Vent management and sedation/pain management

  1. Another thread sparked me to write this:

    Where I'm at our vent management essentially is putting propofol on every person through our door on a vent. Getting pain management can be like pulling teeth (I recently had a pulmonologist give me 1 mg morphine q6hr prn.. I laughed).

    Does anyone remember how their unit went about changing practice to reflect the "analgesia first" guidelines? I think our problem is vent management is scattered throughout the various pulmonology groups and we don't have a medical director or an intensive care committee to look at and disseminate best practices.

    Basically I need help modernizing my unit before I go crazy.
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  2. 10 Comments

  3. by   offlabel
    Depending on your Diprivan dose, that can be "pain control". What kind of patients are we talking about here and what kind of pain do they have?
  4. by   MaxAttack
    Mixed med/surg population. I'm not referring to a specific patient or condition, but to the idea that intubated patients should have any pain managed as a possible cause of agitation before sedation is started.
  5. by   core0
    We used the PAD guidelines did extensive education before we went live. That included provider education and nursing education. It went surprisingly well and quickly became part of the culture. It helped that we had early buy in from our nurse manager and CNS. It also helped that our medical director was behind it. Now, when a resident orders propofol on a vented patient, the nurse reminds them that we treat pain first.

    http://www.learnicu.org/SiteCollecti...20Delirium.pdf
  6. by   delphine22
    So you're saying that if you have an awake pt that's intubated, and they're agitated, it's because they could be in pain, and they should get pain management first before being sedated?

    Have you personally ever been orally intubated??

    It's one of the most terrifying experiences that can ever happen to a person. If it were me, I wouldn't want to know a single thing until the minute they're going to pull the tube out. And I'd want a boatload of anxiolytics before they start SBTs.

    Yes, people with chronic pain and narcotic dependence should have that continued even while sedated. And trauma pts obviously should have their pain addressed in addition to their sedation.

    But IMO if they have an artificial airway and they're on the vent, knock em the hell out. (Preferably with something easily reversible so you can still make sure they're in there for 5 minutes a shift.) To do otherwise is cruel.
  7. by   mcubed45
    Quote from delphine22

    But IMO if they have an artificial airway and they're on the vent, knock em the hell out. (Preferably with something easily reversible so you can still make sure they're in there for 5 minutes a shift.) To do otherwise is cruel.
    That's really old school thinking.

    Have you read any of the research on long term neurological deficits secondary to ICU delirium? Minimizing sedative and analgesia use for the prevention of delirium is one of the major goals for improving patient outcomes.

    ICU Liberation |
    Guidelines


    One of the great things about medicine is that it's always changing. Stay up to date, and get your unit on board with current practice guidelines!

    Snowing our patients may make our shift go way more smoothly, but our patients ultimately pay the price.
  8. by   delphine22
    No, but I had a family member who was awake while intubated and self-extubated. His vivid description of the experience has stayed with me and I think of it every time I see a pair of frightened eyes look up at me as they try to speak, to tell me they feel like they're drowning while I assure them they are not.

    I don't "snow" my patient to make my shift go more smoothly. It's for their comfort, not mine. It's not easy to get to the "sweet spot" of sedation where they're out until we want them not to be. I did mention sedation vacations q shift which is my unit's policy. As for delirium, which do you think is worse -- being asleep and having no memory of the experience, or being in a terrifying twilight state where you can't communicate your fears and, being half sedated, aren't sure what's real and what's not, or whether you're even dead or alive?
  9. by   mcubed45
    Quote from delphine22
    No, but I had a family member who was awake while intubated and self-extubated. His vivid description of the experience has stayed with me and I think of it every time I see a pair of frightened eyes look up at me as they try to speak, to tell me they feel like they're drowning while I assure them they are not.

    I don't "snow" my patient to make my shift go more smoothly. It's for their comfort, not mine. It's not easy to get to the "sweet spot" of sedation where they're out until we want them not to be. I did mention sedation vacations q shift which is my unit's policy. As for delirium, which do you think is worse -- being asleep and having no memory of the experience, or being in a terrifying twilight state where you can't communicate your fears and, being half sedated, aren't sure what's real and what's not, or whether you're even dead or alive?
    I urge you to read the current literature and some of the links users have posted. Many of our ICU's are involved in the SCCM's ABCDEF Bundle Collaborative.

    The "twilight state" you're describing IS delirium. The research shows that a lot of the sedatives/analgesia's we use to "help" our patients are actually causing acute ICU delirium and long-term neurological deficits. Avoiding or minimizing analgesia and sedation is a major component, but other things like promoting proper sleep cycles (e.g. no 2am baths) are important as well.

    You mention sedation vacations, but does your unit routinely assess for delirium using the CAM-ICU tool? What is your target for sedation? Do you use a reliable tool like the RASS?

    It's normal to resist change, but just because we've always done things a certain way or we were taught a certain way does not mean it is right. There was definitely a lot of resistance in my unit initially as well (especially from the more "seasoned" nurses) but we've definitely seen a reduction in vent-days and shorter ICU stays. It's now quite common to most of our vented patients awake/alert. Some of them even ambulate around the unit.

    And yes, there are exceptions. Some patients simply cannot be safely weaned off sedation/analgesia. Patient safety still takes priority. However, you'll find that when your unit is more aggressive with weaning sedation/analgesia and assessing for delirium a lot of your patients were being more heavily medicated than necessary.
    Last edit by mcubed45 on Dec 1, '16
  10. by   Munch
    1mg of morphine q6? I'm sorry that is really funny. I was in a really bad car accident(flipped my mustang and had to be lifted to a trauma center). I was admitted to the step down unit for a week and the night I got to the floor one of residents ordered 1mg of IV morphine. After my nurse pushed it I asked if he had given me a placebo! Sorry this has nothing to do with vent management but any provider worth their salt will know 1mg of morphine might be useful in peds..that's about it.
  11. by   ghillbert
    Quote from delphine22
    So you're saying that if you have an awake pt that's intubated, and they're agitated, it's because they could be in pain, and they should get pain management first before being sedated? Have you personally ever been orally intubated??
    It's one of the most terrifying experiences that can ever happen to a person. If it were me, I wouldn't want to know a single thing until the minute they're going to pull the tube out. And I'd want a boatload of anxiolytics before they start SBTs.

    Yes, people with chronic pain and narcotic dependence should have that continued even while sedated. And trauma pts obviously should have their pain addressed in addition to their sedation. But IMO if they have an artificial airway and they're on the vent, knock em the hell out. (Preferably with something easily reversible so you can still make sure they're in there for 5 minutes a shift.) To do otherwise is cruel.
    As stated above, this would be a grave disservice to your patients. There are many sedative and analgesic options to make someone comfortable which do not involve "knocking them the hell out".
  12. by   SICUmurseCCRN
    unless the pt is telling you they are in pain or they have had some kind of procedure where you know they would be in pain i do not think fentanyl is appropriate. propofol is great short term but pts really shouldn't be on prop long term. in my opinion i like versed, i think it works great, but there are also many other options and combos that can be used (precedex, ativan, pain med iv push etc.). ideally, you want the person calm and/or easily aroused. rarely have i seen a pt intubated without any sedation who is comfortable, maybe twice, but for most of the population they will need some kind of sedation. we really shouldn't be using fentanyl as a sedation (or propofol to knock someone out when they may need fentanyl), although it happens all the time and even MDs will tell you to do it.

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