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CardioPulm II > Pain, Agitation, and Delirium Considerations in the ICU > Flashcards

Pain, Agitation, and Delirium Considerations in the ICU Flashcards

1
Q

Causes of Pain and Agitation

A

Painful procedures

Invasive tubes
Catheters
Drains
Endotracheal tubes

Untreated Pain:
Increased myocardial oxygen consumption
Tachycardia
Persistent catabolism

Acute agitation can lead to self-removal of lines, drains, and tubes

Long-term effects (chronic agitation):

Anxiety
Respiratory Distress
Pain
Post Traumatic Stress Disorder (PTSD)

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2
Q

Reversible causes:

A 
Hypoxemia
Hypoglycemia
Hypotension
Pain
Electrolyte abnormalities 
Withdrawal from ETOH and other drugs
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3
Q

Principles of ICU Sedation

A
  1. Treat reversible causes
  2. Provide adequate ANALGESIA
  3. Initiate SEDATION
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4
Q
  1. Initiate SEDATION: Analgosedation

Steps

A

Sedation should be started only AFTER providing adequate analgesia AND treating reversible causes

Validated sedation scales should be used regularly assess the level of sedation/ agitation and guide the titration of therapy

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5
Q

Goals of Treatment for PAIN

A

Goals of Treatment
Patient comfort, provide adequate pain relief, relief of anxiety/ agitation, prevention of physical injury, decrease oxygen consumption, facilitate care.

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6
Q

Recommended Pain Scale

A

Behavioral Pain Scale (BPS)- i.e. FLACC pain scale

The FLACC (Face, Legs, Activity, Cry, Consolability) is a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain (comatose, unresponsive, and/or sleeping patient.

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7
Q

Are vitals signs enough to assess pain?

A

Vital signs (i.e. elevated HR or BP) can indicate that further assessment of pain is necessary but is NOT always a factor in determining pain.

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8
Q

Non-Pharmacologic Treatment

A

Proper positioning
Stabilization of fractures
Elimination of irritating stimulation
Application of heat/ cold therapy

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9
Q

Pharmacologic Treatment

Morphine Sulfate

A

Standard Drip: 100mg/ 100mL IV infusion

or

2-5 mg IVP q2- 6 hours scheduled and prn

Use in hemodynamically stable patients
—>Can induce (hypotension, bronchospasm)

Contains an active metabolite (accumulates in renal insufficiency)

IV infusion, IV Bolus, and PO

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10
Q

Opioids ADR

A

Respiratory depression, constipation (hypomotility, gastric retention, ileus), nausea

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11
Q

Pharmacologic Treatment

Fentanyl

A

25- 100 mcg IVP q10 min

or

Continuous IV infusion: 25- 200mcg/hr

Use in hemodynamically unstable patients

Most rapid onset, shortest duration

IV (patch, lozenges)

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12
Q

Pharmacologic Treatment

Hydromorphone

A

Use in hemodynamically unstable patients

Formulation: IV and PO

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13
Q

Morphine Sulfate

ADR

A

Hypotension
Flushing
Bronchospasm
Constipation

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14
Q

Hydromorphone

ADR

A

Hypotension
Flushing
Constipation

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15
Q

Fentanyl

ADR

A

Constipation

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16
Q

Preferred IV Analgesic Agent Based on Patient Characteristics

Fentanyl

A

Rapid onset of analgesia in acutely distressed patients

Renal insufficiency

Hemodynamically Unstable

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17
Q

Preferred IV Analgesic Agent Based on Patient Characteristics

Morphine

A

Intermittent IV bolus therapy

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18
Q

Preferred IV Analgesic Agent Based on Patient Characteristics

Hydromorphone

A

Renal insufficiency

Hemodynamically Unstable

Intermittent IV bolus therapy

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19
Q

Other Opioids

A

NSAIDS, acetaminophen, salicylates, lidocaine, local anesthetics, gabapentin (neuropathic pain)

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20
Q

Potential for withdrawal

Opioids

A

flu-like symptoms (i.e. diaphoresis, chills), diarrhea, tachycardia, insomnia) after 5-7 days of therapy with abrupt discontinuation

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21
Q

Benzodiazepines and Propofol

A

Potentiation of the GABA receptors

Sedative, hypnotic and anxiolytic properties

Possesses anxiolytic, sedative, amnestic, and anticonvulsant properties (Note: No analgesic properties)

Hepatically metabolized

22
Q

Benzodiazepines (BZD)

AE and withdraw

A

Potential for withdrawal (tachycardia, HTN, fever, agitation, seizures, hallucinations) after 5-7 days of therapy with abrupt discontinuation

Dose dependent respiratory depression

Tolerance can develop

23
Q

Midazolam (Versed ®)*

A

rapid sedation of acutely agitated patients
Rapid onset of action: 2- 5 minutes

Contains an active metabolite
Prolonged sedation in renal failure

Recommend use for 72 hours

24
Q

Lorazepam (Ativan ®)*

A

NO active metabolite

Intermediate onset of action: 5- 20 minutes

Propylene glycol toxicity from prolonged high doses or prolonged use

  • -> Cannot exceed 7mg/hr
  • ->can crush tablets if more is needed

Formulation: IV, IM, PO

25
Sedative Hypnotics Propofol (Diprivan ®) Possesses sedative, amnestic properties and anticonvulsant effects (Note: No analgesic properties)
Recommended for rapid awakening --> Only for short term use Causes transient rise in triglyceridses-> risk of pancretitis no dependance Requires dedicated IV line due to incompatiablites Infusion bottle and tubing must be changed every 12 hours Continuous IV Drip only** Adverse Effects Hypotension, bradycardia, elevated triglycerides, pancreatitis, peripheral injection site pain, green urine
26
Alpha-2 agonist | Dexmedetomidine (Precedex ®)
Selective a-2 adrenergic agonist Sedative, anxiolytic, and analgesic properties Only used in respiratory depression.-->Does not cause respiratory depression Formulation: IV (given as continuous IV drip only) Continuous infusion: 0.2- 0.7 mcg/kg/hour 8x more potent than clonidine.
27
Scale for sedation +1 Restless 0 Alert and Calm -1 Drowsy
1. RASS ( range -1 to +1 ideal) 2. Ramsay RASS scale is a 10 point scale 4 levels of anxiety/agitation (+1 to +4) 1 level for calm/alert state (0) 5 levels of sedation (-1 to –5) Goal of RASS is to allow more precise medication titration
28
Dexmedetomidine (Precedex ®) | AE
: Hypotension, bradycardia, (hypertension with a loading dose), reduced cardiac output—do not use with patient with Cardiovascular disease
29
Comparison of IV Sedative Agents Adverse Events Midazolam
Dependence Respiratory Depression
30
Comparison of IV Sedative Agents Adverse Events Lorazepam
Dependence Respiratory Depression
31
Comparison of IV Sedative Agents Adverse Events Propofol
``` Respiratory Depression Hypotension Bradycardia Hyperlipidemia Increased Risk of Infection ```
32
Comparison of IV Sedative Agents Adverse Events Dexmedetomidine
Hypotension | Bradycardia
33
Choosing an IV Sedative Agent Based on Patient Characteristics Midazolam
Acute Agitation | Intermittent IV bolus dosing
34
Choosing an IV Sedative Agent Based on Patient Characteristics Lorazepam
Acute Agitation Intermittent IV bolus dosing Long Term Maintenance ( > 72 hours)
35
Choosing an IV Sedative Agent Based on Patient Characteristics Propofol
Head Trauma Rapid Awakening
36
Choosing an IV Sedative Agent Based on Patient Characteristics Dexmedetomidine
Rapid Awakening
37
IV Sedative Agents Special Properties Midazolam
2- 5 min Contains an active metabolite Contains amnestic properties
38
IV Sedative Agents Special Properties Lorazepam
5- 20 min longest onset Contains propylene glycol Contains amnestic properties
39
IV Sedative Agents Special Properties Propofol
1- 2 min Contains amnestic properties Infusion bottle and tubing must be changed every 12 hours
40
IV Sedative Agents Special Properties Dexmedetomidine
1- 5 min Contains analgesic properties
41
Oversedation Slow response to stimulation, sluggish, unarousable, deep sedation Treatment
Hold dose until at goal or increase dosing interval and then decrease dose by 25-50%
42
Undersedation Anxious, restless, combative, agitated
Increase dose by 10-25% and monitor until patient is at goal (assess pain requirements) + prn bolus dose
43
Dosing Strategies for IV Analgesics and Sedatives
Bolus dosing added to continuous infusion : Except with propofol and dexmedetomidine Scheduled daily interruption of continuous infusions: Except with a neuromuscular blockers, seizures, alcohol withdrawal
44
ICU Delirium
Fluctuating mental status ``` Types of delirium: Hypoactive : Withdrawn quiet, paranoid Hyperactive : Restless, agitated, aggressive, paranoid Mixed ``` Assess ICU patients for delirium every shift once Length of stay > 24 hours
45
Prevention of Delirium
Reorient patient (i.e. clocks or calendars) Encourage normal sleep/wake cycles Normalize metabolic disturbances Facilitate mobilization Restore eye glasses, hearing aids Removal of nonessential drugs with CNS side effects Reserve benzodiazepine therapy
46
Method for the ICU (CAM-ICU) Score-Scale for Delirium
Assess ICU patients for delirium every shift once Length of stay > 24 hours: Confusion Assessment Method for the ICU (CAM-ICU) Score-Scale for Delirium
47
How to Assess for Delirium CAM-ICU Feature 1: Acute onset of mental status changes or a fluctuating course Feature 2: Inattention Feature 3: Disorganized Thinking or Feature 4: Altered Level of Consciousness
1 – patient is different from baseline or fluctuation over the past 24 hours? 2 – ask patient to squeeze your hand when you hear the letter A and say a series of 10 letters (SAVEAHAART) + if >2 errors 3 – ask questions such as “does a stone float? Are there fish in the sea? Does one pound weigh more than two pounds?” 4 – if RASS is anything other than 0, indicating calm and alert Patients at high risk for delirium should be monitored at least once per shift for delirium
48
Delirium Treatment
Remove medications which can cause delirium : Benzodiazepines, metoclopramide , H2-blockers (i.e. famotidine), diphenhydramine, etc. and/or Pharmacotherapy Haloperidol Atypical antipsychotics
49
Delirium Pharmacotherapy ``` Neuroleptics Haloperidol (Haldol®) ``` AE's QTC prolongation ETOH AND PMH OF SEIZURES
Haloperidol no longer considered the drug of choice for ICU delirium AE: Adverse effects: Extrapyramidal effects, neuroleptic malignant syndrome, hypotension, **may lower seizure threshold** QTC prolongation Combination with other QT prolonging medications Dose-dependent
50
Delirium Pharmacotherapy Atypical Antipsychotics Adverse effects Short term use (ICU delirium) QTc prolongation, sedation
Quetiapine(Seroquel®) 25mg q12* Risperidone (Risperdal®)1-2 qHS* Olanzapine (Zyprexa®) Ziprasidone (Geodon®
51
dexmedetomidine contraindication
Heart Rate

CardioPulm II (11 decks)

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