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What is the dose for Quetiapine (Seroquel)?
- Initial 12.5 to 25 mg PO twice daily then titrated
- 75 to 750 mg oral total daily dose
______________________________synergistically increase pain perception.
Anxiety and sleep deprivation
Blunting or absence of sensation of pain or noxious stimuli
What is the “fifth vital sign” (Joint Commision)?
Analgesics increased rate of ________________monitoring, use of________________, ______________ and ___ days.
- ventilator days
What are the Benefits of Pain Control?
- Decreased stress response
- Decreased O2 consumption
- Ventilator synchrony
- Decreased heart rate/cardiac irritability
- Decreased unintentional dislocation of tubes/lines/drains
What are the Suggestions for Assisting ICU Patient to Use a Self-Report Pain Assessment Instrument?
- Enlarge the font of the tool
- Include descriptive words below ranges of pain intensities
- 0 = no pain; 1- 4 = mild pain; 5 - 6 = moderate pain;
- 7 - 10 = severe pain
- Show the tool to the patient, explain the purpose
- Provide reading glasses and hearing aids when necessary
- Ask questions slowly and more than once if necessary
- Allow the patient ample time to process instructions and respond
- Ask ventilated patients to point to a number on the NRS
What are the Nonpharmacologic ways of treating pain?
- Proper positioning, stabilization of fractures, and eliminating irritating physical stimulation
- Application of heat or cold
What are the Pharmacologic ways of treating pain?
- Opioids (fentanyl, morphine, hydromorphone)
- NSAIDs (ketorolac, ibuprofen)
____________________demonstrate similar analgesic and sedative properties when administered in equipotent doses
________________are effective for pain control, but lack amnestic effects.
What are the Opioids commonly used in the ICU?
Morphine, fentanyl, hydromorphone
Fentanyl is available in what dosage forms?
________________Synthetic derivative of morphine, 100 times more potent.
What are the kinetic parameters of Fentanyl?
- Rapid onset, short duration
- Metabolized by CYP450 3A4
What is the dose of Fentanyl?
- Bolus 25 to 100 mcg every 30 min to 1 hour
- Infusion begins at 25 to 50 mcg per hour, then titrated
Fentanyl has ___________effect on cardiovascular system and can be used in hemodynamically unstable patients.
Can Fentanyl be used in hemodynamically unstable patients?
Dose of ________________ determined by previous dosage.
Which opioid can be dosed intermittently with long half life?
The onset of Morphine may take up to ________________.
What are the precautions/SE for Morphine?
- Histamine release with IV administration
- Use with caution in hemodynamic insufficiency
What is a normal dose of Morphine?
- Bolus of 2-4 mg IV and titrated upward in 1 to 2 mg increments q 1-3°
- Infusion at 1 mg/hr, titrated to response (2-30 mg/hr)
- Dose should be titrated to desired effect
What drug is a Semisynthetic opiate agonist?
________________ has a similar pharmacokinetic profile to morphine, but more potent.
___________________can be used safely in hemodynamically unstable patients as it does not induce histamine release.
_____________________ may be beneficial for pain management in fluid restricted patients
What is the dose for Hydromorphone (Dilaudid)?
- Moderate to severe pain, given as 0.2 to 0.6 mg as IV bolus every 1 to 2 hours
- Given as IV infusion starting at 0.5 to 3 mg per hour after bolus
What is the MOA of Meperidine (Demerol)?
- Weak mu-agonist
- Meperidine should be avoided in what patients?
- Critically ill patients
Meperidine’s use is limited to:
Postoperative shivering, single dose pre-procedure
What are the SE of Meperidine (Demerol)?
- Can cause neuroexcitation with high doses
- Can cause seizures
- Active metabolite accumulates in renal dysfunction
- Accumulation can cause seizures
- Drug interactions with MAOIs and SSRIs (MAO B inhibitor)
What are the important characteristics of Fentanyl?
Rapid onset, short duration, may accumulate with repeated dosing, titrated to patch dosage form
What are the important characteristics of Morphine?
Longer duration – intermittent dosing, histamine release, hypotension, active metabolite (prolonged sedation)
What are the important characteristics of Hydromorphone?
Similar DOA to morphine, no metabolite or histamine
What are the important characteristics of Meperidine?
Active metabolite (tremors, delirium, seizures), interacts with antidepressants, not recommended for repetitive use
What are the important characteristics of Codeine?
Lacks analgesic potency, not useful for most patients
What are the Opioid Adverse Effects?
- Respiratory depression
- Gastric retention
- CNS effects
Respiratory depression caused by Opioids can be reversed by what drugs?
Naloxone (Narcan) or nalmefene (Revex)
What is a normal Naloxone dose for Opioid reversal?
0.4-2.0 mg q 2 min IV, IM, SC up to a total of 10 mg (IV route preferred)
Which opiod causes Hypotension?
How does Morphine cause Hypotension?
Euvolemic patient , leading to vagal mediated bradycardia and histamine release
What opioids can cause CNS (delirium) ?
Gastric retention and ileus can be controlled without a laxative by using what drugs?
- Peripheral opioid-receptor antagonists:
- Methylnaltrexone (Relistor)(SQ/IV) and alvimopan (Entereg) (PO)
What are the Peripheral opioid-receptor antagonists?
Methylnaltrexone (Relistor)(SQ/IV) and alvimopan (Entereg) (PO)
What are the Opioid Administration Techniques?
- Scheduled doses or a continuous infusion is preferred over PRN dosing to ensure consistent analgesia
- PCA device may be helpful
- PCA nurse-controlled analgesia