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Therapy 3 > ICU Pain/sedation > Flashcards

ICU Pain/sedation Flashcards

1
Q

Which is preferred, scheduled/continuous dosing of analgesia or PRN dosing of analgesia?

A

Scheduled/Continuous

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2
Q

Daily awakenings allow

A

Decreased length of stay and ventilation use

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3
Q

Which requires lower and more frequent dosing, IM or IV?

A

IV

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4
Q

When an IV opioid is required, use…

A

Fentanyl, hydroporphone, or morphine

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5
Q

When you need rapid onset of analgesia, use…

A

Fentanyl 10-200 mcg/hr

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6
Q

For patients who are hemodynamically unstable or have renal dysfunction, use…

A

Fentanyl or hydromorphone (low dose, half of normal dose)

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7
Q

When looking for intermittent therapy of analgesia, use…

A

Morphine 1 - 10 mg/hr or hydromorphone

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8
Q

What day limit should be placed on ketorolac and why?

A

Limit to max of 5 days with close monitoring. Can cause renal insufficiency or GI bleed).

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9
Q

Neuropathic pain should be treated with…

A

Gabapentin and carbamazepine in patients with sufficient GI absorption and motility
(Only comes in oral form!)

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10
Q

Ketorolac dosing in patients under 65…

Toxicities?…

A

IM or IV: 30 mg every 6 hours
Max 120 mg/day
Toxicity: serious GI bleeding, ulceration, perforation in elderly.

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11
Q

What drug is used to treat respiratory depression (OD)? Dose?

A

Naloxone 0.4 - 2.0 mg Q2minutes
IV, IM, IN, SC
Up to a total of 10 mg
IV route preferred

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12
Q

Need rapid onset, short duration

A

Use fentanyl

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13
Q

Need a longer duration of pain treatment…

A

Morphine or hydromorphone

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14
Q

Morphine side effects

A

Hypotension
Flushing
Bronchospasms
Constipation

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15
Q

Fentanyl side effects

A

Constipation

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16
Q

Hydromorphone side effects

A

Hypotension - not as bad as morphine
Flushing - not as bad as morphine
Constipation

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17
Q

Analgesics prolonged in renal failure…

A

Morphine

Hydromorphone

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18
Q

Analgesics prolonged in hepatic failure…

A

Morphine
Fentanyl
Hydromorphone

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19
Q

Equivalent hydromorphone:morphine doses

A

1.5:10 mg

20
Q

Active metabolite effects for morphine…

A

Sedation in renal dysfunction

21
Q

Meperidine and codeine active metabolite effects…

A

Meperidine: neuroexcitation
Codeine: analgesia, sedation

22
Q

Pain scales uses…

A

NRS
CPOT
VAS

23
Q

Sedation scores used…

A

RASS

24
Q

Delirium assessment…

A

CAM-ICU

25
Q

Neuromuscular Blockade Assessment…

A

TOF (train of four)

26
Q

What class of drugs is the most commonly used sedative?

A

Benzodiazepines

27
Q

What are benzo’s MOA? Their effects?

A

They potentiate the GABA receptor which causes mediated inhibition of the CNS

Cause anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects

No analgesic effects

28
Q

Of the three benzo’s discussed, which ones are prolonged in renal failure?

A

Diazepam: no renal effects
Lorazepam: yes and no (prolonged use causes risk of propylene glycol toxicity)
Midazolam: yes

All are prolonged in hepatic failure

29
Q

Diazepam adverse effects…

A

Hypotension

Thrombophlebitis

30
Q

Lorazepam adverse effects…

A

Thrombophlebitis - maybe
Hyperosmolality
Precipitation - maybe

31
Q

Midazolam adverse effects…

A

Midazolam has much less SE’s but is prolonged in renal and hepatic failure

32
Q

Midazolam dose and distribution…

A

Can be given as bolus or infusion at 5 - 10 mg/hr to a max of 20 mg/hr

Decrease or increase per RASS score by 1 mg/hr until desired score is achieved

Widely distributed in fat tissue (wearing off consideration in overweight or obese)

33
Q

Lorazepam dose and considerations…

A

May be given as bolus or infusion at 2-5 mg/hr to a max of 10 mg/hr

Decrease or increase by 1 mg/hr until desired RASS score is achieved.

Propylene glycol carrier leads to hyperosmolity with increased gap metabolic acidosis.

Caution in renal dysfunction.

34
Q

What is the “work horse” sedative agent?

A

Propofol

35
Q

Solubility of Propofol…

A

Highly lipid soluble

  • rapidly crosses the BBB
  • distributes to the peripheral tissues
  • short off-set but can be prolonged in larger patients.
36
Q

Propofol dosing and considerations…

A

Rapid onset and short duration
Starting dose is 5 mcg/kg/min, titration by 5 mcg/kg/mg every 5 minutes for desired effect. Max 80 mcg/kg/min

Monitor BP and TG (consider lipid content in TPNs)

Requires dedicated IV line (milky substance) and frequent tubing changes to decrease infections. GREEN URINE!!

37
Q

Dexmedetomidine dosing and considerations…

A

Loading dose of 1 mcg/kg over 10 minutes (this is not recommended anymore!)

Maintenance dose of 0.2-0.7 mcg/kg/hr

Max dose of 1.4 mcg/kg/hour (going over increases SE but not sedation)

38
Q

Dexmedetomidine length of use…

A

Approved for short-term sedation (under 24 hours)

But has been proven to be effective up to 28 days

You CAN use this in the mechanically ventilated patients and those who aren’t.

No respiratory depression! (Unlike benzo’s)

39
Q

Dexmedetomidine side effects…

A

Hypotension
Bradycardia
Hypertension (increase serum)

40
Q

What agent is preferred for rapid awakenings (neuro checks)?

A

Propofol

41
Q

What sedative is recommended for short-term use?

A

Midazolam

42
Q

What agent(s) to use for rapid sedation of acutely agitated patients?

A

Midazolam or diazepam

43
Q

What sedative to use for intermittent IV admin or continuous infusion?

A

Lorazepam

44
Q

Which sedatives are believed to lead to less ICU hospital days?

A

Non-benzodiazepines

45
Q

Benefits of daily sedation interruptions…

A

1) decreased ICU resources
2) increases likelihood of successful planned extinction
3) reduced complications of the critically ill (bacteremia, GI bleed, VAE, VTE)
4) less sedative, opioid, and Propofol use
5) decreased PTSD

Therapy 3 (12 decks)

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