Pain in ICU PDF

Megan Hellwege PGY2 Critical Care Pharmacy Resident Banner – University Medical Center Tucson 1 Objectives Recognize when scoring tools for pain, agitation, and delirium should be used and interpret their results Explain the rationale for initiating analgesia and sedation in a critically ill patient...

Megan Hellwege PGY2 Critical Care Pharmacy Resident Banner – University Medical Center Tucson 1 Objectives Recognize when scoring tools for pain, agitation, and delirium should be used and interpret their results Explain the rationale for initiating analgesia and sedation in a critically ill patient Differentiate agents used for pain and sedation in critically ill patients Recall drug properties, such as onset, duration and adverse effects of common agents used to treat pain and agitation in the ICU Describe risk factors and identify medications that can increase risk of delirium in critically ill patients Generate a patient specific plan given a clinical scenario for pain, agitation, and prevention of delirium in a critically ill patient 2 3 Pain Assessment Reference standard: patient’s self report of pain Verbal description scale Numeric rating scale Visual analog scale 4 Pain Assessment Critical Care Pain Observational Tool (CPOT) Behavioral Pain Scale (BPS) Item Description Score Facial expression Relaxed Partially tightened Fully tightened Grimacing 1 2 3 4 Upper limbs No movement Partially bent Fully bent with finger flexion Permanently restricted 1 2 3 4 Compliance with ventilation Tolerating movement Coughing but tolerating ventilation most of the time Fighting the ventilator Unable to control ventilation 1 2 3 4 Item Description Score Facial expression Relaxed Tense Grimacing 0 1 2 Body movements None Protection Restless 0 1 2 Muscle tension Relaxed Tense Rigid 0 1 2 Ventilator compliance Tolerating Coughing Fighting 0 1 2 Vocalization Normal Moaning Crying out loud 0 1 2 5 Agitation Richmond Agitation-Sedation Scale (RASS) Score Term Description +4 Combative Overly combative, violent, immediate danger to staff +3 Very agitated Pulls or removes tubes, catheters, aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious but movements not aggressively vigorous 0 Alert and calm -1 Drowsy Not fully alert but has sustained awakening -2 Light sedation Briefly awakens to voice with eye contact (< 10 seconds) -3 Moderate sedation Movement or eye opening to voice (but no eye contact) -4 Deep sedation No response to voice but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation 6 Delirium Prevention is priority CAM-ICU Confusion Assessment Method of the Intensive Care Unit (CAM-ICU) Features Acute onset of fluctuating mentation Inattention Altered level of consciousness Disorganized thinking Cochrane Database Syst Rev. 2018;2018(9):CD013126. 7 8 Management Pain Agitation Delirium 9 Analgesosedation Pain Sedation 10 11 Pharmacologic options for analgesia Agent Dosing (IV route) PK Peak effect Potency ADRs/Comments Morphine Bolus: 2-6 mg q2h Lipophilicity (+/-) 15 minutes 1 Continuous infusion: 1 mg/hr – 10 mg/hr Duration of action: 2-3h Hydromorphone Fentanyl Bolus: 0.3-0.5 mg q3h Lipophilicity (+) Continuous infusion: 0.2-3 mg/hr Duration of action: 3-4h Bolus: 50-100 mcg q30min Lipophilicity (+++) Continuous infusion: 50-200 mcg/hr Rapid onset, short duration of action (0.5-1h) Active metabolite, Accumulates in renal dysfunction, histamine release (hypotension) 10-20 minutes 5 No active metabolite Immediate Serotonergic agent 50 Adjunct medications: acetaminophen, gabapentin, methocarbamol, NSAIDS 12 13 Sedation Goals of sedation Patient comfort Ease anxiety/control pain Avoid self extubation Facilitate nursing management Facilitate ventilator tolerance Reduce oxygen consumption Challenges of sedation Blunting respiratory drive Hemodynamic stability Tolerance Withdrawal Drug interactions Delirium 14 Sedative agents Propofol GABAa agonist and NMDA receptor antagonist Benzodiazepines GABAa agonists Dexmedetomidine Alpha-2 agonist Ketamine NMDA receptor antagonist 15 Deep sedation Light sedation 16 Pharmacologic agents for sedation Agent Mechanism of action Dosing (IV route) Peak effect ADRs/Comments Dexmedetomidine (Precedex) Alpha-2 agonist Continuous infusion: titratable, usual starting dose ~0.2 mcg/kg/hr ~15 minutes Bradycardia, hypotension not useful in suppressing seizures, no respiratory depression Propofol NMDA blockade and GABAa activation Bolus: 1-2 mg/kg Continuous infusion: titratable, usual starting dose ~20 mcg/kg/hr Rapid Respiratory depression, hypotension, propofol-infusion related syndrome (PRIS), hypertriglyceridemia Midazolam GABA Bolus: 2-5 mg Continuous infusion: titratable, usual starting dose 1 mg/hr 2-5 minutes Active metabolite (renally eliminated) Ketamine NMDA antagonist Dosing based on indication (pain vs sedation) 30-60 seconds Limited data on use in critically ill Utility in burn patients 17 18 Delirium Characteristics of delirium Acute onset Altered sleep-wake cycle Disorganized thinking Disorientation Inattention 19 Prevention and treatment of delirium Medications that are associated with delirium Opioids Benzodiazepines Anticholinergic medications Blood transfusions Management Nonpharmacologic Antipsychotics 20 21 Paralytics Last line after optimizing analgesia and sedation Can help facilitate ventilator synchrony Can reduce ICP Options Rocuronium Vecuronium Cisatracurium Succinylcholine 22