Pain, Sedation, and Delirium Flashcards
Significant Pain CPOT
CPOT > 2
Significant pain BPS
BPS > 5
Morphine
onset: 5-10 min
Duration: 3-6 hrs
Pearls:
- accumulates in renal impairment
- histamine release -> hypotension, bronchospasm, urticaria (itchiness)
Fentanyl
Onset: seconds
Duration: 1-2 hrs
Pearls:
- hepatic metabolism
- CYP3A4 interactions
- tachyphylaxis (resistance)
Hydromorphone
Onset: 5 min
Duration: 2-4 hrs
Pearls:
- good in renal impairment
- option for fentanyl tolerance
- minimal histamine release
- available as patient controlled analgesia
Light sedation RASS scale
0 to -2
light sedation SAS scale
3-4
Propofol
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
Dexmedetomidine
A2 adrenergic agonist
Indications:
- procedural sedation
- sedation for mechanical ventilation
- NOT FOR > 24 HRS
Pharmacodynamics:
- sedative and analgesic properties
ADE:
- bradycrdia
- hypotension
Dexmedetomidine Benefits
No respiratory depression (good for pts weaning off ventilator)
effects similar to natural sleep
opioid-sparing
useful as adjunct therapy for alcohol withdrawal
Dexmedetomidine Drawbacks
risk of hypotension
RASS score of - 3 or less unlikely
Risk of withdrawal with prolonged use
Drug induced fever?
Midazolam
Onset: 2-5 min
Duration: 1-2hrs
Pearls:
- lipophilic
- accumulates in renal impairment
- primary use: status epilepticus
Lorazepam
Onset: 5-20 min
Duration: 2-6 hr
Pearls:
- propylene glycol acidosis
- can use in renal/hepatic failure
Diazepam
Onset: -10 min
Duration: t1/2 44-100 hrs
Pearls:
- can taper off quickly
- standing doses used in alcohol withdrawal
BZD drawbacks
- increased risk of delirium
- increased time on ventilator
- increased length of ICU stay
BZD’s are reserved as first line in:
Status epilepticus
Extreme alcohol withdrawal sx
Severe ARDS requiring deep sedation
Ketamine indications
Anesthesia
Pain
Rapid sequence intubation
Acute severe agitation
Status epilepticus
Treatment resistant depression
PTSD
Ketamine mechanisms
NMDA antagonist
Mu and kappa agonist -> analgesia
Muscarinic Ach receptor antagonist -> bronchodilation
Inhibits reuptake of serotonin, norepinephrine, and dopamine
Ketamine dose for pain:
0.15-0.5 mg/kg/hr
Ketamine dose for anesthesia
0.5-2 mg/kg/hr
Ketamine dose for status epilepticus
> 2 mg/kg/hr
IV ketamine onset
anesthesia within 30 min
IM ketamine onset
Anesthesia: 3-4 min
Analgesia: 10-15 min
IV ketamine duration
Anesthetic effect: 5-10 min
Recovery: 1-2 hrs
IM ketamine duration
Anesthetic effect: 12-25 min
Analgesic effect: 15-30 min
Recovery: 3-4 hrs
Ketamine advantages
favorable hemodynamics
bronchodilator
opioid sparing
Ketamine ADEs
- 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
Risk factors for delirium
Modifiable:
- BZD use
- blood transfusion
Non-modifiable:
- elderly
- dementia
- prior coma
- Previous ICU emergency surgery/trauma
- increased APACHE score
Non-pharm delirium interventions
- 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
Pharmacological delirium treatment
PHARM INTERVENTION NOT RECOMMENDED
However:
- opioids
- dexmedetomidine
- melatonin receptor agonists
- antipsychotics (quetiapine, haloperidol, olanzapine)
NBM monitoring
Train of four using a peripheral nerve stimulator
Goal: 2 twitches
Cisatracurium
elimination: Hoffman (within plasma, no organ reliance)
Onset: 2-5 min
Duration: dose dependent 30-90 min
Rocuronium
Elimination: 50% biliary and renal
Onset: 1-2 min
Duration: 30-60 min
Vecuronium
Elimination: biliary and renal
Onset: 3-5 min
Duration: 45-60 min
Succinylcholine
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)
