Pain, agitation, and Delirium in the ICU

Question 1

What are common causes pain agitation and delirium in the ICU

Answer 1

Acute illness, immobility, mechanical ventilation, postoperative pain, trauma, line interstion, frequent blood draws, nasogastric tube placement

Question 2

T/F: Vital signs should be be used for pain but instead the patient verbally

Answer 2

True

Question 3

What are the verbal assesments of pain, non verbal

Answer 3

Visual analogue or Numerical Rating Scale, Faces/ Behavioral Pain Scale and Critical Care Pain Observation Trial

Question 4

What are the backbone of pain management, what is the benefit of using alternative medications

Answer 4

Opiods/ Additive or synergistic effects, Lowered opioid consumption and adverse effects

Question 5

What are the adjunct therapies to consider with opioids

Answer 5

Acetaminophen, ketamine (post-surgical pain), gabapentin (neuropathic pain), non pharmacological options

Question 6

What adjunct therapies should be avoided when used with opioids

Answer 6

NSAIDs and IV lidocaine

Question 7

What are the IV opioids used most often

Answer 7

Fentanyl, hydromorphone, and morphine

Question 8

Which opiods are meatabolized through the glucoronidation, CYP3A4/5, fastest acting, active metabolite

Answer 8

morphine and hydromorphone/ fentanyl/ morphine (6 and 3-glucoronide metabolite)

Question 9

Which opioid causes accumulation in hepatic impairement, renal/hepatic

Answer 9

Fentanyl/ hydromorphone and morphine

Question 10

What are the common adverse effects that come from opioid use

Answer 10

nausea, constipation, and respiratory depression

Question 11

What is the caution with giving a bolus of fentanyl, using morphine

Answer 11

skeletal muscle rigidity (high bolus), histamine release leads to hypotension (vasodilation) and itching

Question 12

What are the IV equivalents between morphine, fentanyl, and morphine parentally/ orally

Answer 12

Fentanyl: 100 mcg = morphine: 10 mg = hydromorphone: 1.5/ morphine: 30 mg = hydromorphone: 7.5 mg

Question 13

What are the scales for sedation scoring

Answer 13

Riker Sedation-Agitation Scale (SAS), Ramsay Scale, Richmond Agitation Sedation Scale (RASS) (most commonly used(most commonly used)

Question 14

T/F: Light sedation is preferred over deep sedation in critically ill, mechanically ventilated patients

Answer 14

True

Question 15

What circumstances would deep sedation be required

Answer 15

Refractory status epilepticus, elevated intracranial pressure, Neuromuscular blockade therapy, hemodynamic instability due to cardiac process requiring mechanical circulatory support

Question 16

What are the types of analgo-sedation

Answer 16

Analgesia first sedation: opioid therapy initiated before a sedative/ analgesia based sedation: opioid therapy used instead of a sedative

Question 17

What are the benefits of using opiods in sedation, limitations

Answer 17

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

Question 18

T/F: Pain should always be treated before sedation

Answer 18

True

Question 19

What is a common GABA agonist to cause sedation due to its fastest onset and is first line following intubation, adverse effects

Answer 19

Propofol/ hyptension, bradycardia, respiratory depression, hypertriglyceridemia, PRIS

Question 20

What are the benefits of using propofol to midazolam

Answer 20

Shorter time to recover with light levels of sedation, shorter time to extubation

Question 21

What is the alpha 2 agonist that is first line to cause light sedation, advantages to propofol, adverse effect

Answer 21

Dexmedetomidine/ less time to extubation and less incidence of delirium/ bradycardia

Question 22

What is the caution when using dexmedetomidine, intervention

Answer 22

Patients may experience withdrawal symptoms if therapy duration greater than 7 days, consider clonidine taper 24-48 hours

Question 23

Which benzodiazepine is used to cause sedation, disadvantages

Answer 23

Midazolam/ increased risk of delirium, oversedation, risk of accumulation in hepatic/renal dysfunction (active metabolite)

Question 24

T/F: Midozalam causes more delerium and and longer time to extubation

Answer 24

True

Question 25

What is characteritization of propofol, what lab value is associated with this, how can this be avoided

Answer 25

hyperosmolarity and anion gap metabolic acidosis, osmolar gap greater than 10 mmoles/L, greater than 0.1 mg/kg/ hour

Question 26

T/F: Polyethylene glycol is NOT a solvent for IV midazolam

Answer 26

True

Question 27

How does ketamine effect blood pressure and heart rate, what kind of sedation does it cause, what is risk of using it

Answer 27

increased blood pressure and heart rate, deep, risk of emergence reactions

Question 28

T/F: If a patient has SAT failure and SBT failure the dose should be reduced by half and tried again in 24 hours

Answer 28

True

Question 29

What is delirium, what are the assessment tools

Answer 29

disturbances of consciousness and cognition that develops over a short period of time and fluctuates over time/ IDSC and CAM-ICU

Question 30

What are the delirium subtypes

Answer 30

Hypoactive: inattention, disorientated thinking, decreased levels of consciousness without agitation/ hyperactive: restlessness, agitation, hyper-vigilance, hallucination and delusions/ mixed

Question 31

What are nonpharmacological interventions for delirium

Answer 31

early mobilization, frequent orientation, avoid physical restraints

Question 32

What is the best way to deal with delirium

Answer 32

Prevent delirium

Question 33

What medications can be given for delerium

Answer 33

Olanzapine, Quetiapine, Haloperidol

Question 34

What medications can be given for delerium

Answer 34

Olanzapine (dose reduction greater than 60), Quetiapine, Haloperidol