A 76-year-old female is admitted after falling on her stairs and fracturing multiple ribs. She is transferred to the intensive care unit (ICU) for increased oxygen requirement. She reports that her pain is very severe. Her breathing is rapid and shallow.
Which of the following would be the MOST effective method of controlling her pain?
Correct Answer: C
Although epidural anesthesia has not definitively been shown to decrease mortality, pulmonary complications, or length of stay in patients with rib fractures, it has been shown to provide superior subjective pain control compared to intravenous narcotics. Lorazepam has no analgesic properties. Lidocaine patches and acetaminophen are good analgesia adjunctive therapies but would not be adequate to control this patient’s pain when used as a primary agent.
Reference:
A patient in your ICU has rapid deterioration of their respiratory status and needs emergent intubation. You would like to use succinylcholine for neuromuscular blockade after your induction agent.
Administering succinylcholine would be most appropriate in which of the following scenarios?
Correct Answer: D
Succinylcholine can trigger malignant hyperthermia and thus contraindicated in patients with suspicion of or known history of malignant hyperthermia. Succinylcholine briefly but routinely increases potassium by 0.5 mEq/L after administration; it is therefore contraindicated in patients with concerningly high baseline potassium levels. The release of potassium can be unpredictably large in patients with upregulation of nicotinic acetylcholine receptors. Examples of conditions in which this can happen are patients with burns, stroke, prolonged immobility, or Guillain-Barré syndrome. It is considered safe to administer succinylcholine within 24 hours (possibly up to 48-72 hours) of these conditions; however, as it takes time for upregulation of the receptors. It is harder to quantify the extent of immobility in a long-term intensive care patient; one study suggests that after 16 days of ICU stay, the risk for greater hyperkalemic response increases markedly.
References:
You have just intubated a patient for respiratory failure and will be initiating a sedation regimen.
Which of the following would be the LEAST preferred choice for sedation?
Correct Answer: A
The 2018 Society for Critical Care Medicine Clinical Practice Guidelines for management for pain and agitation/sedation recommend propofol or dexmedetomidine over benzodiazepines for sedation for shorter duration of mechanical ventilation. Benzodiazepine-based sedation regimens are strongly associated with ICU delirium and thus are the least preferred choice. The guidelines also recommend a protocol-based pain assessment for treating pain before assessing the need for sedation.
Which of these nonpharmacologic analgesic adjunct interventions are NOT suggested for routine use?
Correct Answer: E
The 2018 Society for Critical Care Medicine Clinical Practice guidelines for pain and agitation/sedation suggest using music, massage, cold therapy, and relaxation techniques as nonpharmacologic adjuncts for reducing pain but do not suggest offering hypnosis.
Which of the following medications is recommended to use as a sleep aid for ICU patients?
The 2018 Society for Critical Care Medicine Clinical Practice guidelines for pain and agitation/sedation, delirium, and sleep do not suggest using any medications for sleep. The guidelines state there is currently insufficient evidence to recommend any medications to promote sleep in critically ill patients. There is low-quality evidence to suggest melatonin is helpful for improving sleep in critically ill patients. Although melatonin has a low side effect profile, there is no recommendation for or against its use as the current evidence is of very low quality. The guidelines do not suggest using propofol solely to improve sleep. Dexmedetomidine increases stage 2 sleep in critically ill patients but has not demonstrated reduction in sleep fragmentation, or an increase in deep or REM sleep. So, the guidelines do not recommend dexmedetomidine to promote sleep.
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