PCT V pain, agitation, delirium exam 2

- pain score: 0-10 (10 being worst pain)
- wrong-baker faces pain rating scale (images of happy-hurt faces)
- critical care pain observation tool (CPOT)
- behavioral pain scale (bases score off of facial expression, upper limb movements, compliance with ventilator)

how to assess pain

opioids

mainstay of pain management

- sedation
- delirium
- respiratory depression
- ileus
- immunosuppression
- may lengthen ICU length of stay
- may worsen post-ICU patient outcome

safety concerns with opioids

- fentanyl
- morphine
- hydromorphone

example of opioids

onset: seconds
duration: 30-60 minutes

onset and duration of fentanyl

onset: 5-10 min
duration: 3-4 hours

onset and duration of morphine

onset: 5-15 min
duration: 4-5 hours

onset and duration of hydromorphone

morphine < hydromorphone < fentanyl

potency from least to greatest: morphine, hydromorphone, fentanyl

morphine

which opioid has active metabolites

hepatic elimination

elimination of fentanyl

- glucuronidation
- renal elimination

elimination of morphine

- glucuronidation

elimination of hydromorphone

IV push: 12.5-100mcg q1h prn
infusion: 10-100mcg/hr
continuous infusion if patient is intubated
demand dose when patient has good mental status

dosing for fentanyl

fentanyl < hydromorphone < morphine

accumulation from least to greatest: morphine, hydromorphone, fentanyl

IV push: 2-4 mg q4h
infusion: 1-5mg/hr
continuous infusion for intubated/sedated patients
demand dosing for good mental status patients

dosing for morphine

IV push: 0.5-2mg q4-6h prn
infusion: 0.2-1mg/hr

dosing for hydromorphone

- respiratory depression
- constipation

adverse effects of fentanyl

- respiratory depression
- constipation
- hypotension
- histamine release
- bronchospasm

adverse effects of morphine

- respiratory depression
- constipation
- hypotension
- histamine release (possibly)

adverse effects of hydromorphone

- acetaminophen
- NSAIDs
- ketamine
- lidocaine
- neuropathic medications

pharmacologic adjuvants to opioid therapy for pain

hepatotoxicity

risks with acetaminophen

- GI toxicity
- bleeding
- renal toxicity

safety concerns with NSAIDs

onset: 30 sec
duration 5-10 min
half life: 2.5 hours

onset, duration, and half life of ketamine

hepatic n-dealkylation

metabolism of ketamine

- psychologic disturbance
- bronchospasm
- hypertension
- tachycardia
- sialorrhea

adverse effects of ketamine

0.5mg/kg one time followed by 1-2mcg/kg/min infusion

dosing for ketamine

onset: 45-90 sec
duration: 10-20 min
half life: 1.5-2 hours

onset, duration, and half life of lidocaine

hepatic, active metabolites

metabolism of lidocaine

- CNs toxicity
- QRS prolongation
- hypotension
- bradycardia

adverse effects of lidocaine

0.1-0.3 mg/kg bolus, followed by 0.5-3mg/kg/hr continuous infusio n

dosing for lidocaine

IV lidocaine, but lack of evidence, routine use not recommended

which form of lidocaine has a possible opioid sparing benefit and improved pain control

- arrhythmias
- CNS toxicities
- PK variability

adverse effects of IV lidocaine

- carbamazepine
- gabapentin
- pregabalin

examples of neuropathic pain medications

onset: 2-4 hours
half life: 5-7 hours

onset and half life of gabapentin

onset: 3 hours
half life: 6.3 hours

onset and half life of pregabalin

onset: 4-5 hours
half life: 12-17 hours

onset and half life of carbamazepine

renal excretion, not metabolized

metabolism of gabapentin

90% excreted as unchanged drug in urine

metabolism of pregabalin

oxidation (autoinduction)

metabolism of carbamazepine

- dizziness
- drowsiness
- ataxia

side effects of gabapentin

- peripheral edema
- dizziness
- lethargy
- dry mouth
- vision changes

side effects of pregabalin

- nystagmus
- dizziness
- diplopia
- ataxia
- lethargy
- SJS

side effects of carbamazepine

100-300mg po 1-3x daily
max 3600mg daily

dosing for gabapentin

25-150mg po daily or in 2 divided doses

dosing for pregabalin

200-400mg/day in 2 divided doses
max 1200 mg daily

dosing for carbamazepine

gabapentin

which neuropathic pain medication is renally adjusted

pregabalin

which neuropathic pain medications needs to be withdrawn gradually over 1 week

carbamazepine

which neuropathic pain medication has many cyp mediated drug interactions

- proper positioning
- stabilizing of fractures
- eliminating irritating physical stimulation
- massage therapy
- music therapy
- relaxation techniques
- heating pad
- cold compress

non-pharmacologic strategies for pain

true

T/F you should use a multimodal strategy when treating pain (opioids + other adjuvant options)

false, recommend a multi modal therapy

T/F you cannot use more than 1 treatment strategy when treating pain

- benzodiazepines
- propofol
- dexmedetomidine
- ketamine

sedative agents

Hepatically metabolized

metabolism of benzodiazepines

propylene glycol vehicle in IV lorazepam

metabolic acidosis occurs with which benzodiazepine

- midazolam
- lorazepam
- diazepam

examples of benzodiazepines for sedation

onset: 2-5 min
half life: 3-11 hour

onset and half life of midazolam

onset: 15-20 min
half life: 8-15 hour

onset and half life of lorazepam

onset: 2-5 min
half life: 20-120 hour

onset and half life of diazepam

- midazolam
- diazepam

which benzodiazepine have active metabolites

diazepam < midazolam < lorazepam

ranking potency from least to most: midazolam, lorazepam, diazepam

loading: 0.01-0.05mg/kg
maintenance: 0.02-0.1 mg/kg/hr

loading and maintenance dose for midazolam

loading: 0.02-0.04mg/kg
maintenance: 0.02-0.06mg/kg

loading and maintenance dose for lorazepam

loading: 5-10mg
maintenance: 0.03-0.1mg/kg

loading and maintenance dose for diazepam

- respiratory depression
- hypotension

adverse effects of sedative benzodiazepines

lorazepam

which sedative benzodiazepine has propylene glycol toxicity

false

T/F propofol has an analgesic effect

true

T/F propofol does not have an analgesic effect

propofol

sedative agent that binds to multiple receptor in the CNS including GABAa

onset: 30 sec
duration: 3-10 min
half life: 3-13 hours (short term); \> 50 hours (long term use)

onset, duration and half life of propofol

hepatic, excreted in urine

metabolism of propofol

loading dose: 5mcg/kg over 5 min
maintenance dose: 5-150mcg/kg/min

loading and maintenance dose of propofol

- injection site reactions
- hypotension
- respiratory depression
- hypertriglyceridemia
- pancreatitis
- propofol related infusion syndrome
- deep sedation associated with longer emergence times

adverse effects of propofol

prolonged administration of high doses, but may also occur with low-dose infusions

propofol infusion syndrome is associated with...

propofol

which sedative may precipitate reaction patients with egg or soybean allergies

propofol, because it's highly lipophilic

which sedative poses an infection risk and why

- assess for hypertriglyceridemia
- propofol infusion syndrome

monitoring for propofol

onset: 5-10 min
duration: 60-120 min
half life: 2-3 hours

onset, duration, and half life of dexmedetomidine

- hepatic, excreted in urine
- glucuronidation
- methylation

metabolism of dexmedetomidine

loading: 1mcg/kg over 10 min
maintenance: 0.1-1mcg/kg/hr

loading and maintenance dose for dexmetomidine

- bradycardia
- hypotension
- refractory hypertension
- hepatic dysfunction

adverse effects of dexmedetomidine

dexmedetomidine

only sedative approved for use in non-intubated patients

clonidine

can give \_____ to help prevent withdrawal with dexmedetomidine

- anxiolytic
- amnestic
- hypnotic
- anticonvulsant
- antiemetic

propofol effects

anxiolytic

dexmedetomidine effects

- anxiolytic
- amnestic
- hypnotic
- anticonvulsant
- analgesic

ketamine effects

- anxiolytic
- amnestic
- hypnotic
- anticonvulsant

benzodiazepine effects

propofol or dexmedetomidine over benzodiazepines

guidelines recommendations for sedation in critically ill, mechanically ventilated adults

light, because it is associated with improved clinical outcomes

sedative medications should be titrated to maintain a light/deep level of sedation in adult ICU patients

- when a patient's sedative medication is discontinued and patients can wake up and achieve arousal and/or alertness
- opening eyes in response to a voice, following simple commands

sedation interruption

- anxiety
- fearfulness
- hallucinations
- delusions
- those who are agitated and may be physically harmful to themselves or others

what patients would benefit from atypical antipsychotics for delirium

- recommend not routinely using haloperidol
- recommend not routinely using hmg-coa reductase inhibitor
- recommend not routinely using atypical antipsychotics (quetiapine, ziprazidone, risperidone)
consequences outweighs potential benefits

not recommended for PREVENTING delirium, but if already experiencing delirium, may be useful

overall recommendation of antipsychotics for delirium

- antipsychotics: haloperidol, quetiapine, risperidone
- trazodone
- valproic acid

pharmacologic treatments for delirium

0.5mg-10mg IV q6h prn

dosing for haloperidol

- QTc prolongation
- anticholinergic
- extrapyramidal reaction

adverse effects of haloperidol

increased risk of death in elderly patients with dementia-related psychosis

black box warning with haloperidol

50mg po BID
alternative: 12.5-50mg qhs prn

dosing for quetiapine

- QTc prolongation
- drowsiness/fatigue
- extrapyramidal reaction
- headache

adverse effects of quetiapine

0.25-1mg po BID
max 6mg/day

dosing for risperidone

- QTc prolongation
- drowsiness/fatigue/sedation
- extrapyramidal reaction
- headache

adverse effects of risperidone

25-50mg qhs

dosing for trazodone