Day 3- RSI, Mechanical Ventailation, Pain, Sedation, Delirium Flashcards
Who needs to be intubated?
What are the 7 P’s of intubation?
What is the most inhibitory and excitatory neurotransmitter?
ABCDEF, Airway, Breathing, Circulation, Disability, Exposure, Friendly.
Prepare, Pre-oxygenate, Pretreat, Paralysis with induction, Protect and position, Placement, Post intubation care.
GABA, Glutamate.
What is your depolarizing NMBA vs non depolarizing?
What are your pretreatment options(LOAD)?
When do you use Lidocaine and when do you not?
Succinylcholine is depolarizing. Non are all the curonium’s.
Lidocaine, Opioids(fentanyl), Atropine, De-fasciculation.
Used for cough suppression. Don’t use in Bradycardia, Heartblock without pacemaker, hypotension, allergy to amide. Use in population with head trauma and asthmatic.
What are pros and cons of lidocaine?
When do you use Fentanyl and when do you not?
What are pros and cons of Fentanyl?
Pro- Bronchodilation(asthma), decrease ICP. Cons- Cardiac Dosing.
Blunt catecholamine reflex to limit post-intubation hypertension. Use in elevated ICP, Cardiac Ischemia, Aneursym, Aortic Dissection. Don’t use in hypotension(especially shock).
Reduce post-intubation HR and BP elevations. Risk is respiratory depression and chest wall rigidity.
When and when do you not use Atropine?
Is de-fasciculation often used?
What is Etomidate’s MOA, time, and populations you can or can’t use them in?
Atropine attenuates bradycardia induced by muscarinic stimulation from succinylcholine. Risk is it’s an anticholinergic, use caution in heart block, ONLY used in Pediatrics.
No, it reduces side effects of succinylcholine(small dose NMBA to reduce muscle fasciculations). Takes a lot more time, pharyngeal muscle weakness while patient alert, pulmonary aspiration.
MOA is Non barb anesthetic, enhance effects of GABA and blunt excitation, Fast, Elevated ICP, IOP, hypotensive. Very few reasons not to use it. Does not have analgesic properties(adrenal suppression), septic or seizing be careful.
What is Propofol’s MOA, time, and populations you can or can’t use them in?
What is Ketamine’s MOA, time, and populations to use or not use?
What is Midazolam’s MOA, time, and populations to use or not use?
Global CNS depression, Agonism of GABA, not related to barbs. Fast onset with moderate duration. Can use in Seizing patients, elevated ICP, antiemetic and anticonvulsant. Avoid in hypotensive and hypovalemic., No analgesic or amnesia properties, PRISS, negative inotrope.
NMDA antagonist, phencyclidine derivative. Quick onset and moderate duration. Use in hypotensive patients due to hypertension. Can increase ICP.
Benzo, GABA A subunit, Can use in no IV acess, avoid in hypotensive patients. Not used often. Long duration of action.
What is succinylcholine pros and cons?
What is rocuronium’s pros and cons?
Which NMDA is a powder?
Depolarizing NMBA, Short acting. Causes Fasciculations, increased K(0.5 mEq/L), Malignant hyperthermia. Avoid in HyperK(renal, crush, burn) patients and muscular idsorders liek denervation.
Non-depolarizing NMBA. Long duration of action. No concern for K, and much less fasciulation. Don’t use in seizing.
Vecuronium.
What is the big drug interactions to know with RSI?
What is the train of four and do you ever paralyze anaphylactic patients?
What are special things to know about RSI populations?
Quinidine increases.
Four shocks, 1-2 twitches if properly paralyzed. No!
Myasthenis Gravis(needs more succinylcholine and 75% less of the other). Watch for malignant hyperthermia in succinylcholine and reverse with Dantrolene. Reversal using sugammadex.
What happens in PRIS?
What patients tank normally?
What are your indications for mechanical ventilation?
High mortality, high doses for extended periods of time with propofol.
HOP kills. Hemodynamically unstable, oxygenating isn’t going well, acidic.
Hypercapnic respiratory failure, Hypoxic respiratory failure, Airway protection.
What are the two types of mechanical ventilation?
What is FiO2?
What is PEEP?
Non invasive and invasive.
Percentage of oxygen delivered to a patient during breath. Normal room is 21%. Don’t use for a long time at high due to fibrosis of lung .
Positive pressure maintained in lungs following exhalation. Primary purpose is to increase surface area of alveoli. Starting value is 5 cm. By utilizing PEEP you can decrease FiO2. Risk of pneumothorax and hemodynamic instability.
What is PaO2?
What are your goals of mechanical ventilation?
What are some complications of MV you worry about?
Level of oxygen in arterial blood. <300 is ARDS for PaO2/FiO2(ability to oxygenate blood). May require prone positioning or neuromuscular blockade.
Discontinuation of mechanical ventilation, Maintain patient comfort, Prevent complications.
Pneumothorax or other baro trauma. Stress related gastic ulcer(PPI or H2 for >48 hours). VTE(consider Enoxaparin, Heparin, Fondaparinux). VAP(Assess readiness to come off tube, raise bed 30-45 degrees, facilitate early mobility, change ventilator circuit if soiled, etc.)
Where can you find critical care guidelines?
How do you monitor pain in critical care patients?
What is first line pharmacologic treatment for critical care pain patients?
Society of Critical care medicine, Eastern association for the surgery of trauma, AHA/ASA, Surviving sepsis guidelines.
0-10 face scale. CPOT uncontrolled pain is more than or equal to 3. BPS range is 3-12 uncontrolled pain is more than or equal to 6.
Opioids. Typically given bolus and then drip. They all work fast but hydromorphone is slower. Fentanyl has shorter duration.
What do we give to treat opioid constipation?
What is the preferred opioid and most commonly used?
What are your non opioid analgesics to use?
Senna S.
Fentanyl–> has no renal accumulation. Watch for histamine release with morphine and rigidity with fentanyl.
Acetaminophen(use in adjunct with opioids), Ketamine, NSAIDS(Inflammation, rheumatoid arthritis. Watch for kidneys and bleeding).
What do you give for neuropathic pain?
What treats agitation?
What are your 2 agitation scales and what are their range goals?
Gabapentin(most common), Carbamazepine, TCA’s and Duloxetine all in addition to opioids. Look for diabetes, shingles, fibromyalgia.
1st line is Analgesia, Reorientation, and maintain normal sleep pattern. 2nd line is light sedation with continuous infusion and awakening to check them is gold standard, 3rd line is heavy sedation with continuous infusion.
RASS and SAS. Anything positive in RASS and SAS is agitated and negative is sedated. RASS is 0,-1,-2 goals. If they are -4,-5 they are too sedated. SAS is 3,4 goal and 1,2 is too sedated. Check 4 times per shift.
What are your sedation agents and what property does propofol not have?
What properties does Dexmedetomidine do?
What properties does benzo’s have?
Propofol, Dexmedetomidine, Benzodiazepines. Does NOT have analgesic.
Anxiolytic, Analgesia, CV. Some resp depression. Can ONLY achieve light sedation.
No analgesia. Associated with highest risk of delirium, can cause build up of propylene glycol and so can get aniongap meteabolic acidosis. Use with alcohol withdrawal, active seizures, hemodynamic intolerances.
What is ICU delirium?
What are your risk factors for ICU delirium and why is it important?
How do patients present in Hyper vs hypoactive delirium?
Hallucinations or delusions are not required, being confused basically.
Associated with bad stuff(longer hospitilization, morality, time on vent, long term cognitive badness). Alcoholism, cognitive impairment, hypertension, dementia, sepsis, shock, mechanical ventilation, parenteral sedatives and opioids, benzodiazepines, coma.
Hyper is Delusions, Hallucinations, Agitation, Anger. Hypo is lethargy, sedation, apathy. Rest are a mix(fear, depression, confusion, abnormal psychomotor, euphoria, etc. Monitor every 6-8 hours.
