Acute Care Flashcards
What are the two types of Neruomuscalar blocking agents in acute care?
- Depolarizing & Nondepolarizing
What is the depolarizing agent used in acute care?
- Succinylcholine
What is the MOA for succinylcholine in acute care?
- Resembles acetylcholine; binds to Ach receptors activating them and “depolarizing” the junction –> no contraction
What is dose used for succinylcholine?
- 1.5 mg/kg IV
What is Succinylcholine used for in Acute Care?
- Rapid Sequence Intubation [RSI]: placing endo tube to help with breathing
- NOT for sustained neuromuscalr blockage
What are some Adverse Drug Reactions for Succinylcholine in Acute Care?
- APENA –> no breathing during sleep
- Dull muscle pain
- Hyperkalemia –> lead to cardio issues
What is the MOA of the Nodepolarizing NMBA’s in Acute Care?
- Competitively block the action of Ach [ NO ACTIVATION], no initial fasciculation
What are the two classes in Nondepolarizing NMBA’s in Acute Care?
- Aminosteroidal & Benzylisoquinolinium
Is there a way to reverse the Nondepolarizing NMBA’s in Acute Care?
- Acetylcholinesterase inhibitors & Sugammadex
What are the Aminosteridal NMBA’s?
- Pancuronium: Slow Onset, Lung duration, Renal Elim
- Vecuronium: Slow onset, medium duration, renal/hepatic elim
- Rocuronium: Rapid onset, Heaptic elim, medium duration
What are the Benzylisoquinolinium NMBA’s?
- Atracurium: Medium onset, medium duration, Hoffman [blood] elim
- Cisatracurium: SAME
What are some of the clinical indications for NDNMBA’s
- MECHANICAL VENT –> those with acute respiratory distress syndrome [ARDS]
- Helps improve gas exchange
- NOT all need vents
What way are NDNMBA’s able to help with Theraputic Hypthermia?
- Prevents or Treats shivering; stops the patient from cooling during cardiac arrest
What are some of the adverse drug reactions for the NDNMBA’s?
- APNEA
- Inadequate pain and sediation –> NO analgesic effect; still feel pain
- Prolonged paralysis [ICUAW]
- Drug Interaction with Corticosteroids
What is the way that we monitor Neruomuscular Blockers in actue care?
- 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!!
What is PADIS?
- Pain, Agitation/Sedation, Delirium, Immobility, Sleep
What is the definition of PAIN?
- Unpleasant sensory experience with actual or potential tissue damage
What is the definiation of AGITATION?
- Characterized by apprehension, increased motor activity and autonomic arousal
- state of anxiety accompanied by motor restlessness
What is the definitions of DELIRIUM?
- Acute cerebral dysfunction with a baseline mental status, inattention and disorganized thinking or altered level of consciousness
What are the assessments for pain that we can use of a patient is unable to self report?
- Behavioral Pain Scale [BPS]
- Ciritical Care Pain Observation Tool [CPOT]
What is important to know abot Analgesia in Pain in Acute Care?
- PREEMPTIVE ANALGESIA
- IV opioids are preferred [in Mech Vents]
- Non-opioids can be used [Acetaminophen, Neuro Pain, NSAIDS (Increase Ulcer risk), Ketamine]
What are the common Opioids that are use in Acute Cure?
- Fentanyl, Morphine, Methadone [for long term]
What are some of the adverse clinical outcomes for Agitation/Sediation?
- Hard to Mech Vent
- Increase motor activity
- Increase oxygen consumption
- Removal of lines and caths
What are some of the underlying causes in Agitation/Sedation?
- PAIN [big issue], Mech Vent, Delirium, Hypoxia, Hypotension, Withdrawal
What is the treatment for Agitation?
- Nonpharm or Pharm
What is the nonpharmacologic treatment for Agitations?
- 1st line
- Give good analgesia, reorientation, normal sleep
What is important to know sedatives in the treatment of Agitation-Sediation?
- 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]
What is the goal for the treatment of Agitation-Sedation?
- LESS IS BEST –> Light sedation [decrease Mech Vent, decrease ICU LOS, decrease mortality]
What are some of the assessment scales that are used in Agitation-Sediation?
- Richmond-Agitation-Sedation Scale [RASS]
- Sedation-Agitation-Scale [SAS]
- Bispectral Index [BIS]-
What is the important os the BIS scale in Agitation-Sedation?
- Scale from 100 [completely awake] to 0 [isoelectric EEG]
- Great with patients using NMB
- NOT recommended in all ICU patient tho
What are the sedative drugs that are used in the ICU?>
- Benzos [Lorazepam, Midazolam]
- Propofol
- Dexmedetomidine
What is the MOA for Benzos in Acute Care?
- Binds to GABA receptor inhibiting it and hyperpolarizing cells
What are some of the adverse drug reactions for Benzos in Acute Care?
- Respiratory Depression [DO NOT treat aggressively without Mech Vent]
- Increase risk of seizures
- INCREASED DELIRIUM RISK
What are the two Benzos that are used un Acute Care?
- Lorazepam & Midazalom
What is important to know about Lorazepam?
- IV, PO, IM [IV preferred]
- Half Life 10-20h [Hard to titrate]
- Metabolized by glucuronidation
- Contains Propylene Glycol (PG) [Lactic Acidosis]
- HIGH DELIRIUM RISK
What is important to know about Midazolam?
- IV ONLY –> Used in procedural sedation
- Rapid onset [Half Life = 2h; titratable]
- Hepatically metabolized by 3A4
What is the MOA for Propofol in Acute Care?
- Binds to sites on multiple receptors [GABA, Glycine, Nicotinic, M1] causing CNS depression
What is important to know about Propofol in Acute Care?
- 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!!
What are some of the adverse drug reactions for Propofol?
- Apnea
- HYPOtension, Bradycardia
- Hypertriglyceridemia [b/c of emulsion]
- Propofol Infusion Syndrome
What is the Propofol Infusion Syndrome?
- ACIDOSIS, BRADYCARDIA, LIPIDEMIA [rare]
- Not for peds
- NEED TO MONITOR Propofol
What is the MOA for Dexmedatomidine in Acute Care?
- 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
What is important to know about Dexmedetomidine in Acute Care?
- Sedation BUT can easily arouse patients
- NO respiratory depression
- VERY Little delirium
- Hepatic metabolisim and Elim in urine
What are is the adverse effects for Dexmedetomidine?
- INCREASE blood pressure followed by bradycardia or HYPOtension [loading doses]\
What is the cardinal features of Delirium?
- Decreased awareness
- Change in cognition [hallucination/delusions]
What are some of the symptoms lf Delirium?
- Sleep issues
- Emotions [fear, anxiety, anger, depression, euphoria]
What are the two subtypes of Delirium?
- Hyperactive [Agitated] –> Hallucinations/Delusions
- Hypoactive [calm] –> confusion/sedation [misdianosed]
What are some of the Modifiable and Nonmodifiable risk factors for Delirium?
- Mod: BENZOS, Blood Transfusinos
- Nonmod: Age, prior dementia, coma, severity of illness
What are the two assessments for Delirium?
- ICDSC & CAM-ICU
- Limited by level of arousal
What is the Nonpharmacoligic treatment/prevention for Delirium?
- BIGGEST ROLE
- EARLY Mobilization [want to help the patient to get out of bed]
- Optimization of sleep
What are some of the pharmacologic treatment/prevetions for Delirium?
- NOT recommended for Prevention
- NOT recommended for ROUTINE treatment
- Could use Antipsychotics, Haloperidol, Dexmedetomidine
What is important to know about Haloperidol in Acute Care?
- Dopamine Antagonist
- Causes mild sedation WITHOUT analgesia
- 1-5 mg IV q1h PRN then scheduled dosing
- DOES NOT reduce delirium
What is the adverse effects for Haloperidol?
- QTc Prolongation –> Torsades de Points [when used aggressively]
- Decreases Seziure threshold
- EPS!!
- Neuroleptic Syndrome
What are the Antipsychotics that are used in Delirium?
- Risperidone, Olanzpine, Quetiapine, Aripiprazole, Ziprasidone
- Potentail safety over Haloperidol [AVOIDS EPS]
What are some of the adverse effects for the Antipsychotics in Delirium?
- Decreased EPS
- Better Tolerated than Haloperidol
- Decreased QTc Prolongation [except Ziprasidone]
What is important about Dexmedetomidine in Delirium?
- RECOMMEDED for delirium when the patient agitation is weaning away from vent
What are some of the general PAD guidelines for Pain & Sedation?
- Needs adequate analgesisa; ACTIVE & PREEMPTIVE
- Assess with RASS & SAS [sedation] & BPS & CPOT [pain]
Is light sedation better or worse than deep sediation and why?
- LIGHT SEDATION PREFERRED
- Deep sedation may lead to worse outcomes [increased death, increase mech vent, ICU LOS, neuro issues]
What is the FIRST thing to do in the sediation Algorithm within PAD Gudielines?
- “Analgesia-first Sedation”
- PAIN is the main source for Agitation
- Balence opioids [if on mech vent = more aggresive opioids]
What is important to know about the sedation meds in the Sedation Algorithm?
- Dexmed & Propofol over Benzos [Benzos increase delirium]
- ## Dexmed increases BP tho
In what way can Benzos still be uesd in the Sedation Algorithm?
- Treating anxiety, seizures, withdrawal
- Midazolam: quick onset with short half life [procedural sedation]
- Lorazapam: prolonged sedation [LACTIC ACIDOSIS tho]
In what way is Propofol and Dexmedetomidine used in Sedation Algorithm?
- 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]
What is important to know about the PAD Guidelines for Delirium?
- 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]
