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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
Q

Sedative Hypnotics
Propofol (Diprivan ®)

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

A

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
Q

Alpha-2 agonist

Dexmedetomidine (Precedex ®)

A

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
Q

Scale for sedation

+1 Restless

0 Alert and Calm

-1 Drowsy

A
  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
Q

Dexmedetomidine (Precedex ®)

AE

A

: Hypotension, bradycardia, (hypertension with a loading dose), reduced cardiac output—do not use with patient with Cardiovascular disease

29
Q

Comparison of IV Sedative Agents Adverse Events

Midazolam

A

Dependence

Respiratory Depression

30
Q

Comparison of IV Sedative Agents Adverse Events

Lorazepam

A

Dependence

Respiratory Depression

31
Q

Comparison of IV Sedative Agents Adverse Events

Propofol

A 
Respiratory Depression
Hypotension
Bradycardia
Hyperlipidemia
Increased Risk of Infection
32
Q

Comparison of IV Sedative Agents Adverse Events

Dexmedetomidine

A

Hypotension

Bradycardia

33
Q

Choosing an IV Sedative Agent Based on Patient Characteristics

Midazolam

A

Acute Agitation

Intermittent IV bolus dosing

34
Q

Choosing an IV Sedative Agent Based on Patient Characteristics

Lorazepam

A

Acute Agitation
Intermittent IV bolus dosing

Long Term Maintenance
( > 72 hours)

35
Q

Choosing an IV Sedative Agent Based on Patient Characteristics

Propofol

A

Head Trauma

Rapid Awakening

36
Q

Choosing an IV Sedative Agent Based on Patient Characteristics

Dexmedetomidine

A

Rapid Awakening

37
Q

IV Sedative Agents

Special Properties

Midazolam

A

2- 5 min

Contains an active metabolite

Contains amnestic properties

38
Q

IV Sedative Agents

Special Properties

Lorazepam

A

5- 20 min
longest onset

Contains propylene glycol

Contains amnestic properties

39
Q

IV Sedative Agents

Special Properties

Propofol

A

1- 2 min

Contains amnestic properties

Infusion bottle and tubing must be changed every 12 hours

40
Q

IV Sedative Agents

Special Properties

Dexmedetomidine

A

1- 5 min

Contains analgesic properties

41
Q

Oversedation

Slow response to stimulation, sluggish, unarousable, deep sedation

Treatment

A

Hold dose until at goal or increase dosing interval and then decrease dose by 25-50%

42
Q

Undersedation

Anxious, restless, combative, agitated

A

Increase dose by 10-25% and monitor until patient is at goal (assess pain requirements) + prn bolus dose

43
Q

Dosing Strategies for IV Analgesics and Sedatives

A

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
Q

ICU Delirium

A

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
Q

Prevention of Delirium

A

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
Q

Method for the ICU (CAM-ICU) Score-Scale for Delirium

A

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
Q

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

A

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
Q

Delirium Treatment

A

Remove medications which can cause delirium :
Benzodiazepines, metoclopramide , H2-blockers (i.e. famotidine), diphenhydramine, etc.

and/or

Pharmacotherapy
Haloperidol
Atypical antipsychotics

49
Q

Delirium Pharmacotherapy

Neuroleptics
Haloperidol (Haldol®)

AE’s
QTC prolongation

ETOH AND PMH OF SEIZURES

A

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
Q

Delirium Pharmacotherapy

Atypical Antipsychotics

Adverse effects
Short term use (ICU delirium)
QTc prolongation, sedation

A

Quetiapine(Seroquel®) 25mg q12*

Risperidone (Risperdal®)1-2 qHS*

Olanzapine (Zyprexa®)
Ziprasidone (Geodon®

51
Q

dexmedetomidine

contraindication

A

Heart Rate

CardioPulm II (11 decks)

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