Acute onset Fluctuating mental stage and Disorganised thinking OR Altered level of conciousness

Sedation / Delirium Flashcards by Peter Turton

Mechanism of PRIS

Impaired oxidative phosporylation of the mitochondria

Free fatty acid utilisation

How well did you know this?

Not at all

Perfectly

Features of PRIS

Met acidosis
Arrhythmias (Brady)
High lipids
Renal and hep failure
Rhabdo

How well did you know this?

Not at all

Perfectly

Risk factors for PRIS

Young age
Head injury
Sepsis
High catecholamine level
High glucocorticoid levels
Low carb/high lipid intake

How well did you know this?

Not at all

Perfectly

Propofol dose to prevent PRIS

4mg/kg/hour

How well did you know this?

Not at all

Perfectly

Potential monitoring for PRIS

Daily CK

Triglycerides

How well did you know this?

Not at all

Perfectly

Evidence for dexmed

Is non-inferior to all usual sedative

Reduced delirium compared to lorazepam (MENDS study) and Midaz (MIDEX study)

No difference in MV duration compared to propo (PRODEX study)

Patients can communicate pain better compared to prop and midaz

How well did you know this?

Not at all

Perfectly

Can dexmed be used for deep sedation

How well did you know this?

Not at all

Perfectly

Ketamine side effects in ITU

Sympathetic stimulation

Bronchodilation

Preserved cough reflex

Muscle rigidity

Hallucinations

How well did you know this?

Not at all

Perfectly

Delirium definition

Acute onset

Fluctuating mental stage and

Disorganised thinking

Altered level of conciousness

How well did you know this?

Not at all

Perfectly

Types of delerium

Hyperactive (agitated, restless, paranoid)

Hypoactive (lethargic, inattentive, “pleasantly confused”)

Mixed (fluctuate between two)

How well did you know this?

Not at all

Perfectly

Which is the least common form of delirium

Hyperactive…

How well did you know this?

Not at all

Perfectly

Incidence of deliriu

As high as 83%

How well did you know this?

Not at all

Perfectly

Effects of delirium

Increased hospital LOS
Increased 6/12 month mortality
Neurocognitive issues in survivors

How well did you know this?

Not at all

Perfectly

Is there a role for prophylactic antipsychotics in delirium

How well did you know this?

Not at all

Perfectly

What is the scoring system for RASS, what is normal?

+4 to -5
+4 combative
-5 Unrousable
0 normal

How well did you know this?

Not at all

Perfectly

Scoring system for Ramsey scale

1 - 6

2 is co-operative
1 anxious/agitation

6 unrousable

How well did you know this?

Not at all

Perfectly

Scoring system fro Ryker

1-7

1 unrousable
7 dangerous agitation
4 calm

How well did you know this?

Not at all

Perfectly

Propofol mechanism

? positive modulation of GABA at GABAan receptor

Hyperpolarisation –> chloride influx

How well did you know this?

Not at all

Perfectly

Propofol PKs

Highly protein bounf 98% albumin

Fast onset/offset
High clearence

Accumulates in tissues

How well did you know this?

Not at all

Perfectly

Propofol PDs

Decreased SVR
Decreased CO and BP
Resp depression
Antitussive

How well did you know this?

Not at all

Perfectly

Adverse effect Propofol

PRIS
Pain on bolus
High lipids

How well did you know this?

Not at all

Perfectly

Benzos mechanism

Modulate effect of GABA at GABAa receptors

Benzos PK

Loraz - metabolised by glucuronidation to infactive metabolites

Midaz - oxidized by cP450 to water soluble metabolites (THESE ACCUMULATE)

Benzos PD

Dose dependent resp depresson

Decreased HR/SVR

Fentanyl potency compared to morphine

100

Alfentanil potenicy compared to fent

Remi mechanism

Selective mu agonst

Remi side effects

Brady/hypotension/rigidity of chest wall

Remi breakdown

Plasma esterases - context insensitive

Dexmed mechanism

Centrally acting alpha agonist agonist at the locus coerueus A2 to A1 affinity is 1600:1 Active d-isomer of medotomidine

Dexmed PK

94% protein bound

Clonidine mechanism

Centrally acting a2 agonist at the reticular nucleus of the medulla Increases intrracellular cAMP, increased potassiu Alpha receptor stimulation in spinal cord leads to increased endogenous opiate release A2:A1 200:1

Clonidine side effect

Hypertension (a1) prior to hypotension (a2) Brady Rebound hyper on cessation

Ketamine mech

Non competitive NMDA receptor antagonist

Ket metab

Metab in liver to norketamine, conjugated to inactive metabolites --> urine

Examples of when deep sedation is needed

``` Procedures )trachy) Non physiological ventilation (inverse ratio) Proning Intracranial hypertension Seizures ```

Morphine metabolism

liver to morphine 3 and morphine 6 glucoronide 6 is potent analgesic Excreted in urine

Which opiate has longest half life on infusion

Fentanyl (200mins after 6hours) | Duration of action is determined by redistribution rather than clearnece

How is duration of alfentanil determined

clearence rather than distribution (compare to fent)

Predictors of delerium

``` Male Increasing age Diseae severity Pre-existing dementia Structural brain damage Medication related cholinergic burden ```

Proportion of patients with hyperactive delirium

Proportion of patients with hypoactive delirium

35%

Proportion of patients with mixed delirium

65%

Diagnostic criteria for delirum (DSM 4)

Acute onset and fluctuating Inattention and disturbance of conciousness Change in cognition Pathophysioloigcal cause

how many parts to the Intensive Care Delirium screening cheklist

8, based on obs over a 24 hour period

Does the ICDSC need patient co-operation

Which is more sensitive, ICDSC or CAM-ICU

CAM-ICU

Disadvantage with CAM ICU

Less specific Higher false positive Needs co-operation Does not assess severity not sub-type

Benefit of epidural

``` Analgesia Decreased resp issues ?decreased mortality Less peri-op blood loss, DVT, arrhythmias Faster return to GI function ERAS - shorter length of stay ```

Disadvantages to epidural

``` Retention Itching n/v Hypotension poor/patcyh block ``` ``` Catheter migrate to sub arach space Local anaesthetic tox Wrong site injection Nerve injury absess Verterbral can haematoma Spinal cord infarct ```

Disadvantage of daily sedation holds

Whilst LOS, MV etc reduce, the risk of unplanned self extubation is higher

Ideal RASS for tubed patietn

-1

Which GPRC are opiates providing analgesia and sedation

mu - analgesia | Kappa - sedation