Analgesia/Sedation


Acetaminophen

Rapid Review

  • Mechanism of Action: Antipyretic/Analgesic. Inhibits prostaglandin synthesis on CNS and has direct action on hypothalamic heat-regulating systems.
  • Indications: Mild-moderate pain; fever
  • Contraindications: Allergy to class/drug
  • Dosage: 1000 mg PO q4-6 hours
  • Onset: 15-30 minutes PO for analgesia. 30 minutes for antipyretic
  • Duration: 4-6 hours
  • Adverse Reactions: Nausea, rash, and headache are common. 
  • Special Considerations: Doses above 4 grams/day may cause liver toxicity

Pearls

Video Credit: Simply Nursing


Diazepam

Rapid Review

  • Mechanism of Action: Benzodiazepine; enhances inhibitory effects of GABA receptors
  • Indications: Seizure abortion, agitation, alcohol withdrawal, muscle spasm
  • Contraindications: Allergy to drug/class, severe hepatic impairment
  • Dosage: Generally 2-10 mg PO/IV/IM q 6 hrs prn
  • Onset: 1-3 minutes (IV), 15-60 minutes (PO)
  • Duration: 12 hours
  • Adverse Reactions: Respiratory depression, sedation, hypotension, 
  • Special Considerations: Pregnancy category D

Pearls

Deep Dive

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Etomidate

Rapid Review

  • Mechanism of Action: Ultrashort-acting non-barbiturate hypnotic. Exhibits GABA-like effects on brain stem reticular formation.
  • Indications: RSI induction
  • Contraindications: Allergy to drug/class
  • Dosage: 0.3mg/kg IV
  • Onset: 30-60 seconds
  • Duration: 3-5 minutes
  • Adverse Reactions: Adrenal suppression, lowers seizure threshold
  • Special Considerations: Etomidate does not provide any analgesic effect.
  • Etomidate is a commonly used sedative agent used for induction for intubation. It has a rapid onset with little effect of hemodynamics, making it a valuable agent especially in critically ill or hypotensive patients.

Pearls

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Fentanyl

Rapid Review

  • Mechanism of Action: Narcotic opiate analgesic; binds to opiate receptors and blocks ascending pain pathways.
  • Indications: Moderate-severe pain, adjunct to sedation
  • Contraindications: Allergy to class/drug, respiratory depression, paralytic ileus
  • Dosage: Generally 1-2 mcg/kg IV/IM q30-60 minutes prn
  • Onset: 1-2 minutes (IV)
  • Duration: 2-4 hours
  • Adverse Reactions: Apnea, confusion, constipation, nausea/vomiting
  • Special Considerations: None

Pearls

Video Credit: Nurse Ryan


Hydromorphone

Rapid Review

  • Mechanism of Action: Opioid agonist; pure opioid that binds to several opioid receptors, acting on the mu-opioid receptors to produce analgesia and sedative effects
  • Indications: Moderate-severe pain
  • Contraindications:  Hypersensitivity, respiratory depression, GI obstruction/ileus, hypotension
  • Dosage: 1-2 mg IV q 3-6 hours
  • Onset: <5 minutes (IV),  15-30 minutes (PO)
  • Duration: 2-3 hours (IV), 3-4 hours (PO)
  • Adverse Reactions: Hypotension, respiratory depression, pruritus, nausea/vomiting
  • Special Considerations: 1 mg of IV Dilaudid equals approximately 7 mg of morphine

Pearls

Video Credit: Drug Talk


Ibuprofen

Rapid Review

  • Mechanism of Action: NSAID; inhibits OX-1 and COX-2 enzymes to decrease expression of prostaglandin precursors, thus producing analgesic, antipyretic, and anti-inflammatory effects.
  • Indications: Mild-moderate pain, fever, 
  • Contraindications: Known hypersensitivity, active bleeding
  • Dosage: Generally 800 mg PO q8 hours
  • Onset: 30 minutes
  • Duration: 6 hours
  • Adverse Reactions: GI bleeding, nephrotoxicity, SJS, dyspepsia, nausea, dizziness
  • Special Considerations: None

Pearls

Video Credit: Medical Videos


Ketamine

Rapid Review

  • Mechanism of Action: NMDA receptor antagonist; dissociative anesthetic; analgesic/sedative; 
  • Indications: Analgesia, sedation, RSI induction
  • Contraindications: Allergy to drug/class
  • Dosage:
    • Analgesic dose: 0.1-0.5 mg/kg IV
    • Procedural sedation dose: 0.5-1 mg/kg IV 
    • RSI induction: 2 mg/kg IV
    • Combative patient: 4-6 mg/kg IM or 1 mg/kg IV
  • Onset: Less than 1 minute (IV); 4 minutes (IM)
  • Duration: 5-15 minutes (IV); 15-30 minutes (IM)
  • Adverse Reactions: Laryngospasm, apnea, hypersalivation
  • Special Considerations: Does not affect respiratory drive, making it useful for awake or fiberoptic intubations. Ketamine is first line as an induction agent for intubations in asthmatic patients due to it’s bronchodilatory effects.

Pearls

Video Credit: MedSchool Medic


Lorazepam

Rapid Review

  • Mechanism of Action: Benzodiazepine; enhances inhibitory effects at GABA receptors. 
  • Indications: Seizures, agitation, delirium tremens, serotonin syndrome.
  • Contraindications:
  • Dosage: 1-2 mg IV bolus; 1-10 mg/hr infusion
  • Onset: 5 minutes (IV); 15-30 minutes (IM)
  • Duration: 6-8 hours
  • Adverse Reactions: Respiratory depression, hypotension, ataxia
  • Special Considerations: None

Pearls

Video Credit: Nurse Ryan


Midazolam

Rapid Review

  • Mechanism of Action: Benzodiazepine; occupies GABA receptors to cause membrane hyperpolarization and neuronal inhibition. Produces sedation, anxiolysis, anterograde amnesia, and anticonvulsant effects.
  • Indications: Acute seizure, procedural sedation, agitation, RSI induction (not first line)
  • Contraindications: Hypersensitivity, hypotension, acute angle-closure glaucoma
  • Dosage:
    • Agitation: 1-5 mg IV/IM
    • Procedural sedation: 0.05 mg/kg IV
    • Seizure: 10 mg IV/IM
  • Onset: 1-7 minutes (IV)
  • Duration: < 2 hours
  • Adverse Reactions: Respiratory depression, hypotension, drowsiness, nausea/vomiting
  • Special Considerations: Also available intranasally

Pearls

Deep Dive

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Morphine

Rapid Review

  • Mechanism of Action: Opiate analgesic; binds to opioid receptors in the CNS to inhibit ascending pain pathways. Alters patient’s perception and response to pain.
  • Indications: Acute moderate-severe pain
  • Contraindications: Allergy to drug/class, severe asthma, paralytic ileus
  • Dosage: 0.1 mg/kg bolus (IV)
  • Onset: 5 minutes, peak at 20 minutes
  • Duration: 4-5 hours
  • Adverse Reactions: Respiratory depression, hypotension, nausea/vomiting, urticaria, dependence
  • Special Considerations: None

Pearls

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Propofol

Rapid Review

  • Mechanism of Action: General anesthetic; Short acting, lipophilic sedative/hypnotic agent that causes global CNS depression, presumably through agonist activity on GABAa receptors and sodium channel blockade.
  • Indications: Procedural sedation, status epilepticus
  • Contraindications: Hypersensitivity, severe hypotension
  • Dosage:
    • Procedural sedation: 1 mg/kg IV bolus, then 0.5 mg/kg q3 minutes
    • RSI induction: 1.5 mg/kg IV bolus
    • Ventilator sedation: 5-50 mcg/kg/min IV, increase 5 mcg/kg/min q10 minutes prn
  • Onset: 30-45 seconds
  • Duration: 3-10 minutes
  • Adverse Reactions: Paint at injection site, hypotension, myoclonus, propofol infusion syndrome (PRIS)
  • Special Considerations: None

Pearls

Deep Dive

Video Credit: ICU Advantage


Brandon Simpson, PA-C
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