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レジデントノート

米国にて内科修行中。何ができるか模索している過程を記録していく

鎮静・鎮痛 (ICU)

<鎮痛>

Mild pain (pain score 1-3)

- Fentanyl 25mcg IV q2h prn

- Hydromorphone 0.25mg IV q4h prn

- Morphine 2mg IV q2h prn

- Ketorolac 15mg IV q6h prn

 

Moderate pain (pain score 4-6)

- Fentanyl 50mcg IV q2h prn

- Hydromorphone 0.5mg IV q4h prn

- Morphine 4mg IV q2h prn

- Ketorolac 15mg IV q6h sch 

 

Severe pain (pain score 7-10)

- Fentanyl 75mcg IV q2h prn

- Hydromorphone 1mg IV q4h prn

- Morphine 6mg IV q2h prn

 

[Continuous infusion for analgesia]

Fentanyl 2500mcg/NS 200ml

Start at 25 mcg/hr; titrate by 10 mcg/hr q5 min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 200 mcg/hr

(Adjust in opioid tolerant patients. No max when used for comfort measures)

 

Morphine 100mg/NS 90ml

Start at 1 mg/hr; titrate by 1mg/hr q5min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 20 mg/hr.

(Adjust in opioid tolerant patients. No max when used for comfort measures)

 

Hydromorphone 50mg/NS 50ml

Start at 0.2 mg/hr; titrate by 0.2 mg/hr q30 min to Pain Score 3/10

or GOAL RASS Score 0 to -1; to a maximum of 2 mg/hr

(No max when used for comfort measures)

 

 

<鎮静>

Propofol 1000mg/100ml

Start at 5 mcg/kg/min; titrate by 5 mcg/kg/min q 10 min

to GOAL RASS Score 0 to -1; to a maximum of 70 mcg/kg/min

 

Dexmedetomidine 200mcg/NS 50ml

Loading dose of 1 mcg/kg over 10 min

THEN Start at 0.2 mcg/kg/hr; titrate by 0.1 mcg/kg/hr q30 min to GOAL RASS Score 0 to -1; to a maximum 1.4 mcg/kg/hr as tolerated.

 

Midazolam 100mg/NS 80ml

Start at 1 mg/hr titrate by 1 mg/hr q5 min to GOAL RASS Score 0 to -1; to a maximum of 10 mg/hr

 

[Neuromuscular blocker]

Cisatracurium 200mg/NS 200ml

Loading dose 0.15 mg/kg = [        ]mg

Start at 3 mcg/kg/min; titrate by 0.5 mcg/kg/min q 20 min

to a maximum of 10 mcg/kg/min to a train of four (TOF) 

of at least 1-2/4 to maintain ventilator synchrony

 

 

<Delirium> 

- Quetiapine 25mg PO q8h sch

- Haloperidol lactate 2mg IV q8h sch

(HOLD if QTC greater than 25% increase from baseline QTC or absolute corrected QT of 0.48)

- Dexmedetomidine iv (the same protocol above)

(dexmedetomidine is the sedation medication of choice in hemodynamically stable patient with significant delirium)

 

(米国一施設基準)