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Therapeutics P3 Spring > Pain, Sedation, and Delirium > Flashcards

Pain, Sedation, and Delirium Flashcards

1
Q

Significant Pain CPOT

A

CPOT > 2

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2
Q

Significant pain BPS

A

BPS > 5

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3
Q

Morphine

A

onset: 5-10 min
Duration: 3-6 hrs
Pearls:
- accumulates in renal impairment
- histamine release -> hypotension, bronchospasm, urticaria (itchiness)

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4
Q

Fentanyl

A

Onset: seconds
Duration: 1-2 hrs
Pearls:
- hepatic metabolism
- CYP3A4 interactions
- tachyphylaxis (resistance)

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5
Q

Hydromorphone

A

Onset: 5 min
Duration: 2-4 hrs
Pearls:
- good in renal impairment
- option for fentanyl tolerance
- minimal histamine release
- available as patient controlled analgesia

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6
Q

Light sedation RASS scale

A

0 to -2

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7
Q

light sedation SAS scale

A

3-4

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8
Q

Propofol

A

NO ANALGESIC PROPERTIES
MOA: stimulates GABA, inhibits NMDA
PD:
- hypnotic
- anxiolytic
- amnesic
- anticonvulsant
Onset: < 1 min
Duration: 10-15 min
Clearance: hepatic and extrahepatic
ADE:
- respiratory depression
- hypotension
- bradycardia
- decreased cardiac output
- hypertriglyceridemia (acute pancreatitis)
- propofol related infusion syndrome (PRIS)
Pearls:
- first line in severe alcohol withdrawal and status epilepticus
- lipid emulsion -> provides 1.1 kcal/mL of nutrition
- avoid in pts with egg, sulfite, or soybean allergy
- monitor (if using > 48h) BP, HR, triglycerides, anion gap, lactate, CK

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9
Q

Dexmedetomidine

A

A2 adrenergic agonist
Indications:
- procedural sedation
- sedation for mechanical ventilation
- NOT FOR > 24 HRS
Pharmacodynamics:
- sedative and analgesic properties
ADE:
- bradycrdia
- hypotension

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10
Q

Dexmedetomidine Benefits

A

No respiratory depression (good for pts weaning off ventilator)
effects similar to natural sleep
opioid-sparing
useful as adjunct therapy for alcohol withdrawal

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11
Q

Dexmedetomidine Drawbacks

A

risk of hypotension
RASS score of - 3 or less unlikely
Risk of withdrawal with prolonged use
Drug induced fever?

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12
Q

Midazolam

A

Onset: 2-5 min
Duration: 1-2hrs
Pearls:
- lipophilic
- accumulates in renal impairment
- primary use: status epilepticus

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13
Q

Lorazepam

A

Onset: 5-20 min
Duration: 2-6 hr
Pearls:
- propylene glycol acidosis
- can use in renal/hepatic failure

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14
Q

Diazepam

A

Onset: -10 min
Duration: t1/2 44-100 hrs
Pearls:
- can taper off quickly
- standing doses used in alcohol withdrawal

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15
Q

BZD drawbacks

A
  • increased risk of delirium
  • increased time on ventilator
  • increased length of ICU stay
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16
Q

BZD’s are reserved as first line in:

A

Status epilepticus
Extreme alcohol withdrawal sx
Severe ARDS requiring deep sedation

17
Q

Ketamine indications

A

Anesthesia
Pain
Rapid sequence intubation
Acute severe agitation
Status epilepticus
Treatment resistant depression
PTSD

18
Q

Ketamine mechanisms

A

NMDA antagonist
Mu and kappa agonist -> analgesia
Muscarinic Ach receptor antagonist -> bronchodilation
Inhibits reuptake of serotonin, norepinephrine, and dopamine

19
Q

Ketamine dose for pain:

A

0.15-0.5 mg/kg/hr

20
Q

Ketamine dose for anesthesia

A

0.5-2 mg/kg/hr

21
Q

Ketamine dose for status epilepticus

A

> 2 mg/kg/hr

22
Q

IV ketamine onset

A

anesthesia within 30 min

23
Q

IM ketamine onset

A

Anesthesia: 3-4 min
Analgesia: 10-15 min

24
Q

IV ketamine duration

A

Anesthetic effect: 5-10 min
Recovery: 1-2 hrs

25
Q

IM ketamine duration

A

Anesthetic effect: 12-25 min
Analgesic effect: 15-30 min
Recovery: 3-4 hrs

26
Q

Ketamine advantages

A

favorable hemodynamics
bronchodilator
opioid sparing

27
Q

Ketamine ADEs

A
  • Emergence reaction (caution in pts with schizophrenia, may pretreat with BZD or propofol)
  • oral secretions (do not mistake for pneumonia)
  • tachycardia -> caution in Afib
  • hypertension
28
Q

Risk factors for delirium

A

Modifiable:
- BZD use
- blood transfusion
Non-modifiable:
- elderly
- dementia
- prior coma
- Previous ICU emergency surgery/trauma
- increased APACHE score

29
Q

Non-pharm delirium interventions

A
  • re orient the patient
  • use hearing aids or glasses
  • limit noise and light at night
  • encourage natural sleep-wake cycle
  • early mobilization
  • family presence
  • music therapy
  • limit use of BZDs and anticholinergics
30
Q

Pharmacological delirium treatment

A

PHARM INTERVENTION NOT RECOMMENDED
However:
- opioids
- dexmedetomidine
- melatonin receptor agonists
- antipsychotics (quetiapine, haloperidol, olanzapine)

31
Q

NBM monitoring

A

Train of four using a peripheral nerve stimulator
Goal: 2 twitches

32
Q

Cisatracurium

A

elimination: Hoffman (within plasma, no organ reliance)
Onset: 2-5 min
Duration: dose dependent 30-90 min

33
Q

Rocuronium

A

Elimination: 50% biliary and renal
Onset: 1-2 min
Duration: 30-60 min

34
Q

Vecuronium

A

Elimination: biliary and renal
Onset: 3-5 min
Duration: 45-60 min

35
Q

Succinylcholine

A

Elimination: plasma
Onset: 30-60 seconds
Duration: 5-10 min
ADE:
- malignant hyperthermia
- hyperkalemia (CI with K > 4)
commonly used for rapid sequence intubation (quick on and off)

Therapeutics P3 Spring (32 decks)

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