Intubation and Sedation

Specialties Emergency

Published

Etomidate and Vec are given for initiation of intubation. What time frame does it become inappropriate that the MD does not order continued sedation?

Specializes in ER, OR, Cardiac ICU.

As that tube is sliding past the vocal cords, my ED docs can count on me asking the same thing every time..."What are we keeping him/her down with?"

Saves a bunch of frantic maneuvering when your intubated patient is profoundly tachy and it dawns on you that they are paralyzed but not sedated.

Specializes in cardiac, ICU, education.
Etomidate's duration of action is much shorter than 20-30 min. It is actually 3-10 minutes. Sedation should be quickly started after intubation of a critically ill patient.

First I want to apologize for not re-reading my post. I am really jet lagged and I shouldn't of posted when I did. I originally wanted to say 2-3 minutes but I know many sources site 3-10. The truth of the matter is that many physicians (anesthesiologists usually) don't like Etomidate because of the pain on injection, nausea, vomiting and adrenal surpression (probably one of the biggest concerns I hear from the MD's). Also the OP is right to worry, but she may not be able to do a great deal about it because the ER may be required to use those drugs and since the FDA "highly recommends" that anyone but anesthesiologists/CRNA should not use propofol, the ER doc may have to use what they get. I know they might use it, but their not suppose to. However, it is a great question to suggest to your nursing manager to discuss with the powers that be regarding sedation.

But I will push back on one thing I mentioned, RSI, by complete original definition per ASA guidelines states, "pre-oxygenation, circoid pressure (all the time), a pre fasculating dose (tubo-curare), thiopental followed by sch. No ventilation at any point, followed by intubation. Circoid pressure is continued until confirmation of correct endotracheal intubation."

RSI is used because the patient is not fasted or fasting is in question (ie, trauma, narcotics administration, delayed gastric empting, etc.). Yes, very few in any use a traditional RSI, therefore, a MODIFIED RSI is used mostly with rocuronium replacing tubo-curare and propofol replacing thiopental-everything else stays the same. The only reason I know this is because my husband is a BC Anesthesiologist and he just re-certified for his boards (they now recert every 10 years) and the question was on the review I was helping with with. I guess since I am an educator I get to help him study :). Notwithstanding the fact I accidently mentioned RSI during an intubation and the anesthesiologists "reminded" me that what they do is modified.

Thiopental is in America and it is on every anesthesia cart we have, however it is not used as much because the cost of propofol has been reduced to that of thiopental. Also, because of propofol distribution profile it is a better agent for outpatient surgery, than thiopental. Thiopental also has a disadvantage in that it needs to be mixed before usage, therefore, it is rarely used in E.R.'s and ICU's .

Unfortunately, ER docs in your facility may be using Vecuronium because it is cheaper than the others ones I mentioned. Also, thanks to the person who mentioned roc is a generic, I am aware of that but my comment was about the cost and how it is more expensive than vec.

Msn10, we are not talking about what is on an anaesthesia cart in the operating theatre. The OP is discussing a case specific to the emergency room. Thiopental is not an agent that you will likely encounter in a typical emergency room. Also, "modified RSI" versus "RSI" is frankly an argument in semantics regarding the OP's questions.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Msn10, we are not talking about what is on an anaesthesia cart in the operating theatre. The OP is discussing a case specific to the emergency room. Thiopental is not an agent that you will likely encounter in a typical emergency room. Also, "modified RSI" versus "RSI" is frankly an argument in semantics regarding the OP's questions.

What actual drugs that are used in a facility varies greatly across the United States. Demographic area as well as MD preference locally influences drug choice as much as anything else. msn10 make very good pois nd gives excellent information as to the length of drug effect. I have always encouraged the MD's to give ongoing sedation orders especially before the patient transfers out of the department.:twocents::twocents:

Specializes in Anesthesia.
Exactly, a good rule of thumb that I go by is 100 seconds per every 0.1 mg/kg. Using the common dose of 0.3 mg/kg, you only have about 5 minutes with etomidate.

Msn10, rocuronium is also a generic name. The brand name for rocuronium is Zemuron. I would actually prefer rocuronium over vecuronium because of it's shorter duration of action. However, I still like sux when it's not contraindicated specifically because of it's very short onset and short duration of action. I assume you are not practicing in the United States? The only time I saw thiopental used was when I was working for a South African/Australian company in the Middle East.

Baltimore Shock Trauma was still routinely using thiopental for the emergent intubations when I was there. Some places still like to use it because it can left drawn up for long periods of time without the worry of bacterial contamination.

Specializes in Trauma ICU.

Thiopental is no longer available for use in the United States and if you had some you could probably get a pretty penny for it from one of the states that has a current backup of executions. The last manufacturer of STP moved their operations to Italy and the Italian government essentially blackmailed them into not selling it in the US because of it's use in lethal injections. So, unless you are at a place that stockpiled the stuff it isn't generally available on any anesthesia cart. D-tubo curare has not been on the market for quite a long time due to it's nasty side effects (lots of histamine being one of the worst). While it may be that the strict ASA definition of RSI is as you have said, however due to the inability to acquire the drugs stated it is an impossibility and thus merely semantics. RSI can be accomplished with a higher dosage of Rocuronium instead of Sux if necessary (with an MH patient or a patient with high K) and this may be more correctly termed a "modified RSI" but in the end it is semantics.

Some questioned the use of etomidate but it may be that this person was best sedated with it due to unstable hemodynamics.

In the end though the OP is correct because, as has been stated, the difference in duration of action is quite different the patient was in need of something to sedate them. So, you aren't crazy....

Specializes in Hospice.

As a hospice nurse with almost know knowledge of the intubation procedure, I have had patients who can remember being intubated and paralyzed and TERRIFIED. To me, it is never okay for a patient to be suffering if we can easily counteract, like mild sedation. I can not imagine anything scarier than having a machine breathing for me and being paralyzed. Good for your for questioning that doc.

Specializes in cardiac, ICU, education.
Msn10, we are not talking about what is on an anaesthesia cart

We have anesthesia carts in the ER. Our anesthesiologists set them up and the CRNA's respond to a great deal of codes because the hospital viewed them as the experts with regards to intubation. We have some phenomenal CRNA's!!!!

I realize the OP was talking about the ER in her later posts, but I am trying to give her ideas (based on my experience) if she wants to take this further. There is no question that the OP's ER is involved in a risky practice.

My suggestion would be to research your ER's policy and talk with the physicians as to why they do what they do. You should be given an answer by them because it is your license too. Then talk to someone in your anesthesia department. With our hospital, the 2 departments got together to talk about proper protocol. Now they are taking it a step further and going to other areas in the hospital because of the problems we all know and hear of in GI labs and with some pediatric intensivists. BTW, the discussions of the 2 departments started with a concerned CRNA and an RN just like yourself:)

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thiopental is no longer available for use in the United States and if you had some you could probably get a pretty penny for it from one of the states that has a current backup of executions. The last manufacturer of STP moved their operations to Italy and the Italian government essentially blackmailed them into not selling it in the US because of it's use in lethal injections. So, unless you are at a place that stockpiled the stuff it isn't generally available on any anesthesia cart. D-tubo curare has not been on the market for quite a long time due to it's nasty side effects (lots of histamine being one of the worst). While it may be that the strict ASA definition of RSI is as you have said, however due to the inability to acquire the drugs stated it is an impossibility and thus merely semantics. RSI can be accomplished with a higher dosage of Rocuronium instead of Sux if necessary (with an MH patient or a patient with high K) and this may be more correctly termed a "modified RSI" but in the end it is semantics.

Some questioned the use of etomidate but it may be that this person was best sedated with it due to unstable hemodynamics.

In the end though the OP is correct because, as has been stated, the difference in duration of action is quite different the patient was in need of something to sedate them. So, you aren't crazy....

This is off topic but here it goes....

There are still facilities that import Thiopent thru overseas supplers namely England Although, that too, as of April 1, is in jeporardy because of the common use of the drug for excecutons even though the drug was stoppped production in the US in 2009. an attempt was made at overseas production. Novartis as of Feb 11,2011 has ordered all suppliers to stop supplying to the US here are still spplies of thiopent in the US. There has also as of, I believe, April 1 A federal lawsuit to stop the use of thiopental in executions..........some states have already begun to use pentobarbital..........but the presence of thiopental has yet to dissapear from facilities as there are still some stock piled supplies and some facilities are still able to import the drug if registered with the FDA DEA so as to prove not to be used for executions....

http://www.reuters.com/article/2011/04/01/us-executions-drug-idUSTRE7307ZK20110401

http://www.medpagetoday.com/Anesthesiology/Anesthesiology/24830

Specializes in cardiac, ICU, education.

also wtbcrna

Baltimore Shock Trauma was still routinely using thiopental for the emergent intubations when I was there. Some places still like to use it because it can left drawn up for long periods of time without the worry of bacterial contamination.

You are right and it lasts forever. We have a phenominal anesthesia manager -a CRNA/old military - and I think he has a sixth sense when it comes to ordering because once he hears something is getting low (morphine, thiopental) he orders a ton so we don't feel or see the problems. The MD's love him.

Specializes in cardiac, ICU, education.
There has also as of, I believe, April 1 A federal lawsuit to stop the use of thiopental in executions..........some states have already begun to use pentobarbital..........but the presence of thiopental has yet to dissapear from facilities as there are still some stock piled supplies and some facilities are still able to import the drug if registered with the FDA DEA so as to prove not to be used for executions....

Also, the ASA is almost demanding it come back because of the problems with the production and past shortages of propofol.

http://news.nurse.com/article/20110125/OR02/301250034

I think they will win the argument. But if anyone needs any thiopental, I'll connect you with my CRNA, the guy is a genius!

Specializes in Trauma ICU.

I stand corrected about STP availability. All I know is that generally in the area I am in there is narry a drop to be had. The problem with STP and Propofol are that they are not money makers for the drug companies and thus they are not going to do too much extra to manufacture the drugs.

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