Pain Management: Sedation Flashcards
What should you NOT use for sedation?
BZD drips
If agitation isn’t controlled by opioids, what are your options?
Propofol, Precedex, ketamine, PRN boluses of BZDs
Ideal RASS score for sedation
0 to -2
RASS score: 0
alert and calm
RASS score: -1
not fully alert, but has sustained awakening to voice for ≥10 seconds
RASS score: -2
briefly awakens with eye contact to voice for <10 seconds
Ideal SAS score for sedation
3-4
4: calm and cooperative; awakens easily and follows commands
3: difficult to arouse, awakens to verbal stimuli or gentle shaking, but drifts off again, follows simple commands
Propofol: onset
<1 minute
Propofol: duration
10-15 minutes; rapid hepatic and extra hepatic CL
Propofol: benefits
First-line agent for severe alcohol withdrawal, SE
Propofol: drawbacks
NO ANALGESIC PROPERTIES
Long-term administration can lead to saturation of peripheral tissues
Propofol: PK/PD
Hypnotic, anxiolytic, amnestic, and anticonvulsant effects
Propofol: ADEs
Respiratory depression: use with caution or only in intubated patients
Hypotension, bradycardia, decreased CO, hypertriglyceridemia, PRIS with higher doses and longer duration
Propofol: clinical pearls
Lipid emulsion provides 1.1kcal/ml of nutrition
Avoid in patients with egg, sulfite, soybean allergies
Propofol: monitoring
BP, HR, TGs, anion gap/lactate, and CK when using >48 hours
Precedex: benefits
Used in procedural sedation and sedation for mechanical ventilation not lasting >24 hours
No respiratory depression
Effects similar to naturally-occurring sleep
Opioid-sparing effects
Useful as adjunct therapy for alcohol withdrawal
Precedex: drawbacks
Don’t use as monotherapy in alcohol withdrawal
Risk of hypotension
RASS score of -3 or less is unlikely (heavy sedation)
Risk of withdrawal with prolonged use
Case reports of drug-induced fever
Precedex: PK/PD
Sedative and analgesic properties
Precedex: ADEs
Bradycardia, hypotension
Precedex: pearls
Alpha-2 adrenergic agonist
Don’t use in RASS score more than -3
Midazolam: onset
2-5 minutes
Midazolam: duration
1-2 hours
Midazolam: dosing
Bolus: 2-4mg
Infusion: 1-4 mg/hr
Midazolam: pearls
Lipophilic
Active metabolites
Accumulates in renal impairment
Primary use for status epilepticus
Lorazepam: onset
5-20 minutes
Lorazepam: duration
2-4 hours
Lorazepam: dosing
Bolus: 1-2mg
Infusion: 0.5-4mg/hr
Lorazepam: pearls
Propylene glycol acidosis → propylene glycol is the diluent → metabolic acidosis
Can use in renal/hepatic failure
Diazepam: onset
5-10 minutes
Diazepam: duration
44-100 hours as the half-life
Diazepam: dosing
5-15mg TID
Diazepam: pearls
Active metabolites
Can taper off quickly
Standing doses used in alcohol withdrawal
BZDs drawbacks in sedation
Increased risk of delirium
Increased time on a ventilator
Increased length of ICU stay
DON’T GIVE WHEN A PATIENT IS AGITATED
BZDs are reserved first-line for what situations?
Reserve first line in: status epilepticus, extreme alcohol withdrawal symptoms, severe ARDS requiring deep sedation
Ketamine: onset
IV: within 30 seconds
IM: 3-4 minutes (anesthetic), 10-15 minutes (analgesia)
Ketamine: duration
IV: 5-10 minutes, recovery 1-2 hours
IM: 12-25 minutes (anesthetic), 15-30 minutes for analgesia, recovery 3-4 hours
Ketamine: dosing
Dose-dependent effects
Ketamine: benefits
Favorable hemodynamic
Bronchodilator effects
Opioid-sparing effects
Don’t need to intubate the patient to administer
Ketamine PO bioavailability
20-30% PO bioavailability
Ketamine ADEs
Emergence reaction (pretreat with BZD or propofol)
Agitations, hallucinations
Oral secretions
Tachycardia
HTN
