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It is recommend that ____________________be considered as the first-line drug class of choice to treat NON-NEUROPATHIC pain in critically ill patients.
intravenous (IV) opioids
______________IV opioids, when titrated to similar pain intensity endpoints, are equally effective.
It is suggested that _____________be considered to decrease the amount of opioids administered (or to eliminate the need for IV opioids altogether) and to decrease opioid-related side effects .
It is recommend that either____________________ or _______________________, in addition to____________, be considered/recommended for treatment of neuropathic pain.
- enterally administered gabapentin or carbamazepine
- IV opioids
Maintaining __________levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay)
iv. We recommend that sedative medications be titrated to maintain a __________ level of sedation in adult ICU patients, unless clinically contraindicated .
What does RASS stand for?
Richmond Agitation-Sedation Scale (RASS)
What does SAS stand for?
Sedation-Agitation Scale (SAS)
What are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients?
- Richmond Agitation-Sedation Scale (RASS)
- Sedation-Agitation Scale (SAS)
It is suggested that sedation strategies using _______________________ be preferred over sedation with _________________________ to improve clinical outcomes in mechanically ventilated adult ICU patients.
- non-benzodiazepine sedatives (either propofol or dexmedetomidine)
- benzodiazepines (either midazolam or lorazepam)
Delirium is associated with increased ______________, _____________ and _______________in adult ICU patients.
- prolonged ICU and hospital LOS
- Development of post-ICU cognitive impairment
How is Delirium assessed in the ICU?
- Confusion Assessment Method for the ICU (CAM-ICU)
- Intensive Care Delirium Screening Checklist (ICDSC)
What is ICDSC?
Intensive Care Delirium Screening Checklist (ICDSC)
What is CAM-ICU?
Confusion Assessment Method for the ICU (CAM-ICU)
Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU, what are they?
- Preexisting dementia
- History of hypertension and/or alcoholism
- High severity of illness at admission
___________is an independent risk factor for the development of delirium in ICU patients.
Benzodiazepine use may be a risk factor for the development of _____________in adult ICU patients.
In mechanically ventilated adult ICU patients at risk of developing delirium, ________________________ administered for sedation may be associated with a lower prevalence of delirium compared to benzodiazepine infusions.
We recommend performing early ______________of adult ICU patients whenever feasible to reduce the incidence and duration of delirium .
There is no recommendation for using a ________________delirium prevention protocol in adult ICU patients, as no compelling data demonstrate that this reduces the incidence or duration.
There is ____________ evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients.
Atypical _____________________ may reduce the duration of delirium in adult ICU patients.
Antipsychotics (e.g. Risperidone, Olanzapine, Clozapine, Quetiapine)
In adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of ________________________rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients.
What are the Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes?
- Daily sedation interruption or a light target level of sedation in mechanically ventilated adult ICU patients
- Analgesia-first sedation
- Promoting sleep by optimizing patients’ environments
- Using an interdisciplinary ICU team approach
What are the indications for Sedatives in the ICU?
- Attenuate fear and anxiety
- Potentiate analgesia
- Facilitate mechanical ventilation (improve oxygenation)
- Facilitate tolerance to procedures and patient care
- Promote normal sleep cycle
- Provide patient safety and comfort while avoiding adverse effects (chemical restraint)
- Reduce unnecessary recall (amnesia)
- Mandatory adjunct to NMBs
- Facilitate terminal care
What are the Complications of ICU Sedation?
- Prolonged ICU stay
- Prolonged hospital stay
- Prolonged mechanical ventilation
- Physiologic dependence (withdrawal reactions)
- Respiratory depression
- Increased utilization of diagnostic procedures and imaging modalities
What are the most commonly used sedatives in the ICU?
What is the MOA of Benzodiazepines?
- Potentiate GABA receptor mediated inhibition of the CNS
- Anxiolytic, amnestic effects
- Anticonvulsant effects
Benzodiazepines show Dose-dependent ___________________________.
__________________ are Synergistic with opioids.
_______________________ have minimal cardiovascular effects on ____________patients.
_____________________ are good if hemodynamically unstable.
Do Benzodiazapines develop tolerance with continued administration?
- Have to keep upping the dose
Midazolam (Versed) is used for what?
Sedation, status epilepticus, ethanol withdrawal
What is the dose of Midazolam (Versed)?
- Bolus loading dose of 1 – 4 mg and repeat if necessary
- (can be given intermittently every 15 min to 1hour)
- Initial infusion at 5-10 mg/hr to a max of 20 mg/hr
- Adjust infusion by 1 mg/hr until desired RASS score achieved
What are the important kinetic parameters for Midazolam (Versed)?
- Metabolite can accumulate in renal dysfunction
- Metabolized via CYP3A4, watch for interactions (Not CI, just recognize that it may cause increases sedation w/ Fluconazole, conivaptan, macrolides, verapamil, etc.)
- Widely distributed in fat tissue
What is a normal Lorazepam (Ativan) dose?
- May be given as bolus then infusion
- Intermittent dosing 1- 4 mg every 20 minutes to 6 hours
- Infusion rate 2 - 5 mg/hr to max of 10 mg/hr
- Adjust infusion dose by 1 mg/hr until desired RASS achieved
What are the important kinetic parameters of Lorazepam (Ativan)?
- Lower lipid solubility, slower onset of effect
- Metabolism not affected by liver or renal failure
- Propylene glycol carrier leads to hyperosmolality with an increased gap metabolic acidosis
Lorazepam (Ativan) should be monitored for ___________________with prolonged us.
Propofol (Diprivan) is used for what?
Sedation, refractory migraine, status epilepticus, delirium tremens, alcohol withdrawl
What is the MOA of Propofol (Diprivan)?
Inhibits NMDA subtype of glutamate receptors and has agonist effects at the GABA receptor
What are the important kinetic parameters of Propofol (Diprivan)?
- Hydrophilic with high lipid solubility, crosses blood-brain barrier RAPIDLY
- Rapid redistribution to peripheral tissues
- Pharmacokinetics not affected by renal or chronic hepatic disease
- Rapid onset (1-2 min), short duration (3-5 min)