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Objectives Review guideline recommendations for the management of ICU sedation and delirium ... 8 2018 PADIS Guidelines Treatment of Pain Assessment of Pain Upload Login Mypresentations Profile Feedback Logout Search Login Login Authwithsocialnetwork: Registration Forgotyourpassword? Downloadpresentation Wethinkyouhavelikedthispresentation.Ifyouwishtodownloadit,pleaserecommendittoyourfriendsinanysocialsystem.Sharebuttonsarealittlebitlower.Thankyou! Buttons: Cancel Download Presentationisloading.Pleasewait. CriticalCarePharmacology PublishedbyYulianaSugiarto Modifiedover2yearsago Embed Downloadpresentation Copytoclipboard Similarpresentations More Presentationontheme:"CriticalCarePharmacology"—Presentationtranscript: 1 CriticalCarePharmacologyMonikaMakowiecki,PharmDPGY2CriticalCarePharmacyResidentJuly8,2019 2 ObjectivesReviewguidelinerecommendationsforthemanagementofICUsedationanddeliriumApplyprimaryliteraturetothemanagementofvasopressorsintheICU 3 PatientCaseJSisa75yearoldfemalewithHTN,DM,anddyslipidemiaadmittedforsepticshocksecondarytocommunity-acquiredpneumonia.Sherequiredemergentintubationduetoacuterespiratoryfailure.Howwillthe“sedation”ofthispatientbemanaged? 4 DefinitionsPainSedationAgitationDeliriumUnpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamagePainStateofquietorcalmnessinducedbysedationmedicationSedationPsychomotordisturbancewithmarkedincreaseinmotorandpsychologicalactivityAgitationAcuteonsetcerebraldysfunctionwithchangeorfluctuationinbaselinementalstatus,inattentionandeitherdisorganizedthinkingoranalteredlevelofconsciousnessDeliriumCritCareMed2002;30:CritCareMed2007;11(3):CritCareMed2013;41:CritCareMed2018;46(9)e 5 ABCDEFBundleForoptimizingICUpatientrecoveryandoutcomesEvidence-basedBundleelementsindividuallyandcollectivelycanhelpreducedelirium,improvepainmanagementandreducelong-termconsequencesforadultintensivecareunit(ICU)patientsCritCareClin2017;33(2): 6 Pain 7 PainintheICUIncidenceofpainis>50%inbothmedicalandsurgicalICUpatients82%ofpatientsrememberedpainofETT77%ofpatientsrememberedexperiencingmoderatetoseverepainduringICUstayCausesofpainTrauma/burnsSurgery/procedures/woundcare/suctioningLines,tubes,drainsTurning“What’sroutinetousishardlyroutinetothepatient”-GFraserCritCareMed2013;41:CritCareMed2018;46(9)e 8 2018PADISGuidelinesTreatmentofPainAssessmentofPainPatientsabletoreliablycommunicate:Self-reportofpainviaNRSisthereferencestandard(ungraded)Patientsunabletoreliablycommunicate:BPSandCPOTdemonstrategreatestvalidityandreliability(ungraded)GuidelinesrecommendAGAINSTUseofvitalsignsaloneasindicatorsforpain(ungraded)Vitalsignsshouldbeusedasacue(ungraded)Analgesiafirst:Optimizeanalgesiabeforeaddingsedativeagent*Utilizelowesteffectivedoseofopioid(conditional,moderate)Adjunctiveagentsforpainmanagement(conditional,VL):AcetaminophenandNSAIDsLow-doseketamineNeuropathicpainmedication(gabapentin,carbamazepine,pregabalin)CarbamazepineisaCYP3A4inducerPADIS–pain,agitation,delirium,immobility,sleepNRS–numericratingscaleBPS–behavioralpainscaleCPOT–criticalcarepainobservationtool*Maynotbeappropriateforptswithalcoholordrugwithdrawal,ptsnecessitatingneuromuscularblockade,ptswithelevatedICP,andstatusepilepticusCritCareMed2018;46(9)e 9 AnalgesiaOpioidsUsualdoserangeEliminationFentanylmcg/hrormcgIVPHepatic(CYP3A4)Hydromorphonemg/hrormgIVPHepatic(activemetaboliteisrenallycleared)Morphinemg/hror1-4mgIVPHepatic(activemetaboliteisrenallycleared)Remifentanilmcg/kg/minPlasmaesteraseNon-OpioidsUsualdoserangeEliminationAcetaminophenmgq6hrs(IV-notavailable,PO,PR)HepaticIbuprofenmgq6hrs(IV,PO)RenalKetorolac10-30mgq6hrs(IV,PO)Ketamine0.5–1mg/kg(IV)or10mg(Intranasal)Carbamazepine50–100mgBID(PO)Gabapentin1200–3600mgdividedTID(PO)JPharmPract2011;24:Chest.2008;133:CritCareMed2013;41: 10 Agitation/Sedation 11 AgitatedComaAgitationintheICUCombative:proceduresheld,pullingatlines/tubes/drainsIncreasedICUandhospitalLOS,fewerMV-freedays,delirium,mortalityCritCareMed2018;46(9)eCritCareMed2013;41: 12 2018PADISGuidelinesand2013PADGuidelines:Pain,Agitation,DeliriumRecommendRASSandSASasthemostvalidandreliabletoolsforevaluatingsedationinICUpatients(B)Suggestlightsedationvsdeepsedation(conditional,low)Suggestpropofolordexmedetomidineoverbenzodiazepinesforsedation(conditional,low)Suggestpropofoloverbenzodiazepinesforsedationinadultsaftercardiacsurgery(conditional,low)Recommenddailyinterruption(unlesscontraindicated)orlighttargetlevelofsedation(+1B)Recommendpromotingsleepbyoptimizingpatients’environments(+1c)RASS–RichmondAgitationSedationScaleSAS–SedationAgitationScaleCritCareMed2018;46(9)eCritCareMed2013;41: 13 RASSScaleCritCareMed2013;41: 14 SedativesSedativeDoserangeClearancePropofol5-100mcg/kg/minHepatic(conjugation)Dexmedetomidinemcg/kg/hrHepaticMidazolammg/hr,mgIVPHepatic(CYP3A4,activemetaboliterenallycleared)Lorazepammg/hr,2-6mgIV/POq4-6hrsLoyolamaxrangesDex:(bolusofmcg/kgrarelygivenduetoriskofhypotension/bradycardia)JPharmPract2011;24:27-34 Chest2008;133: 15 DailyInterruptionandLightSedationStudyPatientsInterventionOutcomeStrometal.ICUpatientsrequiringMV(n=140)Nosedationvs.sedationPropofolfor1st48hrs,thenmidazolamBothgroupsreceivedbolusesofmorphineHigherMV-freedays(13.8vs.9.6days,p=0.0191)ShorterICULOS(13.1vs22.8days,p=0.0316)ShorterhospitalLOSHigheragitationratesGirardetal.ICUpatientsrequiringMV(n=336)Dailyspontaneousawakeningtrial+SBTvs.sedation/usualcare+SBTHigherMV-freedays(14.7vs11.6days,p=0.02)ShorterICU/hospitalLOSMoreself-extubationsbutreintubationratessimilarLOS:lengthofstayMV:mechanicalventilation,SBT:spontaneousbreathingtrialCautioninsubstanceabuse,seizuresIflightsedationgoal(e.g.,RASS0to-1),dailyinterruptionmaynotbenecessaryInNOsedationgroup,therewashigherMV-freedays,shorterICULOS,shorterhospitalLOSbuthigherratesofagitationLancet2010;375:Lancet2008;371: 16 MIDEX/PRODEXTrialsPatientsrequiringmechanicalventilation>24hTwophase3multicenter,randomized,double-blindtrialsMIDEX:midzolam+dexmedetomidinePRODEX:propofol+dexmedetomidineEndpoints:Primary:Proportionoftimeintargetrange(RASS0to-3),durationofmechanicalventilation(MV)Secondary:ICULOS,patientcooperationResults:NodifferenceintimeintargetsedationordurationofMVbetweenMIDEX/PRODEXNodifferenceinICULOSSignificantdifferenceinpatientcooperation/interactioninbothMIDEX/PRODEXJAMA. 2012;307(11): 17 MIDEX/PRODEXTrialsADEsLimitationsMorebradycardia/AV-blockwithdexmedetomidine1/10patientswon’trespondtodexmedetomidineLimitationsPatientsinMIDEXtrialreceivedsignificantlylessdexmedetomidine~½thedosecomparedtopatientsinPRODEXtrialPatientsinMIDEXtrialreceivedsignificantlyhighertotaldoseofrescuemedicationsPatientswithlighttomoderatesedationnopatientsreceiveddeepsedationSelectionbiasveryslowenrollmentrateLimitations:nowwhatdosesofDextheygaveJAMA. 2012;307(11): 18 Delirium 19 DeliriumintheICUAffects~80%ofmechanicallyventilatedadultsCardinalsigns/symptomsDisturbedlevelofconsciousnessreducedclarity/awarenessReducedabilitytofocus,sustain,shiftattentionChangeincognitionmemorydeficit,disorientation,languagedisturbanceTypesofDeliriumHyperactive:hallucinationsanddelusionsHypoactive:confusionandsedation(oftenmisdiagnosed)Mixed:combinationofhyperactiveandhypoactiveCritCareMed2013;41: 20 2018PADISand2013PADGuidelinesRecommendroutinemonitoringfordeliriumusingavalidatedtool(+1B)RecommendCAM-ICUandICDSCasthemostreliableandvalidtoolsforassessmentofdeliriuminICUpatients(B)MonitoringCAM-ICU–confusionassessmentmethodfortheICUICDSC–intensivecaredeliriumscreeningchecklistPADIS–pain,agitation,delirium,immobility,sleepPAD–pain,agitation,deliriumCAM-ICU–confusionassessmentmethodfortheICUICDSC–intensivecaredeliriumscreeningchecklistCritCareMed2018;46(9)eCritCareMed2013;41: 21 2018PADISand2013PADGuidelinesSuggestagainsthaloperidol,atypicalantipsychotics,dexmedetomidine,HMG-CoAreductaseinhibitors,orketaminefordeliriumprevention(conditional,VL)Suggestnotroutinelyusinghaloperidol,anatypicalantipsychotic,oranHMG-CoAreductaseinhibitortotreatdelirium(conditional,low)Suggestusingdexmedetomidinefordeliriuminmechanicallyventilatedadultswhereagitationisprecludingweaning/extubation(conditional,low)Suggestutilizingnonpharmacologicinterventionstoreducemodifiableriskfactorsfordeliriumsuchasimprovingcognition,optimizingsleep,mobility,hearing,andvision(conditional,low)Management:PADIS–pain,agitation,delirium,immobility,sleepPAD–pain,agitation,deliriumCritCareMed2018;46(9)eCritCareMed2013;41: 22 23 AtypicalAntipsychoticsforDeliriumMedication(route)DosingSedationEPSQTcProlongationCommentsQuetiapine(PO,NG)mgBID++++++ConsiderforhyperactivedeliriumoragitatedmixeddeliriumLargerPMvs.AMdosesmayhelpwithsleepcycleRisperidone0.5mgBIDConsiderforhypoactivedeliriumLesssedatingandlesslikelytocausehypotensionduetonohistaminereceptoractivityAsenapine(SL,NG)5-10mgBIDLowestriskofQTcprolongationSublingualtabletOlanzapine(IM,PO,NG,SL)PO:5-20mgdailyIM:5-10mgPRN(max30mg/day)ConsiderinpatientswithhyperactivedeliriumandnoenteralaccessZiprasidone(IM,PO,NG)PO:mgBIDIM:10mgq2hoursor20mgq4hours(max40mg/day)HighriskofQTcprolongation 24 EarlymobilizationPhysicalinactivitycontributestomuscleatrophy,atelectasis,insulinresistance,reducedqualityoflifeEarlyPT/OTassociatedwithlowersedativeuse,deliriumratesandhigherratesofindependentfunctionalstatusatdischargeLancet2009;373:ArchPhysMedRehabil2010;91: 25 CaseRevisitedJSisa75yearoldfemalewithHTN,DM,anddyslipidemiaadmittedforsepticshocksecondarytocommunity-acquiredpneumonia.OvernightsherequiredemergentintubationforacuterespiratoryfailureTheABCDEForder-setwasusedtoorderfentanylandpropofolforanalgesiaandsedationSheisnowrequiringfentanylat75mcg/hrandpropofolat40mcg/kg/minSubsequently,sheishypotensivedespiteadequatefluidresuscitation.Howwillyoumanagehervasopressortherapy? 26 Vasopressors 27 SympatheticReceptorsAlpha1receptors(α1)Locatedinheartandbloodvessels↑Contractility↑VasoconstrictionDopaminergicLocatedinvascularsmoothmuscleRenal,coronary,cerebral,splanchnic↑VasodilationBeta1receptors(β1)Locatedinheart↑Heartrate↑Contractility↑RateofconductionBeta2receptors(β2)LocatedinbronchialandGIsmoothmuscleandbloodvessels↑VasodilationBronchodilationRelaxationofGIsmoothmuscle 28 VasopressorsIsoproteronolβDobutamineDopamineEpinephrineNorepinephrinePhenylephrineα 29 Norepinephrine(Levophed®)FIRSTLINEagentformosttypesofshockPotentαandβagentGoodagenttoSVRinhighoutputshockActions0.01to3mcg/kg/minCentrallineadministrationstronglypreferred!Maybeusedperipherally(onlythe8mg/250mLconcentration)inemergentsituationsandrequirescentralaccesswithin4hoursDosing8mg/250mL16mg/250mL(centrallineonly)ConcentrationsBothpremixed 30 Vasopressin(Vasostrict®)V1receptorsonvascularsmoothmusclesTypicallyusedas2ndlinepressortodecreasenorepinephrinerequirementsUsefulinsepticshock,whenaddedtonorepinephrineinfluidresuscitatedpatientsActionsFixed-dosage:0.04units/minShouldNOTbetitratedwhenusedforsepticshockHigherdosescauseconstrictionofcoronaryarteriesDosing20units/100mL(centrallineonly)100units/100mL(centrallineonly)ConcentrationLessclearroleinothershockstates20–premixed100-compounded 31 VasopressinPrimaryLiteratureTrialPatientPopulationStudyArmsPrimaryEndpointConclusionVASSTPatientswithsepticshockresistanttofluidsandlow-dosenorepinephrine(>5µg/min)Norepinephrine(n=396):Titratedfrom5µg/minto15µg/minVasopressin(n=382):Titratedfrom0.01to0.03units/min28-daymortalityNosignificantdifferenceinmortalityTrendtowardreduced28and90-daymortalitywithvasopressininpatientswithless-severeshockVANISHPatientswithsepticshockrequiringvasopressorswithin6hoursaftershockonsetVasopressin+Hydrocortisone(n=101):Vasopressin+Placebo(n=104):Vasopressintitratedto0.06units/minNorepinephrine+Hydrocortisone(n=101):Norepinephrine+Placebo(n=103):Norepinephrinetitratedto12mcg/minIVHydrocortisonetaper:50Q6hx5days->Q12hx3days->dailyx3daysKidneyfailure-freedaysduring28-dayperiodpostrandomizationEarlyvasopressinusedidnotimprovenumberofkidneyfailure-freedayscomparedtonorepinephrineVASST–I=moreNE,vsvasoplusNEVANISH–vasodiddecreasenorepirequirements--Noradrenalinereducesrenalperfusionbypreferentiallybindingα-receptorsonrenalafferentarterioles.Incontrast,thebindingofvasopressintoV1areceptorsonglomerularefferentarteriolesresultsinvasoconstrictionandincreasesglomerularfiltration.TrialshavesuggestedalowerAKIincidenceandareducedneedforrenalreplacementtherapy(RRT)inpatientswithshocktreatedwithvasopressincomparedwithothervasopressors,butdefinitiveevidenceislackingNEJM2008;358:NEJM2010;362: 32 Epinephrine(Adrenalin®)SecondlineforsepsisβandαagentMoremesentericischemiathannorepinephrineMayhavemorerighthearteffectsActionsmcg/kg/minDosing5mgin250mL10mgin250mL(centrallineonly)ConcentrationMaycauseincreasedlactatelevelsEpinephrine transientlyincreases lactatelevels throughanincreaseinglycolysisinskeletalmuscle--beta-agonistssuchasepinephrineareknowntoraiseserumlactatelevelssecondarytohepaticstimulationofglycogenolysis/glycolysis[i.e.increasedB-typelactate];ostensibly,thiseffectiscounterbalancedbyepinephrine’sabilitytoaugmentcardiacoutputand,therefore,tissueoxygendelivery 33 400mg/250mLconcentrationavailableincrashcartsinpremixedbagDopamine(Intropin®)PositivechronotropeandinotropeathigherdosesLastlinetherapyinmostsituationsActionsDopaminergic(2-4mcg/kg/min)β(5-10mcg/kg/min)α(10-20mcg/kg/min)Dosing400mg/250mL800mg/250mL(centrallineonly)Concentrations400mg/250mLconcentrationavailableincrashcartsinpremixedbagBothpremix 34 DopamineandMortalityTrialPatientPopulationStudyArmsPrimaryEndpointConclusionSOAPIIPatientswithvariousshockstatesNorepinephrine(n=821):Titration:0.02mcg/kg/min;max0.19mcg/kg/minDopamine(n=858):Titratedby2mcg/kg/min;max20mcg/kg/min28-daymortalityNosignificantdifferenceinmortalityDopamineassociatedwitharrhythmiasDopamineversusnorepinephrineinthetreatmentofsepticshock:ameta-analysisPatientswithsepticshock(NorthAmerica,Australia,NZ,India)5observationaltrialsand6RCTsNorepinephrine(n=1474):Doses:mcg/kg/minDopamine(n=1294):Doses:1-20mcg/kg/minDAvsNEObservational:RR1.23;95%CI;(p<0.01)RCTs:RR1.12;CI1.01–1.20;(p=0.035)Dopamineversusnorepinephrineinthetreatmentofcardiogenicshock:Meta-AnalysisPatientswithcardiogenicshock(AsiaandAfrica)9RCTsNorepinephrine(n=241)Dopamine(n=269):RR:1.611,95%CI1.219–2.129;(p<.001 phenylephrine newvasopressor:angiotensinii angiotensinii>0.2mcg/kg/minnorepinephrineorequivalentfor>6h)EndpointsMAPat3hours(responsedefinedasMAP>75mmHg)MOA:ActsintheSNCtoincreasevasopressinproductionHowwouldthismakeadifferenceWhatifpatientonACEiorARB?NEJM2017;377:419-30 38 ResultsMAPat3hoursSecondaryEndpointsAngiotensinII:69.9%Placebo:23.4%P<0.001SecondaryEndpointsMeanchangeincardiovascularSOFAscoreat48hrs-1.75(angiotensinII)vs(p=0.01)MeanchangeintotalSOFAscoreat48hrs1.05(angiotensinII)vs(p=0.49)MortalityAllcausemortalityatday729%(angiotensinII)vs.35%;p=0.22All-causemortalityat28days46%(angiotensinII)vs.54%;p=0.12MAP↑rapidlyinangiotensinIIgroupng/kg/mindose↓in67%patientswithin30minutesLimitationsMAPgoal>75mmHgPrimaryendpointisnon-mortalityrelatedSmallsamplesizeSafetyPotentialforvenousandarterialthromboticandthromboemboliceventsNotdiscussedintrialNEJM2017;377:419-30 39 Inotropes 40 Dobutamine(Dobutrex®)β1agonist–increasedmyocardialcontractilityandincreasedHRβ2agonist–systemicvasodilationActionsmcg/kg/minDosingHalf-life:~2minutesPharmacokineticsIncreasedHRandBP(tachyphylaxisafter72hours)Myocardialischemiaandarrhythmiasatdoses>15mcg/kg/minMalignantventriculararrhythmiasatanydoseAdverseeffects500mg/250mLand1000mg/250mL(centrallineonly)ConcentrationsDobutamine stimulates b1and b2 receptorsina3:1 ratioBothpremixed 41 Milrinone(Primacor®)Phosphodiesterase-III(PDE-3)inhibitorDecreaseshydrolysisofcAMPleadingtoincreaseinintracellularCa2+influxPositiveinotropy(increasedcardiacoutput)andvascularsmoothmusclerelaxation(vasodilation)Actionsmcg/kg/minDosingHalf-life:~2hoursPharmacokineticsHypotension,ventriculararrhythmias/angina,bronchospasmMayaccumulateinrenaldysfunctionAdverseeffects20mg/100mLConcentrationspremixed 42 Isoproterenol(Isuprel®)AmericanHeartAssociationGuideline:ConsiderincardiogenicshocksecondarytobradycardiaIndicationPotentβ1andβ2agonistRelaxesbronchial,GI,andskeletalsmoothmuscleMechanismmcg/min(titrateby0.5mcg/minevery10minutes)DosingTachycardia,arrhythmias,myocardialnecrosisAdverseeffectsLowaffinityforalpha-adrenergicreceptorsItactsuponbeta-1adrenergicreceptorsand,unlike dobutamine,hasaprominentchronotropiceffect.Thedrug'shighaffinityforthebeta-2adrenergicreceptorcausesvasodilationandadecreaseinMAP.Therefore,itsutilityinhypotensivepatientsislimitedtosituationsinwhichhypotensionresultsfrombradycardia.MOA:lowersperipheralvascularresistance,primarilyinskeletalmusclebutalsoinrenalandmesentericvascularbedsCost:recentpriceincrease~$/vial 43 GeneralVasopressor/Inotrope“Rules”ObtainCENTRALLINEPeripheralInfusion~4hoursLowconcentrationsof:dopamine,norepinephrine,andphenylephrine+/-arteriallineAlwaysmonitorforischemia/extravasationDobutamine/milrinoneareMDtitrateonly! 44 UsefulOrderSetsABCDEFNeuromuscularblockadeEndotool(insulininfusion)DesensitizationToxicology/antidoteSepsisSepsisSepsis!! 45 AcknowledgementTimCober,PharmD,BCPS,BCCCPMICUClinicalPharmacist 46 Questions? Downloadppt"CriticalCarePharmacology" Similarpresentations DrBronwynAvard,July2010TounderstandthebasicphysiologyofshockTounderstandthepharmacodynamicsandpharmacokineticsofvasoactivedrugs. BestPracticeTomShiffler,MD7/23/10 Thegoldenhour(s)forseveresepsisandsepticshocktreatment GUIDELINESUPDATEDDr.AkhilTaneja SeanForsytheM.D.AssistantProfessorofMedicine SevereSepsisInitialrecognitionandresuscitation CommonCardiovascularDrugs ProceduralSedationPharmacologyDebUpdegraffR.N.,P.N.P,C.N.S.ClinicalNurseSpecialistLPCHPediatricIntensiveCareUnit. DexmedetomidinevsMidazolamforSedationofCriticallyIllPatientsARandomizedTrialJournalClub09/01/11JAMA,February4,2009—Vol301,No SedationandAnalgesiaintheICU.34yearoldmanwasadmittedtotheintensiveareunit3daysagoforincreasingrespiratoryfailurefromcommunity. PainAgitation&DeliriumSCCMPainassessmenti.WerecommendthatpainberoutinelymonitoredinalladultICUpatients(+1B).ii.TheBehavioral. PHARMAKOLOGYVASOPRESSORDRUGSDJUDJUKRAHMADBASUKILab.AnestesidanTerapiIntensiveRSSAMalang. Pain,AgitationandDelirium(PAD):AnOverviewofRecentGuidelines Deliriumintheacutehospital Sedation,AnalgesiaandParalyticsintheICU VasopressorsandInotropesinCanadianEmergencyDepartments Sympathomimetics(continue) SepsisandEarlyGoalDirectedTherapy 2009PandemicEducationPackagePharmacologyReview. Complicationduringpregnancyanditsnursingmanagement:-Pregnancyinduceshypertension.ClinicalAspectofMaternalandChildNursingNUR363Lecture. Similarpresentations Aboutproject SlidePlayer TermsofService DoNotSellMyPersonalInformation Feedback PrivacyPolicy Feedback ©2021SlidePlayer.comInc.Allrightsreserved. Search Tomakethiswebsitework,weloguserdataandshareitwithprocessors.Tousethiswebsite,youmustagreetoourPrivacyPolicy,includingcookiepolicy. Iagree.     AdsbyGoogle