Intubation and Sedation

Continuing sedation orders should commence when the initial intubation orders expire or when the patient exhibits signs of discomfort, whichever comes first.

That totally depends on a multitude of factors....why you want them out mainly, also facility policies.... are you asking how long to sedate someone for in general? Or just using those two meds?

Is this a question for nursing school?

No, it just came up at work today when sedation was not ordered on a patient. They were not "bucking" or visibly uncomfortable. However, I always have the fear that the paralytic will last longer than the etomidate-- so it's not likely that they'll be thrashing around although they could be mentally aware of paralysis. This client's vital signs were already a wreck and unpredictable, so it wasn't possible to determine discomfort by reviewing vitals. I just wanted to see differing opinions and insight!

The action of vecuronium is significantly longer than the action of etomidate, you are right to worry. I often wonder why physicians continue to utilise competitive, long acting neuro-muscular blocking agents such as vecuronium for the initial RSI procedure.

I often wonder why physicians continue to utilise competitive, long acting neuro-muscular blocking agents such as vecuronium for the initial RSI procedure.

Vecuronium is a neuro-muscular blocking agent with two important characteristics. At an intubating dosage it provides very predictable conditions in about 45 seconds, in order to intubate the patient. It predictably provides 45 minutes of paralysis and some cardiovascular stability. Vecuronium is a generic drug and therefore is very inexpensive, as compared to rocuronium, atracurium and cis-atracurium.

Sch is a non-depolarizing neuromuscular blocker that is perfered by most for initial intubations, however, there are concerns with potassium levels with its usage. At intubating dosages, it is ready in 30-45 seconds with a duration of 5-10 minutes.

Etomidate is a amenesic agent that provides the best cardiovascular stabilty amoung these agents. Its onset is about 30 seconds lasting roughly 20-30 minutes with an intubating dosage. Thiopental and propofol both can produce profound hypotension with induction dosages, perhaps that is why it was not chosen.

Therefore, to answer your question Shannon, with the above medications used, additional sedation should be started around 30 minutes. Most physicians, that I deal with, would start a propofol infusion.

long acting neuro-muscular blocking agents such as vecuronium for the initial RSI procedure.

Maybe I am wrong, but by definition isn't RSI intubating with a pre-fasciculating dosage of tubo-curare, followed by thiopental and sch. I know very few people follow this today and most go with a modified RSI.

Well I'm glad to hear it. I made a small stink about it.. wondering why diprivan, versed, etc wasn't started and the answer I received was "we'll do it when she starts showing discomfort." Ermmm... hello?? I'm sure she probably just heard you say that... but she can't do anything about it because of the vec!! I'm with an orienter right now since I moved across Texas... Sedation is always something I've never had to ensure that my patients had until I started this job. Since it was never an issue before (sedation was always carried out immediately), I just needed all of you to remind me that I'm not crazy! People at work didn't seem to think it mattered. This is in an ER setting but I'm used to the ICU setting. Anyways, like I said... sometimes I need confirmation so I know I didn't just make a @$$ out of myself :)

Etomidate is a amenesic agent that provides the best cardiovascular stabilty amoung these agents. Its onset is about 30 seconds lasting roughly 20-30 minutes with an intubating dosage. Thiopental and propofol both can produce profound hypotension with induction dosages, perhaps that is why it was not chosen.

.

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. The OP has a right to be concerned.

Maybe I am wrong, but by definition isn't RSI intubating with a pre-fasciculating dosage of tubo-curare, followed by thiopental and sch. I know very few people follow this today and most go with a modified RSI.

Rapid Sequence induction is giving an hypnotic such as Pentothal, Propofol, Etomidate, Ketamine,

Brevital followed immediately with Succinylcholine or a large dose of a non-depolarizer (Rocuronium is the most common). Cricoid pressure is sometimes but not always done and no ventilation of the patient is done until the endotracheal tube is in correct position. Curare is no longer produced in the US. Modified RSI is a misnomer and just means that cricoid is used while ventilation is given with an ambu bag.

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. The OP has a right to be concerned.

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.

aaos critical care transport textbook

table 6-4 pg 170

"sedative/induction agents"

etomidate (amidate)[anesthetic agent]

dose 0.2-0.6 mg/kg

onset: 15-45s

duration: 3-12 min

table 6-5 pg 172

"neuromuscular blocking agents"

vecuronium (norcuron)

intubation dose: 0.15 mg/kg

onset: 90-120 sec

duration: 60-75 min

notes: "no effect on loc, so they must be administered with adequate anesthesia, analgesia or sedation"

to the op; you may have an obligation to report this as unethical practice or maybe even incompetence - for god's sake, don't let that md take care of you or your family! i would highly suggest you check with your board of nursing to see what your responsibility is; it may even be something you're liable for if you don't report them.

i can scan/email you the exact pages out of the text book if you need.

-mb

Well I'm glad to hear it. I made a small stink about it.. wondering why diprivan, versed, etc wasn't started and the answer I received was "we'll do it when she starts showing discomfort." Ermmm... hello?? I'm sure she probably just heard you say that... but she can't do anything about it because of the vec!! I'm with an orienter right now since I moved across Texas... Sedation is always something I've never had to ensure that my patients had until I started this job. Since it was never an issue before (sedation was always carried out immediately), I just needed all of you to remind me that I'm not crazy! People at work didn't seem to think it mattered. This is in an ER setting but I'm used to the ICU setting. Anyways, like I said... sometimes I need confirmation so I know I didn't just make a @$$ out of myself :)

No, you were thinking correctly, so kudos to you. One of my early questions after intubation was "What sedation and pain meds do you want to order?" Often forgotten in the rush, but PDI for the patient. One of the reasons we intubate is to decrease stress on an already stressed organ system. That INCLUDES the brain, which will send out massive amounts of catecholamines if awake enough to percieve intubation. Man, I would want Fentanyl and Versed/Diprovan in LARGE amounts if I had to go through that!

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.