Adjuvant Management Strategies in the Critically Ill Ventilated Patient

Sponsored by the American College of Chest Physicians.
Supported by an unrestricted educational grant from Hospira Inc.

Program Description
This symposium will emphasize key elements of effective patient-focused sedation and analgesia in the ICU, as well as the current research on patient arousal and early mobility. Participants will watch a video summary and/or read an executive summary of the educational highlights of the program, answer review questions, and complete an activity evaluation.

Educational Objectives

• Review goals for sedation management in critically ill patients supported by mechanical ventilation.
• Define delirium and management strategies for critically ill patients supported by mechanical ventilation.
• Review the benefits and risks associated with early mobilization of critically ill patients supported by mechanical ventilation.

Target Audience
The target audience is pulmonary/critical care physicians, advanced practice nurses, fellows-in-training, physician assistants, registered nurses, respiratory therapists, and other health-care professionals.

Needs Assessment
Critically ill patients, particularly those who are supported by mechanical ventilation, often have pain, anxiety, dyspnea, and other forms of distress.¹ Therefore, the majority of ICU patients, particularly those supported by mechanical ventilation, receive IV sedation and/or analgesia medications.² Management of sedation and analgesia in these critically ill patients is often rather haphazard. A structured approach should include detection of pain, monitoring for sedation and agitation with a scale, proper drug selection, and structured management to optimize patient comfort and safety, yet minimize duration of critical illness.^3,4 Within a structured approach to sedation and analgesia, a focus on the individual patient’s characteristics is critical. Each patient is unique in many regards, including underlying illness and prior use of medications (such as medications to relieve pain, anxiety, or for psychiatric disorders), the presence of pain, and organ dysfunction that may include sedative and analgesic drug metabolism and, thus, optimal selection. Optimal medication selection should also consider risks for adverse drug effects and avoid delirium, delayed recovery from sedation, and prolonged ventilation.

Early mobilization of the critically ill patient has become an issue of debate within the critical care field. Prolonged stays in the ICU and mechanical ventilation are associated with significant and prolonged neuromuscular complications that impair a patient’s physical function and quality of life after hospital discharge, as well as increase morbidity, mortality, cost of care, and length of hospital stay. A new approach for managing patients supported by mechanical ventilation includes reducing deep sedation and increasing rehabilitation therapy and mobilization soon after admission to the ICU. Emerging research in this field provides preliminary evidence supporting the safety, feasibility, and potential benefits of early mobilization in critical care medicine.⁵ Implementation of an early mobility and walking program could have a beneficial effect on the patient and prevent post-ICU complications.⁶

The ACCP membership includes most US pulmonary/critical care physicians. This topic, then, is an issue faced every day in managing patients in the ICU and is an important disease for ACCP educational programs to address.

The CHEST 2009 Program Committee has deemed this session as important to include in the CHEST 2009 program. Critical Care and mechanical ventilation are included in the core curriculum that has been developed by the ACCP to guide its educational programs.

References

1. Desbiens NA, Wu AW. Pain and suffering in seriously ill hospitalized patients. J Am Geriatr Soc 2000; 48:S183-S186
2. Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit. Pharmacotherapy 2005; 25:8S-18S
3. Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27:2609-2615
4. Kress JP, Pohlman AS, O'Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471-1477
5. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA 2008; 300:1685-1690
6. Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care 2009; 18:212-221

Program Chair
Jeffery S. Vender, MD, FCCP

Release: January 2010
CME Expiration: December 2010
Estimated completion time: 30 minutes
This CME product is a Web-based activity.

Participants will watch a video summary and/or read an executive summary of the educational highlights of the program, answer review questions, and complete an activity evaluation to obtain CME credit.

Copyright © 2009 by the American College of Chest Physicians and its Licensors

Accreditation - Designation
The American College of Chest Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The American College of Chest Physicians designates this educational activity for a maximum of 0.5 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Conflict of Interest Disclosure Statement
The ACCP remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our faculty members. It is not the intent of the ACCP to eliminate all situations of potential conflict of interest, but rather to enable those who are working with the ACCP to recognize situations that may be subject to question by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair, the Education Committee, or the Conflict of Interest Review Committee to ensure that such situations are properly evaluated and, if necessary, resolved. The ACCP educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review process, all ACCP CME activities are ensured of independent, objective, scientifically balanced presentations of information. Disclosure of any or no relationships will be made available on-site during all educational activities.

The following faculty member has indicated to the ACCP that no potential conflict of interest exists with any respective company/organization, and this should be communicated to the participants of this educational activity:

Jeffery S. Vender, MD, FCCP

Disclaimer
The American College of Chest Physicians ("ACCP") and its officers, regents, executive committee members, members, related entities, employees, representatives and other agents (collectively, "ACCP Parties") are not responsible in any capacity for, do not warrant and expressly disclaim all liability for, any content whatsoever in any ACCP publication or other product (in any medium) and the use or reliance on any such content, all such responsibility being solely that of the authors or the advertisers, as the case may be. By way of example, without limiting the foregoing, this disclaimer of liability applies to the accuracy, completeness, effectiveness, quality, appearance, ideas, or products, as the case may be, of or resulting from any statements, references, articles, positions, claimed diagnosis, claimed possible treatments, services, or advertising, express or implied, contained in any ACCP publication or other product. Furthermore, the content should not be considered medical advice and is not intended to replace consultation with a qualified medical professional. Under no circumstances, including negligence, shall any of the ACCP Parties be liable for any DIRECT, INDIRECT, INCIDENTAL, SPECIAL or CONSEQUENTIAL DAMAGES, or LOST PROFITS that result from any of the foregoing, regardless of legal theory and whether or not claimant was advised of the possibility of such damages.

CME Instructions
CME for this activity is available through December 31, 2010. To receive CME credit and print your certificate, complete an online evaluation and postactivity questions by following these steps:

1. Go to www.chestnet.org/cme, and click on the "CME Certificates" Button.
2. Log in using your ACCP ID number or e-mail address on file with the ACCP. Enter your ACCP ID number, and click submit, OR, if you do not have an ACCP ID number, click on the link "Create an account here."
3. To locate the product for which you want to claim CME credit, look under the "Available CME" tab on the left navigation bar.
4. Click the "Claim Credit" link next to the product title (#6739 - Chest Soundings Interviews - CHEST 2009) to begin the certificate process.
5. Complete any required posttest and evaluation questions. Please be sure to check the box that states you are finished with the evaluation.
6. Once you submit the evaluation, your CME certificate will be created and show under the tab, “My CME History.” You can print it at any time by clicking the “Certificate” link.

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