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Content 1 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Joanna L. Stollings, Pharm.D., FCCP, FCCM, BCPS, BCCCP Vanderbilt University Medical Center Nashville, Te…

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Content 1 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Joanna L. St…

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Learning Objectives 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Learning Objectives 1. Develop a management strategy for the preven- tion and treatment of pain, agitatio…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade A. Spontaneous awakening and breathing trials. B. Cisatracurium infusion. C. Intermittent vecuronium. D.…

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Exam Content Outline 1 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Cr…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade I.  PAIN, AGITATION/SEDATION, DELIRIUM, IMMOBILITY, AND SLEEP DISRUPTION (PADIS) IN THE INTENSIVE CARE UNI…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade B. Incidence and Causes of Pain: Pain may occur in any type of ICU patient, and considerations for pain m…

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Data Tables 2 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. Kanji et al. found that the CPOT is a valid pain assessment in noncomatose, delirious adult ICU patient…

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Data Tables 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Indicator Description Score Compliance with 
the ventilator 
(intubated patients) Alarms not activated, e…

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Data Tables 2 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. Nonpharmacologic therapy for pain a. The PADIS guidelines suggest offering cold therapy for procedural…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade iv. Significant adverse effects: Decreased respiratory drive: This may be a desired effect in some ICU sc…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade ii. Dosage forms: Injectable (intravenous, subcutaneous) and oral; intravenous-to-oral conversion is not…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade c. Intravenous or oral NSAIDs: Ibuprofen, ketorolac. The PADIS guidelines suggest not routinely using a C…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade c. Pregabalin (Lyrica) i. 50 mg three times daily; may be increased in 1 week depending on tolerability a…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Patient Case Questions 1 and 2 pertain to the following case. T.O. is a 70-year-old man just admitted to th…

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Data Tables 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Table 4. Sedatives for Patients on Mechanical Ventilation in the ICU Drug Onset and Duration Precautions…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 2. The SEDCOM study compared the sedative effects of midazolam with those of dexmedetomidine in medical a…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. Lipid formulation considerations: Standard propofol is a 1% (10 mg/mL) lipid emulsion containing 1.1 k…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 2. Mechanism of action: Highly selective and dose-dependent α2-adrenoceptor agonist in the CNS. Dexmedeto…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 9. Data: SPICE III was an open-label, randomized controlled trial comparing dexmedetomidine as primary se…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 2. Effects: Anxiolysis/sedation, anticonvulsant, muscle relaxant. Maintains anterograde amnesia propertie…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 5. Data: In a multicenter European trial (MIDEX), Jakob et al. compared midazolam (n=251) with dexmedetom…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. In a single-center, nested cohort study within the Awakening and Breathing Controlled (ABC) randomized…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 6. SBT: If a patient tolerates the SBT for 30 to 120 minutes, consider extubation. 7. SBT failure: a. Re…

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Data Tables 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade interruption, nurses stopped benzodiazepine and opiate infusions once a day and assessed hourly for wakefu…

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Data Tables 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Table 5. Richmond Agitation-Sedation Scale (RASS) (continued) Score Term Description Procedure 1. Observe…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade L. Frequency of Screening and Technique Used for SBT 1. A randomized trial (FAST) using a 2×2 factorial d…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Patient Cases 3. A 48-year-old man with cirrhosis and now hepatorenal syndrome was intubated for respirato…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade of delirium. Delirium is also associated with up to a 3-fold increase in mortality, increase in cognitive…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade and research is undergoing. Given the multifactorial nature of delirium in the ICU, clinicians should be l…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade comatose, non-delirious state within 24 hours of corticosteroid administration (odds ratio [OR] 1.52 [1.05…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 3. Decreasing the use of benzodiazepines and anticholinergics in patients at risk of delirium; use the lo…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade F. Treatment of Delirium: The cause of delirium may be multifactorial, and identifying and correcting the…

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Data Tables 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Table 7. Antipsychoticsa Drug CYP Substrate (major) Usual Starting Dose Significant Adverse Effectsb For…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade b. Initial dose range for ICU delirium: 50 mg one to three times daily. Consider lower starting doses for…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade V.  ABCDEF BUNDLE A. Incorporating multiple concomitant patient care interventions into one consolidated b…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade VI.  POST-INTENSIVE CARE SYNDROME A. Advances in critical care have decreased mortality and resulted in an…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. A prospective, observational feasibility study was conducted at an academic hospital between July 2012…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Patients admitted to a hospital with an ICU stay were also more likely to have medications discontinued am…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade VII.  NEUROMUSCULAR BLOCKADE IN THE INTENSIVE CARE UNIT A. The most recent SCCM guidelines for the sustain…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade D. Targeted Temperature Management After Cardiac Arrest 1. The 2016 SCCM NMBA guidelines make no recommen…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade b. Vecuronium: Intermediate-acting aminosteroid; often used as a continuous infusion i. Pharmacokinetics:…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade H. Choice of NMBA: Intermediate- to longer-acting agents such as vecuronium may be tried in bolus fashion…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 4. Awareness: Recent case reports document patient awareness during paralysis in the ICU. These patients…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade REFERENCES Pain Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of p…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Puntillo KA, Wild LR, Morris AB, Stanik-Hutt J, Thompson CL, White C. Practices and predictors of analges…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade 2013;41(9 Suppl 1):S30-S38. https://doi.org/10.1097/ ccm.0b013e3182a16898 Galvin M, Jago-Byrne MC, Fitzsim…

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Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically il…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Jeon K, Jeong BH, Ko MG, et al. Impact of delirium on weaning from mechanical ventilation in medical pati…

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Content 3 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Zaal IJ, Devlin JW, Hazelbag M, et al. Benzodiazepine- associated delirium in critically ill adults. Intens…

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Content 1 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade Med. 2016;44(11):2079-2103. https://doi.org/10.1097/ ccm.0000000000002027 National Heart, Lung, and Blood…

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Answers & Explanations 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: D This patient has a clear indication for intravenous…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade independently associated with the transition to delir- ium from a non-delirious state (Answer B is correct)…

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Self-Assessment 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: D Propofol infusion syndrome is a well-do…

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Content 4 min

Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade can be considered unless contraindicated because of the clinical scenario (e.g., drug-drug interactions, d…

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