to sedate or not to sedate...

[dfk]

at my facility, anesthesia does not sedate during intubation.. the patient is fully awake, writhing, looks uncomfortable and probably in pain through the whole process.. when i ask them why not some propofol or whatever, they say it's better/safer for the patient, i.e. aspiration or the like. at this point, i say, what's the difference, they end up on sedation as soon as the tube is in. i shake my head in disgust. if there's one thing that bothers me the most at my job, is this. your thoughts?

[fergus51]

I don't know how people can think an intubation isn't painful at all. Having a big metal blade shoved into my mouth then having them manipulate my head and neck so they can stick a tube down my throat seems like it would be painful to me.

[dfk, RN, CRNA]

mick,

i'm sorry but i don't agree whole heartedly with what you said.. i have pushed sux before as well as vec, roc, etc... although i do agree with you that i haven't had the education on managing a difficult airway, i have seen many.. no matter what, whether decompensating or not, pt's always respond very similarly, and ALWAYS looking uncomfortable on some level, even if/when LOC is changing.

and for marissa,

sorry, but where i work, it does happen.. all the time. as everyone is prepping for intubation, and myself, or the RT, or the MDA is bagging, people are just focusing on the monitor and usually not the physical patient. for me, this situation is NOT rare, as i hold my propofol, or whichever IVP in my hand, just waiting, which is why the post started.. i can b**ch all i want to the docs, but in the end, it's ultimately their decision (atleast for now anyway).

and for all,

thank you for your input. i'm sure this will forever be an evolving and a no clear cut issue.

[Floridanurse]

I currently work in an OR and work with many anesthesiologists. There are specific conditions in which we do not sedate prior to intubation, however they do use a topical anesthetic to ease the discomfort. For example, a patient with a known cervical fracture may be awake intubated due to the fact that if they can not be intubated then they still have an airway without manipulating their neck. This prevents any emergency intubation from becoming necessary. Most of them go fairly well. However, other than the patients who have the criteria for awake intubations, everyone is sedated.

[FloridaCCRN, CRNA]

No sedation!:uhoh21: :chair:

[madgiclady1]

:(that is totally wrong, if you took your animal to the vet he would sedate your pet why not be that kind to a human

at my facility, anesthesia does not sedate during intubation.. the patient is fully awake, writhing, looks uncomfortable and probably in pain through the whole process.. when i ask them why not some propofol or whatever, they say it's better/safer for the patient, i.e. aspiration or the like. at this point, i say, what's the difference, they end up on sedation as soon as the tube is in. i shake my head in disgust. if there's one thing that bothers me the most at my job, is this. your thoughts?

[rgroyer1RNBSN, BSN, RN]

Im working ICU. I have worked er and I also cover the chopper. And I do have the training to manage a difficult airway from being an emt-p besides a nurse to. None of are docs infact I ask quite a few docs about this, and none of the ones where I work would never not sedate a patient for intubation and neither would any of us on the flight team or any of are emt-p's. I know we usually use the following:

*Succs or pavillon

*Etomidate

*Versed

*Lidocaine

*Benadryl

*Morphine

then we usually maintain with any/any combination of the following:

*propofol

*sumblimaze

*Ketamine

*Fentanyl Drip

*Versed Drip

*Diazepam Drip

*Morphine Sulfate

Rod RN,BSN CEN,CCRN,CFRN:nurse:

P.S. I wanna know which hospital it is that doesnt sedate because im not going there:o :uhoh21: :sofahider

[bsnccrn]

I am well aware of JCAHO pain initiatives but it does not hurt to get intubated, it is simply uncomfortable - I think it is a matter of "best practice" - it sounds like the physicians at that hospital are afraid to sedate patients!

I am not advocating the behavior, I think it is awful. But there is nothing inherently painful about getting intubated, particularly since they numb people's throats before doing it also.

Discomforting feeling getting a tube shoved down your airway? Sure. But I don't discomfort equals pain. But I agree that patients should be sedated. But you can't lose sight of why they are sedated - it's done for ease of the whole process and so they won't remember it - not for strictly "pain control"

How can she say discomfort does not equal pain?? What planet is she from? I have never seen an intubation in the ICU that got numbed. There is without adoubt pain, discomfort and anxiety. If it is not uncomfortable or painfull why do we continue with pain meds/sedation after intubation? Please refer to AACN study of what we do to patients and their perception of pain!

[JiffyGriff]

when i ask them why not some propofol or whatever, they say it's better/safer for the patient, i.e. aspiration or the like.

I'm not gonna go through and take all the time to quote everybodies statments in here, but I think the original debate started out with whether or not to sedate because it poses a risk to the patient (aspiration). I then saw some people mention using a numbing spray for the throat instead of sedation to counterract this problem???? Wouldn't a numbing spray to the throat pose the same risk for aspiration that sedation would, maybe I'm wrong I dunno. Personally though if I had to choose between being sedated and being numbed in the throat, when they both pose the same risk for aspiration then I would choose sedation on grounds of uncomfortableness; and for the following reasons. I think that sedation is safer based on this, when intubating you are passing the tube between the vocal chords, if you just numb the back of the throat it is still uncomfortable and could cause the patient to writhe causing trauma of the vocal chords and/or trachea which could result in permanent loss of voice or a very risky situation if you damage the trachea and the pt. starts to bleed into the lungs. I do agree that in an emergency situation this may be different, but not sedating a pt. before this procedure in a non-life threatening situation is ludacris. There are far worse things that can happen than aspiration if someone moves about too much during the procedure. That's why pt's should always be sedated and aspiration managed through the use of suction and cricoid cartilage pressure. Just my 2 cents.

-Jiffy.

[cpillow]

:crying2: :crying2: :crying2: :crying2:

Truly unbelievable..... Bad doctor behavior.....

[Gompers, BSN, RN]

Wow, intersting thread!

I've been intubated twice. Luckily both times were in a controlled situation in the OR, and both times a very nice anesthesiologist/CRNA gave me some IV sedation and then gas. I don't remember a thing. I do know some people that have been half awake during their intubations, and the stories they tell give me chills. Horrific!

Even in the NICU, where pain medicaton is a relatively new thing (because babies didn't feel pain 30 years ago! ), we do what we can to make intubation more comfortable. If the baby has an IV, we always give at least 2mcg/kg of Fentanyl just before the procedure. We're actually doing a study now using Fentanyl, rocuronium, and atropine. If the baby doesn't have an IV line, it depends on the situation how we proceed. In the delivery room, each second is precious when you have a newborn in respiratory distress. The benefits outweight anything else here - getting that baby tubed is more important that trying to start an IV and give analgesics and sedation. Usually they're unconscious if the distress is severe, which makes it even more vital to place that tube STAT. If a baby goes into respiratory distress on the unit, their condition dictates what we do. If it's a sudden code, we'll get that tube in and get an IV after we have established an airway - to wait is the difference between life and death, and I think this is true of any code due to respiratory failure. If the baby has an IV, we do take the extra minute or two to get the meds while the baby is bagged. If it's not an emergent intubation, we'll get the line in first and give meds beforehand. We'll even use intranasal Versed on babies, but this can only be used on term infants.

Basically, if the patient is down, coding, unconsious, in respiratory distress - getting a tube in is the first priority. They are usually not thrashing around at this piont, so hopefully the intubation should be fast and clean. If a patient has enough energy to be fighting the intubation, then there should be time to establish an IV and give meds beforehand. Do you know what I'm trying to say?

[mcleanl]

I haven't had a chance to read all these posts but I wanted to comment anyway....forgive me if someone has mentioned this already. I too have been involved in a few intubations in which the patients were not given paralytics or sedation. Trans trachael blocks were used in all of these situations. Lidocaine was injected into the trachea via the neck. In all these cases the patients were hypotensive, on pressers and AWAKE. It was really difficult to watch. Yes, I tried to object and question why. I heard a few different answers including, sedation causes further hypotension and expecting a difficult intubation.

[grannynurse FNP student]

I was intubated while I was awake. To the nurse who questioned if discomfort is equal to pain, a few words, try being tubed awake. Do you have any idea what it is like to have a garden hose (that is what it felt like, jammed down your trachea? It is more then discomfort. There is an overwhelming sensation of not being able to breath and an unenviable sensation of pure panic. And I knew why I had to be intubated. If at all possible a patient should receive some sedation, if for no other reason then ensuring a smooth intubation.

Grannynurse