Should we include monitors to improve assessment of awareness and pain in unconscious palliatively sedated patients? A case report

2019 ◽  
Vol 33 (6) ◽  
pp. 712-716 ◽  
Author(s):  
Stefaan Six ◽  
Steven Laureys ◽  
Jan Poelaert ◽  
Johan Bilsen ◽  
Peter Theuns ◽  
...  
Keyword(s):  
Cerebrovascular Accident ◽  
Palliative Sedation ◽  
Deep Sleep ◽  
Discontinue Treatment ◽  
Sedation Scale ◽  
Case Presentation ◽  
Lymphatic Leukemia ◽  
Ramsay Sedation Scale ◽  
Case Outcome ◽  
Monitoring Devices

Background: Awareness and pain during palliative sedation is typically assessed by observational scales, but the use of such scales has been put into question. Case presentation: A woman in her mid-80s was admitted to a palliative care unit, presenting with chronic lymphatic leukemia, depression, and a cerebrovascular accident, with right-sided hemiplegia and aphasia. The patient was unable to eat and was suffering from nausea and vomiting. Before admission, the patient had expressed her desire to discontinue treatment on several occasions. Case management: The decision was made to initiate palliative sedation. The patient consented to take part in a study to assess level of comfort and pain using two monitoring devices (NeuroSense monitor and Analgesia Nociception Index monitor). Case outcome: The patient died 90 h after initiation of palliative sedation. Titration of the medication was challenging and sedation was not deep enough during the first 2 days. Thirteen assessments made with the Ramsay Sedation Scale showed that the patient was considered to be in a deep sleep, while in fact the NeuroSense monitor indicated otherwise. Conclusion: This case demonstrates the feasibility and potential advantages of using monitoring devices to objectify assessments of pain and discomfort in palliatively sedated patients.

scholarly journals How to measure the effects and potential adverse events of palliative sedation? An integrative review

2020 ◽  
pp. 026921632097426
Author(s):  
Alazne Belar ◽  
María Arantzamendi ◽  
Sheila Payne ◽  
Nancy Preston ◽  
Maaike Lee-Rijpstra ◽  
...  
Keyword(s):  
Palliative Care ◽  
Adverse Events ◽  
Palliative Sedation ◽  
Integrative Review ◽  
Patient Comfort ◽  
Cochrane Library ◽  
Inclusion Criteria ◽  
Sedation Scale ◽  
Ramsay Sedation Scale ◽  
Care Assessment

Background: Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed. Aim: To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured. Design: Integrative review of most recent empirical research. Data sources: Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010–2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness. Results: Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agitation-Sedation Scale and The Ramsay Sedation Scale are the most used to measure its effect. Refractory symptoms were assessed through multi-symptom or specific scales; except for psychological or existential distress. Delirium was assessed using the Memorial Delirium Assessment Scale and pain through the Critical Care Pain Observation Tool. The use of technical approaches to monitor effects is upcoming. There is lack of measurement of possible adverse events and variability in timing measurement. Conclusions: There are palliative care validated instruments to assess the sedation effect but this review shows the need for a more standardized approach when assessing it. Instruments should be used within an experienced and trained expert, providing a holistic assessment.

Ramsay Sedation Scale and Richmond Agitation Sedation Scale

2019 ◽  
Vol 38 (2) ◽  
pp. 90-95 ◽  
Author(s):  
Akram M. Rasheed ◽  
Mohammad F. Amirah ◽  
Mohammad Abdallah ◽  
Parameaswari P.J. ◽  
Marwan Issa ◽  
...  
Keyword(s):  
Sedation Scale ◽  
Richmond Agitation Sedation Scale ◽  
Ramsay Sedation Scale

scholarly journals RAMSAY Sedation Scale and Richmond Agitation Sedation Scale (RASS): A Cross Sectional Study

2018 ◽  
Vol 12 (6) ◽  
Author(s):  
Akram Rasheed ◽  
Mohammad Amirah ◽  
Mohammad Abdallah ◽  
Parameaswari PJ ◽  
Marwan Issa ◽  
...  
Keyword(s):  
Cross Sectional Study ◽  
Sectional Study ◽  
Sedation Scale ◽  
Richmond Agitation Sedation Scale ◽  
Cross Sectional ◽  
Ramsay Sedation Scale

Monitoring the depth of palliative sedation by video-pupillometry: A case report

2021 ◽  
pp. 026921632110427
Author(s):  
Elyn Antoine ◽  
Saffon Nicolas ◽  
Larson Merlin
Keyword(s):  
Pupil Size ◽  
Metastatic Cancer ◽  
Palliative Sedation ◽  
Sedation Scale ◽  
Richmond Agitation Sedation Scale ◽  
Actual Case ◽  
Clinical Scales ◽  
Course Of Action ◽  
Research Problems ◽  
Pupillary Reactivity

Background: Palliative sedation is sometimes interrupted by undesired arousals. Pupillometry has been used in anesthesiology to monitor pain and sedation but has never been used during palliative sedation. Actual case: A 48 years-old patient, with multi-metastatic cancer, underwent palliative sedation to manage global suffering. On the second day, the patient experienced arousal which required medication adjustments to ensure pain relief and increased sedation. Possible course of action: Depth of sedation is monitored with clinical scales, such as the Richmond Agitation-Sedation Scale. But these scales do not measure brain stem activity and are poor at predicting arousal. Formulation of a plan: During palliative sedation, an infrared pupillometer was used to monitor pupil size and pupillary reactivity (Neurolight®, IDMed®, Marseille, France). Outcome: The pupillary light reflex was depressed during deep sedation. In our case, we observed a low-normal reflex along with dilated pupil before arousal. Lessons from the case: Our case suggests that reflex intensity and pupil size might predict arousals during palliative sedation. View on research problems, objectives, or questions generated by the case: Prospective studies are needed to confirm our findings. Pupillometry’s acceptability should also be questioned from patient’s, families’, and caregivers’ perspectives.

scholarly journals Performance of the A-line Autoregressive Index (AAI) and of the Bispectral Index (BIS) at Assessing Depth of Short-term Sedation following Cardiac Surgery

2009 ◽  
Vol 37 (3) ◽  
pp. 611-620 ◽  
Author(s):  
V von Dossow ◽  
M Moshirzadeh ◽  
M Kastrup ◽  
K-Di Wernecke ◽  
W Konertz ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Bispectral Index ◽  
Mean Difference ◽  
Sedation Scale ◽  
Short Term ◽  
Elective Cardiac Surgery ◽  
Ramsay Sedation Scale ◽  
Clinical Scoring ◽  
Absolute Agreement ◽  
Different Levels

This study evaluated the correlation and agreement between the Bispectral Index (BIS) or A-line Autoregressive Index (AAI) and a clinical scoring system, the Ramsay Sedation Scale (RSS), in 40 patients after elective cardiac surgery and admission to the intensive care unit. All patients received sedation with propofol according to the study protocol. BIS, AAI and RSS were documented at two different levels of sedation: deep sedation RSS 4–6; and slight sedation/extubation RSS 2–3. Both the BIS and AAI agreed well with the RSS (η-coefficients of 0.902 and 0.836, respectively, for mean overall RSS stages). The systems agreed well among each other (overall intra-class correlations of 0.670 for consistency and 0.676 for absolute agreement). There was significant discrimination between RSS 2–3 and RSS 4–6 with BIS and AAI (BIS mean difference of 24.73, 95% confidence intervals [CI] 21.08–28.37; AAI mean difference of 20.90, 95% CI 14.64–27.16). In conclusion, BIS and AAI correlated well with RSS overall and also at different levels of sedation.

scholarly journals Use of Low Dose Pregabalin for Attenuation of Hemodynamic Response to Laryngoscopy and Intubation in Treated Hypertensive Patients

2019 ◽  
Vol 2 (2) ◽  
pp. 215-219
Author(s):  
Puja Thapa ◽  
Sunita Panta ◽  
Mallika Rayamajhi ◽  
Santosh Khadka ◽  
Bishwo Ram Amatya ◽  
...  
Keyword(s):  
Low Dose ◽  
Hemodynamic Response ◽  
Sedation Scale ◽  
Double Blind ◽  
Hypertensive Patients ◽  
Randomised Study ◽  
Arterial Blood ◽  
Ramsay Sedation Scale ◽  
Dose Oral ◽  
Baseline Characteristics

Introduction: Laryngoscopy and tracheal intubation are two powerful noxious stimuli that can be potentially deleterious especially in hypertensive patients. This study evaluated the efficacy of low dose oral pregabalin used as a premedication for attenuation of this marked sympathetic response of airway instrumentation.Materials and Methods: This was a double-blind randomised study done at a tertiary level referral hospital. The trial was registered as UMIN-000037103 (https://www.umin.ac.jp/ctr/). Patients were randomly assigned into two groups. Placebo arm received multivitamin capsule and treatment arm received Cap. Pregabalin (75 mg), 60 minutes before the induction of general anesthesia. The level of preoperative sedation was assessed with the Ramsay Sedation Scale. Heart rate, systolic, diastolic and mean arterial blood pressure were monitored and recorded before and during induction, during laryngoscopy and 1, 3 and 5 minutes of intubation.Results: A total of 50 patients, 25 in each arm were enrolled. The baseline characteristics were comparable. SBP was significantly lower in the Pregabalin group than in Placebo at all the periods of recording, however, DBP and MAP decreased significantly during, after 1 and 3 minutes of laryngoscopy (p=0.001). Sedation was significantly better in the Pregabalin group with 86% in RSS 3 compared to 80% of a placebo arm in RSS2 (P <0.001).Conclusions: Premedication with a single oral dose of Pregabalin (75 mg) is effective for sedation and attenuation of hemodynamic response to direct laryngoscopy and endotracheal intubation in controlled hypertensive patients without any side effects.

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