Sedation in ICU... your opinions/ experiences?

EyeSeeYuRN · Nov 15, 2012

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.

PMFB-RN, RN · Nov 15, 2012

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?

justatraveler · Nov 15, 2012

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.

:)

PMFB-RN, RN · Nov 15, 2012

[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.

*** 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.

traumasurgRN · Nov 17, 2012

. Neuro patients are sedated obviously, but we don't have those, they are at our NICU .

I find it strange that you are sedating a Neuro patient, how are you then getting an accurate neuro check out of them, especially if they had deficits before the sedation?? Our neurosurgeons RARELY order sedation for their preop or postop patients, and if by some chance they do order sedation, its is usually a very small dose of propofol. They discourage the use of prn ativan unless it is very much needed, like hx of etoh. We even had a neurosurgeon refuse to order a 1x dose of iv benedryl for a patient with a small SDH, even though the were a&o x3.

umcRN, BSN, RN · Nov 17, 2012

I find it strange that you are sedating a Neuro patient, how are you then getting an accurate neuro check out of them, especially if they had deficits before the sedation?? Our neurosurgeons RARELY order sedation for their preop or postop patients, and if by some chance they do order sedation, its is usually a very small dose of propofol. They discourage the use of prn ativan unless it is very much needed, like hx of etoh. We even had a neurosurgeon refuse to order a 1x dose of iv benedryl for a patient with a small SDH, even though the were a&o x3.

I can attest to this as a neuro ICU patient! No matter that I'd just had my head carved into, bits and pieces removed, screwed & stapled back together. I still needed to know what the date was, who I was and where I was q 1 hour starting the moment I woke from surgery! I was allowed fentanyl PRN's but soon found those caused me to vomit so we (I) stopped them. Now I wasn't intubated post op...that I can remember, but it has been my experience (also as a pedi/neonatal ICU nurse) that neuro patients really get the shaft when it comes to sedation

aronii07 · Nov 17, 2012

We've tried using Precedex when we're short on propofol, but the docotors don't realize that Precedex is an adjunct to propofol/other sedation methods, it cannot just be started on its own. The drug company specifically draws out the appropriate way to add Precedex for sedation and wean off propofol, but I have yet to see it ordered that way. I've also had issues with using midazolam drips it seems you still need to add additional fentanyl to better comfort the patient.

Dodongo, APRN, NP · Dec 3, 2012

We use a lot of versed and fentanyl gtts. A little bit of precedex. Propofol is pretty common in a newly intubated pt but we only keep them on it for 3-4 days at the most because of propofol syndrome.

mybanez · Dec 7, 2012

Our facility is fond of using Ativan drips, which I personally hate because of increased binding to fat tissue and people on Ativan drips are very difficult to ween off as opposed to Propofol (which we never use anymore). I also see Fentanyl and Ativan or fentany and versed used quite often in my facility.

imaginations · Dec 14, 2012

I work in a children's ICU but we stock standard start most intubated patients on morph + midaz infusions and work from there. Neuro kids typically come off these quickly to assess their GCS etc. If the child has pain issues rather than sedation issues we'll often switch midaz for ketamine to control their pain. If sedation is an issue we'll either switch midaz for Precedex or just add it. We keep Profopol in our resus drug dish on the end of the bed, and, if the child is lively (and has enough IV access) with keep the syringe on a three way tap just in case. If the child is requiring a large amount of Profopol pushes (and is maxed out on sedation) we will then add an infusion (this happens only occasionally.) We also use Clonidine, Diazepam (instead of a midaz infusion) and Vallergen down an NG if the patient is not NBM and is tolerating some feeds.

pgotm · Dec 14, 2012

Fentanyl is used the most. We are teaching hospital, and they don't like propofol, plus there is a nation wide shortage. Precedex is rarely used.

Sugarcoma, RN · Dec 14, 2012

We have hit or miss sedation. Some of our doctors are very good about sedating usually with either propofol or Versed. Some are kind enough to order a sedation/analgesia combo. Some only order sedation with no analgesia and I find that to be very cruel.

As for neuro patients, we had a wonderful neuro-intensivist who would order propofol for these patients. We would simply turn the drip off for a little while to do neuro checks. His reasoning for ordering sedation was to reduce ICP spikes. We did travel to CT more frequently with his patient's but overall they were much more comfortable than other doctors patients were. He was a very kind man and it was important to him his patients were comfortable and well-ventilated. He has left our facility and our current neuro doc does not believe in sedation/analgesia at all.

Probably the worst shift I have ever had was spent with an elderly gentlemen who had broken his neck/part of his spine leaving him paralyzed. His family had a POA that stated if paralyzed/vegetative state he DID not want intubation etc but we didn't know that when he was brought in. In the end he ended up on a vent with the family, docs, and the patient agreeing he would be terminally weaned in the morning. That poor man tried his level best to chew through his ET tube and bucked the vent all night long. He was so obviously miserable. The doctors refused to sedate him. Their reasoning was it would interfere with his neuro checks!! I begged and pleaded all night long up to and including the attending but no luck. He received no sedation until it was time to extubate. So cruel.