Sedation..Your thoughts?

Specialties MICU

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So I just have a question for my fellow icu RNs. I had a patient last night who while even sedated on 50mcgs/kg/min of propofol and 6 of versed was able to open eyes and follows commands and respond appropriately. I asked her several times if she was comfortable to which we nodded 'yes'. Her Peak pressures were all fine in, her HR was 90s-100s, which is better than the 110-120s she was when she got to me and her BP was now 100-110s which was better than the 70-80 when she got to me (septic, severe PNA). I made the decision to not call the MD and not add anymore sedation to her. She was triggering the vent at a rate of 20-22 on PRVC. So my question is, what would have you done? I know some people like to have their patients snowed wayyy down, but I don't like to. She was a young girl in her 30s, and since she was hemodynamically stable (on only 2.5mcg/min of levo, down from the 10mcg/min she was initially on) I decided to keep her where she was. I know it's a judgement call and everyone will have their own opinion on what they would have done, but i am curious to know. Thanks.

Specializes in Critical Care.
50mcg of propofol ain't squat!

Especially for drinkers, or self medicators. You know, like the majority of our patients!!

Ohh yea I totally agree, it's really not that much. But I didn't write the protocol so what can I do. With the drinkers we usually load up on Ativan...For our Sedation protocol we have Ativan, Versed, and Propofol...We also have a pain protocol which we can use Morphine, Fentanyl, and I THINK dilaudid, but I could be wrong about the Dilaudid to be honest. So we sometimes take a one from each and use them or whatever the docs wanna do..Drinkers, heroin addicts, opiate abusers are the WORST and hardest to keep down..after 12 hrs they are absolutely exhausting

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It sounds like we all are doing a bunch of different things out there with propofol,versed and fentanyl. Is there no universal protocol? When we use propofol or versed we use the Rass scale of -2 or -3 . Propofol max is 50mcg/kg/min and fentanyl max100 mcg/hr. We combine either propofol or versed with fentanyl but never propofol with versed.

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Specializes in Critical Care.
It sounds like we all are doing a bunch of different things out there with propofol,versed and fentanyl. Is there no universal protocol? When we use propofol or versed we use the Rass scale of -2 or -3 . Propofol max is 50mcg/kg/min and fentanyl max100 mcg/hr. We combine either propofol or versed with fentanyl but never propofol with versed.

Is there is a special reason why you don't combine Prop. and Versed ? Is it because of the similar properties, and by that Im meaning hypnotic/amnesic ? Or and I missing something here ?

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Specializes in ER/SICU/Med-Surg/Ortho/Trauma/Flight.
I'm confused: why on earth would you be bolusing someone with propofol unless they were intubated or for the purposes of RSI?

I know alot of our anesthesia staff give propofol boluses on non intubated pts. for mac (monitored anesthesia care) say like when someone is having an egd and the fent, and versed do not put them out they will give a small propofol bolus with, but there is advanced airway equipment near by.:nurse:

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Specializes in ER/SICU/Med-Surg/Ortho/Trauma/Flight.

I had a guy the other night I could'nt keep down, post op GSW to the chest had thoracotomy the works you name it, first started out on 75mcg/kg/min propofol, 4 mg versed, 4 mg dilaudid, and he was wild eyed and awake on that much, we finally ended up giving him 125 mcg/kg/min propofol, another 4 versed, 2 mg ativan, and 3 mg more of dilaudid and got him down for about 5 hours on that and then had to snow him again.:nurse:

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yep... versed or propofol for sedation and amnesia and fentanyl for pain. Propofol in OR is a different ballgame and in the hand of CRNA or Anesthesiologist a totally different scope of practice.

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We're taking a closer look at delirium and the gtts that make it worse; including Versed , Ativan and Propofol. Moving tpowards Precedex. Check out the icudelirium.org site from Vanderbilt.

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We use up to 75mcg/kg/min on the propofol... and sometimes that doesn't even keep the pt comfortable.

It really depends on the pt and the problem... if you have a pt is full blown ARDS, the idea is to knock out their drive to breath and let the vent do the work... so if that were the case, I would have asked for something more, or even a paralytic. HOWEVER, in any another case where they are less critical, the goal is just to keep the comfortable with the least amt possible. I have pt's that are perfectly ok with no medication at all, and others that need to be completely knocked out cold to not fight the vent. And everything inbetween. I like to be able to assess my neuro status and we always do sedation vacations on all our sedated pts, unless like I said before, the extra critical pts where waking them up would be too risky.

I think in your case, you did the same thing I would have done.

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Specializes in ICU.
We're taking a closer look at delirium and the gtts that make it worse; including Versed , Ativan and Propofol. Moving tpowards Precedex. Check out the icudelirium.org site from Vanderbilt.

We used Precedex with post-open hearts consistently. O-m-g it's pretty amazing stuff, but the price of it is just as o-m-g.

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I work in a SICU in Denmark. We do not sedate our patients while intubated, unless there is something that indicates a need for it. F.ex. not being able to accept being intubated, pulling at the tube and so on. Otherwise, it is rare that we sedate. When we do, we use Propofol for short term sedation, and if it is for more than a few days we use Midazolam. (I belive you know it as Versed?) We use Morphin as well for pain and discomfort, given as bolus. Our delirious patients are treated with Haloperidol, if they are very delirious and require constant observation, we will often get extra staff to come and sit with the patient constantly. Research has proven that keeping the patients reduces the length of their stay in SICU and improves their prognosis. Additionally, problems with PTS are reduced.

I've linked the research article that supports this, currently there is ongoing nursing research into how the patients experience this as well as how we nurses experience caring for non-sedated intubated patients.

http://crashingpatient.com/pdf/no%20sedation.pdf

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We used Precedex with post-open hearts consistently. O-m-g it's pretty amazing stuff, but the price of it is just as o-m-g.

we used it the first time the other day but it didn't help. the patient still needed 100mcg fentanyl and 70/mcg/kg/min of propofol and still breathing on cpap on vent.

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Specializes in Critical Care.

Has any of you been on a ventilator? Why in heavens name would you not want to "snow" your patient until they are ready to come off the vent? Do they need to be awake for some reason? Why put them through that? Propofol wears off in 5 minutes for weaning! There is increased chance they will self extubate when not sedated, so you have to add restraints. Doesn't make sense to me. We do wake up calls to check neuro status, and if not weaning, its back to sleep for them! If their pressure is affected, the levo would be increased. If a patient has severe PNA, they need that "rest." I've had no luck with Ativan gtts or Fentanyl gtts at keeping the patient comfortable. If your patient keeps bucking the vent, thats horrible for them. :mad:

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