Pain and Sedation Flashcards
What is the goal for procedural sedation? (4)
- guide patient safety and welfare
- minimize negative psychological responses to tx with analgesia and maximize amnesia
- minimize physical discomfort
- control behavior
What is the criteria for discharge after sedation? (4)
- ability to drink water
- alert and oriented
- stable vital signs
- able to pass gas and urinate
what is the level of sedation defined by? (5)
- airway control
- respiratory responsiveness
- gross motor skills
- level of awareness
- responsiveness to stimuli
example of minimal or light sedation?
anxiolysis: ativan
what is the level of responsiveness with minimal or light sedation?
normal response to verbal stimuli
how is the patients airway affected by minimal/light sedation?
unaffected
how is spontaneous ventilation affected by minimal or light sedation?
unaffected
how is cardiovascular function affected by minimal/light sedation?
unaffected
what is the level of responsiveness with conscious sedation?
purposeful response to verbal or tactile stimuli
how is the airway affected by conscious sedation?
no intervention required
how is spontaneous ventilation with conscious sedation?
adequate
how is cardio function with conscious sedation?
usually maintained
what is the level of responsiveness with deep sedation?
purposeful response following repeated or painful stimuli
how is the patients airway affected by deep sedation?
intervention may be required
how is the patients spontaneous ventilation affected by deep sedation?
inadequate
how is cardio function with deep sedation?
usually maintained
how responsive is the patient with general anesthesia?
unarousable even with repeated or painful stimuli
how is the patients airway during general anesthesia?
intervention is required
how is spontaneous ventilation during general anesthesia?
frequently inadequate and is compromised
how is cardio function with general anesthesia?
maybe impaired
how to prep a patient for sedation? (5)
- NPO
- baseline assessments
- IV starts
- informed consents
- equipment set up
documentation required before surgery?
-Informed consent
-instructions for after
surgery
-last food and fluid intake
-vital signs
-review of systems
Who may sign an informed consent?
- patient may sign
- if emergent can perform without signing
- DPOA may sign
what systems are reviewed before surgery?
- age and weight
- allergies
- current meds (did they take?)
- are you to hold any meds?
- relevant disease processes
- previous hospitalizations
- history of sedation
on site equipment for sedation?
fit all sizes
- positive pressure oxygen delivery
- suction
- ambu bag
- NIBP
- pulse oximetry
- capnography
- emergency cart
What does DEMOS stand for?
are you ready for sedation? D-drugs E-emergency M-monitoring O-oxygen S-suction
discharge criteria after sedation?
- CV function and airway patency are satisfactory
- arousable and protective mechanisms are intact
- appropriate verbalization
- alert and oriented
- state of hydration is adequate
what type of medication is midazolam?
a benzodiazepine
what is midazolam used for?
- immobility
- sedation
- amnesia
- antianxiolytic
what drug is midazolam used with?
fentanyl
why is midazolam used with fentanyl?
because it is unpredicatable as a primary agent
what monitoring is required for use of midazolam?
cardiac monitoring
what is the antidote for midazolam?
flumazenil
what is flumazenil?
benzodiazepine antidote
-reverses induced sedation and amnesia
what can flumazenil cause?
seizures
how fast does flumazenil work?
rapid onset
duration <1hr
how long do you give flumazenil over?
1/2-1 minute
what type of drug is morphine?
opiate analgesic
what does morphine do?
analgesic, sedation, immobility
how do you give morphine?
IV, always give slowly
what is the concern with morphine?
respiratory depression
peak for respiratory depression 20 minutes
what does morphine cause?
causes histamine release
- itching
- flushing
- rash and hives
what is the antidote for morphine?
naloxone
what type of drug is fentanyl?
opiate analgesic
what does fentanyl do?
analgesic, sedation, immobility
how strong is fentanyl?
over 100 times more potent than morphine
how is fentanyl given?
oralet, IM, IV
what is the dosage of fentanyl?
1-2mcg/kg to begin, and titrate to effect
how fast does fentanyl work?
rapid IV onset: 1-5 minutes
duration for fentanyl?
1/2-1 hour
antidote of fentanyl?
naloxone
how do we give fentanyl?
we give slowly through the IV
why do we give fentanyl slowly?
may cause skeletal muscle or chest wall rigidity
what does naloxone?
displaces opioid drugs at the opioid receptor site
how do we give narcan?
give IV slowly until desired response
how fast is the onset of naloxone?
2 minutes, may repeat every 2-3 minutes
what is the duration of naloxone?
15-60minutes
what type of drug is ketamine?
dissociative anesthetic: a form of general anesthesia, but not a complete unconsciousness
what are dissociative anesthetics characterized by?
catalepsy
catatonia
amnesia
what is the onset of ketamine?
1 minute, duration of 20 minutes
what routes can ketamine be given through?
IV, IM, oral, rectal, IN
what vitals are effected by ketamine?
increases pulse, BP, CO/CI, and ICP
what other affect does ketamine have?
increases secretions
what do we treat the increased secretions from ketamine with?
pre treat with glycopyrrolate or atropine
what is dexmedetomidine?
sedative to provide light sedation, anxiolysis, arousable sedation and analgesia
how long should a precedex drip last?
no longer than 24 hours
what is the onset of precedex?
PO-30min IV-10min
what is the half life of precedex?
6 minutes
what is the duration of precedex?
4 hours
what are the side effects of precedex?
N/V, HoTN, bradycardia
what do we treat side effects of precedex with?
fluids, pressors, atropine
what is propofol?
hypnotic agent, little analgesic effect, causing immobility
how is propofol given?
IV only: is painful- can use lidocaine to ease pain
how fast is the half life of propofol?
very fast! patient will be awake within minutes of cessation of med.
when and why are sedation vacations done?
generally done in the morning to check neuro status
what is the medication propofol given through?
med is in lipid emulsion, with strict asepsis (monitor pts triglycerides)
what age can propofol be given to ?
over 12 years of age
what is the primary concern for patients on propofol?
hypotension, monitor blood pressure every 3-5 minutes throughout
What does PRIS stand for?
propofol related infusion syndrome
what is PRIS?
propofol impairs utilization of fatty acids (necessary for cardiac and skeletal muscle activity) resulting in catabolism- muscle necrosis- elevated creatine kinase and myoglobin
what can PRIS result in when combined with critical condition?
cardiac failure, rhabdomyolysis, metabolic acidosis, renal failure
what do we need to watch for in relation to PRIS?
elevated CK, unexplained lactic acidosis, hypotension, ST segment elevation
what is vital with PRIS?
early intervention
what is etomidate?
ultra short acting non-barbituate hypnotic used for anesthesia
what does etomidate produce?
rapid induction
what effects does etomidate have on the body?
- minimal cardio, respiratory, and hemodynamic effects
- lowers cerebral blood flow by 20-30% and slightly reduces ICP
what is Etomidate used for?
RSI
how do we give sedation?
start with low dose and titrate to effect
what is the purpose of continuous sedation?
facilitate oxygenation, decrease tissues oxygenation needs and promote normal ICP
T/F
neuromuscular blockades are not the same as sedation?
true
paralytics are not sedation!
three aspects of the nurse practice act in relation to sedation?
-physician must be available
-RN has competency
accepts only those
-assignments for which she is competent
what are the 5 key concepts for pharm pain management?
- appropriate drugs in appropriate doses
- sedation is not analgesia
- neuromuscular blockers are not analgesics or sedatives
- when switching drugs - check equianalgesic chart
- around the clock to avoid break through pain
definition of tolerance?
a given dose of the drug produces less analgesia or requires a larger dose for the same relief
definition of ceiling effect?
the point beyond which no additional analgesia is
obtained
definition of physical dependence?
altered physiological state produced by repeated administration of an opiate. Withdrawal produces tearing, rhinorrhea, yawning, insomnia, dilated pupils, N& V, diarrhea, muscle
spasms
definition of addiction?
behavioral response characterized by overwhelming preoccupation with securing & using a drug.
what are the 3 coanalgesics?
- gabapentin
- glucocorticoids
- lidocaine patches
what type of drug is gabapentin?
anticonvulsant - used for neuropathic pain and herpetic pain
what type of drug is glucocorticoids?
reduce edema in tumor and nerve tissue, good for patients with bone mets
what are lidocaine patches used for?
postherpetic neuralgia : on 12 hours, off 12 hours
