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Therapeutics III > Pain, Agitation, Delirium - Block 4 > Flashcards

Pain, Agitation, Delirium - Block 4 Flashcards

1
Q

How long can someone be intubated?

A

14 days due to infection

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2
Q

What are causes of immediate pain?

A
  1. Catbolic hypermetabolism
  2. Increasing circulating catecholamines
  3. Insufficient sleep
  4. Suppression of natural killer cells
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3
Q

Causes of long term pain?

A
  1. Chronic pain
  2. Lower HRQoL
  3. Neuropathic pain
  4. PTSD
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4
Q

What are the types of pain evaluation tools?

A

ALert: numerical rating scale
Not alert: behavioral pain scale, Critical-Care Pain Observation Tool

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5
Q

What are you options for ICU pain?

A
  1. Opioids
  2. Non-opioids (APAP, Ketamine, Neuropathic analgesia)
  3. Anticonvulsants for neuropathic pain (gabapentin, pregabalin, carbemazepine)
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6
Q

Describe the tx for procedural pain managemetn?

A
  1. Opioids
  2. NSAIDs (discrete and infrequent procedures)
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7
Q

What medications should not be used for procedural pain management?

A
  1. Local analgesia
  2. NO
  3. Inhaled volatile anesthetics
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8
Q

What are the nonpharms for pain mnagemetn?

A
  1. Massage
  2. Music
  3. Cold packs
  4. Relaxation
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9
Q

What are key points to treat proceudral pain?

A
  1. Treat pain preemptively
  2. Recognize and treat pain promptly
  3. Involve patients and families in plan
  4. Reassess and adjust pain managemetn based on routine assessment
  5. Patient specific
  6. Universal analgesia
  7. Pain control alone may equal comfort
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10
Q

What are the causes of agitation?

A
  1. Alcohol withdrawal
  2. Delirium
  3. Hypoglycemia
  4. Hypotention
  5. Infection
  6. Pain
  7. TBI
  8. Withdrawal
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11
Q

Consequenses of agitation?

A
  1. Harm
  2. Interferes with monitoring
  3. Ventilator asynchrony
  4. increased oxygen consumption
  5. increased ICU length of stay
  6. increased risk of nosocomial infections
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12
Q

What are goals of sedation?

A
  1. Provide comfort by treating pain 1st
  2. Patient focused strategy
  3. Interdisciplinary planning and practice (SBT, SAT)
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13
Q

How do we determine if we should sedate a patient?

A

Riker Sedation-Agitation Scale (SAS)
Richmond Agitation-Sedation Scale (RASS)

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14
Q

What are the sx of oversedation?

A
  1. BRadycardia
  2. Coma
  3. Prolonged MV
  4. Prolonged LOS
  5. Infection
  6. Complications
  7. Increase diagnostic testing
  8. Inability to evaluate delirium
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15
Q

Sx of undersedation?

A
  1. Stress
  2. Ax
  3. Agitation
  4. Hypertension/tachy
  5. Hypoxia
  6. Patient recall
  7. Ischemia
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16
Q

What is the goal for sedation?

A

Target light sedation

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17
Q

How do we select the ideal sedative?

A
  1. Rapid onset
  2. Inexpensive
  3. No ddi
  4. Inactive/no metabolites
  5. Minimal respiratory depression
  6. No CV effect
  7. Independent of organ metabolism and elimination
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18
Q

Pharm for sedation?

A
  1. Analgesia frist
  2. Then, sedative next
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19
Q

How are CI from analgosedation?

A
  1. Alcohol withdrawal
  2. NMBA
  3. Refractory status epilepticus
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20
Q

Describe the tx options for sedation?

A
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21
Q

What are the desired effects for BZD?

A
  1. Sedation
  2. AMnesia
  3. Anticonvulsants
  4. Muscle relaxant
22
Q

ADRs of BZDs?

A
    • Hepatic metabolism
    • Hypotension
    • Accumulation & excessive sedation
    • Propylene glycol toxicity
    • Respiratory depression
    • Withdrawal syndrome
    • Use lower dose in elderly, HF, liver disease
23
Q

What are the desired effects for propofol?

A
  1. Sedation
  2. Amnesia
  3. Rapid onset
  4. SHort duration
24
Q

ADR of propofol?

A
  1. Hypotension
  2. Respiratory depression
  3. HyperTG
  4. Propofol related infusion syndrome
25
Q

What are the desired effects for dexmedetomidine?

A
  1. Sedation
  2. Analgesia
  3. No respiratory depression
  4. Sympatholysis
26
Q

ADR of dexmedetomidine?

A
  1. Bradycardia
  2. Hypotension
  3. Agitation and sympathetic rebound
  4. Expense
27
Q

What is the desirable effects for esketamine?

A
  1. Sedation
  2. Analgesia
  3. Attenuates opioid tolerance
28
Q

ADR of esketamine?

A
  1. HTN
  2. Tachycardia
  3. Emergence rx
29
Q

What are the benefits of using NMBA?

A
  1. Increased O2
  2. Decreases ventilator associated injury
  3. Decreased mortality from ARDs
  4. Decrease barotrauma
30
Q

What are the cons of NMBa?

A
  1. Anaphylaxis
  2. ICU acquired weakness
  3. Increased lung atelectasis
31
Q

What are the types of NMBAs?

A
  1. Vecuronium
  2. Rocuronium
  3. Cisatracurioum
32
Q

What are the ADRs of NMBAs?

A
  1. Corneal abrasion and keratitis
  2. Venous thromboembolism
  3. Decreased lymphatic flow
  4. Skin breakdown
  5. Peripheral muscle and diaphragmatic atrophy
  6. Peripheral nerve injury
33
Q

How do we monitor NMBAs?

A
  1. Train of four peripheral nerve stimulation
  2. Indication
34
Q

What is the difference between delirium and coma?

A

Delirium: arousable to voice
Coma: unarousable to voice

35
Q

What arre the hyperactive subtypes of delirium?

A
  1. Agitation
  2. Restlessness
  3. Attempts to remove catheters
  4. Emotional lability
  5. Uncooperative
  6. Lack of orientation
36
Q

What arre the hypoactive subtypes of delirium?

A
  1. Flat affect & withdrawal
  2. Apathy
  3. Lethargy
  4. Decrease alertness
  5. Slow speech
  6. Psychomotor retardation
37
Q

What are the RF for delieumr?

A
  1. Older age
  2. BZD
  3. Opiates
  4. Propofol
38
Q

What are the differential diagnosis of delirium?

A

Drugs
Eyes, ears, and other senses
Low O2
Infection
Retention
Ictal state
Underhydration/nutrition
Metabolic causes
Subdural hematoma

39
Q

What are the major RF of delirium?

A
  1. High severity of illness (APACHE II)
  2. Alcohol use
  3. HTN
  4. Pre existing dementia
  5. Coma
40
Q

How do we assess delirium using CAM-ICU?

A
41
Q

How do you screen for delirium using ICDSC?

A
42
Q

What are the screening tools for delirium?

A
  1. CAM-ICU
  2. ICDSC
43
Q

How do we prevent delirum?

A
  1. Non-pharm
  2. Haloperidol and atypical antipsychotics are not recommended (-2C)
44
Q

What is the tx for delirium?

A
  1. Non-pharm
  2. Atypical antipsychotics
45
Q

What are non-pharms for delirium?

A
  1. Noise reduction
  2. Reorientation
  3. Cognitive stimulation activities
  4. ROM
  5. Timely removal of catheters & physical restraints
  6. Sensory assistance
  7. Dehydration correction
46
Q

Antipsychotics used for delirium?

A
  1. Haloperidol (not recommended)
  2. Risperidone
  3. Olanzapine
  4. Quetiapine
  5. Ziprasidone
  6. Aripriprazole
47
Q

Anitpsychotics that can lead to QT prolongation?

A
  1. Thioridazone
  2. ZIprasidone
48
Q

What are the BZDs indicated for delirium?

A
  1. Lorazepam
  2. Clonazepam
  3. Temazepam
49
Q

Drugs other than BZDs and Antipsychotics that treat delirium?

A
  1. Physostigmine
  2. Melatonin
  3. Ramelteon
50
Q

Describe the components of Pain, Agitation, and Delirium Algorithm?

A
51
Q

What is the ABCDEF Approach?

A
52
Q

What is the role of pharmacist?

A
  1. Protocol development
  2. Protocol implementation
  3. Re-evaluation

Therapeutics III (40 decks)

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