Sedation choices for vented babies

[wensday, MSN, RN, APN, NP]

Hi all,

Do you give your babies sedation for ventilation and if so, what do you give?

This is for continuing ventilation, not intubation itself.

We give Sux and Fent to tube and then morphine for pain/synchronicity if they aren't going to come off quick. If we are still struggling then midazolam is used.

I've read these aren't great drugs but not sure of the alternatives in regular use in nicus.

Thanks

Debs- trainee ANNP

[vandydani]

Fentanyl and Precedex usually. The occasional Vecuronium drip for sedation nightmares.

[wensday, MSN, RN, APN, NP]

Thanks, yes we use Vec sometimes too.

[NICUNurseEliz]

We use fentanyl and vec or propofol to intubate and then fentanyl as a maintenance sedation. If fentanyl isn't working well enough, we'll use morphine as a backup. We almost never paralyze our babies except to intubate and very rarely if the baby has very poor gases despite sedating/suctioning/increased vent settings.

[wasabirush]

Fentanyl & Sux to tube, morphine to sedate, midaz infusions. Vec infusions or intermittent pancuronium. In a previous NICU I worked in, they used the same to tube, morphine or fentanyl infusions, midaz infusions, panc bolus', no vec.

[babyNP., APRN]

The vast majority of ventilated babies do not need sedation just because they are intubated. It is not painful in and of itself just to be intubated. Versed has been shown to cause brain cell apoptosis (programmed cell death) and there are deleterious effects of giving narcotics to neonates, particularly preemies.

[essT]

Simply being on the vent isn't an indication for sedation in our unit. If a baby is showing signs of pain not controlled by boundaries/positioning/non-pharma measures, or if the gases are really bad, we'll use low-dose fentanyl to start. Every now and then we'll have a kid that requires a higher dose of fentanyl or even a paralytic. Usually this is our older ex-preemies or term newborns with MAS/PPHN/etc. If they're vented without an IV, some OG/SL versed is used. Often a baby who is truly that ticked off about being intubated will be extubated to NIV-NAVA or bubble CPAP to see if they'll fly -- and they usually do. Because of the negative effects, sedation is really a last resort for our neos.

[melbae9]

I was not under the impression RNs were not allowed to push propofol or sux. For intubation we use fentanyl since it has the least risks from a cardiac standpoint in regards to hypotension or bradycardia and always a paralytic, sometimes Cis but usually Roc.

[TiffyRN, BSN, PhD]

I voted morphine, but it's not common. We manage the vast majority of our kids on BCPAP, almost all intubated kids have failed BCPAP. Of course not post-op or specific conditions, but the average preterm will be given a chance to fail CPAP, even if that means they are initially intubated while the MD dilates their nares for a day or two in preparation for nasal CPAP.

But I digress. . . The majority of the kids that are intubated, even chronically so, are not routinely on sedation. If they are really chronic, those are the ones who will be sedated because they are older, and very chronic, and difficult to keep intubated. Undoubtedly these are the ones who have been on HFOV for most of their life and if they could ever get their settings down, they would go straight to BCPAP. Those kids will be on morphine or more likely on methadone. They will also probably have PRN ativan.

We had an excellent talk by one of our MDs a couple of months ago presenting all the evidence on apoptosis with benzos. He had led the push to really decrease their use in our unit and his presentation was very convincing. He did share that sometimes you have to just go with the benzos when there is no other option. He has also helped introduce Precedex for our kids, problem being, they aren't ready to use it on preemies yet and that is our biggest population.

[wensday, MSN, RN, APN, NP]

Thanks for your replies, it's really interesting reading the different practice.

When I started out all our vented patients were on morphine and midazolam (Versed). Ten years later and we tend to use morphine when they are uncomfortable on the vent and usual comfort measures are failing, or if they are fighting but fail non-invasive. Midaz is rare now although we do use it when struggling. Both we wean as quickly as possible. Nurses get very protective of weaning sedation and argue the decision...pain being preventable. However we (ANNPs/doctors) are thinking about the side effects a bit more.

I'm looking at other options because of the risks associated with the above.

I'm currently looking at fent and also dexmedetomidine (precedex) research and wondered what everyone else was using. One of our problems is money. The NHS is poor and new drugs are expensive.

[Maevish, ASN, RN]

I was not under the impression RNs were not allowed to push propofol or sux. For intubation we use fentanyl since it has the least risks from a cardiac standpoint in regards to hypotension or bradycardia and always a paralytic, sometimes Cis but usually Roc.

Are nurses just not supposed to do that in NICU? I do it fairly often (and at two jobs, I've done that almost exclusively-at plastic surgery centers) because the nurses are the only ones there, for example, if the MD is at the head of the bed intubating. I mean, they don't usually want to push meds from what I can tell, and I've only seen a doc push a med a couple times in my nearly 9 years (unless they're an anesthesiologist, of course).

I'm curious if that's only a NICU thing so thanks for asking cause I'd never really thought about it before.

xo

[HotLips4077]

When I started in the NICU 4 years ago almost all of our vented babies were either on fentanyl and versed drips or had it ordered PRN. In the last year, though, our neos have stopped ordering them. Part of the reason for this is because our IVH rates have been pretty high and our unit is implementing a sort of quality improvement project aimed at reducing these rates. Now whenever sedation IS ordered, it's just a one time order that has to be justified. I can't even recall the last time I gave sedation to a vented patient on our unit.

Larger kids do sometimes have some PRN's available, but for the most part there has been an overall push to decrease its use across the board.

We also rarely give anything for intubation.