Critical Care

Question 1

Morphine (narcotic)

Answer 1

Peak: 30 mins IV
Duration: 3-7 hrs
May cause histamine release and hypotensive response 
May cause respiratory suppression
Decrease in GI motility

Question 2

Fentanyl (narcotic)

Answer 2

Peak: 4 hours IV (nearly immediate onset)
Duration: 30-60 mins
May cause respiratory depression, drowsiness, sedation
Minimum CV depressing effects unlike morphine (drug of choice in hemodynamically unstable patients)
No histamine release
Rare bradycardia and chest wall rigidity if rapidly infused in large dose

Question 3

Hydromorphone -aka Dilaudid (narcotic)

Answer 3

Peak: 20 mins IV
Duration: 4-5 hours
Alternative to morphine (semisynthetic opioid)
Like fentanyl, has less CV side effects and no histamine release
Side effects may include itching (pruritus), sedation, nausea

Question 4

Ketamine (strong narcotic)

Answer 4

Peak: 30-60 mins
Half-life: 2-3 hours (duration can be unpredictable)
Usually used in addition to other pain control drugs to help control
Bolus dose may increase BP, HR, and CO, or bronchodilation
Cautions in patients with increased ICP…hallucinations may occur

Question 5

Dexmedetomidine (strong narcotic)

Answer 5

Peak: 1-2 mins
Half-life: 2-3 hours
Sedative and analgesic properties
Continuous infusion, provides sedation without respiratory depression
May help with tolerance of mechanical ventilation

Question 6

Narcotic reversal

Answer 6

Naloxone (Narcan)

Onset of 1-3 mins (IV), 10-15 (IM)
rebound sedation may occur
May cause withdrawal in patients with chronic narcotic use

Question 7

Benzodiazepines (sedatives)

Answer 7

Most common are;

Midazolam (Versed) -more rapid onset, high cost
Diazepam (valium) -low cost, rapid onset, long half-life (36hrs)
Lorazepam (Ativan) -longer acting, low cost

Lipophilic

Question 8

Diazepam (valium) (benzodiazepine)

Answer 8

Onset: rapid, 2-5 mins
Half-life: 20-120 hours

Intermittent dosing only, no infusion

Question 9

Midazolam (Versed) (Benzodiazepine)

Answer 9

Onset: 2-5 mins
Peak: 5-30 mins (30-120 minute duration)
Fast onset, short duration
May accumulate in renal failure, so generally use avoided if so

Question 10

Lorazipam (Ativan) (benzodiazepine)

Answer 10

Onset: 5-15 mins
Duration: 6-8 hrs
Less lipophilic=slower onset
Shown to be more cost effective and provides greater adequacy of sedation than midazolam (versed)
May be the preferred benzo in patients with renal failure

Question 11

Reversal of benzodiazepines

Answer 11

Flumazenil (romazicon)

May precipitate seizures unresponsive to to benzos

Question 12

Haloperidol (neuroleptic)

Answer 12

Used to treat extreme agitation and delerium (CNS depression)
Has antidopaminergic and anticholinergic effects

Onset: 3-20 mins
Max dose of 200mg
Used to treat ICU delirium

Question 13

Propofol -aka Diprivan (anesthetic)

Answer 13

Onset: 30 seconds
Duration: 3-10 mins
CV and Resp depression (decreases SVR, BP, and HR in initial phase)
Combined with morphine to control ICP
Important to monitor triglycerides

Question 14

Neuromuscular blocking agents (NMBA’s) (paralytics)

Answer 14

Depolarizing
-Mimic acetylcholine, initially results in fasciculations, prolongs depolarization at the NMJ. Causes paralyzation by inhibiting repolarization of the NMJ

Non-depolarizing
-Competitive antagonist to acetylcholine, most common type used. Bind to acetylcholine receptors at the NMJ and inhibit Ach’s action. Blocks transmission of nerve impulses (depolarization) causing paralysis.

Question 15

Succinylcholine (Depolarizing paralytic)

Answer 15

4-6 minute duration of action per single administration
Complete blockade in 30-60 seconds
NO REVERSAL AGENTS, only time

Complications
K+ efflux, increasing serum potassium (may cause arrhythmias, CA)
malignant hyperthermia (hypermetabolic state of skeletal tissue)

Question 16

Cisatracurium (Nimbex) (Non-depolarizing paralytic)

Answer 16

Duration: 40-60 mins
Onset: 2-3 mins
NOT eliminated by liver or kidney, may be best choice for patients with hepatic or renal failure
May be poor choice for patients with unstable ICP

Question 17

Rocuronium (Zemuron) (Non-depolarizing paralytic)

Answer 17

Duration: 30-60 mins
Onset: 1-2 mins

Question 18

Vecuronium (Norcuron) (Non-depolarizing paralytic)

Answer 18

Duration: 60-90 mins
Onset: 2-4 mins
Does not have vagolytic properties of pancuronium
Metabolized to minimally active metabolites
Not best choice for renal/hepatic failure

Question 19

Pancuronium (Pavulon) (Non-depolarizing paralytic)

Answer 19

Duration: Long (120-180 mins)
Onset: 4-6 mins
Used for prolonged paralysis of MV patients in ICU

Side effects; tachycardia, increased CO, elevated MAP, vagolytic effects

Question 20

Vasopressor (Levophed)

Answer 20

Norepinephrine (Levophed)

Catecholamine, strong vasoCONSTRICTOR, also increases both HR and contractility

Used to treat acute hypotension resulting from conditions such as MI, drug reactions, spinal anesthesia, and septicemia

FIRST CHOICE of vasopressor in sepsis

Question 21

Vasopressor (Neo-synephrine)

Answer 21

Phenlyephrine (Neo-Synephrine)

Purely alpha agonist

Induces vasoconstriction in most vascular beds, elevates systolic and diastolic BP.

Does not increase HR or contractility

NOT recommended in septic shock unless Norepi is associated with serious arrhythmias or CO is low and BP is very low, or when other combinations have failed.

Question 22

Vasopressor (Pitressin)

Answer 22

Vasopressin (Pritressin)

- Direct vasoconstriction without chronotropic/inotropic effects
- Second line vasoconstrictor in addition to norepi, to increase BP or reduce the dose of Norepi
- Low dose initially is ineffective in sepsis

Question 23

Inotrope (Inotropin)

Answer 23

Dopamine

Precursor to norepinephrine

Dose between 5-20 produce inotropic and chronotropic effects and increase CO

Renal blood flow improvement secondary to increased CO

Alternative to norepinephrine in sepsis in patients with low risk of tachyarrhythmias

Question 24

Inotrope (Dobutrex)

Answer 24

Dobutamine

Indicated for SHORT-term support in patients with decompensated heart failure due to depressed contractility

Does not stimulate dopamine receptors and it not metabolized to norepinephrine

Effects due to racemic components

Vasoconstrictive and vasodilatory effects

Question 25

Epinephrine

Answer 25

Potent beta-1 adrenergic receptor activity
Moderate beta-2 and alpha-1 activity
Increases blood pressure by increasing cardiac index and peripheral vascular tone

Often used in septic shock second to norepi

Side effects include arrhythmias and increased splanchnic circulation

Question 26

Drugs that induce metHB

Answer 26

Dapsone (antibacterial) and topical agents (benzocaine, lidocaine) most commonly the cause

Nitric oxide (pulmonary vasodilator)
Nitroprusside (vasodilator/antihypertensive)
Treatment usually methylene blue

Question 27

Diuretics

Answer 27

P otassium-sparing (collecting duct) (spironolactone-ALDACTONE)
L oop (Ascending loop) (furosemide-LASIX)
O smotic (descending loop) (mannitol-ARIDOL)
C arbonic anhydrase inhibitors (proximal tubule) (acetazolamide)
T hiazides (Distal tubule) (hydrochlorothiazide-MICROZIDE)

Question 28

Narcotic Analgesics

Answer 28

• Used to treat moderate to severe pain
• bind to opioid receptors in brain and SC
• most metabolized by liver and excreted in urine
• popular for drug abuse
• can develop a rapid tolerance with painful withdrawal