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Thp III Exam 1 > Pain and Sedation > Flashcards

Flashcards in Pain and Sedation Deck (33)
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1
Q

Objectives

A
  1. Compare and contrast the different sedatives and analgesics used in the ICU setting with regards to pharmacokinetics, dosing, use and adverse effects.
  2. Given a patient scenario, design an appropriate analgesic/sedation drug regimen for a patient undergoing mechanical ventilation.
  3. State risk factors for ICU delirium.
  4. Recommend appropriate treatment
    (pharmacologic and non-pharmacologic) for a patient with ICU delirium.
2
Q

First-line medication to treat pain in ICU patients- IV route

A

Opioids

3
Q

Most common opioids in ICU

A

Fentanyl, hydromorphone and morphine

4
Q

Opioid with fastest onset

A

Fentanyl

5
Q

All opioids eliminated in

A

Urine

6
Q

Only opioid with active metabolite

A

Morphine

7
Q

ADE’s of opioids

A
Hypotension - Morphine
Respiratory depression
Altered mental status
Sedation
Constipation, ileus
Nausea/vomiting
Spasm of sphincter of Oddi – worsened pancreatitis
8
Q

Ideal sedative

A
Rapid onset
Easy titration
Lack of accumulation 
No active metabolites 
Rapid awakening 
Inexpensive
9
Q

Most remembered event in ICU

A

Pain

10
Q

Most common problem in ICU

A

Anxiety

11
Q

Consequences of neglecting anxiety

A
Loss of control of the patient
  -Ventilator dyssynchrony
  -Agitation
  -Increased O2 consumption
  -Removal of lines/catheters
Uncomfortable patient
  -Anxiety and fear
  -Lack of sleep
  -Painful procedures and paralysis (amnestic effects)
12
Q

Goals of Analgesia & Sedation

A
Improve patient comfort while using invasive devices (i.e. ventilator)
Minimize patient harm
  -Pulling IV lines
  -Self extubation
  -Pulling catheters
Decrease anxiety/stress response
13
Q

Slower onset BZD

A

Lorazepam

14
Q

Faster onset BZD

A

Diazepam

Midazolam

15
Q

BZD with no active metabolite

A

Lorazepam

16
Q

BZD with active metabolites

A

Diazepam

Midazolam

17
Q

BZD used in acutely agitated patients

A

Midazolam

18
Q

BZD used for long-term sedation (i.e. > 48 hrs of MV)

A

Lorazepam

19
Q

BZD used for alcohol withdrawal

A

Lorazepam

20
Q

BZD not ideal for acute agitation

A

Lorazepam

21
Q

BZD ADE’s

A

No significant hemodynamic reactions except for midazolam

  • Respiratory depression (less than opioids when used alone)
  • Propylene glycol toxicity with lorazepam
  • Monitor serum osmolality or bicarbonate
22
Q

BZD that causes accumulation concerns with hepatic and renal failure and with prolonged use

A

Midazolam

23
Q

Lorazepam ADE

A
“Diluent toxicity”
Propylene glycol vehicle
- Renal failure
- Hyperosmolality
- Lactic acidosis
Risk factors
- High-dose, prolonged infusions
- Renal or hepatic dysfunction
24
Q

Propofol ADE’s

A

Hypotension: dose-dependent
-Urine discoloration (green)
-Hypertriglyeridemia
Increased risk of acute pancreatitis
Discontinue if triglycerides > 400 mg/dL
Monitor serum TG levels: prior to
initiation, every 3-7 days
thereafter, especially if receiving for
>48 hours with doses exceeding
50 mcg/kg/minute
Propofol-related infusion syndrome (PRIS) Associated with doses > 80 mcg/kg/min for ≥ 48hrs
Symptoms include: bradycardia, lactic acidosis, rhabdomyolysis, renal failure
STOP INFUSION IMMEDIATELY

25
Q

When to use Propofol

A

Useful for acutely agitated patients & patients requiring sedation with frequent neuro checks
Short-term use preferred
- Less than 72 hrs

26
Q

Only sedative approved for use in non-intubated ICU patients in the US

A

Dexmedetomidine

  • like clonidine
  • central alpha-2 agonist
  • Actions NOT mediated through GABA
  • Sedative and analgesic properties without producing respiratory depression
27
Q

Dexmedetomidine ADE’s

A
Bradycardia
Hypertension
Hypotension
- More common with bolus doses
Cardiac arrhythmias
28
Q

Dexmedetomidine Place in Therapy

A

Post-surgical sedation with an anticipated short intubation period
Adjunct agent to benzodiazepines
Procedural sedation
Associated with less ICU delirium??

29
Q

Assessment of Delirium (2 methods)

A
  • Confusion Assessment Method for ICU (CAM- ICU)
  • Intensive Care Delirium Screening Checklist (ICDSC)
  • Both have good reliability and validity
30
Q

Most common type of Delirium

A

ICU delirium is common

31
Q

Tx of Delirium

A
NO preferred drug for treating delirium
 -Orient patient to room and time
 -Give patients their eyeglasses and 
   hearing aids if needed
 -Calendars and clocks
 -Reduce noise and distractions
 -Place patient in a room with a window
32
Q

Opioid that causes hypotension

A

Morphine

33
Q

DOC for sedation in pt with hypotension and renal failure

A

lorazepam b/c no active metabolite

Not propofol or dexmedetomide b/c hypotension