NRNP 6566 WEEK 8 KNOWLEDGE CHECK WITH ANSWERS
• Question 1
What type of ICU sedation would be appropriate for a 32 year old male patient who
... [Show More] is intubated with bilateral chest tube following a motor vehicle crash.
Correct Answer:
The Society of Critical Care Medicine publishes a guideline on sedation. It is:
Guidelines for the Prevention and Management of Pain, Agitation/Sedation,
Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018).
Light sedation is suggested for intubated ICU patients. Non-benzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults.
• Question 2
Describe the levels of sedation (minimal, moderate, deep, general anesthesia, and dissociation) and its affect on consciousness, airway, ventilation, and reflexes.
Correct
Answer: Sedation decreases a patient’s awareness to the environment and their responses to external stimulation. Sedation occurs a long a continuum which includes minimal, moderate, deep, general anesthesia, and dissociation. Minimal sedation is a drug induced relief of anxiety or apprehension with minimal to no affection on sensorium. Most often this is achieved with an antianxiety medication.
Moderate sedation causes a depression of consciousness but the patient can
still respond to external stimuli. Airway, spontaneous ventilation, and cardiovascular function are maintained.
Deep sedation causes a depression of consciousness in which the patient cannot be aroused but responds purposefully to repeated or painful stimuli. Cardiovascular function is maintained but airway and spontaneous ventilation may be compromised.
General anesthesia is a state of unconsciousness where the patient is unable to respond to any stimuli. Close monitoring of all airway, ventilation, and cardiovascular function is essential.
Dissociation is considered to be a type of moderate sedation that occurs when using medications in the phencyclidine group (such as ketamine). They cause a dissociation of the limbic system preventing higher centers from receiving sensory stimuli. Like moderate sedation, airway reflexes, spontaneous ventilation, and cardiovascular function are all maintained.
• Question 3
The APRN has determined that a 21 year old motor vehicle crash victim needs a rapid sequence intubation. The patient weighs 77 kg. What medications are indicated to successfully achieve the rapid sequence intubation?
Correct
Answer: Rapid sequence intubation requires the use of induction agent to cause unresponsiveness and a neuromuscular blocking agent to cause muscular relaxation. It is the fast and most effective means of controlling the emergency airway. There are no contraindications to using Etomidate and
Succinylcholine
Etomidate 23 mg IV and Succinylcholine 115 mg IV
Here are details about the different medications and their uses.
INDUCTION AGENTS
Etomidate
0.3mg/kg IV onset: 10-15 seconds
Use: good option for most situations including
hemodynamically unstable patient. Avoid in sepsis or seizures
Can cause adrenal suppression, myoclonus, pain on injection
Ketamine
Dose: 1.5 mg/kg IV (4mg/kg IM)
Onset: 60-90 sec
Duration: 10-20 min
Use: good option for any RSI,especially if hemodynamically
unstable. May be used in TBI (no increase in ICP) and reactive airway disease
(causes bronchodilation)
Can cause an increase in secretions, caution in hypertension
and tachycardia, may cause laryngospasm and increased intra-ocular pressure.
Thiopentone
Dose: 3-5 mg/kg IV TBW
Onset: 30-45 sec
Duration: 5-10 min
Use: good option in hemodynamically stable patients, also for
status epilepticus
Causes histamine release, myocardial depression, vasodilation,
hypotension
Propofol
Propofol 1.5-2.5 mg/kg x TBW as the general guide
Onset: 15-45 seconds
Duration: 5 – 10 minutes
Use: should be used in hemodynamically stable patients,
appropriate for patients with reactive airways disease or status epilepticus
Can cause hypotension, myocardial depression, reduced
cerebral perfusion muscular rigidity in high induction doses, bradycardia, tissue
saturation at high doses
PARALYTIC AGENTS
Suxamethonium (aka succinylcholine)
Dose: 1.5 mg/kg IV (2 mg/kg IV if myasthenia gravis) and 4
mg/kg IM (in extremities)
Onset: 45-60 seconds
Duration: 6-10 minutes
Use: widely used unless contra-indicated; ideal if need to
extubate rapidly following an elective procedure or to assess neurology in an intubated patient
Drawbacks: numerous contra-indications (hyperkalemia,
malignant hyperthermia, >5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations
Rocuronium
Dose: 1.2 mg/kg IV IBW
Onset: 60 seconds
Use: can be used for any RSI unless contra-indication or require
rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e.
immobile patient for cricothyroidotomy) – can be reversed by sugammadex Drawbacks: allergy (Rare)
• Question 4
A 66 year old women in the ICU is diagnosed with delirium. What would be the best approach to treating her delirium?
Correct
Answer: Delirium is common in critically ill adults. Delirium is a clinical diagnosis which
can be detected with some screening tools such as the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist.
Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018) by the Society of Critical Care Medicine recommends a muticomponent, nonpharmacologic intervention focused on reducing modifiable risk factors. These interventions include reorientation, cognitive stimulation, use of clocks, improved sleep, reduced sedation, early rehabilitation and mobilization, use of hearing aids and eye glasses.
Haloperidol is not routinely recommended and studies have not shown that it shortens the duration of the delirium. However, short term use of haloperidol or an atypical antipsychotic may be warranted for those patients who experience significant distress, agitation, or physical risk to themselves or others.
• Question 5
The NP is beginning to repair a laceration on a 22 year old female. The patient mentions that she is allergic to lidocaine. What medication would be an appropriate alternative for this patient?
Correct
Answer: Local anesthetics include two classes of medications that include esters and amides. Lidocaine and bupivacaine are amide anesthetics. In this patient, an ester anesthetics should be utilized. Procaine is an example of an ester local anesthetic.
• Question 6
A 54 year old 112 kg women is admitted for incision and drainage of a left renal abscess. She needs TID wet to dry dressing changes that are very painful. She rates the pain during the dressing change as a 10 and describes in as sharp, pulling, and burning. Prior to the last dressing change she received 2 mg of morphine IV which was totally ineffective in relieving any pain of the dressing change. How would you manage the medication dosing prior to the next dressing change?
Correct
Answer: Recommended IV morphine dosing is 0.05 to 0.1 mg/ kg. Based on her weight, the recommend-ed dose would be 6-12 mg IV every 1-2 hours. Since 2 mg was ineffective, it would be reasonable to increase the next dose to 6 mg IV 20 minutes prior to the dressing change. Assess her response to this dose increase and determine if it is appropriate or another increase (add 2 mg) is needed to achieve pain relief during the dress-ing change.
• Question 7
A 36 year old man complains of sciatic type nerve pain in his left posterior leg. What medication would be best to manage his pain?
Correct
Answer: Nerve pain is usually poorly treated with opioids. Anti-inflammatories, anticonvulsants (such as gabapentin, carbamazepine, and pregabalin), and antidepressants are more effective in treating never pain such as sciatica, peripheral neuropathy, or other nerve related pain secondary to cancer or HIV.
• Question 8
A 44 year old man was given fentanyl to achieve moderate sedation for a colonoscopy. During the procedure, the patients oxygen saturation begins to decline and while assessing the patient the NP notices chest wall rigidity. What is the cause of the rigidity and how would you treat it?
Correct
Answer: Intravenous administration of narcotics, especially fentanyl, can cause chest wall rigidity which is an uncommon but life threatening complication. The patient is unable to be ventilated because of the tightness in the chest wall. To treat this, succinylcholine should be administered and the patient ventilated
with a bag-valve-mask device until his respiratory drive returns. A dose of naloxone should also be administered to combat the effects of the narcotics. Additional doses can be administered if needed.
• Question 9
A 66 year old man is admired to the ICU with respiratory distress and bilateral pneumonia. He has a history of a CVA 2 years ago with right hemiplegia and aphasia. Current vitals signs are T 98.8 HR 115 BP 170/99. RR 32. Oxygen saturation is 90% on a nonrebreather mask. The patient weighs 70 kg. The NP decides to perform a rapid sequence intubation. What medications and doses would be appropriate for this patient? [Show Less]