Avoiding versed?

Wile E Coyote, ASN, RN · Oct 14, 2016

For MAC primarily or for all your cases?

I'd love to transition away from our go-to Fent/Versed combo for vent sedation in our ICU for the same reasons. As you know, I'll have lots of data to back up my appeal.

allnurses Guide · Oct 14, 2016

I have been using versed less than I used to. We have been avoiding preoperative sedation for PNBs too. I mainly now use versed for patients that are extremely anxious. It does seem to help with quicker return of cognitive function, especially when paired with multimodal pain relief such as PNB and reduction of VAs and opioids.

Postoperative Cognitive Dysfunction

offlabel · Oct 14, 2016

I have been using versed less than I used to. We have been avoiding preoperative sedation for PNBs too. I mainly now use versed for patients that are extremely anxious. It does seem to help with quicker return of cognitive function, especially when paired with multimodal pain relief such as PNB and reduction of VAs and opioids.
Postoperative Cognitive Dysfunction

Me too...Most of my patients need an a line for induction, so I do use some fentanyl for sedation for that. Also, the nature of the cases that I do is pretty anxiogenic, so I pretty much give something to every one. For a while, when I asked the patient if they were anxious enough to need something before we went back and they said "no", I'd take their word for it and not give anything until I was ready for induction. Then I realized that almost without fail, the first blood pressures in the room with these folks would be north of 180/95. That is in a population that is nearly 100% on a beta blocker.

I will confess, I've had to change my bedside manner a little bit as well as instructing the room to do so as these patients will remember everything up to going to sleep. That was kind of an adjustment, I'm not proud to say. I've also noticed that with just giving fentanyl without versed causes a little more nausea with these folks and I need to "feather" it in with a little more finesse.

In the end, though, it is absolutely worth it.

Khaan · Oct 22, 2016

I've been backing way off of versed for most patients over 50-55 years old. I'm finding that they wake up far more quickly and are more "clear". Other advantages too....
Anyone else?

Versed just sucks for older individuals period. If they aren't anxious after a good bedside talk, why not?

trytounderstand · Jan 15, 2018

I am not a nurse but I can tell you that there are patients who hesitate even going to a doctor or having a procedure done because of losing control to strangers. As far as having to change your behavior or how you are handling patients should never happen. You are professionals and you should always be professionals whether the patient is awake or not. No one should ever be laying on a table helpless and have someone walk into a room and watch a highly personal procedure done and watch a procedure being done whether they are sedated or not. After my experiences and watching providers not respect me and other patients I can only imagine what some do when you are sedated. A patient should always be told what a drug will go to them and make an informed decision and if these drugs are being administered to shut a patient up it is morally wrong. I also understand there are many cases where these drugs are necessary for proper care in the case of patients who are in extreme pain burn patients dementia patients

I have also been told by nurses with a giggle and a wink that as soon as male patients are under they lift their gown to see what they have. Lost total respect for them.

trytounderstand · Jan 15, 2018

If the patient has said no it is no!

allnurses Guide · Jan 15, 2018

I am not a nurse but I can tell you that there are patients who hesitate even going to a doctor or having a procedure done because of losing control to strangers. As far as having to change your behavior or how you are handling patients should never happen. You are professionals and you should always be professionals whether the patient is awake or not. No one should ever be laying on a table helpless and have someone walk into a room and watch a highly personal procedure done and watch a procedure being done whether they are sedated or not. After my experiences and watching providers not respect me and other patients I can only imagine what some do when you are sedated. A patient should always be told what a drug will go to them and make an informed decision and if these drugs are being administered to shut a patient up it is morally wrong. I also understand there are many cases where these drugs are necessary for proper care in the case of patients who are in extreme pain burn patients dementia patients
I have also been told by nurses with a giggle and a wink that as soon as male patients are under they lift their gown to see what they have. Lost total respect for them.

I understand what you are saying, and if a patient specifically asks that a certain drug not be used, like versed, then I generally won't use it, if I feel that drug is needed then I will tell them it's either I use that drug or I don't do the anesthesia. It has never got to that point though. I have had to convince some patients that they couldn't have general anesthesia because of the risk d/t their health and it not being necessary for the procedure.

I know things happen that are less than ideal when patients are sedated/under general anesthesia, but it's up to everyone in the OR to put a stop to it. Where I have worked disrespecting patients and unnecessary exposing patients are all grounds for termination. I cannot speak for other areas of the hospital, but in the OR we see people without clothes all the time. Seeing someone nude loses its uniqueness after working in the OR for even a short time.

It's unlikely that other than the medications we give preoperatively that we sit and tell patients every medication we are going to give. This isn't meant to be deceptive. It is just the simple fact most people wouldn't understand what we are giving even if we told them. I've had patients ask what all I was going to give them occasionally, and I will tell them what meds and why I'm giving those medications, but still it's unlikely that most patients really understand each medication.

Versed is anxiolytic. It decreases anxiety and also effects short-term memory. This is something that many patients want and beneficial to helping patients relax. Versed also has synergistic reactions with other medications allowing us to use smaller doses of each to get the desired effect.

trytounderstand · Jan 15, 2018

I have seen nurses totally disregard patient dignity even when they are awake. Actually had it happen to me. I can imagine what happens when you are asleep. Until the last few years I did not even consider this. I just have a problem when a patient is told this will help you relax but not told the effects and then walkinto their room during visiting hours only to find them partially exposed from the waist down and they don't even realize it. So did they lay like all night exposed to housekeepers janitors it people other visitors who may have walked into their room by mistake. Totally wrong. Or someone walking into a surgery during a very personal procedure that has no business being there. Makes me not want to spend a night in a hospital. I have also has these drugs such as Valium when I was just sitting in my bed for observation no problem with blood pressure. Why should I have to take something that might cause amnesia or compliance when I was sitting there calmly watching tv waiting for morning to be released. Nurse/doctor convenience? Make the patient sleep so we won't have to deal with them. But whether it is in or or on the floor a patient should never be exposed unnecessarily just for nurse/doctor convenience. Would you want to be treated in that manner? Or your mother father daughter son. I know after a while it is just part of the job but sedating a person so you can disregard their privacy and dignity is wrong. I do not want my short term memory affected and all the after affects of nightmares. I want to know what is going on and be in control of what someone is doing to me. For some patients it is devastating and degrading. Actually probably much more than any patient will admit because it is just expected by some in healthcare they the patient should just suck it up. So what if you were exposed or made fun of you survived didn't you? Had a similar comment made to me by a patient advocate. Just has done bad personal experiences that have made me distrustful and ready to question any medical professional.

Bluebolt · Jan 15, 2018

Anybody used 15mg of Ketamine and 2mg of Versed mixed together right before you go back? I worked with a CRNA who called it her ketamine kiss. I gave it to my patients when working under her and it seemed to help knock out the anxiety for sure. In fact, they were kind of tripping (but pleasantly) as we moved from bed to OR table. I found that after induction I usually didn't see as much of a drop in BP as well.

As an SRNA I'm always asking if they want Fent/Versed before we go back but I'm frequently being told no. I'd say it's more common to give them no Versed at all and only 50 mcg of Fent on induction, they roll back to the OR natural.

Offlabel, hold their hand, start pushing your drugs and tell them you're giving them your ketamine kiss, pet their hair and I guarantee you'll get an A+ on bedside manner.

allnurses Guide · Jan 15, 2018

I have seen nurses totally disregard patient dignity even when they are awake. Actually had it happen to me. I can imagine what happens when you are asleep. Until the last few years I did not even consider this. I just have a problem when a patient is told this will help you relax but not told the effects and then walkinto their room during visiting hours only to find them partially exposed from the waist down and they don't even realize it. So did they lay like all night exposed to housekeepers janitors it people other visitors who may have walked into their room by mistake. Totally wrong. Or someone walking into a surgery during a very personal procedure that has no business being there. Makes me not want to spend a night in a hospital. I have also has these drugs such as Valium when I was just sitting in my bed for observation no problem with blood pressure. Why should I have to take something that might cause amnesia or compliance when I was sitting there calmly watching tv waiting for morning to be released. Nurse/doctor convenience? Make the patient sleep so we won't have to deal with them. But whether it is in or or on the floor a patient should never be exposed unnecessarily just for nurse/doctor convenience. Would you want to be treated in that manner? Or your mother father daughter son. I know after a while it is just part of the job but sedating a person so you can disregard their privacy and dignity is wrong. I do not want my short term memory affected and all the after affects of nightmares. I want to know what is going on and be in control of what someone is doing to me. For some patients it is devastating and degrading. Actually probably much more than any patient will admit because it is just expected by some in healthcare they the patient should just suck it up. So what if you were exposed or made fun of you survived didn't you? Had a similar comment made to me by a patient advocate. Just has done bad personal experiences that have made me distrustful and ready to question any medical professional.

You should talk to your Anesthesia provider the next time you have a procedure, but this isn't the thread to discuss this.

allnurses Guide · Jan 15, 2018

Anybody used 15mg of Ketamine and 2mg of Versed mixed together right before you go back? I worked with a CRNA who called it her ketamine kiss. I gave it to my patients when working under her and it seemed to help knock out the anxiety for sure. In fact, they were kind of tripping (but pleasantly) as we moved from bed to OR table. I found that after induction I usually didn't see as much of a drop in BP as well.
As an SRNA I'm always asking if they want Fent/Versed before we go back but I'm frequently being told no. I'd say it's more common to give them no Versed at all and only 50 mcg of Fent on induction, they roll back to the OR natural.
Offlabel, hold their hand, start pushing your drugs and tell them you're giving them your ketamine kiss, pet their hair and I guarantee you'll get an A+ on bedside manner.

Ketamine can cause sexual dreams. You don't want to give the patient any reason to think you might be taking advantage of them d/t sexual associations with ketamine induced dreams. This happened to a coworker doing a MAC case using ketamine for a breast biopsy. The patient had a dream that the anesthesia provider was fondling her breasts during the surgery even though it would have been impossible to do during the surgery without the surgical team knowing. The anesthesia provider had to go through two rounds of investigations, which they were cleared both times, because the patient was so adamant about it. The anesthesia provide wasn't allowed to do patient care for months. Just something to think about..

That being said I had an opioid free anesthethetic done on me last month for my surgery. I didn't receive versed but I did get precedex and ketamine up front. The ketamine relaxed me, but it also made me dizzy every time I turned my head prior to going to sleep.