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Crit Care, Oncology & Hematology > Pain/Agitation/Sedation In Critically-Ill > Flashcards

Pain/Agitation/Sedation In Critically-Ill Flashcards

1
Q

What in the ICU can cause patients to have cognitive and mental impairment?

A

Sedative medications
Intubation
Catheters
Multiple lines

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2
Q

When a critically-ill patient is admitted, what is the order of sedation, checking for delirium, and analgesia?

A
  1. Treat pain FIRST (analgesia)
  2. Sedation
  3. Check for delirium
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3
Q

What are the tools used to assess pain in the critically-ill?

A

Critical Care Pain Observation Tool (CPOT)
Score >2 = significant pain

Behavioral Pain Scale (BPS)
Score >5 = significant pain

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4
Q

What pain medications are used in the critically ill?

A

Morphine - lasts 3-6hrs, accumulates in kidneys
Fentanyl - extremely fast onset (seconds), hepatic metabolism, CYP3A4 interactions, tachyphylaxis
Hydromorphone - good for renally impaired, available as PCA (patient-controlled analgesia) [reserved for tachyphylaxis & fentanyl intolerance]

Fentanyl is 1st line for continuous infusion (fast on/off)

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5
Q

How does opioid use affect pain tolerance in the critically ill?

A

Opioids induce hyperalgesia, likely neurologically lowers pain threshold

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6
Q

Other than opioids, what analgesics can be used in critically ill patients?

A

APAP (avoid in acute liver failure)
NSAIDS (avoid in AKI, GI bleeds)
Methadone (for long-term sedation and pain, slowly titrate QTc prolongation)
Gabapentin (for neuropathic pain, slow onset)
Ketamine
PCA (patient-controlled analgesia)

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7
Q

What is the tool used to assess the level of sedation in critically-ill patients? What score is the usual goal?

A

Richmond Agitation Sedation Scale (RASS)
GOAL: RASS score 0 to -2

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8
Q

What drugs can be used to induce sedation in critically ill patients?

A

Propofol
Dexmedetomidine
Benzodiazepines
Ketamine

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9
Q

What is the mechanism of propofol? What effects does it have on patients? How quick is onset?

A

MOA: Stimulates GABA and inhibits glutamate

Hypnotic, anxiolytic, amnestic, anticonvulsant effects
no analgesic effect!
Onset = < 1 min

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10
Q

What are some ADRs of propofol?

A

Respiratory depression (pt should be intubated)
Hypotension
Bradycardia
Decreased CO
Hypertriglyceridemia
Propofol-Related Infusion Syndrome

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11
Q

Propofol is a potential first-line sedative in what 2 conditions? What are some notable clinical pearls?

A

1st line: Severe EtOH withdrawal, status epilepticus (w/opioids)

Pearls:
- Lipid emulsion = provides 1.1 kcals/mL
- avoid in egg/soybean/sulfite allergies
- monitor BP, HR, lipids, anion gap, creatinine kinase if >48h use

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12
Q

What is the MOA of dexmedetomidine? What is the FDA approved use?

A

MOA: alpha-2 adrenergic agonist (like clonidine but super potent)
FDA approved for procedural sedation & sedation for ventilating do not use >24 hrs
Sedating AND analgesic!

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13
Q

What are 4 benefits of demedetomidine?

A

BENEFITS
- NO respiratory depression
- Similar to natural sleep
- Opioid-sparing
- Adjunct to BZDs in EtOH withdrawal

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14
Q

What BZDs are used in sedation of critically-ill patients?

A

Midazolam (fast-acting)
Lorazepam
Diazepam (long-acting)

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15
Q

BZDs are reserved as first-line for what 3 conditions in the critically ill?

A
  1. Status epilepticus
  2. Extreme EtOH withdrawal
  3. Severe respiratory distress requiring deep sedation
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16
Q

What are some drawbacks of BZDs?

A

Risk of delirium
Increased ventilation time
Increased length of ICU stay

17
Q

According to PADIS 2018 Guideline recommendations: We suggest using either ________ or _________ over ________ for sedation in critically ill, mechanically ventilated adults

A

Suggest propofol or dexmedetomidine over BZDs

18
Q

Ketamine is a flexible drug with many indicated uses. What are some in critically-ill patients?

A

Anesthesia
Pain
Rapid intubation
Acute, severe agitation
Status epilepticus
Resistant depression
PTSD

19
Q

What are some MOAs of ketamine? Think about its indications and how mechanisms might affect that. (4)

A

Glutamate NMDA antagonist
Mu + Kappa agonist (opioid receptors, for analgesia)
Muscarinic ACh receptor antagonist (recall ACh is excitatory)
Inhibit reuptake of serotonin, NE and dopamine (antidepressant properties)

20
Q

Patients don’t need to be intubated to be on ketamine. Oral ketamine is available. Why don’t we regularly use it?

A

Has very low oral bioavailability (20-30%)

21
Q

What are 3 advantages of ketamine?

A
  1. Favorable hemodynamics (no hypotension, bradycardia)
  2. Bronchodilating events
  3. Opioid-sparing
22
Q

What are 4 drawbacks of dexmedetomidine?

A

DRAWBACKS
- Hypotension
- RASS score of ≤ -3 unlikely (not very strong)
- Withdrawal with extended use
- Possible drug-induced fever

23
Q

What are some common ADRs of ketamine? (4)

A

Emergence reaction/hyperactivity (must pretreat with benzodiazepines or propofol)
Drooling
Tachycardia
Hypertension

24
Q

What kinds of patients would be candidates for ketamine? Think about the advantages/effects of the drug. (4)

A
  1. Hypotensive patients (causes HTN)
  2. Post-surgery (pain+anesthesia coverage)
  3. Hx schizophrenia (antidepressant properties)
  4. Hx of asthma (bronchodilating)
25
Q

What is delirium?

A

Acute changes in mental status with inattention, disorganized thinking, and altered level of consciousness

26
Q

What are some adverse effects (for pt and system) that come from patients in delirium?

A

Increased mortality
Cognitive impairment
Functional decline
Prolonged ventilation
Increased length of stay
Increased health system costs

27
Q

What are modifiable risk factors of delirium? (2)

A

BZD use
Blood transfusion

28
Q

What are non-modifiable risk factors of delirium? (4)

A

Increased age
Hx of dementia
Hx of coma
Pre-ICU emergency surgery/trauma

29
Q

An ICDSC score ≥ ____ suggests delirium

A

4

30
Q

What are some non-pharmacological interventions for delirium?

A

Re-orient patient
Use hearing aids/glasses
Limit noise & light at night
Encourage natural sleep-wake cycle
Early mobilization
Family
Music
Limit BZDs and AChs

31
Q

What are some Rx options to treat delirium? What do the PADIS guidelines suggest about using meds in delirium?

A

Opioids (delirium from pain)
Dexmedetomidine (sedating + pain)
Melatonin (encourage normal sleep cycle)
Antipsychotics

PADIS does NOT recommend Rx use in PREVENTION of delirium, but Rx ok for treatment (Precedex best for ventilated, antipsychotics last line)

32
Q

Neuromuscular blockers are not listed on PADIS guidelines for treating critically-ill pts, however they are often used still. What do NMBs do?

A

Facilitate ventilation
Minimizes oxygen consumption
Forces muscles to RELAX
Alleviates intracranial and intraabdominal pressure
Surgical procedures

33
Q

What happens to the body when a pt has neuromuscular blockers?

A

Complete relaxation (including lungs), no communication or movement BUT completely alert! No analgesia or sedation! Almost like sleep paralysis

Pt MUST be intubated to ensure O2 delivery

34
Q

How are patients’ neuromuscular blockade levels monitored by nurses? What is the goal?

A

“Train of Four” - uses peripheral nerve stimulators, counting the patient’s # of twitches indicates level of blockade

Goal = 2 twitches (80-90% block)

35
Q

What are the 3 non-depolarizing neuromuscular blocker agents?

A

Cisatracurium
Vecuronium
Rocuronium*
(Most end in -nium)

36
Q

What is the depolarizing neuromuscular blocking agent?

A

Succinylcholine

Crit Care, Oncology & Hematology (18 decks)

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