PHRM 864: Therapeutics IV > Acute Care > Flashcards

Acute Care Flashcards

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1
Q

What are the two types of Neruomuscalar blocking agents in acute care?

A
  • Depolarizing & Nondepolarizing
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2
Q

What is the depolarizing agent used in acute care?

A
  • Succinylcholine
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3
Q

What is the MOA for succinylcholine in acute care?

A
  • Resembles acetylcholine; binds to Ach receptors activating them and “depolarizing” the junction –> no contraction
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4
Q

What is dose used for succinylcholine?

A
  • 1.5 mg/kg IV
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5
Q

What is Succinylcholine used for in Acute Care?

A
  • Rapid Sequence Intubation [RSI]: placing endo tube to help with breathing
  • NOT for sustained neuromuscalr blockage
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6
Q

What are some Adverse Drug Reactions for Succinylcholine in Acute Care?

A
  • APENA –> no breathing during sleep
  • Dull muscle pain
  • Hyperkalemia –> lead to cardio issues
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7
Q

What is the MOA of the Nodepolarizing NMBA’s in Acute Care?

A
  • Competitively block the action of Ach [ NO ACTIVATION], no initial fasciculation
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8
Q

What are the two classes in Nondepolarizing NMBA’s in Acute Care?

A
  • Aminosteroidal & Benzylisoquinolinium
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9
Q

Is there a way to reverse the Nondepolarizing NMBA’s in Acute Care?

A
  • Acetylcholinesterase inhibitors & Sugammadex
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10
Q

What are the Aminosteridal NMBA’s?

A
  • Pancuronium: Slow Onset, Lung duration, Renal Elim
  • Vecuronium: Slow onset, medium duration, renal/hepatic elim
  • Rocuronium: Rapid onset, Heaptic elim, medium duration
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11
Q

What are the Benzylisoquinolinium NMBA’s?

A
  • Atracurium: Medium onset, medium duration, Hoffman [blood] elim
  • Cisatracurium: SAME
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12
Q

What are some of the clinical indications for NDNMBA’s

A
  • MECHANICAL VENT –> those with acute respiratory distress syndrome [ARDS]
  • Helps improve gas exchange
  • NOT all need vents
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13
Q

What way are NDNMBA’s able to help with Theraputic Hypthermia?

A
  • Prevents or Treats shivering; stops the patient from cooling during cardiac arrest
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14
Q

What are some of the adverse drug reactions for the NDNMBA’s?

A
  • APNEA
  • Inadequate pain and sediation –> NO analgesic effect; still feel pain
  • Prolonged paralysis [ICUAW]
  • Drug Interaction with Corticosteroids
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15
Q

What is the way that we monitor Neruomuscular Blockers in actue care?

A
  • Peripheral Nerve Stimulation [Twitch Monitoring]
  • Stimulate the Ulnar nerve 4 times
  • 4/4 <75% suppress; 3/4 75% supress; 2/4 80% suppress; 1/4 90% suppress; 0/4 100% suppress
  • WANT 1 or 2 / 4!!
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16
Q

What is PADIS?

A
  • Pain, Agitation/Sedation, Delirium, Immobility, Sleep
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17
Q

What is the definition of PAIN?

A
  • Unpleasant sensory experience with actual or potential tissue damage
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18
Q

What is the definiation of AGITATION?

A
  • Characterized by apprehension, increased motor activity and autonomic arousal
  • state of anxiety accompanied by motor restlessness
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19
Q

What is the definitions of DELIRIUM?

A
  • Acute cerebral dysfunction with a baseline mental status, inattention and disorganized thinking or altered level of consciousness
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20
Q

What are the assessments for pain that we can use of a patient is unable to self report?

A
  • Behavioral Pain Scale [BPS]
  • Ciritical Care Pain Observation Tool [CPOT]
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21
Q

What is important to know abot Analgesia in Pain in Acute Care?

A
  • PREEMPTIVE ANALGESIA
  • IV opioids are preferred [in Mech Vents]
  • Non-opioids can be used [Acetaminophen, Neuro Pain, NSAIDS (Increase Ulcer risk), Ketamine]
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22
Q

What are the common Opioids that are use in Acute Cure?

A
  • Fentanyl, Morphine, Methadone [for long term]
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23
Q

What are some of the adverse clinical outcomes for Agitation/Sediation?

A
  • Hard to Mech Vent
  • Increase motor activity
  • Increase oxygen consumption
  • Removal of lines and caths
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24
Q

What are some of the underlying causes in Agitation/Sedation?

A
  • PAIN [big issue], Mech Vent, Delirium, Hypoxia, Hypotension, Withdrawal
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25
What is the treatment for Agitation?
- Nonpharm or Pharm
26
What is the nonpharmacologic treatment for Agitations?
- 1st line - Give good analgesia, reorientation, normal sleep
27
What is important to know sedatives in the treatment of Agitation-Sediation?
- Reduce stress of Mech Vent, relieve anxiety, prevent agitated harm - Should NOT be used as restraint - OVERSEDATION is a problem [increase Mech Vent time and ICU LOS]
28
What is the goal for the treatment of Agitation-Sedation?
- LESS IS BEST --> Light sedation [decrease Mech Vent, decrease ICU LOS, decrease mortality]
29
What are some of the assessment scales that are used in Agitation-Sediation?
- Richmond-Agitation-Sedation Scale [RASS] - Sedation-Agitation-Scale [SAS] - Bispectral Index [BIS]-
30
What is the important os the BIS scale in Agitation-Sedation?
- Scale from 100 [completely awake] to 0 [isoelectric EEG] - Great with patients using NMB - NOT recommended in all ICU patient tho
31
What are the sedative drugs that are used in the ICU?>
- Benzos [Lorazepam, Midazolam] - Propofol - Dexmedetomidine
32
What is the MOA for Benzos in Acute Care?
- Binds to GABA receptor inhibiting it and hyperpolarizing cells
33
What are some of the adverse drug reactions for Benzos in Acute Care?
- Respiratory Depression [DO NOT treat aggressively without Mech Vent] - Increase risk of seizures - INCREASED DELIRIUM RISK
34
What are the two Benzos that are used un Acute Care?
- Lorazepam & Midazalom
35
What is important to know about Lorazepam?
- IV, PO, IM [IV preferred] - Half Life 10-20h [Hard to titrate] - Metabolized by glucuronidation - Contains Propylene Glycol (PG) [Lactic Acidosis] - HIGH DELIRIUM RISK
36
What is important to know about Midazolam?
- IV ONLY --> Used in procedural sedation - Rapid onset [Half Life = 2h; titratable] - Hepatically metabolized by 3A4
37
What is the MOA for Propofol in Acute Care?
- Binds to sites on multiple receptors [GABA, Glycine, Nicotinic, M1] causing CNS depression
38
What is important to know about Propofol in Acute Care?
- RAPID ONSET and RAPID OFFEST [ - Used in Neurosurgical Patients [reduce intracranial pressure (ICP)] - Emulsion [contiains 1.1kcal/mL; hang for only 12 hours] - NO DELIRIUM!!
39
What are some of the adverse drug reactions for Propofol?
- Apnea - HYPOtension, Bradycardia - Hypertriglyceridemia [b/c of emulsion] - Propofol Infusion Syndrome
40
What is the Propofol Infusion Syndrome?
- ACIDOSIS, BRADYCARDIA, LIPIDEMIA [rare] - Not for peds - NEED TO MONITOR Propofol
41
What is the MOA for Dexmedatomidine in Acute Care?
- Selective a-2 agonist [like clonidine?] that activates a-2 receptors inhibiting norepi release - VAGUS nerse has a lot of a-2 receptors so possible bradycardia and hyportensive effects
42
What is important to know about Dexmedetomidine in Acute Care?
- Sedation BUT can easily arouse patients - NO respiratory depression - VERY Little delirium - Hepatic metabolisim and Elim in urine
43
What are is the adverse effects for Dexmedetomidine?
- INCREASE blood pressure followed by bradycardia or HYPOtension [loading doses]\
44
What is the cardinal features of Delirium?
- Decreased awareness - Change in cognition [hallucination/delusions]
45
What are some of the symptoms lf Delirium?
- Sleep issues - Emotions [fear, anxiety, anger, depression, euphoria]
46
What are the two subtypes of Delirium?
- Hyperactive [Agitated] --> Hallucinations/Delusions - Hypoactive [calm] --> confusion/sedation [misdianosed]
47
What are some of the Modifiable and Nonmodifiable risk factors for Delirium?
- Mod: BENZOS, Blood Transfusinos - Nonmod: Age, prior dementia, coma, severity of illness
48
What are the two assessments for Delirium?
- ICDSC & CAM-ICU - Limited by level of arousal
49
What is the Nonpharmacoligic treatment/prevention for Delirium?
- BIGGEST ROLE - EARLY Mobilization [want to help the patient to get out of bed] - Optimization of sleep
50
What are some of the pharmacologic treatment/prevetions for Delirium?
- NOT recommended for Prevention - NOT recommended for ROUTINE treatment - Could use Antipsychotics, Haloperidol, Dexmedetomidine
51
What is important to know about Haloperidol in Acute Care?
- Dopamine Antagonist - Causes mild sedation WITHOUT analgesia - 1-5 mg IV q1h PRN then scheduled dosing - DOES NOT reduce delirium
52
What is the adverse effects for Haloperidol?
- QTc Prolongation --> Torsades de Points [when used aggressively] - Decreases Seziure threshold - EPS!! - Neuroleptic Syndrome
53
What are the Antipsychotics that are used in Delirium?
- Risperidone, Olanzpine, Quetiapine, Aripiprazole, Ziprasidone - Potentail safety over Haloperidol [AVOIDS EPS]
54
What are some of the adverse effects for the Antipsychotics in Delirium?
- Decreased EPS - Better Tolerated than Haloperidol - Decreased QTc Prolongation [except Ziprasidone]
55
What is important about Dexmedetomidine in Delirium?
- RECOMMEDED for delirium when the patient agitation is weaning away from vent
56
What are some of the general PAD guidelines for Pain & Sedation?
- Needs adequate analgesisa; ACTIVE & PREEMPTIVE - Assess with RASS & SAS [sedation] & BPS & CPOT [pain]
57
Is light sedation better or worse than deep sediation and why?
- LIGHT SEDATION PREFERRED - Deep sedation may lead to worse outcomes [increased death, increase mech vent, ICU LOS, neuro issues]
58
What is the FIRST thing to do in the sediation Algorithm within PAD Gudielines?
- "Analgesia-first Sedation" - PAIN is the main source for Agitation - Balence opioids [if on mech vent = more aggresive opioids]
59
What is important to know about the sedation meds in the Sedation Algorithm?
- Dexmed & Propofol over Benzos [Benzos increase delirium] - Dexmed increases BP tho -
60
In what way can Benzos still be uesd in the Sedation Algorithm?
- Treating anxiety, seizures, withdrawal - Midazolam: quick onset with short half life [procedural sedation] - Lorazapam: prolonged sedation [LACTIC ACIDOSIS tho]
61
In what way is Propofol and Dexmedetomidine used in Sedation Algorithm?
- Propofol: rapid awakening in neruotrauma [great for neurochecks] & preferred over benzos in cardiac surgery - Dexmed: Less delirium & mech vent time; DRUG OF CHOICE for delirium and agitation [gets around agitation]
62
What is important to know about the PAD Guidelines for Delirium?
- Pharmacologic is NOT good for prevention or ROUTINE treatment - Antipsychotic for short term treatment of delirium [Haloperidol & Atypicals] - Dexmed: GREAT for agitation is precluding weaning off vent]
PHRM 864: Therapeutics IV
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