Sedation, Analgesia and Paralytics in the

ICU

What is used for what?O Analgesic

O Pain controlO Always should be first before sedation

O SedativeO Achieve sedation, anxiolysis, amnesia,

altered consciousnessO Paralytic

O Prevents movementO Never should be used without analgesia

and sedation

Sedatives

SedativesO EtomidateO PropofolO KetamineO Dexmedetomidine

EtomidateO Used mostly for Rapid Sequence

Intubation (RSI)O GABA like effectsO Minimal effect on BP; can lower ICPO Can reduce plasma cortisol levelsO Hepatic metabolism; renally excretedO Dose 0.3mg/kg for RSI

PropofolO Anesthetic agentO Respiratory and CV depressant can

drop BP by as much as 30%O Vasodilation and negative inotropic

effectO PRISO Dose is 1-1.5mg/kg for RSIO For ICU sedation: 5-50mcg/kg/min

KetamineO Anesthetic and dissociative agentO Also has analgesic effectO Hepatic metabolismO Can cause laryngeal spasm,

hypertensionO Psychomimetic effects given with

benzoO 1-2mg/kg for RSIO 5-15mcg/kg/min for sedations

Benzodiazepenes: GABA agonists

Lorazepam MidazolamO Better choice for

elderly and hepatic/renal dysfunction

O Propylene glycol diluent – risk of metabolic acidosis

O .01-.1 mg/kg/hr and 1-2mg IVP

O Has an active metabolite

O .02-.2mg/kg/hr and 2-4mg IVP

DexmedetomidineO Recommended first line sedative for

intubated pts*O Central alpha-2 agonistO Hepatically metabolizedO Renally excreted 95% unchangedO Dosed 0.2-1.4 mcg/kg/hrO Can cause bradycardia and hypotensionO Does NOT cause respiratory depressionO Has analgesic component

Analgesics

AnalgesicsO Always treat pain before giving

sedation or paralyticsO Not all patients requires analgesic

infusion as PRN dosing can be just as effective

O If able, evaluate your interventions to ensure pain level reduced

AnalgesicsFentanyl Morphine

O 80-100x more potent than morphine

O Bolus: 1mcg/kg q5 minutes

O Infusion 0.5-3mcg/kg/hr

O Can cause rigid chest, hypotension

O Causes histamine release itching

O Bolus .3mg/kg q10 minutes

O Infusion: .015-0.2mg/kg/hr

AnalgesicsHydromorphone Hydrocodone

O 1.5mg hydromorphone = 15mg morphine

O T1/2 2-3 hours; duration 4-5hours

O Oral/enteral formulaO Usually combined

with acetaminophenO 25mg hydrocodone

= 10mg morphineO T½ 4 hours; duration

4-8 hours

Paralytics

ParalyticsO Never use without analgesia and

sedationO Used to facilitate intubation (rapid

sequence intubation)O Also used in patients with severe

pulmonary dysfunction on mechanical ventilation

O Cisatricurium most commonly used for infusions

Assessing Degree of Paralysis: Train of Four

O Goal of TOF usually 2 twitches About 80% receptors inactive)

O 4 twitches = 0-75% of receptors blocked

O Sites: Ulnar nerve, facial nerve, posterior tibial

O Start at 10mA and increase until twitches seen

O If no twitches seen, check different site

ParalyticsO SuccinylcholineO VecuroniumO RocuroniumO Cisatricurium

SuccinylcholineO Only depolarizing NMBO Avoid in hyperkalemia, 24 hour post

major burn, neuromuscular disease, patients with several days of ICU critical illness

O Onset in 60 seconds and lasts around 5 minutes

O 1-1.5mg/kg for RSI dosing

RocuroniumO NondepolarizingO Onset about 90 seconds and last 30-

40 minutesO Lasts longer in those with hepatic

impairmentO Dose is 0.6-1mg/kgO Effect is dose dependent

VecuroniumO Similar to rocuroniumO Slower onset time (up to 4 minutes)O Lasts 40-60 minutesO 0.08-0.1mg-kg

CisatricuriumO Bolus: .15-.2mg/kgO Infusion: 1-10mcg/kg/min based on

train-of-fourO T1/2 about 20 minutes

O Metabolism by Hoffman degredation