Sedation/Analgesia for HFOV, HFJV, Vents?

babyNP., APRN · Jan 23, 2017

I would first try to understand where the provider is coming from- analgesics and anti-anxiety drugs (like versed) have been demonstrated to cause brain cell apoptosis (programmed cell death). That is scary. These are little tiny humans that have developing brains. There's also the concern of becoming habituated to the drugs, which can delay the removal of a central line, which is demonstrated to increase a CLABSI- which has its own complications as we all know.

The counter-argument is that of course, it's also not good for the brain to be in constant pain and that it can be life-threatening if the baby is so agitated that he self-extubates.

The first line of action should always be non-pharmacologic measures, including things like darkness, quiet, containment, and limited hands-on time. Some units do cares only twice a 12 hour shift to help facilitate this. I'm not saying that you didn't provide these things or that your patient was not in pain. But if you've been able to document all of these measure to the neo, I would describe in objective terms what is happening- agitated, consistently tachycardic, breathing heavily over the oscillator, etc etc. Ask the neo to come to the bedside to see what you're seeing to see how you both might agree.

Of course, then the the question becomes, will the provider actually come to the bedside to assess if he feels so strongly against pharmacologic treatment. Perhaps not, if he is busy with another sick child or (for the less scrupulous) simply doesn't want to deal with it. I always come to the bedside (if I'm able) if I have a nurse telling me what you're describing. Unfortunately, that's not always the case for each provider. My suggestion in those cases would be to go to your charge RN who can help you advocate for your patient, going up to your manager as needed if you have someone who consistently won't listen to your concerns and won't come look at your patient with you.

ETA: I will say that I won't order analgesia just because the baby is intubated. That's inappropriate for reasons I've discussed above. I've taken care of many happy intubated babies as a nurse who needed a bath rather than morphine in order to settle down. Babies in pain are different, but not every baby that is intubated is in pain.

24gaDalek · Jan 23, 2017

BabyNP,

Thank you for your detailed and thoughtful response. I feel somehow like I have to defend my question based on some of your answers as it feels like from your answer you think maybe I don't understand the implications of having premature infants as patients (developing brain, risk of addiction, etc.). I am not trying to step on your toes, just expressing how I felt at first blush reading your response.

I didn't give full information on the particulars of the actual situation because I was just curious in general what nurses have available to them in their unit. I can assure you that I attempted all non-pharmacologic interventions. I have a full complement of tricks up my sleeve for quieting agitated infants. I work night shift and I don't like to rouse the on-call Doc out of his or her bed for any old reason out of courtesy to them and they know that based on our working relationship. We also have two docs in house so if one is busy with a sick baby they can defer to the other doc.

As far as using the charge or ANM to help me advocate, while I understand that in some cases that may be necessary the idea that I would even need to go that far makes me extremely sad. I have used that route once when a NAS observation baby was intermittently screaming, vomiting, and vibrating off the bed and the on call doc refused to start medicating until the primary doc did rounds in the am.

I don't think there would be such a hesitation to treat pain in the adult world. I also know that there used to be very old-school ideas about premature infants and pain. Conversely, pain medication should not be used as a crutch to "snow" an infant into oblivion. But I do think there is something to be said for nursing judgment in the case of PRNs.

babyNP., APRN · Jan 24, 2017

No problem. I will give the caveat that I did write a disclaimer saying that I wasn't there and you might have provided all of those non-pharm interventions I wrote it mostly for the benefit of folks reading this forum... and to be quite frank, most nurses I teach on this matter have no idea about the effects on the brain or don't think forward to the idea of a central line causing a greater risk of a CLABSI and subsequent problems. And I get it to some degree- life is easier with a central line and being able to give a baby a drug. Being at the bedside all the time can be tiring and I think it can be a tougher job.

And you're right that it's sad if one has to go up the chain of command to get someone to do their job. Also probably right about adults- I've never worked with them as a nurse but have read quite a bit on this forum. The difference is that adults don't have the developing brains that babies do (or not as much; I guess your frontal cortex isn't fully developed until your 20s!). In a perfect world, nursing judgment is exactly for what PRNs are written. Sorry that you and the baby had a bad experience with an unhelpful doc. I hope the little one will get better soon.

RNtoNNP, BSN, DNP, APRN · Jan 25, 2017

I have had similar frustrations in my unit in regards to the neos not wanting pain meds for intubated infants. I do agree with BabyNP that there are risks with using pain meds with our little patients, but there are definitely times when some pain medication is appropriate. The previous NICU I worked in seemed to prescribe pain medications more often for intubated babies (either as a continuous drip or PRN) than my current unit does. I took care of a baby recently who started fighting the ventilator all of a sudden one night so his oxygen requirements went up and his blood gas looked terrible. They almost had to put him on the oscillator, but the neo decided to switch up his vent settings a little and give him Vecuronium. The baby loved it and quickly weaned down on his oxygen requirements. However, the neo on the next day said there was no way we were going to give the baby any more Vec, but he did tell us we could be fairly liberal with the PRN Fentanyl. Thankfully, the Vec helped the baby through the critical period and the PRN Fentanyl was enough to keep him calm the rest of the day shift, but what if the Fentanyl wasn't enough? What do we do when the infant is fighting the vent so hard they almost end up on an oscillator or if they are fighting the oscillator so much that the vent isn't able to do its job? I think there is a fine balance between completely snowing the baby and giving the baby some pain control so that they can let the vent work so their lungs can heal. Like BabyNP, I haven't worked with adults as a nurse, but it does seem that they are often completely sedated when on a ventilator. I was talking to a pediatric nurse who works in the same hospital as me when she floated to the NICU for a shift. She was asking me why we don't sedate our babies on vents because if they have a kid on the vent in PICU, the kid is almost always sedated. She said even if they had a two-week-old infant in PICU, the baby would be sedated. I found it interesting that our two units have such different views on sedation for kids on ventilators. That being said, I do agree that not every baby on the vent NEEDS to be sedated or given pain meds on a regular basis. As BabyNP said, there are plenty of babies on vents who actually are pretty happy. I don't think there can be a hard and fast rule that EVERY baby on a ventilator gets pain meds or is sedated, but having PRN orders available for those babies is important. It is frustrating to have to fight for an order for a PRN pain med while the baby is struggling against the vent or trying to extubate themselves. It's nice when an order for PRN pain meds is already in place so the med can be given as soon as the baby needs it. Thanks for bringing up this issue!

KRVRN, BSN, RN · Jan 29, 2017

I've brought actual numbers before. "My pt has NAS scores of 13" or "my pt's very agitated, sats are labile, he seems to be in pain and pain scores are X." Document your pain scores and that you informed the doctor.