Pain and Sedation

Question 1

Objectives

Answer 1

1. Compare and contrast the different sedatives and analgesics used in the ICU setting with regards to pharmacokinetics, dosing, use and adverse effects.
2. Given a patient scenario, design an appropriate analgesic/sedation drug regimen for a patient undergoing mechanical ventilation.
3. State risk factors for ICU delirium.
4. Recommend appropriate treatment
   (pharmacologic and non-pharmacologic) for a patient with ICU delirium.

Question 2

First-line medication to treat pain in ICU patients- IV route

Answer 2

Opioids

Question 3

Most common opioids in ICU

Answer 3

Fentanyl, hydromorphone and morphine

Question 4

Opioid with fastest onset

Answer 4

Fentanyl

Question 5

All opioids eliminated in

Answer 5

Urine

Question 6

Only opioid with active metabolite

Answer 6

Morphine

Question 7

ADE’s of opioids

Answer 7

Hypotension - Morphine
Respiratory depression
Altered mental status
Sedation
Constipation, ileus
Nausea/vomiting
Spasm of sphincter of Oddi – worsened pancreatitis

Question 8

Ideal sedative

Answer 8

Rapid onset
Easy titration
Lack of accumulation 
No active metabolites 
Rapid awakening 
Inexpensive

Question 9

Most remembered event in ICU

Answer 9

Pain

Question 10

Most common problem in ICU

Answer 10

Anxiety

Question 11

Consequences of neglecting anxiety

Answer 11

Loss of control of the patient
  -Ventilator dyssynchrony
  -Agitation
  -Increased O2 consumption
  -Removal of lines/catheters
Uncomfortable patient
  -Anxiety and fear
  -Lack of sleep
  -Painful procedures and paralysis (amnestic effects)

Question 12

Goals of Analgesia & Sedation

Answer 12

Improve patient comfort while using invasive devices (i.e. ventilator)
Minimize patient harm
  -Pulling IV lines
  -Self extubation
  -Pulling catheters
Decrease anxiety/stress response

Question 13

Slower onset BZD

Answer 13

Lorazepam

Question 14

Faster onset BZD

Answer 14

Diazepam

Midazolam

Question 15

BZD with no active metabolite

Answer 15

Lorazepam

Question 16

BZD with active metabolites

Answer 16

Diazepam

Midazolam

Question 17

BZD used in acutely agitated patients

Answer 17

Midazolam

Question 18

BZD used for long-term sedation (i.e. > 48 hrs of MV)

Answer 18

Lorazepam

Question 19

BZD used for alcohol withdrawal

Answer 19

Lorazepam

Question 20

BZD not ideal for acute agitation

Answer 20

Lorazepam

Question 21

BZD ADE’s

Answer 21

No significant hemodynamic reactions except for midazolam

• Respiratory depression (less than opioids when used alone)
• Propylene glycol toxicity with lorazepam
• Monitor serum osmolality or bicarbonate

Question 22

BZD that causes accumulation concerns with hepatic and renal failure and with prolonged use

Answer 22

Midazolam

Question 23

Lorazepam ADE

Answer 23

“Diluent toxicity”
Propylene glycol vehicle
- Renal failure
- Hyperosmolality
- Lactic acidosis
Risk factors
- High-dose, prolonged infusions
- Renal or hepatic dysfunction

Question 24

Propofol ADE’s

Answer 24

Hypotension: dose-dependent
-Urine discoloration (green)
-Hypertriglyeridemia
Increased risk of acute pancreatitis
Discontinue if triglycerides > 400 mg/dL
Monitor serum TG levels: prior to
initiation, every 3-7 days
thereafter, especially if receiving for
>48 hours with doses exceeding
50 mcg/kg/minute
Propofol-related infusion syndrome (PRIS) Associated with doses > 80 mcg/kg/min for ≥ 48hrs
Symptoms include: bradycardia, lactic acidosis, rhabdomyolysis, renal failure
STOP INFUSION IMMEDIATELY

Question 25

When to use Propofol

Answer 25

Useful for acutely agitated patients & patients requiring sedation with frequent neuro checks Short-term use preferred - Less than 72 hrs

Question 26

Only sedative approved for use in non-intubated ICU patients in the US

Answer 26

Dexmedetomidine - like clonidine - central alpha-2 agonist - Actions NOT mediated through GABA - Sedative and analgesic properties without producing respiratory depression

Question 27

Dexmedetomidine ADE's

Answer 27

``` Bradycardia Hypertension Hypotension - More common with bolus doses Cardiac arrhythmias ```

Question 28

Dexmedetomidine Place in Therapy

Answer 28

Post-surgical sedation with an anticipated short intubation period Adjunct agent to benzodiazepines Procedural sedation Associated with less ICU delirium??

Question 29

Assessment of Delirium (2 methods)

Answer 29

- Confusion Assessment Method for ICU (CAM- ICU) - Intensive Care Delirium Screening Checklist (ICDSC) - Both have good reliability and validity

Question 30

Most common type of Delirium

Answer 30

ICU delirium is common

Question 31

Tx of Delirium

Answer 31

``` NO preferred drug for treating delirium -Orient patient to room and time -Give patients their eyeglasses and hearing aids if needed -Calendars and clocks -Reduce noise and distractions -Place patient in a room with a window ```

Question 32

Opioid that causes hypotension

Answer 32

Morphine

Question 33

DOC for sedation in pt with hypotension and renal failure

Answer 33

lorazepam b/c no active metabolite | Not propofol or dexmedetomide b/c hypotension