Pain/Agitation/Sedation Flashcards
(76 cards)
1
Q
Analgosedation
A
- Analgesia
* Bolus or PRN opioids first - Sedation
* If still agitated, propofol/dexmedtomidine/ketamine
* benzo prn boluses only - Delirium
* screen/identify early
* #1 nonpharm prevention!
* #2 consider pharm options after
NO DRIPS YET!!
2
Q
Causes of ICU related distress
A
- multiple line placements
- Turning/cleanning
- Medications
- lab draws
- life support
3
Q
A
4
Q
Assessing Analgesia
A
CPOT: goal <2
BPS: goal <5
5
Q
IV opioid options
A
- Morphine
- Fentanyl
- Hydromorphone
6
Q
Managing hyperalgesia
A
if opioid induced - switch opioid
potentially dt tachyphylaxis
7
Q
Non-opioid analgesia
A
- APAP
- NSAIDs
- Methadone
- Gabapentin
- Ketamine
- PCAs
8
Q
Morphine onset/duration
A
on: 5-10 min (quick)
duration: 3-6 hours (long)
9
Q
Fentanyl onset/duration
A
on: seconds (super fast)
duration: 1-2 hr (short)
10
Q
Hydromorphone onset/duration
A
on: 5 min
duration: 2-4 hr
onset similar to morphine
duration inbetween morphine/fentanyl
11
Q
Morphine clinical pearls
A
Active metabolite M6G
accumulates in renal impairment (avoid drip)
Histamine release: hypotension, bronchospasm, itchy (uticaria)
12
Q
Fentanyl clinical pearls
A
Hepatic metabolism (liver failure = longer duration)
CYP3A4 DDI
Tachyphylaxis (tolerance = switch to hydromorphone)
1st line choice for drip
13
Q
Hydromorphone clinical pearls
A
good in renal impaired
Alt if fentanyl tolerance
minimal histamine release
available as PCA
14
Q
APAP caution
A
in acute liver failure
15
Q
A
16
Q
NSAID caution
A
acute AKI
increase GI bleed
17
Q
Methadone caution
A
slow titration, avoid QTc prolongation
Long acting - if sedated long time wean off
18
Q
Gabapentin caution
A
may not see benefit for a couple of days
19
Q
Sedation scales
A
RASS
SAS
20
Q
A
21
Q
Propofol MOA
A
Stimulate GABA
inhibit NMDA
22
Q
Propofol PD
A
hypnotic
anxiolytic
anticonvulsant
amnesic
anesthesia
NO PAIN RELIEF
23
Q
Propfol PK
A
Onset: <1 min (fast)
Duration: 10-15 min
rapid hepatic/extrahepatic CL
24
Q
Propofol long term caution
A
saturation of peripheral tissues (lipophillic)
25
Propofol ADR
Respiratory depression (must intubate)
Hypotension (pressors)
Bradycardia
Decreased cardiac output
HyperTG (acute pancreatitis)
PRIS (infusion syndrome - acidosis)
26
Propofol pearls
Lipid emulsion = 1.1kcal/ml nutrition
AVOID if allergy: egg, sulfites, soybean
27
Propofol monitoring
BP
HR
TG
Anion gap/lactate
CK if use >48 hrs
28
Dexmedetomidine MOA
A2 agonist
decrease Ne and Da release in CNS
decrease fight/flight response
29
Dexmedetomidine indications
FDA: procedural sedation, mechanical vent sedation not > 24 hours
| we use it > 24 hours anyways LOL
30
Dexmedetomidine PD
sedative
**analgesia**
31
Dexmedetomidine ADR
bradycardia
hypotension
32
Dexmedetomidine Pros
* No respiratory depression (don't need to intubate to using as sedation)
* Effects similar to nautrally occuring sleep (mimics rem sleep)
* Opioid sparing (pain relief)
* adjunct therapy for alcohol withdrawal (helps w/ anxiety)
33
Dexmedetomidine Cons
Risk of hypotension
RASS score <-3 unlikely =NOT for DEEP sedation
if prolonged use >24 hours:
* Risk of withdrawal if prolonged use -- need to taper, like clonidine
* Drug induced fever case reports
34
Benzodiazepines
1. midazolam
2. lorazepam
3. diazepam
| short term use only
35
Midazolam on/off
On: 2-5 min
Duration: 1-2 hr
36
37
Lorazepam on/off
On: 5-20 min
Off: 2-6 hr
38
Diazepam on/off
on: 5-10 min
Off: 44-100 hrs
39
Midazolam pearls
Lipophillic
active metabolites
accumulates in renal impairment
primary use = status epilepticus, AUD (benzo drip)
| metabolites: once anxiolytic wears off, left with delirious amnesic fx
40
Lorazepam pearls
Diluted with proplyene glycol = acidosis risk w/ high dose
OK to use in renal/hepatic failure
40
41
Diazepam pearls
Acitve metabolite accumulation
Can taper off quickly
Super long half life - titrate; less risk of abrupt withdrawal/seizure risk
Standing doses used in alcohol withdrawal
42
Benzo indication first line
* Status epilepticus
* Extreme alcohol withdrawal sx
* severe ARDS requiring DEEP sedation
43
Benzo Cons
increased
* risk of delirium
* time on ventillator
* length of ICU stay
44
Choosing sedative agent: PADIS 2018 guideline
propofol/dexmedtomidine >>> benzo
| in sedating critically ill, mechanically ventillated adults
45
Ketamine indications
| there are 7
1. Anesthesia
2. Pain
3. Rapid sequence intubation
4. Acute severe agitation
5. Status Epilepticus
6. Treatment resistant depression
7. PTSD
46
Ketamine MOAs
| 4 MOAs
1. NMDA antagonist
2. Mu/Kappa agonist
3. Muscarinic ACH agonist
4. inhibit 5HT, DA, NE
2. analgesia
3. bronchodilator
4. antidepressant
| calming, analgesia, bronchodilator, antidepressant
47
Ketamine bolus dose
| IV push vs IM
IV push 1-2mg/kg
IM 4-5 mg/kg
48
Ketamine dose dependent fx
Pain: 0.15-0.50 mg/kg/hr
Anesthesia: 0.50-2.0 mg/kg/hr
SE: >2 mg/kg/hr (comatose)
| intubation not necessary for lower doses
49
IV Ketamine on/off
| anesthetic only
On: 30 seconds
Duration: 5-10min, recovery 1-2 hr
50
IM ketamine on/off
| Anesthetic and analgesia
On Anesthetic: 3-4 min, analgesia:10-15 min
Duration: anesthetic 12-24min, analgesia 15-30 min, recovery 3-4 hrs
51
PO ketamine
terrible bioavailability
20-30%
52
Ketamine Pros
Favorable hemodynamics (esp if shock)
Bronchodilator effect
opioid sparing
| tachycardia, hypertension
53
Ketamine ADR
**emergence reaction**
* pretreat with bzd or propofol
* avoid if elderly or baseline schizo = get too hyper
Oral secretions (r/o other causes)
Tachycardia
HTN
54
Delirium definition
acute changes in mental status
55
Delirium sequalae
* increased mortality
* cognitive impairment
* functional decline
* increase costs
* prolonged mechanical vent
* increase length of stay
56
Delirum risk factors
| prevention is best treatment
Modifiable
* BZD use
* Blood transfusions
Non-modifiable
* Older age
* dementia hx
* prior coma
* pre-icu emergency surgery/trauma
* increased APACHE score
57
Delirium screening tools
1. CAM-ICU (y/n)
2. ICDSC (0-4)
| regularly assess for delirum using valid tool
58
Preventing delirium: nonpharm
* reorient patient
* use hearing aid/glasses
* limit noise/light at night
* encourage natural sleep/wake cycle
* early mobilization
* family presence
* music therapy
* limit bzd and anticholinergic medications
59
Treating delirium: pharm
1. Opioids
2. Dexmedetomidine
3. melatonin
4. APS (many ADR)
- quetiapine, haloperidol, olanzapine
60
PADIS guideline for delirium
No pharm agent for delirum PREVENTION
Dexmedetomdine = mechanical vent adult w/ agitation
APS: not used routinely
61
Neuromuscular blockers indication
paralyzes patient
facilitate mechanical vent/ rapid sequence intubation
* override gag reflex
* take away neurologic drive
Minimize O2 consumption
* allow brain/lung perfusion
* less muscle perfusion
Increased muscle activity
* tetany, NMS, anti-shivering
Increased ICP or intra-abdominal pressure
Surgical procedures
62
Neuromuscular blockers Pros
* inhibit diaphragmatic function
* reduce chest wall rigidity
* reduces o2 consumption
* elminates work of breathing (when intubated)
63
Neuromuscular blockers Cons
* pt can't communicate
* no analgesic/sedative properties
Long term:
* increase risk of DVT/skin breakdown
* corneal abrasion risk (ATC artificial tears)
* critical illness polyneuropathy (req. PT)
| should put patient in deep sedation to prevent them from freaking out dt
64
Neuromuscular blockers monitoring
| when given as continuous IV infusion
Train of four using peripheral nerve stimulator
Goal target: 2 twitches = 80-90% blockage
65
Neuromuscular blocker agents
Non-depolarizing agents: ACh antagonists (drips)
* Cisatracurium
* Rocuronium
* Vecuronium
Depolarizing agent (bolus)
* Succinylcholine
66
Cisatracurium elimination
Hoffman
hydrolysis in blood - enzyme mediated
67
Cisatracurium on/off
on: 2-5 min
off: dose depndent
30-90 min
68
Rocuronium elimination
50% billiary/renal
69
Vecuronium elimination
billiary and renal
69
Rocuronium on/off
On: 1-2 min (fastest)
off: 30-60 min
70
Vecuronium on/off
on: 3-5 min
off: 45-60 min
71
Succinylcholine elimination
plasma pseudo-cholinesterase
72
Succinylcholine on/off
on: 30-60 SeCONDS
Off: 5-10 min (short)
| much shorter duration than non-depolarizing agents
73
succinylcholinesterase precautions
avoid use if
* malignant hyperthermia
* hyperkalemia (torsades risk)
74
