Exam 1 - Pain, Agitation, Delirium, Immobility, & Sedation Flashcards
List general analgesia treatments in ICU?
boluses or infusion of opioids, breakthrough PRN opioids
List general sedation treatments in ICU?
propofol, dexmedetomidine, ketamine, PRN boluses of BZDRAs
What is the goal CPOT? Goal BPS?
less than 2; less than 5
Explain the onset, duration, and pearls for morphine?
5-10 min, 3-6 hrs, active metabolite accumulates in renal impairment and can cause histamine release (hypotension, bronchospasm, urticaria)
Explain the onset, duration, and pearls for fentanyl?
seconds, 1-2 hrs, hepatic metabolism and CYP3A4 interactions and tachyphylaxis
Explain the onset, duration, and pearls for hydromorphone?
5 minutes, 2-4 hrs, good for renal impairment and fentanyl tolerance and minimal histamine release, available as PCA
What is the recommendation for hyperalgesia?
switch opioid
List additional options for analgesia in ICU?
acetaminophen, NSAIDs, methadone, gabapentin, ketamine, PCAs
What is the goal RASS score for sedation?
0 to -2
What is the MOA of propofol?
stimulates GABA and inhibits NMDA receptors
What are the AEs of propofol?
respiratory depression, hypotension, bradycardia, hypertriglyceridemia, propofol related infusion syndrome (PRIS)
List the clinical pearls for propofol? (2)
lipid emulsion can provide 1.1 kcal/mL, avoid in egg/sulfite/soybean allergy
What conditions is propofol a first-line agent in? (2)
severe alcohol withdrawal, status epilepticus
What is the MOA of dexmedetomidine?
alpha-2 adrenergic agonist
What are the AEs of dexmedetomidine? (2)
bradycardia, hypotension
List the clinical pearls for dexmedetomidine? (2)
NO RESPIRATORY DEPRESSION, does not work well for deep sedation, risk of withdrawal
Explain the onset, duration, and pearls for midazolam?
2-5 min, 1-2 hrs, lipophilic and active metabolites accumulate in renal impairment
Explain the onset, duration, and pearls for lorazepam?
5-20 min, 2-6 hrs, can cause propylene glycol acidosis (via additive) and renal/hepatic failure
Explain the onset, duration, and pearls for diazepam?
5-10 min, 44-100 hrs, active metabolites but can taper quickly
List the drawbacks to BZDRAs? (3)
increase risk of delirium, time on ventilator, and length of ICU stay
What conditions are BZDRAs a first-line agent in? (3)
status epilepticus, severe alcohol withdrawal, severe ARDS
What is the MOA of ketamine?
NMDA antagonist, mu and kappa agonist, muscarinic acetylcholine receptor antagonist, catecholamine reuptake inibitor
What dose of ketamine provides pain relief?
0.15-0.5 mg/kg/hr
What dose of ketamine provides anesthesia relief?
0.5-2 mg/kg/hr
What dose of ketamine provides status epilepticus relief?
> 2 mg/kg/hr
What are the AEs of ketamine?
hypertension, tachycardia, oral secretions, emergence reaction (hyperactivity (especially in schizo/elderly), can be pretreated with BZDRA or propofol)
List the delirium sequelae?
increased mortality, cognitive impairment, functional decline, health system costs, prolonged mechanical ventilation, length of stay
List modifiable risk factors for delirium? (2)
BZDRA use, blood transfusions
List non-modifiable risk factors for delirium?
age, dementia Hx, prior coma, pre-ICU emergency surgery/trauma, high APACHE score
What are screening tools for delirium?
confusion assessment method ICU (CAM-ICU), intensive care delirium screening checklist (ICDSC)
List treatments for delirium in ICU?
opioids, dexmedetomidine, melatonin receptor agonists, antipsychotics (quetiapine/haloperidol/olanzapine)
What is the recommendation for immobility and sleep?
non-pharm options
List indications for a neuromuscular blockade?
facilitate mechanical ventilation, minimize oxygen consumption (ARDS), conditions with increased muscle activity (tetanus, neuroleptic malignant syndrome), increased intracranial/abdominal pressures, surgical procedures, rapid sequence intubation
List the drawbacks to NMBs?
no analgesic or sedative properties, increase risk of DVT and skin breakdown, corneal abrasion, critical illness polyneuropathy
What is the goal for twitching in NMB monitoring?
2 twitches (80-90%) blockage
Explain the onset, duration, and elimination pathway for cisatracurium?
2-5 min, 30-90 min, Hoffman elimination
Explain the onset, duration, and elimination pathway for rocuronium?
1-2 min, 30-60 min, biliary and renal
Explain the onset, duration, and elimination pathway for vecuronium?
3-5 min, 45-60 min, biliary and renal
Explain the onset, duration, and elimination pathway for succinlycholine?
30-60 s, 5-10 min, plasma pseudo-cholinesterase
What conditions should succinylcholine NOT be used in?
malignant hyperthermia, hyperkalemia
