Sedation in ICU... your opinions/ experiences? - page 4

by IheartICUnursing

19,368 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


  1. 1
    Quote from expatRNdk
    Neuro patients are sedated obviously, but we don't have those, they are at our NICU .
    This was making no sence to me. I just realized that you are calling neuro ICU NICU. Here in the USA NICU refers to Neonatal ICU. I though what are the neuro patients doing in the baby ICU? I got it now
    DeLanaHarvickWannabe likes this.
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    lol... yes, I can see where that would be confusing. Unfortunately, I cannot go back and correct it.

    And just for the record, our practices here are evidence based.
    http://www.biostat.sdu.dk/courses/f1...o-sedation.pdf

    There is a higher incidence of agitated delirium in these patients, which we treat with bolus Midazolam PN, which is given following a protocol.

    I cannot argue with your personal experiences, but there is also evidence for a lower incidence of PTSD associated with this practice. If I can find the evidence I will link it.
    Last edit by expatRNdk on Nov 14, '12
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    Quote from expatRNdk
    lol... yes, I can see where that would be confusing. Unfortunately, I cannot go back and correct it.

    And just for the record, our practices here are evidence based.
    http://www.biostat.sdu.dk/courses/f1...o-sedation.pdf

    There is a higher incidence of agitated delirium in these patients, which we treat with bolus Midazolam PN, which is given following a protocol.

    I cannot argue with your personal experiences, but there is also evidence for a lower incidence of PTSD associated with this practice. If I can find the evidence I will link it.
    *** I will tell you this. The first time I was intubated for several days and I have no memory of it except for just a few hours before they pulled the tube out. It was a not unpleasent floating feeling.
    The second time I was wide awake and have nothing but horrible and tramatic memories. If I have to go though that again I will make myself a DNI........
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    So sorry your experience was so horrible. If you wouldn't mind telling about it, I would be very interested to learn about your experience.
    On our unit, we do not use restraints. If patients are anxious we will stay by their side, hold their hands, explain everything that is happening. Much effort is spent informing them and making them as comfortable as possible. It is not unusual to see patients sitting up in a chair, watching TV or visiting with their families while intubated. Their families can be with them almost all the time.

    http://www.kristeligt-dagblad.dk/art...ed-aabne-oejne

    This a picture of Henning, who was admitted in our icu. The link is to a danish article about Henning's experiences with being awake while intubated, while not always pleasant, he was glad to be able to remember his stay in icu. Sry, there is no english translation available.
    Last edit by expatRNdk on Nov 14, '12
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    Studies are showing that awake pt have better outcomes. There's less delerium, lower VAP's, and shorter days on the vent. We basically sedate all of our pts, but some doc's are moving toward prn meds unless the pt isn't tolerating. Our hospital is looking into ambulating intubated pts. Some major hospitals are already doing this. There is exclusion criteria, but studies are proving the benefits of ambulating ventilated pts. The nurse, PT, RT are walking pts while bagging them or having the vent on a rolling table. There are videos of this on Youtube. It's pretty wild. There they are, walking in the room with an ET tube.
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    One of the Intensivists in our unit trialled all of the nurses on our unit on the vent. We each had a nose plug and a tube that we put in our mouth. He ran us through all of the vent settings. It was really interesting. Some of the nurses immediately yanked the tube from their mouths, it just freaked them out. Others, like myself, had no issues with it. So, I think sedation should be individualized. Just like pain meds, if someone looks liked their freaking out, bucking the vent or indicating that they're not doing well, by all means advocate to sedate. But, if someone's doing fine, why keep them down? I would hate to be sedated. But you would never know that I would do fine if you never gave me the chance to ask... Also, studies do show less days on the vent/delerium/PTSD/VAP...
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    Expat, that's very interesting that you don't use restraints. I can see how that could be employed in our unit for our standard resp failure patients, but that's not all we have. How do you control organically agitated patients, eg ETOH or hepatic encephalopathy without restraint use? I can't see how any amount of talking down and deescalating would keep these types of patients from yanking their tubes out..... I'm curious to hear your experiences.
  8. 1
    Quote from EyeSeeYuRN
    Expat, that's very interesting that you don't use restraints. I can see how that could be employed in our unit for our standard resp failure patients, but that's not all we have. How do you control organically agitated patients, eg ETOH or hepatic encephalopathy without restraint use? I can't see how any amount of talking down and deescalating would keep these types of patients from yanking their tubes out..... I'm curious to hear your experiences.
    *** Good questions I would like to hear her response too. Furthermore why would not using restraints be a goal or something to strive for?
    nrsang97 likes this.
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    Quote from EyeSeeYuRN
    Expat, that's very interesting that you don't use restraints. I can see how that could be employed in our unit for our standard resp failure patients, but that's not all we have. How do you control organically agitated patients, eg ETOH or hepatic encephalopathy without restraint use? I can't see how any amount of talking down and deescalating would keep these types of patients from yanking their tubes out..... I'm curious to hear your experiences.
    Well, for most patients who are agitated, we will have a 'sitter' who stays with the patient constantly keeps a constant watch over the patient. If the patient is very agitated/delirious (we CAM-icu score) we will give the PN Midazolam according to our protocol. We start out with 2,5mg. If that is not effective the dose is doubled progressively until the patient quiets down. The next day the physician will look at the total amount given over the past 24hrs and then for example if the pt was given 50mg total, will order 10mg x 5 in the course of the day. The 2nd day,the 50mg will be halved, the 3rd day halved again. The idea is to wean off of the Midazolam and continuously evaluate if the treatment is effective.
    If agitated patients are suffering from withdrawals we treat that.
    Severely agitated patients that cannot be managed in this way are sedated.

    As per restraints. The opinion in Denmark is that physically restraining a patient is such an extreme measure that it should only be done in extreme cases. I have seen it on psych wards, but never icu. I have heard a story about one icu patient who was restrained, but it is the only instance I have heard of. We can always sedate our way out of those situations, in combination with a sitter. I think the idea is that restraints can easily become the norm and can easily be abused and we don't want that.

    I realize that the major reason this works is because we have a 1:1 patient/nurse ratio and because we have the resources to call in sitters. Our sitters are typically nursing students who work for a temp agency we use.

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    [QUOTE=expatRNdk;7033720
    As per restraints. The opinion in Denmark is that physically restraining a patient is such an extreme measure that it should only be done in extreme cases. I have seen it on psych wards, but never icu. I have heard a story about one icu patient who was restrained, but it is the only instance I have heard of. [/QUOTE]

    *** I guess you don't have many patients trying to beat the crap out of you in your ICU Certainly use of restraints should be minimized and they should only ever be used by staff that have been trained in their use and restrained patients should alwasy be closely supervised. I don't view restraint free as something we should strive for. I error on the side of staff safety. Recently we had a superb ICU nurse take a hard right hook to her eye causing permant damage with a detached retina and a broken superorbital foramen. The patient, who had a long history of violence aginst women (wich of course we didn't know about) had been well behaved up until then. When asked why he hit his nurse he replied "I don't like a gook ***** toutching me" (his nurse was of Phillipino decent). We restrained him. Of course he was arrested and charged but I doubt he cared since he has been in and out of prison a lot.
    I have been stabbed by a patient with a (thankfully clean) needle, punched, bit, kicked, spit on, had produce of ejaculation flung at me, poop thrown at me, and once had a patient rip a phone off the nurses station and throw it at my head. You get all kinds in trauma.


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