are common but undesirable because their adverse effects include ileus, delayed extubation, tolerance, and opioid‐induced hyperalgesia. Narcotics also place patients at risk for withdrawal. For most patients, especially those you plan to extubate soon or those at risk for complications, narcotic infusions are not the first choice. A stepwise approach including multimodal analgesia with acetaminophen, intermittently dosed narcotics and ketamine (0.5 mg/kg IVP × 1 followed by 1–2 mcg/kg/min infusion) is recommended. The goal is to minimize opioid therapy when managing postsurgical adult patients in the ICU (conditional recommendation, very low quality of evidence) and ketamine can be used as an IV adjunct. Gabapentin is also available as part of stepwise approach. Acetaminophen and pain‐dose ketamine infusions are excellent analgesics and can be added to an intermittently dosed narcotic plan as needed, making choice B the best answer. Choices A, C, and D are also incorrect because they rely on opioid infusions and do not represent the best stepwise approach. It is especially important to avoid continuous narcotic infusions in patients at high risk for opioid toxicity, such as those with sleep apnea or at patients at risk for ileus. Although dexmedetomidine (Precedex) has some pain effects as an alpha 2 agonist, its primary effect is sedation and would not be the best choice for pain in combination with propofol. The patient is calm and does not need two sedative agents, so choice (E) is also incorrect.Answer: BDevlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825–73.4 A 67‐year‐old woman is in the ICU on postoperative day 2 after laparotomy. Current medications include clonidine, quetiapine, hydromorphone, melatonin, and metoprolol. Her sleep pattern is altered and she shows signs of agitated delirium. Which of her medications increases her risk for aspiration?ClonidineDexmedetomidine (Precedex)Quetiapine (Seroquel)Hydromorphone (Dilaudid)Melatonin (N‐acetyl‐5‐hydroxytryptamine)Antipsychotic medications such as haloperidol and quetiapine are used to manage delirium. These medications can increase the QTC interval but also antagonize dopamine signaling, which affects the swallow mechanism and increases the risk of aspiration. Therefore, choice C is correct.Both clonidine (choice A) and dexmedetomidine (choice B) are useful adjuncts in pain management because of their effects at central α2 receptors. Clonidine blocks sympathetic outflow, reduces arterial blood pressure, and ameliorates symptoms of alcohol and opiate withdrawal but does not increase aspiration risk. When used in epidural pain catheters, clonidine produces analgesia at the presynaptic and post junctional alpha 2 receptors. Dexmedetomidine (Precedex) produces centrally mediated sympatholytic sedation, anxiolysis, and analgesia. A transient increase in blood pressure during the loading dose of dexmedetomidine may occur, followed by hypotension which may be concerning for patients needing strict blood pressure control. A valuable characteristic of dexmedetomidine is the ability to produce sedation without respiratory depression. In some critically ill patients, night time sleep patterns are enhanced when patients are lightly sedated with dexmedetomidine. When compared to GABA agonists, dexmedetomidine resembles natural non‐REM‐type sleep.Postsynaptic activation of α2 receptors inhibits sympathetic activity, decreasing blood pressure and heart rate, having no effect on dopamine receptors or aspiration. According to the FDA, dexmedetomidine is indicated for initial sedation for the first 24 hours. Although not contraindicated, prolonged use of dexmedetomidine can lead to withdrawal effects like rebound hypertension, especially in higher doses. Hydromorphone (choice D) is an opioid receptor agonist used for severe pain. Hydromorphone is about 8–9 times more potent than morphine. Side effects of hydromorphone are pruritus, sedation, constipation, nausea, and vomiting. Adverse effects are more pronounced with excessive dosages and include respiratory and cardiovascular depression, dependency, and ileus. An overdose of hydromorphone resulting in loss of consciousness could result in aspiration, but it does not contribute to aspiration in usual therapeutic doses.Melatonin (N‐acetyl‐5‐hydroxytryptamine) is a mild hypnotic and generally well tolerated and regarded as safe with few adverse effects. It is synthesized in the pineal gland and its release helps regulate sleep and circadian rhythms. The anterior hypothalamus regulates melatonin which has its effects at MT2 and MT1 receptors. Melatonin (M) receptors are ubiquitous, found in the brain, retina, throughout the cardiovascular system, in the liver, gallbladder, colon, and skin. The MT1 receptor agonism is related to sleep onset. The most frequently reported adverse effects are daytime sleepiness, headache, dizziness, and hypothermia. Aspiration is not among reported adverse effects of melatonin, so choice E is incorrect.Answer: CAlexopoulou C, Kondili E, Diamantaki E, Psarologakis C, Kokkini S, Bolaki M, Georgopoulos D . Effects of dexmedetomidine on sleep quality in critically ill patients: a pilot study. Anesthesiology. 2014; 121(4):801–7.Besag FMC, Vasey MJ, Lao KSJ, Wong ICK . Adverse events associated with melatonin for the treatment of primary or secondary sleep disorders: a systematic review. CNS Drugs 2019; 33(12):1167–86.Herzig SJ, LaSalvia MT, Naidus E, Rothberg MB, Zhou W, Gurwitz JH, Marcantonio ER. Antipsychotics and the risk of aspiration pneumonia in individuals hospitalized for nonpsychiatric conditions: a cohort study. J Am Geriatr Soc 2017; 65(12):2580–6.DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care. 2015; 30(1): 40–8.Longnecker D ; Brown DL, Newman MF, Zapol W. Anesthesiology , Second Edition. New York: McGraw‐Hill Professional; 2012. 1748 p. p.
5 Which commonly prescribed medications in the intensive care unit is most likely to cause an unstable arrhythmia and sudden death?Fentanyl, opioid analgesicMeperidine (Demerol), opioid analgesicHaloperidol (Haldol), typical antipsychoticDexmedetomidine (Precedex), alpha 2 agonistPropofol, short‐acting lipophilic intravenous general anestheticHaldol (choice C) has a proven association with torsade de pointe and sudden death. Prolonged QT intervals can be congenital or acquired as in a patient receiving haldol, methadone, atypical antipsychotics, or antidepressants. Long QT associated with polymorphic ventricular tachycardia (PMVT) is called torsade de pointes. Factors that increase the QT and risk for torsades are rapid administration of QT prolonging drugs, coexisting myocardial ischemia, older age, recent dysrhythmia, hypomagnesemia, or hypokalemia. The first‐line treatment of acquired QT prolongation with torsade de pointes is 2–4 gm intravenous magnesium followed by infusion 1 gm/h, replacement of potassium if needed, cardioversion or isoproterenol for bradycardia or pauses. PMVT without long QT can also be seen in acute coronary syndromes.Fentanyl infusions typically in the range of 50–200 mcg/h are used for sedation and pain control. Adverse effects of fentanyl include tolerance, constipation, hyperalgesia, and dependence. Fentanyl can cause hypotension; however, it is not associated with life‐threatening arrhythmias (choice A). Similarly, meperidine (Demerol) is an opioid analgesic. Adverse effects of meperidine include respiratory and circulatory depression, lightheadedness, constipation, nausea, vomiting, and dependence. Meperidine does not have a known association with life‐threatening arrhythmias (choice B).Common side effects of the sedative‐anxiolytic dexmedetomidine (Precedex) are sinus bradycardia and hypotension. Dexmedetomidine also provides some analgesic effects. It is a centrally acting sympatholytic alpha 2 agonist but it does not prolong the QT interval (choice D).Propofol (choice E) is a hypnotic agent for induction of anesthesia or for sedation. It produces sedation through GABA potentiation. Some of the more serious adverse effects or propofol are hypotension from reduced systemic vascular resistance or direct myocardial depression and propofol infusion syndrome (PRIS). PRIS is a metabolic derangement manifested by metabolic acidosis, renal injury, and rhabdomyolysis. However, propofol is not usually associated with life‐threatening arrhythmias or sudden death.Answer: CRay WA, Chung CP, Murray KT, Hall K, Stein CM. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med. 2009; 360(3):225–35.Huffman JC, Stern TA. QTc prolongation and the use of antipsychotics: a case discussion. Prim Care Companion J Clin Psychiatry. 2003; 5(6):278–81.Milbrandt EB, Kersten A, Kong L, Weissfeld LA, Clermont G, Fink MP, Angus DC. Haloperidol use is associated with lower hospital mortality in mechanically ventilated patients. Crit Care Med. 2005; 33(1):226–9; discussion 263‐5.Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA,
