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72 Cards in this Set
- Front
- Back
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stress response
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increased O2 consumption and metabolic demands when body is under stress (like in ICU)
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what is the most reliable pain assessment? how is it performed?
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patient self reporting
visual analogue or numeric rating scales |
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ideal analgesic characteristics
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-rapid onset/offset
-easily titrated -limited accumulation -no active metabolite -no severe adverse effects/interactions -low cost YEAH...RIGHT!!! |
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opioids MOA
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-most commonly used for pain and sedation
-stimulate opioid receptors in CNS -mu and kappa are most targeted |
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opioids adverse effects
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-resp depression
-hypotension -constipation -N/V -dependence -withdrawal |
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opioids monitoring parameters
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-pain control
-level of consciousness -RR (less important if mechanically ventilated) -BP |
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opioid drugs used in ICU
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-morphine
-fentanyl -hydromorphone -meperidine -naloxone |
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morphine
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-longer DOA allows intermittent dosing (q 1-2 hrs) or continuous IV
-active metabolite: morphine-6-glucoronide accumulates in renal failure -histamine release: "morphine itch" and hypotension |
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fentanyl
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-more potent and rapid than morphine
-immediate onset -infusion preferred (intermittent q 30-60 min) -NO active metabolite -NO histamine release -NO renal impairment effect |
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fentanyl preferred for...
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-rapid analgesia in acutely distressed pts
-hemodynamic instability -renal insufficiency |
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hydromorphone
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-longer onset/DOA
-intermittent or continuous -NO active metabolite -NO histamine release |
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hydromorphone preferred for...
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-intermittent therapy
-renal impairment -hemodynamic instability |
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meperidine
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-NOT recommended in ICU
-active metabolite: normeperidine -neuroexcitation (apprehension, tremors, delirium, seizures) -accumulation in renal failure/elderly |
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naloxone
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-opioid antidote
-pure opioid antagonist -reverses resp/CNS depression AND analgesia -0.4-2 mg IV q 2-3 min PRN -shorter half life than opioid so repeat dose to avoid rebound opioid crash -induces opioid withdrawal |
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rapid analgesia DOC
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fentanyl
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hemodynamically-STABLE pt analgesia DOC
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morphine
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hemodynamically-UNSTABLE pt analgesia DOC
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fentanyl
hydromorphone |
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renal impairment analgesia DOC
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fentanyl
hydromorphone (no active metabolites) |
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intermittent dosing analgesia DOC
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morphine
hydromorphone |
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ketorolac
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-the only IV NSAID
-30mg IV q6h -max 120 mg/day -max 60 mg/day for >65 years, <50kg, renal insufficiency -NOT MORE THAN 5 DAYS |
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acetaminophen
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-mild pain relief
-anti-pyretic -synergistic with opioids -hepatotoxic |
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CPOT is used to assess...
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PAIN
the higher the #, the more pain |
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when to provide sedation
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only AFTER adequate analgesia and treatment of underlying causes
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goal of sedation
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calm, easily arousable patient with maintenance of natural sleep-wake cycle
deeper sedation for mechanical ventilation |
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the RAMSAY scale assesses...
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SEDATION
goal score = 2 cooperative, oriented, tranquil 1-3 = awake states 4-6 = sleep states |
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the RASS scale assesses...
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SEDATION
goal score = 0/-1 0 = alert and calm -1 = drowsy, not fully alert, sustained wakening with eye contact to voice stimulation |
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EEG monitors...
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SEDATION
100 - completely awake 0 - absence |
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sedation drugs
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-midazolam
-lorazepam -flumazenil -propofol -dexmedetomidine |
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benzodiazepines
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-binds and enhances GABA receptors (main inhibitory neurotransmitter)
-sedative hypnotic: causes anterograde amnesia -lack analgesia -opioid sparing -titrated to achieve sedation goal |
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benzo adverse effects
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-hypotension
-resp depression -prolonged effects -tolerance -dependence |
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benzo monitoring
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-level of sedation
-RR -BP |
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caution benzos with...
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-elderly
-renal/hepatic dysfunction -hemodynamic instability |
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midazolam
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-short answer, short duration
-intermittent or continuous admin -unpredictable waking with long term use -active metabolite -accumulation in obese, low albumin, renal failure |
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midazolam preferred for...
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acute agitation
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lorazepam
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-intermediate onset/duration
-intermittent or continuous -less titratable -NO active metabolites -contains PROPYLENE GLYCOL: lactic acidosis, acute tubular necrosis |
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lorazepam preferred for...
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long-term sedation
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flumazenil
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-benzo antidote
-competitive binding to GABA/benzo receptor complex -IVP dosing -may repeat q 60 sec until response -maximum 3mg/hr |
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flumazenil adverse effects
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-seizures, acute withdrawal, dizziness, N/V, headache
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propofol
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-sedative hypnotic
-NO analgesia -rapid onset, short duration -initial 5mcg/kg/min q 5-10 min then titrate by 5-10 mcg/kg/min -MD 5-50 mcg/kg/min IV |
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propofol preferred for...
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when rapid awakening is important
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propofol adverse effects
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-resp depression
-apnea (requires mechanical ventilation) -hypotension -pain at injection site |
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precautions with propofol
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-phospholipid emulsion (soy/egg allergies)
-caloric source -potential for hyperTG, pancreatitis -strict aseptic technique required (great medium for bacterial growth) |
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maximum duration of propofol use
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48 hours
longer use of higher doses cause propofol infusion syndrome (bradycardia, asystole) |
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monitoring with propofol
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-level of sedation
-BP -caloric component -TGs -hang time for bottle/tubing (asepsis) |
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dexmedetomidine
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-selective alpha2 agonist (like clonidine)
-sedation, analgesia, anxiolysis (trifecta!) -intermediate onset, variable duration -LD frequently bottoms out BP -NO resp depression -pts easily arousable -used prior, during and after extubation |
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maximum duration of dexmedetomidine use
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24 hours
adrenal suppression >24 hours |
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dexmedetomidine adverse effects
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-hypotension
-bradycardia -a.fib |
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sedation holidays NOT indicated if....
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patient receiving paralytics
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acute agitation DOC
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midazolam
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intermittent sedation DOC
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lorazepam
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continuous sedation
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1. propofol (up to 5 days)
2. midazolam (up to 48 hours) 3. lorazepam (long term) |
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delirium
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-fluctuating mental status
-inattention -disorganized thinking -altered level of consciousness - +/- agitation |
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CAM-ICU assesses...
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DELIRIUM
delirium defined as presence of feature 1 (mental status change) + feature 2 (inattention) + either feature 3 (disorganized thinking) OR feature 4 (altered level of consciousness) |
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haloperidol
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-the only drug approved for delirium
-LD 2-10mg IV q 20-30 min until effect -MD 25% of effective LD q6h |
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haloperidol adverse effects
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-extrapyramidal symptoms
-QT prolongation -neuroleptic malignant syndrome |
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NMBA uses
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-NO sedative
-NO amnesic -NO analgesic -paralysis for surgery -facilitate mechanical ventilation -manage trauma/tetanus -last resort |
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NMBA requirements
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-adequate sedation and analgesia prior to start of NMBAs
-trained staff -mechanical ventilation -daily drug holidays for paralytic, NOT sedation!!! |
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NMBA monitoring
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-depth of blockade
-skeletal muscle movement -respiratory efforts/ventilator synchrony -peripheral nerve stimulation (train of 4): goal 1-2 twitces out of 4 electrical impulses |
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types of NMBAs
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-depolarizing agents: depolarize muscle continuously to block NM transmission (causes muscle twitches)
-non-depolarizing agents: competitively inhibit ACh receptor to block depolarization |
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succinylcholine
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-depolarizing NMBA
-facilitates endotracheal intubation -rapid onset, ultra short duration -initial dose 0.3-1.1 mg/kg IV -MD 0.04-0.07 mg/kg/dose IV |
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succinylcholine adverse effects
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-muscle fasciculation
-hyperkalemia -arrhythmia -bradycardia -hypotension -increased intracranial/intraocular pressure -malignant hyperthermia |
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succinylcholine contraindications
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-major burns
-multiple trauma -acute neurologic injury (increased intracranial pressure) -hyperkalemia |
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pancuronium
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-non-depolarizing
-LD 0.04-0.1 mg/kg IV -MD 0.1-0.2 mg/kg IV q 1-3 h (intermittent) or 0.8-1.7 mg/kg/min (continuous IV) -active metabolite -vagolytic properties: tachycardia, HTN, increased CO |
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pancuronium should NOT be used in...
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CHF, CAD, MI due to vagolytic properties
renal/hepatic failure due to accumulation of active metabolite |
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atracurium
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-non-depolarizing
-shorter duration -LD 0.4-0.5 mg/kg IV -MD 5-10 mcg/kg/min IV -histamine release: hypotension -NO adjustment in renal/hepatic impairment -NO vagolytic properties: ok for CV disease |
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cisatracurium
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-non-depolarizing
-more potent, short onset and duration -less histamine release than atracurium -LD 0.1-0.2 mg/kg IV -MD 0.5-10 mcg/kg/min IV -no adjustment in renal/hepatic impairment |
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vecuronium
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-shorter acting
-metabolite 50% active: renal hepatic ajustment needed -NO vagolytic properties -LD 0.1 mg/kg IV -MD 0.1-0.2 mg/kg/dose IV q hr or 0.8-1.7 mcg/kg/min |
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rocuronium
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-non-depolarizing
-less potent, short onset and duration -LD 0.6-1.2 mg/kg IV -MD 10 mcg/kg/min IV -metabolite 5-10% active: more significant for liver failure |
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NMBA adverse effects
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-prolonged recovery from paralysis
-myopathy -aspiration/hypostatic pneumonia -skin breakdown -venous thrombosis |
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paralysis DOC for normal hepatic/renal function
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pancuronium
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paralysis DOC for renal/hepatic impairment
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atracurium
cisatracurium "curiums are the cure for renal/hepatic toxicity" |
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paralysis DOC for CV disease or hemodynamic instability
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vecoronium
rocuronium "CV needs RV" both have Vs |
