Pain, agitation, and Delirium in the ICU Flashcards
What are common causes pain agitation and delirium in the ICU
Acute illness, immobility, mechanical ventilation, postoperative pain, trauma, line interstion, frequent blood draws, nasogastric tube placement
T/F: Vital signs should be be used for pain but instead the patient verbally
True
What are the verbal assesments of pain, non verbal
Visual analogue or Numerical Rating Scale, Faces/ Behavioral Pain Scale and Critical Care Pain Observation Trial
What are the backbone of pain management, what is the benefit of using alternative medications
Opiods/ Additive or synergistic effects, Lowered opioid consumption and adverse effects
What are the adjunct therapies to consider with opioids
Acetaminophen, ketamine (post-surgical pain), gabapentin (neuropathic pain), non pharmacological options
What adjunct therapies should be avoided when used with opioids
NSAIDs and IV lidocaine
What are the IV opioids used most often
Fentanyl, hydromorphone, and morphine
Which opiods are meatabolized through the glucoronidation, CYP3A4/5, fastest acting, active metabolite
morphine and hydromorphone/ fentanyl/ morphine (6 and 3-glucoronide metabolite)
Which opioid causes accumulation in hepatic impairement, renal/hepatic
Fentanyl/ hydromorphone and morphine
What are the common adverse effects that come from opioid use
nausea, constipation, and respiratory depression
What is the caution with giving a bolus of fentanyl, using morphine
skeletal muscle rigidity (high bolus), histamine release leads to hypotension (vasodilation) and itching
What are the IV equivalents between morphine, fentanyl, and morphine parentally/ orally
Fentanyl: 100 mcg = morphine: 10 mg = hydromorphone: 1.5/ morphine: 30 mg = hydromorphone: 7.5 mg
What are the scales for sedation scoring
Riker Sedation-Agitation Scale (SAS), Ramsay Scale, Richmond Agitation Sedation Scale (RASS) (most commonly used(most commonly used)
T/F: Light sedation is preferred over deep sedation in critically ill, mechanically ventilated patients
True
What circumstances would deep sedation be required
Refractory status epilepticus, elevated intracranial pressure, Neuromuscular blockade therapy, hemodynamic instability due to cardiac process requiring mechanical circulatory support
What are the types of analgo-sedation
Analgesia first sedation: opioid therapy initiated before a sedative/ analgesia based sedation: opioid therapy used instead of a sedative
What are the benefits of using opiods in sedation, limitations
Reduces agitation due to pain and discomfort, avoids potential sedative-related adverse effects/ may interfere with respiratory drive gastric motility and hemodynamics, may not be appropiate for patients with GABA agonist/ deep sedation needs
T/F: Pain should always be treated before sedation
True
What is a common GABA agonist to cause sedation due to its fastest onset and is first line following intubation, adverse effects
Propofol/ hyptension, bradycardia, respiratory depression, hypertriglyceridemia, PRIS
What are the benefits of using propofol to midazolam
Shorter time to recover with light levels of sedation, shorter time to extubation
What is the alpha 2 agonist that is first line to cause light sedation, advantages to propofol, adverse effect
Dexmedetomidine/ less time to extubation and less incidence of delirium/ bradycardia
What is the caution when using dexmedetomidine, intervention
Patients may experience withdrawal symptoms if therapy duration greater than 7 days, consider clonidine taper 24-48 hours
Which benzodiazepine is used to cause sedation, disadvantages
Midazolam/ increased risk of delirium, oversedation, risk of accumulation in hepatic/renal dysfunction (active metabolite)
T/F: Midozalam causes more delerium and and longer time to extubation
True
What is characteritization of propofol, what lab value is associated with this, how can this be avoided
hyperosmolarity and anion gap metabolic acidosis, osmolar gap greater than 10 mmoles/L, greater than 0.1 mg/kg/ hour
T/F: Polyethylene glycol is NOT a solvent for IV midazolam
True
How does ketamine effect blood pressure and heart rate, what kind of sedation does it cause, what is risk of using it
increased blood pressure and heart rate, deep, risk of emergence reactions
T/F: If a patient has SAT failure and SBT failure the dose should be reduced by half and tried again in 24 hours
True
What is delirium, what are the assessment tools
disturbances of consciousness and cognition that develops over a short period of time and fluctuates over time/ IDSC and CAM-ICU
What are the delirium subtypes
Hypoactive: inattention, disorientated thinking, decreased levels of consciousness without agitation/ hyperactive: restlessness, agitation, hyper-vigilance, hallucination and delusions/ mixed
What are nonpharmacological interventions for delirium
early mobilization, frequent orientation, avoid physical restraints
What is the best way to deal with delirium
Prevent delirium
What medications can be given for delerium
Olanzapine, Quetiapine, Haloperidol
What medications can be given for delerium
Olanzapine (dose reduction greater than 60), Quetiapine, Haloperidol
