Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Analgesia & sedatives in ICU patients

No description
by

HYAE MIN LEE

on 10 December 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Analgesia & sedatives in ICU patients

R2 LEE HYAE MIN
Analgesia & Sedation
in ICU patients

- OPIOID ANALGESIA
- NONOPIOID ANALGESIA
* PAIN IN THE ICU
Pain is a subjective sensation
Monitoring pain
OPIOIDS ANALGESIA
opiates : natural chemical derivatives of opium
opioids : opiates + substances stimulating opioid receptors
OPIOIDS ALALGESIA
Morphine, fentanyl, hydromorphone
Intravenous Opioids
excitatoy neurotoxin in critically ill patients
Meperidine
(demerol, pethidine)
NONOPIOID ANALGESIA
Ketorolac
Sedation
INTERRUPTION OF DRUG INFUSIONS
Daily Interruptions
of drug infusions
*Prolonged infusions + drug accumulation & persistent sedation

* daily interruption of drug infusion
- reduced ICU stay
- fewer diagnostic tests to evaluate depressed consciousness
APPROACH TO THE AGITATED PATIENT
Bedside approach to the agitated patient
first priority
in ICU
* ANXIETY IN THE ICU
- BENZODIAZEPINES
- OTHER SEDATIVES
* INTERRUPTION OF DRUG INFUSION
* APPROACH TO THE AGITATED PATIENT
IN THE ICU
<3: effective analgesia
Critically ill patients
- physiological parameters (heart rate)
- elicited behaviors (facial expressions)
effect -
analgesia, sedation
, euphoria, pupil constriction, respiratory depression, bradycardia, constipaton, nausea, vomiting, urinary retention, pruritis
effective
relieving
dull tonic
pain
less
effective
intermittent
sharp pain
relatively
inffective
neuropathic
pain
*faster acting
*no active metabolites
*less likely to decrese BP
Meperidine -> (liver) normeperidine -> kidney (half-life: 15-40hrs)

neurotoxicity
: agitation, tremor, myoclonus, delirium, hallucinations, tonic-clonic seizure
* pancreatico-bliary pain
: NSAIDs(ketorolac)
* meperidine: control of shiverng
Ketorolalc: the only alternative agent approved in the US
dose not sedation or respiratory depression
Analgesic effects
* nonspecific inhibitor of cyclooxygenase
-> strong analgesics activity
moderated anti-inflammatory activity
* opioids sparing effect
Adverse effects
* inhibits PLT aggragation
* risk of GI bleeding
* impair renal function
ANXIETY IN THE ICU
Anxiety and related disorders
* anxiety: absence of a sense of well-being
* agitation: + motor activity
* delirium: specific syndrome of altered mental status
process of establishing a state of calm
Monitoring sedation:
modified Ramsay scale
sedation scores are not intended for patients who are unconscious or receiving neuromuscular blocking agent
BENZODIAZEPINES
Other sedatives
Toxic effects
* hypotension, respiratory depression, excessive sedation

* propylene glycol toxicity (lorazepam, diazepam)
-> change midazolam, propofol

* withdrawal syndrome
-> transitioning to propofol

* Drug interactions
*short-term
sedation
*continuous
infusion
* prolonged sedation
CNS accumulation
renal failure inhibition of cytochrome P450,
drug interaction, hepatic insufficiency
- infusion rate should be determined usins IDEAL BODY WEIGHT
*prolonged
sedation
*risk for
oversedation
Propofol
* anesthesia & short-term sedation
- no analgesic activity
- onset: <1min / duration: 10-15min
- neurologic injury, status epilepticus, delirium tremens

* dose based on ideal body weight
* no dose adjustment

* adverse effects
- hypotension, apnea, hyperlipidemia, contamination, sepsis, rhabdomyolysis,
bradycardia-acidosis (propofol insusion syndrome)
Dexmedetomidine
* highly selective a2-adrenergic agonist
- onset: 1-3min/ duration: 6-10min
-> continuous infusion

* no respiratory depression
* dose reduction: severe liver dysfunction

* adverse effects
- hypotension, bradycardia,
"sympathetic rebound"
-> infusion
should not be continued for longer than 24 hrs
Haloperidol
* antipsycotic effect
- onset: 10-20min/ duration: hours
- not suitable for continuous infusion
- BDZ can be added
: more rapid sedation

* little or no risk cardiorespiratory depression
* calming patients with delirium

* adverse effects
- extrapyramidal reaction
- should be avoided Parkinson'dz pt
-
neuroleptic malignant syndrome, torsades de pointes
intravenous haloperidol for sedation
* IV dose
mild anxiety: 0.5-2mg
moderate: 5-10mg
severe: 10-20mg

1. administer dose by IV push
2. allow 10-20 minutes
no response: double the dose, or add lorazepam(1mg)
3. still no response: switch to another sedative
4. give 1/4 of loading dose q6hrs for maintenance
1. immediate threat to life
(ABCs: airway, breathing, circulation)

2. consider patient's condition
(
pain, anxiety, delirium
) !!
Remifentanil
ultra-short acting opioid for sedation & general anesthesia
*
Supplemental oxygen is recommended

* side-effects
- dizziness, pruritis, nausea, respiratory depression, bradycardia, hypotension, muscle rigidity

* before or after local anesthesia
*
Critically-ill patients
: Continuous infusion
:
0.01-0.25 mcg/kg/minute
(or 0.6-15 mcg/kg/hour) [60kg: 36mcg~900mcg/hr]
Dose should be based on ideal body weight (IBW) in obese patients (>30% over IBW).
Sedation in mechanically ventilated patients: I.V.:
* Initial dose: 0.01-0.05 mg/kg (~0.5-4 mg)
-> may repeat at 5- to 15-minute intervals until adequate sedation achieved

* maintenance infusion: 0.02-0.1 mg/kg/hour (0.3-1.7 mcg/kg/minute).
* Consider a trial of daily awakening

- if agitated after discontinuation of drip, then restart at 50% of the previous dose
* Rapid tranquilization of agitated patient
: Oral, I.M.: 1-2 mg, every 30-60 minutes;
- may be administered with an antipsychotic
(eg, haloperidol)
- Average total dose : 4-8 mg

* Agitation in the ICU patient:
- I.V.: 0.02-0.06 mg/kg every 2-6 hours or 0.01-0.1 mg/kg/hour

* Dosage adjustment for lorazepam with concomitant medications: Probenecid or valproic acid: Reduce lorazepam dose by 50%
* ICU sedation: I.V.:
- Loading infusion: 1 mcg/kg over 10 minutes
(risk of hemodynamic compromise
-> loading dose may be omitted.)
- maintenance infusion: 0.2-0.7 mcg/kg/hour
(it is thought that doses >1.5 mcg/kg/hour do not add to clinical efficacy)
Full transcript