Nonsedated Pt's equal self extubations

calivianya, BSN, RN · Mar 6, 2015

I read somewhere that doctors always think patients are oversedated and nurses always think they are undersedated.

Sounds about right. I have started cutting the sedation way back at 0600 so that when the MDs round, the patient is clearly awake and the MDs won't D/C any of the sedation meds. Of course, I tell the day shift nurse what amounts of which drips worked the best to keep the patient calm and comfortable all night long so he/she can get the patient back to that spot after the physicians leave. I hate doing it, but it seems like it's the only way to keep adequate sedation ordered sometimes.

I hate Precedex too, for the record.

firstinfamily, RN · Mar 6, 2015

We stopped using restraints on our intubated pts about 5 years ago, there are some who extubate themselves when the sedation wears off. We also follow-up with incident reports, sometimes it makes changes happen, sometimes it does not. This is a very gray area with pain being a subjective assessment, do we consider the discomfort of the ETT as a cause of pain and if so how can this be treated if narcotics are being held due to trial of extubation???

blondy2061h, MSN, RN · Mar 6, 2015

How is leaving a patient wide awake and restrained on a ventilator that much different from having them on a paralytic without sedation?

VANurse2010 · Mar 6, 2015

Does your institution not use Precedex? You can extubate patients while still on the gtt. We usually do Fentanyl and Precedex. Each morning is a sedation holiday and if they pass and meet the other qualifications, the patient will have a spontaneous breathing trial. If they fail, the sedation resumes.
It just seems cruel to basically physically restrain someone who is lucid on a ventilator. I sure wouldn't want that for myself.

Precedex sucks.

I'll quote another post here that perfectly summarizes it:

Precedex is great if you want one of the following:

- a toally unsedated ( = wild, tachypneic, combative) patient

- a pt totally snowed on a less-than-theoretically minimal dose of precedex

- a pt who goes from normal sinus (or sinus tach) to a nice brady rate in the 40's

- a pt with a normal heart rate plus (at no additional charge!) hypotension

RNperdiem, RN · Mar 6, 2015

The combination of undersedation and intubation plus minimally secured endotracheal tubes is one reason I would never work in neuro ICU. There is a lot of self-extubation around there. I understand the rationale for going really light on sedation, but it does not make it easy to work with.

In my home unit, sedation is something that is cut off when extubation is imminent.

ixchel · Mar 6, 2015

How is leaving a patient wide awake and restrained on a ventilator that much different from having them on a paralytic without sedation?

Jesus, that's just as horrific, maybe more so. I can't imagine how horrifying it would be to wake up strapped down and feeling like I'm gagging on tubes.

My facility does sedation vacations and resumes sedation as appropriate. We use a sedation scale to determine if the level of sedation is appropriate and parameters are in place to increase or decrease as the nurse finds necessary. I'm not an ICU nurse, but every time I've been pulled to ICU, it's been obvious that patient comfort is a high priority and I have yet to see anyone under- or over-sedated. Soft restraints are used as needed, but most are restrained. It's rare we have any self extubations, as far as I know. The nurses and intensivists tend to work well together in terms of trusting each other's judgment on things like this.

Altra, BSN, RN · Mar 6, 2015

The one piece of the puzzle I see missing from this discussion is that a patient whose sedation is d/c'd may well be ready to come off of the vent. That is the point of the daily morning weaning trial where I work - wean sedation for the purpose of assessing respiratory status.

Otherwise, if the patient is not yet stable enough/ready for consideration of weaning from the vent, yes, sedation should remain, except for a daily "holiday" per your policy. The answer to preventing oversedation is accountability for titrating/maintaining a RASS of -2 or whatever your policy requires -- not discontinuing sedation altogether.

mercurysmom · Mar 7, 2015

I had ARDS in 2007. Apparently the sedation was lightened for 24h pre-extubation, so I was awake enough to freak out but not enough to figure out what was going on. I failed 3 extubation trials and eventually was trached.

I had worked at that specific hospital, and I heard through the grapevine that some of the intubations/extubations *might* have been done as "practice runs" for residents rather than in response to physiological signs that I was ready to be extubated. After the trach was placed, I went home with Hospice support and a plan for a terminal wean. (Considering I'm still here, I'd say that the terminal wean was "unsuccessful! LOL).

Over time, I was able to be decannulated and return to noninvasive ventilation. ðŸ˜„. However, I didn't come through unscathed. My four bottom front teeth were broken, I had a hole in my nasal septum due to a lousy job placing a nasopharyngeal airway, and PTSD. I had horrific nightmares for at least 5 years.

Withdrawing sedation didn't make extubation any easier. IMO, it made it worse.

MunoRN, RN · Mar 7, 2015

Ideally there is no need for restraints or sedation, but in reality there is a need for balance, both to avoid excessive torture (beyond regular ICU torture) and to achieve good patient outcomes.

Having a low rate of restraint use in intubated patients isn't a good thing, it typically means patients are being excessively sedated in order to negate the need for restraints, which is bad practice; the additional risk and harm of excessive sedation far exceeds the downside of reasonable restraint use. It's the same idea as re-intubation rates; it's a problem if your rate is too high, but it's also a problem if it's too low since that indicates a lack of effort to get tubes out as early as possible.

But just as a RASS goal of -4 isn't a good idea just to make your restraint numbers look "better", insufficient use isn't good either and not just for patient comfort, which should be good enough reason by itself to justify reasonable analgesia/anxiolysis, but even for those who focus more on medical treatment outcomes than ethical responsibilities it's still to the patient's benefit to be adequately treated. For one thing, some falsely assume that patients are less likely to experience delirium with no analgesia/anxiolysis at all, which isn't true, excessive sympathetic stimulation, such as that caused by foreign object in your airway, can contribute to delirium just as well as excessive medication can, and that's in addition to the adverse effects of increased metabolic demand that comes from inadequate medication.

blondenurse12, MSN, NP · Mar 7, 2015

Precedex sucks.
I'll quote another post here that perfectly summarizes it:
Precedex is great if you want one of the following:
- a toally unsedated ( = wild, tachypneic, combative) patient
- a pt totally snowed on a less-than-theoretically minimal dose of precedex
- a pt who goes from normal sinus (or sinus tach) to a nice brady rate in the 40's
- a pt with a normal heart rate plus (at no additional charge!) hypotension

Really? I'm surprised. My facility started using it a few years ago and we love it. The only time we use it as a stand alone is for fresh open hearts that are transitioning from waking from anesthesia to being extubated. We use an additional medication such as Fentanyl or Versed at varying doses depending on how experienced the patient is with narcotics. Then when the time for extubation comes, the Fentanyl and Versed is d/c'd and the Precedex is left at 0.2 if needed since it does not suppress the respiratory drive.

Yes, bradycardia can potentially be an issue but typically it's corrected when the dose is lowered. As for hypotension, I have not encountered that. Research has shown that compared to other sedatives, Precedex shortens the length of intubation, decreases the risk of delirium, and decrease the risk of hypotension. I think the benefits outweigh the possibility of bradycardia.

ausrnurse · Mar 7, 2015

Really? I'm surprised. My facility started using it a few years ago and we love it. The only time we use it as a stand alone is for fresh open hearts that are transitioning from waking from anesthesia to being extubated. We use an additional medication such as Fentanyl or Versed at varying doses depending on how experienced the patient is with narcotics. Then when the time for extubation comes, the Fentanyl and Versed is d/c'd and the Precedex is left at 0.2 if needed since it does not suppress the respiratory drive.
Yes, bradycardia can potentially be an issue but typically it's corrected when the dose is lowered. As for hypotension, I have not encountered that. Research has shown that compared to other sedatives, Precedex shortens the length of intubation, decreases the risk of delirium, and decrease the risk of hypotension. I think the benefits outweigh the possibility of bradycardia.

I see you've never had a patient go into asystole from precedex There is a small group of patients it does work well on - typically post-ops with anaesthetics still on board and imminent extubation and the occasional tubed patient withdrawing from alcohol. That's about it. I've only had maybe one or two good experiences with the stuff, some of our intensivists love it in the MICU but the cardiovascular side effects are SCARY. I've seen blood pressures swing up and down from 50 systolic to over 250, patients brady down to nothing out of the blue. After seeing someone have a cardiac arrest that was directly linked to the precedex, I have really hated it and that person was on a minimal dose of the drug and was only tubed for psych reasons (nothing medical going on). I can barely bring myself to titrate up to an effective dose these days. You guys sound really lucky in your ICU! :)

sallyrnrrt, ADN, RN · Mar 7, 2015

i promise if you have me intubated, with little or no sedation, i will self extubate