Exam 1 - Pain, Agitation, Delirium, Immobility, & Sedation

Question 1

List general analgesia treatments in ICU?

Answer 1

boluses or infusion of opioids, breakthrough PRN opioids

Question 2

List general sedation treatments in ICU?

Answer 2

propofol, dexmedetomidine, ketamine, PRN boluses of BZDRAs

Question 3

What is the goal CPOT? Goal BPS?

Answer 3

less than 2; less than 5

Question 4

Explain the onset, duration, and pearls for morphine?

Answer 4

5-10 min, 3-6 hrs, active metabolite accumulates in renal impairment and can cause histamine release (hypotension, bronchospasm, urticaria)

Question 5

Explain the onset, duration, and pearls for fentanyl?

Answer 5

seconds, 1-2 hrs, hepatic metabolism and CYP3A4 interactions and tachyphylaxis

Question 6

Explain the onset, duration, and pearls for hydromorphone?

Answer 6

5 minutes, 2-4 hrs, good for renal impairment and fentanyl tolerance and minimal histamine release, available as PCA

Question 7

What is the recommendation for hyperalgesia?

Answer 7

switch opioid

Question 8

List additional options for analgesia in ICU?

Answer 8

acetaminophen, NSAIDs, methadone, gabapentin, ketamine, PCAs

Question 9

What is the goal RASS score for sedation?

Answer 9

0 to -2

Question 10

What is the MOA of propofol?

Answer 10

stimulates GABA and inhibits NMDA receptors

Question 11

What are the AEs of propofol?

Answer 11

respiratory depression, hypotension, bradycardia, hypertriglyceridemia, propofol related infusion syndrome (PRIS)

Question 12

List the clinical pearls for propofol? (2)

Answer 12

lipid emulsion can provide 1.1 kcal/mL, avoid in egg/sulfite/soybean allergy

Question 13

What conditions is propofol a first-line agent in? (2)

Answer 13

severe alcohol withdrawal, status epilepticus

Question 14

What is the MOA of dexmedetomidine?

Answer 14

alpha-2 adrenergic agonist

Question 15

What are the AEs of dexmedetomidine? (2)

Answer 15

bradycardia, hypotension

Question 16

List the clinical pearls for dexmedetomidine? (2)

Answer 16

NO RESPIRATORY DEPRESSION, does not work well for deep sedation, risk of withdrawal

Question 17

Explain the onset, duration, and pearls for midazolam?

Answer 17

2-5 min, 1-2 hrs, lipophilic and active metabolites accumulate in renal impairment

Question 18

Explain the onset, duration, and pearls for lorazepam?

Answer 18

5-20 min, 2-6 hrs, can cause propylene glycol acidosis (via additive) and renal/hepatic failure

Question 19

Explain the onset, duration, and pearls for diazepam?

Answer 19

5-10 min, 44-100 hrs, active metabolites but can taper quickly

Question 20

List the drawbacks to BZDRAs? (3)

Answer 20

increase risk of delirium, time on ventilator, and length of ICU stay

Question 21

What conditions are BZDRAs a first-line agent in? (3)

Answer 21

status epilepticus, severe alcohol withdrawal, severe ARDS

Question 22

What is the MOA of ketamine?

Answer 22

NMDA antagonist, mu and kappa agonist, muscarinic acetylcholine receptor antagonist, catecholamine reuptake inibitor

Question 23

What dose of ketamine provides pain relief?

Answer 23

0.15-0.5 mg/kg/hr

Question 24

What dose of ketamine provides anesthesia relief?

Answer 24

0.5-2 mg/kg/hr

Question 25

What dose of ketamine provides status epilepticus relief?

Answer 25

>2 mg/kg/hr

Question 26

What are the AEs of ketamine?

Answer 26

hypertension, tachycardia, oral secretions, emergence reaction (hyperactivity (especially in schizo/elderly), can be pretreated with BZDRA or propofol)

Question 27

List the delirium sequelae?

Answer 27

increased mortality, cognitive impairment, functional decline, health system costs, prolonged mechanical ventilation, length of stay

Question 28

List modifiable risk factors for delirium? (2)

Answer 28

BZDRA use, blood transfusions

Question 29

List non-modifiable risk factors for delirium?

Answer 29

age, dementia Hx, prior coma, pre-ICU emergency surgery/trauma, high APACHE score

Question 30

What are screening tools for delirium?

Answer 30

confusion assessment method ICU (CAM-ICU), intensive care delirium screening checklist (ICDSC)

Question 31

List treatments for delirium in ICU?

Answer 31

opioids, dexmedetomidine, melatonin receptor agonists, antipsychotics (quetiapine/haloperidol/olanzapine)

Question 32

What is the recommendation for immobility and sleep?

Answer 32

non-pharm options

Question 33

List indications for a neuromuscular blockade?

Answer 33

facilitate mechanical ventilation, minimize oxygen consumption (ARDS), conditions with increased muscle activity (tetanus, neuroleptic malignant syndrome), increased intracranial/abdominal pressures, surgical procedures, rapid sequence intubation

Question 34

List the drawbacks to NMBs?

Answer 34

no analgesic or sedative properties, increase risk of DVT and skin breakdown, corneal abrasion, critical illness polyneuropathy

Question 35

What is the goal for twitching in NMB monitoring?

Answer 35

2 twitches (80-90%) blockage

Question 36

Explain the onset, duration, and elimination pathway for cisatracurium?

Answer 36

2-5 min, 30-90 min, Hoffman elimination

Question 37

Explain the onset, duration, and elimination pathway for rocuronium?

Answer 37

1-2 min, 30-60 min, biliary and renal

Question 38

Explain the onset, duration, and elimination pathway for vecuronium?

Answer 38

3-5 min, 45-60 min, biliary and renal

Question 39

Explain the onset, duration, and elimination pathway for succinlycholine?

Answer 39

30-60 s, 5-10 min, plasma pseudo-cholinesterase

Question 40

What conditions should succinylcholine NOT be used in?

Answer 40

malignant hyperthermia, hyperkalemia