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Pete FFICM SOE/OSCE > Neuro - Sedation / Delirium > Flashcards

Neuro - Sedation / Delirium Flashcards

1
Q

Mechanism of PRIS

A

Impaired oxidative phosporylation of the mitochondria

Free fatty acid utilisation

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2
Q

Features of PRIS

A 
Met acidosis
Arrhythmias (Brady)
High lipids
Renal and hep failure
Rhabdo
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3
Q

Risk factors for PRIS

A 
Young age
Head injury
Sepsis
High catecholamine level
High glucocorticoid levels
Low carb/high lipid intake
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4
Q

Propofol dose to prevent PRIS

A

4mg/kg/hour

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5
Q

Potential monitoring for PRIS

A

Daily CK

Triglycerides

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6
Q

Evidence for dexmed

A

Is non-inferior to all usual sedative

Reduced delirium compared to lorazepam (MENDS study) and Midaz (MIDEX study)

No difference in MV duration compared to propo (PRODEX study)

Patients can communicate pain better compared to prop and midaz

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7
Q

Can dexmed be used for deep sedation

A

No

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8
Q

Ketamine side effects in ITU

A

Sympathetic stimulation

Bronchodilation

Preserved cough reflex

Muscle rigidity

Hallucinations

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9
Q

Delirium definition

A

Acute onset

Fluctuating mental stage and

Disorganised thinking

OR

Altered level of conciousness

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10
Q

Types of delerium

A

Hyperactive (agitated, restless, paranoid)

Hypoactive (lethargic, inattentive, “pleasantly confused”)

Mixed (fluctuate between two)

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11
Q

Which is the least common form of delirium

A

Hyperactive…

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12
Q

Incidence of deliriu

A

As high as 83%

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13
Q

Effects of delirium

A

Increased hospital LOS
Increased 6/12 month mortality
Neurocognitive issues in survivors

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14
Q

Is there a role for prophylactic antipsychotics in delirium

A

No

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15
Q

What is the scoring system for RASS, what is normal?

A

+4 to -5
+4 combative
-5 Unrousable
0 normal

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16
Q

Scoring system for Ramsey scale

A

1 - 6

2 is co-operative
1 anxious/agitation

6 unrousable

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17
Q

Scoring system fro Ryker

A

1-7

1 unrousable
7 dangerous agitation
4 calm

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18
Q

Propofol mechanism

A

Potentiates the inhibitory transmitters glycine & GABA which enhance spinal inhibition.
Hyperpolarisation –> chloride influx

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19
Q

Propofol PKs

A

Highly protein bounf 98% albumin

Fast onset/offset
High clearence

Accumulates in tissues

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20
Q

Propofol S/E

A

Decreased SVR
Decreased CO and BP
Resp depression
Antitussive

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21
Q

Adverse effect Propofol

A

PRIS
Pain on bolus
High lipids

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22
Q

Benzos mechanism

A

Enhancing effect of GABA at GABAa receptors

23
Q

Benzos PK

A

Loraz - metabolised by glucuronidation to infactive metabolites

Midaz - oxidized by cP450 to water soluble metabolites (THESE ACCUMULATE)

24
Q

Benzos PD

A

Dose dependent resp depresson

Decreased HR/SVR

25
Q

Fentanyl potency compared to morphine

A

100

26
Q

Alfentanil potenicy compared to fent

A

10

27
Q

Remi mechanism

A

Selective mu agonst

28
Q

Remi side effects

A

Brady/hypotension/rigidity of chest wall

29
Q

Remi breakdown

A

Plasma esterases - context insensitive

30
Q

Dexmed mechanism

A

Centrally acting alpha agonist agonist at the locus coerueus

A2 to A1 affinity is 1600:1

Active d-isomer of medotomidine

31
Q

Dexmed PK

A

94% protein bound

32
Q

Clonidine mechanism

A

Centrally acting a2 agonist at the reticular nucleus of the medulla

Increases intrracellular cAMP, increased potassiu
Alpha receptor stimulation in spinal cord leads to increased endogenous opiate release

A2:A1 200:1

33
Q

Clonidine side effect

A

Hypertension (a1)
prior to hypotension (a2)

Brady
Rebound hyper on cessation

34
Q

Ketamine mech

A

Non competitive NMDA receptor antagonist

35
Q

Ket metab

A

Metab in liver to norketamine, conjugated to inactive metabolites –> urine

36
Q

Examples of when deep sedation is needed

A 
Procedures )trachy)
Non physiological ventilation (inverse ratio)
Proning
Intracranial hypertension
Seizures
37
Q

Morphine metabolism

A

liver to morphine 3 and morphine 6 glucoronide
6 is potent analgesic

Excreted in urine

38
Q

Which opiate has longest half life on infusion

A

Fentanyl (200mins after 6hours)

Duration of action is determined by redistribution rather than clearnece

39
Q

How is duration of alfentanil determined

A

clearence rather than distribution (compare to fent)

40
Q

Predictors of delerium

A 
Male
Increasing age
Diseae severity
Pre-existing dementia
Structural brain damage
Medication related cholinergic burden
41
Q

Proportion of patients with hyperactive delirium

A

1%

42
Q

Proportion of patients with hypoactive delirium

A

35%

43
Q

Proportion of patients with mixed delirium

A

65%

44
Q

Diagnostic criteria for delirum (DSM 4)

A

Acute onset and fluctuating
Inattention and disturbance of conciousness
Change in cognition
Pathophysioloigcal cause

45
Q

how many parts to the Intensive Care Delirium screening cheklist

A

8, based on obs over a 24 hour period

46
Q

Does the Intensive Care Delirium Screening Checklist (ICDSC) need patient co-operation

A

No

47
Q

Which is more sensitive, ICDSC or CAM-ICU

A

CAM-ICU

48
Q

Disadvantage with CAM ICU

A

Less specific
Higher false positive
Needs co-operation
Does not assess severity not sub-type

49
Q

Benefit of epidural

A 
Analgesia
Decreased resp issues
?decreased mortality
Less peri-op blood loss, DVT, arrhythmias
Faster return to GI function
ERAS - shorter length of stay
50
Q

Disadvantages to epidural

A 
Retention
Itching
n/v
Hypotension
poor/patcyh block
Catheter migrate to sub arach space
Local anaesthetic tox
Wrong site injection
Nerve injury
absess
Verterbral can haematoma
Spinal cord infarct
51
Q

Disadvantage of daily sedation holds

A

Whilst LOS, MV etc reduce, the risk of unplanned self extubation is higher

52
Q

Ideal RASS for tubed patietn

A

-1

53
Q

Which GPRC are opiates providing analgesia and sedation

A

mu - analgesia

Kappa - sedation

Pete FFICM SOE/OSCE (199 decks)

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