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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 Without a means to objectively titrate the level of sedation, patients may be: Over-sedated Under-sedated • increased drug costs • delayed weaning • increased ICU length of stay • increased testing • anxiety and agitation • awareness and recall • post-traumatic stress disorder • increased adverse events • increased use of paralytics Incidence of Inappropriate Sedation Olson D et al 2003 Kaplan L and Bailey H 2000 15.4% 20% 10% 30.6% 54% 70% Over-sedation On Target Under-sedation 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 Madiators Tissue products • Prostaglandins • P • Bradykinin • Histamin • Serotonin • Cytokines • Acetaminophen, ibu - 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: sub p inhibit release Ketamine: glutamate Alpha block: release of NE bloc inhibit - Increase inhibitory neurotransmitters: BZD, Barbiturate increase GABA Paralytics Drug Succinylcholine Pancuronium Vecuronium Atracurium Rocuronium Tubocurare Adjust for Adjust for Onset Duration Route of elimination renal liver 1-1.5 5-10 acetylcholinesterase No Yes 1.5-2 60 85% kidney Yes Yes 1.5 30 biliary, liver, kidney No Yes 30 Plasma (Hoffman) No No 30-60 Hepatic No Yes 80 90% kidney Yes Yes wean - Low risk (infusion < days): no wean or wean over 12hrs if high dose - Moderate (3-5 days): redution 50%, 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 (> 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 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 ... 4(1):S110 Olson D et al NTI Proceedings 2003; CS82:196 DEFINITIONS - Step 1: tissue damage Madiators Tissue products • Prostaglandins • P • Bradykinin • Histamin • Serotonin • Cytokines • Acetaminophen,... ANALGESIA AND SEDATION - Facilitate of MV - Post of operation pain - Invasive iatrogenic pain - Trauma - Agitation/anxiety - Increased ICP - imaging Strategies - Consider intermitter (q2-3) sedation. .. 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: