Therapeutics Exam 3 Iii Sedation

Front 1

Define delirium:

Back 1

Acutely changing mental status
Inattention, disorganized thinking
May or may not be by agitation
Perceptual disturbances

Front 2

Delirium is often viewed as:

Back 2

Fluctuating levels of arousal t/out the day
Associated w/ sleep-wake cycle disruption
Hastened by reversed day-night cycles

Front 3

The 3 types of delirium:

Back 3

Hypoactive- 35% of pts: worst prognosis:aka silent delirium:
psychomotor retardation illust by a calm appearance, inattention, decreased mobility, & obtundation in extreme cases

Hyperactive: 1% of pts; agitation, combative, laughing, lack of orientation, progressive confusion following sedation

Mixed

Front 4

Complications of sedation:

Back 4

1. Prolonged ICU stay
2. Prolonged mechanical ventilation
3. Physiological dependance
4. Respiratory depression

Front 5

Characteristics of Agitation:

Back 5

Often associated w/ pain
Motor restlessness
Heightened response to stimuli
Irratibility; aggressive
Fluctuations of Sx overtime
Decreased sleep
Can by caused by fear
Pulling at tubes
Ventilator dyssynchrony
Frequent non-purposeful movements

Front 6

Indications for sedation in ICU pts:

Back 6

Tx of agitation/anxiety
improve sleep
restore normal sleep-wake cycle
facilitate mechanical ventilation
improve pt care
provide amnesia (not in guidelines)

Front 7

What do 15% of ICU pts develop after 1 stay?

Back 7

PTSD!!!

Front 8

What sedative is always the first recommendation? Why?

Back 8

Analgesic is always first line because pain is the most common cause of agitation.

Front 9

What admin freq is best for sedatives?

Back 9

Infusion or scheduled-> stays ahead of pain

Front 10

Which assessment scale is best?

Back 10

the 0-10 scale

Front 11

What are the analgesics used in sedation?
Do they induce amnesia?
What are 3 most often used?

Back 11

Morphine: NOT for pts who are hemodyn unstable-> histamine released-> decr BP!
Hydromorphone
Fentanyl: Rapid onset, usu drip, GOOD in renal dysfx
Meperdine: CAUTION w/ renal insufficiency
Remifentanil: Untra short acting, good for neuro pts

NONE cause amnesia

Morphine, Hydromorphone, Fentanyl

Front 12

What 2 effects do all bezos used in ICU have?

Back 12

Sedation
Amnesia
NOT analgesia

Front 13

Which is the most lipophilic benzo?
What does this mean in pts?

Back 13

Midazolam
Accumulation, especially in chubby

Front 14

Which benzo has fastest onset?

Back 14

Midazolam

Front 15

Which 3 benzos are used in the ICU setting?

Back 15

Midazolam (Versed)
Lorazepam (Ativan)
Diazepam (Valium)

Front 16

Midazolam:
Onset?
Dur of Action?
Administration?
Use?
Special considerations?

Back 16

Onset 1-5 minutes
Dur of Action @ 2 hrs
Continuous
Great for rapid daily wake up (ie if want to do neuro exam); used for short term sedation <72hrs
Special considerations: AVOID in RENAL/HEPATIC failure; Metab by CYP3A4-> DDI

Front 17

Lorazepam:
Onset?
Dur of Action?
Administration?
Use?
Special considerations?

Back 17

Onset: 5-20 min (slowest)
DOA (6hrs)
Boluses or continuous infustion
Long term Sedation
Special considerations: No hepatic metblsm-> ok in liver failure
Metab by glucu-> few DDIs
Formulated in propylene glycol (IV)
LEAST lipophilic of the 3

Front 18

Which benzo used in ICU has slowest onset of action?
Which benzo used in ICU has quickest onset of action?

Back 18

Lorazepam (5-20min)

Diazepam (1-5 min)

Front 19

Which benzo used in ICU has the longest DOA?
Which one has the shortest DOA?

Back 19

Lorazepam (6 hrs)

Midazolam (2hrs)

Front 20

Diazepam:
Onset?
Dur of Action?
Administration?
Use?
Special considerations?

Back 20

Onset: 1-5 minutes (shortest)
DOA: 4 hrs
Intermittent boluses
Special considerations:
Formulated in prop glycol (IV)
Most likely to cause phlebitis
2nd most lipophilic

Front 21

SEs from the benzos used for sedation in ICU?

Back 21

Respiratory depression
Specific adverse effects: propr glycol toxicity w/ some
Hypotension
Delirium
Tolerance

Front 22

Drug/Dose/freq/route/admin for Analgesia in Hemodynamically Unstable?

Back 22

Fentanyl: 25-100mcg IVP q5-15min
OR
Hydromorphone: 0.25 - 0.75 mg IVP q5-15 min

Repeat until pain controlled, then scheduled doses + PRN

Front 23

What is used for Analgesia in Hemodyn. stable?

Back 23

Morphine: 2-5mg IVP q5-15min

Repeat until pain controlled, then scheduled doses + PRN

Front 24

What is used for Sedation of Acute agitation?

Back 24

Midazolam: 2-5mg IVP q5-15 min until acute event is controlled

Front 25

What is used for Ongoing sedation (not acute) in the ICU?

Back 25

Lorazepam: 1-4mg IVP q10-20min until at goal, then q2-6hr scheduled + PRN
OR
Propofol: start 5mcg/kg/min, titrate q5min until at goal. If propofol is used for MT 3 days (except neurosurg pts) ten convert to lorazepam!

Front 26

What is used for Delirium in ICU?

Back 26

Haloperidol: 2-10mg IVP q20-30min, then 25% of loading dose q6hr

Front 27

Commonly used ANALGESIA assessment scales?
Commonly used SEDATION assessment scales?

Back 27

Numerical Rating Scale
Visual Analog Scale
Pain Faces Scale

Ramsey Scale
Riker Sedation Agitation Scale (SAS)
Richmond Agitation-Sedation Scale (RASS)
Motor Activity Assessment Scale (MAAS)

Front 28

What objective assessment methods exist for sedation?

Back 28

Assess pts vital signs:
HR variability, lower esophageal contractility
Raw EKG score
BIS (bispectral index) for assessment of pts sedation & hypnotic drug effect

Front 29

What is the commonly used Delirium assessment scale? What 4 features of delirium does it assess?

Back 29

CAM-ICU
1. Acute change or fluctuation in mental status
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

Front 30

What are the goal #'s & corresponding states for each of the sedation scales?

Back 30

Ramsay: 4: brisk response to light stimuli
Riker: 3/4: sedated-calm/cooperative
Richmond: -2/-3: Light to moderate sedation
MAAS: 2: Responsibe to touch, name, or both

Front 31

What are the indications for NMBAs?

Back 31

a. Help w/ trach tube
b. Control ICP
c. Control muscle spasms (convulsions OR tetanus)
d. Decrease oxygen consumption
e. In surgery if movement w/b bad
f. Decr body temp

Front 32

What are the principles of use for NMBAs?

Back 32

a. Use lowest possible dose for shortest possible time
b. Use only after deep sedation has proven inadequate
c. Pts MUST recieve sedation furing NMBA therapy

Front 33

What are the commonly used paralytics (ntk gen & brands)?

Back 33

Depolarizing NMBA: Succinylcholine (Anectin, Quelicin)

Nondepol NMDAs:
--Aminosteroidal's:
-----Pancuronium
-----Vecuronium (Norcuron)
-----Rocuronium (Zemuron)
--Benzylisoquinlinium's:
-----Atracurium (Tracrium)
-----Cisatricurium (Nimbex)
-----Mivacurium (Mivacron)

Front 34

NMBAs: DOAs? Which are Long, Intermediate, SHort?

Back 34

Long: Pancuronium
Short: Mivacurium
Intermediate: all others

Front 35

Which NMBA has vagolytic activity?

Back 35

Pancuronium

Front 36

Which NMBA has histamine release?

Back 36

atracurium

Front 37

Which NMBAs ok to use in hepatic failure?
Renal failure?

Back 37

Cisatracurium, atracurium
same

Front 38

What are the complications of NMBAs?

Back 38

1. Incr risk of VTE
2. Keratitis or corneal abrasion
3. Prolonged recovery
4. AQMS

Front 39

How can the complications of NMBAs be prevented?

Back 39

1. VTE: Physical therapy & DVT prophylaxis
2. Keratitis/Corneal ablasion: Prophylactic eye care: methylcellulose drops/ Opth ointment/tape/eye patches
3. Prolonged recovery: d/c NMBAs asap for pt recvng NMBA+Corticosteroids
4. AQMS: Drug holidays- only restart based on pts condition

Front 40

What is Train of Four?
What is GOAL

Back 40

Periph Nerve stim delivers 4 quick impulses to nerve.
In absence of NMBA, get 4 contraction.
Goal is 1-2 twitches

Front 41

What clinical monitoring is performed w/ NMBAs?

Back 41

Assessment of ventilator synchrony

Front 42

Lorazepam dose for sedation in ICU?

Back 42

1-4mg IVP q10-20min until at goal, then 2-6hr scheduled+PRN

Front 43

When is lorazepam good to use?

Back 43

Obese
Renal probs
Low albumin (not sure what this means?)

Front 44

When should midazolam NOT be used?

Back 44

Midazolam s/n/b used in pts who have:
obesity
low albumin (below 3.5)
renal failure

Front 45

When should propofol NOT be used?

Back 45

Propofol s/n/b used in:
Obese (b/c it contains fat)
where cost is an issue

Front 46

Besides Benzos, what can be used for sedation in the ICU?

Back 46

Propofol (Diprivan)
Cetra alpha-agonists including clonodine(rare) & dexmedetomidine

Front 47

Properties of Propofol:

Back 47

Sedation & amnesia (NO analgesia)
Ultra short acting (1-2 min)
Short DOA (15min) -> given as continuous, pushed in OR
Clinical niche: Neuro patients (brain injury/trauma)
May help wean Benzo pts
DECREASES ICP
made in 10% LIPID solution

Front 48

Properties of Dexmedetomidine:

Back 48

Alpha-2 agonist w/ some analgesic properties.
NO amnesia props
May lower opioid reqs
Short term sedation->24 hrs
RISK FOR REBOUND TACHY & HTN
Continuous infusion
EXPENSIVE, but good b/c get out of ICU quicker
CAN be used safely for >24hrs

Front 49

Do Precedex & Opioids have amnestic props?

Back 49

NO

Front 50

Which of all the sedative options in the ICU are short acting?

Back 50

Midazolam & Propofol

Front 51

How can we objectively assess sedation level?

Back 51

BIS index or BIS monitoring: Uses pts EEG, processes into a #
Scale 0 (isoelectric) - 100 (alert)
Goal<40
Widely used in pts under general anesthesia
Use in ICU Increasing

Front 52

Are there reversal agents available for any of the sedatives?

Back 52

Flumazenil (Romazicon) for Benzos

Naloxone (Narcan) for Opiates

Front 53

In using the CAM-ICU, what specs -> presence of delirium?

Back 53

3 or more of the items listed;
1 + 2 must be present (acute onset or fluctuation of mental change & Inattention)

Front 54

If a pt was found to have hypoactive delirium, what tx changes would be recommended?

Back 54

1st: see if fxrs contributing: drugs/malnutrition/pre-existing dementia
2nd: try non-rx therapies:
Hearing aid, glasses, clock, calendar
3nd: Haloperidol

Front 55

Haloperidol properties?

Back 55

Sedative effect, but does NOT cause respiratory depression
CI for Parkinsons- EPS, Prolongs QT
Intermittent boluses
Slow onset (20 min)

Front 56

What do you give pts who have hypoactive delirium who have Parkinsons?

Back 56

NOT Haloperidol:
OK to give:
Olanzipine (Zyprexa)
Risperidone
Quetiapine (Seroquel)
NOTE: Olanzapine is 2nd line b/c comes IM

Front 57

Why is Haloperidol used as opposed to Chlorpromazine or Droperidol?

Back 57

B/c Halidol has a lesser sedative effect & a lower risk of HypoTN. So, Haliperidol preferred but need to monitor QT prolongation.
Droperidol=frightening dreams + enhanced hypoTN

Front 58

When are NMBAs always indicated?

Back 58

Mechanical vent
Tetanus
Increased ICP

Front 59

When is pancuronium CI?

Back 59

Hepatic/Renal dysfx
CI to vagolytic meds

Front 60

When is succinylcholine usu used?

Back 60

To facilitate intubation

Front 61

How can succinylcholine affect electrolyte levels?

Back 61

May cause hyperkalemia

Front 62

Which dx state makes succinylcholine CI?

Back 62

hyperkalemia
Increased IOP (glaucoma?)

Front 63

Pancuronium (Pavulon) props:

Back 63

Longest acting
Only Vagolytic (Increases HR)-> avoid in CV pts
Modest histamine release (HypoTN/flushing)
Avoid in Renal/Hepatic dx

Front 64

Vercuronium (Norcuron) props:

Back 64

Intermediate acting
No effect on HR

Front 65

Rocuronium props:

Back 65

SUPER FAST acting
Not very common

Front 66

Atricurium (Tracrium) Properties:

Back 66

Intermediate acting
HISTAMINE RELEASE (HypoTN, flushing)
Metabolite that induces seizures (BEWARE of accum w/ liver disease)
GOOD for RENAL dysfx

Front 67

Cisatricurium (Nimbex)

Back 67

Intermediate acting
MILD histamine release
NO risk of seizures
NICHE=multi-organ dysfx
OK for renal & hepatic

Front 68

Mivacurium properties:

Back 68

Shortest acting
2nd line for rapid intubation (to Succ)
some histamine release (hypoTN)

Front 69

Which NMBAs s/n/b used in Renal dysfx?
Liver Dysfx?

Back 69

Renal: Pancuronium, vecuronium CI
Liver: Pancuronium, Vecuronium, & Atracurium

Front 70

What lab s/b monitored daily for pts on NMDAs?

Back 70

CPK

Front 71

Other than the strategies mentioned for complications, what meds should paralytic pts recieve?

Back 71

Stress ulcer prophylaxis; a PPI or H2RA)

Front 72

What are the reversible agents for NMBAs?

Back 72

Pyridostigmine (Mestinon)
Neostigmine (Prostigmin)