Pain/Agitation/Sedation In Critically-Ill Flashcards
What in the ICU can cause patients to have cognitive and mental impairment?
Sedative medications
Intubation
Catheters
Multiple lines
When a critically-ill patient is admitted, what is the order of sedation, checking for delirium, and analgesia?
- Treat pain FIRST (analgesia)
- Sedation
- Check for delirium
What are the tools used to assess pain in the critically-ill?
Critical Care Pain Observation Tool (CPOT)
Score >2 = significant pain
Behavioral Pain Scale (BPS)
Score >5 = significant pain
What pain medications are used in the critically ill?
Morphine - lasts 3-6hrs, accumulates in kidneys
Fentanyl - extremely fast onset (seconds), hepatic metabolism, CYP3A4 interactions, tachyphylaxis
Hydromorphone - good for renally impaired, available as PCA (patient-controlled analgesia) [reserved for tachyphylaxis & fentanyl intolerance]
Fentanyl is 1st line for continuous infusion (fast on/off)
How does opioid use affect pain tolerance in the critically ill?
Opioids induce hyperalgesia, likely neurologically lowers pain threshold
Other than opioids, what analgesics can be used in critically ill patients?
APAP (avoid in acute liver failure)
NSAIDS (avoid in AKI, GI bleeds)
Methadone (for long-term sedation and pain, slowly titrate QTc prolongation)
Gabapentin (for neuropathic pain, slow onset)
Ketamine
PCA (patient-controlled analgesia)
What is the tool used to assess the level of sedation in critically-ill patients? What score is the usual goal?
Richmond Agitation Sedation Scale (RASS)
GOAL: RASS score 0 to -2
What drugs can be used to induce sedation in critically ill patients?
Propofol
Dexmedetomidine
Benzodiazepines
Ketamine
What is the mechanism of propofol? What effects does it have on patients? How quick is onset?
MOA: Stimulates GABA and inhibits glutamate
Hypnotic, anxiolytic, amnestic, anticonvulsant effects
no analgesic effect!
Onset = < 1 min
What are some ADRs of propofol?
Respiratory depression (pt should be intubated)
Hypotension
Bradycardia
Decreased CO
Hypertriglyceridemia
Propofol-Related Infusion Syndrome
Propofol is a potential first-line sedative in what 2 conditions? What are some notable clinical pearls?
1st line: Severe EtOH withdrawal, status epilepticus (w/opioids)
Pearls:
- Lipid emulsion = provides 1.1 kcals/mL
- avoid in egg/soybean/sulfite allergies
- monitor BP, HR, lipids, anion gap, creatinine kinase if >48h use
What is the MOA of dexmedetomidine? What is the FDA approved use?
MOA: alpha-2 adrenergic agonist (like clonidine but super potent)
FDA approved for procedural sedation & sedation for ventilating do not use >24 hrs
Sedating AND analgesic!
What are 4 benefits of demedetomidine?
BENEFITS
- NO respiratory depression
- Similar to natural sleep
- Opioid-sparing
- Adjunct to BZDs in EtOH withdrawal
What BZDs are used in sedation of critically-ill patients?
Midazolam (fast-acting)
Lorazepam
Diazepam (long-acting)
BZDs are reserved as first-line for what 3 conditions in the critically ill?
- Status epilepticus
- Extreme EtOH withdrawal
- Severe respiratory distress requiring deep sedation
What are some drawbacks of BZDs?
Risk of delirium
Increased ventilation time
Increased length of ICU stay
According to PADIS 2018 Guideline recommendations: We suggest using either ________ or _________ over ________ for sedation in critically ill, mechanically ventilated adults
Suggest propofol or dexmedetomidine over BZDs
Ketamine is a flexible drug with many indicated uses. What are some in critically-ill patients?
Anesthesia
Pain
Rapid intubation
Acute, severe agitation
Status epilepticus
Resistant depression
PTSD
What are some MOAs of ketamine? Think about its indications and how mechanisms might affect that. (4)
Glutamate NMDA antagonist
Mu + Kappa agonist (opioid receptors, for analgesia)
Muscarinic ACh receptor antagonist (recall ACh is excitatory)
Inhibit reuptake of serotonin, NE and dopamine (antidepressant properties)
Patients don’t need to be intubated to be on ketamine. Oral ketamine is available. Why don’t we regularly use it?
Has very low oral bioavailability (20-30%)
What are 3 advantages of ketamine?
- Favorable hemodynamics (no hypotension, bradycardia)
- Bronchodilating events
- Opioid-sparing
What are 4 drawbacks of dexmedetomidine?
DRAWBACKS
- Hypotension
- RASS score of ≤ -3 unlikely (not very strong)
- Withdrawal with extended use
- Possible drug-induced fever
What are some common ADRs of ketamine? (4)
Emergence reaction/hyperactivity (must pretreat with benzodiazepines or propofol)
Drooling
Tachycardia
Hypertension
What kinds of patients would be candidates for ketamine? Think about the advantages/effects of the drug. (4)
- Hypotensive patients (causes HTN)
- Post-surgery (pain+anesthesia coverage)
- Hx schizophrenia (antidepressant properties)
- Hx of asthma (bronchodilating)
What is delirium?
Acute changes in mental status with inattention, disorganized thinking, and altered level of consciousness
What are some adverse effects (for pt and system) that come from patients in delirium?
Increased mortality
Cognitive impairment
Functional decline
Prolonged ventilation
Increased length of stay
Increased health system costs
What are modifiable risk factors of delirium? (2)
BZD use
Blood transfusion
What are non-modifiable risk factors of delirium? (4)
Increased age
Hx of dementia
Hx of coma
Pre-ICU emergency surgery/trauma
An ICDSC score ≥ ____ suggests delirium
4
What are some non-pharmacological interventions for delirium?
Re-orient patient
Use hearing aids/glasses
Limit noise & light at night
Encourage natural sleep-wake cycle
Early mobilization
Family
Music
Limit BZDs and AChs
What are some Rx options to treat delirium? What do the PADIS guidelines suggest about using meds in delirium?
Opioids (delirium from pain)
Dexmedetomidine (sedating + pain)
Melatonin (encourage normal sleep cycle)
Antipsychotics
PADIS does NOT recommend Rx use in PREVENTION of delirium, but Rx ok for treatment (Precedex best for ventilated, antipsychotics last line)
Neuromuscular blockers are not listed on PADIS guidelines for treating critically-ill pts, however they are often used still. What do NMBs do?
Facilitate ventilation
Minimizes oxygen consumption
Forces muscles to RELAX
Alleviates intracranial and intraabdominal pressure
Surgical procedures
What happens to the body when a pt has neuromuscular blockers?
Complete relaxation (including lungs), no communication or movement BUT completely alert! No analgesia or sedation! Almost like sleep paralysis
Pt MUST be intubated to ensure O2 delivery
How are patients’ neuromuscular blockade levels monitored by nurses? What is the goal?
“Train of Four” - uses peripheral nerve stimulators, counting the patient’s # of twitches indicates level of blockade
Goal = 2 twitches (80-90% block)
What are the 3 non-depolarizing neuromuscular blocker agents?
Cisatracurium
Vecuronium
Rocuronium*
(Most end in -nium)
What is the depolarizing neuromuscular blocking agent?
Succinylcholine
