GIẢM ĐAU , AN THẦN , GÂY TÊ TRONG HỒI SỨC NHI, Đ H Y DƯỢC TP HCM

bài giảng dành cho sinh viên y khoa, bác sĩ, sau đại học , ĐH Y DƯỢC TP HCM Depression of Conscious level by drugs to immobilize, reliev pain, anxioslysis tissue damage Madiators Tissue products Prostaglandins P Bradykinin Histamin Serotonin Cytokines Acetaminophen, ibu

ALNALGESIA, SEDATION AND

PARALYSIS

Definition

- Depression of Conscious level by drugs to immobilize, reliev pain, anxioslysis

Sedation: Current Issues

• anxiety and agitation

• awareness and recall

• post-traumatic stress disorder

• increased adverse events

• increased use of paralytics

Without a means to objectively titrate the level of sedation, patients may be:

Incidence of Inappropriate Sedation

Over-sedation

On Target Under-sedation

54%

15.4%

30.6%

Kaplan L and Bailey H Critical Care 2000; 4(1):S110.

Olson D et al NTI Proceedings 2003; CS82:196.

DEFINITIONS

- Step 1: tissue damage

- Step 2: transduction

- Local anesthetics: lidocain stop this step by inhibiting Nainflux and pain signal transduction.

- Step 3: transmission

- Release of neurotranmitters

(Subtance p NE glutamate)

to transmite pain signal.

 Opiate: inhibit release sub p

 Ketamine: bloc glutamate

 Alpha block: inhibit release of NE.

- Increase inhibitory neurotransmitters: BZD, Barbiturate increase GABA

- Step 4: perception

INDICATION FOR ANALGESIA AND

SEDATION

- Facilitate of MV

- Post of operation pain

- Invasive iatrogenic pain

- Trauma

- Agitation/anxiety

- Increased ICP

- imaging

- Escalate tocontinuous analgesia (fentanyl) and sedation (midazolam).

- Reassee mutiple time during the day Consider a dayly interruption of continuous infution once the child is in their recovery phase of illness Turn off sedation drip, when the child is able to folllow commends (open the eyes, squeeze hand, track with eyes), then restart infusion at 50% of the dose and tirate as needed.

- If the child requires significant escalation in opioid infution, consider swithching (fentanyl to morphin) with 50% equidose redution

Benzodiazepines

Adjust for Adjust for

- Low risk (infusion < 3 days): no wean or wean over 12hrs if high dose.

- Moderate (3-5 days): redution 50%, 4 hrs prior to extubation, then wean

by 20% qd-bid with goal of off drip 24-48 hrs.

- Moderate-high (5-9days): reduce infution by 25%, then wean 10-20% qd and consider a transition to oral replacement.

- High (> 9 days): reduce 20%, then 10% qd

Fails to weaning process

- Withdral include: CNS activation: irritability, tremors, clonus, frequent yawning, sneezing, dilirium, seizurez, halllucinations, GI disturbances, sympathetic hyperactivity

- BZD: increase anxiety, fear, dread, panic, extreme agitation, delirium, nause, myoclonus, tach, hypertetion, tachypnea, refractory seizures.

What do we do?

- Weaning process should be halted or altered.

- Contineu dose at which the child was stable for at least 24 hrs.

- Restart slower wean.

- Alternatively, rescue dse of a short acting opioid or benzo

Trân trọng cảm ơn