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72 Cards in this Set

  • Front
  • Back
stress response
increased O2 consumption and metabolic demands when body is under stress (like in ICU)
what is the most reliable pain assessment? how is it performed?
patient self reporting

visual analogue or numeric rating scales
ideal analgesic characteristics
-rapid onset/offset
-easily titrated
-limited accumulation
-no active metabolite
-no severe adverse effects/interactions
-low cost

YEAH...RIGHT!!!
opioids MOA
-most commonly used for pain and sedation
-stimulate opioid receptors in CNS
-mu and kappa are most targeted
opioids adverse effects
-resp depression
-hypotension
-constipation
-N/V
-dependence
-withdrawal
opioids monitoring parameters
-pain control
-level of consciousness
-RR (less important if mechanically ventilated)
-BP
opioid drugs used in ICU
-morphine
-fentanyl
-hydromorphone
-meperidine
-naloxone
morphine
-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
fentanyl
-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
fentanyl preferred for...
-rapid analgesia in acutely distressed pts
-hemodynamic instability
-renal insufficiency
hydromorphone
-longer onset/DOA
-intermittent or continuous
-NO active metabolite
-NO histamine release
hydromorphone preferred for...
-intermittent therapy
-renal impairment
-hemodynamic instability
meperidine
-NOT recommended in ICU
-active metabolite: normeperidine
-neuroexcitation (apprehension, tremors, delirium, seizures)
-accumulation in renal failure/elderly
naloxone
-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
rapid analgesia DOC
fentanyl
hemodynamically-STABLE pt analgesia DOC
morphine
hemodynamically-UNSTABLE pt analgesia DOC
fentanyl
hydromorphone
renal impairment analgesia DOC
fentanyl
hydromorphone

(no active metabolites)
intermittent dosing analgesia DOC
morphine
hydromorphone
ketorolac
-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
acetaminophen
-mild pain relief
-anti-pyretic
-synergistic with opioids
-hepatotoxic
CPOT is used to assess...
PAIN

the higher the #, the more pain
when to provide sedation
only AFTER adequate analgesia and treatment of underlying causes
goal of sedation
calm, easily arousable patient with maintenance of natural sleep-wake cycle

deeper sedation for mechanical ventilation
the RAMSAY scale assesses...
SEDATION

goal score = 2
cooperative, oriented, tranquil

1-3 = awake states
4-6 = sleep states
the RASS scale assesses...
SEDATION

goal score = 0/-1
0 = alert and calm
-1 = drowsy, not fully alert, sustained wakening with eye contact to voice stimulation
EEG monitors...
SEDATION

100 - completely awake
0 - absence
sedation drugs
-midazolam
-lorazepam
-flumazenil
-propofol
-dexmedetomidine
benzodiazepines
-binds and enhances GABA receptors (main inhibitory neurotransmitter)
-sedative hypnotic: causes anterograde amnesia
-lack analgesia
-opioid sparing
-titrated to achieve sedation goal
benzo adverse effects
-hypotension
-resp depression
-prolonged effects
-tolerance
-dependence
benzo monitoring
-level of sedation
-RR
-BP
caution benzos with...
-elderly
-renal/hepatic dysfunction
-hemodynamic instability
midazolam
-short answer, short duration
-intermittent or continuous admin
-unpredictable waking with long term use
-active metabolite
-accumulation in obese, low albumin, renal failure
midazolam preferred for...
acute agitation
lorazepam
-intermediate onset/duration
-intermittent or continuous
-less titratable
-NO active metabolites
-contains PROPYLENE GLYCOL: lactic acidosis, acute tubular necrosis
lorazepam preferred for...
long-term sedation
flumazenil
-benzo antidote
-competitive binding to GABA/benzo receptor complex
-IVP dosing
-may repeat q 60 sec until response
-maximum 3mg/hr
flumazenil adverse effects
-seizures, acute withdrawal, dizziness, N/V, headache
propofol
-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
propofol preferred for...
when rapid awakening is important
propofol adverse effects
-resp depression
-apnea (requires mechanical ventilation)
-hypotension
-pain at injection site
precautions with propofol
-phospholipid emulsion (soy/egg allergies)
-caloric source
-potential for hyperTG, pancreatitis
-strict aseptic technique required (great medium for bacterial growth)
maximum duration of propofol use
48 hours

longer use of higher doses cause propofol infusion syndrome (bradycardia, asystole)
monitoring with propofol
-level of sedation
-BP
-caloric component
-TGs
-hang time for bottle/tubing (asepsis)
dexmedetomidine
-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
maximum duration of dexmedetomidine use
24 hours

adrenal suppression >24 hours
dexmedetomidine adverse effects
-hypotension
-bradycardia
-a.fib
sedation holidays NOT indicated if....
patient receiving paralytics
acute agitation DOC
midazolam
intermittent sedation DOC
lorazepam
continuous sedation
1. propofol (up to 5 days)
2. midazolam (up to 48 hours)
3. lorazepam (long term)
delirium
-fluctuating mental status
-inattention
-disorganized thinking
-altered level of consciousness
- +/- agitation
CAM-ICU assesses...
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)
haloperidol
-the only drug approved for delirium
-LD 2-10mg IV q 20-30 min until effect
-MD 25% of effective LD q6h
haloperidol adverse effects
-extrapyramidal symptoms
-QT prolongation
-neuroleptic malignant syndrome
NMBA uses
-NO sedative
-NO amnesic
-NO analgesic
-paralysis for surgery
-facilitate mechanical ventilation
-manage trauma/tetanus
-last resort
NMBA requirements
-adequate sedation and analgesia prior to start of NMBAs
-trained staff
-mechanical ventilation
-daily drug holidays for paralytic, NOT sedation!!!
NMBA monitoring
-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
types of NMBAs
-depolarizing agents: depolarize muscle continuously to block NM transmission (causes muscle twitches)

-non-depolarizing agents: competitively inhibit ACh receptor to block depolarization
succinylcholine
-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
succinylcholine adverse effects
-muscle fasciculation
-hyperkalemia
-arrhythmia
-bradycardia
-hypotension
-increased intracranial/intraocular pressure
-malignant hyperthermia
succinylcholine contraindications
-major burns
-multiple trauma
-acute neurologic injury (increased intracranial pressure)
-hyperkalemia
pancuronium
-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
pancuronium should NOT be used in...
CHF, CAD, MI due to vagolytic properties

renal/hepatic failure due to accumulation of active metabolite
atracurium
-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
cisatracurium
-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
vecuronium
-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
rocuronium
-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
NMBA adverse effects
-prolonged recovery from paralysis
-myopathy
-aspiration/hypostatic pneumonia
-skin breakdown
-venous thrombosis
paralysis DOC for normal hepatic/renal function
pancuronium
paralysis DOC for renal/hepatic impairment
atracurium
cisatracurium

"curiums are the cure for renal/hepatic toxicity"
paralysis DOC for CV disease or hemodynamic instability
vecoronium
rocuronium

"CV needs RV" both have Vs