Nonsedated Pt's equal self extubations

ausrnurse · Mar 5, 2015

We turn off our sedation every day to assess the patient for extubation and give them a "sedation vacation" (leading to shorter length of intubation). When they are ready we extubate. If they are not ready but comfortable, we leave the sedation off until they are ready. If they are not ready and uncomfortable we resedate (possibly changing the sedative) and try again later.

It sounds like your hospital needs to rethink your sedation protocols. Imagine the psychological effect of being awake, tied to a bed, unable to communicate until someone takes the tube out. I would consider it assault, they need to either resedate or extubate. We almost never use restraints.

calivianya, BSN, RN · Mar 5, 2015

I have seen a lot of this recently. The worst part of it is that we have a NP who used to work as a critical care nurse, and she's the one who usually goes in and D/Cs a bunch of the sedation/pain meds! I wonder if she really remembers what it's like to be a bedside nurse. It's hard to watch people flail around and struggle in their restraints, wide awake and unable to get away.

vanilla bean · Mar 5, 2015

We turn off our sedation every day to assess the patient for extubation and give them a "sedation vacation" (leading to shorter length of intubation). When they are ready we extubate. If they are not ready but comfortable, we leave the sedation off until they are ready. If they are not ready and uncomfortable we resedate (possibly changing the sedative) and try again later.

We do the same. Fortunately, my facility takes self-extubations very seriously and requires that an Incident Report be filled out every time it happens. Incident Reports are completed online and then a copy is automatically sent to all of the dept heads/chiefs (in the chain for the involved area) all the way up the chain to the CNO. Then they actually follow up and investigate what happened. I can't imagine lack of sedation would be an acceptable excuse for an increase in self-extubations.

0.adamantite · Mar 5, 2015

I'm not a critical care nurse and do not work with patients who are intubated. Therefore, I may not be educated enough to comment on the matter. But as a patient, if I have a tube shoved down my throat please keep me sedated - I can't imagine how terrifying it would be to be awake and choking on an ET tube.

calivianya, BSN, RN · Mar 5, 2015

We do the same. Fortunately, my facility takes self-extubations very seriously and requires that an Incident Report be filled out every time it happens. Incident Reports are completed online and then a copy is automatically sent to all of the dept heads/chiefs (in the chain for the involved area) all the way up the chain to the CNO. Then they actually follow up and investigate what happened. I can't imagine lack of sedation would be an acceptable excuse for an increase in self-extubations.

This is great; I wish we did this where I worked. I think maybe I will start filing incident reports if my patients self-extubate now. Maybe that will bring some attention to how under-sedated some of my patients are.

ausrnurse · Mar 5, 2015

I'm not sure how supportive the medical team is in your particular unit, and it might be easier for me as I work in a closed ICU with 24/7 intensivist cover, but if one of the more junior doctors tries this nonsense with me I start with "how would you like it if that was you?" followed by "the patient is undersedated and they are going to self-extubate." I normally refuse restraints on a patient for the sole purpose of keeping someone undersedated if that is brought up - obviously depending on the patients mental status. If they continue to refuse appropriate sedation I go over their head - I will bring in senior nursing and medical staff if necessary. I am not prepared to restrain (assault!)* someone because a doctor isn't confident in their ability to appropriately assess a patient for extubation and if necessary, reintubate, which is really what this sort of thing is all about. Self extubations always require an incident report in my unit.

*obviously I'm not talking about patients that are confused/take days to wake/etc. I'm talking about a normal extubation where some people seem to think that even if the patient is totally appropriate, the sedation needs to be left off for a certain period of time before pulling the tube.

blondenurse12, MSN, NP · Mar 5, 2015

Does your institution not use Precedex? You can extubate patients while still on the gtt. We usually do Fentanyl and Precedex. Each morning is a sedation holiday and if they pass and meet the other qualifications, the patient will have a spontaneous breathing trial. If they fail, the sedation resumes.

It just seems cruel to basically physically restrain someone who is lucid on a ventilator. I sure wouldn't want that for myself.

Here.I.Stand, BSN, RN · Mar 5, 2015

Oh. my. goodness. That is horrible. :mad:

Most of our pts are on propofol and fentanyl. We do a daily sedation vaca where we wean down the propofol but DON'T stop the fentanyl. Propofol has such a short half-life that there is usually NO reason to take it off hours and hours before extubation.

We generally titrate our sedation to a RASS of -1 to 0; deeper if they have ICP issues, are on neuromuscular blockers, have ARDS, or other such reasons they'd need deeper sedation. If they're flailing around or trying to self-extubate, I'm picturing a RASS of +2 or +3, so by parameters they need more sedation.

HouTx, BSN, MSN, EdD · Mar 5, 2015

Hang on just a minute here. "Facilities" cannot direct medication administration..... this is a function limited to medical staff. Pharmaceutical protocols for mechanical ventilation need to be approved by pulmonology/anesthesiology. Even then, protocols cannot ever be substituted for critical thinking and our basic patient care duties which include ensuring safety, managing pain and easing emotional distress.

Whenever your patient is experiencing pain & emotional distress -- for heaven's sake, advocate for your patient rather than simply falling into line with blind obedience to a generic protocol. Go up the chain of command if you need to. Be courageous for your patient's sake.

dirtyhippiegirl, BSN, RN · Mar 5, 2015

Saw this in my ICU too. Or switch q1h IVP. I think they are reactionary policies to all the m&m coming out on prolonged sedation. Now we have to wait for studies on the effects of undersedation to even things out. Although I also think some of our NPs just think we (bedside RNs) are oversedating patients because we are lazy.

I have not been impressed with Precedex in adults, fwiw. But that is just my experience.

ausrnurse · Mar 6, 2015

Saw this in my ICU too. Or switch q1h IVP. I think they are reactionary policies to all the m&m coming out on prolonged sedation. Now we have to wait for studies on the effects of undersedation to even things out. Although I also think some of our NPs just think we (bedside RNs) are oversedating patients because we are lazy.
I have not been impressed with Precedex in adults, fwiw. But that is just my experience.

I read somewhere that doctors always think patients are oversedated and nurses always think they are undersedated. Personally, I've never seen a nurse deliberately oversedate a patient, and if they did someone would say something to them. Occasionally a new ICU might, usually out of fear/anxiety more than anything - but I think it's better for a new nurse to give an extra bolus of propofol and ask for help than ask for help after the ETT is lying on the floor. Much easier to fix the sedation. Totally agree with you on the precedex, I HATE the stuff.