to sedate or not to sedate... - page 2

at my facility, anesthesia does not sedate during intubation.. the patient is fully awake, writhing, looks uncomfortable and probably in pain through the whole process.. when i ask them why not some... Read More

  1. by   heartICU
    Ok for those of you whose patients are not sedated, what are the circumstances of the situation? Is the patient wide awake, are they in respiratory distress, respiratory arrest? I am guessing they are given something, otherwise you would not be able to even pass the blade on a coughing gagging person. So the people who are intubating at your facility are not giving anything whatsoever?
  2. by   dfk
    usually just some hurricaine spray.. the pt is usually in some good distress, so usually pooped out.. but when the blade is moving the airway around, i can tell from the pts tearing that it isn't comfortable. the funny thing is that the docs say "ok, load em up with some propofol now" after the part that can be most irritating and nerve racking both for pt and nurse..
  3. by   Balder_LPN
    Couldnt the Pain/discomfort debate be settled by asking some pt's to rate their pain, that should be a good indication of if the pt is feeling Pain or not.
  4. by   ZASHAGALKA
    Quote from Balder
    Couldnt the Pain/discomfort debate be settled by asking some pt's to rate their pain, that should be a good indication of if the pt is feeling Pain or not.
    The problem is that 'AFTER' they are extubated and can talk, they will have been on diprivan for long enough not to have any memory of the event.

    At the time of intubation, they will be too worn out to try to play a hand signal game before sedating them.

    But just because they might 'forget' the event doesn't make it any less barbaric.

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Dec 9, '05
  5. by   PJMommy
    Quote from ZASHAGALKA
    But just because they might 'forget' the event doesn't make it any less barbaric.
    Amen.
  6. by   marissa81579
    In reply to the post from AZ, I have seen doctors use the hurricane spray and some not use it. I would imagine if a doctor intubating insisted on not sedating the patient, a diligent nurse would direct the doctor to use some numbing agent *at the least*. And no, I have never seen a patient in severe pain when a doctor is trying to intubate - but this is because the ICUs I worked in always sedated patients sufficiently beforehand.

    Is it less barbaric to sedate? Yes. However, as nurses, we can't ignore a body of research that physicians may be referring to in deciding not to sedate the patient. And some people (on a more philosophical point of view) consider pain to have not existed if a person does not remember it. It's along the same lines as "Did a tree fall in the woods if no one hears it" or whatever.

    I would hate to not sedate a patient for intubation - I don't know about the research supporting it because where I have worked it is just never done - we always sedate the patients. But I am just playing devil's advocate here. Aspiration risk is real, significant and you all know what it can lead to. So I can *understand* why some physicians in some facilities weigh both sides of it and decide that pain (that the patient will not remember) is better than the risk of aspiration. I personally disagree, but it is unwise to just dismiss is as "cruel" - a lot of what we do in ICU is arguably barbaric. It is important to look at both sides of the argument and understand why people make different judgment calls for patients.

    And as for the person who suggested that people rate their pain - that isn't gonna happen with most critically ill patients getting intubated. We just have to watch and observe the patients for signs of acute pain. If a doctor is hacking up someone's airway to intubate - they probably should not be doing it as I have never seen even a resident do it that incompetently. Usually, intubations are fairly uncomplicated as long as the positioning is good and the doc has enough light. At least in my experience - they take but a few minutes.
  7. by   dfk
    marissa, sorry, but i don't agree.. pts do remember, and they do feel pain.. we as nurses do have a say, whether teaching facility or not. it just has to be louder when necessary. i can tell you i am not hesitant at all to speak up when needed, ET tube, central line, or whatever. i put myself in that place, for which i consider myself rather alright... so, for that, i can feel for anyone in such a place.. empathy? yes! sympathy? why not! i can't believe one cannot feel such discomfort and not associate pain as any relevance!
  8. by   PJMommy
    Okay...I have to speak up. First of all, sedatives are not pain medications. Two different things. I think we all know this but the discussion has spun off to a discussion justifying sedation because of the possibility of pain.

    If this "body of evidence" showing the risks of sedation exists, then nurses shouldn't just take docs word for it -- go look for it. If you do not have access to a library or electronic journals, then go to websites like www.guidelines.gov or www.ihi.org. I don't find a body of evidence supporting no sedation in my 5 minutes of searching this morning. All I find is the typical recommendations are for pentothal and succylcholine (sp?) which is exactly what our CRNAs and anesthesiologists use. Cricoid pressure is done to prevent aspiration in rapid sequence intubation.

    A change in practice for docs or nurses should never be justified based on one or two studies. And the docs certainly don't have the market on reading the latest research. It's out there for us as well.

    As a previous poster stated, the evidence they are citing should be produced. I suspect, as is often the case, some doc got a wild hair based on some random study he/she read and is insisting on no sedation for all pt's. If ethics committee won't touch it, do you have an ethics hotline? Medical review board? State medical board?
  9. by   dfk
    yes, pjmommy, you're right about the difference and you're right about the tangent.. it's funny how far and fast things happen. (that's why we're here, right??) anyway, i do agree with you re: the one or two study thing.. people are quite willing to offer their opinion based on such. it happens. docs, nurses, attorneys, pushcart people... i think it's important we all LISTEN to others thoughts, and with a specific grain of salt sometimes. i don't know, i still think it should be looked at a bit closer, by all.
  10. by   marissa81579
    I also do not know why this has spun off into a pain management issue. Pain meds are not indicated for intubation. If people here have experiences where their patients have remembered being intubated, that is in the minority as I have never known a patient to remember any of it.

    We usually need to sedate patients because it would be next to impossible to do the procedure if a patient is writhing around. I don't know what else to say. We use pento or succ, propofol bolus followed by a propofol drip (in most cases). Not PAIN meds! I do not think it is proper to think of this as pain management issue. More like an anxiety management issue as being intubated is strange feeling and who wants to be awake for it?

    I have been intubated before and it is not painful. I tihnk if most intubations were painful, people later extubated would complain of it but usually they just complain of horseness, not horrific throat pain.

    Don't lose sight of what this is an issue of.

    And to whoever "disagreed" with me, that's really great but like i said I was playing devil's advocate. I don't know if the body of research is large or small, or if these docs are just playing maverick here. I don't know. Of course if a patient was in some ridiculous discomfort I tell the docs I need to give them opiates or benzos or whatever else depending. I think it is a problem of nurses because many are doormats who do not speak up. But I am not one of them. However, I am not just going to dismiss these docs practice as "barbaric" until I see studies contraindicating it. Sometimes 1 or 2 studies is not enough, but every medical procedure/drug etc starts off with only 1 or 2 studies.
  11. by   Mick2003
    ..
    Last edit by Mick2003 on Nov 5, '06
  12. by   Simba&NalasMom
    Quote from dfk
    i hear all of u.. it's the doctor's call, not our nurse mgr. (who just resigned - YAHOOOOO!!!) it seems to be somewhat of common practice from what i am gathering (doc wise). at this point, ethics committee won't get involved (the same nurse mgr that's resigning was on committee)- how funny is that? i'd be interested to take a poll of those that got tubed and ask of experience
    r/t awake/asleep, and their thoughts. (not that breathing thru a large straw is not memorable enough!!) -
    Sounds like that's what has to happen...they'll only listen to the patients. Wouldn't it be wonderful if we could encourage our patients to complain without fear of retribution? :angryfire
  13. by   ZASHAGALKA
    Quote from Mick2003
    It must be comforting to be a “patient advocate.”

    However, in the real world of a CRNA/Anesthesiologist, we have to manage airways on an emergency basis. Most times, when called to the ICU, despite the fact that we would love to sedate/anesthetise/paralyze, it’s not in the patient’s best interest. We make this decision based upon the patients condition, stability and ancillary resources. We secure airways in the safest and most humane ways possible. As a nurse, you have absolutely no responsibility for a lost airway and the suffocation that “just a little propofol” can cause. You have no training in the evaluation and management of the potentially difficult airway. Take a little responsibility for airway management and its ultimate control (have you ever pushed sux by yourself?) and you’ll know what I’m writing about.

    Mick
    Look, we are talking about a rare subset of these pts. Most pts needing emergent intubation have signicant LOC changes anyway.

    But if someone stuck a tube down a wide awake person without giving anything to ease the uncomfortableness of that procedure in my presence, I'd loudly and persistently object then and there, and I'd take them to the ethics committee.

    A higher education doesn't entitle someone to arrogant unconcern for the effects of what they do to pts under their care. And it's not just me that says so. JCAHO has my backside on this.

    There is room in the 'real world' for both effectiveness AND compassion. To say there isn't points out the shortcomings of someone that would advocate that viewpoint, not mine.

    And IT IS comforting to know that I am a pt advocate. I'd have it no other way.

    ~faith,
    Timothy.

    And for the record, I was and have been speaking in generalities and not attributing characteristics to any individual.
    Last edit by ZASHAGALKA on Dec 18, '05

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