vents and sedation?

  1. I work at a smaller hopital in a 12 bed ICU. We frequently have patients who are unsedated on the vent. I am new to the ICU, but I thought sedating vented patients was pretty much standard of care.
    I asked around at work and some of my co-workers told me that if the patient seems content no sedation is necessary.
    So how common is this? What is standard of care for sedation and vents? Thanks in advance for your input.
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  2. 22 Comments

  3. by   dfk
    Quote from emmycRN
    I work at a smaller hopital in a 12 bed ICU. We frequently have patients who are unsedated on the vent. I am new to the ICU, but I thought sedating vented patients was pretty much standard of care.
    I asked around at work and some of my co-workers told me that if the patient seems content no sedation is necessary.
    So how common is this? What is standard of care for sedation and vents? Thanks in advance for your input.
    i guess you need to define 'standard of care'... institutions may have protocols for vented pts... it is ideal to have less to no sedation so that weaning becomes less difficult... i've taken care of all types of vented pts, from awake to drooling... either way, it can't be too comfortable breathing thru a straw of sorts.. some patients actually smile and tolerate a vent without sedation quite miraculously...
  4. by   RN Randy
    Well.... think of this:

    What would be objective numero uno 5 minutes after putting a pt on a vent?

    Weaning them off.

    So it's usually [and I say that with rolling eyes] a good idea to *initially* sedate and then wean it off. Some places want the sedation off every morning to check progress, etc, and others simply follow a protocol and bring everything down on a schedule. Either way the simplest point of view is as your colleagues said: If you're content on your vent, why sedate?
    [Noting of course, there are exceptions to every situation/rule!]

    What type of sedation are you speaking of? I've noticed facility specific definitions when it comes to stuff like that.
    Sedation meaning Lorazepam/Fentanyl or sedation meaning Propofol?
    rb
  5. by   nurse4theplanet
    Not all our vent patients are sedated. It just depends on whether they are tolerating the vent or not. Some patients get really anxious with the tube down their throat (and rightly so), their HR and BP sky-rocket, they fight the vent to the point it is constantly alarming, they thrash about in bed, tears streaming down their checks, hands having to be restrained to keep them from yanking the tube right out...OBVIOUSLY, these are the patient's that we keep sedated. The ventilator is there for a purpose, and they need to be calm and let the vent do the job. They are usually ordered on a Diprivan gtt. It is decreased each shift to do neuro checks and weaned to the lowest level needed to maintain comfort.

    Sometimes pt's don't mind the vent but get overly anxious when visitors/family/staff come in and they can't speak and communicate their needs verbally. We try to provide cards and picture communication boards, pen and paper, and whatever else we can get our hands on...but if they get frustrated then the MD will order a little ativan prn to help keep them calm. These patients need lots of reassurance and psychological support.

    Then we have patients that are cool as cucumbers, never seem bothered by the vent at all, and don't even report any pain when you ask them...only signs of discomfort are during suctioning which is expected. No reason to sedate.
    Last edit by nurse4theplanet on Jan 15, '07
  6. by   cardiacRN2006
    It's very rare that our vented pts aren't sedated.
  7. by   wd272003
    Hi, I'm an ICU trained RN from Singapore. In the ICU at my side, most patients are sedated especially when they've just been intubated. But we do check on the sedation score to ensure that the patients are too overly drowsy. We titrate the sedation till the patient is comfortable and not struggling with the vent. If the patient is awake and calm, we might even turn off the sedation. Especially so when the anaesthtists plan to extubate the the patients. However, we do practice restraining our ventilated patients unless the patient has been with us for a long time and we are sure that he/she will not yank out his tube...:uhoh21:
  8. by   just_peachy83
    I work in a medical ICU and we have the same approach that the majority of others have already mentioned. Most of our patients are sedated on Fentanyl/Ativan or Fentanyl/Versed gtts, but that's only because most people get agitated when a tube and lots of pressurized air are being shoved down their throats.

    However, there are those rare few who do great without sedation, and we don't mess with them if they are. It's less weaning to be done, and better for them neuro-wise.

    For pts on continuous IV sedation, we "dose optimize" once a day - in other words, we turn off the sedation to observe how the pt tolerates it. If the sedation has to be turned back on, we turn it on at half the original dose, thereby gradually weaning them as tolerated. Plus, the docs have told me that studies show interruptions in sedation actually improves neurologic outcomes.

    Also, sedation and even chemical paralysis is always used on our unit if we have to use an unusual mode of ventilation, such as pressure control, volume control, oscillation, or even if we are reversing the inspiratory/expiratory times, etc. Anything that would feel extremely unnatural or uncomfortable to the pt (at least, more so than your "normal" modes of mechanical ventilation).
  9. by   ICURN2004
    Quote from emmycRN
    I work at a smaller hopital in a 12 bed ICU. We frequently have patients who are unsedated on the vent. I am new to the ICU, but I thought sedating vented patients was pretty much standard of care.
    I asked around at work and some of my co-workers told me that if the patient seems content no sedation is necessary.
    So how common is this? What is standard of care for sedation and vents? Thanks in advance for your input.


    Just remember Patient comfort and Patient care. each patient is different. i have learned that nursing could change for any patient before you finish empting the bedpan. debbie
  10. by   rgroyer1RNBSN
    Most of my patients in SICU on vents are sedated. There usually on propofol titrated up or down according to what they need and we eventually wean them off it. Some of ares arent sedated but have an order for Fentanyll/Versed to be pushed if they have problems with it , its a prn order and there nurse decides if they need it then he or she will go push it, put I have had one older surgeon put some one on a Versed drip and he accidently hooked it to the persons A-Line seeing as how he doesnt know how to ask the nursing staff for help since hes to good to use us nurses and knows how to do everything, hes a smarta$$ and no one likes to put up with him.:smilecoffeecup:
  11. by   dfk
    Quote from rgroyer1RNBSN
    Most of my patients in SICU on vents are sedated. There usually on propofol titrated up or down according to what they need and we eventually wean them off it. Some of ares arent sedated but have an order for Fentanyll/Versed to be pushed if they have problems with it , its a prn order and there nurse decides if they need it then he or she will go push it, put I have had one older surgeon put some one on a Versed drip and he accidently hooked it to the persons A-Line seeing as how he doesnt know how to ask the nursing staff for help since hes to good to use us nurses and knows how to do everything, hes a smarta$$ and no one likes to put up with him.:smilecoffeecup:
    i smell necrotic limb.. i'd slap that surgeon with an idiot lawsuit
  12. by   burn out
    Why are you even putting them on the vent them? Most of the time we put a patient on the vent because they are so weak and sick that they can't maintain their own airway and in this case they are sedated to give their body a rest to heal and recover. Or perhaps they have had and MI and you don't want to work the heart anymore than necessary to even breath so they are intubated and sedated. the only time a patient is not sedated on a vent is when they are getting ready to be extubated.
  13. by   BamaFlightRN
    Sedation should be considered with any vent patient. Many ventilator patients are just not a candidate to wean. I like propofol infusions, very safe. But for the long term, Versed infusion is a very nice drug. I also like to add Morphine to the sedation. Most of the time we use 1-2 mg Versed/hr and 2-4mg/Morphine/hr.
  14. by   RN Randy
    How about a side note...
    What's everyone's protocols for sedation with the initial intubation? I just got home from work where my last act was to take a MET call out on the floor, and watch grandma-in-her-makeup-CRNA with standard-issue surgery attitude begin an intubation.

    She had good skill of course, but my problem was with her standing bolt upright and striking a pose to give me a very long, quiet, dirty look when I asked if we going to give the guy anything [as I watched him weakly struggle and bite down on the blade]. He had no energy to fight, but was wide awake.

    She was so cool, she used a Mac blade about half in the oropharynx with the guy biting teeth on it, and succeeded on the first try. Excellent manual dexterity.
    Woopty freakin doo. She really showed me.
    ...and left the patient a nice memory too.

    These surgery people make me want to puke; all nice and clean, 3 people with a large trauma bag full of God knows what; [one person to tube, one to do cric pressure and one to dig in the bag], coming in to do a low-level ACLS skill like it's some awe-inspiring feat, and we should drop and give thanks.
    I say she can come ride with me one shift and try her little trick alone in the pouring rain through the sunroof of a car lying on it's side.
    I'm betting she won't be so cocky then.

    Anyway, the issue is the questionable treatment of the patient. Just because one isn't ABLE to fight you off, they get no sedation or even 'twilight' meds...?
    Am I asking too much here?

    Sorry for the venting but that just gets my goat.
    rb

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