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PulmCrit- Reengineering the analgesic ladder for critically ill patients

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We all want to alleviate pain and suffering. Most critically ill patients are treated with opioids for this reason. Unfortunately, opioids have numerous side-effects including delirium, constipation, vomiting, and delayed extubation. Opioid infusions may eventually lead to withdrawal, causing pain, nausea, and depression. This post explores the optimal use of systemic medications to control pain while minimizing complications.

EMCrit 26 – Patient Controlled Analgesia by Edward Gentile

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Even when we can’t cure a patient, we can relieve suffering. On average, we kind of stink at pain control in the ED. One physician, Dr. Ed Gentile, has created a simple path to optimal acute pain control in the ED. I heard this lecture on the EM:RAP podcast and got permission from Drs. Gentile and Herbert to repost it here. This is not a critical care topic per se, but it is applicable to the critically ill, the non-critically ill–basically any patient who is in pain in the ED.

Analgesia and sedation for the critically ill patient

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CONTENTS spectrum of medications available Pure analgesics Acetaminophen Ketamine, pain-dose ➡️ Methocarbamol (Lidocaine) (NSAIDs) Analgosedatives (analgesia > sedation) Opioids Opioid PCA Gabapentinoids Tizanidine Sedalgesics (sedation > analgesia) Dexmedetomidine Clonidine Ketamine, high-dose infusion ➡️ Pure sedatives  Propofol ➡️ Guanfacine Phenobarbital ➡️ Melatonin (Benzodiazepines) (Hydroxyzine) Antipsychotics / anti-agitation Butyrophenones (haloperidol & droperidol) ➡️ Olanzapine ➡️ Quetiapine ➡️ […]

Buprenorphine & opioid use disorder

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CONTENTS Rapid Reference 🚀 All hands on deck Buprenorphine basics Buprenorphine induction Acute pain in a patient on chronic buprenorphine Podcast Questions & discussion Pitfalls Between 1999-2017, ~400,000 people died from opioid overdose. That’s over half the number of Americans who have ever died from HIV. It is increasingly clear that opioid use disorder (OUD) […]

PulmCrit- Alpha-2 agonists: clonidine, guanfacine, lofexidine, and KetaDex

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Dexmedetomidine is an intravenous alpha-2 agonist used as a sedative infusion.  It has some uniquely useful properties, particularly that it doesn’t suppress respiration (allowing it to be safely used in non-intubated patients).  The main drawbacks of dexmedetomidine are logistic:  it is expensive and can be administered only as an IV infusion within an ED or ICU.  Oral clonidine offers some similar benefits compared to dexmedetomidine, without these logistic constraints.

Acute Pancreatitis (including hypertriglyceridemic pancreatitis)

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CONTENTS Rapid Reference 🚀 Diagnosis Clinical findings Laboratory studies (lipase) Radiology Diagnostic criteria Evaluating the cause of pancreatitis Risk stratification – who needs ICU? Treatment General principle: pancreatoseptic equivalence Treatment of causative factors ERCP? Resuscitation Analgesia Nutrition Non-hypertriglyceridemic pancreatitis Hypertriglyceridemic pancreatitis Prophylactic & early antibiotics Fluid collections & infected necrosis Abdominal compartment syndrome Hemorrhage Hypertriglyceridemic […]

Neurological examination & neuroanatomy

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CONTENTS Rapid Reference 🚀 Neurological examination Global function & mental status Level of consciousness Motor responses to pain Breathing patterns Aphasia Cranial nerves CN2,3 – Pupillary abnormalities Approach to anisocoria Unilateral pupillary abnormalities Horner’s syndrome Bilateral pupillary abnormalities CN3,4,6 – Extraocular movements CN3-Oculomotor nerve CN6-Abducens nerve Testing of horizontal gaze abnormalities Specific abnormalities of horizontal […]

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