Critical Care RAT NT

Opioids used for pain in the ICU

Fentanyl (most used)

Morphine

Hydromorphone

Opioids - common ADRs

Oversedation

Respiratory depression delirium

Hypotension

Decreased GI motility

Concurrent medication options for treatment of pain in the ICU

Acetaminophen

NSAIDs

Lidocaine

Ketamine

Concurrent medication options for treatment NEUROPATHIC of pain in the ICU

Gabapentin and pregabalin

Non-pharm options for pain

Music and pets

Massage

Temp control

Relaxation techniques

Meds used for anxiety and agitation

Benzos, propofol, dexmedetomidine

Only used if not relieved by analgosedation for mechanically ventilated patients

What do the PADIS guidelines recommend for anti anxiety or anti agitation?

Propofol and dexmedetomidine

Nonbenzos to maintain light goal of sedation and to minimize delirium

Lorazepam - onset of action

IV: 10 min

IM: 20-30 min

PO: 20-30 min

Lorazepam - duration of action

6-8 hours

Lorazepam - ADRs

Anterograde amnesia

CNS effects

Neurodevelopmental (kids)

Paradoxical reactions

Propylene glycol toxicity

Withdrawal syndromes

Injection site pain

Lorazepam - clinical pearls

Intermittent dosing —> continuous infusion

Long term sedation

C/I in pts with alcohol withdrawal or risk of seizures

Propofol - onset of action

9-51 seconds (averages 30 sec)

Propofol - duration of action

3-10 min

Propofol - ADRs

Injection site pain

Hypertriglyceridemia

Pancreatitis

Propofol-related infusion syndrome (PRIS)

Hypotension

Hypersensitivity (soy, egg, peanut allergies)

CV (MI, afib..)

Propofol - clinical pearls

Pt needs to be awakened rapidly for neurological evaluation

Good for head injury with elevated intracranial pressures

Causes light sedation

Dexmedetomidine - onset of action

IV (loading dose): 5-10 min

IN: 10-20 min

Dexmedetomidine - duration of action

1-2 hours

Dexmedetomidine - ADRs

CV (hypotension, bradycardia, HTN)

Tolerance, tachyphylaxis

Withdrawal, constipation, NA

Agitation and drowsiness

Dexmedetomidine - clinical pearls

Only drug approved for sedation of non-intubated ICU patients

You can extubate and continue giving this medication

It does not cause respiratory depression

May require adjunct benzo

Used for light sedation (<24 hours ICU pts)

Preventing delirium

Reduce benzo utilization

Patient reorientation

Improving sleep hygiene

Early mobilization

Lighter sedation strategies

How to improve sleep for patients in ICU

Minimize noise and light disturbances