Pain, Agitation, and Delirium Considerations in the ICU Flashcards
Causes of Pain and Agitation
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)
Reversible causes:
Hypoxemia Hypoglycemia Hypotension Pain Electrolyte abnormalities Withdrawal from ETOH and other drugs
Principles of ICU Sedation
- Treat reversible causes
- Provide adequate ANALGESIA
- Initiate SEDATION
- Initiate SEDATION: Analgosedation
Steps
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
Goals of Treatment for PAIN
Goals of Treatment
Patient comfort, provide adequate pain relief, relief of anxiety/ agitation, prevention of physical injury, decrease oxygen consumption, facilitate care.
Recommended Pain Scale
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.
Are vitals signs enough to assess pain?
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.
Non-Pharmacologic Treatment
Proper positioning
Stabilization of fractures
Elimination of irritating stimulation
Application of heat/ cold therapy
Pharmacologic Treatment
Morphine Sulfate
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
Opioids ADR
Respiratory depression, constipation (hypomotility, gastric retention, ileus), nausea
Pharmacologic Treatment
Fentanyl
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)
Pharmacologic Treatment
Hydromorphone
Use in hemodynamically unstable patients
Formulation: IV and PO
Morphine Sulfate
ADR
Hypotension
Flushing
Bronchospasm
Constipation
Hydromorphone
ADR
Hypotension
Flushing
Constipation
Fentanyl
ADR
Constipation
Preferred IV Analgesic Agent Based on Patient Characteristics
Fentanyl
Rapid onset of analgesia in acutely distressed patients
Renal insufficiency
Hemodynamically Unstable
Preferred IV Analgesic Agent Based on Patient Characteristics
Morphine
Intermittent IV bolus therapy
Preferred IV Analgesic Agent Based on Patient Characteristics
Hydromorphone
Renal insufficiency
Hemodynamically Unstable
Intermittent IV bolus therapy
Other Opioids
NSAIDS, acetaminophen, salicylates, lidocaine, local anesthetics, gabapentin (neuropathic pain)
Potential for withdrawal
Opioids
flu-like symptoms (i.e. diaphoresis, chills), diarrhea, tachycardia, insomnia) after 5-7 days of therapy with abrupt discontinuation
Benzodiazepines and Propofol
Potentiation of the GABA receptors
Sedative, hypnotic and anxiolytic properties
Possesses anxiolytic, sedative, amnestic, and anticonvulsant properties (Note: No analgesic properties)
Hepatically metabolized
Benzodiazepines (BZD)
AE and withdraw
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
Midazolam (Versed ®)*
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
Lorazepam (Ativan ®)*
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
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
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.
Scale for sedation
+1 Restless
0 Alert and Calm
-1 Drowsy
- RASS ( range -1 to +1 ideal)
- 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
Dexmedetomidine (Precedex ®)
AE
: Hypotension, bradycardia, (hypertension with a loading dose), reduced cardiac output—do not use with patient with Cardiovascular disease
Comparison of IV Sedative Agents Adverse Events
Midazolam
Dependence
Respiratory Depression
Comparison of IV Sedative Agents Adverse Events
Lorazepam
Dependence
Respiratory Depression
Comparison of IV Sedative Agents Adverse Events
Propofol
Respiratory Depression Hypotension Bradycardia Hyperlipidemia Increased Risk of Infection
Comparison of IV Sedative Agents Adverse Events
Dexmedetomidine
Hypotension
Bradycardia
Choosing an IV Sedative Agent Based on Patient Characteristics
Midazolam
Acute Agitation
Intermittent IV bolus dosing
Choosing an IV Sedative Agent Based on Patient Characteristics
Lorazepam
Acute Agitation
Intermittent IV bolus dosing
Long Term Maintenance
( > 72 hours)
Choosing an IV Sedative Agent Based on Patient Characteristics
Propofol
Head Trauma
Rapid Awakening
Choosing an IV Sedative Agent Based on Patient Characteristics
Dexmedetomidine
Rapid Awakening
IV Sedative Agents
Special Properties
Midazolam
2- 5 min
Contains an active metabolite
Contains amnestic properties
IV Sedative Agents
Special Properties
Lorazepam
5- 20 min
longest onset
Contains propylene glycol
Contains amnestic properties
IV Sedative Agents
Special Properties
Propofol
1- 2 min
Contains amnestic properties
Infusion bottle and tubing must be changed every 12 hours
IV Sedative Agents
Special Properties
Dexmedetomidine
1- 5 min
Contains analgesic properties
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%
Undersedation
Anxious, restless, combative, agitated
Increase dose by 10-25% and monitor until patient is at goal (assess pain requirements) + prn bolus dose
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
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
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
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
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
Delirium Treatment
Remove medications which can cause delirium :
Benzodiazepines, metoclopramide , H2-blockers (i.e. famotidine), diphenhydramine, etc.
and/or
Pharmacotherapy
Haloperidol
Atypical antipsychotics
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
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®
dexmedetomidine
contraindication
Heart Rate
