Chapter 6 - Comfort & Sedation

Dyssynchrony

Patient fights the mechanical ventilator

Why should an opoids be given with an analgesc or anxiolytic?

It enhances the effect and uses less amount of opioid

Behavioral Pain Scale (BPS)

• assess pain nonverbal ICU pts

Critical Care Pain Observational Tool (CPOT)

• for intubated and extubated patients

• more recommended for ventilated patients to distinguish painful vs nonpainful interventions

Uses for Continuous EEG Monitoring

• assess levels of sedation

• monitors elevated ICP

Bispectral Index Score (BIS) Monitor

• use for sedation assessment

• BIS of 40 to 60 = full sedation

• BIS < 60 is the GOAL for icu pts

Pupillometry/ Pupil Dilation Reflex (PDR)

Assess effect of opioids

• Opioid administration =⬇ PDR

• So if PDR keep decreasing while pt is ongoing pain, ADDITIONAL OPIODS ARE NOT BENEFICIAL

Hyperactive Delirium

• Agitation

• Attempting to remove catheters

• Rapid mood shifts

Hypoactive Delirium

• Withdrawal

• Decreased responsiveness

• Lethargy

Mixed Delirium

Has clinical manifestations of both types

What medication should not be used routinely?

Haloperidol (Haldol)

What is considered 1st line med class for neuropathic pain?

IV opioids

Why may fentanyl patches not be recommended for acute analgesia?

Takes 12 to 24 hrs to achieve peak effect

Opioid Adverse Effects

• Hypotension

• Respiratory Depression

• Gastric retention & ileus

Why should naloxone (narcan) not be administered after prolonged analgesia?

It may induce withdrawals

Ofirmev

IV Tylenol

• Pain reliever and fever reducers

• Antidote: Acetylcysteine

Ketamine

• low dose pain reliever

• wide safety margin

What medications require pts to swallow or have an enteral tube>

Neuropathic Meds

Neuropathic Meds (ex. Pregabalin)

Using these reduced opioid consumption

NSAIDs are not for pts with

• asthma and aspirin sensitivity

PCA Pumps

NOT for pts with sleep apnea

Uncommonly used in ICU pts

Epidural Analgesia Advantages in ICU

• Relief for pts with multiple rib fractures

• Improves pulmonary function

-caine

SEs of Epidural Analgesia

• Hypotension

• Urinary retention

• Respiratory depression

• Vomitting

Propofol

• preferred sedative for mech.ventilated patients with rapid onset

• emulsion → high triglycerides

• se: hypotension, bradycardia, pain (w PIV admin)

• should NOT hang > 12hrs

Dexmedetomidine (Precedex)

• short-term sedative with mild analgesia & anxiolytic

• se: bradycardia & hypotension

Midazolam (Versed)

• Sedative that treats agitation and anxiety

  • given b4 central line placements (GM)

  • se: hypotension/cns depression

Neuromuscular Blockades (NMB)

• Induced chemical paralysis to

  • facilitate intubation/mech.vent

  • control ICP

• NA: SEDATE THE PATIENT AS WELL!!!!

Why may we need to lubricate the pts eyelids to prevent corneal abrasions while receiving a NMB?

The pt is unable to blink (they’re paralyzed)

Train of Four (TOF)

• evaluates the NMB level to assess degree of paralysis

• four energy impulses delivered → # of twitches assessed

  • 0 twitches = Complete NBM (Paralysis ✅)

  • TOF Goal: 2/4 twitches

Succinylcholine (Paralytic)

• Paralytic/NMB

• Avoid in pts with hyperkalemia (se: hyperkalemia)

Cisatracurium (Nimbex)

• newer and safer NMB

• used in ARDS

Opioid Withdrawal Symptoms

• pupil dilation

• sweating

• tachycardia/tachypnea

• htn

• anxiety

Benzodiazepine Withdrawal

• tremor

• agitation

• sleep disturbances

• seizures

Procedural/Conscious Sedation

• sedative/analgesic given to avoid resp depression or hypotension during procedure

T/F: Pts with history of alcoholism higher risk of septic shock

T

Alcohol Withdrawal Syndrome (AWS)

• agitation

• delirium tremens (twitching digits)

• seizures

• death

Treatment? Benzodiazepines or Precedex