Sedatives, Paralytics, Analgesics Flashcards
What are the goals of Analgesics and Sedatives?
Patient Comfort
Reduce Anxiety/Agitation
Provide Pain Relief
Retrograde Amnesia
What are the goals of Paralytics?
Facilitate Procedures
Minimize Movement
Control Ventilation
What is the side effect that we are most concerned about when giving Analgesics, Sedatives, Paralytics?
A drop in BP
What are the drug classes in Sedatives?
Benzodiazepines
Neuroleptics
Anesthetic Agents
What are the drug classes in Analgesics?
Opioids
What drugs are under Benzos?
Diazepam - Valium
Midazolam - Versed
Lorazepam - Ativan
What is Haldol?
Neuroleptics
Treatment for agitation and delirium
Onset 3 – 20 minutes
Duration 18 – 54 hours
Potential side effects Drowsiness/Lethargy Muscle rigidity QT prolongation Torsades de Pointes
What is the reversal agent for Benzos?
Flumazanil
What is the commonly used low cost sedative?
Benzos
What are concerns with using Benzo’s in ICU patients?
ICU delirum when combined with Sleep disruption
Depression of Respiratory drive when mixed with Opioids in COPD
Tell me about Diazepam/Valium (onset, duration, elimination)
Rapid onset
2 – 5 minutes
Lipid soluble – can build up in the tissues for longer release
Easily crosses blood brain barrier
Long duration
Long half life of up to 120 hours!
Eliminated by kidney
Patients with renal impairment will have difficulty clearing
Tell me about Midazolam/Versed (onset, duration, elimination)
Rapid onset
2 – 5 minutes
Lipid soluble – can build up in the tissues for longer release
Easily crosses blood brain barrier
Shorter duration
Short half life of 3 – 11 hours
Eliminated by kidney
Patients with renal impairment will have difficulty clearing
Anterograde amnesic effect
Tell me about Lorazapam/Ativan (onset, duration, elimination)
Slower onset
5 – 20 minutes
Less lipid soluble
Does not easily crosses blood brain barrier
Longer duration
Longer half life of 8 – 15 hours
Metabolized by liver to inactive metabolites
What are side effects of Lorazapam/Ativan?
Lactic acidosis – Propylene Glycol used in manufacturing!
Hyperosmolar coma
Nephrotoxicity
Tell me about Propofol (onset, duration, Who its best used for)
Onset is very rapid
Duration is short when discontinued
Drug of choice for TBI patients
Ease of neuro assessment
Reduction of ICP
What are side effects of Propofol?
Significant and immediate hypotension can occur!
Bradycardia
Elevated Pancreatic Enzymes – Pancreatitis
Elevated Kcal
Pediatric Patients – Lactic Acidosis and hyperlipidemia
Propofol induced hypoxemia – dilute o2
What is the reversal agent for Opioids?
Nalaxone
What are side effects of Opioids?
Respiratory Depression
Bradycardia/Hypotension
Histamine release
Dependence
Tell me about Morphine (onset, duration, elimination)
Naturally occurring opioid agonist
Slow onset due to low lipid solubility
Slower transit across Blood Brain Barrier
Long acting due to active metabolites
What are side effects of Morphine?
Hypotension Hypoventilation Decreased CPP/ICP Drowsiness Constipation/Vomiting Bronchospasm! (histamine release)
Tell me about Fentanyl/Sublimaze (
Synthetic opioid 150 times more potent than MSO4
Increased lipid solubility
Decreased onset and longer half life
Better choice for unstable cardiovascular patients
No histamine release
Respiratory depression with increased doses
What are the uses of Paralytics?
Facilitation of less conventional mechanical ventilation strategies (e.g., inverse I:E ratios, high-frequency ventilation, permissive hypercapnia)
Facilitation of intubation, ensuring stability of the airway during transport or repositioning
Dynamic hyperinflation that cannot be corrected
Adjunctive therapy for controlling raised ICP
Reduction of oxygen consumption and carbon dioxide production
What is minimal sedation?
Patients can respond to verbal commands, although cognitive function may be impaired.
Ventilatory and cardiovascular functions are unaffected.
What is moderate or conscious sedation?
The patient can perform purposeful response following repeated or painful stimulation. (Note: Reflex withdrawal from painful stimulus is not considered a purposeful response.)
Modification of painful and frightening experiences
Spontaneous ventilation is adequate, and cardiovascular function is usually maintained.
What is deep sedation?
The patient is not easily aroused but can respond to painful stimulation.
Spontaneous ventilation and maintenance of patent airway may be inadequate.
Cardiovascular function is usually maintained.
What does it mean for a patient to be under Anesthesia?
This level involves general anesthesia, spinal, or major regional anesthesia; local anesthesia is not included.
Patient cannot be aroused, even by painful stimulation.
Ventilatory assistance is typically required (i.e., artificial airway and positive-pressure ventilation).
Cardiovascular function may be impaired.
What is the reversal agent to non-depolarizing agents?
Neostigmine followed by Atropine (for bronchospams, brady, and increased secretions)
Tell me about Succinylcholine (onset, duration, side effects)
Quick onset; less than 60 sec, with short duration;
5 – 10 mins
Minimal cardiac effect
Side effects Hyperkalemia Increased ICP and intraocular pressures Malignant hyperthermia Tx: Dantrolene CANNOT BE REVERSED!
Tell me about pancuronium (onset, duration, side effects)
Long term continuous infusion for ICU
Prolonged paralysis
Due to metabolites maintaining 50% active
Side effects - Vagolytic
Tachycardia
Increased CO and MAP
Pulmonary Vasoconstriction
Tell me about vecuronium (onset, duration, side effects)
Intermediate duration
Lack of Vagolytic effects makes it a better choice
Better for asthma patients
Tell me about Atricurium/Cisatricurium (onset, duration, side effects)
Intermediate duration
Less hemodynamic effect than pancuronium
Can cause hypotension secondary to mast cell degranulation At increased doses
How can you monitor the effect of paralytics?
Spontaneous breathing or train of four
How can you assess pain relief?
Pain scale
Who can benefit from an BIS monitor, what is the scale?
Anesthesia/sedation
Level of 40 – 60 shows adequate anesthesia
Controversial regarding efficacy
How do you assess a train of four?
the # of twitches that a patient gives dictates the level of paralysis.
4 out of 4 is no paralysis
Non-depolarizing agents block muscle contractions by what method?
Competitive inhibition
when given a non-depolarizing agent is given, are patients still able to regain movement with their receptor sites still occupied?
yes
you can move with 75% of the sites occupied. >75% start to show effects.
depolarizing agents block muscle contractions by what method?
Prolonged occupation and persistent binding
what can you say about non-depolarizing agents with regards to dosages and effect
non-depolarizing drugs are dose dependent.
dosage are based on weight
What do non-depolarizing reversal agents do at the neuromuscular junction?
they clear the NMJ of actylcholenesterase in order to flood the area with more ACH to knock out the drug.
Actylcholenesterase Inhibitors (AChEI)
what is a test doctors use to measure ach production during non-depolarizing agent weaning?
head neck lift test.
the ability of the patient to lift the neck can burn ACH and see if the patient has enough ability to replace it.
what is the onset and duration of a depolarizing agent?
60-90 secs with a duration of 10-15 mins
Who do you NOT give a depolarizing agent to?
hyperkalemic patients (like burn patients and chest trama patients)
patients who have a full stomach
increased intraoccular pressure
increased intacranial pressure
what are 2 alternative metabolism pathways for NMBAs?
hoffman degradation and plasma cholinesterase
Atricurium/Cisatricurium are eliminated in the body by how?
nonenzymatic breakdown Hofmann degradation
What is laudanosine?
breakdown product of Hofmann degradation in Atricurium.
Small amounts in Cisatricurium
Can cause neurostimulatory effects
What are the effects of Prolonged propofol in PEDS parients?
Lactic Acidosis and Hyperlipidemia
What drug should be avoided for patients with reye syndrome?
Aspirin
What sedative has the least effect on blood pressure?
Etomidate
Toxic levels of alcohol that affect the respiratory arrest are at what range?
400-600 mg/dl
