Hourly doses of vent sedation, is this common?

[jkej]

This small ICU doc uses, (almost exclusively) 1mg to 4mg iv doses prn of ativan and morphine for vent sedation. No drips are used. Do any other ICU's do this? Are there any advantages to this? Septic patients with "iffy" blood pressures don't seem to like the morphine too well.

[Circejane]

Our CCU is also small, but we almost always use a titrated Propofol drip. I have seen an Ativan drip used, but not Ativan pushes.

My understanding with the Propofol is that it is easily titratable, easy to rapid bolus, and well tolerated by most patients. The patients I've had generally (not always) hold their BPs decently on it, comparatively. Last night I had a pt. on both Propofol and Epi drips, but she was both sepsis and anaphylaxis, so the epi was serving a dual purpose. We were able to wean the epi by the end of the shift, and still keep her MAP >65 on the Propofol.

Not sure why morphine and lorazepam pushes would be used instead. Cost, maybe?

[BelgianRN]

I can recall only one instance where I kept a patient under with diazepam and fentanyl pushes and that was when we where going in and out of codes when the BP was barely holding under massive amounts of pressors and inotropes.

Our post-op hearts are "sedated" with just remifentanyl so they wake up really easily if there is too much disturbance. They'll get midazolam prn to keep them lightly under if this happens until we can extubate them a few hours later.

[diprifan]

Morphine will decrease LVR and LVEDP. The histamine release will cause sympathetic tone reduction and thus decreased BP.

Fentanyl on the other hand has minimal effect on the cardiovascular system and lacks the histamine release. One side effect is stiff chest syndrome (Skeletal Muscle stiffness = hard to ventilate).

Midazolam is a better choice than Ativan also, it has a far shorter half life.

The physician should really be writing orders for a drip instead of IVP. If the patient was off of sedation and ready for extubation it is appropriate for PRN opioids and benzos. I personally would hate to have to go to the pyxis every hour to get the meds out.

[NurseIn11]

We have that on our vent protocol but we usually use propofol. The prn morphine is good because not everyone needs continuous pain meds but I'm not a big fan of prn Ativan either. Actually I'm not a fan of Ativan gtts either bc it ALWAYS builds up and takes forever to wear off!

[Perpetual Student]

When extubation is anticipated soon (e.g. a patient with pseudocholinesterase deficiency who's taking a while to process her succinylcholine), I've maintained sedation with intermittent pushes of a benzodiazepine and an opiod. I tend to be pretty opiod heavy in my sedation approach given that I work in the PACU. Usually we start a propofol drip on our patients who'll be vented for more than a few hours.

[CrufflerJJ, BSN, RN, EMT-P]

Some of our docs prefer PRN fentanyl/versed pushes to fent/versed drips. Their theory is that nurses will be less likely to "snow" patients with pushes versus the drips. Depending on the pt, the "push" approach can be more of a pain. If you have a pt who requires heavy doses to keep sedated, I've seen a greater chance of self-extubation when the pt is on pushes versus drips. Its almost like a roller coaster - with "wimpy" ordered doses, the pt tends to alternate between agitation and mild sedation. Not good.

[Esme12, ASN, BSN, RN]

Morphine and Ativan IV push is a common means of sedation but less frequently used today due to the use of titrated drips for a more consistent level sedation. While an "old fashioned" approach it is completely "normal" and an acceptable practice.

[nurseprnRN, BSN, RN]

if i'm ever intubated i want the max. it's one of my biggest fears, being conscious and intubated, and i would probably be insanely wild if i weren't completely snowed.

[detroitdano]

We start off with Morphine/Ativan 2-4 mg IVP PRN and if they consistently need it or are climbing out of the bed nonstop, we go to continuous drips of Fentanyl/Versed. Some people are nice and cooperative and only need Morphine/Ativan for comfort, others are off the hook and need to be kept down with drips. I like Propofol for unstable hemodynamics with the need to keep them down, we usually run it by itself or if we have a suspicion of pain or they're IVDA/similar we run Fentanyl with it.

Morphine/Ativan has been proven on our unit to decrease vent days (and the associated risk of VAP) dramatically. We ran an entire study on it. It's really the way to go if you guys are not starting off with it already. Like I mentioned above, some people it will just not work for, but for the majority of folks it's a really good idea.

[detroitdano]

if i'm ever intubated i want the max. it's one of my biggest fears, being conscious and intubated, and i would probably be insanely wild if i weren't completely snowed.

i hear ya. if i'm ever admitted and tubed, i've told my staff that i want to be completely stoned until they're taking the tube out lol.

[sapphire18]

Almost all of our vented pts get propofol gtts. You do have to be careful with septic or otherwise hemodynamically compromised pts though bc it can really hit the BP hard. Someone mentioned cost- constantly getting tiny little morphine/ativan vials, needles, syringes, and flushes for this hourly sedation would be far more expensive than a continuous gtt. And I say, if you are not weaning a pt, why not have continuous sedation? Letting the pt be conscious and uncomfortable, unable to breathe with a tube down their throat is just cruel. For myself, I want fentanyl, versed, AND propofol gtts. Lol.