Pain, Agitation, and Delirium Considerations in the ICU Flashcards Preview

CardioPulm II > Pain, Agitation, and Delirium Considerations in the ICU > Flashcards

Flashcards in Pain, Agitation, and Delirium Considerations in the ICU Deck (51):
1

Causes of Pain and Agitation

Painful procedures

Invasive tubes
Catheters
Drains
Endotracheal tubes



Untreated Pain:
Increased myocardial oxygen consumption
Tachycardia
Persistent catabolism


Acute agitation can lead to self-removal of lines, drains, and tubes


Long-term effects (chronic agitation):

Anxiety
Respiratory Distress
Pain
Post Traumatic Stress Disorder (PTSD)

2

Reversible causes:

Hypoxemia
Hypoglycemia
Hypotension
Pain
Electrolyte abnormalities
Withdrawal from ETOH and other drugs

3

Principles of ICU Sedation

1. Treat reversible causes

2. Provide adequate ANALGESIA

3. Initiate SEDATION

4

3. Initiate SEDATION: Analgosedation

Steps

Sedation should be started only AFTER providing adequate analgesia AND treating reversible causes

Validated sedation scales should be used regularly assess the level of sedation/ agitation and guide the titration of therapy

5

Goals of Treatment for PAIN

Goals of Treatment
Patient comfort, provide adequate pain relief, relief of anxiety/ agitation, prevention of physical injury, decrease oxygen consumption, facilitate care.

6

Recommended Pain Scale

Behavioral Pain Scale (BPS)- i.e. FLACC pain scale

The FLACC (Face, Legs, Activity, Cry, Consolability) is a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain (comatose, unresponsive, and/or sleeping patient.

7

Are vitals signs enough to assess pain?

Vital signs (i.e. elevated HR or BP) can indicate that further assessment of pain is necessary but is NOT always a factor in determining pain.

8

Non-Pharmacologic Treatment

Proper positioning
Stabilization of fractures
Elimination of irritating stimulation
Application of heat/ cold therapy

9

Pharmacologic Treatment

Morphine Sulfate

Standard Drip: 100mg/ 100mL IV infusion

or

2-5 mg IVP q2- 6 hours scheduled and prn



Use in hemodynamically stable patients
--->Can induce (hypotension, bronchospasm)

Contains an active metabolite (accumulates in renal insufficiency)

IV infusion, IV Bolus, and PO

10

Opioids ADR

Respiratory depression, constipation (hypomotility, gastric retention, ileus), nausea

11

Pharmacologic Treatment

Fentanyl

25- 100 mcg IVP q10 min

or

Continuous IV infusion: 25- 200mcg/hr

Use in hemodynamically unstable patients

Most rapid onset, shortest duration


IV (patch, lozenges)

12

Pharmacologic Treatment

Hydromorphone

Use in hemodynamically unstable patients
Formulation: IV and PO

13

Morphine Sulfate

ADR

Hypotension
Flushing
Bronchospasm
Constipation

14

Hydromorphone


ADR

Hypotension
Flushing
Constipation

15

Fentanyl

ADR

Constipation

16

Preferred IV Analgesic Agent Based on Patient Characteristics

Fentanyl

Rapid onset of analgesia in acutely distressed patients

Renal insufficiency

Hemodynamically Unstable

17

Preferred IV Analgesic Agent Based on Patient Characteristics

Morphine

Intermittent IV bolus therapy

18

Preferred IV Analgesic Agent Based on Patient Characteristics

Hydromorphone

Renal insufficiency

Hemodynamically Unstable

Intermittent IV bolus therapy

19

Other Opioids

NSAIDS, acetaminophen, salicylates, lidocaine, local anesthetics, gabapentin (neuropathic pain)

20

Potential for withdrawal

Opioids

flu-like symptoms (i.e. diaphoresis, chills), diarrhea, tachycardia, insomnia) after 5-7 days of therapy with abrupt discontinuation

21

Benzodiazepines and Propofol

Potentiation of the GABA receptors

Sedative, hypnotic and anxiolytic properties


Possesses anxiolytic, sedative, amnestic, and anticonvulsant properties (Note: No analgesic properties)

Hepatically metabolized

22

Benzodiazepines (BZD)

AE and withdraw

Potential for withdrawal (tachycardia, HTN, fever, agitation, seizures, hallucinations) after 5-7 days of therapy with abrupt discontinuation

Dose dependent respiratory depression

Tolerance can develop


23

Midazolam (Versed ®)*

rapid sedation of acutely agitated patients
Rapid onset of action: 2- 5 minutes

Contains an active metabolite
Prolonged sedation in renal failure


Recommend use for 72 hours

24

Lorazepam (Ativan ®)*

NO active metabolite

Intermediate onset of action: 5- 20 minutes

Propylene glycol toxicity from prolonged high doses or prolonged use
--> Cannot exceed 7mg/hr
-->can crush tablets if more is needed

Formulation: IV, IM, PO

25

Sedative Hypnotics
Propofol (Diprivan ®)

Possesses sedative, amnestic properties and anticonvulsant effects (Note: No analgesic properties)

Recommended for rapid awakening
--> Only for short term use Causes transient rise in triglyceridses-> risk of pancretitis

no dependance

Requires dedicated IV line due to incompatiablites

Infusion bottle and tubing must be changed every 12 hours

Continuous IV Drip only**


Adverse Effects
Hypotension, bradycardia, elevated triglycerides, pancreatitis, peripheral injection site pain, green urine

26

Alpha-2 agonist
Dexmedetomidine (Precedex ®)

Selective a-2 adrenergic agonist

Sedative, anxiolytic, and analgesic properties

Only used in respiratory depression.-->Does not cause respiratory depression

Formulation: IV (given as continuous IV drip only)
Continuous infusion: 0.2- 0.7 mcg/kg/hour


8x more potent than clonidine.

27

Scale for sedation

+1 Restless

0 Alert and Calm

-1 Drowsy

1. RASS ( range -1 to +1 ideal)
2. Ramsay

RASS scale is a 10 point scale

4 levels of anxiety/agitation (+1 to +4)

1 level for calm/alert state (0)

5 levels of sedation (-1 to –5)

Goal of RASS is to allow more precise medication titration

28

Dexmedetomidine (Precedex ®)
AE

: Hypotension, bradycardia, (hypertension with a loading dose), reduced cardiac output—do not use with patient with Cardiovascular disease

29

Comparison of IV Sedative Agents Adverse Events

Midazolam

Dependence

Respiratory Depression

30

Comparison of IV Sedative Agents Adverse Events

Lorazepam

Dependence

Respiratory Depression

31

Comparison of IV Sedative Agents Adverse Events

Propofol

Respiratory Depression
Hypotension
Bradycardia
Hyperlipidemia
Increased Risk of Infection

32

Comparison of IV Sedative Agents Adverse Events

Dexmedetomidine

Hypotension
Bradycardia

33

Choosing an IV Sedative Agent Based on Patient Characteristics

Midazolam

Acute Agitation
Intermittent IV bolus dosing

34

Choosing an IV Sedative Agent Based on Patient Characteristics

Lorazepam

Acute Agitation
Intermittent IV bolus dosing

Long Term Maintenance
( > 72 hours)

35

Choosing an IV Sedative Agent Based on Patient Characteristics

Propofol

Head Trauma

Rapid Awakening

36

Choosing an IV Sedative Agent Based on Patient Characteristics

Dexmedetomidine

Rapid Awakening

37

IV Sedative Agents

Special Properties

Midazolam

2- 5 min

Contains an active metabolite

Contains amnestic properties

38

IV Sedative Agents

Special Properties

Lorazepam

5- 20 min
longest onset

Contains propylene glycol

Contains amnestic properties

39

IV Sedative Agents

Special Properties

Propofol

1- 2 min

Contains amnestic properties

Infusion bottle and tubing must be changed every 12 hours

40

IV Sedative Agents

Special Properties

Dexmedetomidine

1- 5 min

Contains analgesic properties

41

Oversedation

Slow response to stimulation, sluggish, unarousable, deep sedation

Treatment

Hold dose until at goal or increase dosing interval and then decrease dose by 25-50%

42

Undersedation

Anxious, restless, combative, agitated

Increase dose by 10-25% and monitor until patient is at goal (assess pain requirements) + prn bolus dose

43

Dosing Strategies for IV Analgesics and Sedatives

Bolus dosing added to continuous infusion :
Except with propofol and dexmedetomidine

Scheduled daily interruption of continuous infusions:
Except with a neuromuscular blockers, seizures, alcohol withdrawal





44

ICU Delirium

Fluctuating mental status

Types of delirium:
Hypoactive :
Withdrawn quiet, paranoid
Hyperactive :
Restless, agitated, aggressive, paranoid
Mixed

Assess ICU patients for delirium every shift once Length of stay > 24 hours

45

Prevention of Delirium

Reorient patient (i.e. clocks or calendars)

Encourage normal sleep/wake cycles

Normalize metabolic disturbances

Facilitate mobilization

Restore eye glasses, hearing aids

Removal of nonessential drugs with CNS side effects

Reserve benzodiazepine therapy

46

Method for the ICU (CAM-ICU) Score-Scale for Delirium

Assess ICU patients for delirium every shift once Length of stay > 24 hours:


Confusion Assessment Method for the ICU (CAM-ICU) Score-Scale for Delirium

47

How to Assess for Delirium CAM-ICU

Feature 1: Acute onset of mental status changes or a fluctuating course

Feature 2: Inattention

Feature 3: Disorganized Thinking

or

Feature 4: Altered Level of Consciousness

1 – patient is different from baseline or fluctuation over the past 24 hours?
2 – ask patient to squeeze your hand when you hear the letter A and say a series of 10 letters (SAVEAHAART) + if >2 errors
3 – ask questions such as “does a stone float? Are there fish in the sea? Does one pound weigh more than two pounds?”
4 – if RASS is anything other than 0, indicating calm and alert

Patients at high risk for delirium should be monitored at least once per shift for delirium

48

Delirium Treatment

Remove medications which can cause delirium :
Benzodiazepines, metoclopramide , H2-blockers (i.e. famotidine), diphenhydramine, etc.

and/or

Pharmacotherapy
Haloperidol
Atypical antipsychotics

49

Delirium Pharmacotherapy

Neuroleptics
Haloperidol (Haldol®)


AE's
QTC prolongation

ETOH AND PMH OF SEIZURES

Haloperidol no longer considered the drug of choice for ICU delirium


AE:

Adverse effects:
Extrapyramidal effects, neuroleptic malignant syndrome, hypotension, **may lower seizure threshold**

QTC prolongation
Combination with other QT prolonging medications
Dose-dependent

50

Delirium Pharmacotherapy

Atypical Antipsychotics

Adverse effects
Short term use (ICU delirium)
QTc prolongation, sedation


Quetiapine(Seroquel®) 25mg q12*

Risperidone (Risperdal®)1-2 qHS*

Olanzapine (Zyprexa®)
Ziprasidone (Geodon®



51

dexmedetomidine

contraindication

Heart Rate