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ICP > Pain and anxiety > Flashcards

Pain and anxiety Flashcards

1
Q

What is sedation

A

Continuum which extends from normal alert consciousness to complete unresponsiveness - ranges from minimal sedation to general anaesthesia

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2
Q

Minimal sedation (4)

A

Normal response to verbal commands

Airway is unaffected

Ventilation is unaffected

Cardiovasularly unaffected

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3
Q

Moderate sedation (4)

A

Purposeful response to verbal or tactile stimulation

Airway maintained without intervention

Ventilation is adequate

Cardiovascularly usually maintained

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4
Q

Deep sedation (4)

A

Purposeful response following repeated or painful stimulation

Airway intervention may be required

Ventilation may be inadequate

Cardiovascularly usually maintained

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5
Q

General anaesthetia (4)

A

Unrousable even with pain stimulus

Airway intervention often required

Ventilation frequently inadequate

Cardiovascularly may be impaired

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6
Q

What is ventilation

A

Moving of gas into and out of the lungs

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7
Q

What is diffusion

A

Transfer of gases from the lungs into the blood

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8
Q

What is transport

A

Transfer of oxygen by the blood to the cells and the transport away of carbon dioxide

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9
Q

What is oxidation

A

Use of oxygen to produce energy within the cell and the production of carbon dioxide

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10
Q

How is oxygen delivered to cells

A

O2 binds to haemoglobin

Each molecule of Hb can carry 4 O2 molecules

CaO2 = 1.34 x Hb x SpO2 Delivery = CaO2 x cardiac output

O2 released when it gets to the tissue

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11
Q

What is the cellular respiration equation

A

Glucose + O2 = CO2 + H2O + ATP

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12
Q

What basic clinical signs to monitor in sedation (6)

A

Respiratory rate (10 -18 per min)

Depth of breathing

Pattern of breathing

Cyanosis

Pulse oximetry

Carbon dioxide

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13
Q

Limitations of pulse oximetry (5)

A

Ambient light

Movement

Cold peripheries

Nail varnish

Measurement lag

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14
Q

What is the effect of sedation on muscles of the pharynx

A

Sedation leads to decrease in tone of muscles of the pharynx

Leads to pharyngeal collapse

Tongue falls against back wall of pharynx

Mild = partial obstruction

Severe = complete obstruction

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15
Q

Signs of airway obstruction (5)

A

Snoring

Stridor

Drop in O2 saturation

Loss of CO2 tracing

Seesaw respiration

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16
Q

Management of airway obstruction (4)

A

Supplementary oxygen

Careful titration of sedation

Opening airway manoeuvres - tilt head and lift chin

Airway adjuncts

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17
Q

How does hypoventilation occur in sedation

A

Sedative drugs sedate the respiratory centre of the brain and reduced receptor sensitivity to CO2

CO2 build up leads to narcosis

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18
Q

How can hypoventilation be prevented

A

Monitor respiratory rate and drop in oxygen saturation

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19
Q

Hypoventilation management (2)

A

Reversal of sedation with Flumazenil or naloxone

Assisted ventilation with self inflating AMBU bag

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20
Q

Causes of hypotension in sedation (4)

A

Vasodilation caused by sedative drugs

Some drugs decrease the strength of heart contraction

Dose related

Elderly patients or those with existing cardiovascular disease

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21
Q

Treatment for hypoventilation (4)

A

Prevention better than cure

Stop administering agent

Place patient head down and with feet elevated

IV fluids may be required

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22
Q

What is cardiac arrhythmia and its treatment in sedation

A

Group of conditions that causes heart to beat irregularly, too slow or too quiet

Call for expert help

23
Q

What is cardiac arrest and its treatment in sedation

A

Sudden loss of blood supply resulting in the failure of the heart to pump blood effectively

Resuscitation

24
Q

Common drug types used for sedation (3)

A

Benzodiazepines - midazolam

Opiates - fentanyl, remifentanil

Others - propofol, ketamine, dexomethomedine

25
Q

Midazolam onset peak and duration

A

Onset - 1-3 mins

Peak - 5-7 mins

Duration - 20-30 mins

26
Q

Midazolam dosage

A

Initial dose - 2.5mg given over 2 mins

Wait 2 mins

All subsequent doses - 1mg

No more than 5mg total

27
Q

Advantages of midazolam (3)

A

Quick onset

Short action of duration

Minimal cardiovascular effects

28
Q

Adverse effects of midazolam (2)

A

Respiratory depression

Airway obstruction

29
Q

What is flumazenil used for

A

Reversal of benzodiazepine effects

30
Q

Dose of flumazenil administered

A

200mcg every 1-2 mins as required

31
Q

Flumazenil onset, peak

A

Onset - 1-2 mins

Peak - 6-10 mins

32
Q

Fentanyl onset, peak and duration

A

Onset - 1-2 mins

Peak - 10-15 mins

Duration - 30-60 mins

33
Q

Fentanyl dose

A

20mcg (05ml) bolus up to 200mcg

34
Q

Advantages of fentanyl (3)

A

Provides analgesia as well as sedation

Fast onset

Short duration

35
Q

Adverse effects of fentanyl (3)

A

Hypotension and bradycardia

Respiratory depression

Nausea and vomitting

36
Q

Propofol onset and duration

A

Onset - 30 seconds

Duration - 10-15 mins

37
Q

What is propofol

A

Intravenous anaesthetic induction agent

38
Q

Propofol dose

A

10-20 mg (1-2ml) every 5 minutes or continuous infusion

39
Q

Advantages of propofol (2)

A

Very potent sedative

Rapid onset

40
Q

Adverse effects of propofol (3)

A

Only for trained staff

Can rapidly progress to GA

Significant CV and resp depression

41
Q

Advantages of poly pharmacy (2)

A

Different drugs have different effects

Giving second means you can administered less of the first which could potentially reduce side effects

42
Q

Disadvantages of poly pharmacy (3)

A

Greater OD risk

Drugs with same side effects increases chance of those side effects

Must be aware of time to peak for both drugs

43
Q

What is conscious sedation

A

Technique where drug(s) produce a state of depression of the CNS - allowing treatment to be carried out

44
Q

Preoperative instructions for N2O/O2 sedation (5)

A

Light meal

Take routine medicines as usual

Children must be accompanied to and from appoitnment

Do not bring other children

Higher doses can cause dizziness/nausea/headaches

45
Q

Pharmocokinetics of N2O/O2 sedation (6)

A

Inhaled into lungs with oxygen through nasal mask

Travels down partial pressure gradient

Alevolus to capillaries

Hardly metabolised

Excreted through lungs

Elimination half life is around 5 mins

46
Q

Pharmacodynamics of N2O/O2 sedation (4)

A

Analgesic

Anaesthetic

Hypnotic

Anxiolytic

47
Q

Indications for Inhalation sedation (3)

A

Social - mild anxiety, enable cannulation

Medical - conditions aggrevated by stress, where continuous o2 delivery is beneficial, conditions affecting cooperation

Dental - unpleasant procedure, avoid GA

48
Q

Contraindications for Inhalation sedation (3)

A

Social - severe anxiety and lack of understanding

Medical - blocked nose, recent eye surgery, bleomycin therapy, pregnancy

Dental - traumatic procedures, upper anterior teeth treatment

49
Q

Impact of dental anxiety (4)

A

3% avoid completely

Dental health state is usually poor

Poor oral hygiene

Risks from sedation

50
Q

Advantages of inhalation sedation (6)

A

Non invasive

Drug levels easily altered and discontinued

Minimal impairment of reflexes

Drug administered and excreted through the lungs - no metabolism and thus rapid recovery

No fasting required

Some analgesia

51
Q

Disadvantages of inhalation sedation (9)

A

Lack of potency of N2O

Expense of equipment

Requirement for clear nasal airway

Intrusion of nasal mask into operating field

Patient perception of equipment

Space occupying equipment

Chronic exposure to staff

Potential for staff addiction

Lack of operator control

52
Q

Indications for inhalation sedation (8)

A

Lack of operator control

Suitable patients

Unpleasant treatment

Anxious children/adults

Needlephobia

Patients with gag reflex

Special needs

Medically compromised

53
Q

Contraindications for Inhalation sedation (16)

A

Respiratory tract obstruction

Nasal obstruction

Cyanosis

Inability to communicate

Pregnancy

Acute fear of GA mask

Multiple sclerosis

Myasthenia gravis

Claustrophobia

Severe personality disorders

Recent ophthalmic surgery

Air entrapment

Where mask will obstruct treatment

Psychiatric disorders

Medication - methotrexate

Substance abuse

54
Q

Properties of ideal inhalation sedation agent (9)

A

Alleviate fear and anxiety

Produce a degree of amnesia and analgesia

Suppress vomiting reflex, but not protective reflexes

Prolong potential operating time

Be rapidly effective

Be easily eliminated

Have no side effects

Be safely and easily administered by the operator

Require no special precautions or procedures

ICP (5 decks)

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