Exam 1 - Pain, Agitation, Delirium, Immobility, & Sedation Flashcards

1
Q

List general analgesia treatments in ICU?

A

boluses or infusion of opioids, breakthrough PRN opioids

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2
Q

List general sedation treatments in ICU?

A

propofol, dexmedetomidine, ketamine, PRN boluses of BZDRAs

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3
Q

What is the goal CPOT? Goal BPS?

A

less than 2; less than 5

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4
Q

Explain the onset, duration, and pearls for morphine?

A

5-10 min, 3-6 hrs, active metabolite accumulates in renal impairment and can cause histamine release (hypotension, bronchospasm, urticaria)

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5
Q

Explain the onset, duration, and pearls for fentanyl?

A

seconds, 1-2 hrs, hepatic metabolism and CYP3A4 interactions and tachyphylaxis

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6
Q

Explain the onset, duration, and pearls for hydromorphone?

A

5 minutes, 2-4 hrs, good for renal impairment and fentanyl tolerance and minimal histamine release, available as PCA

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7
Q

What is the recommendation for hyperalgesia?

A

switch opioid

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8
Q

List additional options for analgesia in ICU?

A

acetaminophen, NSAIDs, methadone, gabapentin, ketamine, PCAs

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9
Q

What is the goal RASS score for sedation?

A

0 to -2

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10
Q

What is the MOA of propofol?

A

stimulates GABA and inhibits NMDA receptors

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11
Q

What are the AEs of propofol?

A

respiratory depression, hypotension, bradycardia, hypertriglyceridemia, propofol related infusion syndrome (PRIS)

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12
Q

List the clinical pearls for propofol? (2)

A

lipid emulsion can provide 1.1 kcal/mL, avoid in egg/sulfite/soybean allergy

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13
Q

What conditions is propofol a first-line agent in? (2)

A

severe alcohol withdrawal, status epilepticus

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14
Q

What is the MOA of dexmedetomidine?

A

alpha-2 adrenergic agonist

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15
Q

What are the AEs of dexmedetomidine? (2)

A

bradycardia, hypotension

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16
Q

List the clinical pearls for dexmedetomidine? (2)

A

NO RESPIRATORY DEPRESSION, does not work well for deep sedation, risk of withdrawal

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17
Q

Explain the onset, duration, and pearls for midazolam?

A

2-5 min, 1-2 hrs, lipophilic and active metabolites accumulate in renal impairment

18
Q

Explain the onset, duration, and pearls for lorazepam?

A

5-20 min, 2-6 hrs, can cause propylene glycol acidosis (via additive) and renal/hepatic failure

19
Q

Explain the onset, duration, and pearls for diazepam?

A

5-10 min, 44-100 hrs, active metabolites but can taper quickly

20
Q

List the drawbacks to BZDRAs? (3)

A

increase risk of delirium, time on ventilator, and length of ICU stay

21
Q

What conditions are BZDRAs a first-line agent in? (3)

A

status epilepticus, severe alcohol withdrawal, severe ARDS

22
Q

What is the MOA of ketamine?

A

NMDA antagonist, mu and kappa agonist, muscarinic acetylcholine receptor antagonist, catecholamine reuptake inibitor

23
Q

What dose of ketamine provides pain relief?

A

0.15-0.5 mg/kg/hr

24
Q

What dose of ketamine provides anesthesia relief?

A

0.5-2 mg/kg/hr

25
Q

What dose of ketamine provides status epilepticus relief?

A

> 2 mg/kg/hr

26
Q

What are the AEs of ketamine?

A

hypertension, tachycardia, oral secretions, emergence reaction (hyperactivity (especially in schizo/elderly), can be pretreated with BZDRA or propofol)

27
Q

List the delirium sequelae?

A

increased mortality, cognitive impairment, functional decline, health system costs, prolonged mechanical ventilation, length of stay

28
Q

List modifiable risk factors for delirium? (2)

A

BZDRA use, blood transfusions

29
Q

List non-modifiable risk factors for delirium?

A

age, dementia Hx, prior coma, pre-ICU emergency surgery/trauma, high APACHE score

30
Q

What are screening tools for delirium?

A

confusion assessment method ICU (CAM-ICU), intensive care delirium screening checklist (ICDSC)

31
Q

List treatments for delirium in ICU?

A

opioids, dexmedetomidine, melatonin receptor agonists, antipsychotics (quetiapine/haloperidol/olanzapine)

32
Q

What is the recommendation for immobility and sleep?

A

non-pharm options

33
Q

List indications for a neuromuscular blockade?

A

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

34
Q

List the drawbacks to NMBs?

A

no analgesic or sedative properties, increase risk of DVT and skin breakdown, corneal abrasion, critical illness polyneuropathy

35
Q

What is the goal for twitching in NMB monitoring?

A

2 twitches (80-90%) blockage

36
Q

Explain the onset, duration, and elimination pathway for cisatracurium?

A

2-5 min, 30-90 min, Hoffman elimination

37
Q

Explain the onset, duration, and elimination pathway for rocuronium?

A

1-2 min, 30-60 min, biliary and renal

38
Q

Explain the onset, duration, and elimination pathway for vecuronium?

A

3-5 min, 45-60 min, biliary and renal

39
Q

Explain the onset, duration, and elimination pathway for succinlycholine?

A

30-60 s, 5-10 min, plasma pseudo-cholinesterase

40
Q

What conditions should succinylcholine NOT be used in?

A

malignant hyperthermia, hyperkalemia