Acute pain and ICU Flashcards
What are some CVS manifestations of pain
tachycardia, hypertension, increased SVR, increased myocardial oxygen consumption
What are some respiratory manifestations of pain
decreased lung volumes, atelectasis, decreased cough, sputum retention, infection, hypoxaemia
What are some GI manifestations of pain
decreased gastric and bowel motility
What are some GU manifestations of pain
urinary retention
what scale can be used to rate pain
simple verbal rating scale
what is the simple verbal rating scale
0 = no pain at rest or on movement 1 = no pain at rest, slightly on movement 2 = intermittent at rest, moderate on movement 3 = continuous at rest, severe on movement
In post-op patients, how do you move along the analgesic ladder
from top to bottom
in palliative patients, how do you move along the analgesic ladder
from bottom to top
what are special circumstances to consider when treating pain
drug dependency
chronic pain
renal failure
if a patient is on methadone, can you give normal opioids?
yes
what type of analgesia should be avoided in patients with renal failure
NSAIDs
what types of analgesia won’t accumulate in those with renal failure
paracetamol
fentanyl
what is the mechanism of action of paracetamol
inhibits prostaglandin synthesis in the CNS
what is the dosing of paracetamol
1g 6 hourly
reduce if <50kg
What is the mechanism of action of NSAIDs
COX-1/2 inhibition
what are contraindications to NSAIDs
peptic ulcer disease / GI bleeding asthma heart failure hypertension renal impairment dehydration pregnancy coagulopathy aspirin/NSAID allergy
how can opioids be administered
PO, SC, IM, IV, intrathecal, epidural
what is the mechanism of action of opioids
agonist of mu receptors
list strong opioids
morphine oxycodone diamorphine fentanyl methadone
list weak opioids
codeine
tramadol
who should you not give tramadol to
epileptics
common side effect of opioids (especially codeine)
constipation
N+V
what is PCA
Patient controlled analgesia
prescribed by Dr, administered by patient
must be prescribed on kardex AND on a separate PCA chart
what is the usual prescription of PCA
1mg bolus morphine with a 5 min lockout
ie 12mg in an hour
where is analgesia delivered to in the epidural route
in the epidural space (outside the dura mater)
what are advantages to epidural analgesia
excellent control
lower incidence of DVT
earlier mobilisation
earlier recovery of GIT function
what are disadvantages of epidural analgesia
special staff required
hypotension
contraindicated if on anticoagulants
spinal haematoma/abscess
What drug class are the following anti-emetics: cyclizine ondansetron prochlorperazine metoclopramide hyoscine
cyclizine = antihistamine
ondansetron = 5HT3 antagonist
prochlorperazine + metoclopramide = antidopaminergic
hyoscine = anticholinergic
indications for central venous catheter insertion
measuring CVP
haemodialysis
cardiac pacing
administration of inotropes
common sites for CVC insertion
IJV
subclavian vein
femoral vein
antecubital fossa (PICC)
what is the correct placement of a CVC
the tip should be sitting at the entrance to the right atrium
what is a normal CVP value
0-8cmH2O
what are inotropes
drugs that affect cardiac contractility
positive and negative
what is a vasopressor
substance which increases SVR
how should inotropes always be administered
through a CVC
examples of (positive) inotropes
adrenaline
dobutamine
action of adrenaline
it is a catecholamine which acts as an agonist of alpha and beta receptors
action of dobutamine
synthetic catecholamine
B1 agonist
increases cardiac contractility with minimal effect on HR and vascular tone
examples of vasopressors
and main MOA
Primarily alpha agonists noradrenaline metaraminol ephidrine adrenaline
action of noradrenaline
powerful alpha 1 agonist used to increase SVR
what are the different levels of critical care
Level 0 = ward based
1 = ward based with critical care support
2 = HDU (single organ system failing)
3 = ICU (multiorgan support, invasive ventilation)
what are the different types of ventilation
invasive and non-invasive
what is involved in invasive ventilation
performed via an ETT or other airway device
what is non-invasive ventilation
performed via a tight fitting mask
either: CPAP or BiPAP
in the acute setting (eg COPD exacerbation, type 2 resp failure), what would you use, CPAP or BiPAP
BiPAP
When would you use CPAP
OSA
Type 1 resp failure (pulmonary oedema - unresponsive acute HF)
what is an intra-aortic balloon pump
inflatable balloon inserted percutaneously via the femoral artery
provides counter pulsation to improve myocardial oxygen supply and reduced myocardial work
improves outcomes in post MI and cardiogenic shock
what are patients at risk of post resuscitation
re arrest
hypoxic brain injury
how many doctors are needed to confirm brainstem death
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