de midazo- DESPUÉS DE INFUSIONES PROLONGADAS DE MIDAZOLAM SE RECOMIENDA EL CAMBIO A LORACEPAM . VO TB 2 MG CADA 12 HORAS DESPUÉS DE LA 2 DOSIS DE LORACEPAM REDUCIR UN 50% DE LA DOSIS DEL MIDAZOLAM < 50% TRAS CADA DOSIS POR VÍA ORAL Después de infusiones prolongadas de midazo- lam se recomienda el cambio a loracepam tb 2 mg por vía oral, teniendo en cuenta que la relación potencia y vi- da media midazolam/loracepam es de 1:2 y 1:6 res- pectivamente. Después de la segunda dosis de lorace- pam por vía oral se iniciará la reducción a un 50% de la dosis del midazolam y otro 50% tras cada dosis por vía oral104,105.

PROPOFOL HIPNOTICO ANSIOLISIS AMNESIA NO ANALGESÌA NO EN PACIENTE INESTABLE . Ventajas: Descontinuación rápida de la ventilación mecáncia. Permite la realización de evaluaciones neurológicas seriadas Disminuye la PIC más efectivamente que el Fentanyl, en TCE severo Es mejor reservado a pacientes en quienes la BDZ fallan y en aquellos que requieren una titulación rápida. Efectos colaterales: Hipotensión más común en pacientes hipovolémicos e inestables Infección nosocomial postoperatoria Hipertrigliceridemia: particularmente a dosis altas por varios días y con formulación al 1%. Los pacientes deben ser monitorizados para acidosis metabólica inexplicada ó arritmias. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

QUE SEDANTE HAY QUE ESCOGER PARA PACIENTES QUE NECESITAN VIGILANCIA NEUROLOGICA? 1 – 2 MIN 15 MIN RAPIDO DESPERTAR EVALUACION NEUROLOGICA SERIADA < PIC 2 mg/h 5-75 µg/Kg/min amp 10mg/cc MONITORIZAR TRIGLICERIDOS 1 KCAL X CC 10 % Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Crit Care Med 2002

Intensive Care UnitPharmacotherapy 2005 PROPOFOL Hipotensión en pacientes hipovolémico Pancreatitis Síndrome de infusión de propofol M:80% acidosis metabólica arritmias colapso cardiovascular falla renal Mala tecnica aseptica … no mas de 12 horasnvolve treatment with sustained (usually > 48 hrs) high-dose propofol (> 75 µg/kg/min or propofol infusion syndrome has been implicated in several deaths of children and adults when the drug was used in higher doses and for prolonged periods. 10,11 The syndrome is charac- terized by rhabdomyolysis (involving both skeletal and myo- cardial muscle), elevated potassium levels, troponin-I release, metabolic acidosis, cardiac arrhythmias, cardiovascular col- lapse, and acute renal failure. The syndrome is frequently fatal. Rapid recognition and treatment of the metabolic disturbances are essential if the patient is to survive. Avoidance of high doses of propofol for prolonged periods may be the key to prevention. Adverse Events Associated with Sedatives, Analgesics, and Other Drugs That Provide Patient Comfort in the Intensive Care UnitPharmacotherapy 2005

a consideration for sepsis Immunosedation: a consideration for sepsis Maclaren R . Crit Care 2009 modelo en ratas uso de dexmedetomidina midazolam suprime la generación de mediadores proinflamatorios < mortalidad

Dexmedetomidine Curr Opin Crit Care DEXMEDETOMIDINA ALFA 2 AGONISTA PROPIEDADES ANALGESICAS, ANSIOLITICAS MINIMA DEPRESION RESPIRATORIA < DURACION DE LA VENTILACION MECANICA < EFECTOS EN LA FUNCION COGNITIVA REDUCE LA INCIDENCIA DE DELIRIO HIPOTENSION, BRADICARDIA DOSIS DEPENDIENTE HIPERTENSION Dexmedetomidine Curr Opin Crit Care Altering intensive care sedation paradigms to improve patient outcomes Crit Care Clin 2009

DEXMEDETOMIDINA Dosis de carga 1 mcg/Kg en 10 minutos FDA : INFUSION CONTINUA POR < 24 HORAS Dosis de carga 1 mcg/Kg en 10 minutos Infusión 12 mcg/h 0.2-0.7 mcg/Kg/hora Amp 200 mcg IV: From 10–20% of patients treated with dex- medetomidine in dosages up to 0.7 µg/kg/hour require supplementation with additional sedative agents.60–65 When the dosage range is extended above 0.7 µg/kg/hour to as high as 2.5 µg/kg/ hour, more patients are adequately sedated with little or no supple-mentation required.62, 66, 67 In a multicenter report of nonprotocol dexmedeto- midine therapy in 136 adult patients, 37 (27%) received 0.7–1.4 µg/kg/hour.68 In a similar retro- spective report of 107 patients, dexmedetomidine was administered at dosages as high as 1.0 µg/kg/hour.69Dosis de carga: 1-2 µg / Kg o 0.6 µg / Kg / hora por 10 minutos. Mantenimiento: 0.2 a 0.7 µg / Kg / hora.

RAMSAY NIVELES DE SEDACION DESPIERTO 1. ANSIOSO AGITADO INQUIETO 2. ORIENTADO TRANQUILO COOPERADOR DORMIDO 3. RESPONDE A ORDENES No validada. • No valora adecuadamente la agitación, sólo la sedación. • Sus seis niveles no son excluyentes entre sí. • No es muy útil en los pacientes en ventilación mecánica. • Para realizarla hay que estimular y molestar al enfermo. RESPONDE A ORDENES RESPUESTA RAPIDA A ESTIMULOS RESPUESTA LENTA A ESTIMULOS AUSENCIA DE RESPUESTA 1. DESPIERTO ANSIOSO AGITADO INQUIETO DESPIERTO ORIENTADO – TRANQUILO – COOPERADOR DORMIDO , RESPONDE A ORDENES DORMIDO, RESPUESTA RAPIDA A ESTIMULOS BREVE A LA LUZ Y AL SONIDO DORMIDO, RESPUESTA LENTA A ESTIMULOS TARDIA, RESPUESTA AL DOLOR DORMIDO, AUSENCIA DE RESPUESTA SIN RESPUESTA A NINGUN ESTIMULO 4. RESPUESTA RAPIDA A ESTIMULOS 5. RESPUESTA LENTA A ESTIMULOS 6. SIN RESPUESTA BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002

NIVELES DE SEDACION ENTRE 2 Y 4 CUALES SON LOS NIVELES DE SEDACION ADECUADOS EN EL PACIENTE CON VENTILACION MECANICA ? NIVELES DE SEDACION ENTRE 2 Y 4 1. DESPIERTO ANSIOSO AGITADO INQUIETO DESPIERTO ORIENTADO – TRANQUILO – COOPERADOR DORMIDO , RESPONDE A ORDENES DORMIDO, RESPUESTA RAPIDA A ESTIMULOS BREVE A LA LUZ Y AL SONIDO DORMIDO, RESPUESTA LENTA A ESTIMULOS TARDIA, RESPUESTA AL DOLOR DORMIDO, AUSENCIA DE RESPUESTA SIN RESPUESTA A NINGUN ESTIMULO 4 : dormido con ojos cerrados, rta l a estimulos verbales Aunque el prototipo del se- dante intravenoso es el diacepam, ya no se recomienda porque: a) causa con frecuencia dolor y tromboflebi- tis cuando se administra por una vena periférica; b) la administración en forma de bolos puede llevar a una sedación excesiva; c) la administración en infusión intravenosa continua aumenta su vida media, llegan- do a ser hasta de siete días en algunos pacientes; d) re- quiere dilución en un volumen grande, lo que impli- caría el riesgo de sobrecarga hídrica en el uso prolongado. Sin embargo, en algunos centros se utili- za por su bajo coste y por su rápido mecanismo de ac- ción para maniobras cortas (cardioversión eléctrica, IT), indicándose un bolo único3. Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007

EN QUE PACIENTES USAMOS SEDACION PROFUNDA RAMSAY 5 – 6 ? Hipertensión endocraneal Tétanos Aspiración traqueal Ventilación totalmente controlada 1. DESPIERTO ANSIOSO AGITADO INQUIETO DESPIERTO ORIENTADO – TRANQUILO – COOPERADOR DORMIDO , RESPONDE A ORDENES DORMIDO, RESPUESTA RAPIDA A ESTIMULOS BREVE A LA LUZ Y AL SONIDO DORMIDO, RESPUESTA LENTA A ESTIMULOS TARDIA, RESPUESTA AL DOLOR DORMIDO, AUSENCIA DE RESPUESTA SIN RESPUESTA A NINGUN ESTIMULO Debe recordarse que la sedación profunda de nivel 5 o 6 de la escala propuesta podría ser útil úni- camente en la sedación que forma parte del trata- miento de la hipertensión endocraneal o en situacio- nes como el tétanos o la hipertermia maligna12 Aspiracion traqueal , ventilacion totalmente controlada 4 : dormido con ojos cerrados, rta l a estimulos verbales Aunque el prototipo del se- dante intravenoso es el diacepam, ya no se recomienda porque: a) causa con frecuencia dolor y tromboflebi- tis cuando se administra por una vena periférica; b) la administración en forma de bolos puede llevar a una sedación excesiva; c) la administración en infusión intravenosa continua aumenta su vida media, llegan- do a ser hasta de siete días en algunos pacientes; d) re- quiere dilución en un volumen grande, lo que impli- caría el riesgo de sobrecarga hídrica en el uso prolongado. Sin embargo, en algunos centros se utili- za por su bajo coste y por su rápido mecanismo de ac- ción para maniobras cortas (cardioversión eléctrica, IT), indicándose un bolo único3. Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007

BIS: Análisis biespectral 29/03/2017 BIS: Análisis biespectral 100 Despierto Sedación Silencio cortical 80 60 40 GRADO DE ACTIVIDAD ELECTRICA CEREBRAL ELCTROENCEFALOGRAMA NIVEL DE SEDACION ESCALA DE 0 A 100 TS: calculo del porcentaje de tiempo en el último minuto que la señal de EEG queda suprimida 20 2004

PAUTAS EVALUE DIARIAMENTE LA META TITULE LA TERAPIA PARA MANTENERLA DOSIS SI > 1 SEMANA A DOSIS ALTAS CONSIDERE EL DESPERTAR DIARIO MONITORICE SIGNOS DE SUPRESION

NO ADMINISTRAR NINGUN FCO DE FORMA INMEDIATA Considerarse problemas amenazantes de la vida: Hipoxia Hipercapnia Reacción adversa a fármacos Sind. de retiro (abstinencia) Retención urinaria Método ventilatorio inadecuado Consenso sedación, analgesia y relajación neuromuscular en cuidado intensivo. Acta colombiana de Cuidado Intensivo 2007

,

DELIRIO BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety chologic and physical sources and may be more com- Anxiety and agitation may arise from innumerable psy- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

Método para la Evaluación de la Confusión ó CAM EVALUACION DEL DELIRIO Método para la Evaluación de la Confusión ó CAM El delirio se define como una altera- ción de la conciencia con inatención, acompañada de alteraciones cognitivas y/o de percepción que se de- sarrollan en un corto período de tiempo (horas o días) y fluctúan con el tiempo45. Los cambios cognitivos se manifiestan como alteraciones de la memoria, deso- rientación, agitación o habla confusa. L Las alteracio- nes (usualmente visuales), ilusiones y/o delusiones nes de la percepción se manifiestan como alucinacio- Hiperactivo (30%): se caracteriza por agitación, agresividad, inquietud, labilidad emocional, tenden- 2. Hipoactivo (24%): se caracteriza por letargia, cia a retirarse sondas, catéteres y tubos. indiferencia afectiva, apatía y disminución en la res- puesta a estímulos externos. Con el empleo de medi- camentos psicoactivos es más prevalente que el hipe- ractivo. Se asocia a la prolongación de la estancia 3. Mixto (46%): presenta características de los dos hospitalaria y a un incremento de la mortalidad. anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia and often originates from sources such as surgical inci- Pain is a common experience in critically ill patients [1] sions, vascular catheter placement, and endotracheal suc- tioning. In addition to suffering, adverse effects of pain in critically ill patients may include increased endog- duction of hypermetabolic states, and anxiety. There is enous catecholamine activity, myocardial ischemia, in- some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- algesia is the first priority when administering sedation in Anxiety the ICU [3••]. Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- monly recognized than pain. Anxiety that is difficult to Dyspnea remedy may be a result of inadequately treated pain. The subjective sense of dyspnea is common in ICU pa- tients and may be a source of severe anxiety and distress. Likewise, coughing is common in intubated ICU pa- cessive coughing may contribute to patient–ventilator tients, particularly during endotracheal suctioning. Ex- dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium deprivation, electrolyte disturbances, hepatic encepha- Potential causes of delirium include drugs, sepsis, sleep lopathy, withdrawal syndromes, and many others. Ely et al. [4•] have recently reported the incidence of delirium to be extremely high in critically ill patients. Sedatives are often used to facilitate the delivery of nurs- To facilitate care ing care (dressing wounds, administering baths, and so forth), to prevent adverse events such as self-extubation, and to ensure synchrony with mechanical ventilation. University of Chicago, Chicago, Illinois, USA. Section of Pulmonary and Critical Care Medicine, Department of Medicine, Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. Current Opinion in Critical Care 2002, 8:290–298 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of dyspnea, and delirium. Minimizing the volume of oxy- oxygen utilization associated with analgesia, anxiety, gen utilization is particularly important in patients with acute hypoxemic respiratory failure and shock. To achieve amnesia patients, data supporting this notion are lacking. Rather, Although this seems intuitively desirable for critically ill there are reports of adverse psychological sequelae in patients unable to recall factual memories from their ill- ness [5,6•]. The only circumstance in which amnesia is being administered. mandatory is when neuromuscular blocking agents are

EVALUACION DEL DELIRIO FALTA DE ATENCION Hiperactivo (30%): se caracteriza por agitación, agresividad, inquietud, labilidad emocional, tenden- cia a retirarse sondas, catéteres y tubos. 2. Hipoactivo (24%): se caracteriza por letargia, indiferencia afectiva, apatía y disminución en la res- puesta a estímulos externos. camentos psicoactivos es más prevalente que el hipe- Con el empleo de medi- ractivo. Se asocia a la prolongación de la estancia hospitalaria y a un incremento de la mortalidad. 3. Mixto (46%): presenta características de los dos anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is ated with adverse outcomes [2]. Achieving adequate an- some evidence that inadequate analgesia may be associ- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator of lung-protective strategies that result in hypercapnia. dyssynchrony. Dyspnea may be exacerbated by the use Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption 290 Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

EVALUACION DEL DELIRIO FALTA DE ATENCION Con el empleo de medi- camentos psicoactivos es más prevalente que el hipe- hospitalaria y a un incremento de la mortalidad. ractivo. Se asocia a la prolongación de la estancia 3. Mixto (46%): presenta características de los dos anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- sions, vascular catheter placement, and endotracheal suc- tioning. In addition to suffering, adverse effects of pain enous catecholamine activity, myocardial ischemia, in- in critically ill patients may include increased endog- duction of hypermetabolic states, and anxiety. There is some evidence that inadequate analgesia may be associ- ated with adverse outcomes [2]. Achieving adequate an- the ICU [3••]. algesia is the first priority when administering sedation in Anxiety Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- remedy may be a result of inadequately treated pain. monly recognized than pain. Anxiety that is difficult to Dyspnea The subjective sense of dyspnea is common in ICU pa- tients and may be a source of severe anxiety and distress. tients, particularly during endotracheal suctioning. Ex- Likewise, coughing is common in intubated ICU pa- cessive coughing may contribute to patient–ventilator dyssynchrony. Dyspnea may be exacerbated by the use of lung-protective strategies that result in hypercapnia. Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- lopathy, withdrawal syndromes, and many others. Ely et al. [4•] have recently reported the incidence of delirium To facilitate care to be extremely high in critically ill patients. Sedatives are often used to facilitate the delivery of nurs- ing care (dressing wounds, administering baths, and so forth), to prevent adverse events such as self-extubation, Section of Pulmonary and Critical Care Medicine, Department of Medicine, and to ensure synchrony with mechanical ventilation. University of Chicago, Chicago, Illinois, USA. Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL Current Opinion in Critical Care 2002, 8:290–298 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. 290 DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- gen utilization is particularly important in patients with acute hypoxemic respiratory failure and shock. To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, there are reports of adverse psychological sequelae in patients unable to recall factual memories from their ill- mandatory is when neuromuscular blocking agents are ness [5,6•]. The only circumstance in which amnesia is being administered.

EVALUACION DEL DELIRIO Hiperactivo (30%): se caracteriza por agitación, agresividad, inquietud, labilidad emocional, tenden- cia a retirarse sondas, catéteres y tubos. 2. Hipoactivo (24%): se caracteriza por letargia, indiferencia afectiva, apatía y disminución en la res- puesta a estímulos externos. camentos psicoactivos es más prevalente que el hipe- Con el empleo de medi- ractivo. Se asocia a la prolongación de la estancia hospitalaria y a un incremento de la mortalidad. 3. Mixto (46%): presenta características de los dos anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is ated with adverse outcomes [2]. Achieving adequate an- some evidence that inadequate analgesia may be associ- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator of lung-protective strategies that result in hypercapnia. dyssynchrony. Dyspnea may be exacerbated by the use Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption 290 Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

EVALUACION DEL DELIRIO Hiperactivo (30%): se caracteriza por agitación, agresividad, inquietud, labilidad emocional, tenden- cia a retirarse sondas, catéteres y tubos. 2. Hipoactivo (24%): se caracteriza por letargia, indiferencia afectiva, apatía y disminución en la res- puesta a estímulos externos. camentos psicoactivos es más prevalente que el hipe- Con el empleo de medi- ractivo. Se asocia a la prolongación de la estancia hospitalaria y a un incremento de la mortalidad. 3. Mixto (46%): presenta características de los dos anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is ated with adverse outcomes [2]. Achieving adequate an- some evidence that inadequate analgesia may be associ- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator of lung-protective strategies that result in hypercapnia. dyssynchrony. Dyspnea may be exacerbated by the use Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption 290 Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

UNA MEJOR VALORACION DEL DELIRIO CONLLEVA MEJORES RESULTADOS EN LOS SUPERVIVIENTES DE LA UCI HIPERACTIVO (30%): AGITACIÓN - AGRESIVIDAD HIPOACTIVO (24%): LETARGIA - APATÍA > MORTALIDAD DETERIORO COGNITIVO A LARGO PLAZO Hiperactivo (30%): se caracteriza por agitación, agresividad, inquietud, labilidad emocional, tenden- cia a retirarse sondas, catéteres y tubos. 2. Hipoactivo (24%): se caracteriza por letargia, indiferencia afectiva, apatía y disminución en la res- puesta a estímulos externos. camentos psicoactivos es más prevalente que el hipe- Con el empleo de medi- ractivo. Se asocia a la prolongación de la estancia hospitalaria y a un incremento de la mortalidad. 3. Mixto (46%): presenta características de los dos anteriores. BK Gehlbach. Sedation in the intensive care unit Curr Opin Crit Care 2002 Indications for sedation Analgesia Pain is a common experience in critically ill patients [1] and often originates from sources such as surgical inci- tioning. In addition to suffering, adverse effects of pain sions, vascular catheter placement, and endotracheal suc- in critically ill patients may include increased endog- enous catecholamine activity, myocardial ischemia, in- duction of hypermetabolic states, and anxiety. There is ated with adverse outcomes [2]. Achieving adequate an- some evidence that inadequate analgesia may be associ- algesia is the first priority when administering sedation in the ICU [3••]. Anxiety Anxiety and agitation may arise from innumerable psy- chologic and physical sources and may be more com- monly recognized than pain. Anxiety that is difficult to remedy may be a result of inadequately treated pain. Dyspnea tients and may be a source of severe anxiety and distress. The subjective sense of dyspnea is common in ICU pa- Likewise, coughing is common in intubated ICU pa- tients, particularly during endotracheal suctioning. Ex- cessive coughing may contribute to patient–ventilator of lung-protective strategies that result in hypercapnia. dyssynchrony. Dyspnea may be exacerbated by the use Delirium Potential causes of delirium include drugs, sepsis, sleep deprivation, electrolyte disturbances, hepatic encepha- al. [4•] have recently reported the incidence of delirium lopathy, withdrawal syndromes, and many others. Ely et to be extremely high in critically ill patients. To facilitate care Sedatives are often used to facilitate the delivery of nurs- forth), to prevent adverse events such as self-extubation, ing care (dressing wounds, administering baths, and so and to ensure synchrony with mechanical ventilation. Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, USA. Medicine, University of Chicago, 5841 S. Maryland Ave., MC 6026, Chicago, IL Correspondence to John P. Kress, MD, Section of Pulmonary and Critical Care 60637, USA; e-mail: jkress@medicine.bsd.uchicago.edu Current Opinion in Critical Care 2002, 8:290–298 ISSN 1070–5295 © 2002 Lippincott Williams & Wilkins, Inc. DOI: 10.1097/01.CCX.0000022651.36796.80To decrease excess oxygen consumption 290 Sedatives are commonly used to decrease the volume of oxygen utilization associated with analgesia, anxiety, dyspnea, and delirium. Minimizing the volume of oxy- acute hypoxemic respiratory failure and shock. gen utilization is particularly important in patients with To achieve amnesia Although this seems intuitively desirable for critically ill patients, data supporting this notion are lacking. Rather, patients unable to recall factual memories from their ill- there are reports of adverse psychological sequelae in ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered. Gunther The cognitive consequences or critical illness: practical recommendations for screenin and assessment. Crit Care Clinic 2007

LAS BENZODIACEPINAS - OPIOIDES INCREMENTAN ENTRE 3 Y 11 VECES EL RIESGO DE DESARROLLAR DELIRIO oxygen utilization associated with analgesia, anxiety, Sedatives are commonly used to decrease the volume of dyspnea, and delirium. Minimizing the volume of oxy- gen utilization is particularly important in patients with acute hypoxemic respiratory failure and shock. Although this seems intuitively desirable for critically ill To achieve amnesia patients, data supporting this notion are lacking. Rather, there are reports of adverse psychological sequelae in patients unable to recall factual memories from their ill- ness [5,6•]. The only circumstance in which amnesia is mandatory is when neuromuscular blocking agents are being administered.

MANEJO DEL DELIRIO LAS INTERVENCIONES GENERALES : ADECUADA SEDACIÓN TRAQUEOSTOMÍA TEMPRANA REDUCE LA NECESIDAD DE SEDACIÓN MEJORA LA CAPACIDAD DE COMUNICACIÓN ADECUADO MANEJO DEL DOLOR n. El haloperidol es una buti- rofenona con efecto antipsicótico que no suprime el reflejo respiratorio y actúa como antagonista dopa- minérgico; además, tiene unLos efectos adversos del haloperidol incluyen dales, espasmos laríngeos, síndrome neuroléptico hipotensión, distonías agudas, síntomas extrapirami- maligno, efectos anticolinérgicos, reducción del um- bral de convulsiones y desregulación del metabolis- mo de la glucosa y de los lípidos. Gunther The cognitive consequences or critical illness: practical recommendations for screenin and assessment. Crit Care Clinic 2007

MANEJO DEL DELIRIO HALOPERIDOL AMP 5 MG 2 - 10 MG CADA 30 MINUTOS DUPLICANDO LA DOSIS PREVIA MIENTRAS LA AGITACION PERSISTA 25% DE LA DOSIS DE CARGA CADA 6 HORAS MONITORIZAR CAMBIOS ELECTROCARDIOGRAFICOS PROLONGACION DEL QT - TAQUICARDIA VENTRICULAR SINDROME NEUROLEPTICO MALIGNO HIPERTERMIA, RIGIDEZ MUSCUALAR, RABDOMIOLISIS n. El haloperidol es una buti- rofenona con efecto antipsicótico que no suprime el reflejo respiratorio y actúa como antagonista dopa- minérgico; además, tiene unLos efectos adversos del haloperidol incluyen dales, espasmos laríngeos, síndrome neuroléptico hipotensión, distonías agudas, síntomas extrapirami- maligno, efectos anticolinérgicos, reducción del um- bral de convulsiones y desregulación del metabolis- mo de la glucosa y de los lípidos. Gunther The cognitive consequences or critical illness: practical recommendations for screenin and assessment. Crit Care Clinic 2007

HIPOTENSION - ARRITMIAS NO RECOMENDADA MANEJO DEL DELIRIO LEVOPROMAZINA 25 MG ANTICOLINERGICO HIPOTENSION - ARRITMIAS NO RECOMENDADA OLANZAPINA antisicóticos atípicos 10 mg día There is very little evidence regarding the use of atypical antipsychotics for delirium treatment in the Atypical antipsychotics critical care setting where published data is limited to one prospective randomised trial and a case report39, 40. Olanzapine 5mg daily was found to be as effective as 2.5mg-5mg haloperidol enterally three times haloperidol use in both groups was similar. daily in a randomised group of critically ill patients who were screened for delirium. Rescue Enteral olanzapine may therefore be useful in patients who do not tolerate haloperidol due to extra- pyramidal side effects. Recent advice from the Committee on Safety of Medicines regarding the increased risk of stroke in patients with dementia who are treated with olanzapine in the general population should also be borne in mind41, particularly as dementia is a risk factor for the development of delirium. The orodispersible formulation is not absorbed sublingually, although may be dispersed in water to facilitate administration through enteral feeding tubes. There is no reported experience with using parenteral atypical antipsychotics agents in critically ill patients. Intramuscular olanzapine should only be used as an alternative to intravenous haloperidol available. Risperidone is presented as a depot injection for chronic schizophrenia and cannot be where side effects are particularly troublesome (e.g. in Parkinson’s disease) and the enteral route is not recommended. the risk of hypotension, tachycardias and cardiac arrhythmias, an. El haloperidol es una buti- Phenothiazines exhibit greater anticholinergic activity than butyrophenones and this increases rofenona con efecto antipsicótico que no suprime el reflejo respiratorio y actúa como antagonista dopa- minérgico; además, tiene unLos efectos adversos del haloperidol incluyen dales, espasmos laríngeos, síndrome neuroléptico hipotensión, distonías agudas, síntomas extrapirami- maligno, efectos anticolinérgicos, reducción del um- bral de convulsiones y desregulación del metabolis- mo de la glucosa y de los lípidos.

MANEJO DEL DELIRIO Atypical antipsychotics There is very little evidence regarding the use of atypical antipsychotics for delirium treatment in the Atypical antipsychotics critical care setting where published data is limited to one prospective randomised trial and a case report39, 40. Olanzapine 5mg daily was found to be as effective as 2.5mg-5mg haloperidol enterally three times haloperidol use in both groups was similar. daily in a randomised group of critically ill patients who were screened for delirium. Rescue Enteral olanzapine may therefore be useful in patients who do not tolerate haloperidol due to extra- pyramidal side effects. Recent advice from the Committee on Safety of Medicines regarding the increased risk of stroke in patients with dementia who are treated with olanzapine in the general population should also be borne in mind41, particularly as dementia is a risk factor for the development of delirium. The orodispersible formulation is not absorbed sublingually, although may be dispersed in water to facilitate administration through enteral feeding tubes. There is no reported experience with using parenteral atypical antipsychotics agents in critically ill patients. Intramuscular olanzapine should only be used as an alternative to intravenous haloperidol available. Risperidone is presented as a depot injection for chronic schizophrenia and cannot be where side effects are particularly troublesome (e.g. in Parkinson’s disease) and the enteral route is not recommended. the risk of hypotension, tachycardias and cardiac arrhythmias, an. El haloperidol es una buti- Phenothiazines exhibit greater anticholinergic activity than butyrophenones and this increases rofenona con efecto antipsicótico que no suprime el reflejo respiratorio y actúa como antagonista dopa- minérgico; además, tiene unLos efectos adversos del haloperidol incluyen dales, espasmos laríngeos, síndrome neuroléptico hipotensión, distonías agudas, síntomas extrapirami- maligno, efectos anticolinérgicos, reducción del um- bral de convulsiones y desregulación del metabolis- mo de la glucosa y de los lípidos.

MANEJO DEL DELIRIO Atypical antipsychotics There is very little evidence regarding the use of atypical antipsychotics for delirium treatment in the Atypical antipsychotics critical care setting where published data is limited to one prospective randomised trial and a case report39, 40. Olanzapine 5mg daily was found to be as effective as 2.5mg-5mg haloperidol enterally three times haloperidol use in both groups was similar. daily in a randomised group of critically ill patients who were screened for delirium. Rescue Enteral olanzapine may therefore be useful in patients who do not tolerate haloperidol due to extra- pyramidal side effects. Recent advice from the Committee on Safety of Medicines regarding the increased risk of stroke in patients with dementia who are treated with olanzapine in the general population should also be borne in mind41, particularly as dementia is a risk factor for the development of delirium. The orodispersible formulation is not absorbed sublingually, although may be dispersed in water to facilitate administration through enteral feeding tubes. There is no reported experience with using parenteral atypical antipsychotics agents in critically ill patients. Intramuscular olanzapine should only be used as an alternative to intravenous haloperidol available. Risperidone is presented as a depot injection for chronic schizophrenia and cannot be where side effects are particularly troublesome (e.g. in Parkinson’s disease) and the enteral route is not recommended. the risk of hypotension, tachycardias and cardiac arrhythmias, an. El haloperidol es una buti- Phenothiazines exhibit greater anticholinergic activity than butyrophenones and this increases rofenona con efecto antipsicótico que no suprime el reflejo respiratorio y actúa como antagonista dopa- minérgico; además, tiene unLos efectos adversos del haloperidol incluyen dales, espasmos laríngeos, síndrome neuroléptico hipotensión, distonías agudas, síntomas extrapirami- maligno, efectos anticolinérgicos, reducción del um- bral de convulsiones y desregulación del metabolis- mo de la glucosa y de los lípidos.

S.A.R

H+ RELAJACION EN UCI

INDICACIONES H+ FACILITAR LA VENTILACION MECANICA SDRA ESTATUS ASMATICO REDUCCION DEL CONSUMO DE OXIGENO CONTROL HIPERTENSION ENDOCRANEANA ESTATUS EPILEPTICO - TETANOS IMPOSIBLE LA ADEPATACION AL MODO VENTILATORIO ALTAS PRESIONES EN LA VIA AEREA SCHOCK SEPTICO Y CARDIOGENICO OPTIMIZAR TCONSUMO DE OXIGENO TCE SEVERO, TOS , DESADABTACION,,,, DIFICUTLTA EVALUACION CLINICA Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior RECOMENDACIÓN SOLAMENTE CUANDO OTRAS MEDIDAS NO HAN SIDO EFECTIVAS Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

Monitoring of neuromuscular blocking Med Intensiva 2008 MONITOREO DEL BLOQUEO NEUROMUSCULAR H+ SIEMPRE TITULAR LA MINIMA DOSIS BIS 60 - 80 Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior TAQUIFILAXIA CAMBIAR RM Monitoring of neuromuscular blocking Med Intensiva 2008

Monitoring of neuromuscular blocking Med Intensiva 2008 MONITOREO DEL BLOQUEO NEUROMUSCULAR H+ RTA DEL MUSCULO A ESTIMULACION DE 1 NERVIO MOTOR 4 ESTIMULOS COMPARAR AMPLITUD DE LA RTAS RECOMENDADO: NERVIO CUBITAL ADUCTOR PULGAR Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior FACIAL EDEMA Tª PIEL Monitoring of neuromuscular blocking Med Intensiva 2008

REALIZAR CADA 6 HORAS H+ INTENSIDAD 50 MA GEL grado de relajación determina la amplitud de las respuestas al 2,3 y 4 estímulo esta relación T4/T1 se denomina TOF ratio comparando la amplitud de la cuarta respuesta T 4 respecto a la primera respuesta se aplica 4 estímulos 2 Hz cada 2 segundos repetidos cada 10 segundos No twiches 0-4 después de la estimulación TOF se usa el estimulador de nervio periferico para evaluar la respuesta del musculo a la estimulación de un nervio motor periférico el estimulador envía una corriente a un par de electrodos que se colocan sobre un nervio motor periférico, se observa la respuesta evocada del musculo inervadodeben contener gel electrodo positivo proximal al electrodo negativo electrodo distal a 2 cm del proximal Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

% BLOQUEO DE RECEPTORES GUIA PARA USO DEL TOF 4 ESTIMULOS COMPARAR AMPLITUD DE LA RTAS RESPUESTA MOTORAS % BLOQUEO DE RECEPTORES EFECTO INFUSION NINGUNA RESPUESTA 100% PARAR LA INFUSION LA OBSERVACION DE 1 O 2 RTAS MTORAS EN EL PULGAR NOS HABLA DE UN BLOQUEO MUSCULAR CERCANO AL 90% LA PRESENCIA DE 2 RTAS SUFICIENE PARALISIS DEL DIAFRAGMA PARA PREVENIR LA TOS, U MVTOS RESPIRATORIAO RTA NORMAL SON 4 CONTRACCIONES DE IGUAL FUERZA BLOQUEO FUERZA DISMIUYE UNA SOLA RTA INDICA UN 90% DE BLOQUEO NEUROMUSCULAR NINGUNA RTA >90% DE BLOQUEO 2 RTAS 80% BLOQUEO CERO RTA: PARAR LA INFUSION REESTABLECER CUANDO ESTEN PRESENTES 2 RTAS 2 RTAS: MISMA PERFUSION 1 RTA: < 80% LA DOSIS 1 - 2 90% PARALISIS DIAFRAGMATICA SIEMPRE MONITOREO TOF META : 1 – 2 CONTRACCIONES < 60%

VECURONIO 3 mg/hora NO ALTERA LA FUNCION CARDIOVASCULAR NO LIBERA HISTAMINA METABOLITO ACTIVO 3 OH VECURONIO NO EN INSUFICIENCIA RENAL NO EN DISFUNCION HEPATICA 3 mg/hora 0.8 – 1 MCG/KG/MIN 10 MG grado de relajación determina la amplitud de las respuestas al 2,3 y 4 estímulo esta relación T4/T1 se denomina TOF ratio comparando la amplitud de la cuarta respuesta T 4 respecto a la primera respuesta se aplica 4 estímulos 2 Hz cada 2 segundos repetidos cada 10 segundos No twiches 0-4 después de la estimulación TOF se usa el estimulador de nervio periferico para evaluar la respuesta del musculo a la estimulación de un nervio motor periférico el estimulador envía una corriente a un par de electrodos que se colocan sobre un nervio motor periférico, se observa la respuesta evocada del musculo inervadodeben contener gel electrodo positivo proximal al electrodo negativo electrodo distal a 2 cm del proximal Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

CISATRACURIO H+ 5 mg/hora METABOLIZACION VIA DE HOFFMAN HIDRÓLISIS ESTER NO LIBERA HISTAMINA ELIMINACION ORGANO INDEPENDIENTE NO ACUMULACION 5 mg/hora 1.5 – 3 MCG/KG/MIN 2mg/cc. grado de relajación determina la amplitud de las respuestas al 2,3 y 4 estímulo esta relación T4/T1 se denomina TOF ratio comparando la amplitud de la cuarta respuesta T 4 respecto a la primera respuesta se aplica 4 estímulos 2 Hz cada 2 segundos repetidos cada 10 segundos No twiches 0-4 después de la estimulación TOF se usa el estimulador de nervio periferico para evaluar la respuesta del musculo a la estimulación de un nervio motor periférico el estimulador envía una corriente a un par de electrodos que se colocan sobre un nervio motor periférico, se observa la respuesta evocada del musculo inervadodeben contener gel electrodo positivo proximal al electrodo negativo electrodo distal a 2 cm del proximal Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

INDICACION PARA USO DE RNM ESTA EL PACIENTE SEDADO ADECUADAMENTE ? OPTIMIZAR SEDACION Y ANALGESIA DISFUNCION HEPATICA O RENAL? USAR CISATRACURIO Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

RNM POTENCIAN LA ACCION DE LOS RELAJANTES MUSCULARES BENZODIACEPINAS AMINOGLUCOSIDOS VANCOMICINA BENZODIACEPINAS FENTANIL - MORFINA RNM ACIDOSIS HIPOTERMIA HIPOKALEMIA ACIDOSIS HIPOTERMIA HIPOKALEMIA BLOQUEANTES CANALES DE CALCIO BETABLOQUEADORES DIURETICOS NITROGLICERINA Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

EVITE CORTICOIDES DEBILIDAD PROLONGADA H+ Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior EVITE CORTICOIDES Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

COMPLICACIONES EN UCI H+ PACIENTE DESPIERTO Y PARALIZADO DESCONEXION DEL VENTILADOR RIESGO DE DESACONDICIONAMIENTO FISICO INJURIA DE N. PERIFERICO – ABRASION CORNEAL TAQUIFILAXIA , DOSIS MAYORES PARA CONSEGIR EL MISMO EFECTOS DESPIERTO Y PARALIZADO SUFRE SERIOS PROBLEMAS SICOLOGICOS Y ESTRÉS EMOCIONAL Facilitar la ventilación mecánica.: Pacientes que requieran control de la presión de la ventilación Reducir las presiones intratorácicas y mejorar la ventilación alveolar en pacientes asincrónicos con la ventilación asistida. Reducir el consumo de oxigeno en shock o falla respiratoria hipóxica. Soporte en el paciente con TCE e HEC intratable Mejorar la oxigenación en pacientes con status asmaticus. B. Proveer relajación muscular y evitar contracciones en las siguientes situaciones: Pacientes con abdomen abierto o a riesgo de evisceración. Pacientes con tétano. Pacientes con compromiso de la vía aérea superior DEBILIDAD MUSCULAR PROLONGADA MIOSITIS OSIFICANTE ULCERAS Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

IMPORTANTE DIFERENCIAR H+ RECUPERACION PROLONGADA RECUPERACION DEL PREDICHO X PARAMETROS FCOLOGICOS X ACUMULACION MIOPATIA CUADRIPLEJICA AGUDA PARESIA, MIONECROSIS, HIPORREFLEXIA MEDIR CPK B. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

PARA NO OLVIDAR H+ SOLO ESTRICTAMENTE INDICADO SEDACION ANALGESIA MONITORIZAR PROTECCION EXTREMIDADES, CAMBIOS POSTURAL LUBRICACION OJOS PROFILAXIS ANTITROMBOTICA EVITAR EL USO DE CORTICOIDES Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient Crit Care Med 2002

CONCLUSIONES ANALGESIA “atención al detalle” TRATAR AGRESIVAMENTE EL DOLOR CALIFIQUE EL DOLOR FENTANIL PTE INESTABLE SOLICITE LA PCA CLINICA DE DOLOR NO AINES “atención al detalle”

CONCLUSIONES SEDACION RAPIDA DEL PACIENTE AGITADO MIDAZOLAM S. SUPRESION > DE 7 DIAS GRADUAL DE LA DOSIS DELIRIO HALOPERIDOL “atención al detalle”

CONCLUSIONES RELAJACION CUANDO TODAS LAS OTRAS MEDIDAS NO HAN TENIDO ÉXITO NO CORTICOIDES “atención al detalle”