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?

[Simba&NalasMom, LPN]

i hear all of u.. it's the doctor's call, not our nurse mgr. (who just resigned - YAHOOOOO!!!) it seems to be somewhat of common practice from what i am gathering (doc wise). at this point, ethics committee won't get involved (the same nurse mgr that's resigning was on committee)- how funny is that? i'd be interested to take a poll of those that got tubed and ask of experience

r/t awake/asleep, and their thoughts. (not that breathing thru a large straw is not memorable enough!!) -

Sounds like that's what has to happen...they'll only listen to the patients. Wouldn't it be wonderful if we could encourage our patients to complain without fear of retribution? :angryfire

[ZASHAGALKA, RN]

It must be comforting to be a “patient advocate.”

However, in the real world of a CRNA/Anesthesiologist, we have to manage airways on an emergency basis. Most times, when called to the ICU, despite the fact that we would love to sedate/anesthetise/paralyze, it’s not in the patient’s best interest. We make this decision based upon the patients condition, stability and ancillary resources. We secure airways in the safest and most humane ways possible. As a nurse, you have absolutely no responsibility for a lost airway and the suffocation that “just a little propofol” can cause. You have no training in the evaluation and management of the potentially difficult airway. Take a little responsibility for airway management and its ultimate control (have you ever pushed sux by yourself?) and you’ll know what I’m writing about.

Mick

Look, we are talking about a rare subset of these pts. Most pts needing emergent intubation have signicant LOC changes anyway.

But if someone stuck a tube down a wide awake person without giving anything to ease the uncomfortableness of that procedure in my presence, I'd loudly and persistently object then and there, and I'd take them to the ethics committee.

A higher education doesn't entitle someone to arrogant unconcern for the effects of what they do to pts under their care. And it's not just me that says so. JCAHO has my backside on this.

There is room in the 'real world' for both effectiveness AND compassion. To say there isn't points out the shortcomings of someone that would advocate that viewpoint, not mine.

And IT IS comforting to know that I am a pt advocate. I'd have it no other way.

~faith,

Timothy.

And for the record, I was and have been speaking in generalities and not attributing characteristics to any individual.

[Gennaver, MSN]

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"

Hi,

Even if merely 'discomfortable' how about traumatizing unfairly? Isn't there an ethical code for not unduley assaulting, (intimidating/traumatizing) a patient?

Or something like that?

This is not sarcastic, but, just a direct question from a new student who just started an externship in an ICU.

Thanks!

Gen

[Gennaver, MSN]

... 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"

Hi Marissa,

I get you now. I see how you are separting using JHACO pain protocols as faulty justification when the true justification is for actual sedation.

Very good point and a more legitimate justification for 'sedation' during intubation.

Gen

p.s. sorry, I hadn't read through the thread when I posted and had not even read your final first posts paragraph!

[Gennaver, MSN]

...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.

...

Wow,

This is not a philosophical view that I agree with. No matter if someone fogets that they were in pain. Upon the time of the pain/stress/insult to the body, it does have a physiologic effect on a person immediately and afterwards. As an added stressor on top of all the other insult and stress to the body then yeah, I would say that pain does indeed have an effect, regardless if anyone is around to see or remember it. The system's and organ's recetors sites and endocrine reactions to that stress will happen regardless, right?

It sounds like saying that a diabetic coma won't matter later because the patients blood sugar will have returned to normal, as if the crisis was not relevant to the day and therefore did not exist?! Huh?

Gen

[PJMommy]

Look, we are talking about a rare subset of these pts. Most pts needing emergent intubation have signicant LOC changes anyway.

But if someone stuck a tube down a wide awake person without giving anything to ease the uncomfortableness of that procedure in my presence, I'd loudly and persistently object then and there, and I'd take them to the ethics committee.

A higher education doesn't entitle someone to arrogant unconcern for the effects of what they do to pts under their care. And it's not just me that says so. JCAHO has my backside on this.

There is room in the 'real world' for both effectiveness AND compassion. To say there isn't points out the shortcomings of someone that would advocate that viewpoint, not mine.

And IT IS comforting to know that I am a pt advocate. I'd have it no other way.

~faith,

Timothy.

And for the record, I was and have been speaking in generalities and not attributing characteristics to any individual.

Well said

[Undecided7]

Ya know, if you even HELP with intubation without sedation- you absolutely DESERVE a lawsuit. Are you EVIL? Or just joking with us? Don't give that crap about the doctors. If they want to do that, just stay out of the way. REAL NURSES don't do that kind of stuff in the USA. (Are you working in Iran?)

[ZASHAGALKA, RN]

Hi Marissa,

I get you now. I see how you are separting using JHACO pain protocols as faulty justification when the true justification is for actual sedation.

Very good point and a more legitimate justification for 'sedation' during intubation.

Gen

p.s. sorry, I hadn't read through the thread when I posted and had not even read your final first posts paragraph!

I disagree. Sedation is appropriate for an already intubated pt. But when performing an invasive procedure on a conscious pt, that pt has a right to have his awareness of the painfulness of that procedure reduced. You can sedate (i.e. induce amnesia) for that control, but the goal at that point is supressing the pt's awareness of an invasive procedure; to do less is not only cruel, but unneccessary.

And that does indeed meet the JCAHO standard. It meets it because it is a violation of that pt's rights. And if you doubt that, take a look at your pt's rights statement that is posted in several places at your hospital and given to all pts on admission.

Now, I'm sure you can cite me an off the bell curve example of where intubation cannot wait for a few seconds for pain relief (although I'd suspect that if you can get a tube down, then you can ambu, so that would probably be either an emer trach issue or a protect the airway immediately from bleeding, etc.) but the OP was talking about ROUTINELY using no sedation/pain control for intubation. And so I'm not addressing the possibility of an extreme example, but rather the OP's original comments. Obviously there can be a situation where intubation cannot wait for anything and the pt's immediate safety is priority and an ambu bag can't suffice for a few seconds, but that is not the 'routine' presentation.

I'm not saying that pain control is the highest priority care in an emergency. I AM saying that pain control during an emergency, invasive procedure is not only NOT an optional priority, it is a high priority, not the highest, but high nonetheless.

~faith,

Timothy.

[traumaRUs, MSN, APRN]

I work in a level one ER and there is no way, no how our MD's would ever do intubation awake. And...what's more, our nurses wouldn't stand for it. I have been a nurse over 15 years and yes, we used to intubate without RSI. However, that is not current practice and an awake intubation should rarely be done. I wouldn't participate in this procedure. However, I would provide research-based info to the MD:

"The major risk of RSI is that a physician could potentially paralyze a patient and lose the ability to control the airway, and morbidity (eg, cerebral ischemia, surgical airway) or death may result.

Although no absolute contraindication to RSI exists, a couple of distinct clinical scenarios deserve mention.

RSI should be used cautiously or avoided in patients who are dependent on the muscle tone in the upper airway to maintain the airway patency in conditions such as a partial airway obstruction. As paralysis occurs and as physiologic muscle tone is lost, partial airway obstruction can progress to complete airway obstruction. In this group of patients, carefully titrated sedation and awake intubation may be preferred. Equipment for alternate airway control, such as a surgical kit or a fiberoptic device, should be at the bedside.

Also, for the patient in cardiac arrest or for those in a severe comatose state who have no response to laryngoscopy and in whom sedation and paralysis are redundant, RSI is not necessary. These patients need immediate endotracheal intubation and further resuscitation".

http://www.emedicine.com/emerg/topic939.htm

[marissa81579]

Interesting dialogue since I have not been here. I can't respond to everyone's post in regards to mine, since most of my arguments were either devil's advocate stuff or highly theoretical. The point is, there are things RNs do not know, that CRNAs/anesthesia people do know. Period. These cases of no sedation are rare, and I have faith there are good reasons for these to occur occasionally. As for the hospital that never does it, I am not even sure I believe the original poster, because I can't see how it would even be feasible to intubate people without sedation, especially big strong young men!!

That's all I am going to say. The vast majority of you missed the point of most of my posts, so I don't feel the need to respond literally, since that was not the point of my other posts.

[Gennaver, MSN]

Hi there,

I think there may be some miscommunication here. The way I read it, we are all three, (you, myself and the poster I replied to) in agreement.

Gen

p.s. and I could not even name a citation right now, this is the first time I have ever encountered this, I am a new student nurse...

I disagree. Sedation is appropriate for an already intubated pt. But when performing an invasive procedure on a conscious pt, that pt has a right to have his awareness of the painfulness of that procedure reduced. You can sedate (i.e. induce amnesia) for that control, but the goal at that point is supressing the pt's awareness of an invasive procedure; to do less is not only cruel, but unneccessary.

And that does indeed meet the JCAHO standard. It meets it because it is a violation of that pt's rights. And if you doubt that, take a look at your pt's rights statement that is posted in several places at your hospital and given to all pts on admission.

Now, I'm sure you can cite me an off the bell curve example of where intubation cannot wait for a few seconds for pain relief (although I'd suspect that if you can get a tube down, then you can ambu, so that would probably be either an emer trach issue or a protect the airway immediately from bleeding, etc.) but the OP was talking about ROUTINELY using no sedation/pain control for intubation. And so I'm not addressing the possibility of an extreme example, but rather the OP's original comments. Obviously there can be a situation where intubation cannot wait for anything and the pt's immediate safety is priority and an ambu bag can't suffice for a few seconds, but that is not the 'routine' presentation.

I'm not saying that pain control is the highest priority care in an emergency. I AM saying that pain control during an emergency, invasive procedure is not only NOT an optional priority, it is a high priority, not the highest, but high nonetheless.

~faith,

Timothy.

[traumaRUs, MSN, APRN]

Actually, the new ACLS standard states that if intubation might be difficult, it is just fine to provide adequate bag-valve mask breaths until trained personnel can arrive. I'm an RN and if I felt that something is being mismanaged, I certainly speak up...not be confrontative, just asking in order to learn. I'm responsible for my actions and its just like following all orders: if it is not a good order, question it, document it, and obtain a second opinion.