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PHM 703: Critical Care/Cancer > Pain/Agitation/Sedation > Flashcards

Pain/Agitation/Sedation Flashcards

1
Q

Analgosedation

A
  1. Analgesia
    * Bolus or PRN opioids first
  2. Sedation
    * If still agitated, propofol/dexmedtomidine/ketamine
    * benzo prn boluses only
  3. Delirium
    * screen/identify early
    * #1 nonpharm prevention!
    * #2 consider pharm options after

NO DRIPS YET!!

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2
Q

Causes of ICU related distress

A
  • multiple line placements
  • Turning/cleanning
  • Medications
  • lab draws
  • life support
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3
Q
A
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4
Q

Assessing Analgesia

A

CPOT: goal <2
BPS: goal <5

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5
Q

IV opioid options

A
  • Morphine
  • Fentanyl
  • Hydromorphone
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6
Q

Managing hyperalgesia

A

if opioid induced - switch opioid

potentially dt tachyphylaxis

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7
Q

Non-opioid analgesia

A
  • APAP
  • NSAIDs
  • Methadone
  • Gabapentin
  • Ketamine
  • PCAs
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8
Q

Morphine onset/duration

A

on: 5-10 min (quick)
duration: 3-6 hours (long)

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9
Q

Fentanyl onset/duration

A

on: seconds (super fast)
duration: 1-2 hr (short)

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10
Q

Hydromorphone onset/duration

A

on: 5 min
duration: 2-4 hr

onset similar to morphine
duration inbetween morphine/fentanyl

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11
Q

Morphine clinical pearls

A

Active metabolite M6G
accumulates in renal impairment (avoid drip)
Histamine release: hypotension, bronchospasm, itchy (uticaria)

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12
Q

Fentanyl clinical pearls

A

Hepatic metabolism (liver failure = longer duration)
CYP3A4 DDI
Tachyphylaxis (tolerance = switch to hydromorphone)
1st line choice for drip

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13
Q

Hydromorphone clinical pearls

A

good in renal impaired
Alt if fentanyl tolerance
minimal histamine release
available as PCA

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14
Q

APAP caution

A

in acute liver failure

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15
Q
A
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16
Q

NSAID caution

A

acute AKI
increase GI bleed

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17
Q

Methadone caution

A

slow titration, avoid QTc prolongation
Long acting - if sedated long time wean off

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18
Q

Gabapentin caution

A

may not see benefit for a couple of days

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19
Q

Sedation scales

A

RASS
SAS

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20
Q
A
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21
Q

Propofol MOA

A

Stimulate GABA
inhibit NMDA

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22
Q

Propofol PD

A

hypnotic
anxiolytic
anticonvulsant

amnesic
anesthesia

NO PAIN RELIEF

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23
Q

Propfol PK

A

Onset: <1 min (fast)
Duration: 10-15 min

rapid hepatic/extrahepatic CL

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24
Q

Propofol long term caution

A

saturation of peripheral tissues (lipophillic)

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25
Q

Propofol ADR

A

Respiratory depression (must intubate)
Hypotension (pressors)
Bradycardia
Decreased cardiac output
HyperTG (acute pancreatitis)
PRIS (infusion syndrome - acidosis)

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26
Q

Propofol pearls

A

Lipid emulsion = 1.1kcal/ml nutrition
AVOID if allergy: egg, sulfites, soybean

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27
Q

Propofol monitoring

A

BP
HR
TG
Anion gap/lactate
CK if use >48 hrs

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28
Q

Dexmedetomidine MOA

A

A2 agonist
decrease Ne and Da release in CNS
decrease fight/flight response

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29
Q

Dexmedetomidine indications

A

FDA: procedural sedation, mechanical vent sedation not > 24 hours

we use it > 24 hours anyways LOL

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30
Q

Dexmedetomidine PD

A

sedative
analgesia

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31
Q

Dexmedetomidine ADR

A

bradycardia
hypotension

32
Q

Dexmedetomidine Pros

A
  • 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)
33
Q

Dexmedetomidine Cons

A

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

34
Q

Benzodiazepines

A
  1. midazolam
  2. lorazepam
  3. diazepam

short term use only

35
Q

Midazolam on/off

A

On: 2-5 min
Duration: 1-2 hr

36
Q
A
37
Q

Lorazepam on/off

A

On: 5-20 min
Off: 2-6 hr

38
Q

Diazepam on/off

A

on: 5-10 min
Off: 44-100 hrs

39
Q

Midazolam pearls

A

Lipophillic
active metabolites
accumulates in renal impairment
primary use = status epilepticus, AUD (benzo drip)

metabolites: once anxiolytic wears off, left with delirious amnesic fx

40
Q

Lorazepam pearls

A

Diluted with proplyene glycol = acidosis risk w/ high dose
OK to use in renal/hepatic failure

40
Q
A
41
Q

Diazepam pearls

A

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

42
Q

Benzo indication first line

A
  • Status epilepticus
  • Extreme alcohol withdrawal sx
  • severe ARDS requiring DEEP sedation
43
Q

Benzo Cons

A

increased
* risk of delirium
* time on ventillator
* length of ICU stay

44
Q

Choosing sedative agent: PADIS 2018 guideline

A

propofol/dexmedtomidine&raquo_space;> benzo

in sedating critically ill, mechanically ventillated adults

45
Q

Ketamine indications

there are 7

A
  1. Anesthesia
  2. Pain
  3. Rapid sequence intubation
  4. Acute severe agitation
  5. Status Epilepticus
  6. Treatment resistant depression
  7. PTSD
46
Q

Ketamine MOAs

4 MOAs

A
  1. NMDA antagonist
  2. Mu/Kappa agonist
  3. Muscarinic ACH agonist
  4. inhibit 5HT, DA, NE
  5. analgesia
  6. bronchodilator
  7. antidepressant

calming, analgesia, bronchodilator, antidepressant

47
Q

Ketamine bolus dose

IV push vs IM

A

IV push 1-2mg/kg
IM 4-5 mg/kg

48
Q

Ketamine dose dependent fx

A

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

49
Q

IV Ketamine on/off

anesthetic only

A

On: 30 seconds
Duration: 5-10min, recovery 1-2 hr

50
Q

IM ketamine on/off

Anesthetic and analgesia

A

On Anesthetic: 3-4 min, analgesia:10-15 min
Duration: anesthetic 12-24min, analgesia 15-30 min, recovery 3-4 hrs

51
Q

PO ketamine

A

terrible bioavailability
20-30%

52
Q

Ketamine Pros

A

Favorable hemodynamics (esp if shock)
Bronchodilator effect
opioid sparing

tachycardia, hypertension

53
Q

Ketamine ADR

A

emergence reaction
* pretreat with bzd or propofol
* avoid if elderly or baseline schizo = get too hyper

Oral secretions (r/o other causes)
Tachycardia
HTN

54
Q

Delirium definition

A

acute changes in mental status

55
Q

Delirium sequalae

A
  • increased mortality
  • cognitive impairment
  • functional decline
  • increase costs
  • prolonged mechanical vent
  • increase length of stay
56
Q

Delirum risk factors

prevention is best treatment

A

Modifiable
* BZD use
* Blood transfusions

Non-modifiable
* Older age
* dementia hx
* prior coma
* pre-icu emergency surgery/trauma
* increased APACHE score

57
Q

Delirium screening tools

A
  1. CAM-ICU (y/n)
  2. ICDSC (0-4)

regularly assess for delirum using valid tool

58
Q

Preventing delirium: nonpharm

A
  • 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
59
Q

Treating delirium: pharm

A
  1. Opioids
  2. Dexmedetomidine
  3. melatonin
  4. APS (many ADR)
    - quetiapine, haloperidol, olanzapine
60
Q

PADIS guideline for delirium

A

No pharm agent for delirum PREVENTION
Dexmedetomdine = mechanical vent adult w/ agitation
APS: not used routinely

61
Q

Neuromuscular blockers indication

A

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

62
Q

Neuromuscular blockers Pros

A
  • inhibit diaphragmatic function
  • reduce chest wall rigidity
  • reduces o2 consumption
  • elminates work of breathing (when intubated)
63
Q

Neuromuscular blockers Cons

A
  • 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

64
Q

Neuromuscular blockers monitoring

when given as continuous IV infusion

A

Train of four using peripheral nerve stimulator
Goal target: 2 twitches = 80-90% blockage

65
Q

Neuromuscular blocker agents

A

Non-depolarizing agents: ACh antagonists (drips)
* Cisatracurium
* Rocuronium
* Vecuronium

Depolarizing agent (bolus)
* Succinylcholine

66
Q

Cisatracurium elimination

A

Hoffman
hydrolysis in blood - enzyme mediated

67
Q

Cisatracurium on/off

A

on: 2-5 min
off: dose depndent
30-90 min

68
Q

Rocuronium elimination

A

50% billiary/renal

69
Q

Vecuronium elimination

A

billiary and renal

69
Q

Rocuronium on/off

A

On: 1-2 min (fastest)
off: 30-60 min

70
Q

Vecuronium on/off

A

on: 3-5 min
off: 45-60 min

71
Q

Succinylcholine elimination

A

plasma pseudo-cholinesterase

72
Q

Succinylcholine on/off

A

on: 30-60 SeCONDS
Off: 5-10 min (short)

much shorter duration than non-depolarizing agents

73
Q

succinylcholinesterase precautions

A

avoid use if
* malignant hyperthermia
* hyperkalemia (torsades risk)

74
Q
A

PHM 703: Critical Care/Cancer (17 decks)

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