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Therapy 3 > ICU Delirium/NMB > Flashcards

ICU Delirium/NMB Flashcards

1
Q

What is the gold standard of treatment for delirium?

A

Non-pharmacological

  • early mobilization of ICU patients (walking them around.
  • currently there are no recommendations for pharmacological agents to treat delirium.
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2
Q

What is the most common pharmacological treatment of delirium?

A

Haloperidol, but there is limited data for its use.

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3
Q

Haloperidol Adverse Effects…

A

QT interval prolongation
Lowered seizure threshold
EPS (tardive dyskinesia)

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4
Q

Haloperidol dosing and considerations…

A

2-5 mg IV every 4-6 hours for poorly controlled patients (non-pharm isn’t working)

Max dose of 20 mg every 4 hours

Can be given scheduled or PRN

Taper over 5-7 days

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5
Q

Alternative delirium treatment options other than Haldol…

A

Second-generation antipsychotics

  • olanzapine
  • risperidone
  • quetiapine

But all are oral forms, can be a problem if mechanically ventilated.

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6
Q

Dose and considerations of Olanzapine…

A

2.5-5 mg PO/NG/IM daily

Has less QT side effects

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7
Q

Risperidone dose and considerations…

A

2-10 mg PO daily

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8
Q

Quetiapine dose and considerations…

A

75-750 mg PO daily

Has sedation and delirium effects

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9
Q

Top four indications for NMB therapy…

A

1) facilitate mechanical ventilation
2) ARDS
3) manage increased ICP
4) stop shivering in therapeutic hypothermia

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10
Q

MOA of NMB agents…

A

Blocks normal neuromuscular transmission resulting in paralysis

ALL NMBs lack sedative, amnestic, and analgesic properties

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11
Q

Depolarizing NMB agents MOA…

A

Mimics ACh and causes sustained depolarization with blockade of neurotransmission
(Goes through one more action potential)

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12
Q

Non-Depolarizing NMB agents MOA…

A

Bind to ACh receptor and block transmission

Does not go through one more action potential

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13
Q

What is the only Depolarizing NMB agents available?

A

Succinylcholine (Anectine)

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14
Q

Succinylcholine uses…

A

to facilitate intubation (not to be kept on)

Ultra-short acting agent

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15
Q

Succinylcholine considerations and adverse effects…

A

Caution in disease states that predispose patients to hyperkalemia (potassium)

May increase serum potassium by 0.5 to 1.0 mEq/L due to effluent of potassium from muscle cells

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16
Q

Most commonly used NON-Depolarizing NMB agents…

A

Atracurium

Cisatracurium

17
Q

What are the two agents used for NMB that ARE NOT prolonged in renal and hepatic failure?

A

Atracurium and Cisatracurium

18
Q

What non-Depolarizing NMBs have the most adverse effects?

A

Pancuronium and Vecuronium

Both are prolonged in renal and hepatic failure.

Pancuronium causes tachycardia

19
Q

What is the NMB of choice and what are some considerations?

A

Cisatracurium is three times as potent as Atracurium.

Degraded by pH and temp-dependent Hoffman elimination (not renal or hepatic!)

Relatively slow onset of action so DO NOT use in those who need intubation right away.

20
Q

Most important clinical considerations in NMB therapy…

A

1) first, optimize sedation and analgesia
2) consider renal and haptic function
3) method of administration
- ARDS and mechanical ventilation = infusion

21
Q

Duration of Action of nondepolarizing NMBs…

A

Atracurium: 0.25-0.5 hour
Cisatracurium: 0.5-1 hour

22
Q

What are the two subtypes of delirium?

A

1) hyperactive: agitated, hallucinations, delusions

2) hypoactive: calm, lethargic, confusion, sedation

23
Q

What tool is used to assess neuromuscular blockage

A

Peripheral nerve stimulator

24
Q

SCCM guidelines for NMB monitoring

A

Assess NM blockade clinically and by the train of four

Before initiating NMBA, must sedate and put on analgesia

25
Q

Complications from NMB use…

A
  • prolonged recovery and deconditioning (atrophy)
  • AQMS post paralytic paralysis (indiscriminate NMB use)
  • keratitis and corneal abrasion (or can’t blink! Give a lubricant!)
  • tachyphylaxis
  • DVT/PEs
  • ulcers
  • lung buildup
26
Q

Drugs that potentiate NMBs (won’t have to give as much NMBA)…

A

Antibiotics (AG’s, vanco)
Diuretics
Magnesium
Steroids

27
Q

Drugs that antagonize NMBA’s (need higher doses)…

A
  • phenytoin
  • carbamazepine
  • theophylline
  • chronic exposure to NMBs (tachyphylaxis)
28
Q

Conditions that potentiate NMBAs (need lower doses)…

A
  • Liver and renal failure
  • myasthenia gravis
  • hypothermia
  • MS
29
Q

Conditions that antagonize NMBAs (need higher doses)…

A 
Major burns and trauma
Hepatic failure with ascites
Diabetes
Hypercalcemia
Endotoxemia and sepsis

Patients are usually in a HYPERCATABOLIC state

30
Q

NMB: renal or insufficiency? Use…

A

Cisatracurium or Atracurium

31
Q

NMB: tachycardia or hypertension NOT acceptable?…

A

Vecuronium
Cisatracurium
Atracurium

32
Q

NMB: tachycardia or HTN acceptable with intermittent dosing?

A

Pancuronium

Therapy 3 (12 decks)

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