sedation, analgesia and paralytics in the icu. what is used for what? o analgesic o pain control o...
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Sedation, Analgesia and Paralytics in the
ICU
What is used for what?O Analgesic
O Pain controlO Always should be first before sedation
O SedativeO Achieve sedation, anxiolysis, amnesia,
altered consciousnessO Paralytic
O Prevents movementO Never should be used without analgesia
and sedation
Sedatives
SedativesO EtomidateO PropofolO KetamineO Dexmedetomidine
EtomidateO Used mostly for Rapid Sequence
Intubation (RSI)O GABA like effectsO Minimal effect on BP; can lower ICPO Can reduce plasma cortisol levelsO Hepatic metabolism; renally excretedO Dose 0.3mg/kg for RSI
PropofolO Anesthetic agentO Respiratory and CV depressant can
drop BP by as much as 30%O Vasodilation and negative inotropic
effectO PRISO Dose is 1-1.5mg/kg for RSIO For ICU sedation: 5-50mcg/kg/min
KetamineO Anesthetic and dissociative agentO Also has analgesic effectO Hepatic metabolismO Can cause laryngeal spasm,
hypertensionO Psychomimetic effects given with
benzoO 1-2mg/kg for RSIO 5-15mcg/kg/min for sedations
Benzodiazepenes: GABA agonists
Lorazepam MidazolamO Better choice for
elderly and hepatic/renal dysfunction
O Propylene glycol diluent – risk of metabolic acidosis
O .01-.1 mg/kg/hr and 1-2mg IVP
O Has an active metabolite
O .02-.2mg/kg/hr and 2-4mg IVP
DexmedetomidineO Recommended first line sedative for
intubated pts*O Central alpha-2 agonistO Hepatically metabolizedO Renally excreted 95% unchangedO Dosed 0.2-1.4 mcg/kg/hrO Can cause bradycardia and hypotensionO Does NOT cause respiratory depressionO Has analgesic component
Analgesics
AnalgesicsO Always treat pain before giving
sedation or paralyticsO Not all patients requires analgesic
infusion as PRN dosing can be just as effective
O If able, evaluate your interventions to ensure pain level reduced
AnalgesicsFentanyl Morphine
O 80-100x more potent than morphine
O Bolus: 1mcg/kg q5 minutes
O Infusion 0.5-3mcg/kg/hr
O Can cause rigid chest, hypotension
O Causes histamine release itching
O Bolus .3mg/kg q10 minutes
O Infusion: .015-0.2mg/kg/hr
AnalgesicsHydromorphone Hydrocodone
O 1.5mg hydromorphone = 15mg morphine
O T1/2 2-3 hours; duration 4-5hours
O Oral/enteral formulaO Usually combined
with acetaminophenO 25mg hydrocodone
= 10mg morphineO T½ 4 hours; duration
4-8 hours
Paralytics
ParalyticsO Never use without analgesia and
sedationO Used to facilitate intubation (rapid
sequence intubation)O Also used in patients with severe
pulmonary dysfunction on mechanical ventilation
O Cisatricurium most commonly used for infusions
Assessing Degree of Paralysis: Train of Four
O Goal of TOF usually 2 twitches About 80% receptors inactive)
O 4 twitches = 0-75% of receptors blocked
O Sites: Ulnar nerve, facial nerve, posterior tibial
O Start at 10mA and increase until twitches seen
O If no twitches seen, check different site
ParalyticsO SuccinylcholineO VecuroniumO RocuroniumO Cisatricurium
SuccinylcholineO Only depolarizing NMBO Avoid in hyperkalemia, 24 hour post
major burn, neuromuscular disease, patients with several days of ICU critical illness
O Onset in 60 seconds and lasts around 5 minutes
O 1-1.5mg/kg for RSI dosing
RocuroniumO NondepolarizingO Onset about 90 seconds and last 30-
40 minutesO Lasts longer in those with hepatic
impairmentO Dose is 0.6-1mg/kgO Effect is dose dependent
VecuroniumO Similar to rocuroniumO Slower onset time (up to 4 minutes)O Lasts 40-60 minutesO 0.08-0.1mg-kg
CisatricuriumO Bolus: .15-.2mg/kgO Infusion: 1-10mcg/kg/min based on
train-of-fourO T1/2 about 20 minutes
O Metabolism by Hoffman degredation