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CCN > PADIS > Flashcards

PADIS Flashcards

1
Q

How does the peripheral pathophys of pain work? What are the 2 peipheral fibres?

A
  • Painful stimulus causes cell damage
  • Damage received by nociceptors, turning noxious stimuli into impulses and transmit along peripheral nerve fibres (A delta fibers or C fibres)
  • A DELTA –> Thermal or mechanical cellular changes transmit pain quickly through densely myelinated fibres. Result in “prickling” or “sharp” pain
  • C FIBRES –> Less myelinated, transmit chemical changes in cellular environment. Associated with “dull”, “aching”, or “diffuse” pain
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2
Q

How does central pathophys of pain work?

A

Neurotransmitters (Substance P) carry impulses across synapse from PNS to the central nervous system.

  • Impulse enters dorsal horn of spinal cord and travels along spinothalamic tract
  • Pain interpreted at the CEREBRAL CORTEX
  • Body produces endorphins to reduce the pain, produced in the brainstem and travel down the spinal cord and block the transmission of pain
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3
Q

What do synthetic opioid analgesics mimic?

A

Mimic action of natural endorphins produced at the brainstem and travel down the spinal cord binding to nerve receptor sits to block pain transmission

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4
Q

What is the pain assessment hierarchy?

A

1) Self report (NRS, non-verbal communications)
2) Behavioural pain assessment tool
3) Minimize emphasis of physiological indicators of pain

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5
Q

What are valid physiological indicators of pain?

A

NO VALID PHYSIOLOGIC INDICATORS.

Changes may arise from multiple causes associated with catecholamine release, difficult to isolate to pain. They can be used as a CUE to begin pain assessment

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6
Q

How is morphine used for pain management?

A

For acute pain, mod-severe

Dose: 2-4mg IVP
Onset: 5 min
Duration: 4-5 hrs

For hemodynamically stable pts, causes histamine release that can cause hypotension (especially with hypovolemia). Can cause resp. depression

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7
Q

How is hydromorphone used for pain management?

A

For acute pain, mod-severe

Dose: 0.2-1mg IVP
Onset: 5 mins
Duration: 3-4 hrs

Less side effects than morphine (pruritus, sedation, N/V), approx 10 times stronger than morphine

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8
Q

How is fentanyl used for pain management?

A

For acute pain, mod-severe

Dose: 25-100mcg IVP (MCG)
Onset: 1-2min
Duration: 30-60 min

For hemodynamically unstable pts, procedural analgesic, renal impairment, no histamine release, more rapid onset than morphine but drug accumulation in liver.

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9
Q

What are 2 routes opiates can be administered in ICU?

A

1) Intravenous
2) Epidural

-Push, continuous infusion, patient controlled analgesic

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10
Q

When is epidural opiate route recommended?

A

For pts with abdominal aortic surgery and traumatic rib fractures

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11
Q

What is sedation?

A

State where pt is calm, relaxed, and relatively pain free. Used in management of anxiety, agitation, and short turn procedural intervention

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12
Q

What is agitation?

A

Excessive, usually non purposeful motor activity associated with muscle tone and catecholamine release

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13
Q

What is anxiety?

A

Prolonged state of apprehension in response to real or perceived fear

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14
Q

How can sedation be assessed?

A

Riker Sedation Agitation Scale (SAS)

EEG or Bispectral Index (BIS) record brain wave activity illustrating sedation

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15
Q

How is midazolam / versed used for sedation?

A

Acute rapid sedation, short term / immediate use

Onset: Short half life, shortest acting benzo
Metabolism: Liver, metabolite causes hypotension

-If used as continuous infusion, short acting benefits are lost and drug accumulates in fatty tissue. Tolerance can develop and risk of delirium

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16
Q

How is propofol used for sedation?

A

Useful for neuro pts requiring waking for assessment, post op, short term, or long term use, management of increased ICP

Onset: Short acting, rapid onset
Metabolism: Liver (rapidly metabolized)

-Does not have analgesic properties, monitor triglyceride levels after 2 days of use, associated with hypotension

17
Q

Why must we balance sedation?

A

Prolonged sedation = delayed weaning

Inadequate sedation = anxiety, agitation

18
Q

How do we avoid over-sedation?

A

1) Daily sedation interruption

2) Light sedation

19
Q

What are symptoms of sedation withdrawal?

A
  • Increased HR, BP, RR
  • Irritability, anxiety, delirium
  • Confusion, short term memory issues
20
Q

How are Alpha 2 agonists used?

A

Can be used as a sedative as they inhibit effects of norepinephrine. Traditionally used as anti-hypertensive but also has sedative and anxiolytic properties.

  • Used to wean off sedatives and opioids, or in withdrawal syndrome
  • Clonidine, dexmedetomidine are examples
21
Q

Why is it important to manage delirium?

A
  • Increased length of ICU stay, hospital stay
  • Increased mortality
  • Long term cognitive impairment
22
Q

What is delirium?

A

Syndrome characterized by acute onset of cerebral dysfunction associated with:

1) Disturbed LOC
2) Change in cognition

23
Q

What are the 3 subtypes of delirium?

A

1) Hypoactive (Lethargy, decreased LOC)
2) Hyperactive (Agitation, restlessness)
3) Mixed (fluctuation)

24
Q

What is the pathophys of delirium?

A

Unknown, but possibly imbalance of neurotransmitters such as serotonin, acetylcholine, or dopamine

25
Q

What are risk factors for delirium?

A
  • Pre-existing dementia
  • Hypertension
  • Alcoholism
  • High severity of illness
  • Coma
  • Benzo use
  • Sleep deprivation
26
Q

What are the most valid pain scales in ICU?

A
  • BPS

- CSPOT

27
Q

What is the recommendation for first line analgesic therapy?

A

IV opioids. Use non-opioid analgesics to reduce opioid side effects. Use gabapentin or carbamazepine in conjunction to IV opioids for neuropathic pain.

28
Q

Should procedural pain be pre-treated?

A

Yes, pre-treat procedural pain

29
Q

What are the most valid scales for assessing sedation?

A

RASS and SAS, suggest using brain function monitors for pts on NMBA

30
Q

What are the most valid delirium scales?

A

CAM-ICU and ICDSC

31
Q

What is the most important intervention to reduce the incidence and duration of delirium?

A

Early mobilization

32
Q

Should prophylactic meds be given to prevent delirium?

A

No. Most important to mobilize early and protect pt sleep cycles

33
Q

What should be held in pts with baseline QT prolongation?

A

Anti-psychotics like haloperidol

34
Q

What is the risk of ICU acquired weakness? What is the primary recommendation as intervention to reduce?

A

Occurs in 25-50% of pts, associated with impairments to long term survival, functioning and quality of life.

Mobilization is primary intervention.

35
Q

What is the effect of sleep disruption?

A

Associated with distress, delirium, increased length of mechanical ventilation, immune dysfunction, cognitive decline

CCN (27 decks)

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