1. Sedation, Analgesia and Paralytics in the ICU

2. What is used for what? Analgesic Sedative Paralytic Pain control
Always should be first before sedation
Sedative
Achieve sedation, anxiolysis, amnesia, altered consciousness
Paralytic
Prevents movement
Never should be used without analgesia and sedation

3. Sedatives

4. Sedatives
Etomidate
Propofol
Ketamine
Dexmedetomidine

5. Etomidate Used mostly for Rapid Sequence Intubation (RSI)
GABA like effects
Minimal effect on BP; can lower ICP
Can reduce plasma cortisol levels
Hepatic metabolism; renally excreted
Dose 0.3mg/kg for RSI

6. Propofol Anesthetic agent
Respiratory and CV depressant  can drop BP by as much as 30%
Vasodilation and negative inotropic effect
PRIS
Dose is 1-1.5mg/kg for RSI
For ICU sedation: 5-50mcg/kg/min

7. Ketamine Anesthetic and dissociative agent Also has analgesic effect
Hepatic metabolism
Can cause laryngeal spasm, hypertension
Psychomimetic effects given with benzo
1-2mg/kg for RSI
5-15mcg/kg/min for sedations

8. Benzodiazepenes: GABA agonists
Lorazepam
Midazolam
Better choice for elderly and hepatic/renal dysfunction
Propylene glycol diluent – risk of metabolic acidosis
mg/kg/hr and 1-2mg IVP
Has an active metabolite
.02-.2mg/kg/hr and 2-4mg IVP

9. Dexmedetomidine Recommended first line sedative for intubated pts*
Central alpha-2 agonist
Hepatically metabolized
Renally excreted 95% unchanged
Dosed mcg/kg/hr
Can cause bradycardia and hypotension
Does NOT cause respiratory depression
Has analgesic component
*Per PAD (pain, agitation, sedation guidelines from society of critical care medicine)

10. Analgesics

11. Analgesics Always treat pain before giving sedation or paralytics
Not all patients requires analgesic infusion as PRN dosing can be just as effective
If able, evaluate your interventions to ensure pain level reduced

12. Analgesics Causes histamine release  itching
Fentanyl
Morphine
80-100x more potent than morphine
Bolus: 1mcg/kg q5 minutes
Infusion 0.5-3mcg/kg/hr
Can cause rigid chest, hypotension
Causes histamine release  itching
Bolus .3mg/kg q10 minutes
Infusion: mg/kg/hr

13. Analgesics 1.5mg hydromorphone = 15mg morphine
Hydrocodone
1.5mg hydromorphone = 15mg morphine
T1/2 2-3 hours; duration 4-5hours
Oral/enteral formula
Usually combined with acetaminophen
25mg hydrocodone = 10mg morphine
T½ 4 hours; duration 4-8 hours

14. Paralytics

15. Paralytics Never use without analgesia and sedation
Used to facilitate intubation (rapid sequence intubation)
Also used in patients with severe pulmonary dysfunction on mechanical ventilation
Cisatricurium most commonly used for infusions

16. Assessing Degree of Paralysis: Train of Four
Goal of TOF usually 2 twitches About 80% receptors inactive)
4 twitches = 0-75% of receptors blocked
Sites: Ulnar nerve, facial nerve, posterior tibial
Start at 10mA and increase until twitches seen
If no twitches seen, check different site

17. Paralytics
Succinylcholine
Vecuronium
Rocuronium
Cisatricurium

18. Succinylcholine Only depolarizing NMB
Avoid in hyperkalemia, 24 hour post major burn, neuromuscular disease, patients with several days of ICU critical illness
Onset in 60 seconds and lasts around 5 minutes
1-1.5mg/kg for RSI dosing

19. Rocuronium Nondepolarizing
Onset about 90 seconds and last minutes
Lasts longer in those with hepatic impairment
Dose is 0.6-1mg/kg
Effect is dose dependent

20. Vecuronium Similar to rocuronium Slower onset time (up to 4 minutes)
Lasts minutes
mg-kg

21. Cisatricurium Bolus: .15-.2mg/kg
Infusion: 1-10mcg/kg/min based on train-of-four
T1/2 about 20 minutes
Metabolism by Hoffman degredation
4 twitches = 0-75% of receptors blocked