Sedation in ICU... your opinions/ experiences? - page 2
by IheartICUnursing 20,777 Views | 48 Comments
Just wondering, how many of your vented pts are sedated, and with what? Are there certain pts that you always do or do not sedate, or is it always a case by case basis. Most nurses on my unit would agree that we do NOT sedate... Read More
- 0Aug 22, '12 by EMTtoRNinVAWe have nursing driven Sedation protocols (fentanyl, dilaudid, versed, diprivan), we use CAM-ICU, Richmond Agitation Scores, BIS monitoring, and a Train of Four to assess our paralyzed/sedated patients.
We have daily SBTs, and occasionally use Precedex, but it's crazy expensive. Our # of trachs has gone down dramatically in the last couple years.
- 0Aug 22, '12 by ckh23Fentnyl,Versed, and restraints. Do they really need to investigate why you have and increase in unplanned extubations? Perhaps some protocols need to be put into place about sedating the patients on continuous gtts or more training to nurses.
I notice some nurses will titrate sedation gtts up with agitation, not realizing it will take some time for that increase to take effect. Next thing you know the patient is on 300 of Fentnyl and 5 of versed before adequate sedation is achieved. However, you can usually keep your continuous gtt rates lower and the patient well sedated by just giving prn boluses of a particular drug.
- 0Aug 23, '12 by gregpezzutiAlways used sedation in my experience.........its been a while since I did ICU but the effects of sedation usually wear off fast for pulmonologists to make determinations, and u cant give enough ativan PRN........Jesus if this is how they r doing things now God please dont let me linger in an ICU intubated.
- 0Aug 23, '12 by roma4204decrease your number of unplanned extubations?! that statement should NOT be plural!!! that just should not be happening. if the patient is strong and awake enough to pull their ET tube they are either ready to have it out or need an intervention such as mittens, restraints or if that doesn't work, they need to be a 1:1. That is just unacceptable to me that your facility would try to be decreasing unplanned extubations...it's that big of an issue?! It just should not happen. but to answer your question:
- depends on the vent mode and patient condition. just intubated? usually propofol or versed/fent drips after pushes
- if they are on full controlled support like in ARDS we usually use the above plus a vec drip if the patient is really fighting the vent
- we rarely use benzo drips because of the link to ICU delirium
- if we are having trouble extubating because of agitation during SBT we will usually try to switch to precedex which I know is a really pricey med so not everywhere uses it. we use precedex for some alc withdrawal patients as well since they can be on it and not intubated
of course there is a delicate balance with sedation but who is saying to use so little? the docs? the unit? it sounds really traumatizing to the patient but there are times they will be better in the long run. but self extubating is never good for anyone, patient or provider
- 2Aug 23, '12 by juan de la cruz GuideI look at sedation as just one piece of the puzzle in caring for mechanically ventilated patients. There are many forms of respiratory failure requiring an advanced airway and mechanical ventilation. For run of the mill post-surgical patients on the vent who had no lung pathology prior to surgery, the easiest approach is to use fast track protocols that utilize rapid FiO2 weaning, use short-acting agents such as Propofol until minimum vent settings are achieved, and initiate spontaneous breathing trials right away and extubate.
The patients with hypoxemia are more difficult to address. If the hypoxemia is due to ARDS based on diagnostic criteria, the literature calls for low lung ventilation strategies. These involve low tidal volumes (as low as 5 cc/kg) with high PEEP which can be uncomfortable to patients leading to ventilator dyssynchrony so these patients really need to be sedated. The choice of sedating agents are wide and the only limiting factor would be side effects, hypotension being one of the most common.
Propofol is ideal because it's short acting but long-term use requires regular monitoring of serum triglyceride levels which can increase and cause pancreatitis. Propofol Infusion Syndrome is rather rare but is also worth watching out for. Opioids such as Fentanyl infusions will help with air hunger as well. But large doses of long-term Opioids can cause ileus. Paralytics may be indicated if hypoxemia is refractory despite high vent settings.
Neuro patients are typically on Propofol because it is short acting and allows for immediate wearing off for asessing neuro exam periodically. It also has the benefit of seizure suppression and ICP lowering effect. Opioids such as Fentanyl (though short acting as far as Opioids go) can linger after a while and cause the patient to be asleep for longer periods than we want them to be. Benzodiazepines such as Midazolam will do the same.
Another consideration to explore why patients fight the vent is to look into what vent mode is being used. Assist-Control Ventilation using Volume Trigger can be uncomfortable and Pressure Control triggers tend to be better tolerated. Better yet, patients should be assessed for ability to spontaneously breathe using Pressure Support Ventilation even when PEEP levels are still above 5 and FiO2 are still not at minimum for extubation because this is much more comfortable for patients.
Dexmetetomidine is becoming popular for sedation though it has not been approved for long-term sedation. Some institutions are using it long-term as an off label indication. It has the advantage of not suppressing the respiratory drive so patients tend to be arousable, spontaneously breathing, yet calm on it and it is also short-acting like Propofol. It's also been used to extubate patients who wake up agitated on the vent yet passes all extubation parameters in terms of respiratory mechanics.
- 5Aug 23, '12 by lovingtheunlovedNot an ICU nurse, but I've been an ICU patient, and looking over my medical records and seeing all the invasive, unpleasant crap that was done to me in there, I'm eternally grateful that they snowed my butt. I have no recollection of any of it. Yay for fentanyl and versed.
- 0Aug 23, '12 by juan de la cruz GuideQuote from lovingtheunlovedThat's a good point I didn't mention in my post. "No recollection of it" or the amnesic effect is only achieved with Propofol and the benzodiazepines such as Midazolam (Versed). Long-term paralytic use for instance, calls for using any of these agents concurrently. A patient can sue for the distress of being placed under, unable to move, yet remembering the whole ordeal.Not an ICU nurse, but I've been an ICU patient, and looking over my medical records and seeing all the invasive, unpleasant crap that was done to me in there, I'm eternally grateful that they snowed my butt. I have no recollection of any of it. Yay for fentanyl and versed.
- 0Aug 24, '12 by larooThat is terrible... WOW. I had a patient on 50mcg/kg/hr of propofol and a 50mcg/hr fentanyl gtt yesterday. We routinely propofol our people unless their lipid profile is out of control, or if they are on propofol too long... then we switch to versed. Have used an ativan gtt too. Mostly though, propofol for sedation and fentanyl underneath for pain. Sedated patients can still feel pain. Precedex when weaning a difficult patient from the vent/extubating.
We titrate the propofol however we feel according to what the patient needs- are you all allowed to titrate your sedation independently?
- 0Aug 27, '12 by traceydeniseI work at a government facility. We use propofol all the time. We used it at the university hospitals I worked in as well. The doses I've seen used vary. we must remember that many patients we see now are polysubstance abusers. Their tolerance will be much higher than the average person. We must be willing to treat the patient and not the textbook numbers. The human body is unique. What works for one may do nothing for another