Pain, Sedation, and Delirium

Question 1

Significant Pain CPOT

Answer 1

CPOT > 2

Question 2

Significant pain BPS

Answer 2

BPS > 5

Question 3

Morphine

Answer 3

onset: 5-10 min
Duration: 3-6 hrs
Pearls:
- accumulates in renal impairment
- histamine release -> hypotension, bronchospasm, urticaria (itchiness)

Question 4

Fentanyl

Answer 4

Onset: seconds
Duration: 1-2 hrs
Pearls:
- hepatic metabolism
- CYP3A4 interactions
- tachyphylaxis (resistance)

Question 5

Hydromorphone

Answer 5

Onset: 5 min
Duration: 2-4 hrs
Pearls:
- good in renal impairment
- option for fentanyl tolerance
- minimal histamine release
- available as patient controlled analgesia

Question 6

Light sedation RASS scale

Answer 6

0 to -2

Question 7

light sedation SAS scale

Answer 7

3-4

Question 8

Propofol

Answer 8

NO ANALGESIC PROPERTIES
MOA: stimulates GABA, inhibits NMDA
PD:
- hypnotic
- anxiolytic
- amnesic
- anticonvulsant
Onset: < 1 min
Duration: 10-15 min
Clearance: hepatic and extrahepatic
ADE:
- respiratory depression
- hypotension
- bradycardia
- decreased cardiac output
- hypertriglyceridemia (acute pancreatitis)
- propofol related infusion syndrome (PRIS)
Pearls:
- first line in severe alcohol withdrawal and status epilepticus
- lipid emulsion -> provides 1.1 kcal/mL of nutrition
- avoid in pts with egg, sulfite, or soybean allergy
- monitor (if using > 48h) BP, HR, triglycerides, anion gap, lactate, CK

Question 9

Dexmedetomidine

Answer 9

A2 adrenergic agonist
Indications:
- procedural sedation
- sedation for mechanical ventilation
- NOT FOR > 24 HRS
Pharmacodynamics:
- sedative and analgesic properties
ADE:
- bradycrdia
- hypotension

Question 10

Dexmedetomidine Benefits

Answer 10

No respiratory depression (good for pts weaning off ventilator)
effects similar to natural sleep
opioid-sparing
useful as adjunct therapy for alcohol withdrawal

Question 11

Dexmedetomidine Drawbacks

Answer 11

risk of hypotension
RASS score of - 3 or less unlikely
Risk of withdrawal with prolonged use
Drug induced fever?

Question 12

Midazolam

Answer 12

Onset: 2-5 min
Duration: 1-2hrs
Pearls:
- lipophilic
- accumulates in renal impairment
- primary use: status epilepticus

Question 13

Lorazepam

Answer 13

Onset: 5-20 min
Duration: 2-6 hr
Pearls:
- propylene glycol acidosis
- can use in renal/hepatic failure

Question 14

Diazepam

Answer 14

Onset: -10 min
Duration: t1/2 44-100 hrs
Pearls:
- can taper off quickly
- standing doses used in alcohol withdrawal

Question 15

BZD drawbacks

Answer 15

• increased risk of delirium
• increased time on ventilator
• increased length of ICU stay

Question 16

BZD’s are reserved as first line in:

Answer 16

Status epilepticus
Extreme alcohol withdrawal sx
Severe ARDS requiring deep sedation

Question 17

Ketamine indications

Answer 17

Anesthesia
Pain
Rapid sequence intubation
Acute severe agitation
Status epilepticus
Treatment resistant depression
PTSD

Question 18

Ketamine mechanisms

Answer 18

NMDA antagonist
Mu and kappa agonist -> analgesia
Muscarinic Ach receptor antagonist -> bronchodilation
Inhibits reuptake of serotonin, norepinephrine, and dopamine

Question 19

Ketamine dose for pain:

Answer 19

0.15-0.5 mg/kg/hr

Question 20

Ketamine dose for anesthesia

Answer 20

0.5-2 mg/kg/hr

Question 21

Ketamine dose for status epilepticus

Answer 21

> 2 mg/kg/hr

Question 22

IV ketamine onset

Answer 22

anesthesia within 30 min

Question 23

IM ketamine onset

Answer 23

Anesthesia: 3-4 min
Analgesia: 10-15 min

Question 24

IV ketamine duration

Answer 24

Anesthetic effect: 5-10 min
Recovery: 1-2 hrs

Question 25

IM ketamine duration

Answer 25

Anesthetic effect: 12-25 min Analgesic effect: 15-30 min Recovery: 3-4 hrs

Question 26

Ketamine advantages

Answer 26

favorable hemodynamics bronchodilator opioid sparing

Question 27

Ketamine ADEs

Answer 27

- Emergence reaction (caution in pts with schizophrenia, may pretreat with BZD or propofol) - oral secretions (do not mistake for pneumonia) - tachycardia -> caution in Afib - hypertension

Question 28

Risk factors for delirium

Answer 28

Modifiable: - BZD use - blood transfusion Non-modifiable: - elderly - dementia - prior coma - Previous ICU emergency surgery/trauma - increased APACHE score

Question 29

Non-pharm delirium interventions

Answer 29

- re orient the patient - use hearing aids or glasses - limit noise and light at night - encourage natural sleep-wake cycle - early mobilization - family presence - music therapy - limit use of BZDs and anticholinergics

Question 30

Pharmacological delirium treatment

Answer 30

PHARM INTERVENTION NOT RECOMMENDED However: - opioids - dexmedetomidine - melatonin receptor agonists - antipsychotics (quetiapine, haloperidol, olanzapine)

Question 31

NBM monitoring

Answer 31

Train of four using a peripheral nerve stimulator Goal: 2 twitches

Question 32

Cisatracurium

Answer 32

elimination: Hoffman (within plasma, no organ reliance) Onset: 2-5 min Duration: dose dependent 30-90 min

Question 33

Rocuronium

Answer 33

Elimination: 50% biliary and renal Onset: 1-2 min Duration: 30-60 min

Question 34

Vecuronium

Answer 34

Elimination: biliary and renal Onset: 3-5 min Duration: 45-60 min

Question 35

Succinylcholine

Answer 35

Elimination: plasma Onset: 30-60 seconds Duration: 5-10 min ADE: - malignant hyperthermia - hyperkalemia (CI with K > 4) commonly used for rapid sequence intubation (quick on and off)