Difficulties With Intubated Patients on Sedatives?

[All4NursingRN]

Hi all!

So recently in my ED we had 3 intubated patients border with us for at least 2 days because all ICU's were "full". We the RN's and also the ED docs were very displeased with the fact that these patients remained in our ED for so long because our ED can get dangerously busy and as we all know the level of care is just not the same as in the ICU's where a nurse has 2-3 patients max.

2 of the 3 patients became very agitated at varying points over the 2 days despite being on multiple sedatives and 2 of them extubated themselves.

So because I see this as a potentially re-curring issue in my workplace I wanted to gather some tips on how to properly manage sedation.

In my experience Versed and Fentanyl seem to do a better job... especially in combination over Propofol alone (which our Intensivists prefer using especially for our neuro-ICH/SDH patients)

Blood pressure is much more sensitive to Propofol than the other two. As far as Precedex... well ...I've never used it???

Do you guys have any tips on which sedative, or combo works best to keep patients down? Has anyone ever had an extremely hard to sedate vented patient? Are paralytics ever considered? What's the best course of treatment? One of our patients was a pretty large man, do you ever go beyond the max dose?

I personally think the ED environment is what largely contributed to these patients extubating. The ED is loud and boisterous at times and we do NOT have a separate area for critical patients, this among other issues..... sigh.

Thanks in advance!

[Corey Narry, MSN, RN, NP]

I find that in many cases Propofol is adequate. The dose I order (as per our protocol) is 0-100 mcg/kg/min to keep our desired RASS score. Unfortunately, hypotension can be a limiting factor with Propofol as you uptitrate. You could usually support the BP with a pressor (such as Neosynephrine drip) if you are certain that the hypotension is sedation related. The other limiting factor for Propofol is a high triglyceride level which is a contraindication to its use.

In patients who are septic or in cardiogenic shock, Propofol may not be the wisest choice. That's when we use Fentanyl and Versed infusion in combination. Sometimes, Propofol isn't enough with younger patients and those with a known history of opioid dependence. In those cases, Fentanyl and Propofol infusion can be helpful to maintain a background opioid dose to match their usual daily requirements.

Paralytics are always a last resort. They are known for causing myopathies which can interfere with weaning and physical rehab later on. We typically reserve them for patients with refractory hypoxemia and increased ICP despite multiple sedatives. Be aware that if you are going to paralyze, make sure you have an amnesia inducing agent along with it in addition to an Opioid like Fentanyl. Only Versed and Propofol have amenstic properties. These should be used with all paralyzed patients so they don't remember the experience of being paralyzed.

Versed also takes longer to wean off/metabolize if used over a long period of time in comparison to Propofol which has short half life. Versed is also associated with delirium like any of the other benzos like Ativan. Precedex is a good drug to use but I find that patients who don't respond to high doses of Propofol will likely not respond to Precedex.

We've used Precedex in patients who wake up writhing and agitated with Propofol wean. It does provide a background sedation and does not suppress the respiratory drive. For that reason, you can extubate a patient with Precedex infusing.

The other consideration for ventilator management is the mode of ventilation you are using. ACVC is very uncomfortable for patients especially now that low tidal volumes are en vogue. If agitation is seen alongside ventilator dysynchrony ,try to adjust your vent mode to see if your patient can tolerate spontaneous breathing mode (pressure support ventilation) or pressure control ventilation which is easier to tolerate.

Lastly, restraints are unfortunately inevitable with ventilated patients. Make sure you have them on.

[calivianya, BSN, RN]

I feel like I have more awake and calm people on Precedex. People on a Precedex drip seem more likely to actually open their eyes, look at me, and follow commands. I have had people on Precedex very calmly changing channels on their television - that doesn't happen nearly as often with propofol. I feel like Precedex doesn't affect blood pressure as much but hits the heart rate harder than propofol. I have seen low 40s/high 30s heart rates - at that point, it's time to switch to something else.

Not everyone responds well to Precedex, and I've definitely had agitated patients that developed heart rate issues before they even remotely looked like they were sedated, but I think it's worth a try in agitated people who aren't responding to propofol. Either way, whether you're using Precedex or propofol, it's definitely worth adding a fentanyl drip to see what that does. Some people are just agitated because of pain. Sometimes, vented patients do just fine with only a fentanyl drip and don't need an amnesic or sedative at all.

Paralytics should absolutely be a last ditch effort. I have seen PRN paralytic pushes for agitation before, but only in extreme cases - usually hardcore IV drug users who run propofol so high they develop hypotension, who need Precedex so high that their heart rate drops dangerously low, who Fentanyl boluses might as well saline, and whose lungs are in such horrible shape that being out of sync with the ventilator can cause a lot of damage.

[spacemonkey15]

In my experience we tend to go for propofol and an opiate (usually morphine or alfent) especially if sedation is only short term and for longer term patients midazolam and morphine. We only paralyse as a last resort to keep patients safe from issues such as vent dis-synchrony. We never use physical restraint, but we have much better staffing ratios for this, ventilated patients are what we define as level 3 (https://www.rcn.org.uk/__data/assets/pdf_file/0005/435587/ICS_Levels_of_Critical_Care_for_Adult_Patients_2009.pdf) so they're nursed 1:1. We tend to manage hypotension secondary to sedation with a noradrenaline infusion or with metaraminol if we don't have central access.

If I were in the OP's situation, I'd probably look at deepening sedation as you're probably not going to be looking at weaning and extubating the patients and you need to keep them safe. Over here you wouldn't get a patient down in the ED for that length of time, they'd look at moving them to theatre recovery or manage to create a bed for them on ICU some way.

[ICURN3020]

Wow, great answers and explanations from the pp. I don't have much to add except that personally, I found Precedex to often be ineffective. Propofol is a wonderful drug and works amazingly, although of course there are situations where its use is contraindicated (hypotension, etc).

I have been intubated/ventilated and sedated on propofol (thankfully I tolerated it) and it was a Godsend. I distinctly remember the times in which I was awakened with a sedation holiday and responded to my nurses and doctors questions with a head nod/shake and followed their other commands. I did not feel overly anxious and was able to drift back off to lala land peacefully. I am so thankful that I was blessed with effective sedation because it is very traumatizing to be in that helpless, frightening situation. One of the things that infuriates me is when I'm caring for a ventilated patient and have to fight tooth and nail with the doctors for adequate sedation. Sometimes I think a requirement of doctors and nurses training should be to experience intubation and being on a ventilator, being restrained and being unable to communicate. Of course that will never happen, but let me tell you, when you've been the one in that bed in that position, you're ability to understand your patient's point of view and feelings is much clearer. PLEASE DO NOT UNDERESTIMATE THE NEED FOR ADEQUATE SEDATION!! Advocate for your patients so the experience is not any more traumatic than it has to be. Not to mention it will make your job caring for that person much easier and it's safer for the patient as well.

[Smalltimore]

Nursing student here, it seems like keeping critical patients in the ED for that long would be dangerous. Is this something that happens in cities with lots of hospitals, or only in more remote areas where transferring the patient isn't possible? I understand transferring critical patients is difficult, but I would imagine it would still be safer to get them to an ICU. Am I wrong?

Thanks!

[VANurse2010]

Nursing student here, it seems like keeping critical patients in the ED for that long would be dangerous. Is this something that happens in cities with lots of hospitals, or only in more remote areas where transferring the patient isn't possible? I understand transferring critical patients is difficult, but I would imagine it would still be safer to get them to an ICU. Am I wrong?

Thanks!

The ED should be capable of boarding a patient until an ICU bed becomes available. Not ideal, but ED nursing is a form of critical care.

[emilyewrn]

I work in SICU and we usually use the propofol/fentanyl combo for short term use. We never use propofol alone without something for pain management as well. For longer term, ativan/fentanyl. We use precedex on those who wake up agitated and crazy when weaning proposal. Precedex is nice because it can be used on extubated patients as well.

[L♡vER]

It is VERY common to board patients in the ER unfortunately. Frequently these are critical 1:1 ICU cases. It is not ideal for the patient, families or the ER nurse who is likely still taking a load of emergency patients. We are capable, yes, but these patients are absolutely better off in a quiet icu with a nurse who lives intensive care day in and day out. Initiating critical drips is a much different ballgame than the longterm management of them.

[delphine22]

Restraints!!

But yeah, more propofol. I've generally found precedex to be useless, and it's not for you in the ED, bc you're not ready to wean anyway. More Milk of Amnesia, sprinkled lightly with Levo if their pressure needs it.

[VANurse2010]

It is VERY common to board patients in the ER unfortunately. Frequently these are critical 1:1 ICU cases. It is not ideal for the patient, families or the ER nurse who is likely still taking a load of emergency patients. We are capable, yes, but these patients are absolutely better off in a quiet icu with a nurse who lives intensive care day in and day out. Initiating critical drips is a much different ballgame than the longterm management of them.

LOL! You think ICUs are quiet? Perhaps compared to an ED, but still...