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?

[Mayflye]

I never see docs use the cetacaine spray, and rarely the lido gel. Marissa, haven't you seen the docs cranking around with the blade so that you think it's going to pop out their crichoid? That's PAIN, not discomfort. Look at the patients eyes, I've seen it happen.

[heartICU]

Ok for those of you whose patients are not sedated, what are the circumstances of the situation? Is the patient wide awake, are they in respiratory distress, respiratory arrest? I am guessing they are given something, otherwise you would not be able to even pass the blade on a coughing gagging person. So the people who are intubating at your facility are not giving anything whatsoever?

[dfk, RN, CRNA]

usually just some hurricaine spray.. the pt is usually in some good distress, so usually pooped out.. but when the blade is moving the airway around, i can tell from the pts tearing that it isn't comfortable. the funny thing is that the docs say "ok, load em up with some propofol now" after the part that can be most irritating and nerve racking both for pt and nurse..

[Balder_LPN, LPN]

Couldnt the Pain/discomfort debate be settled by asking some pt's to rate their pain, that should be a good indication of if the pt is feeling Pain or not.

[ZASHAGALKA, RN]

Couldnt the Pain/discomfort debate be settled by asking some pt's to rate their pain, that should be a good indication of if the pt is feeling Pain or not.

The problem is that 'AFTER' they are extubated and can talk, they will have been on diprivan for long enough not to have any memory of the event.

At the time of intubation, they will be too worn out to try to play a hand signal game before sedating them.

But just because they might 'forget' the event doesn't make it any less barbaric.

~faith,

Timothy.

[PJMommy]

But just because they might 'forget' the event doesn't make it any less barbaric.

Amen.

[marissa81579]

In reply to the post from AZ, I have seen doctors use the hurricane spray and some not use it. I would imagine if a doctor intubating insisted on not sedating the patient, a diligent nurse would direct the doctor to use some numbing agent *at the least*. And no, I have never seen a patient in severe pain when a doctor is trying to intubate - but this is because the ICUs I worked in always sedated patients sufficiently beforehand.

Is it less barbaric to sedate? Yes. However, as nurses, we can't ignore a body of research that physicians may be referring to in deciding not to sedate the patient. And some people (on a more philosophical point of view) consider pain to have not existed if a person does not remember it. It's along the same lines as "Did a tree fall in the woods if no one hears it" or whatever.

I would hate to not sedate a patient for intubation - I don't know about the research supporting it because where I have worked it is just never done - we always sedate the patients. But I am just playing devil's advocate here. Aspiration risk is real, significant and you all know what it can lead to. So I can *understand* why some physicians in some facilities weigh both sides of it and decide that pain (that the patient will not remember) is better than the risk of aspiration. I personally disagree, but it is unwise to just dismiss is as "cruel" - a lot of what we do in ICU is arguably barbaric. It is important to look at both sides of the argument and understand why people make different judgment calls for patients.

And as for the person who suggested that people rate their pain - that isn't gonna happen with most critically ill patients getting intubated. We just have to watch and observe the patients for signs of acute pain. If a doctor is hacking up someone's airway to intubate - they probably should not be doing it as I have never seen even a resident do it that incompetently. Usually, intubations are fairly uncomplicated as long as the positioning is good and the doc has enough light. At least in my experience - they take but a few minutes.

[dfk, RN, CRNA]

marissa, sorry, but i don't agree.. pts do remember, and they do feel pain.. we as nurses do have a say, whether teaching facility or not. it just has to be louder when necessary. i can tell you i am not hesitant at all to speak up when needed, ET tube, central line, or whatever. i put myself in that place, for which i consider myself rather alright... so, for that, i can feel for anyone in such a place.. empathy? yes! sympathy? why not! i can't believe one cannot feel such discomfort and not associate pain as any relevance!

[PJMommy]

Okay...I have to speak up. First of all, sedatives are not pain medications. Two different things. I think we all know this but the discussion has spun off to a discussion justifying sedation because of the possibility of pain.

If this "body of evidence" showing the risks of sedation exists, then nurses shouldn't just take docs word for it -- go look for it. If you do not have access to a library or electronic journals, then go to websites like http://www.guidelines.gov or http://www.ihi.org. I don't find a body of evidence supporting no sedation in my 5 minutes of searching this morning. All I find is the typical recommendations are for pentothal and succylcholine (sp?) which is exactly what our CRNAs and anesthesiologists use. Cricoid pressure is done to prevent aspiration in rapid sequence intubation.

A change in practice for docs or nurses should never be justified based on one or two studies. And the docs certainly don't have the market on reading the latest research. It's out there for us as well.

As a previous poster stated, the evidence they are citing should be produced. I suspect, as is often the case, some doc got a wild hair based on some random study he/she read and is insisting on no sedation for all pt's. If ethics committee won't touch it, do you have an ethics hotline? Medical review board? State medical board?

[dfk, RN, CRNA]

yes, pjmommy, you're right about the difference and you're right about the tangent.. it's funny how far and fast things happen. (that's why we're here, right??) anyway, i do agree with you re: the one or two study thing.. people are quite willing to offer their opinion based on such. it happens. docs, nurses, attorneys, pushcart people... i think it's important we all LISTEN to others thoughts, and with a specific grain of salt sometimes. i don't know, i still think it should be looked at a bit closer, by all.

[marissa81579]

I also do not know why this has spun off into a pain management issue. Pain meds are not indicated for intubation. If people here have experiences where their patients have remembered being intubated, that is in the minority as I have never known a patient to remember any of it.

We usually need to sedate patients because it would be next to impossible to do the procedure if a patient is writhing around. I don't know what else to say. We use pento or succ, propofol bolus followed by a propofol drip (in most cases). Not PAIN meds! I do not think it is proper to think of this as pain management issue. More like an anxiety management issue as being intubated is strange feeling and who wants to be awake for it?

I have been intubated before and it is not painful. I tihnk if most intubations were painful, people later extubated would complain of it but usually they just complain of horseness, not horrific throat pain.

Don't lose sight of what this is an issue of.

And to whoever "disagreed" with me, that's really great but like i said I was playing devil's advocate. I don't know if the body of research is large or small, or if these docs are just playing maverick here. I don't know. Of course if a patient was in some ridiculous discomfort I tell the docs I need to give them opiates or benzos or whatever else depending. I think it is a problem of nurses because many are doormats who do not speak up. But I am not one of them. However, I am not just going to dismiss these docs practice as "barbaric" until I see studies contraindicating it. Sometimes 1 or 2 studies is not enough, but every medical procedure/drug etc starts off with only 1 or 2 studies.

[Mick2003]

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