to sedate or not to sedate... - page 3

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   Gennaver
    Quote from marissa81579
    I am well aware of JCAHO pain initiatives but it does not hurt to get intubated, it is simply uncomfortable - I think it is a matter of "best practice" - it sounds like the physicians at that hospital are afraid to sedate patients!

    I am not advocating the behavior, I think it is awful. But there is nothing inherently painful about getting intubated, particularly since they numb people's throats before doing it also.

    Discomforting feeling getting a tube shoved down your airway? Sure. But I don't discomfort equals pain. But I agree that patients should be sedated. But you can't lose sight of why they are sedated - it's done for ease of the whole process and so they won't remember it - not for strictly "pain control"
    Hi,
    Even if merely 'discomfortable' how about traumatizing unfairly? Isn't there an ethical code for not unduley assaulting, (intimidating/traumatizing) a patient?

    Or something like that?

    This is not sarcastic, but, just a direct question from a new student who just started an externship in an ICU.

    Thanks!
    Gen
  2. by   Gennaver
    Quote from marissa81579
    ... But I agree that patients should be sedated. But you can't lose sight of why they are sedated - it's done for ease of the whole process and so they won't remember it - not for strictly "pain control"
    Hi Marissa,

    I get you now. I see how you are separting using JHACO pain protocols as faulty justification when the true justification is for actual sedation.

    Very good point and a more legitimate justification for 'sedation' during intubation.

    Gen
    p.s. sorry, I hadn't read through the thread when I posted and had not even read your final first posts paragraph!
  3. by   Gennaver
    Quote from marissa81579

    ...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.

    ...
    Wow,

    This is not a philosophical view that I agree with. No matter if someone fogets that they were in pain. Upon the time of the pain/stress/insult to the body, it does have a physiologic effect on a person immediately and afterwards. As an added stressor on top of all the other insult and stress to the body then yeah, I would say that pain does indeed have an effect, regardless if anyone is around to see or remember it. The system's and organ's recetors sites and endocrine reactions to that stress will happen regardless, right?

    It sounds like saying that a diabetic coma won't matter later because the patients blood sugar will have returned to normal, as if the crisis was not relevant to the day and therefore did not exist?! Huh?

    Gen
  4. by   PJMommy
    Quote from ZASHAGALKA
    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.
    Well said
  5. by   Undecided7
    Ya know, if you even HELP with intubation without sedation- you absolutely DESERVE a lawsuit. Are you EVIL? Or just joking with us? Don't give that crap about the doctors. If they want to do that, just stay out of the way. REAL NURSES don't do that kind of stuff in the USA. (Are you working in Iran?)
  6. by   ZASHAGALKA
    Quote from Gennaver
    Hi Marissa,

    I get you now. I see how you are separting using JHACO pain protocols as faulty justification when the true justification is for actual sedation.

    Very good point and a more legitimate justification for 'sedation' during intubation.

    Gen
    p.s. sorry, I hadn't read through the thread when I posted and had not even read your final first posts paragraph!
    I disagree. Sedation is appropriate for an already intubated pt. But when performing an invasive procedure on a conscious pt, that pt has a right to have his awareness of the painfulness of that procedure reduced. You can sedate (i.e. induce amnesia) for that control, but the goal at that point is supressing the pt's awareness of an invasive procedure; to do less is not only cruel, but unneccessary.

    And that does indeed meet the JCAHO standard. It meets it because it is a violation of that pt's rights. And if you doubt that, take a look at your pt's rights statement that is posted in several places at your hospital and given to all pts on admission.

    Now, I'm sure you can cite me an off the bell curve example of where intubation cannot wait for a few seconds for pain relief (although I'd suspect that if you can get a tube down, then you can ambu, so that would probably be either an emer trach issue or a protect the airway immediately from bleeding, etc.) but the OP was talking about ROUTINELY using no sedation/pain control for intubation. And so I'm not addressing the possibility of an extreme example, but rather the OP's original comments. Obviously there can be a situation where intubation cannot wait for anything and the pt's immediate safety is priority and an ambu bag can't suffice for a few seconds, but that is not the 'routine' presentation.

    I'm not saying that pain control is the highest priority care in an emergency. I AM saying that pain control during an emergency, invasive procedure is not only NOT an optional priority, it is a high priority, not the highest, but high nonetheless.

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Dec 18, '05
  7. by   traumaRUs
    I work in a level one ER and there is no way, no how our MD's would ever do intubation awake. And...what's more, our nurses wouldn't stand for it. I have been a nurse over 15 years and yes, we used to intubate without RSI. However, that is not current practice and an awake intubation should rarely be done. I wouldn't participate in this procedure. However, I would provide research-based info to the MD:

    "The major risk of RSI is that a physician could potentially paralyze a patient and lose the ability to control the airway, and morbidity (eg, cerebral ischemia, surgical airway) or death may result.

    Although no absolute contraindication to RSI exists, a couple of distinct clinical scenarios deserve mention.

    RSI should be used cautiously or avoided in patients who are dependent on the muscle tone in the upper airway to maintain the airway patency in conditions such as a partial airway obstruction. As paralysis occurs and as physiologic muscle tone is lost, partial airway obstruction can progress to complete airway obstruction. In this group of patients, carefully titrated sedation and awake intubation may be preferred. Equipment for alternate airway control, such as a surgical kit or a fiberoptic device, should be at the bedside.

    Also, for the patient in cardiac arrest or for those in a severe comatose state who have no response to laryngoscopy and in whom sedation and paralysis are redundant, RSI is not necessary. These patients need immediate endotracheal intubation and further resuscitation".

    http://www.emedicine.com/emerg/topic939.htm
  8. by   marissa81579
    Interesting dialogue since I have not been here. I can't respond to everyone's post in regards to mine, since most of my arguments were either devil's advocate stuff or highly theoretical. The point is, there are things RNs do not know, that CRNAs/anesthesia people do know. Period. These cases of no sedation are rare, and I have faith there are good reasons for these to occur occasionally. As for the hospital that never does it, I am not even sure I believe the original poster, because I can't see how it would even be feasible to intubate people without sedation, especially big strong young men!!

    That's all I am going to say. The vast majority of you missed the point of most of my posts, so I don't feel the need to respond literally, since that was not the point of my other posts.
  9. by   Gennaver
    Hi there,

    I think there may be some miscommunication here. The way I read it, we are all three, (you, myself and the poster I replied to) in agreement.

    Gen
    p.s. and I could not even name a citation right now, this is the first time I have ever encountered this, I am a new student nurse...

    Quote from ZASHAGALKA
    I disagree. Sedation is appropriate for an already intubated pt. But when performing an invasive procedure on a conscious pt, that pt has a right to have his awareness of the painfulness of that procedure reduced. You can sedate (i.e. induce amnesia) for that control, but the goal at that point is supressing the pt's awareness of an invasive procedure; to do less is not only cruel, but unneccessary.

    And that does indeed meet the JCAHO standard. It meets it because it is a violation of that pt's rights. And if you doubt that, take a look at your pt's rights statement that is posted in several places at your hospital and given to all pts on admission.

    Now, I'm sure you can cite me an off the bell curve example of where intubation cannot wait for a few seconds for pain relief (although I'd suspect that if you can get a tube down, then you can ambu, so that would probably be either an emer trach issue or a protect the airway immediately from bleeding, etc.) but the OP was talking about ROUTINELY using no sedation/pain control for intubation. And so I'm not addressing the possibility of an extreme example, but rather the OP's original comments. Obviously there can be a situation where intubation cannot wait for anything and the pt's immediate safety is priority and an ambu bag can't suffice for a few seconds, but that is not the 'routine' presentation.

    I'm not saying that pain control is the highest priority care in an emergency. I AM saying that pain control during an emergency, invasive procedure is not only NOT an optional priority, it is a high priority, not the highest, but high nonetheless.

    ~faith,
    Timothy.
  10. by   traumaRUs
    Actually, the new ACLS standard states that if intubation might be difficult, it is just fine to provide adequate bag-valve mask breaths until trained personnel can arrive. I'm an RN and if I felt that something is being mismanaged, I certainly speak up...not be confrontative, just asking in order to learn. I'm responsible for my actions and its just like following all orders: if it is not a good order, question it, document it, and obtain a second opinion.
  11. by   fergus51
    I don't know how people can think an intubation isn't painful at all. Having a big metal blade shoved into my mouth then having them manipulate my head and neck so they can stick a tube down my throat seems like it would be painful to me.
  12. by   dfk
    mick,
    i'm sorry but i don't agree whole heartedly with what you said.. i have pushed sux before as well as vec, roc, etc... although i do agree with you that i haven't had the education on managing a difficult airway, i have seen many.. no matter what, whether decompensating or not, pt's always respond very similarly, and ALWAYS looking uncomfortable on some level, even if/when LOC is changing.

    and for marissa,
    sorry, but where i work, it does happen.. all the time. as everyone is prepping for intubation, and myself, or the RT, or the MDA is bagging, people are just focusing on the monitor and usually not the physical patient. for me, this situation is NOT rare, as i hold my propofol, or whichever IVP in my hand, just waiting, which is why the post started.. i can b**ch all i want to the docs, but in the end, it's ultimately their decision (atleast for now anyway).

    and for all,
    thank you for your input. i'm sure this will forever be an evolving and a no clear cut issue.
  13. by   Floridanurse
    I currently work in an OR and work with many anesthesiologists. There are specific conditions in which we do not sedate prior to intubation, however they do use a topical anesthetic to ease the discomfort. For example, a patient with a known cervical fracture may be awake intubated due to the fact that if they can not be intubated then they still have an airway without manipulating their neck. This prevents any emergency intubation from becoming necessary. Most of them go fairly well. However, other than the patients who have the criteria for awake intubations, everyone is sedated.

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