Pain Management: Sedation

Question 1

What should you NOT use for sedation?

Answer 1

BZD drips

Question 2

If agitation isn’t controlled by opioids, what are your options?

Answer 2

Propofol, Precedex, ketamine, PRN boluses of BZDs

Question 3

Ideal RASS score for sedation

Answer 3

0 to -2

Question 4

RASS score: 0

Answer 4

alert and calm

Question 5

RASS score: -1

Answer 5

not fully alert, but has sustained awakening to voice for ≥10 seconds

Question 6

RASS score: -2

Answer 6

briefly awakens with eye contact to voice for <10 seconds

Question 7

Ideal SAS score for sedation

Answer 7

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

Question 8

Propofol: onset

Answer 8

<1 minute

Question 9

Propofol: duration

Answer 9

10-15 minutes; rapid hepatic and extra hepatic CL

Question 10

Propofol: benefits

Answer 10

First-line agent for severe alcohol withdrawal, SE

Question 11

Propofol: drawbacks

Answer 11

NO ANALGESIC PROPERTIES

Long-term administration can lead to saturation of peripheral tissues

Question 12

Propofol: PK/PD

Answer 12

Hypnotic, anxiolytic, amnestic, and anticonvulsant effects

Question 13

Propofol: ADEs

Answer 13

Respiratory depression: use with caution or only in intubated patients

Hypotension, bradycardia, decreased CO, hypertriglyceridemia, PRIS with higher doses and longer duration

Question 14

Propofol: clinical pearls

Answer 14

Lipid emulsion provides 1.1kcal/ml of nutrition
Avoid in patients with egg, sulfite, soybean allergies

Question 15

Propofol: monitoring

Answer 15

BP, HR, TGs, anion gap/lactate, and CK when using >48 hours

Question 16

Precedex: benefits

Answer 16

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

Question 17

Precedex: drawbacks

Answer 17

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

Question 18

Precedex: PK/PD

Answer 18

Sedative and analgesic properties

Question 19

Precedex: ADEs

Answer 19

Bradycardia, hypotension

Question 20

Precedex: pearls

Answer 20

Alpha-2 adrenergic agonist
Don’t use in RASS score more than -3

Question 21

Midazolam: onset

Answer 21

2-5 minutes

Question 22

Midazolam: duration

Answer 22

1-2 hours

Question 23

Midazolam: dosing

Answer 23

Bolus: 2-4mg
Infusion: 1-4 mg/hr

Question 24

Midazolam: pearls

Answer 24

Lipophilic
Active metabolites
Accumulates in renal impairment
Primary use for status epilepticus

Question 25

Lorazepam: onset

Answer 25

5-20 minutes

Question 26

Lorazepam: duration

Answer 26

2-4 hours

Question 27

Lorazepam: dosing

Answer 27

Bolus: 1-2mg Infusion: 0.5-4mg/hr

Question 28

Lorazepam: pearls

Answer 28

Propylene glycol acidosis → propylene glycol is the diluent → metabolic acidosis Can use in renal/hepatic failure

Question 29

Diazepam: onset

Answer 29

5-10 minutes

Question 30

Diazepam: duration

Answer 30

44-100 hours as the half-life

Question 31

Diazepam: dosing

Answer 31

5-15mg TID

Question 32

Diazepam: pearls

Answer 32

Active metabolites Can taper off quickly Standing doses used in alcohol withdrawal

Question 33

BZDs drawbacks in sedation

Answer 33

Increased risk of delirium Increased time on a ventilator Increased length of ICU stay DON'T GIVE WHEN A PATIENT IS AGITATED

Question 34

BZDs are reserved first-line for what situations?

Answer 34

Reserve first line in: status epilepticus, extreme alcohol withdrawal symptoms, severe ARDS requiring deep sedation

Question 35

Ketamine: onset

Answer 35

IV: within 30 seconds IM: 3-4 minutes (anesthetic), 10-15 minutes (analgesia)

Question 36

Ketamine: duration

Answer 36

IV: 5-10 minutes, recovery 1-2 hours IM: 12-25 minutes (anesthetic), 15-30 minutes for analgesia, recovery 3-4 hours

Question 37

Ketamine: dosing

Answer 37

Dose-dependent effects

Question 38

Ketamine: benefits

Answer 38

Favorable hemodynamic Bronchodilator effects Opioid-sparing effects Don’t need to intubate the patient to administer

Question 39

Ketamine PO bioavailability

Answer 39

20-30% PO bioavailability

Question 40

Ketamine ADEs

Answer 40

Emergence reaction (pretreat with BZD or propofol) Agitations, hallucinations Oral secretions Tachycardia HTN