Sedation and Hypotension

[Dempather, RN]

Hi,

I had a large male patient (~120kg) with a dx. of PNA/sepsis who went into respiratory failure. He was on a dopamine drip prior to this episode for hypotension. Normal RSI took place and he was intubated. Once his respiratory status was stabilized on the vent, it was difficult to sedate him with propofol and atracurium without dropping his pressure drop further. The Dopamine gtt was changed to Levophed because Dopamine was making him tachycardic, and his heart rate went back to SR after the switch. I titrated both the Levophed and Propofol accordingly, but I found myself balancing out his blood pressure and sedation levels the whole morning until I could get him to the ICU. He had also received a total of 2L NS in the ED.

I'd like to get some of your thoughts on maintaining sedation in agitated patients who have been intubated. Especially those who struggle with hypotension. Prior to transfer, his blood pressure dropped and I had to hold the propofol. While I delivered him to the ICU with a stable blood pressure (which I'd prefer over perfect sedation and unstable vital signs), the sedation had begun to wear off and the ICU nurse was shooting me glares (we're not talking severe agitation, but becoming restless).

I feel like I couldn't get the right balance prior to transfer. In my attempts to do this better next time, I'd appreciate some feedback from some of you guys -- what are your thoughts/what would you have done differently?

Thanks a lot.

[nurse2033, MSN, RN]

It sounds like you did great job. He probably could have used more fluid. 2L in the ER was appropriate at the time, but how much time had passed since that? What was his UOP? CVP? Anyone on a pressor must have adequate fluid resusitation either prior or concurrent. If he was too labile on the propofol you could have asked for ativan/fentanyl drip.

[Creamsoda, ASN, RN]

Agree with the above. sounds like he could have used more fluid. Sounds like he was in septic shock with resp failure.

20 ml/kg IVF so he would need at least 2400 ml, likely more. The propofol can drop your pressure, but my bet is he really needed more fluids. Also trying narcotics for pain management. And or switching to ativan/fentanyl drips for sedation.

[Zaphod, BSN, RN]

Decompensated sepsis usually needs a lot more fluid res. unless there are other issues such as renal or chf when you would be more conservative. It is not unheard to give 7-8L in severe sepsis. I like albumin as well unless contraindicated. Thats the nice thing about ICU because that nurse will have the benefit of knowing CVP, all the lab values so its easier to manage.

[CRNA1982]

Wow! All the wrong drugs were used in this case for both muscle relaxation and sedation. What kind of a doctor orders these drugs? Atracurium is a dead drug.....I can't even believe that a pharmacy dispenses this to pts. on a unit. Atracurium causes significant histamine release; that is why it is rarely used anymore as there are much better muscle relaxants available at a similar price without histamine release. When dealing with a hemodynamically unstable pt. why give drugs causing histamine release leading to further hypotension? Then he orders a propofol gtt.....A little versed fentanyl get could have produced adequate sedation and analgesia without the massive drop in SVR that propofol would cause. Septic pts. already have no SVR, why add to the problem with a propofol gtt?

[sapphire18]

I often find myself doing this dance too. I simply try to use the least amount of any given drip in order to achieve the desired effect. And you are correct that a stable BP takes priority over perfect sedation, however that can backfire when the pt starts biting the tube and bucking the vent...sounds like you did good though:) ICU nurses will always find something wrong with their ER (or any kind of) transfer...hehe.

[Crux1024]

I also have found myself in this same situation. Our ED DOES NOT do fentanyl or versed gtts, not allowed and we wouldnt get it even if it was ordered down there. So, mainting a propofol gtt on a hypotensive or running in with 2-4 mg IVP doses of Versed gets old real fast. Best thing Ive come up with is getting them to ICU as soon as possible, in the mean time. Im stuck at their bedside. Looking forward to more responses. IVF bolus' doesnt always help, ive found.

[meandragonbrett]

Why are you using a paralytic in the first place?

As far as sedation in the hypotensive patient......Don't use propofol.....Turn your pressors up if you have to, etc.

Haldol, midazolam, fentanyl, and dilaudid are all good choices whether as an infusion or prn dosing.

We tend to do a lot of PRN dosing at times and slowly titrate the drug to effect while trying to balance their pressure. One has to be patient when working them in for their effect. A quick bolus isn't going to cut it hemodynamically.

I don't see where you mentioned that any opioids were being given....Haldol is a big thing now in the ICUs for ventilator patients to reduce the use of BZDs. A lot of what we think to be restlessness and agitation has turned out to be delirium.

[Esme12, ASN, BSN, RN]

Wow! All the wrong drugs were used in this case for both muscle relaxation and sedation. What kind of a doctor orders these drugs? Atracurium is a dead drug.....I can't even believe that a pharmacy dispenses this to pts. on a unit. Atracurium causes significant histamine release; that is why it is rarely used anymore as there are much better muscle relaxants available at a similar price without histamine release. When dealing with a hemodynamically unstable pt. why give drugs causing histamine release leading to further hypotension? Then he orders a propofol gtt.....A little versed fentanyl get could have produced adequate sedation and analgesia without the massive drop in SVR that propofol would cause. Septic pts. already have no SVR, why add to the problem with a propofol gtt?

I agree.....sounds like thie nurse did great in light of the fact being left with sedation orders that weren't the best. I have found that there are little corners in the US where these dead drugs are still being given because they are cheap or the medical directors are hanging on to their personal preferences leaving the nurse to fight with for the patient to have good care. The OP said "when I got him to the ICU" which must have meant the patient was on stepdown (on dopa prior to code) coded and cared for on gthe floor then finally transfered.

OP the patient needed more fluid as septic patients can require massive amounts of fluid and the choice of drugs to be given could have been better.....Proprfol causes a drop in the SVR so in the septic patient that needs fluid when the SVR drops further and needs fluid hypotension ensues. MOre fluid would have helped but it sounds like you did a great job under the circumstances.

As far as the ICU nurses glares.......simply ignore them, smile sweetly, offer to help and pretend not to see their display. They are just unhappy at the situation of moving someone out and a really sick one in and probably close to shift change. If I was the super I'd take the time later to call them out on bad behavior........I don't like that passive aggressive baloney......being an ICU nurse myself.

Good Job.

[ICU_RN2]

We hardly ever use propofol in our ICU...

We frequently use Fent. gtts, Ativan IVP, and Versed IVP. We do see the Haldol IVP as well. Propofol will drop your pressure pretty much every time, just varies on how much - with a patient on pressors already, we def. avoid it at all costs.

No many how many pressors you pour into someone, if they need fluid, you won't get better BP's until your fluids have been replaced. We're a trauma ICU, so nearly everyone seems to needs tons of fluids and products...and until they get them all...your pressures going to be crap and its going to be a pressor vs sedation fight.

[GilaRRT]

Another agree regarding the atracurium. I am a big fan of fentanyl in patients who are haemodynamically compromised. Also, another good consideration in some septic patients is ketamine. You can have issues with catecholamine depleted patients; however, this is probably a better option than using large amounts of Diprivan.

Another issue that we run into is blowing the ventilator management. We often neglect patient/ventilator interaction at the cost of having very uncomfortable patients and haemodynamic complications.

[Dempather, RN]

This forum is a great educational tool for the person presenting the case, as well as the people contributing to the discussion. I feel compelled to add that identifying what's "wrong" serves absolutely no purpose, and is quite frankly, irritating. It neither changes what has happened or promotes openness in others when they want to share their cases. In addition to what I mentioned before:

I work in the Emergency Room and was waiting for an ICU bed when the patient went into failure. He had arrived and the dopamine was started on the previous shift. There was no CVP monitor at that point, UOP was approx 300cc from when the foley was placed during the arrest and transfer to the ICU approx 2-3 hrs later. The patient was also incontinent of a large amount of urine during the arrest, ? seizure activity which led to it?. ABG showed pt. was in respiratory acidosis. Appropriate changes to the ventilator was made to accommodate for that (change in tV and RR). Lactic Acid was elevated, and with the concurrent hypotension, I'm suspecting the patient was suffering from a later form of septic shock, which (to my understanding) increases SVR? If I'm wrong, please correct me.

In regards to the atracurium, this drug could very well be outdated. This hospital is outdated (no computer charting yet). I've worked for other hospitals where this isn't on formulary. While the patient was restless and out of synch with the vent, my thoughts were on improvement of ventilation and CO2 clearance. I found it interesting that you mentioned "the medical directors hanging on to personal preferences" because the ordering doctor was a previous medical director who, I strongly believe, was hanging on to his personal preference.

With all the hubdub, his repeat ABG was normal prior to transfer to ICU.

Thank you for your feedback, guys.