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Therapeutics 4 > Supportive Care in the ICU and Pain, Agitation, and Delirium (PAD) > Flashcards

Supportive Care in the ICU and Pain, Agitation, and Delirium (PAD) Flashcards

1
Q

Spportive Care in the ICU

Define: Acute Pain

A

results from acute illness or injury and dissolves as injury heals- usually responds to pain meds. onset and duration is defined, predictable, and limited

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2
Q

Spportive Care in the ICU

Define: Chronic Pain

A

source may be unknown and pain persists longer than expected that may not respond to pain meds. onset and duration is not well defined and is unpredicable and unlimited

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3
Q

Spportive Care in the ICU

What are the potential causes of pain in the ICU?

A
  • burns
  • devices
  • endotracheal intubation
  • immobility
  • pre-existing pain
  • procedures
  • surgery
  • trauma
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4
Q

Spportive Care in the ICU

What are the impacts of pain in the ICU?

A
  • sleep depivation
  • anxiety
  • PTSD
  • delirium
  • higher rate of chronic pain
  • negative quality of life
  • DVT
  • depression
  • physiologic stress response= decreased tissue perfusion, respiratory compromise, catabolic/hypermetabolic, cardiac instability, impaired wound healing
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5
Q

Spportive Care in the ICU

Define: Analgosedation

A
  • analgesia-first sedation
    OR
  • analgesia-based sedation
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6
Q

Spportive Care in the ICU

What is the benefit of utilizing analgosedation?

A
  • decreased sedative requirements
  • decreased duration of ventilation
  • decreased ICU length of stay
  • decreased pain intensity
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7
Q

Spportive Care in the ICU

What pain scales are utilized in the ICU?

A
  • numerical pain rating scales
  • behavioral pain scale
  • critical-care pain observation tool (CPOT)
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8
Q

Spportive Care in the ICU

How is CPOT used in the ICU to determine if a patient is in pain?

A

CPOT of 2 or less= no pain, CPOT > 2= pain

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9
Q

Spportive Care in the ICU

What are the opioid pharmacologic actions?

A
  • central nervous system (euphoria, sedation, respiratory depression, cough supression, pupil constriction)
  • cardiovascular system (arterial dilation, venous dilation)
  • gastrointestinal (decreased gastric motility, decreased gastric tone)
  • renal (decreased renal blood flow)
  • flushing and warming of skin
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10
Q

Spportive Care in the ICU

What opioids are considered mild-moderate?

A
  • hydrocodone/APAP
  • oxycodone/APAP
  • oxycodone
  • oxycodone ER

all are PO

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11
Q

Spportive Care in the ICU

What opioids are considered strong?

A
  • morphine (IV, PO, PCA)
  • hydromorphone (IV, PO, PCA)
  • fentanyl (IV, patch, PCA)
  • methadone (PO)
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12
Q

Spportive Care in the ICU

What ICU opioid caused tachyphylaxis?

A

fentanyl

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13
Q

Spportive Care in the ICU

What is tachyphylaxis?

A

after some time on opioids there is no more benefit seen and opioid agent will need to be changed

fentanyl is the worst offender

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14
Q

Spportive Care in the ICU

What agent is used when patients are tolerant to fentanyl and morphine?

A

hydromorphone

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15
Q

Spportive Care in the ICU

What opioid agent has the most hypotension?

A

morphine

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16
Q

Spportive Care in the ICU

What opioid is associated with serogenic effects?

A

fentanyl

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17
Q

Spportive Care in the ICU

Which opioid is used to decrease air hunger in hospice patients?

A

morphine

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18
Q

Spportive Care in the ICU

Can acetaminophen be used in the ICU for the multimodal approach to pain?

A

yes, although IV formulation is expensive so may limit use in the ICU setting

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19
Q

Spportive Care in the ICU

Can ketamine be used in the ICU for the multimodal approach to pain?

A

yes, low dose of 1-2 mcg/kg/hr as an adjunct to opioids and may be specifically beneficial for patients post-operative admitted to the ICU

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20
Q

Spportive Care in the ICU

Can neuropathic pain meds be used in the ICU for the multimodal approach to pain?

A

yes, if neuropathic pain is present- consider using gabapentin, carbamazepine, or pregabalin

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21
Q

Spportive Care in the ICU

Can IV lidocaine be used in the ICU for the multimodal approach to pain?

A

no, lack of clinical evidence and scope of use for pain is limited

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22
Q

Spportive Care in the ICU

Can COX-1 selective NSAIDs be used in the ICU for the multimodal approach to pain?

A

maybe, but be aware of adverse effects and minimal clinical outcomes

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23
Q

Spportive Care in the ICU

Can opioids for procedures be used in the ICU for the multimodal approach to pain?

A

yes, at the lowest effective dose

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24
Q

Spportive Care in the ICU

What are the causes of anxiety and agitation in the ICU?

A
  • hypoxemia/hypotension
  • alcohol/drug withdrawal
  • mechanical ventilation
  • other devices
  • extreme anxiety/delirium
  • untreated pain
  • inability to communicate
  • noises
  • lighting
  • stimulation
  • immobility
25
Q

Spportive Care in the ICU

Why are patients sedated in the ICU?

A
  • tolerate mechanical ventilation or other procedures
  • protect the agitated patient and caregivers
  • prevent recall of stressful or traumatic events
  • reduce metabolic rate or energy consumption
  • analgesia as a component- for pain relief/minimization
26
Q

Spportive Care in the ICU

How can over-sedation be prevented in the ICU?

A
  • address and treat pain
  • titrate to a defined sedation goal
  • utilize benzodiazepine
27
Q

Spportive Care in the ICU

What is the goal score on the richmond agitation sedation scale (RASS)?

28
Q

Spportive Care in the ICU

What are the sedative options in the ICU?

A
  • benzodiazepines (lorazepam, midazolam, diazepam)
  • propofol
  • central alpha-2 agonists (clonidine, dexmedetoomidine)
  • NMDA antagonist (ketamine)
29
Q

Spportive Care in the ICU

Which sedative has the quickest onset of action?

30
Q

Spportive Care in the ICU

Which sedative has the shortest duration of action?

31
Q

Spportive Care in the ICU

Which sedative has the longest duration of action?

32
Q

Spportive Care in the ICU

When would it be appropiate to use propofol in the ICU setting?

A

short term and only if the patient is hemodynamically stable

33
Q

Spportive Care in the ICU

What are the common side effects of propofol?

A

bradycardia, hypotension, propofol infusion syndrome (PRIS)

34
Q

Spportive Care in the ICU

What is the place in therapy of lorazepam?

A

long-term sedation

35
Q

Spportive Care in the ICU

What are the side effects of lorazepam?

A

prolonged sedation

36
Q

Spportive Care in the ICU

What is the place in therapy of midazolam?

A

short term sedation

frequent neuro checks needed

37
Q

Spportive Care in the ICU

What are the side effects of midazolam?

A

accumulation with renal and hepatic disease

38
Q

Spportive Care in the ICU

What is Virchow’s Triad?

A
  • hypercoaguable state
  • circulatory stasis
  • vascular wall injury
39
Q

Spportive Care in the ICU

What factors would consider a patient high risk for VTE?

40
Q

Spportive Care in the ICU

What is the VTE prophylaxis agent given to patients at low/minor risk?

A

heparin 5000 units subcutaneous Q8H

41
Q

Spportive Care in the ICU

What is the dosing of enoxaparin with a CrCl < 30 mL/min?

A

enoxaparin 30mg subcutaneous Q24H

42
Q

Spportive Care in the ICU

What is the thrombosis prevention recommendation for high-risk trauma patients?

A

enoxaparin 30mg subcutaneous Q12H AND mechanical prophylaxis (unless containdicated by lower extremity injury)

43
Q

Spportive Care in the ICU

What patient populations qualify for antifactor-Xa monitoring?

A
  • extremes of weight (obesity and low-weight)
  • renal dysfunction
  • hypermetabolic (trauma, burn)
44
Q

Spportive Care in the ICU

What is the goal antifactor-Xa for VTE prophylaxis?

A

0.2-0.4 IU/mL

45
Q

Spportive Care in the ICU

What is the angle a patients head should be above the bed while in the ICU?

A

30 degrees

46
Q

Spportive Care in the ICU

What patients need stress ulcer prophylaxis?

A
  • coagulopathy (INR >1.5, aPPT >2x baseline, and/or platelet < 50000)
  • shock
  • chronic liver disease
  • neurocritical care adults
47
Q

Spportive Care in the ICU

What are the treatment options for stress ulcer prophylaxis?

A
  • H2RAs= famotidine, ranitidine
  • PPIs= pantoprazole, esomeprazole
48
Q

Spportive Care in the ICU

What ulcer prophylaxis requires dosing adjustments for renal dysfunction?

A

H2RAs, twice daily dosing -> once daily for CrCl < 50 mL/min

49
Q

Spportive Care in the ICU

What is the black box warning for PPIs?

A

risk of C. diff infection

50
Q

Spportive Care in the ICU

When should insulin therapy be initiated in ICU patients?

A

two consecutive BG levels greater than 180 mg/dL

51
Q

Spportive Care in the ICU

What is the goal BG for a patient in the ICU?

A

higher BG is tolerated to avoid hypoglycemia, 140-200 mg/dL, but lower targets may be accepted if risk of hypoglycemia is very low

52
Q

Spportive Care in the ICU

What is the recommended dosing of insulin for patients in the ICU?

A

continuous IV infusion

53
Q

Spportive Care in the ICU

What are the recommended bowel regimen in the ICU?

A
  • docusate/senna
  • polyethylene glycol
  • bisacodyl
  • sorbitol 70%
  • magnesium citrate
54
Q

Spportive Care in the ICU

What screening tools can be used to assess delirum in the ICU?

A

CAM-ICU

and many others…

55
Q

Spportive Care in the ICU

How is delirum treated in the ICU?

A

eliminate contributing factors and implement/optimize non-pharm therapy then consider pharmacological options

56
Q

Spportive Care in the ICU

What are the modifable factors that may aid delirum in the ICU?

A
  • isolation
  • no clock/daylight/visitors
  • excessive noise
  • restraints
  • length of stay
  • fever
  • malnutrition
  • hypotension
  • sepsis
  • metabolic disorders
  • tubes/catheters
  • medications
57
Q

Spportive Care in the ICU

What should be done pharmacologically before beginning antipsychotics for delirum in the ICU?

A
  • adequate pain control
  • discontinue deliriogenic medications
  • resume home psychoactive medications
  • treat withdrawal
  • consider patient specific factors
58
Q

Spportive Care in the ICU

What antipsychotics may be used to treat delirum?

A
  • haloperidol
  • quetiapine
  • olanzapine
59
Q

Spportive Care in the ICU

What are the required monitoring parameters when treating delirum with antipsychotics?

Therapeutics 4 (7 decks)

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