Exam 3 lecture 7 Flashcards
What are PAD guidelines for analgesia?
provide analgesia and treat reversible physiological causes
- active and preemptive analgesia
- sleep promotion
- mobility
What are PAD guidelines on sedation
Less is more. Light sedation preferred vs deep sedation
sedation strategies that encourage deep sedation may lead to worse outcomes
define the sedation algorithim
protocol based on analgesia-first sedation.
this is because pain is often primary source of agitation
WHat role do benzodiazepines play in PAD guidelines?
Use of midazolam? Lorazepam? Monitoring with lorazepam?
Treating anxiety
patient with seizures
withdrawal
Midazolam- may be used for very rapid sedation. Only for short term use. Becomes less predictable as time progresses.
Lorazepam- prolonged sedation. Gradual onset and long duration. Does not have changes in metabolism and elimination because it is glucuronidated.
We also have to monitor propylene glycol toxicity if we use high doses. We monitor Osmol gap if we are worried about patient receiving high doses.
What is the preferred sedative when rapid awakening is desired? BZDs vs propofol for carduac surgery?
Propofol may be preferred sedative when rapid awakening is desired
Propodol over BZDs for cardiac surgery.
What is the drug of choice in a patient with delirium and agitation?
Dexmed
What drug is associated with less delirium and decreased duration of mechanical ventilation
Dexmed
How should we stop the sedation drugs?
There is a risk for withdrawal-> Dose should be tapered gradually. ESPECIALLY with patients at risk for seizures.
WHat tools to use to assess patients for delirium regularly? DO we prophylax pharmacologcally for delirium
CAM ICU
ICDSC
We do not use pharmacologic measures for prevention
propofol is frequently used in neurosurgical patients because
It has a short duration which helps facilitate neurological checks and Decreases ICP
Which sedative may have analgesic sparing effects
Dexmed (allows reduced dose of analgesic)
why would we not use BZDs in patients on mechanical ventilation that are in ICU. Compare lorazepam and midazolam
BZDs associated with delirium
lorazepam takes a while to work, doe not get past BBB quickly and has intermediate half life
Midazolam is more titrateable than lorazepam. quicker onset and offset. Goes through BBB quickly. DOes cause delirium too.
If a patient needs sedation for a longer period of time (more than 48 hrs), we do not use BZDs.
when would we pick propofol over dexmed?
propofol helps with ICU and is titrateable.
Dexmed is also titrateable, but does not give us the depth of sedation we may need in really sick patients.
If a patient is not responding well to propofol and is still agitated, what drug do we use
optimize patient on opioid to attack source of agitation (pain)
What are some risk factors for stress ulcers
-anticoag/ antiplatelety/ NSAIDs/ antithrombotic drugs
- intubation (mechanical ventilation)
shock
-coagulopathy
-chronic liver failure
Can we use EN as SUP alone?
No, it does offer protective effects, however, it should not be used alone.
When can we dx SUP
When risk factors are gone
Do we have to check PTT for prophylactic dose of UFH?
no
What do we monitor on prophylactic dose of UFH
CBC for s/s of bleeding and thrombocytopenia
What is the biggest side effect we look at with dex med?
hypotension
What do we use for septic shock
Norepinephrine infusion is drug of choice
Hydrocortisone for refractory septic shock
Dobutamine (it is an ionotrope), not 1st choice
vasopressin (as adjunct)
Dopamine is also an option but is not common at all
what is succinylcholine used for
RSI (for intubation)
not used if patient is already mechanicLly ventilated
should sedation come first or analgesia with opioid?
Sedation should be done after analgesic.
What is a BIS monitor used for?
Used to assess EEG (computerized) used when RASS or SAS can not be used for patient to assess sedation on neuromuscular blocker
is train of four an efficacy endpoint or toxicity end point
Toxicity end point that stops us from giving too much sedative.
What drug should we monitor QT for
Haloperidol
Do we have to monitor aPTT on Enoxaparin (prophylactic)? What do we monitor
No aPTT
monitor CBC
calories of propofol we take into consideration
1.1 kcal/ml
what drug affects triglycerides
Propofol (monitor)
What drug affects Osmol gap?
lorazepam
What drugs do we use train-of-four on?
neuromuscular blocker
define FAST HUGS BID
F- feeding/fluids
A- Analgesia
S- Sedation
T- Thromboprophylaxis
H-HOB elevation
U- Ulcer (stress ulcer) Prophylaxis
G- Glycemic control
S- Spontaneous awakening trial
B- bowel regimen
I- Indwelling catheters
D- De-escalation of antibiotics and delirium assessment
target for glycemic control
140-180
When do we start insulin in ICU ppts
> 180
consequences of high BG
Slow wound healing
What is the role of PPI for stress related mucosal disease prophylaxis? Adverse effect?
PPI are effective and provide adequate acid suppression, however, it is unclear whether they are associated with an increase in incidence of pneumonia.
can we use enteral PPI
Yes sometimes
