Analgesia, Sedation, Paralytics, and Vasoactive Medications

Info

🌱 來自: Huppert’s Notes

Analgesia, Sedation, Paralytics, and Vasoactive Medications🚧 施工中

Analgesia, Sedation, Paralytics, and Vasoactive Medications

This section includes key medications used in the ICU, including their indications, pharmacokinetics, and adverse effects. Typical dosing and dosing considerations will be provided. However, selecting the proper medication, dose, and route of administration requires clinical context and is patient-specific. Please use appropriate resources for dosing in clinical contexts and speak with your clinical pharmacists.

Pain management

•   Goal: Control pain adequately to ideally achieve a maximally functional patient

-   Note: Does not mean zero pain, as this is often not possible to achieve, but the goal is to control pain as best as possible

•   General principles:

-   See Table 3.10 for pain medications commonly used in the ICU

TABLE 3.10 • Pain Medications Commonly Used in the ICU

-   Try PRNs first to determine needs prior to starting drips

-   Treat pain first, as it can also be causing anxiety, delirium

-   Assess analgesic needs daily

-   Note: For patients on chronic opiates, best practice is to convert opiates to oral morphine equivalents (OME) and then convert this amount to the desired opiate using a conversion table. A dose reduction for incomplete cross-tolerance (often 25–50%) is then applied for patient safety, and the remainder total dose is divided into the number of doses per day with additional PRNs.

•   Indications: Patient-reported pain, postoperative pain, trauma, chronic opioid use, decreased air hunger associated with certain modes of mechanical ventilation, neuromuscular blockade (paralysis)

•   Adverse effects: Respiratory depression, constipation, withdrawal, nausea; adverse effects may be magnified when used with other sedatives such as benzodiazepines

Sedation

•   Goal: To ensure comfort while using the minimal amount of sedative/hypnotics possible

-   Ideally, patients should be calm, lucid, pain-free, and interactive

•   General principles:

-   See Table 3.11 for medications commonly used for sedation in the ICU

TABLE 3.11 • Medications Commonly Used for Sedation in the ICU

-   Perform a daily sedation interruption (DSI) if possible

-   Assess pain and sedation needs daily

-   Target a sedation goal using a scale (often the Richmond Agitation and Sedation Scale [RASS])

•   Ideal is patient at RASS 0 (awake, cooperative)

•   Often initial goal is 0–2 in most patients and then reassess

•   For neuromuscular blockade/paralysis, requires RASS –5

-   Dexmedetomidine is not appropriate sedation in paralyzed patients; propofol or benzodiazepine is needed

•   Indications: Ventilator dyssynchrony, anxiety not due to delirium, neuromuscular blockade, intracranial hypertension, refractory status epilepticus, severe respiratory failure, agitation when safety of the patient or providers is at risk, procedural sedation

•   Adverse effects: Delirium, hypotension, dependence with subsequent risk for withdrawal, prolonged ICU stay

Neuromuscular blocking agents (NMBAs)

•   General principles:

-   See Table 3.12 for commonly used neuromuscular blocking agents used in the ICU

TABLE 3.12 • Neuromuscular Blocking Agents

-   Mechanism: Blocks acetylcholine-mediated transmission at the neuromuscular junction

•   Indications: Severe ARDS/hypoxemia and severe ventilatory dyssynchrony not controlled by sedation. NMBAs paralyze the patient, so deep sedation (RASS –5) and adequate pain control are required

Vasopressors and inotropes

•   Indications: To support blood pressure and contractility

•   Medications: See Tables 3.13 and 3.14

TABLE 3.13 • Vasopressors

TABLE 3.14 • Inotropes