- Critical Care Pain Observation Tool (CPOT) (0-8)
- Behaviour Pain Scale (BPS)
- Sedation is Richmond Agitation Sedation Scale (RASS) or Sedation-Agitation Scale (SAS)
- Rapid onset (1-2 minutes)
- Short duration (3-5 minutes).
- Avoid prolonged infusions greater than 50 mcg/kg/min.
- Monitor BP, triglycerides, adjust lipid calories
- Monitor for propofol infusion syndrome: metabolic acidosis, hemodynamic instability, cardiac failure, arrhythmias, cardiac arrest, rhabdomyolysis, hypertriglyceridemia, kidney failure, and hyperkalemia
- Usually for infusion rates higher than 75-83 mg/kg/min for more than 48 hours.
- Causes respiratory depression, must be intubated.
- Dexmedetomidine: Dexmedetomidine is a highly selective α2-adrenergic receptor agonist. It has effects similar to other α2-adrenergic receptor agonists (think clonidine) and is used as a sedative
- Rapid onset (5-15 minutes)
- Short duration (2-hour half-life)
- Can cause bradycardia and hypotension (again think clonidine). However, initial titrations can cause a vasoconstrictive rise in BP (temporary and usually not clinically significant). It can also have EKG effects.
- Can affect blood sugar.
- Can be used to decrease intracranial pressure.
- Low incidence of delirium.
- Does not cause respiratory depression.
- Dexmedetomidine can have withdrawal symptoms if used long term (1-2 days). Rebound increase in heart rate and blood pressure and increased anxiety unless titrated.
- Adverse effects are mostly additive effects with other sedatives or medications that lower heart rate and blood pressure.
- Ketamine –
- Analgesic and sedative properties.
- Risk of delirium.
- Adverse effects: hypertension, tachycardia, and delirium.
- No respiratory depression
- CAM-ICU Scale – Confusion Assessment Scale for ICU
- ICDSC: Intensive Care Delirium Screening Checklist
- Best course is prevention, including minimizing BZD doses, opioids, and anticholenergic medications.
- Can treat with: haloperidol, quetiapine, olanzapine, risperidone, ziprasidone. Olanzapine and risperidone have the lowest risk of QTc prolongation.
- Never use a neuromuscular blocker on someone who is not sedated and doesn’t have analgesia.
- Drugs/Electrolytes that potentiate block: corticosteroids, aminoglycosides, clindamycin, tetracyclines, polymixin, calcium channel blockers, Type 1a antiarrhythmics, furosemide, lithium, hypocalcemia, hypermagnesemia, hypokalemia
- Drugs/Electrolytes that antagonize block: aminophylline, theophylline, carbamazepine, phenytoin, hyperkalemia, hypercalcemia
- Succinylcholine and atracurium cause direct mast cell release. Pancuronium, rocuronium, and vecuronium cause the least. This is not anaphylaxis.
- When neuromuscular blockers are used in combination with steroids, it increases the risk of acute quadriplegic myopathy syndrome.
- Reverse non-depolarizing agents with neostigmine or edrophonium (acetylcholinesterase inhibitors). DO NOT USE THESE WITH succinylcholine. They make succ induced paralysis worse.
|Succinylcholine||30-60 sec||4-6 m||< 1min||Succ is the only depolarizing agent.|
Do NOT use neostigmine with succ.
|Atracurium||2-3 m||20-35 m||2-20 m||no renal or hepatic dosing|
|Pancuronium||2-3 m||60-100 m||110 m||the longest duration of action|
|Rocuronium||1-2 m||30 m||60-70 m||caution in pulmonary HTN|
|Vecuronium||3-5 m||45-65 m||65-70 m|
|Cisatracurium||2-3 m||20-35 m||22-29 m||does not release histamine|