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PHRM 864: Therapeutics IV > Acute Care > Flashcards

Acute Care Flashcards

1
Q

What are the two types of Neruomuscalar blocking agents in acute care?

A
  • Depolarizing & Nondepolarizing
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2
Q

What is the depolarizing agent used in acute care?

A
  • Succinylcholine
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3
Q

What is the MOA for succinylcholine in acute care?

A
  • Resembles acetylcholine; binds to Ach receptors activating them and “depolarizing” the junction –> no contraction
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4
Q

What is dose used for succinylcholine?

A
  • 1.5 mg/kg IV
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5
Q

What is Succinylcholine used for in Acute Care?

A
  • Rapid Sequence Intubation [RSI]: placing endo tube to help with breathing
  • NOT for sustained neuromuscalr blockage
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6
Q

What are some Adverse Drug Reactions for Succinylcholine in Acute Care?

A
  • APENA –> no breathing during sleep
  • Dull muscle pain
  • Hyperkalemia –> lead to cardio issues
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7
Q

What is the MOA of the Nodepolarizing NMBA’s in Acute Care?

A
  • Competitively block the action of Ach [ NO ACTIVATION], no initial fasciculation
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8
Q

What are the two classes in Nondepolarizing NMBA’s in Acute Care?

A
  • Aminosteroidal & Benzylisoquinolinium
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9
Q

Is there a way to reverse the Nondepolarizing NMBA’s in Acute Care?

A
  • Acetylcholinesterase inhibitors & Sugammadex
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10
Q

What are the Aminosteridal NMBA’s?

A
  • Pancuronium: Slow Onset, Lung duration, Renal Elim
  • Vecuronium: Slow onset, medium duration, renal/hepatic elim
  • Rocuronium: Rapid onset, Heaptic elim, medium duration
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11
Q

What are the Benzylisoquinolinium NMBA’s?

A
  • Atracurium: Medium onset, medium duration, Hoffman [blood] elim
  • Cisatracurium: SAME
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12
Q

What are some of the clinical indications for NDNMBA’s

A
  • MECHANICAL VENT –> those with acute respiratory distress syndrome [ARDS]
  • Helps improve gas exchange
  • NOT all need vents
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13
Q

What way are NDNMBA’s able to help with Theraputic Hypthermia?

A
  • Prevents or Treats shivering; stops the patient from cooling during cardiac arrest
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14
Q

What are some of the adverse drug reactions for the NDNMBA’s?

A
  • APNEA
  • Inadequate pain and sediation –> NO analgesic effect; still feel pain
  • Prolonged paralysis [ICUAW]
  • Drug Interaction with Corticosteroids
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15
Q

What is the way that we monitor Neruomuscular Blockers in actue care?

A
  • Peripheral Nerve Stimulation [Twitch Monitoring]
  • Stimulate the Ulnar nerve 4 times
  • 4/4 <75% suppress; 3/4 75% supress; 2/4 80% suppress; 1/4 90% suppress; 0/4 100% suppress
  • WANT 1 or 2 / 4!!
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16
Q

What is PADIS?

A
  • Pain, Agitation/Sedation, Delirium, Immobility, Sleep
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17
Q

What is the definition of PAIN?

A
  • Unpleasant sensory experience with actual or potential tissue damage
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18
Q

What is the definiation of AGITATION?

A
  • Characterized by apprehension, increased motor activity and autonomic arousal
  • state of anxiety accompanied by motor restlessness
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19
Q

What is the definitions of DELIRIUM?

A
  • Acute cerebral dysfunction with a baseline mental status, inattention and disorganized thinking or altered level of consciousness
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20
Q

What are the assessments for pain that we can use of a patient is unable to self report?

A
  • Behavioral Pain Scale [BPS]
  • Ciritical Care Pain Observation Tool [CPOT]
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21
Q

What is important to know abot Analgesia in Pain in Acute Care?

A
  • PREEMPTIVE ANALGESIA
  • IV opioids are preferred [in Mech Vents]
  • Non-opioids can be used [Acetaminophen, Neuro Pain, NSAIDS (Increase Ulcer risk), Ketamine]
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22
Q

What are the common Opioids that are use in Acute Cure?

A
  • Fentanyl, Morphine, Methadone [for long term]
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23
Q

What are some of the adverse clinical outcomes for Agitation/Sediation?

A
  • Hard to Mech Vent
  • Increase motor activity
  • Increase oxygen consumption
  • Removal of lines and caths
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24
Q

What are some of the underlying causes in Agitation/Sedation?

A
  • PAIN [big issue], Mech Vent, Delirium, Hypoxia, Hypotension, Withdrawal
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25
Q

What is the treatment for Agitation?

A
  • Nonpharm or Pharm
26
Q

What is the nonpharmacologic treatment for Agitations?

A
  • 1st line
  • Give good analgesia, reorientation, normal sleep
27
Q

What is important to know sedatives in the treatment of Agitation-Sediation?

A
  • Reduce stress of Mech Vent, relieve anxiety, prevent agitated harm
  • Should NOT be used as restraint
  • OVERSEDATION is a problem [increase Mech Vent time and ICU LOS]
28
Q

What is the goal for the treatment of Agitation-Sedation?

A
  • LESS IS BEST –> Light sedation [decrease Mech Vent, decrease ICU LOS, decrease mortality]
29
Q

What are some of the assessment scales that are used in Agitation-Sediation?

A
  • Richmond-Agitation-Sedation Scale [RASS]
  • Sedation-Agitation-Scale [SAS]
  • Bispectral Index [BIS]-
30
Q

What is the important os the BIS scale in Agitation-Sedation?

A
  • Scale from 100 [completely awake] to 0 [isoelectric EEG]
  • Great with patients using NMB
  • NOT recommended in all ICU patient tho
31
Q

What are the sedative drugs that are used in the ICU?>

A
  • Benzos [Lorazepam, Midazolam]
  • Propofol
  • Dexmedetomidine
32
Q

What is the MOA for Benzos in Acute Care?

A
  • Binds to GABA receptor inhibiting it and hyperpolarizing cells
33
Q

What are some of the adverse drug reactions for Benzos in Acute Care?

A
  • Respiratory Depression [DO NOT treat aggressively without Mech Vent]
  • Increase risk of seizures
  • INCREASED DELIRIUM RISK
34
Q

What are the two Benzos that are used un Acute Care?

A
  • Lorazepam & Midazalom
35
Q

What is important to know about Lorazepam?

A
  • IV, PO, IM [IV preferred]
  • Half Life 10-20h [Hard to titrate]
  • Metabolized by glucuronidation
  • Contains Propylene Glycol (PG) [Lactic Acidosis]
  • HIGH DELIRIUM RISK
36
Q

What is important to know about Midazolam?

A
  • IV ONLY –> Used in procedural sedation
  • Rapid onset [Half Life = 2h; titratable]
  • Hepatically metabolized by 3A4
37
Q

What is the MOA for Propofol in Acute Care?

A
  • Binds to sites on multiple receptors [GABA, Glycine, Nicotinic, M1] causing CNS depression
38
Q

What is important to know about Propofol in Acute Care?

A
  • RAPID ONSET and RAPID OFFEST [
  • Used in Neurosurgical Patients [reduce intracranial pressure (ICP)]
  • Emulsion [contiains 1.1kcal/mL; hang for only 12 hours]
  • NO DELIRIUM!!
39
Q

What are some of the adverse drug reactions for Propofol?

A
  • Apnea
  • HYPOtension, Bradycardia
  • Hypertriglyceridemia [b/c of emulsion]
  • Propofol Infusion Syndrome
40
Q

What is the Propofol Infusion Syndrome?

A
  • ACIDOSIS, BRADYCARDIA, LIPIDEMIA [rare]
  • Not for peds
  • NEED TO MONITOR Propofol
41
Q

What is the MOA for Dexmedatomidine in Acute Care?

A
  • Selective a-2 agonist [like clonidine?] that activates a-2 receptors inhibiting norepi release
  • VAGUS nerse has a lot of a-2 receptors so possible bradycardia and hyportensive effects
42
Q

What is important to know about Dexmedetomidine in Acute Care?

A
  • Sedation BUT can easily arouse patients
  • NO respiratory depression
  • VERY Little delirium
  • Hepatic metabolisim and Elim in urine
43
Q

What are is the adverse effects for Dexmedetomidine?

A
  • INCREASE blood pressure followed by bradycardia or HYPOtension [loading doses]\
44
Q

What is the cardinal features of Delirium?

A
  • Decreased awareness
  • Change in cognition [hallucination/delusions]
45
Q

What are some of the symptoms lf Delirium?

A
  • Sleep issues
  • Emotions [fear, anxiety, anger, depression, euphoria]
46
Q

What are the two subtypes of Delirium?

A
  • Hyperactive [Agitated] –> Hallucinations/Delusions
  • Hypoactive [calm] –> confusion/sedation [misdianosed]
47
Q

What are some of the Modifiable and Nonmodifiable risk factors for Delirium?

A
  • Mod: BENZOS, Blood Transfusinos
  • Nonmod: Age, prior dementia, coma, severity of illness
48
Q

What are the two assessments for Delirium?

A
  • ICDSC & CAM-ICU
  • Limited by level of arousal
49
Q

What is the Nonpharmacoligic treatment/prevention for Delirium?

A
  • BIGGEST ROLE
  • EARLY Mobilization [want to help the patient to get out of bed]
  • Optimization of sleep
50
Q

What are some of the pharmacologic treatment/prevetions for Delirium?

A
  • NOT recommended for Prevention
  • NOT recommended for ROUTINE treatment
  • Could use Antipsychotics, Haloperidol, Dexmedetomidine
51
Q

What is important to know about Haloperidol in Acute Care?

A
  • Dopamine Antagonist
  • Causes mild sedation WITHOUT analgesia
  • 1-5 mg IV q1h PRN then scheduled dosing
  • DOES NOT reduce delirium
52
Q

What is the adverse effects for Haloperidol?

A
  • QTc Prolongation –> Torsades de Points [when used aggressively]
  • Decreases Seziure threshold
  • EPS!!
  • Neuroleptic Syndrome
53
Q

What are the Antipsychotics that are used in Delirium?

A
  • Risperidone, Olanzpine, Quetiapine, Aripiprazole, Ziprasidone
  • Potentail safety over Haloperidol [AVOIDS EPS]
54
Q

What are some of the adverse effects for the Antipsychotics in Delirium?

A
  • Decreased EPS
  • Better Tolerated than Haloperidol
  • Decreased QTc Prolongation [except Ziprasidone]
55
Q

What is important about Dexmedetomidine in Delirium?

A
  • RECOMMEDED for delirium when the patient agitation is weaning away from vent
56
Q

What are some of the general PAD guidelines for Pain & Sedation?

A
  • Needs adequate analgesisa; ACTIVE & PREEMPTIVE
  • Assess with RASS & SAS [sedation] & BPS & CPOT [pain]
57
Q

Is light sedation better or worse than deep sediation and why?

A
  • LIGHT SEDATION PREFERRED
  • Deep sedation may lead to worse outcomes [increased death, increase mech vent, ICU LOS, neuro issues]
58
Q

What is the FIRST thing to do in the sediation Algorithm within PAD Gudielines?

A
  • “Analgesia-first Sedation”
  • PAIN is the main source for Agitation
  • Balence opioids [if on mech vent = more aggresive opioids]
59
Q

What is important to know about the sedation meds in the Sedation Algorithm?

A
  • Dexmed & Propofol over Benzos [Benzos increase delirium]
  • ## Dexmed increases BP tho
60
Q

In what way can Benzos still be uesd in the Sedation Algorithm?

A
  • Treating anxiety, seizures, withdrawal
  • Midazolam: quick onset with short half life [procedural sedation]
  • Lorazapam: prolonged sedation [LACTIC ACIDOSIS tho]
61
Q

In what way is Propofol and Dexmedetomidine used in Sedation Algorithm?

A
  • Propofol: rapid awakening in neruotrauma [great for neurochecks] & preferred over benzos in cardiac surgery
  • Dexmed: Less delirium & mech vent time; DRUG OF CHOICE for delirium and agitation [gets around agitation]
62
Q

What is important to know about the PAD Guidelines for Delirium?

A
  • Pharmacologic is NOT good for prevention or ROUTINE treatment
  • Antipsychotic for short term treatment of delirium [Haloperidol & Atypicals]
  • Dexmed: GREAT for agitation is precluding weaning off vent]

PHRM 864: Therapeutics IV (28 decks)

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