Pain/Agitation/Sedation Flashcards
Analgosedation
- Analgesia
* Bolus or PRN opioids first - Sedation
* If still agitated, propofol/dexmedtomidine/ketamine
* benzo prn boluses only - Delirium
* screen/identify early
* #1 nonpharm prevention!
* #2 consider pharm options after
NO DRIPS YET!!
Causes of ICU related distress
- multiple line placements
- Turning/cleanning
- Medications
- lab draws
- life support
Assessing Analgesia
CPOT: goal <2
BPS: goal <5
IV opioid options
- Morphine
- Fentanyl
- Hydromorphone
Managing hyperalgesia
if opioid induced - switch opioid
potentially dt tachyphylaxis
Non-opioid analgesia
- APAP
- NSAIDs
- Methadone
- Gabapentin
- Ketamine
- PCAs
Morphine onset/duration
on: 5-10 min (quick)
duration: 3-6 hours (long)
Fentanyl onset/duration
on: seconds (super fast)
duration: 1-2 hr (short)
Hydromorphone onset/duration
on: 5 min
duration: 2-4 hr
onset similar to morphine
duration inbetween morphine/fentanyl
Morphine clinical pearls
Active metabolite M6G
accumulates in renal impairment (avoid drip)
Histamine release: hypotension, bronchospasm, itchy (uticaria)
Fentanyl clinical pearls
Hepatic metabolism (liver failure = longer duration)
CYP3A4 DDI
Tachyphylaxis (tolerance = switch to hydromorphone)
1st line choice for drip
Hydromorphone clinical pearls
good in renal impaired
Alt if fentanyl tolerance
minimal histamine release
available as PCA
APAP caution
in acute liver failure
NSAID caution
acute AKI
increase GI bleed
Methadone caution
slow titration, avoid QTc prolongation
Long acting - if sedated long time wean off
Gabapentin caution
may not see benefit for a couple of days
Sedation scales
RASS
SAS
Propofol MOA
Stimulate GABA
inhibit NMDA
Propofol PD
hypnotic
anxiolytic
anticonvulsant
amnesic
anesthesia
NO PAIN RELIEF
Propfol PK
Onset: <1 min (fast)
Duration: 10-15 min
rapid hepatic/extrahepatic CL
Propofol long term caution
saturation of peripheral tissues (lipophillic)
Propofol ADR
Respiratory depression (must intubate)
Hypotension (pressors)
Bradycardia
Decreased cardiac output
HyperTG (acute pancreatitis)
PRIS (infusion syndrome - acidosis)
Propofol pearls
Lipid emulsion = 1.1kcal/ml nutrition
AVOID if allergy: egg, sulfites, soybean
Propofol monitoring
BP
HR
TG
Anion gap/lactate
CK if use >48 hrs
Dexmedetomidine MOA
A2 agonist
decrease Ne and Da release in CNS
decrease fight/flight response
Dexmedetomidine indications
FDA: procedural sedation, mechanical vent sedation not > 24 hours
we use it > 24 hours anyways LOL
Dexmedetomidine PD
sedative
analgesia
Dexmedetomidine ADR
bradycardia
hypotension
Dexmedetomidine Pros
- No respiratory depression (don’t need to intubate to using as sedation)
- Effects similar to nautrally occuring sleep (mimics rem sleep)
- Opioid sparing (pain relief)
- adjunct therapy for alcohol withdrawal (helps w/ anxiety)
Dexmedetomidine Cons
Risk of hypotension
RASS score <-3 unlikely =NOT for DEEP sedation
if prolonged use >24 hours:
* Risk of withdrawal if prolonged use – need to taper, like clonidine
* Drug induced fever case reports
Benzodiazepines
- midazolam
- lorazepam
- diazepam
short term use only
Midazolam on/off
On: 2-5 min
Duration: 1-2 hr
Lorazepam on/off
On: 5-20 min
Off: 2-6 hr
Diazepam on/off
on: 5-10 min
Off: 44-100 hrs
Midazolam pearls
Lipophillic
active metabolites
accumulates in renal impairment
primary use = status epilepticus, AUD (benzo drip)
metabolites: once anxiolytic wears off, left with delirious amnesic fx
Lorazepam pearls
Diluted with proplyene glycol = acidosis risk w/ high dose
OK to use in renal/hepatic failure
Diazepam pearls
Acitve metabolite accumulation
Can taper off quickly
Super long half life - titrate; less risk of abrupt withdrawal/seizure risk
Standing doses used in alcohol withdrawal
Benzo indication first line
- Status epilepticus
- Extreme alcohol withdrawal sx
- severe ARDS requiring DEEP sedation
Benzo Cons
increased
* risk of delirium
* time on ventillator
* length of ICU stay
Choosing sedative agent: PADIS 2018 guideline
propofol/dexmedtomidine»_space;> benzo
in sedating critically ill, mechanically ventillated adults
Ketamine indications
there are 7
- Anesthesia
- Pain
- Rapid sequence intubation
- Acute severe agitation
- Status Epilepticus
- Treatment resistant depression
- PTSD
Ketamine MOAs
4 MOAs
- NMDA antagonist
- Mu/Kappa agonist
- Muscarinic ACH agonist
- inhibit 5HT, DA, NE
- analgesia
- bronchodilator
- antidepressant
calming, analgesia, bronchodilator, antidepressant
Ketamine bolus dose
IV push vs IM
IV push 1-2mg/kg
IM 4-5 mg/kg
Ketamine dose dependent fx
Pain: 0.15-0.50 mg/kg/hr
Anesthesia: 0.50-2.0 mg/kg/hr
SE: >2 mg/kg/hr (comatose)
intubation not necessary for lower doses
IV Ketamine on/off
anesthetic only
On: 30 seconds
Duration: 5-10min, recovery 1-2 hr
IM ketamine on/off
Anesthetic and analgesia
On Anesthetic: 3-4 min, analgesia:10-15 min
Duration: anesthetic 12-24min, analgesia 15-30 min, recovery 3-4 hrs
PO ketamine
terrible bioavailability
20-30%
Ketamine Pros
Favorable hemodynamics (esp if shock)
Bronchodilator effect
opioid sparing
tachycardia, hypertension
Ketamine ADR
emergence reaction
* pretreat with bzd or propofol
* avoid if elderly or baseline schizo = get too hyper
Oral secretions (r/o other causes)
Tachycardia
HTN
Delirium definition
acute changes in mental status
Delirium sequalae
- increased mortality
- cognitive impairment
- functional decline
- increase costs
- prolonged mechanical vent
- increase length of stay
Delirum risk factors
prevention is best treatment
Modifiable
* BZD use
* Blood transfusions
Non-modifiable
* Older age
* dementia hx
* prior coma
* pre-icu emergency surgery/trauma
* increased APACHE score
Delirium screening tools
- CAM-ICU (y/n)
- ICDSC (0-4)
regularly assess for delirum using valid tool
Preventing delirium: nonpharm
- reorient patient
- use hearing aid/glasses
- limit noise/light at night
- encourage natural sleep/wake cycle
- early mobilization
- family presence
- music therapy
- limit bzd and anticholinergic medications
Treating delirium: pharm
- Opioids
- Dexmedetomidine
- melatonin
- APS (many ADR)
- quetiapine, haloperidol, olanzapine
PADIS guideline for delirium
No pharm agent for delirum PREVENTION
Dexmedetomdine = mechanical vent adult w/ agitation
APS: not used routinely
Neuromuscular blockers indication
paralyzes patient
facilitate mechanical vent/ rapid sequence intubation
* override gag reflex
* take away neurologic drive
Minimize O2 consumption
* allow brain/lung perfusion
* less muscle perfusion
Increased muscle activity
* tetany, NMS, anti-shivering
Increased ICP or intra-abdominal pressure
Surgical procedures
Neuromuscular blockers Pros
- inhibit diaphragmatic function
- reduce chest wall rigidity
- reduces o2 consumption
- elminates work of breathing (when intubated)
Neuromuscular blockers Cons
- pt can’t communicate
- no analgesic/sedative properties
Long term: - increase risk of DVT/skin breakdown
- corneal abrasion risk (ATC artificial tears)
- critical illness polyneuropathy (req. PT)
should put patient in deep sedation to prevent them from freaking out dt
Neuromuscular blockers monitoring
when given as continuous IV infusion
Train of four using peripheral nerve stimulator
Goal target: 2 twitches = 80-90% blockage
Neuromuscular blocker agents
Non-depolarizing agents: ACh antagonists (drips)
* Cisatracurium
* Rocuronium
* Vecuronium
Depolarizing agent (bolus)
* Succinylcholine
Cisatracurium elimination
Hoffman
hydrolysis in blood - enzyme mediated
Cisatracurium on/off
on: 2-5 min
off: dose depndent
30-90 min
Rocuronium elimination
50% billiary/renal
Vecuronium elimination
billiary and renal
Rocuronium on/off
On: 1-2 min (fastest)
off: 30-60 min
Vecuronium on/off
on: 3-5 min
off: 45-60 min
Succinylcholine elimination
plasma pseudo-cholinesterase
Succinylcholine on/off
on: 30-60 SeCONDS
Off: 5-10 min (short)
much shorter duration than non-depolarizing agents
succinylcholinesterase precautions
avoid use if
* malignant hyperthermia
* hyperkalemia (torsades risk)
