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Pain Control and Sedation in Mechanically Ventilated Patients: Review - PulmCCM
  • Only intensivists have admitting privileges to the ICU.
  • ICU Staffing • LITFL Medical Blog • CCC Administration
  • The Letter to this article has been published in Critical Care The Letter to this article has been published in Critical Care Abstract Background Ventilator-dependent patients in the ICU often experience difficulties with one of the most basic human functions, namely communication, due to intubation.
  • These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus when deep sedation fails or is not tolerated.
  • Pain Control and Sedation in Mechanically Ventilated Patients: Review - PulmCCM
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  • Он преодолел уже столько препятствий, что мог позволить себе не обращать серьезного внимания на новые.

Untreated hypernatremia is an under-recognized and under-treated cause of agitation among intubated patients.

Too often it's treated with sedatives, rather than water.

The vast majority of hypernatremia in the ICU is due to inadequate administration of free water. A diagnostic workup usually isn't needed unless the patient has brain injury and there is concern for central diabetes insipidus. Hypernatremia should be treated by administration of free water preferably via the gut, or otherwise in the form of intravenous D5W.

Invasive Monitoring - Hemodynamics (Part 5)

Free water deficits are generally under-estimated. It's useful to calculate them e. Don't just arbitrarily give some random amount of water — calculate exactly how much water is required to achieve the desired drop in serum sodium.

If the sodium is creeping upwards, be pro-active in treatment of hypernatremia. If mild hypernatremia is ignored, it will generally get worse over time hypernatremia usually represents a free water deficit, which cannot improve on its own.

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For popular sites for making money on the Internet with simultaneous volume overload plus hypernatremia, both processes should be treated simultaneously: Furosemide plus high-dose thiazide may be used to promote sodium excretion natriuresis; discussed in the section above. Free water administration is provided to treat hypernatremia.

More on hypernatremia: see the full chapter here.


This doesn't require aggressive management or evaluation. However, patients with end-stage renal disease on chronic dialysis will simply need to be dialyzed. A maximally aggressive diuretic combination is the nephron bomb which consists of mg IV furosemide, mg IV chlorothiazide, and mg IV acetazolamide.

Fluid: The goal here is to bring the patient to a point of euvolemia and keep them there. For patients without metabolic acidosis, the preferred fluid is lactated ringers, plasmalyte, or normosol.

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Normal saline is contraindicated in hyperkalemia, because it will worsen it. More in the chapter on hyperkalemia here. When possible, potassium should be repleted via the gut.

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Administration of enteral potassium is easier, cheaper, and safer than IV potassium. It's hard to kill someone reviews about icyu option enteral potassium, whereas this isn't necessarily that difficult with IV potassium. Check the magnesium level and replete if necessary. Hypokalemia and hypomagnesemia often coexist. Hypomagnesemia will cause ongoing potassium wasting, so successful repletion of potassium may depend on fixing the magnesium as well.

Be very cautious about treating hypokalemia in patients with severe renal failure: The target potassium might be around Discontinue PRN potassium orders. Should be treated with IV magnesium sulfate oral magnesium causes diarrhea and is ineffective at improving serum magnesium levels. Patients with total body magnesium depletion e. This is an epiphenomenon of critical illness, which doesn't seem to actually cause harm with certain exceptions, most notably massive transfusion.

Treatment of mild hypocalcemia is generally ineffective and might actually be harmful. Overall, it's probably best not to check calcium levels, with the exception of admission labs or a specific reason to expect hypocalcemia e.

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Troponin should be checked only if there is a genuine clinical suspicion for myocardial infarction based on the EKG and clinical presentation.

When this occurs, we need to sort out what is causing the troponin elevation.


Using this definition, troponin elevation can be sorted into three categories: Non-MI troponin elevation These patients have troponin elevation without other features of MI they don't meet the definition of MI above. This is extremely common among critically ill patients and requires no specific treatment. Treatment should focus on management of the underlying disease.

Analgesia Treating Pain in Mechanically Ventilated Patients Adult patients in the intensive care unit ICU frequently experience pain, resulting from acute and chronic illness as well the positioning and interventions standard to ICU care. There are also many physiologic responses to acute pain that can impact patient care in the ICU, including tachycardia, hypertension, increased work of breathing, increased cortisol release, and increased risk of infection. Intravenous IV opioids are first line for non-neuropathic pain, and all IV opioids are equally efficacious in regards to treatment of pain. In practice, fentanyl is typically preferred as it does not have problematic metabolites and causes less hypotension than other agents. In contrast, morphine has metabolites that could potentially accumulate to a harmful level in renal or hepatic impairment.

There is no therapeutic benefit to ongoing cycling of the troponin in this situation. Most patients with type-I MI will initially present to the hospital with cardiac-related signs or symptoms. Type-I MI can arise as a complication of critical illness, but this is rare.

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Type-I MI should be treated with the typical treatment regimen generally associated with MI if possible e. However, the ability to provide such treatments is often limited by bleeding, hypotension, and acute kidney injury. Sorting out type-I vs. When in doubt, urgent echocardiography can be helpful.

The treatment for type-II MI focuses on treatment of the underlying disease e. Aspirin is reasonable, but otherwise these patients don't require specific treatment directed towards plaque stabilization.

However, initiating a heparin infusion is rarely wise here. Heparin is indicated only if reviews about icyu option of the following two conditions are met: 1 The patient has a type-I plaque-rupture MI. This can occur in patients who present with non-cardiac diagnoses, but it's uncommon.

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