EMmedonline
Spreading Emergency Medicine Across the Globe ..
emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
PAIN, DELIRIUM & AGITATION GUIDELINES
Pain & Analgesia
The international association for the study of pain defines pain as an “ unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage.
TREATMENT
Opioids such as fentanyl, hydromorphone, methadone, morphine and remifentanil are the primary medications for managing pain in critically ill patients.
Other analgesic agents like local and regional anesthetics (eg: bupivacaine), non steroidal anti-inflammatory medications (eg:ketrolac, ibuprofen), IV acetaminophen and anticonvulsant can be used as adjunctive pain medication to reduce the use of opioid requirement. But their safety and effectiveness as a sole agent have not been adequately studied in ill patients.
OPIOID ANALGESICS
| Equivalent Dose (mg) | Onset | Half life | Intermittent Dose | IV infusion rate | Comments | |
IV | PO | ||||||
Fentanyl | 0.1 | N/A | 1-2 min | 2-4 hr | 0.35 – 0.5 mcg/kg IV Q 0.5 – 1hr | 0.7 -10 mcg/kg/hr | Less hypotension than morphine. Accumulation with hepatic impairement. |
Hydromorphone | 1.5 | 7.5 | 5 –15 min | 2 -3 hr | 0.2 – 0.6 mg IV q 1-2 hr | 0.5 – 3mg/hr | Accumulation with hepatic/ renal impairment |
Morphine | 10 | 30 | 5 -10 min | 3 -4 hr | 2-4 mg IV q 1-2 hr | 2-30mg/hr | Accumulation with hepatic/ renal impairment. Histamine release. |
Methadone | N/A | N/A | 1-3 d | 15 -60hr | PO : 10 – 40 mg q 6 -12 hr; IV : 2.5 – 10 mg q 8 -12hr | Not recommended |
|
Remifentanil | N/A | N/A | 1-3 min | 3-10 min |
| Loading dose: 1.5 mcg/kg IV; Maintence dose : 0.5 – 15 mcg/kg/hr IV | No accumulation in hepatic/ renal failure. |
Non Opioid Analgesic
Drug | Onset | Half life | DOSE | SIDE EFFECT |
Acetaminophen (PO) | 30 – 60 MIN | 2-4 hr | 325 – 1000 mg every 4 – hr; max : 4gm/d | May be contraindicated in patients with significant hepatic dysfunction. |
Acetaminophen (IV) | 5 – 10 Min | 2 hr | 650 mg IV every 4hrs – 1000mg IV every 6 hrs; max 4 gm/day |
|
Ketamine | 30 -40 sec | 2 – 3 hr | Loading dose 0.1 -0.5 mg/kg IV followed by 0.05 – 0.4 mg/kg/hr | Attenuates the development of acute tolerance to opioids. |
Ketrolac (IM/IV | 10 min | 2.4 – 8.6 hr | 30 mg IM/IV then 15 -30 mg IM/IV every 6 hr upto 5 days; Max dose = 120mg/day x 5 days | Avoid in renal dysfunction; gi bleeding; platelet abnormality; concomitant angiotensin converting enzyme inhibitor therapy, congestive heart failure, cirrhosis, asthma. CI in perioperative pain in CABG |
Ibuprofen (PO) | 25 min | 1.8 – 2.5 hr | 400 – 800 every 4hrs; max dose 2.4 gm /day |
|
Gabapentin (PO) | N/A | 5-7 hr | 100 mg PO tid ; then slowly increases upto 900 -3600mg/day in 3 divided doses. | Sedation, confusion, dizziness, ataxia. Abrupt discontinuation associated with drug withdrawal syndrome, seizures |
Carbamazepine immediate release (PO | 4-5 HR | 25-65 hr intially, then 12- 17 hr | 50 – 100 mg PO BD; Maintence dose : 100 -200mg every 4-6 hrs; Max: 1200 mg/d | Nystagmus, dizziness, diplopia, lightheadedness, lethargy, agranulocytosis; steven johnson syndrome. |
Sedation
It is recommended to maintain a light level of sedation as it is associated with improved clinical outcomes.
The Richmond Agitation-Sedation Scale (RAAS) and sedation Agitation Scale (SAS) are the most valid and reliable sedation assessments tools for measuring quality and depth of sedation in adult ICU patients.
Objective measures of brain function (eg: Auditory evoked potentials, bispectral index or Narcotend Index , Patient state index) are used as a adjunct to subjective sedation assessments in adult ICU patients receiving NMBA, as subjective sedation assessments may be unobtainable.
Non benzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines.
Agent | Onset | Half life | Loading Dose | Maintenance dose | Adverse effect |
Midazolam | 2-5 min | 3-11hr | 0.01- 0.05 mg/kg | 0.02 -0.1 mg/kg/hr | Respiratory depression, hypotension |
Lorazepam | 15 -20 min | 8 -15 hr | 0.02 -0.04 mg/kg | 0.01 -0.1 mg/kg/hr | Respiratory depression; propylene glycol related acidosis, nephrotoxicity |
Diazepam | 2-5 min | 20 -120 hr | 5-10mg | 0.03-0.1 mg/kg q 0.5-6hr | Respiratory depression, hypotension, phlebitis |
Propofol | 1 -2 min |
| 5 mcg/kg/min over 5 min | 5 -50 mcg/kg/min | Pain on injection, hypotension, respiratory depression, hypertriglyceridemia, pancreatitis, allergic reactions |
Dexmedetomidine | 5 -10 min | 1.8 – 3.1 hr | 1 mcg/kg over 10 min | 0.2 -0.7 mcg/kg/hr | Bradycardia, hypotension; hypertension with loading dose; loss of airway reflex. |
Updated on 30/8/2013
Reference
- Clinical Practice Guidelines for the management of Pain, agitation and delirium in adult patients in ICU : 2013
Copyright 2020. emmedonline. All rights reserved.
Website is designed for desktop. Mobile user are advised use firefox for best results.
emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor