Quiz One Flashcards
Be able to give 5 examples of causes of delirium.
D-Drugs (Continuous drips, Na+, Ca+, BUN/Cr, NH3+) E-Environmental factors (hearing aids, eyes glasses, sleep/wake cycle) L-Labs (Na, K, Ca, BUN/Cr, NH3+) I-Infection R-Respiratory Status (ABGs, PaO2, PaCO2) I-Immobility O-Organ Failure U-Unrecognizable Dementia S-Shock (Sepsis, cardiogenic, steroid)
What are the different features that are associated with the definition of delirium
1)Acute Changes or fluctuating Mental status 2) Inattention 3) Altered LOC or Disorganized Thinking
ABCDE Protocol
Awakening and Breathing Coordination Delirium Management Exercise and Mobility It is important to know so that the RN and Rt can coordination the SAT and SBT trial to be done together Rt can help with the non pharm intervention in delirium management RT may help with airways in early exercise
What is you ICP normals
10-15 mmHg
How to calculate MAP
(Systolic + [Diastolic *2]) /3
Ideal CPP
>60-70 But may depend on dr. Orders
Jugular Venous Saturation
Measures SjvO2 (could also give PO2) Gives a global approximation Can be used both as a spot check and continuous monitor
Cerebral Oximetry
SO2 of the underlying tissue Can be continuous or used for spot checks
Licox
PO2 of underlying tissue Is a continuous measurement
What type of ICP monitor allows for concurrent EVD
Fluid filled system where catheter is inserted into the ventricle of the brain
What is the relationship between SjvO2, Cerebral Metabolic Rate, and Cerebral Oxygen Therapy Delivery
SjvO2=(Cerebral Oxygen Delivery)/(Cerebral Metabolic Rate)
GCS-Motor Response
6-Obey Command
5-Localizes to pain
4- Withdrawl frm pain
3- Adbnormal flexion
2-Abnormal extension
1-No movement
GCS-Verbal Response
Oriented (5) Confused (4) Inappropriate Words (3) Inappropriate sounds (2) No Response (1)
GCS-Eye Opening Response
Spontaneously(4) To Speech (3) To Pain (2) None (1)
Glossopharyngeal Nerve
Cranial Nerve IX Gagging and swallowing (Sensory) and taste Assessed through oral care
Vagus Nerves
Cranial Nerve X Gagging and swallowing speech and cough Assessed through suctioning
RASS -3
Patient has any movement in response to voice but no eye contact
RASS -4
Patient has any movement to physical stimulation
RASS -5
Patient has no response to any stimulation
RASS
- Observe the Patient-The patient is alert, restless, or agitated (Score 0 to +4) 2.If Not Alert, State Patient Name and Ask to Open Eyes and Look at Speaker-Patient awake with sustained eye opening and eye contact (Score -1) Patient awakened with eye opening and eye contact, but it is not sustained (Score -2) Patient has any movement in response to voice but no eye contact (Score -3) 3.There is no response to verbal stimulation, physically stimulate by shaking shoulder and/or rubbing sternum •Patient has any movement to physical stimulation (Score -4) •Patient has no response to any stimulation (Score -5)
Sedative
any drug that reduces CNS arousal Sleep is not the same as sedative Benzodiazepines Nonbenzodiazepines Barbituates
Hypnotic
any drug that induces sleep
Anxiolytic
any drug that reduces symptoms of anxiety
Analgesia
any drug that reduces the sensation of pain General anesthesia has four characteristics: unconsciousness, analgesia, muscle relaxation, and depression of reflexes.
Anesthetics
any drug that reduces the ability to perceive sensations
Pharmacological Therapies
Many drugs can have multiple effects! Effect(s) often dose dependent Can get sedation effects at low dose and full anesthetic at high dose. Most available evidence regarding sedatives and analgesics in ICU patients indicates that it may be less important which drugs are delivered than their proper titration using goal-directed delivery (RASS Target) to optimize patient comfort while avoiding complications such as prolonged mechanical ventilation or reintubation
Benzodiazepines
Sedatives/Hypnotics/Anxiolytics Used for its effects of sedative (madadala), hypnotic (valum), anxiolytic Used to treat: anxiety, agitation, insomnia, seizures/ status epilepticus, muscle spasms, alcohol withdrawal (DTs) Can be short, intermediate or long-acting (longer-acting used for anxiety) Outside ICU used for anxiety and insomnia-Note: there are other benzo’s that are prescribed for assisting with sleep Some common benzo’s used for anxiety/hypnotic effects
Benzodiazepines Cautions
Can cause loss of airway reflexes at high doses and decreased tidal volume at lower doses
Benzodiazepines Reversal Agent
flumazenil (Romazicon)
Benzos for Sleep:
Flurazepam Triazolam (Halcion) Zopiclone(Imovane)
Trade Name Midazolam
Versed It is a Benzodiazepines
Trade Name Iorazepam
Ativan It is a Benzodiazepines
Trade Name Diazepam
It is a Benzodiazepines Valium
Trade Name Alprazolam
Xanax It is a Benzodiazepines
Dexmedetomidine (Precedex)
Sedative, analgesic, sympatholytic, and anxiolytic properties
Will provide sedation with respiratory system depression
Benefits include less deliruim, shortened intubation time, and reduce ICU stay
Very Expensive!
Barbituates
E.g. Thiopental (Sodium Pentothal), phenobarbital (Luminal) One of the oldest group of sedative drugs; use has largely been replaced by benzo’s Can be used as anesthetics (thiopental) or hypnotics
Phenobarbital
Barbituates Phenobarbital used for seizure control Phenobarbital is a barbiturate and the most widely used anticonvulsant worldwide,[1] and the oldest still commonly used. It also has sedative and hypnotic properties, but as with other barbiturates, it has been superseded by the benzodiazepines for these indications.
Anesthetics Stages
Stage 1: analgesia; patient retains consciousness without experiencing pain (“conscious sedation”) Stage 2: loss of consciousness Stage 3: respiratory depression; loss of reflexes (“surgical anesthesia”) Stage 4: complete loss of respiratory drive; may be loss of cardiovascular tone] All of the drugs discussed, in a dose-dependent fashion, can result in the different stages of anesthesia! (i.e. not just anesthetic drugs!)
Diprivan (Propofol)
Propofol is often used for sedation for mechanically ventilated patients, for induction and maintenance of anesthesia and for conscious sedation. “milk of amnesia” Short-acting hypnotic agent Recovery is rapid and “clear” Does NOT have analgesic properties
Diprivan (Propofol) Side Effects
Hypotension Respiratory depression Pain on injection
Diprivan (Propofol) Uses
Induction and maintenance of general anesthesia
Sedation for mechanically ventilated patients
Procedural sedation
Narcotics (Opioids)
Opioid – derivative of naturally occurring drug mixture opium, derived from the Poppy
Narcotics (Opioids) Overdose
Pinpoint pupils, coma, and respiratory depression
Narcotics (Opioids) Reversal Agent
Reversal agents are the narcotic antagonists naloxone (Narcan) or naltrexone (ReVia). Note: the reversal agent doesn’t last as long as the drug itself! Redosing may be needed!
Common Narcotics
(Can be given via a bolus or infusion; Top 3 are most common in ICU) Morphine Fentanyl Codeine Meperidine (demerol) Oxycodone
Morphine
Narcotic Can be aerosolized for palliative care Numerous brands
Fentanyl
Narcotic Ex. Sublimaze, etc
Oxycodone + acetaminophen
Percocet
Narcotics (Opioids) Effects
Analgesia Sedation Decreases preload and afterload on the left ventricle Antitussive qualities (cough supression)
Narcotics (Opioids) Side Effects:
Nausea and vomiting Constipation Tolerance/addiction Causes release of histamine Thus narcotic use in someone with hypersentive airways is discouraged! Bronchospasm, rashes, inflammation can result
Non Steroidal Anti-Inflammatory Drugs (NSAIDs)
Acetaminophen (e.g. Tylenol/acetaminophen) Salicylates (Aspirin/acetylsalicylic acid) Ibuprofen (e.g. Advil/ibuprofen)
Acetaminophen
Tylenol
Used in ICU for anti-pyretic effects
OD can cause hepatotoxicity
Salicylates (Aspirin/acetylsalicylic acid)
(Aspirin/acetylsalicylic acid) Not used in ICU for it’s analgesia or anti-pyretic properties Given in acute coronary syndromes as it inhibits platelet aggregation Asthmatics can be sensitive to aspirin resulting in bronchospasm!
Ibuprofen (e.g. Advil/ibuprofen)
(e.g. Advil/ibuprofen) Has analgesic, anti-inflammatory and antipyretic effects Not typically used in ICU environment
Anti-Psychotics
Eg. Haldol (haloperidol) Typically used to control active psychotic symptoms in someone with psychotic disorders (e.g. schizophrenia disorders) Used in delirium management after other management is tried
Paralytics (Neuromuscular Blocking Agents – NMBAs)
= Paralytics or skeletal muscle relaxants All patients require proper eye care as no more blinking; light taping of eyes Paralyze only!! (i.e. lack amnesic, sedative and analgesic properties!) MUST sedate patient and use analgesics as necessary! Two types: 1) Non-depolarizing 2) Depolarizing
Non-depolarizing NMBAs
Tubocurarine, atracurium (Tracrium), pancuronium (Pavulon), rocuronium (Zemuron) etc. Mechanism of action: Competitively blocking the binding of acetylcholine to its receptors preventing Acetylcholine from depolarizing the muscle fiber causing vagolytic effedct The increased MAP can incresae ICP! Slow onset of action, longer duration These tend to be used to maintain paralysis in ICU
Non-depolarizing NMBAs Side effects
Cardiovascular effects (tachycardia, vasoconstriction and hypertension). Pavulon the worst. Have a tendency to release histamine Need to provide ventilation!
Non-depolarizing NMBAs Reversal Agent
Neostigmine-Neostigmine is a cholinesterase inhibitor (cholinesterase is the enzyme that breaks down AcH)
Depolarizing NMBAs
Rapid onset; short duration Used for short procedures (e.g. intubation) Succinylcholine (Anectine) There are NO reversal agents!! Sensitivity to Succinycholine –metabolized by plasma cholinesterase. Pts with abnormal or deficient pseudocholinesterase do not meatbolize effective and have a prolonged recovery requiring mechanical ventialitn
Depolarizing NMBAs Mechanism of Action
Act by depolarizing the muscle fiber and prolonging the depolarized state; results in fasiculations (uncoordinated skeletal muscle contractions) First depolarize the muscle fiber and then prolong the depolarized state to prevent repolarization
Depolarizing NMBAs Side Effects
Tachycardia, hypertension Histamine release (and thus brochospasm; hypotension) Hyperkalemia Increased ICP Malignant hyperthermia (rarely) Sensitivity to Succinycholine Side effect Muscle pain and soreness
Depolarizing NMBAs When are they Used
For intubation Reduce ICP in intubated patients with uncontrollable ICP To achieve patient-ventilator synchrony To reduce oxygen consumption To stop status epilepticus or shivering (therapeutic hypothermia) In surgery, or to facilitate procedures or diagnostic studies To paralyze selected patients who must remain immobile (e.g. trauma patients).
A decreased PaCO2 level has what impact on cerebral blood flow
Decreased CO2 will result in vasoconstriction and decrease cerebral blood flow
Over Sedation
Prolonged mechanical ventilation, ICU stay-Trach, VAP
Additional Testing
Added Cost
Inability to Communicate
Cannot evaulate Delirium
Delirium Definition
An acute brain dsyfunction (not chronic, like dementia) that involves altered LOC and inattention or disorganized thinking
Tends to flucuate throughout the day
Why is it important to evaulate delirium
It it is a sign that there is an underlying medical problem
Will help us to improve sedation level
Will improve overall care
CNS and PNS
CNS-Brain and Spinal Cord
PNS-12 pairs of cranial nerves and 31 spinal nerves
What part of the brain controls respirtion
Medulla (dorsal and ventral groups, primary control)
Pons (apneustics and pneumotaxics center that fire tunes the main controls)
There are also central and peripheral chemorecptors
Where does the phrenic nerve arise from
C3-C5
