Sedation in ICU... your opinions/ experiences? - page 2

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... Read More

  1. Visit  gregpezzuti profile page
    0
    Always 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.
  2. Visit  roma4204 profile page
    0
    decrease 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
  3. Visit  juan de la cruz profile page
    3
    I 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.
  4. Visit  lovingtheunloved profile page
    5
    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.
  5. Visit  juan de la cruz profile page
    0
    Quote from lovingtheunloved
    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.
    That'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.
  6. Visit  laroo profile page
    0
    That 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?
  7. Visit  traceydenise profile page
    0
    I 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
  8. Visit  libbyliberal profile page
    0
    I have seen Propofol mis-used in many ICUs. The foot drop and the weakness in their hands is from the buildup of propofol in the tissues- especially the fatty tissue and it can take a week to clear. In my opinion it should only be used for procedural sedation.

    We never exceed 35mcg of propofol and if they aren't sedate on that much we'll add some midazolam.

    The new "paradigm" is sedation and analgesia - an ativan(for DTs) or midazolam gtt - with a fentanyl gtt.
  9. Visit  CrufflerJJ profile page
    0
    Quote from libbyliberal
    I have seen Propofol mis-used in many ICUs. The foot drop and the weakness in their hands is from the buildup of propofol in the tissues- especially the fatty tissue and it can take a week to clear. In my opinion it should only be used for procedural sedation.

    We never exceed 35mcg of propofol and if they aren't sedate on that much we'll add some midazolam.

    The new "paradigm" is sedation and analgesia - an ativan(for DTs) or midazolam gtt - with a fentanyl gtt.
    Low dose sedation is the goal. Unfortunately, however, some pts have built up such a tolerance to opiates/benzos (due to "recreational" use outside a hospital setting) that it might take 300 mcg/hr of fentanyl + 30 mg/hr of versed to only mildly sedate them. Some pts require big whopping doses of both Propofol & fentanyl to keep them from "bucking" the vent.
  10. Visit  meandragonbrett profile page
    1
    Quote from libbyliberal

    The new "paradigm" is sedation and analgesia - an ativan(for DTs) or midazolam gtt - with a fentanyl gtt.
    That's really not the new paradigm anymore. That's the old one. We use too much benzo. The trend is to use little to no benzo and to use halodol if really needed. Propofol + Fentanyl.

    Why do you think propofol should be used for procedural sedation on?
    CrufflerJJ likes this.
  11. Visit  EyeSeeYuRN profile page
    0
    Anybody using ABCDE bundle? Outcomes for well sedated patients are pretty poor. We're trying to adopt some of these aspects in our unit, but having more awake patients is definitely a lot more work...and more traumatic for the patients (we all argue). We're using Precedex in indicated cases, but have yet to have a patient where we say, "wow, ya that really worked for him". We generally go back to propofol, fentanyl gtt, or versed gtt.
  12. Visit  07302003 profile page
    2
    95% of patients where I work are intermittent sedation - Morphine 2-4 and Ativan 2-4 Q 15min-2 hours prn MAAS (very nurse driven). Of course, if the patient is hard to sedate it's easy to get an order for a continuous fentanyl + versed gtt or propofol + versed if needed. Intermittent sedation has been shown to decrease vent days, and I'd agree, because I've seen the patients who have had a hard time waking up from continuous drips. And with intermittent sedation, we're using much less meds per day, especially in the elderly, who have a hard time clearing the meds from their system.
    libbyliberal and CrufflerJJ like this.
  13. Visit  AICU RN profile page
    0
    I had a pt over the weekend who was nasally intubated after a radical neck surgery. ENT wanted him pretty snowed but that was easier said than done. First night I had him we were up to 150mcg of Fent per hour and 50 of Propofol/hr. He was still sitting straight up in bed and trying to kick his feet over the siderails. I had to wrist restrain him unfortunately. Finally talked the docs into believing it wasn't working and the next night I had him on the same dose fo Fent with 12 of Versed. That didn't touch him. The next night I had him we were trying boluses of KETAMINE...that didn't work either. Finally started Precedex but after 24h that started making him brady (of course). So the last night before I was off they had me wean him off Precedex before I left and ordered bolus doses of Haldol. Sheesh....don't know how it finally worked out. No history of drug abuse either.

    Honestly, in our ICU, I'd say it's about 50/50 as far as whether our patient's are sedated while intubated. If they are, Prop is usually our first choice. We have been using Precedex more. Also started using the Fent/Versed combo someone talked about earlier. The people who are vented but NOT sedated that amaze me. Just lying in bed all calm, just amazing. Not me. If I'm tubed I better have some major sedation on board .

    Anyway, we did just start using the ABCDE bundle. It seems pretty useful so far.

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