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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
Midazolam onset peak and duration
Onset - 1-3 mins Peak - 5-7 mins Duration - 20-30 mins
26
Midazolam dosage
Initial dose - 2.5mg given over 2 mins Wait 2 mins All subsequent doses - 1mg No more than 5mg total
27
Advantages of midazolam (3)
Quick onset Short action of duration Minimal cardiovascular effects
28
Adverse effects of midazolam (2)
Respiratory depression Airway obstruction
29
What is flumazenil used for
Reversal of benzodiazepine effects
30
Dose of flumazenil administered
200mcg every 1-2 mins as required
31
Flumazenil onset, peak
Onset - 1-2 mins Peak - 6-10 mins
32
Fentanyl onset, peak and duration
Onset - 1-2 mins Peak - 10-15 mins Duration - 30-60 mins
33
Fentanyl dose
20mcg (05ml) bolus up to 200mcg
34
Advantages of fentanyl (3)
Provides analgesia as well as sedation Fast onset Short duration
35
Adverse effects of fentanyl (3)
Hypotension and bradycardia Respiratory depression Nausea and vomitting
36
Propofol onset and duration
Onset - 30 seconds Duration - 10-15 mins
37
What is propofol
Intravenous anaesthetic induction agent
38
Propofol dose
10-20 mg (1-2ml) every 5 minutes or continuous infusion
39
Advantages of propofol (2)
Very potent sedative Rapid onset
40
Adverse effects of propofol (3)
Only for trained staff Can rapidly progress to GA Significant CV and resp depression
41
Advantages of poly pharmacy (2)
Different drugs have different effects Giving second means you can administered less of the first which could potentially reduce side effects
42
Disadvantages of poly pharmacy (3)
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
What is conscious sedation
Technique where drug(s) produce a state of depression of the CNS - allowing treatment to be carried out
44
Preoperative instructions for N2O/O2 sedation (5)
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
Pharmocokinetics of N2O/O2 sedation (6)
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
Pharmacodynamics of N2O/O2 sedation (4)
Analgesic Anaesthetic Hypnotic Anxiolytic
47
Indications for Inhalation sedation (3)
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
Contraindications for Inhalation sedation (3)
Social - severe anxiety and lack of understanding Medical - blocked nose, recent eye surgery, bleomycin therapy, pregnancy Dental - traumatic procedures, upper anterior teeth treatment
49
Impact of dental anxiety (4)
3% avoid completely Dental health state is usually poor Poor oral hygiene Risks from sedation
50
Advantages of inhalation sedation (6)
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
Disadvantages of inhalation sedation (9)
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
Indications for inhalation sedation (8)
Lack of operator control Suitable patients Unpleasant treatment Anxious children/adults Needlephobia Patients with gag reflex Special needs Medically compromised
53
Contraindications for Inhalation sedation (16)
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
Properties of ideal inhalation sedation agent (9)
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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