Sedation: Choosing the Right Drug for the Right Patient
|
|
- Amos West
- 8 years ago
- Views:
Transcription
1 Sedation: Choosing the Right Drug for the Right Patient Kimberly Varney Gill, Pharm.D., BCPS VCU Health System VCU School of Pharmacy Associate Professor of Critical Care Medicine
2 Objectives 1. Discuss a general sedation strategy 2. Review commonly used sedatives 3. Present individual uses for specific sedative medications
3
4
5
6 Sedation Strategy New Goal: Awake, but Comfortable
7 Sedation Strategy New Goal: Awake, but Comfortable I. Medication Reconciliation and Patient History 1. Restart home psych / pain medications if not contraindicated, to prevent drug withdrawal 2. Identify specific disease states which direct toward a particular class of sedatives. (pain indication? EtOH abuse? Opiate / bzd abuse?)
8 Sedation Strategy New Goal: Awake, but Comfortable I. Medication Reconciliation and Patient History 1. Restart home psych / pain medications if not contraindicated, to prevent drug withdrawal 2. Identify specific disease states which direct toward a particular class of sedatives. (pain indication? EtOH abuse? Underlying psych disorder?) II. Drug or Delivery Method 1. Analgesia 1 st : A1 method 1,2 2. PRN only method 4 3. Patient Controlled Sedation (PCS) / PCA method 3 4. Shorter acting infusion agents: propofol, dexmedetomidine 5. Anti-psychotics over benzos for hyperactive delirium 1 Breen D, Wilmer A, Bodenham A, et al. Crit Care 2004;8:R SCCM Sedation and Analgesia Guidelines Chian LL et al. Chest Nov;138(5): Strom T et al. Lancet Feb 6;375(9713):475-80
9 Sedation Strategy III. Monitoring and Mobilization 1. RASS to lighter goal: -1 to -2 may be more appropriate. REASSESS daily 1 2. Daily interruption in appropriate pts 3. Delirium assessment 4. Daily mobilization protocol 2 1 Patel SB, Kress JP. Sedation and Analgesia in the mechanically ventilated patient. Am J Resp and Crit Care Med Oct 20, Schweickert WD et al.. Early physical and occupational therapy in critically ill patients. Lancet 2009;373:
10 Sedation Strategy III. Monitoring and Mobilization 1. RASS to lighter goal: -1 to -2 may be more appropriate. REASSESS daily 2. Daily interruption in appropriate pts 3. Delirium assessment 4. Daily mobilization protocol IV. Weaning to Extubate 1. Pairing daily interruption with spontaneous breathing trial (ABC Trial) 1 2. Observe for withdrawal from pre-hosp exposure, or ICU exposure to continuous sedative meds of >/= 3 days 3. If withdrawal: transition to longer acting agents (oral route). PLAN FOR TAPERING OFF POST-ICU should be well documented to avoid inadvertent long-term / post hospital exposure to anxiolytics/antipsychotics/opiates. 1 Girard T et al. ABC Trial. Lancet 2008;371:
11 Analgesia Before Sedation Patients experience pain in the ICU Endotracheal tube suctioning Repositioning Insertion of lines and tubes Desired outcomes have not been achieved; report of pain (50-65%) same now as data from 17 yrs ago Szokol JW, Vender JS. Crit Care Clin 2001, 17:
12 Characteristic Analgesia First Remifentanyl-based vs Standard hypnotic-based sedation in the ICU: a randomised trial 1 Remifentanil (n = 57) Control (n = 48) Number (%) of pts extubated 29 (51%) 16 (33%) Hours from start of study drugs to weaning - (Difference) Hours from start of study drugs to extubation - (Difference) Hours from weaning time until extubation - (Difference) Hours from start of study drugs until ICU discharge - (Difference) 83.0 (- 15.0) 94.0 (- 53.5) 0.9 (- 26.6) (- 22.5) P < Des Breen et al. Decreased duration of mechanical ventilation when comparing analgesia-based sedation with standard hypnotic-based sedation. Critical Care Dec :R
13 Benzodiazepine a Infusions Appropriate Use Status Epilepticus Alcohol Withdrawal Patients < 65 yrs Chronic outpt benzo use Use Caution or Avoid Use Older population (>65 yrs) Treatment of delirium b Hepatic failure, cirrhosis End-stage renal failure No hepatic failure No end stage renal failure A midazolam and lorazepam b avoid infusion or prn use Patel SB, Kress JP. Sedation and Analgesia in the mechanically ventilated patient. Am J Resp Crit Care Med Oct 2011.
14 Propofol Mechanism of Action - sedative and hypnotic properties; no analgesic properties - GABA A receptor agonist; NMDA receptor blockade - Highly lipophilic with high Vd Short acting agent Adult Dose: mcg/kg/min Onset ~ 30 seconds; Duration ~ 3-10 minutes (may be prolonged in obese, elderly) Titration fast, ~ every 5-10 minutes Monitoring BP, HR, RR Triglycerides > 500 mg/dl (~ 10 %) 10% Lipid emulsion: 1.1 kcal/ml; the calories count PRIS McKeage K, Perry CM: Propofol: a review of its use in ICU sedation. CNS Drugs 2003, 17(4):
15 Propofol Use has steadily increased over last 10 years. 1 IV infusion sedation almost doubled : 39% to 68% Attributed to increased use of propofol : 31% to 55% Meta-analysis of Propofol from controlled studies, 1386 patients on mechanical ventilation Endpoint Mortality Length of ICU stay (med-long term sedation Duration of mech ventilation (4 studies) Propofol vs Control No difference Decreased LOS vs sedatives; No diff LOS compared to midazolam Shorter duration vs control 1 Wunsch, H ET all. Project IMPACT data. Crit Care Med Dec 2009; Ho KM, Ng, KY. Propofol Meta-Analysis. Int Care Med Nov 2008;34(11):
16 PRIS 36 yo female adm to MICU for severe sepsis/resp failure requiring intubation, secondary to strep pneumoniae. PMH included substance abuse, HIV, and hep C, schizoaffective, and DM. Abx, fluids, and pressors were started. Sedation included propofol 30 mcg/kg/min, and midazolam infusion. Renal and hepatic lab values WNL. Day 7 Morbilliform rash on neck, shoulders, chest AST 115 ALT 536 Amylase 294 Lipase 608 CK 36,327 TGs 1005 Sinus tach Abd CT showed hepatomegaly w/ fatty infiltration of liver Orsini J et al. Am J Health-Syst Pharm Vol 66 May15, 2009
17 PRIS Total dose of propofol over 8 days 35,200 mg (avg 49 mcg/kg/min). Propofol stopped and phenobarb was added. Laboratory test values normalized, and rash and tachycardia resoved within 72 hrs of propofol discontinuation. Orsini J et al. Am J Health-Syst Pharm Vol 66 May15, 2009
18 PRIS High mortality, must stop infusion Lipemic serum may be an indicator Rhabdomyolysis, heart failure, renal failure, liver failure, high triglycerides, metabolic acidosis, lactic acidosis, arrhythmias Dose and time related (> 50 mcg/kg/min), for 48hrs Labs: lactate, TGs, CK, SCr, LFTs, pancreatic enzymes, ECG, echocardiogram Roberts RJ et al. Crit Care 2009;13(5):R169
19 Propofol Place in Therapy Along with an opiate, patients on mechanical ventilation (out to 7-10 days..) Effective to prevent alcohol withdrawal Preferred over midazolam in patients with renal failure, hepatic failure If on a longer acting infusion, can consider switching to propofol as pt gets closer to extubation (shorter acting) Monitor for hypertriglyceridemia, PRIS Riker R, Gilles F Crit Care Clinics. 2009(25):
20 Dexmedetomidine (Precedex ) Central alpha 2 agonist Sedation / Analgesia ( opiate requirements ~ 25-30%) HR and BP NO effect on respiratory drive Mimics non-rem sleep Dosing and Monitoring Starting dose: 0.2 mcg/kg/hr 1.4 mcg/kg/hr (optional bolus) Titration up: every 30 mins Titration down: every 2-4 hrs; maybe longer if on for several days Peak effect (steady state): ~2-4 hours if no bolus given Monitor for bradycardia, hypotension Ann Pharmacother. 2009;43: , Acta Anaesthesiol Scand. 2008;52:
21 N Ohtani et al. Peri-operative effects of dexmedetomidine. J Anesth Sept 2011 Tian-Zhi Guo et al. Anesthesiology 1996;84(4): Dexmedetomidine for Pain Dexmedetomidine produces antinociception via -2 A,C agonist activity in the locus ceruleus, and dorsal horn in the spinal cord. decreased opiate and anesthesia requirements peri- and postoperatively, and in the intensive care unit
22 Dexmedetomidine for Pain Palliative care: intractable pain control and decreased delirium at end of life Opioid-induced hyperalgesia (OIH): opiates in high dose and with prolonged exposure can have pronociceptive /antinociceptive properties Unable to achieve pain control despite escalating opioid doses Dexmedetomidine provides pain control via a different mechanism which acts synergistically with opioids. Coyne PJ et al. Dexmedetomidine: its role for intractable pain and dosing guideline. J of Pain and Pall Care Pharmacother Dec 2010;24(4): E Prommer. Dexmedetomidine: role in palliative care medicine. Am J Hosp P Med 2011;28(4): Belgrade M, Hall S. Dexmedetomidine for OIH. Pain Med Dec 2010;11(12):
23 Alcohol Withdrawal Neurotransmitter Long term EtOH Removal of EtOH Targeted Drug Therapy GABA(a) (inh) 1 GABA receptors inhibitory fxn leading to anxiety and seizures Benzos, Barbs Carbamazepine Propofol Glutamate (excit) 2 glutamate via NMDA receptors excitatory function from elevated receptor levels Propofol Calcium channel blockers Norepinephrine brain adrenergic (excit) 3 output noradren levels to above pre-etoh levels (early in w/dr) Clonidine Dexmedetomidine 1 Muzyk AJ et al. Annals of Pharm May 2011, Vol 45: Davis KM et al. J Biomed Sci 2000;8: Patkar AA et al. Alcohol Alcohol 2003;38:
24 Alcohol Withdrawal Neurotransmitter Long term EtOH Removal of EtOH Targeted Drug Therapy GABA(a) (inh) 1 GABA receptors inhibitory fxn leading to anxiety and seizures Benzos, Barbs Carbamazepine Propofol Glutamate (excit) 2 glutamate via NMDA receptors excitatory function from elevated receptor levels Propofol Calcium channel blockers Norepinephrine brain adrenergic (excit) 3 output noradren levels to above pre-etoh levels (early in w/dr) Clonidine Dexmedetomidine 1 Muzyk AJ et al. Annals of Pharm May 2011, Vol 45: Davis KM et al. J Biomed Sci 2000;8: Patkar AA et al. Alcohol Alcohol 2003;38:
25 Dexmedetomidine in Alcohol Withdrawal 30 year old male hx of chronic alcohol abuse admitted for AMS and agitation. Last EtOH intake was 24 hrs previous. Pt went into withdrawal on hosp d 2. Lorazepam IM bolus, midazolam gtt titrated to 12 mg/hr Pt remained altered with episodes of severe agitation, tremors. Dexmed initiated at 0.2 mcg/kg/hr titrated to 0.7 mcg/kg/hr. Total of 39 hrs of dexmed. Midazolam titrated down after 3 hrs of dexmed; mental status, tremors/agitation improved. Midaz stopped after 14 hrs of overlap with dexmed. Patient on oxazepam by day 3; discharged home day 5. Darrouj J, et al. Annals of Pharmacotherapy. Nov 2008 Vol 42(11);
26 Dexmed 4 ½ hrs mcg/kg/hr 1.2, 1, 0.6, 0.5, 0.25, off Patient had been on high dose dexmed for roughly 7 days. Dexmed was titrated off over 4 ½ hrs. Lorazepam also decreased slightly (from q4h to q6). Next morning 10 am, pt having rigors, tachy 130s, hypertsn 160s, extreme anxiety. Gave 2 mg midazolam, HR decreased to 110s; gave dexmed full bolus, HR to 70s and SBP to 105/65. Patient calm and sedated. Total dexmed infusion time was 32 days; pt eventually started on PO phenobarb and clonidine to wean off infusion medications. Dexmed was not successfully weaned off until clonidine was initiated.
27 Dexmedetomidine Place in Therapy Short-medium term sedation and analgesia Pain requiring increased opiate dosing with concerns for respiratory depression; intractable pain, palliative care Substance abuse withdrawal w/ benzo, barb Decrease benzodiazepine use* Cost: ~60 $ per bag (~ $ / day) Concerns Still FDA approved for only 24 hours Case reports of severe withdrawal when weaned too quickly from long term use (>7 days) Titration down can be tricky when on drug for several days.? Consider PO clonidine if withdrawal occurs. Arain SR, Ebert TJ: Anesth Analg 2002, 95:
28 Delirium in the ICU Cause(s) of delirium is usually multifactorial, therefore needing a multicomponent approach to targeting treatment of delirium. Expected based on disease state(s)? Correctable diseaserelated cause? Drug related? Attempt to correct underlying pathophysiology and/or removing medications that may be causing delirium DRUGS causing delirium and/or altered mental status Benzodiazepines, opiates, propofol, dexmedetomidine, antipsychotics 1 Devlin J et al. Crit Care Med 2010 Feb:38(2):
29 Delirium * Non-pharmacologic therapy Normalizing ICU atmosphere: sleep, light, alarms, family visitation Discontinue medications contributing to delirium Antipsychotics May be beneficial for hyperactive delirium 1 Haloperidol, quetiapine, olanzapine, ziprasidone have been published with some efficacy Adverse effects: sedation, QTc prolongation, EPS Medication reconciliation If treatment drugs are started, need to plan for taper or discontinue before ICU or hospital discharge** 1 Devlin J et al. Crit Care Med 2010 Feb:38(2):
30 Summary Think through sedation strategy on a case by case basis. Use individual drug characteristics to base decision.
31 Questions
32 PRN method study, Lancet 2010 Outcome data No sedation (n=55) Sedation (n=58) p value Days w/o MV 13 8 (11 0) 9 6 (10 0) * Length of stay (days) Intensive care unit 13 1 (5 7) 22 8 (11 7) * Hospital 34 (17 65) 58 (33 85) * Mortality Intensive care unit 12 (22%) 22 (38%) 0 06 Hospital 20 (36%) 27 (47%) 0 27 Drug doses (mg/kg) Propofol (per h of infusion) ** 0 ( ) ( ) Midazolam (per h of infusion) 0 (0 0) ( ) < Morphine (per h of MV) ( ) ( ) 0 39 Haloperidol (per day of MV) 0 ( ) 0 (0 0) Tracheostomy 16 (29%) 17 (29%) 0 98 Ventilator-associated pneumonia 6 (11%) 7 (12%) 0 85
Targeting patients for use of dexmedetomidine
Targeting patients for use of dexmedetomidine H a n n a h W u n s c h, M D M S c H e r b e r t I r v i n g A s s i s t a n t P r o f e s s o r o f A n e s t h e s i o l o g y & E p i d e m i o l o g y
More informationAlcohol Withdrawal. Introduction. Blood Alcohol Concentration. DSM-IV Criteria/Alcohol Abuse. Pharmacologic Effects of Alcohol
Pharmacologic Effects of Alcohol Alcohol Withdrawal Kristi Theobald, Pharm.D., BCPS Therapeutics III Fall 2003 Inhibits glutamate receptor function (NMDA receptor) Inhibits excitatory neurotransmission
More informationPhilip Moore DO, Toxicology Fellow, PinnacleHealth Toxicology Center Joanne Konick-McMahan RN MSRN, Staff RN, PinnacleHealth
Philip Moore DO, Toxicology Fellow, PinnacleHealth Toxicology Center Joanne Konick-McMahan RN MSRN, Staff RN, PinnacleHealth I. II. Background A. AWS can occur in anyone who consumes alcohol B. Risk correlates
More informationWITHDRAWAL OF ANALGESIA AND SEDATION
WITHDRAWAL OF ANALGESIA AND SEDATION Patients receiving analgesia and/or sedation for longer than 5-7 days may suffer withdrawal if these drugs are suddenly stopped. To prevent this happening drug doses
More informationCase. History of psoriatic arthritis, htn, essential tremor Meds: propranolol, etodolac, etanercept No history of prior psychiatric disease.
Case 48 year old man admitted complaining of hallucinations. Mild hallucinations for a year. Worsened tremor for 3 weeks and then markedly worse hallucinations last 2 days History of psoriatic arthritis,
More informationJason Hoppe, D.O. Department of Emergency Medicine University of Colorado
Jason Hoppe, D.O. Department of Emergency Medicine University of Colorado Remember that patient you admitted 56 yo M broken hip and mild alcohol withdrawal, no other complaints, non-focal exam and workup
More informationObjectives. Important Principles
Management of the Intubated Patient Christopher J. Edwards, PharmD, BCPS Clinical Pharmacist - Emergency Medicine March 19 th, 2013 REPS EC SAG 2 Objectives Describe the rationale for post intubation analgesia
More informationPACT Module Sedation. Intensive Care Training Program Radboud University Medical Centre Nijmegen
PACT Module Sedation Intensive Care Training Program Radboud University Medical Centre Nijmegen Important concepts Prolonged use of sedatives associated with significant side effects - drug holiday & sedation
More informationAlcohol Withdrawal Syndromes
Alcohol Withdrawal Syndromes Should You Treat This Patient s Alcohol Withdrawal With Benzodiazepines?! Meta-analysis of RCTs of benzodiazepines for the treatment of alcohol withdrawal! 11 RCTs identified,
More informationSutter Health: Sacramento-Sierra REGIONAL ICU DELIRIUM PROTOCOL
Sutter Health: Sacramento-Sierra REGIONAL ICU DELIRIUM PROTOCOL Delirium-(acute brain dysfunction) is defined as a disturbance of consciousness with inattention accompanied by a change in cognition or
More informationThe Difficult to Sedate ICU Patient
The Difficult to Sedate ICU Patient Dan Burkhardt, M.D. Associate Professor Department of Anesthesia and Perioperative Care University of California San Francisco burkhard@anesthesia.ucsf.edu Richmond
More informationSymptom Based Alcohol Withdrawal Treatment
Symptom Based Alcohol Withdrawal Treatment -Small Rural Hospital- Presenter CDR Dwight Humpherys, DO dwight.humpherys@ihs.gov Idaho State University Baccalaureate Nursing Program Lake Erie College of Osteopathic
More informationPain Management in the Critically ill Patient
Pain Management in the Critically ill Patient Jim Ducharme MD CM, FRCP President-Elect, IFEM Clinical Professor of Medicine, McMaster University Adjunct Professor of Family Medicine, Queens University
More information4/18/14. Background. Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients. Background. Signs and Symptoms of Withdrawal
Background 1 Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients Alyssa Cavanaugh, PharmD PGY1 Pharmacy Resident Children s Hospital of Michigan **The speaker has no actual or
More informationHow To Treat Alcohol Withdrawal In The Elderly
ALCOHOL ABUSE AND WITHDRAWAL SYNDROME IN THE ELDERLY Colin Muscat Family Medicine Case 90 year old Female Lives with son on vacation Admitted for FTT Consult -? GARP Develops increasing confusion during
More informationEMS Branch / Office of the Medical Director. Active Seziures (d) Yes Yes Yes Yes. Yes Yes No No. Agitation (f) No Yes Yes No.
M07 Medications 2015-07-15 All ages EMS Branch / Office of the Medical Director Benzodiazepines Primary Intermediate Advanced Critical INDICATIONS Diazepam (c) Lorazepam (c) Midazolam (c) Intranasal Midazolam
More informationEvaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients
Evaluation of a Morphine Weaning Protocol in Pediatric Intensive Care Patients Jennifer Kuhns, Pharm.D. Pharmacy Practice Resident Children s Hospital of Michigan **The speaker has no actual or potential
More informationMEDICATION ABUSE IN OLDER ADULTS
MEDICATION ABUSE IN OLDER ADULTS Clifford Milo Singer, MD Adjunct Professor, University of Maine, Orono ME Chief, Division of Geriatric Mental Health and Neuropsychiatry The Acadia Hospital and Eastern
More informationNURSING SERVICES DEPARTMENT
NURSING SERVICES DEPARTMENT TITLE: Mechanical Ventilation PATIENT CARE PLAN DIAGNOSIS: DISCHARGE CRITERIA: 1 The patient will: Maintain adequate mechanics of PERTINENT INFORMATION:. ventilation as demonstrated
More informationPhenobarbital Use as Adjunct to Benzodiazepines in the Treatment of Severe Alcohol Withdrawal Syndrome
Journal of Pharmacy and Pharmacology (014) 1-7 D DAVID PUBLISHING Phenobarbital Use as Adjunct to Benzodiazepines in the Treatment of Severe Alcohol Withdrawal Cristina Roman, Sibusisiwe Gumbo and Kevin
More informationThe ideal intensive care unit (ICU) sedative CHOICE OF SEDATION FOR CRITICALLY ILL PATIENTS: A RATIONAL APPROACH * PROCEEDINGS. Louis Brusco, Jr, MD
CHOICE OF SEDATION FOR CRITICALLY ILL PATIENTS: A RATIONAL APPROACH * Louis Brusco, Jr, MD ABSTRACT Because no single, ideal sedative exists, the clinician must take care to select the best agent to ensure
More informationPhenobarbital in Severe Alcohol Withdrawal Syndrome. Jordan Rowe Pharm.D. Candidate UAMS College of Pharmacy
Phenobarbital in Severe Alcohol Withdrawal Syndrome Jordan Rowe Pharm.D. Candidate UAMS College of Pharmacy Disclosure: No relevant financial relationship exists. Objectives 1. Describe the pathophysiology
More informationINTOXICATED PATIENTS AND DETOXIFICATION
VAMC Detoxification Decision Tree Updated May 2006 INTOXICATED PATIENTS AND DETOXIFICATION Patients often present for evaluation of substance use and possible detoxification. There are certain decisions
More informationPHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Condition/Status This powerplan is only intended for use in those patients having symptoms related to alcohol withdrawal. See DSM-IV-TR criteria listed in the Alcohol Withdrawal ICU
More informationDrug Shortage Alert 8/1/2014
Headquarters 500 Midway Drive Mount Prospect, Illinois 60056-5811 USA Main Telephone +1 847 827-6869 Customer Service +1 847 827-6888 Facsimile +1 847 827-6886 Email info@sccm.org www.sccm.org Drug Shortage
More informationTreatment of Opioid Dependence with Buprenorphine/Naloxone (Suboxone )
Treatment of Opioid Dependence with Buprenorphine/Naloxone (Suboxone ) Elinore F. McCance-Katz, M.D., Ph.D. Professor and Chair, Addiction Psychiatry Virginia Commonwealth University Neurobiology of Opiate
More informationHow To Treat An Alcoholic Withdrawal
Alcohol Withdrawal Sorrento, Italy (September 19, 2007) Lewis R. Goldfrank, MD Professor and Chairman, Emergency Medicine New York University School of Medicine Director, Emergency Medicine Bellevue Hospital/NYU
More informationRecommendations for Alternative Analgesic and Sedative Agents in the Setting of Drug Shortages
Recommendations for Alternative Analgesic and Sedative Agents in the Setting of Drug Shortages Gail Gesin, PharmD* Clinical Phramacist for Trauma Critical Care Carolinas Medical Center Charlotte, North
More informationGeneral PROVIDER INITIALS: PHYSICIAN ORDERS
Height Weight Allergies If appropriate for patient condition, please consider the following order sets: Initiate Electrolyte Replcement: Med/Surg, Med/Surg Tele Physician Order #842 General Vital Signs
More informationAwareness of the inappropriate use of GI prophylaxis and its cost. Adverse effects of proton pump inhibitor
Understand the indication for stress ulcer/gi prophylaxis Awareness of the inappropriate use of GI prophylaxis and its cost Adverse effects of proton pump inhibitor A. 65yo w/ HTN and ESRD on HD p/w left
More informationAlcohol withdrawal syndromes in the intensive care unit
本 檔 僅 供 內 部 教 學 使 用 檔 案 內 所 使 用 之 照 片 之 版 權 仍 屬 於 原 期 刊 公 開 使 用 時, 須 獲 得 原 期 刊 之 同 意 授 權 Alcohol withdrawal syndromes in the intensive care unit MaryClare Sarff, MD; Jeffrey A. Gold, MD Crit Care Med 2010
More informationAcute Pain Management in the Opioid Dependent Patient. Maripat Welz-Bosna MSN, CRNP-BC
Acute Pain Management in the Opioid Dependent Patient Maripat Welz-Bosna MSN, CRNP-BC Relieving Pain in America (IOM) More then 116 Million Americans have pain the persists for weeks to years $560-635
More informationHow To Treat An Alcoholic Patient
Height Weight Allergies If appropriate for patient condition, please consider the following order sets: Initiate Electrolyte Replcement: Med/Surg, Med/Surg Tele Physician Order #842 Discontinue all lorazepam
More information9/16/2010. Contact Information. Objectives. Analgesic Ketamine (Ketalar )
Analgesic Ketamine (Ketalar )..the long and winding road to clinical practice Contact Information Lois Pizzi BSN, RN-BC Inpatient Pain Management Clinician UPMC Presbyterian Shadyside pizzilj@upmc.edu
More informationPlace hospital logo here
Place hospital logo here Nurse-Driven Protocol for the Management of Patients in Alcohol/Substance Withdrawal Maimonides Medical Center (MMC) Sharon Hawthorne, RN, BSN, CCRN, SSN II Ariadne Williams, RN,
More informationSaint Thomas Hospital Protocol. Protocol Title: Terminal Weaning from Ventilator Protocol No.: V-09. Medical Staff departments
Saint Thomas Hospital Protocol Protocol No.: V-09 Operating Unit(s) Medical Staff departments Important s: Affected: affected:! Hospital! Medicine of Origin: 2/00 " Regional Network! Surgery Reviewed:
More informationGeneral Internal Medicine Grand Rounds. Julie Taub, MD Denver Health & Hospital Authority, Denver CO
The Treatment of Acute Alcohol Withdrawal General Internal Medicine Grand Rounds February 14, 2012 Julie Taub, MD Denver Health & Hospital Authority, Denver CO Pharmacology Ethanol Benzodiazepines Chlormethiazole
More informationAssessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal
Assessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal Roger Cicala, M. D. Assistant Medical Director Tennessee Physician s Wellness Program Step 1 Don t 1 It is legal in
More informationTHERAPEUTIC INDUCED HYPOTHERMIA GUIDELINES
THERAPEUTIC INDUCED HYPOTHERMIA GUIDELINES Guidelines for Inclusion: (check all that apply) Cardiac arrest patients with any of the following: Ventricular fibrillation Pulseless Ventricular tachycardia
More informationSubstance Use Learning Event Nov 3, 2015 Bill Bullock MD, CCFP
Substance Use Learning Event Nov 3, 2015 Bill Bullock MD, CCFP Medical assessment of patient with Alcohol Use Disorder Identification patients suitable for home detox Process for referral to inpatient
More informationPharmacology of Procedural Sedation
AACN Advanced Critical Care Volume 23, Number 4, pp.349 354 2012, AACN ECG Challenges Earnest Alexander, PharmD, and Gregory M. Susla, PharmD Department Editors Pharmacology of Procedural Sedation Danyel
More informationThere are approximately 18.3 million people
Hosp Pharm 2015;50(3):208 213 2015 Thomas Land Publishers, Inc. www.hospital-pharmacy.com doi: 10.1310/hpj5003-208 Original Article Retrospective Review of Critically Ill Patients Experiencing Alcohol
More informationUniversity of Michigan Alcohol Withdrawal Guidelines Overview
University of Michigan Alcohol Withdrawal Guidelines Overview The following document contains the University of Michigan Alcohol Withdrawal Guidelines. These guidelines were developed through an intensive
More informationBenzodiazepines: A Model for Central Nervous System (CNS) Depressants
Benzodiazepines: A Model for Central Nervous System (CNS) Depressants Objectives Summarize the basic mechanism by which benzodiazepines work in the brain. Describe two strategies for reducing and/or eliminating
More informationOpioid Agonist Therapy: The Duration Dilemma Edwin A. Salsitz, MD, FASAM Mount Sinai Beth Israel, New York, NY March 10, 2015
Q: I have read 40 mg of methadone stops withdrawal, so why don t we start at 30mg and maybe later in the day add 10mg? A: Federal Regulations stipulate that 30mg is the maximum first dose in an Opioid
More informationPOST-TEST Pain Resource Professional Training Program University of Wisconsin Hospital & Clinics
POST-TEST University of Wisconsin Hospital & Clinics True/False/Don't Know - Circle the correct answer T F D 1. Changes in vital signs are reliable indicators of pain severity. T F D 2. Because of an underdeveloped
More informationConceptualizing and Integrating Medication Assistant Treatment into your Court s Armamentarium
Conceptualizing and Integrating Medication Assistant Treatment into your Court s Armamentarium Ted Parran JR. M.D. FACP Carter and Isabel Wang Professor of Medical Education CWRU School of Medicine tvp@case.edu
More information!!! BOLUS DOSE IV. Use 5-10 mcg IV boluses STD ADRENALINE INFUSION. Use IM adrenaline in advance of IV dosing!
ADRENALINE IVI BOLUS IV Open a vial of 1:1000 ADRENALINE 1 mg /ml Add 1 ml to 9 ml N/Saline = 1mg adrenaline in 10 ml (or 100 mcg/ml) Add 1 ml 1:10,000 to 9 ml N/Saline = 100 mcg adrenaline in 10 ml (or
More information03/20/12. Recognize the right of patients to appropriate assessment and management of pain
Narcotic Bowel Syndrome Alvin Zfass M.D. M.D. Professor of Medicine Toufic Kachaamy M.D. GI Fellow Chronic Pain 110 million Americans suffer from chronic pain according to the NIH Cost of untreated t or
More informationOPIOID NEUROTOXICITY - BACK TO BASICS. Dr. Suzy Pinnick (PGY-3): Palliative Medicine Fellow
OPIOID NEUROTOXICITY - BACK TO BASICS Dr. Suzy Pinnick (PGY-3): Palliative Medicine Fellow OBJECTIVES Some Cases Definitions: Including what is opioid neurotoxicity A bit of biochemistry What patients
More informationOutpatient Treatment of Alcohol Withdrawal. Daniel Duhigg, DO, MBA
Outpatient Treatment of Alcohol Withdrawal Daniel Duhigg, DO, MBA DSM V criteria for Alcohol Withdrawal A. Cessation or reduction of heavy/prolonged alcohol use B. 2 or more of the following in hours to
More informationUpdate and Review of Medication Assisted Treatments
Update and Review of Medication Assisted Treatments for Opiate and Alcohol Use Disorders Richard N. Whitney, MD Medical Director Addiction Services Shepherd Hill Newark, Ohio Medication Assisted Treatment
More informationGuidelines for Cancer Pain Management in Substance Misusers Dr Jane Neerkin, Dr Chi-Chi Cheung and Dr Caroline Stirling
Guidelines for Cancer Pain Management in Substance Misusers Dr Jane Neerkin, Dr Chi-Chi Cheung and Dr Caroline Stirling Patients with a substance misuse history are at increased risk of receiving inadequate
More informationLumbar Fusion. Reference Guide for PACU CLINICAL PATHWAY. All patient variances to the pathway are to be circled and addressed in the progress notes.
Reference Guide for PACU Lumbar Fusion CLINICAL PATHWAY All patient variances to the pathway are to be circled and addressed in the progress notes. This Clinical Pathway is intended to assist in clinical
More informationSue Carol Verrillo, RN, MSN, CRRN The Johns Hopkins Hospital November 14, 2014
Early Detection of Patient Deterioration Using Remote Patient Monitoring with Wireless Nurse Notification Sue Carol Verrillo, RN, MSN, CRRN The Johns Hopkins Hospital November 14, 2014 1 Why Remote Patient
More informationAlcohol Withdrawal and Delirium 11-4-03
Alcoholism Lecture Alcohol Withdrawal and Delirium Jeff Thiele MD 11-4-03 Alcohol intoxication occurs at blood levels of.050 to.080 depending on your criteria. In MO the legal definition is now a BAL of.80
More informationTHE A,B,C,D,E of F. Appropriate Prescribing of Oral Benzodiazepines in Patients Over the Age of 65
THE A,B,C,D,E of F Appropriate Prescribing of Oral Benzodiazepines in Patients Over the Age of 65 INTRODUCTION Anne Fullerton Clinical Pharmacist for Aged Care at John Hunter Hospital Disclaimer: I did
More informationACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767
ACLS Cardiac Arrest Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767 Copyright 2010 American Heart Association ACLS Cardiac Arrest Circular Algorithm Neumar, R. W. et al. Circulation 2010;122:S729-S767
More informationPrevention and Treatment of Opioid and Benzodiazepine Withdrawal
1.0 Introduction The purpose of this guideline is to ensure that patients who are at risk of developing withdrawal symptoms can be weaned off opioids and benzodiazepines in a timely fashion. It is appropriate
More informationTreatment of Anxiety in the Methadone Maintained Patient
Treatment of Anxiety in the Methadone Maintained Patient Abigail Kay M.D., M.A. Medical Director Narcotic Addiction Rehabilitation Program Department of Psychiatry and Human Behavior Thomas Jefferson University
More informationBENZODIAZEPINE CONSIDERATIONS IN WORKERS COMPENSATION: IMPLICATIONS FOR WORK DISABILITY AND CLAIM COSTS By: Michael Erdil MD, FACOEM
3 rd Quarter 2015 BENZODIAZEPINE CONSIDERATIONS IN WORKERS COMPENSATION: IMPLICATIONS FOR WORK DISABILITY AND CLAIM COSTS By: Michael Erdil MD, FACOEM Introduction Benzodiazepines, sometimes called "benzos",
More informationHospital Management of Opioid Dependence. Dependence. Disclosure. Pharmacologic Management. Methadone Utilization. Hospital Management of Opioid
Disclosure Hospital Management of Opioid Dependence Attended Buprenorphine advisory board meeting (Schering Canada) May 2007, but personal honorarium/compensation was declined Dr. Alex Chan alexchchan@hotmail.com
More informationPatient Care Services Policy & Procedure Title: No. 8720-0059
Page: 1 of 8 I. SCOPE: This policy applies to Saint Francis Hospital, its employees, medical staff, contractors, patients and visitors regardless of service location or category of patient. This policy
More informationCase Studies: Acute pain management in patients with opioid addiction. Shannon Levesque, PharmD Clinical Pharmacist
Case Studies: Acute pain management in patients with opioid addiction Shannon Levesque, PharmD Clinical Pharmacist Disclosure I have no financial relationships with industry to disclose Objectives Misconceptions
More informationPain Medication Taper Regimen Time frame to taper off 30-60 days
Pain Medication Taper Regimen Time frame to taper off 30-60 days Medication to taper Taper Regimen Comments Methadone Taper by no more than 25% Morphine Taper by no more than 25% Tramadol Taper by no more
More informationInterventional MRI (imri) guided Deep Brain Stimulation for Parkinson s Disease
Interventional MRI (imri) guided Deep Brain Stimulation for Parkinson s Disease Anesthetic considerations A case study Lydia Cendana University of Pittsburgh School of Nurse Anesthesia Parkinson s disease
More informationSource: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.
Diagnosis and Treatment of Alcohol Dependence Lon R. Hays, MD, MBA Professor and Chairman Department of Psychiatry University of Kentucky Medical Center Defining the Standard Drink A standard drink = 14
More informationAlcohol Withdrawal Syndrome. Jeffrey P Schaefer MSc MD FRCPC GI Emergencies Update October 14, 2007 http:dr.schaeferville.com
Alcohol Withdrawal Syndrome Jeffrey P Schaefer MSc MD FRCPC GI Emergencies Update October 14, 2007 http:dr.schaeferville.com Objectives Alcohol Intoxication Take-Aways diagnosis avoid mis-diagnosis management
More informationMODERATE SEDATION RECORD (formerly termed Conscious Sedation)
(POLICY #DOC-051) Page 1 of 6 WELLSPAN HEALTH - YORK HOSPITAL NURSING POLICY AND PROCEDURE Dates: Original Issue: September 1998 Annual Review: March 2012 Revised: March 2010 Submitted by: Brenda Artz
More informationAlison White Devang Rai Richard Chye
Ketamine use in hospice patients before and after the sentinel randomised controlled trial of ketamine in cancer pain: A single centre retrospective review Alison White Devang Rai Richard Chye Overview
More informationSource: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.
Diagnosis and Treatment of Alcohol Dependence Lon R. Hays, MD, MBA Professor and Chairman an Department of Psychiatry University of Kentucky Medical Center Defining the Standard Drink A standard drink
More informationManagement of Neonatal Abstinence Syndrome and Iatrogenic Drug Withdrawal
Management of Neonatal Abstinence Syndrome and Iatrogenic Drug Withdrawal Kirsten H. Ohler, Pharm.D., BCPS Clinical Assistant Professor Neonatal / Pediatric Clinical Pharmacist University of Illinois at
More informationWeaning the Unweanable
Weaning the Unweanable Gerald W. Staton, Jr, MD Professor of Medicine Pulmonary & Critical Care Medicine Emory University School of Medicine Atlanta, GA gerald.staton@emory.edu Disclosures Pulmonary Program
More informationNurses Self Paced Learning Module on Pain Management
Nurses Self Paced Learning Module on Pain Management Dominican Santa Cruz Hospital Santa Cruz, California Developed by: Strategic Planning Committee Dominican Santa Cruz Hospital 1555 Soquel Drive Santa
More informationAcute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction
Acute & Chronic Pain Management (requiring opioid analgesics) in Patients Receiving Pharmacotherapy for Opioid Addiction June 9, 2011 Tufts Health Care Institute Program on Opioid Risk Management Daniel
More informationTriage, Assessment & Treatment
Triage, Assessment & Treatment Launette Rieb, MSc, MD, CCFP, FCFP, dip ABAM Clinical Associate Professor, Dept. Family Practice, UBC Physician Director, St. Paul's Hospital Goldcorp Addiction Medicine
More informationMOH CLINICAL PRACTICE GUIDELINES 2/2008 Prescribing of Benzodiazepines
MOH CLINICL PRCTICE GUIELINES 2/2008 Prescribing of Benzodiazepines College of Family Physicians, Singapore cademy of Medicine, Singapore Executive summary of recommendations etails of recommendations
More informationAdjunctive psychosocial intervention. Conditions requiring dose reduction. Immediate, peak plasma concentration is reached within 1 hour.
Shared Care Guideline for Prescription and monitoring of Naltrexone Hydrochloride in alcohol dependence Author(s)/Originator(s): (please state author name and department) Dr Daly - Consultant Psychiatrist,
More informationTTTF2- Project ECHO Selecting the Optimal Tobacco Cessation Medication Rosario Wippold
TTTF2- Project ECHO Selecting the Optimal Tobacco Cessation Medication Rosario Wippold Selecting the Optimal Tobacco Cessation Medication Review medical/ mental health conditions to have into account when
More informationReview of Pharmacological Pain Management
Review of Pharmacological Pain Management CHAMP Activities are possible with generous support from The Atlantic Philanthropies and The John A. Hartford Foundation The WHO Pain Ladder The World Health Organization
More informationSouth Denver Prehospital Services 2014
South Denver Prehospital Services 2014 Overview of 2014 BACKBOARD EMS PATIENT OUTCOMES EMS Pain management MED RECONCILIATION Attention! BACKBOARD DRILL!! BEFORE AND AFTER PROTOCOL CHANGE Measure: Injury:
More informationANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY. Guidelines for Use of Intravenous Isoproterenol
ANNE ARUNDEL MEDICAL CENTER CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY Guidelines for Use of Intravenous Isoproterenol Major Indications Status Asthmaticus As a last resort for
More informationCardiac Arrest VF/Pulseless VT Learning Station Checklist
Cardiac Arrest VF/Pulseless VT Learning Station Checklist VF/VT 00 American Heart Association Adult Cardiac Arrest Shout for Help/Activate Emergency Response Epinephrine every - min Amiodarone Start CPR
More informationConsiderations in Medication Assisted Treatment of Opiate Dependence. Stephen A. Wyatt, D.O. Dept. of Psychiatry Middlesex Hospital Middletown, CT
Considerations in Medication Assisted Treatment of Opiate Dependence Stephen A. Wyatt, D.O. Dept. of Psychiatry Middlesex Hospital Middletown, CT Disclosures Speaker Panels- None Grant recipient - SAMHSA
More information28 Year-old Male w/uncontrolled Type 2 Diabetes, Bipolar Disorder Presents with Epigastric Pain. Jess Hwang 9/27/12
28 Year-old Male w/uncontrolled Type 2 Diabetes, Bipolar Disorder Presents with Epigastric Pain Jess Hwang 9/27/12 HPI Presented to an OSH with epigastric pain, diarrhea. + fevers up to 104.9 1 year ago
More informationVA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 118-28 SAN DIEGO, CA
GUIDELINES FOR PATIENT-CONTROLLED ANALGESIA (PCA) AND PATIENT- CONTROLLED EPIDURAL ANALGESIA (PCEA) FOR ACUTE PAIN MANAGEMENT 1. PURPOSE: To assure the safe and effective use of patient controlled analgesia
More informationAddressing Substance and Alcohol Use Prior to HCV Treatment
Addressing Substance and Alcohol Use Prior to HCV Treatment Glenn J. Treisman, MD, PhD The Johns Hopkins University School of Medicine Baltimore, Maryland Disclosure Information Dr Treisman has no relevant
More informationCase conference November 13, 2015
Case conference November 13, 2015 52-year-old Man CC: Fatigue and vomiting PMHx: Afib CAD s/p CABG HTN Hyperlipidemia GERD PUD Cirrhosis Pancreatitis DM II Low back pain OSA- does not use CPAP FHx: Mother:
More informationLidocaine Infusion for Perioperative Pain Management. Marley Linder, PharmD Matt McEvoy, MD
Lidocaine Infusion for Perioperative Pain Management Marley Linder, PharmD Matt McEvoy, MD Perioperative Surgical Home: PCS Shared Goals Improved Outcomes (pain, PONV, LOS, SSI) Improve Throughput (Clinic
More informationAlcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice
Dr IM Joubert Alcohol and nicotine are widely abused substances and are often used together One study showed that 15% of patients visiting a primary care practice for any reason had either an at-risk pattern
More informationOctober 2012. We hope that our tool will be a useful aid in your efforts to improve pain management in your setting. Sincerely,
October 2012 he Knowledge and Attitudes Survey Regarding Pain tool can be used to assess nurses and other professionals in your setting and as a pre and post test evaluation measure for educational programs.
More informationDelirium Toolbox Inpatient/Outpatient high value care considerations. Birju B. Patel, MD, FACP, AGSF N. Wilson Holland, MD, FACP, AGSF
Delirium Toolbox Inpatient/Outpatient high value care considerations Birju B. Patel, MD, FACP, AGSF N. Wilson Holland, MD, FACP, AGSF Goals for this session Understand prevalence, differential diagnosis,
More informationPrior Authorization Guideline
Prior Authorization Guideline Guideline: CSD - Suboxone Therapeutic Class: Central Nervous System Agents Therapeutic Sub-Class: Analgesics and Antipyretics (Opiate Partial Agonists) Client: County of San
More informationBehavioral Health Policy: Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction
Behavioral Health Policy: Methadone Treatment and Intensive Detoxification or Ultra-Rapid Detoxification for Opiate Addiction Table of Contents Policy: Commercial Coding Information Information Pertaining
More informationMedication-Assisted Addiction Treatment
Medication-Assisted Addiction Treatment Molly Carney, Ph.D., M.B.A. Executive Director Evergreen Treatment Services Seattle, WA What is MAT? MAT is the use of medications, in combination with counseling
More informationAtrial Fibrillation in the ICU: Attempting to defend 4 controversial statements
Atrial Fibrillation in the ICU: Attempting to defend 4 controversial statements Salmaan Kanji, Pharm.D. The Ottawa Hospital The Ottawa Hospital Research Institute Conflict of Interest No financial, proprietary
More informationAddition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study
DOI 10.1186/s13613-015-0075-7 RESEARCH Open Access Addition of dexmedetomidine to benzodiazepines for patients with alcohol withdrawal syndrome in the intensive care unit: a randomized controlled study
More informationRecommendations: Other Supportive Therapy of Severe Sepsis*
Recommendations: Other Supportive Therapy of Severe Sepsis* K. Blood Product Administration 1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances, such as myocardial
More informationAbstral Prescriber and Pharmacist Guide
Abstral Prescriber and Pharmacist Guide fentanyl citrate sublingual tablets Introduction The Abstral Prescriber and Pharmacist Guide is designed to support healthcare professionals in the diagnosis of
More informationGuidelines for the Diagnosis and Management of Acute Confusion (delirium) in the Elderly
Guidelines for the Diagnosis and Management of Acute Confusion (delirium) in the Elderly Author: Madeleine Purchas (SpR Care of the Elderly) Consultant Supervisor: Dr Neil Pollard Date: 16 th Dec 2005
More information