Therapeutics - Sedation 2
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What is a normal dose of Propofol (Diprivan)?
Starting dose 5 mcg/kg/min, titrate by 5 -10 mcg/kg/min every 5 min to achieve desired effect (max 50 mcg/kg/min)
What should you monitor with Propofol (Diprivan) use?
Monitor blood pressure and TG (adjust lipid content in TPN)
___________________is oil in water emulsion that provides 0.1 gram of fat (1.1 kcal) per ml (equivalent to 10% lipids)
Propofol (Diprivan) is oil in water emulsion that provides ___________________ per mL___________, equivalent to _______________
- 0.1gram of fat (1.1 kcal) per ml
- 0.2 equivalent to 10% lipids
What are the Side effects of Propofol (Diprivan)?
- hypotension, green/whitish urine
- Propofol infusion syndrome (rare and often fatal): cardiac arrest, heart failure, metabolic acidosis or rhabdomyolysis
What is Propofol infusion syndrome?
Cardiac arrest, heart failure, metabolic acidosis or rhabdomyolysis (rare but often fatal)
What drug requires a dedicated IV line, tubing changes?
___________________ has a lower mortality risk compared to benzodiazepine treated patients requiring ventilation.
What is the MOA for Dexmedetomidine (Precedex)?
- 2 agonist with analgesic, anxiolytic, and sedative properties
- Locus ceruleus, not in cerebral cortex
Why does Dexmedetomidine (Precedex) have a Low likelihood of over sedation/hypnosis, no respiratory depression?
Has effects in the Locus ceruleus, not in cerebral cortex
Dexmedetomidine (Precedex) is preferred when _____________ is present.
Dexmedetomidine (Precedex) is approved for sedation of intubated and mechanically ventilated patients in the intensive care setting for up to ___ hours.
- What are the indications for Dexmedetomidine (Precedex)?
- Use in non-intubated patients requiring sedation prior to and/or during surgical and other procedures
- sedation of intubated and mechanically ventilated patients in the intensive care setting for up to 24 hours
What are the Adverse effects of Dexmedetomidine (Precedex)?
- Extension of physiologic effects
- Hypotension, bradycardia, hypertension ( serum)
_______________________ demonstrated less delirium than midazolam in mechanically ventilated patients and Shortened duration of ventilation and ICU length of stay.
_________________________demonstrated less delirium days than lorazepam continuous infusion.
What is the dose for Dexmedetomidine (Precedex)?
- Loading: 1 mcg/kg over 10 min
- Maintenance: 0.2 to 0.7 mcg/kg/hr
- In practice dosing 0.2 to 1.5 mcg/kg/hr is common
Etomidate (Amidate) has what indications?
- Used to facilitate endotracheal intubation in hemodynamically unstable patients
- Used for rapid-sequence intubation
What is a normal dose of Etomidate (Amidate)?
0.2 - 0.4 mg/kg IV, onset within 5 to 15 seconds
What is a normal Elimination pattern for Etomidate (Amidate)?
- T ½ is 2.6-3.5 hours, but clinical hypnotic effects are shorter (5-15 min)
- _______________appears to facilitate GABAminergic neurotransmission, by increasing the number of available GABA receptors by _____________ endogenous inhibitors of GABA binding
- Etomidate (Amidate)
What effects does Etomidate (Amidate) have on CV and Respiratory organs?
Minimal cardiovascular and respiratory effects
What are the Side effects for Etomidate (Amidate)?
- Pain at injection site (30-80%), myoclonic movements on induction (if used w/o NMB), hiccups (30%)
- Even a single dose of etomidate blocks ____________synthesis by inhibiting the activity of _______________________________ that inhibits ___________________in the_____________, resulting in _________________with effects lasting up to 48-72 hours .
- 11ß-hydroxylase that converts 11ß-deoxycortisol into cortisol
- adrenal gland
- primary adrenal insufficiency
Adrenal insufficiency is associated with higher rates of mortality and morbidity in the ICU, what drug can cause this after one dose?
Some clinicians use Etomidate (Amidate) despite adrenal insufficenciy risk and administer __________________________.
Concurrent corticosteroid therapy
Use of etomidate best avoided in ______________patients.
Goal-Directed Sedation Management should include what general framework?
- Patient assessment
- Consider underlying problems
- Consider role of pain
- Consider role of delirium
- Tools to evaluate sedation, pain, delirium
- Match patient needs, characteristics to therapy
- Protocols for Sedation
- Evidence-based (best practice)
- Targeted endpoints
- Sedation “vacation” daily
- Standardize care
Benefits of Daily Sedation Interruption are:
- Statistically significant decrease in ICU resources (LOS, duration of mechanical ventilation)
- Statistically significant increase in likelihood of successful planned extubation
- Reduced complications of critical illness (bacteremia, GI bleeding, VAP, VTE)
- Less sedative, opioid, and propofol use
- Statistically significant decrease in PTSD
- No documented increase in recall or adverse events from agitation in ICU (self-extubation)
- Sedation Scores
MAAS stands for?
Motor activity assessment scale
VICS Stands for:
Vancouver interactive and calmness scale
ATICE stands for:
Adaption to intensive care environment
MSAT stands for:
Minnesota sedation assessment tool (MSAT)
What are the sedation scales available?
- Ramsay Sedation Scale
- Sedation agitation scale (SAS)
- Motor activity assessment scale (MAAS)
- Vancouver interactive and calmness scale (VICS)
- Richmond agitation-sedation scale (RASS)
- Adaption to intensive care environment (ATICE)
- Minnesota sedation assessment tool (MSAT)
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