Welcome to SOVAH Resident's 360!
This is where topics/questions will be posted and residents will need to comment with answers and supporting evidence for their answer. Residents will be required to post their answers and supporting evidence by midnight that evening. The questions will then be readdressed the subsequent morning before rounds in a 15-30 minute conversation.
Tuesday, October 16, 2018
What is the correct sequencing of analgesic and sedative drugs in the ventilated patient?
First I would assess patient for pain with an appropriate pain assessment scale. For instance, numerical pain scale or behavioral pain scale. If pain is present, I would choose an appropriate analgesic. When choosing an analgesic, I would take into account the patient's hemodynamic, respiratory, cognitive and comorbid states. For instance, I would avoid giving a patient with hypotension an analgesic like morphine which causes release of histamine and, thus, vasodilation. I would also avoid using morphine in patient's with ESRD as the active metabolites accumulate and may cause seizures. Fentanyl is a fast acting opioid that does not induce hypotension or produce active metabolites. Remifentanil is a rapid onset opioid that is particularly useful in patients who need frequent evaluation of cerebral function.
Once an analgesic was chosen, I would assess patient for sedation needs. The ICU and ventilator are inherently uncomfortable for patients and can produce anxiety, agitation, or delerium. Sedation strategies include daily sedation interruptions or sedation scale based strategies or both. Propofol is a commonly used sedative that is rapid in onset and particularly useful in head trauma cases that need to decrease ICP. Side effects include hypotension, respiratory depression and hyperlipidemia. Precedex is an option as it uniquely maintains arousal state, thus not requiring discontinuation to arouse patient, It is also particularly useful for weaning patient's from the ventilator as they are arousable and able to follow commands while sedated. Haloperidol is useful for delerium. Benzodiazepines can potentially induce delerium and active metabolites can accumulate in renal disease. Ativan is bound to propylene glycol which enhances solubility, but is metabolized to lactic acid.
There are many considerations for the critically ill ventilated patient beyond treatment of pathology including analgesia and sedation. This is confounded by the inability of the patient to communicate necessitating metrics such the Behavioral pain scale or the Critical care pain observation tool for analgesia and the Riker sedation agitation scale or the Richmond Agitation sedation scale for agitation. Per the society of critical care medicine guidelines of 2002, Fentanyl and Hydromorphone are good first choices for pushes for the hemodynamically unstable patient. Morphine is considered the optimal choice for stable patients; for continuous infusion, fentanyl remains the optimal option. For agitation, Midazolam 2-5 mg IVP q 5-15 minutes is preferred followed by Propafol or Midazolam infusion being mindful of hypotension and longer half life issues respectively.
First I would assess patient for pain with an appropriate pain assessment scale. For instance, numerical pain scale or behavioral pain scale. If pain is present, I would choose an appropriate analgesic. When choosing an analgesic, I would take into account the patient's hemodynamic, respiratory, cognitive and comorbid states. For instance, I would avoid giving a patient with hypotension an analgesic like morphine which causes release of histamine and, thus, vasodilation. I would also avoid using morphine in patient's with ESRD as the active metabolites accumulate and may cause seizures. Fentanyl is a fast acting opioid that does not induce hypotension or produce active metabolites. Remifentanil is a rapid onset opioid that is particularly useful in patients who need frequent evaluation of cerebral function.
ReplyDeleteOnce an analgesic was chosen, I would assess patient for sedation needs. The ICU and ventilator are inherently uncomfortable for patients and can produce anxiety, agitation, or delerium. Sedation strategies include daily sedation interruptions or sedation scale based strategies or both. Propofol is a commonly used sedative that is rapid in onset and particularly useful in head trauma cases that need to decrease ICP. Side effects include hypotension, respiratory depression and hyperlipidemia. Precedex is an option as it uniquely maintains arousal state, thus not requiring discontinuation to arouse patient, It is also particularly useful for weaning patient's from the ventilator as they are arousable and able to follow commands while sedated. Haloperidol is useful for delerium. Benzodiazepines can potentially induce delerium and active metabolites can accumulate in renal disease. Ativan is bound to propylene glycol which enhances solubility, but is metabolized to lactic acid.
There are many considerations for the critically ill ventilated patient beyond treatment of pathology including analgesia and sedation. This is confounded by the inability of the patient to communicate necessitating metrics such the Behavioral pain scale or the Critical care pain observation tool for analgesia and the Riker sedation agitation scale or the Richmond Agitation sedation scale for agitation. Per the society of critical care medicine guidelines of 2002, Fentanyl and Hydromorphone are good first choices for pushes for the hemodynamically unstable patient. Morphine is considered the optimal choice for stable patients; for continuous infusion, fentanyl remains the optimal option.
ReplyDeleteFor agitation, Midazolam 2-5 mg IVP q 5-15 minutes is preferred followed by Propafol or Midazolam infusion being mindful of hypotension and longer half life issues respectively.
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