Therapeutics - Sedation 5
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. What would you like to do?
How do IV and IM opioid dosage forms compare?
IV requires lower and more frequent dosing compared to IM
What drugs are available for Neuropathic Pain?
Gabapentin has a Starting and Maintenance dose of:
- 100 mg PO three times daily
- Maintenance dose is 900-3600 mg/day in 3 divided doses
When should you adjust the dose of Gabepentin?
Adjust dose for renal function
What are the SE of Gabapentin?
Causes a lot of edema
_____________can be used instead of Gabapentin, because it doesn’t cause as much edema.
Carbamazepine is Rarely used, why?
Many drug interactions – inducer
______ or _________may be used as adjuncts to opioids in select patients.
NSAIDs or APAP
NSAID use limited by risks of:
- Surgical site bleeding
- GI bleeding
- Delay in bone healing
- Development of acute kidney injury
Ketorolac should be limited to max of __ days with close monitoring for _____________ or ___________..
- renal insufficiency or GI bleeding
Acetaminophen used as antipyretic, may have _________________effect.
Ketorolac (Toradol) comes in what dosage forms?
IM or IV
_____________comparable to moderate doses of morphine or meperidine.
What is the onset for Ketorolac (Toradol)?
Onset is 10 minutes
What is the Dose for Ketorolac (Toradol) in < 65 yrs? IM or IV: 15-30 mg q 6h (Max 120 mg/day)
Ketorolac (Toradol) si Contraindicated for:
Peri-op pain of CABG surgery
What are the SE of Ketorolac (Toradol)?
- Renal effects and package labeling
- Serious GI toxicity
- Bleeding, ulceration, perforation in elderly
What is the name of IV Ibuprofen?
What are the indications for IV Ibuprofen (Calodor)?
Indicated for fever, mild to moderate pain, or as adjunct to opioids in adults
IV Ibuprofen (Calodor) has a boxed warning for what?
Boxed Warnings for cardiovascular and GI risk ( especially with CABG)
What are the Contraindications of IV Ibuprofen (Calodor)?
- Asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs
- Peri-operative period in the setting of coronary artery bypass graft (CABG) surgery
What are the most common adverse reactions of IV Ibuprofen (Calodor)?
Nausea, flatulence, vomiting, headache, hemorrhage and dizziness (>5%)
What are the DDI’s associated with IV Ibuprofen (Caldolor)?
Drug interactions: ACE inhibitors, aspirin, warfarin, lithium, diuretics
What is the Pain dose of IV Ibuprofen (Calodor)?
400 mg to 800 mg intravenously over 30 minutes every 6 hours as necessary
What is the fever dose of IV Ibuprofen (Calodor)?
400 mg intravenously over 30 minutes, followed by 400 mg every 4 to 6 hours or 100-200 mg every 4 hours as necessary
What should the Infusion time for IV Ibuprofen (Calodor) be?
Must be no less than 30 minutes
What is the Max dose of IV Ibuprofen (Calodor)?
Acetaminophen PO/PR has what OOA?
Onset is 30-60 minutes (variable)
What is the Dose of Acetaminophen PO/PR ?
- 325 – 1000 mg ever 4-6 hours
- Max dose is ≤ 4 g/day
IV Acetaminophen (Ofirmev) has what Indications?
- Management of mild to moderate pain
- Management of moderate to severe pain with adjunctive opioid analgesics
- Reduction of fever
What is the normal Dose of IV Acetaminophen (Ofirmev) in adults and adolescents > 50 kg?
- 1000 mg IV every 6 hours or 650 mg IV every 4 hours to a maximum of 4000 mg per day ( GIVE 4 grams for IV, don’t do the 3 grams that is only for the oral products)
- Minimal dosing interval at 4 hours
- May be given as single or repeated dose
What are the Side effects of IV Acetaminophen (Ofirmev)?
- ≥ 3% nausea, vomiting, headache, insomnia
- All similar incidence to placebo
IV Acetaminophen (Ofirmev) Patient Selection includes:
- Suspected ileus
- Avoid CNS depression
- Thrombocytopenia– allows us to avoid NSAIDs
- Renal dysfunction – allows us to avoid NSAIDs
- Opioid sparing effect
- Avoid NSAIDs
- Clinical Studies with IV Acetaminophen
- Pain – placebo controlled studies
- Ear, nose and throat surgery, spinal surgery, orthopedic surgery, GI surgery, gynecologic surgery, urologic surgery
- Cardiac surgery, hernia repair, orthopedic surgery, gynecologic and obstetric surgery, ear, nose and throat surgery, dental surgery
Indications for NMBs:
- Facilitate mechanical ventilation – Biggest reason
- Manage increased intracranial pressure
- Treat muscle spasms
- Neuroleptic malignant syndrome
- Decease oxygen consumption
- Stop seizure activity
- Avoid self injury
- Severe acute respiratory distress syndrome
What are the Neuromuscular Blocking (NMB) Agents, Depolarizing Agents:
- Short acting
What are the Neuromuscular Blocking (NMB) Agents, Nondepolarizing Agents:
- Atracurium (Tracrium)
- Cisatracurium (Nimbex)
- Rocuronium (Zemuron)
- Vecuronium (Norcuron)
- Pancuronium (Pavulon)-Long acting
All NMBs LACK ___________,______________ and _____________PROPERTIES
SEDATIVE, AMNESTIC, AND ANALGESIC
What is the MOA of NMB Depolarizers?
Mimic ACh; cause sustained depolarization with block of neurotransmission
What is the MOA of NMB Nondepolarizers?
Bind to ACh receptor and block transmission
What is Succinylcholine (Anectine) used for and why
- Used to facilitate intubation
- Ultra-short acting
What are the SE of Succinylcholine (Anectine)?
- Muscle fasciculations (jerky)
- Caution for hyperkalemia – HAVE TO KNOW THEIR K LEVELS
- May increase serum potassium by 0.5 to 1.0 mEq/L due to EFFLUX OF POTASSIUM FROM MUSCLE CELLS
___________________________ is an Isomer of atracurium with three times its potency.
______________________ is Degraded by pH- and temperature-dependent Hoffman elimination
__________________________ has no adverse effect >1% in clinical trials.
Can cisatracurium (nimbex) be used with hepatic and renal insufficiency?
What does a Peripheral Nerve Stimulator do?
Monitors whether a patient is blocked
Dosing of NMB is based upon:
Clinical judgment and discretion of nurse in past
Peripheral nerve stimulator objectively assesses:
- The degree of blockage
- helps guide optimal dose of NMB
- thumb adduction caused by contraction of the adductor pollicis in response to stimulation of the ulnar nerve is the most widely used electrode placement
- train of four quantifies the range of depth of NMB
Doses of NMB should be titrated to achieve:
- One or two twitches on train-of-four and desired clinical effect
- Train of four pulses where each is 0.5 seconds apart
One to two twitches corresponds to ___-___% blockade
Train Of Four should be assessed how often?
Several times per day
________ is used to ensure adequate sedation and assess need for continued paralysis.
What are the risks of NMBs?
- Complications From NMBs
- Critical illness polyneuropathy
- Prolonged recovery/deconditioning – GET WEAK
- Accumulation of NMBs or metabolites
- Diffuse weakness that persists long after the NMB is discontinued
- Keratitis and corneal abrasian
- Myositis ossificans (heterotropic ossification)
- Increased risk of VTE
- Skin breakdown and decubitus ulcers
Medications that Potentiate NMBs include:
- Type Ia Antiarrhythmics (and magnesium)
- Calcium channel blockers and ß-blockers
- Chemotherapy (cyclophosphamide)
Medications that Antagonize NMBs include:
- Sympathomimetic agents
- Chronic exposure to NMBs
Conditions that Potentiate NMBs include:
- Myasthenia gravis
- Neoplastic syndrome
- Muscular dystrophies and myotonia
- Multiple sclerosis
- Amyotrophic lateral sclerosis
- Acute intermittent porphyria
- Electrolyte disturbances
- Renal failure
- Liver failure
Conditions that Antagonize NMBs:
- Endotoxemia and sepsis
- Major burns and trauma
- Hepatic failure with ascites
- Denervation syndrome
- Peripheral neuropathies
What are the main Agents for sedative and amnestic effects?
What are the main Analgesic agents?
fentanyl, morphine, hydromorphone
What are the main Delirium in the ICU patient?
haloperidol (Haldol), quetiapine (Seroquel)
What would you like to do?
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