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Sedation, Analgesia and Paralytics in the ICU

Sedation, Analgesia and Paralytics in the ICU. What is used for what?. Analgesic Pain control Always should be first before sedation Sedative Achieve sedation, anxiolysis , amnesia, altered consciousness Paralytic Prevents movement Never should be used without analgesia and sedation.

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Sedation, Analgesia and Paralytics in the ICU

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  1. Sedation, Analgesia and Paralytics in the ICU

  2. What is used for what? • Analgesic • Pain control • Always should be first before sedation • Sedative • Achieve sedation, anxiolysis, amnesia, altered consciousness • Paralytic • Prevents movement • Never should be used without analgesia and sedation

  3. Sedatives

  4. Sedatives • Etomidate • Propofol • Ketamine • Dexmedetomidine

  5. Etomidate • Used mostly for Rapid Sequence Intubation (RSI) • GABA like effects • Minimal effect on BP; can lower ICP • Can reduce plasma cortisol levels • Hepatic metabolism; renally excreted • Dose 0.3mg/kg for RSI

  6. Propofol • Anesthetic agent • Respiratory and CV depressant  can drop BP by as much as 30% • Vasodilation and negative inotropic effect • PRIS • Dose is 1-1.5mg/kg for RSI • For ICU sedation: 5-50mcg/kg/min

  7. Ketamine • Anesthetic and dissociative agent • Also has analgesic effect • Hepatic metabolism • Can cause laryngeal spasm, hypertension • Psychomimetic effects given with benzo • 1-2mg/kg for RSI • 5-15mcg/kg/min for sedations

  8. Benzodiazepenes: GABA agonists Midazolam Better choice for elderly and hepatic/renal dysfunction Propylene glycol diluent – risk of metabolic acidosis .01-.1 mg/kg/hr and 1-2mg IVP Has an active metabolite .02-.2mg/kg/hr and 2-4mg IVP Lorazepam

  9. Dexmedetomidine • Recommended first line sedative for intubated pts* • Central alpha-2 agonist • Hepatically metabolized • Renally excreted 95% unchanged • Dosed 0.2-1.4 mcg/kg/hr • Can cause bradycardia and hypotension • Does NOT cause respiratory depression • Has analgesic component

  10. Analgesics

  11. Analgesics • Always treat pain before giving sedation or paralytics • Not all patients requires analgesic infusion as PRN dosing can be just as effective • If able, evaluate your interventions to ensure pain level reduced

  12. Analgesics Morphine 80-100x more potent than morphine Bolus: 1mcg/kg q5 minutes Infusion 0.5-3mcg/kg/hr Can cause rigid chest, hypotension Causes histamine release  itching Bolus .3mg/kg q10 minutes Infusion: .015-0.2mg/kg/hr Fentanyl

  13. Analgesics Hydrocodone 1.5mg hydromorphone= 15mg morphine T1/2 2-3 hours; duration 4-5hours Oral/enteral formula Usually combined with acetaminophen 25mg hydrocodone = 10mg morphine T½ 4 hours; duration 4-8 hours Hydromorphone

  14. Paralytics

  15. Paralytics • Never use without analgesia and sedation • Used to facilitate intubation (rapid sequence intubation) • Also used in patients with severe pulmonary dysfunction on mechanical ventilation • Cisatricurium most commonly used for infusions

  16. Assessing Degree of Paralysis: Train of Four • Goal of TOF usually 2 twitches About 80% receptors inactive) • 4 twitches = 0-75% of receptors blocked • Sites: Ulnar nerve, facial nerve, posterior tibial • Start at 10mA and increase until twitches seen • If no twitches seen, check different site

  17. Paralytics • Succinylcholine • Vecuronium • Rocuronium • Cisatricurium

  18. Succinylcholine • Only depolarizing NMB • Avoid in hyperkalemia, 24 hour post major burn, neuromuscular disease, patients with several days of ICU critical illness • Onset in 60 seconds and lasts around 5 minutes • 1-1.5mg/kg for RSI dosing

  19. Rocuronium • Nondepolarizing • Onset about 90 seconds and last 30-40 minutes • Lasts longer in those with hepatic impairment • Dose is 0.6-1mg/kg • Effect is dose dependent

  20. Vecuronium • Similar to rocuronium • Slower onset time (up to 4 minutes) • Lasts 40-60 minutes • 0.08-0.1mg-kg

  21. Cisatricurium • Bolus: .15-.2mg/kg • Infusion: 1-10mcg/kg/min based on train-of-four • T1/2 about 20 minutes • Metabolism by Hoffman degredation

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