Supportive Care in the ICU and Pain, Agitation, and Delirium (PAD)

Question 1

Spportive Care in the ICU

Define: Acute Pain

Answer 1

results from acute illness or injury and dissolves as injury heals- usually responds to pain meds. onset and duration is defined, predictable, and limited

Question 2

Spportive Care in the ICU

Define: Chronic Pain

Answer 2

source may be unknown and pain persists longer than expected that may not respond to pain meds. onset and duration is not well defined and is unpredicable and unlimited

Question 3

Spportive Care in the ICU

What are the potential causes of pain in the ICU?

Answer 3

• burns
• devices
• endotracheal intubation
• immobility
• pre-existing pain
• procedures
• surgery
• trauma

Question 4

Spportive Care in the ICU

What are the impacts of pain in the ICU?

Answer 4

• sleep depivation
• anxiety
• PTSD
• delirium
• higher rate of chronic pain
• negative quality of life
• DVT
• depression
• physiologic stress response= decreased tissue perfusion, respiratory compromise, catabolic/hypermetabolic, cardiac instability, impaired wound healing

Question 5

Spportive Care in the ICU

Define: Analgosedation

Answer 5

• analgesia-first sedation
  OR
• analgesia-based sedation

Question 6

Spportive Care in the ICU

What is the benefit of utilizing analgosedation?

Answer 6

• decreased sedative requirements
• decreased duration of ventilation
• decreased ICU length of stay
• decreased pain intensity

Question 7

Spportive Care in the ICU

What pain scales are utilized in the ICU?

Answer 7

• numerical pain rating scales
• behavioral pain scale
• critical-care pain observation tool (CPOT)

Question 8

Spportive Care in the ICU

How is CPOT used in the ICU to determine if a patient is in pain?

Answer 8

CPOT of 2 or less= no pain, CPOT > 2= pain

Question 9

Spportive Care in the ICU

What are the opioid pharmacologic actions?

Answer 9

• central nervous system (euphoria, sedation, respiratory depression, cough supression, pupil constriction)
• cardiovascular system (arterial dilation, venous dilation)
• gastrointestinal (decreased gastric motility, decreased gastric tone)
• renal (decreased renal blood flow)
• flushing and warming of skin

Question 10

Spportive Care in the ICU

What opioids are considered mild-moderate?

Answer 10

• hydrocodone/APAP
• oxycodone/APAP
• oxycodone
• oxycodone ER

all are PO

Question 11

Spportive Care in the ICU

What opioids are considered strong?

Answer 11

• morphine (IV, PO, PCA)
• hydromorphone (IV, PO, PCA)
• fentanyl (IV, patch, PCA)
• methadone (PO)

Question 12

Spportive Care in the ICU

What ICU opioid caused tachyphylaxis?

Answer 12

fentanyl

Question 13

Spportive Care in the ICU

What is tachyphylaxis?

Answer 13

after some time on opioids there is no more benefit seen and opioid agent will need to be changed

fentanyl is the worst offender

Question 14

Spportive Care in the ICU

What agent is used when patients are tolerant to fentanyl and morphine?

Answer 14

hydromorphone

Question 15

Spportive Care in the ICU

What opioid agent has the most hypotension?

Answer 15

morphine

Question 16

Spportive Care in the ICU

What opioid is associated with serogenic effects?

Answer 16

fentanyl

Question 17

Spportive Care in the ICU

Which opioid is used to decrease air hunger in hospice patients?

Answer 17

morphine

Question 18

Spportive Care in the ICU

Can acetaminophen be used in the ICU for the multimodal approach to pain?

Answer 18

yes, although IV formulation is expensive so may limit use in the ICU setting

Question 19

Spportive Care in the ICU

Can ketamine be used in the ICU for the multimodal approach to pain?

Answer 19

yes, low dose of 1-2 mcg/kg/hr as an adjunct to opioids and may be specifically beneficial for patients post-operative admitted to the ICU

Question 20

Spportive Care in the ICU

Can neuropathic pain meds be used in the ICU for the multimodal approach to pain?

Answer 20

yes, if neuropathic pain is present- consider using gabapentin, carbamazepine, or pregabalin

Question 21

Spportive Care in the ICU

Can IV lidocaine be used in the ICU for the multimodal approach to pain?

Answer 21

no, lack of clinical evidence and scope of use for pain is limited

Question 22

Spportive Care in the ICU

Can COX-1 selective NSAIDs be used in the ICU for the multimodal approach to pain?

Answer 22

maybe, but be aware of adverse effects and minimal clinical outcomes

Question 23

Spportive Care in the ICU

Can opioids for procedures be used in the ICU for the multimodal approach to pain?

Answer 23

yes, at the lowest effective dose

Question 24

Spportive Care in the ICU

What are the causes of anxiety and agitation in the ICU?

Answer 24

• hypoxemia/hypotension
• alcohol/drug withdrawal
• mechanical ventilation
• other devices
• extreme anxiety/delirium
• untreated pain
• inability to communicate
• noises
• lighting
• stimulation
• immobility

Question 25

# Spportive Care in the ICU Why are patients sedated in the ICU?

Answer 25

- tolerate mechanical ventilation or other procedures - protect the agitated patient and caregivers - prevent recall of stressful or traumatic events - reduce metabolic rate or energy consumption - analgesia as a component- for pain relief/minimization

Question 26

# Spportive Care in the ICU How can over-sedation be prevented in the ICU?

Answer 26

- address and treat pain - titrate to a defined sedation goal - utilize benzodiazepine

Question 27

# Spportive Care in the ICU What is the goal score on the richmond agitation sedation scale (RASS)?

Answer 27

+1 -> -1

Question 28

# Spportive Care in the ICU What are the sedative options in the ICU?

Answer 28

- benzodiazepines (lorazepam, midazolam, diazepam) - propofol - central alpha-2 agonists (clonidine, dexmedetoomidine) - NMDA antagonist (ketamine)

Question 29

# Spportive Care in the ICU Which sedative has the quickest onset of action?

Question 30

# Spportive Care in the ICU Which sedative has the shortest duration of action?

Question 31

# Spportive Care in the ICU Which sedative has the longest duration of action?

Question 32

# Spportive Care in the ICU When would it be appropiate to use propofol in the ICU setting?

Answer 32

short term and only if the patient is hemodynamically stable

Question 33

# Spportive Care in the ICU What are the common side effects of propofol?

Answer 33

bradycardia, hypotension, propofol infusion syndrome (PRIS)

Question 34

# Spportive Care in the ICU What is the place in therapy of lorazepam?

Answer 34

long-term sedation

Question 35

# Spportive Care in the ICU What are the side effects of lorazepam?

Answer 35

prolonged sedation

Question 36

# Spportive Care in the ICU What is the place in therapy of midazolam?

Answer 36

short term sedation | frequent neuro checks needed

Question 37

# Spportive Care in the ICU What are the side effects of midazolam?

Answer 37

accumulation with renal and hepatic disease

Question 38

# Spportive Care in the ICU What is Virchow's Triad?

Answer 38

- hypercoaguable state - circulatory stasis - vascular wall injury

Question 39

# Spportive Care in the ICU What factors would consider a patient high risk for VTE?

Question 40

# Spportive Care in the ICU What is the VTE prophylaxis agent given to patients at low/minor risk?

Answer 40

heparin 5000 units subcutaneous Q8H

Question 41

# Spportive Care in the ICU What is the dosing of enoxaparin with a CrCl < 30 mL/min?

Answer 41

enoxaparin 30mg subcutaneous Q24H

Question 42

# Spportive Care in the ICU What is the thrombosis prevention recommendation for high-risk trauma patients?

Answer 42

enoxaparin 30mg subcutaneous Q12H AND mechanical prophylaxis (unless containdicated by lower extremity injury)

Question 43

# Spportive Care in the ICU What patient populations qualify for antifactor-Xa monitoring?

Answer 43

- extremes of weight (obesity and low-weight) - renal dysfunction - hypermetabolic (trauma, burn)

Question 44

# Spportive Care in the ICU What is the goal antifactor-Xa for VTE prophylaxis?

Answer 44

0.2-0.4 IU/mL

Question 45

# Spportive Care in the ICU What is the angle a patients head should be above the bed while in the ICU?

Answer 45

30 degrees

Question 46

# Spportive Care in the ICU What patients need stress ulcer prophylaxis?

Answer 46

- coagulopathy (INR >1.5, aPPT >2x baseline, and/or platelet < 50000) - shock - chronic liver disease - neurocritical care adults

Question 47

# Spportive Care in the ICU What are the treatment options for stress ulcer prophylaxis?

Answer 47

- H2RAs= famotidine, ranitidine - PPIs= pantoprazole, esomeprazole

Question 48

# Spportive Care in the ICU What ulcer prophylaxis requires dosing adjustments for renal dysfunction?

Answer 48

H2RAs, twice daily dosing -> once daily for CrCl < 50 mL/min

Question 49

# Spportive Care in the ICU What is the black box warning for PPIs?

Answer 49

risk of C. diff infection

Question 50

# Spportive Care in the ICU When should insulin therapy be initiated in ICU patients?

Answer 50

two consecutive BG levels greater than 180 mg/dL

Question 51

# Spportive Care in the ICU What is the goal BG for a patient in the ICU?

Answer 51

higher BG is tolerated to avoid hypoglycemia, 140-200 mg/dL, but lower targets may be accepted if risk of hypoglycemia is very low

Question 52

# Spportive Care in the ICU What is the recommended dosing of insulin for patients in the ICU?

Answer 52

continuous IV infusion

Question 53

# Spportive Care in the ICU What are the recommended bowel regimen in the ICU?

Answer 53

- docusate/senna - polyethylene glycol - bisacodyl - sorbitol 70% - magnesium citrate

Question 54

# Spportive Care in the ICU What screening tools can be used to assess delirum in the ICU?

Answer 54

CAM-ICU | and many others...

Question 55

# Spportive Care in the ICU How is delirum treated in the ICU?

Answer 55

eliminate contributing factors and implement/optimize non-pharm therapy then consider pharmacological options

Question 56

# Spportive Care in the ICU What are the modifable factors that may aid delirum in the ICU?

Answer 56

- isolation - no clock/daylight/visitors - excessive noise - restraints - length of stay - fever - malnutrition - hypotension - sepsis - metabolic disorders - tubes/catheters - medications

Question 57

# Spportive Care in the ICU What should be done pharmacologically before beginning antipsychotics for delirum in the ICU?

Answer 57

- adequate pain control - discontinue deliriogenic medications - resume home psychoactive medications - treat withdrawal - consider patient specific factors

Question 58

# Spportive Care in the ICU What antipsychotics may be used to treat delirum?

Answer 58

- haloperidol - quetiapine - olanzapine

Question 59

# Spportive Care in the ICU What are the required monitoring parameters when treating delirum with antipsychotics?

Answer 59

QTc