Oscillators & sedation

Pediatric Critical Care Columnist · Feb 26, 2009

We don't have a specific protocol for any mode of ventilation, our docs sort of make it up as we go along. All of our ventilated patients are sedated with one or more agents, and since we have a new director of cardiac critical care we're in flux right now. The usual was a cocktail of morphine and midazolam infusions, lorazepam and chloral hydrate PRN. Lately we've been seeing more fentanyl and ketamine infusions, since our new director doesn't like morphine or midazolam. And we've been using phenobarbital and clonidine for additional sedation where needed.

It is important to sedate oscillated patients adequately. It's not a comfortable treatment at all, and the positive effects can definitely be undone by more than the occasional spontaneous breath. And you absolutely don't want them SITTING UP!! The paperwork associated with unplanned extubations isn't worth it.

Sorry I haven't really answered your question.

Redneckmedic63 · Feb 27, 2009

We generally use fentenyl and versed drips, with minimal boluses as needed. The patients that are very difficult to sedate might receive ketamine or pentobarbital gtts instead or in addition. All of our pts on oscillators will be paralyzed, usually with a norcuron gtt. Paralytics are usually d/c'd as soon as the patient is placed back on regular vent.

mabell52 · Feb 28, 2009

We keep our patients who are on HFV paralyzed utilizing a train of 4 to titrate their vec drip. They are also on sedation drips also. I am from CA incase you were interested as to how diffrent states work.

Pediatric Critical Care Columnist · Feb 28, 2009

Okay so tonight I have a patient on an oscillator. All was well until 0330 when I told the RT that the MAP and amplitude were fluctuating a lot. She came in, played with the settings, suctioned, re-recruited and played some more. Kid started breathing. I gave Ativan. Kid kept breathing, now getting a little tachy. I gave rocuronium. Kid stopped breathing but by now HR had gone from 68 to 120. Gave morphine. Now HR is 155... Stat CXR was done and there's a crowd in the room. I've been sent for a break and have no clue what's going on in there. Oh, wait, one of the other girls just told me that SBP is in the 50's now... Geez Louise.

AlabamaBelle · Feb 28, 2009

Hope things are better for your patient, Jan, and for you.

We utilize a sedation protocol, which gives us, the RN, the ability to titrate our sedation gtts up/down as needed according to the level of sedation (1-6). At level 6, a paralytic is utilized, obtaining a baseline TOF with regular checks. We normally use morphine and versed, occasionally we use fentanyl. We are not allowed to give ketamine (I think we may do IM, not IV). We also aren't allowed to use propofol (only anesthesia can do that). We routinely use a paralytic agent on our oscillated kiddos.

Pediatric Critical Care Columnist · Feb 28, 2009

We got her through that crisis, but she was made a DNR yesterday so there are only so many things we can do. She's a severely disabled teenager and her mom wasn't even sure she should be tubed. Dad, who does zero care for this kid was all "Oh yeah, do everything" but the docs don't think she'll survive this, and truthfully neither do I. She's back on conventional ventilation and seems to be holding her own.

It's interesting how different things are from one place to another. In this province, specially-trained RNs may give propofol, ketamine, cis-atracurium and thiopental both as an infusion and IVP. About the only thing I've come across that nurses cannot give is sufentanil. And by "specially-trained" they mean nurses who have completed the PICU certification process on orientation.

BTW, a DNR on our unit doesn't mean what it means everywhere else. In this case all it means is we won't do compressions or give cardiac resus drugs but will provide full respiratory support. We can, and did, start epinephrine by infusion (which I almost had off by the time I left) and give fluid boluses. And I think someone would argue that V-V ECLS wouldn't be out of the question.

tryingtohaveitall · Mar 1, 2009

Most of our oscillated kids are on Versed, Fentanyl, and Vec drips continuously. It is extremely rare for our drs to allow them to move or breathe against it.

AlabamaBelle · Mar 1, 2009

Our DNRs can be quite the same - we'll provide ventilatory support and provide comfort care, but if compressions are needed or any additional pressors are required, at the parent's request, we will go no further. We have a "modified" status which is drugs, no compression (ironic, isn't it).

PICNICRN, BSN, RN · Mar 1, 2009

Hope things are better for your patient, Jan, and for you.
We utilize a sedation protocol, which gives us, the RN, the ability to titrate our sedation gtts up/down as needed according to the level of sedation (1-6). At level 6, a paralytic is utilized, obtaining a baseline TOF with regular checks. We normally use morphine and versed, occasionally we use fentanyl. We are not allowed to give ketamine (I think we may do IM, not IV). We also aren't allowed to use propofol (only anesthesia can do that). We routinely use a paralytic agent on our oscillated kiddos.

I just heard a rumor that we are supposedly not allowed to "push" propofol- like an LP for example, the doc is supposed to do it..... they have decided that we can still do it "under the docs disgression" - basicly, the intensivist says "ok, push some more propofol" as they are doing their procedure. Not sure of the legalities of that LOL! Propofol gtts are ok.

As for the original post..... I have NEVER had a pt on HFOV that has NOT been paralyzed! ALWAYS a fent/morphine, versed, vec/nimbex gtt. They really need to be adequately sedated.

Redneckmedic63 · Mar 2, 2009

In our state, ketamine and propofol are both classified as anesthetic agents. RN's may initiate, monitor & often titrate infusions, but cannot give as IV pushes - that has to be done by doc or CRNA.

Like I said - all of our oscillator pt's are paralyzed with full anticipation / precautions for pneumos. Never had one that I can recall that we haven't paralyzed. Like Jan said, just shows the differences in practice!

picuRN0430 · Mar 9, 2009

In our PICU, the oscillated kids are always on sedative/analgesic drips (Fentanyl and Versed), as well as a paralyzing drip (Vecuronium). Our docs don't want any chance of our patients trying to breathe against the vent. We usually stop the paralytic upon transitioning them back to the Servo-I.