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Sedation and ICU Delirium : Case Study
Did you know Pain, agitation and delirium (PAD) increase the burden of disease for critically ill patients, contributing to adverse outcomes. The 2013 PAD Guidelines for managing patients with these interrelated problems were updated in 2018, based on new evidence and input from a diverse, intraprofessional committee, resulting in “Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the ICU,” or the PADIS Guidelines.
About the Speaker
Dr Surabhi Awasthi
MD(Anaes),AMPH (ISB),FICM,FIECMO,PGDMLS,PGDHHM. Director and Head Critical Care Medicine. Delhi, India
Role Played by ECMO in Critical Care
Extracorporeal Membrane Oxygenation (ECMO) plays a pivotal role in critical care, providing advanced life support for patients with severe cardiac or respiratory failure. By temporarily assuming the function of the heart and lungs, ECMO allows vital organs to recover, offering a crucial bridge to recovery or transplant. Its capacity to maintain oxygenation and circulation in critically ill patients underscores ECMO's significance as a lifesaving intervention in the intensive care setting.
ICU Management of Interstitial Lung Disease
The intensive care unit (ICU) management of interstitial lung disease (ILD) involves addressing respiratory distress, optimizing oxygenation, and treating underlying causes, such as infections or exacerbations. Mechanical ventilation strategies, including positive end-expiratory pressure (PEEP) and lung-protective ventilation, are employed, and meticulous attention is given to fluid balance and hemodynamic stability. Corticosteroids and immunosuppressive agents may be used for specific ILD types, and collaborative efforts between pulmonologists and intensivists are crucial for tailored care, monitoring complications, and achieving optimal outcomes in critically ill ILD patients.
Management of Cystic Fibrosis
Cystic fibrosis is a chronic, progressive disease that primarily affects the respiratory and digestive systems. It is caused by a gene mutation leading to dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. While there is no cure for CF, the goals of treatment are to ease the severity of symptoms and slow the progress of the disease. Treatment options may include antibiotics, bronchodilators, mucolytics, and airway clearance techniques to manage respiratory symptoms, as well as pancreatic enzyme replacement therapy and nutritional support to manage digestive symptoms. Gene and small molecule-based treatments are being researched and may have more potential to halt disease progression. A multidisciplinary team of specialists is typically involved in the management of CF, including respiratory therapists, dietitians, and social workers
Case Discussion on Acute Coronary Syndrome
Acute Coronary Syndrome (ACS) is a term used to describe a group of potentially life-threatening conditions related to the heart and blood vessels. ACS encompasses a spectrum of cardiac emergencies, including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). The hallmark of ACS is inadequate blood supply to the heart muscle due to partial or complete blockage of coronary arteries, often caused by atherosclerosis or blood clot formation. STEMI, the most severe form of ACS, is characterized by ST-segment elevation on an electrocardiogram and demands immediate reperfusion therapy, such as angioplasty or thrombolytic drugs, to restore blood flow to the affected area. NSTEMI and unstable angina are also serious conditions requiring medical attention. NSTEMI involves elevated cardiac biomarkers but no ST-segment elevation, while unstable angina presents with chest pain at rest or with minimal exertion and no biomarker elevation.
Ventilatory Strategies in ARDS
Ventilatory strategies in Acute Respiratory Distress Syndrome (ARDS) are crucial for optimizing oxygenation and minimizing further lung injury. Ventilating with low tidal volumes (6 mL/kg of predicted body weight or lower) reduces the risk of ventilator-induced lung injury (VILI). PEEP is used to maintain alveolar recruitment and improve oxygenation while preventing lung collapse during expiration. A lung-protective ventilation strategy combines low tidal volume and appropriate PEEP levels to minimize barotrauma and volutrauma. Prone positioning can be beneficial in ARDS patients by improving oxygenation and reducing ventilator-induced lung injury. Allowing for higher levels of carbon dioxide (permissive hypercapnia) may be necessary to avoid excessive ventilator pressures. Continuous monitoring of oxygenation, ventilation, and lung mechanics is essential to adjust ventilatory settings as needed. Individualized PEEP selection using techniques like the recruitment-to-inflation (R/I) ratio helps tailor ventilatory support to each patient's needs.