ICU Delirium/NMB Flashcards
What is the gold standard of treatment for delirium?
Non-pharmacological
- early mobilization of ICU patients (walking them around.
- currently there are no recommendations for pharmacological agents to treat delirium.
What is the most common pharmacological treatment of delirium?
Haloperidol, but there is limited data for its use.
Haloperidol Adverse Effects…
QT interval prolongation
Lowered seizure threshold
EPS (tardive dyskinesia)
Haloperidol dosing and considerations…
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
Alternative delirium treatment options other than Haldol…
Second-generation antipsychotics
- olanzapine
- risperidone
- quetiapine
But all are oral forms, can be a problem if mechanically ventilated.
Dose and considerations of Olanzapine…
2.5-5 mg PO/NG/IM daily
Has less QT side effects
Risperidone dose and considerations…
2-10 mg PO daily
Quetiapine dose and considerations…
75-750 mg PO daily
Has sedation and delirium effects
Top four indications for NMB therapy…
1) facilitate mechanical ventilation
2) ARDS
3) manage increased ICP
4) stop shivering in therapeutic hypothermia
MOA of NMB agents…
Blocks normal neuromuscular transmission resulting in paralysis
ALL NMBs lack sedative, amnestic, and analgesic properties
Depolarizing NMB agents MOA…
Mimics ACh and causes sustained depolarization with blockade of neurotransmission
(Goes through one more action potential)
Non-Depolarizing NMB agents MOA…
Bind to ACh receptor and block transmission
Does not go through one more action potential
What is the only Depolarizing NMB agents available?
Succinylcholine (Anectine)
Succinylcholine uses…
to facilitate intubation (not to be kept on)
Ultra-short acting agent
Succinylcholine considerations and adverse effects…
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
Most commonly used NON-Depolarizing NMB agents…
Atracurium
Cisatracurium
What are the two agents used for NMB that ARE NOT prolonged in renal and hepatic failure?
Atracurium and Cisatracurium
What non-Depolarizing NMBs have the most adverse effects?
Pancuronium and Vecuronium
Both are prolonged in renal and hepatic failure.
Pancuronium causes tachycardia
What is the NMB of choice and what are some considerations?
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.
Most important clinical considerations in NMB therapy…
1) first, optimize sedation and analgesia
2) consider renal and haptic function
3) method of administration
- ARDS and mechanical ventilation = infusion
Duration of Action of nondepolarizing NMBs…
Atracurium: 0.25-0.5 hour
Cisatracurium: 0.5-1 hour
What are the two subtypes of delirium?
1) hyperactive: agitated, hallucinations, delusions
2) hypoactive: calm, lethargic, confusion, sedation
What tool is used to assess neuromuscular blockage
Peripheral nerve stimulator
SCCM guidelines for NMB monitoring
Assess NM blockade clinically and by the train of four
Before initiating NMBA, must sedate and put on analgesia
