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releases hystamines and worry about BP going down



dramatically affects drive to breath.  Can cause resp depression long after affects are gone



when do you wean patients of pain meds.  Morphine and fentanyl.

  • As soon as tolerated.  Use london health care model
  • Morphine: If dose is less than 4mg per hour , then decrease by half every six hours.  If dose is more than 4mg an hour, decrease by 25% every 6 hours until less than 4
  • Fentanyl: on less than 50 mc per hour, cut in half every 6 hours.  On more than 50mc per hour, than reduce by 25% every 6 hours. 



Most beneficial in reducing pain in patients

Touch and family


Neonatal: Sensorial Interventions for pain

  • containment & swaddling
  • facilitated tucking
  • vestibular stimulation (rocking)
  • orotactal stimulation: non-nutritive sucking (NNS) sweet solutions
  • Combining interventions offers additional benefits


Neonatal: Mother-Driven Interventions for pain

  • breastfeeding
  • skin-to-skin care
  • maternal voice, maternal heartbeat with NNS
  • olfactory, aromatherapy recognition


Provide adequate
Rule these out first:

→ hypoxia
→ hypoglycemia
→ withdrawal
→ sleep deprivation
→ immobility
→ fear




Three purposes of sedation

  • Amnesia: to forget what's going on
  • Agitation: 
  • Anxiety: go to sedation as last resort


Ramsey sedation scale

  • sedation guiding principles standardized scale
  • Measures: consciousness, agitation, anxiety, sleep, patient-ventilator syncrony
  1. Patient is anxious and agitated or restless, or both
  2. Patient is cooperative, oriented and tranquil
  3. Patient responds to commands only
  4. Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
  5. Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
  6. Patient exhibits no response


Ramsey scale goal for a patient on a ventilator



Ramsey scale for a nonventilated patient who just requires sedation goal



When you want a sedation medication that acts rapidly and ends rapidly?

Propofol (Diprivan): short-acting general anesthetic agent
    * onset: 40 seconds, duration 3 to 5 minutes
    * sedation is necessary with rapid awakening
    * bolus, then continuous

-usually on ventilated patients

-containers it's in can only be used for 12 hours

-(lipid) generally used through central line or used large bore peripherally because it's very irritating

-if drip is stopped, expect them to wake up in 8 minutes


Sedation med used for long term, or low level sedation

Lorazepam (Ativan): benzodiazepine
    * intravenous onset: 15 to 30 minutes, duration ~8 hours
    * intermittent or continuous

-can only be mixed with d5w

-can cause renal tubular necrosis


Other common sedation med for short term sedation for procedure

Dexmedetomidine (Precedex): an alpha-2 agonist
    * rapid onset, should be used for < 24 hours
    * sedated, but arousable


  • Common in critically ill patients (esp. on ventilator)
  • Caused by neurotransmitter imbalance in brain

  • Predisposing factors

-Patient (age, substance use, sensory impairment)

-Illness (infection, electrolyte imbalance, low HCT)

-Iatrogenic (polypharmacy, sleep disruption, immobility)


  • can cause hospitals to not get reimbursed


Delirium classifications

  • Hyperactive (agitated): Most common. sudden change, hallucinated, hyperactive
  • Hypoactive (quiet) – often misdiagnosed as depression, become nonresponsive and sluggish
  • Mixed:  Second most common, bipolar-ish


ABCDE bundle

  • Awakening and Breathing Coordination:Sedation vacations , protocol-driven sedation.  Ventilator  weaning, spontaneous breathing trials
  • Delirium monitoring: CAM-ICU
  • Exercise/Early mobility: Passive – bathing/grooming, turning/ repositioning.  Active – dangling, sitting in chair, walking



Treat Cause of Delirium Acronym


  • Toxic situations and medication:  CHF, shock, dehydration, organ failure.  Benzodiazepines, anticholinergics, and steroids
  • Hypoxemia
  • Infection/sepsis, inflammation, immobilization
  • Nonpharmacological interventions: sleep, reorientation/reassurance, familiar people/objects
  • K+ (potassium) or other electrolyte imbalances


Benefits of adequate nutrition

  • Improved wound healing
  • Decreased catabolism of muscle tissue

  • Improved GI function
  • Reduced complications, length of stay, and cost


Assessment for nutrition in critical care

  • BMI (weight / height)
  • Swallowing / GI issues
  • Albumin / Prealbumin (indicator of protein status) Normal Pre: 20-30




Interventions for nutrition in critical care

  • Oral / Enteral nutrition by day 1 or 2
  • Prevent aspiration
  • Prevent bacterial colonization of GI tract
  • Prevent diarrhea


Risks/complications of enteral nutrition

  • Aspiration pneumonia
  • Bacterial colonization
  • GI Intolerance (V/D)
  • Complications associated with high gastric residuals: Monitor  (replace or discard)
    GI motility agents (Reglan)




Parenteral Nutrition (TPN)

When indicated, delayed for how long, risks and complications

  • Used when enteral nutrition is contraindicated
  • Delay until day 7-10: Enteral provides better nutrition.  Increased risk of complications with TPN

Risks / Complications

  • Infection (access device)
  • Glucose imbalances
  • Hyperglycemia -- may require insulin infusion
  • Hypoglycemia when TPN interrupted -- may require dextrose infusion
  • Overfeeding
  • GI mucosal atrophy


When would you hold tube feed continuous

  • more than two hours worth of the feed residual, then hold it recheck in an hour
  • less than two hours then continue


bolus feed residual rules

bolus feed, subtract the residual, and give them the remaining amount.  If residual is more than 100, wait one hour and recheck


Oral/enteral nutrition for the neonate

  • Feeding method driven by sucking ability
  • OG/NG bolus
  • Bottle
  • Human milk preferred due to immunologic benefits


Parenteral nutrition in the neonate

  • Started sooner than in adults – day 1 if enteral feeding unlikely by day 7
  • TPN complications outweighed by decreased risk of necrotizing enterocolitis (NEC)

  • Make sure to give tiny enteral feedings if possible

  • Breast milk is THE BEST thing to do, also coats the GI and protects it


Tropic feeds

give small amount of high fat feed for the neonate who gets the parenteral feed.  Dramatically decreases NEC


Neonates have _____ caloric & protein requirements than adults.

4 to 5 X higher caloric and protein requirements


Three stages of NEC

  • Stage 1: apnea, bradycardia, abdominal distention.  Start having reflex or vomiting
  • Stage 2: all factors of stage 1 plus pneumastosis (pockets of air trapped inside gut wall.  Can be seen on x-ray)
  • Stage 3: decreased BP, multisystem organ failure, bradycardic, acidosis, DIC, renal failure

*best thing for NEC is prevention


Best way to prevent NEC

  • early feeds ideally with high fat content human milk