Nonsedated Pt's equal self extubations

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My current hospital seems to think it's a good idea to cut sedation off of our intubated patients 24, 48, even 72 hours prior to extubation. To me that just seems cruel. Propofol usually wears out off so fast I don't see the need to keep them awake and uncomfortable and restrained for so long. They complain that our restraint use is too high since here if you are intubated you are also restrained because in my opinion adequate sedation is not used. Last week we had an unusually high 3 self extubations. I do hear of it happening more than it should, but even that's high for us. What does your facility do? How long are patients off sedation before you extubate?

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.

On paper, dex is a wonder drug, but its widely reviled on my unit for undersedation. Now, bear in mind that I work in a MICU with people routinely on 90% Fi02 and 18 of PEEP (granted, these folks probably won't be given Precedex), not post-op extubation protocol folks.

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

Are you speaking figuratively, or about an actual neuromuscular blockade agent? It would highly unethical to use a paralytic without sedated to RASS -5. NMB is not allowed at my hospital until the sedation is titrated to RASS -5. Precedex cannot be used as a sedative by itself with NMB.

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Specializes in ICU.

Ugh I just went on my soap box about this while giving report tonight after getting an 84 y/o intubated septic pt. One if our problems is primarily we get surgical and trauma pts and rather than consulting pulmonology we have surgeons running the vents. Intensivist.... What's that-ha! In an ideal world we would have those. When we actually have a doc who consults 2 specific pulmonologists they do a great job acting as intensivists and things get done in a more appropriate manner but otherwise no intensivists. Hell I've been pushing to get just a sepsis bundle implemented for quite sometime. Vent standing orders.... Nope again! I have suggested those but nixed because too many groups of physicians would have to approve. Same reason my sepsis bundle idea got the ax. Common sense does not prevail in our administration and management. I've really considered leaving, however I am now one of the ones with the most ICU experience (all of 3 years in ICU) and I really would like to keep pushing for a better change, but it gets fustrating and defeating after a while!

I did tell the nurse I was talking too if I ever end up in the unit and they pull that crap on me I would hunt them all down and there would be bodily harm involved 😉

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Specializes in Oncology.
Are you speaking figuratively, or about an actual neuromuscular blockade agent? It would highly unethical to use a paralytic without sedated to RASS -5. NMB is not allowed at my hospital until the sedation is titrated to RASS -5. Precedex cannot be used as a sedative by itself with NMB.

Precisely. I'm speaking of NMB's. Without sedation, we would never DREAM of giving a paralytic (at least I would hope not). But people are okay with leaving someone tied to a bed and awake with a tube down their throat, another in their bladder, one going to their heart, one going in an artery (or frequent arterial punctures). They're still going to be terrified and likely in pain (or minimally highly uncomfortable) with no ability to do anything about it and next to no ability to communicate.

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Specializes in Oncology.
Ugh I just went on my soap box about this while giving report tonight after getting an 84 y/o intubated septic pt. One if our problems is primarily we get surgical and trauma pts and rather than consulting pulmonology we have surgeons running the vents. Intensivist.... What's that-ha! In an ideal world we would have those. When we actually have a doc who consults 2 specific pulmonologists they do a great job acting as intensivists and things get done in a more appropriate manner but otherwise no intensivists. Hell I've been pushing to get just a sepsis bundle implemented for quite sometime. Vent standing orders.... Nope again! I have suggested those but nixed because too many groups of physicians would have to approve. Same reason my sepsis bundle idea got the ax. Common sense does not prevail in our administration and management. I've really considered leaving, however I am now one of the ones with the most ICU experience (all of 3 years in ICU) and I really would like to keep pushing for a better change, but it gets fustrating and defeating after a while!

I did tell the nurse I was talking too if I ever end up in the unit and they pull that crap on me I would hunt them all down and there would be bodily harm involved ������

I hope you're including your nurse manager in these discussions, along with a nursing executive counsel of you have anything like that. Not having an intensivist is a shame. I can't imagine our surgeons writing vent orders. Do you at least have some experienced RT's they'll take cues from?

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When our facility tried going restraint free, we had a huge increase in patient falls and patients pulling out tubes and lines including ETT, ngt, foley, piv, central lines, arterial lines, chest tubes, ventric, surgical drains, etc. There was also an increase in using costlier sitters and usually an increase in length of stay. Restraint use came back shortly afterwards.

As for sedation vacation/holiday...done daily on appropriate patient populations.

Precedex...not my favorite drug. It either works or it doesn't! Side effects are common.

As for awake vent patients on NO restraints...yes they happen. Recently, I had an intubated younger adult with an asthma attack. He had his cell phone clutched in his hand at all times and would type out in texting fashion his needs & questions. He had just a touch of sedative infusing. But my favorite was another asthmatic lady who applied full makeup & did her own hair while intubated & not restrained & having no sedatives infusing. I just remember these bright red lips around the ETT! We got a huge laugh that day! These patients are few in the slew of intubated, sedated, & restrained population I usually deal with.

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