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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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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
Sedatives • Etomidate • Propofol • Ketamine • Dexmedetomidine
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
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
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
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
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
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
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
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
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
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
Paralytics • Succinylcholine • Vecuronium • Rocuronium • Cisatricurium
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
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
Vecuronium • Similar to rocuronium • Slower onset time (up to 4 minutes) • Lasts 40-60 minutes • 0.08-0.1mg-kg
Cisatricurium • Bolus: .15-.2mg/kg • Infusion: 1-10mcg/kg/min based on train-of-four • T1/2 about 20 minutes • Metabolism by Hoffman degredation