Sedation and Hypotension

[Dempather]

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.

[GilaRRT]

Identifying potential problems, issues with medications and other appreciating other considerations is good because you can implement knowledge gained into your future practice.

[Creamsoda, ASN, RN]

Sepsis severely decreases SVR. Vasculature becomes very dilated and leaky which is why you need +++ fluids to fill the tank and keep it filled.

[CRNA1982]

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.

You are right, this forum is a good educational tool for the person presenting the case. We often do Morbidity and Mortality presentations in our anesthesia dept to discuss "cases that went south" among anesthesia providers. The purpose of these presentations are to gain a better understanding from peers about what may have been implemented in order to see a better outcome. There is never animosity or hard feelings during these presentations. You must check your ego at the door. After all, its not about YOU it is about the pt. Everyone in a dept. comes with different levels of education and experience. This is why teamwork is so important, especially when collectively working together for the well being of a sick pt.

Clearly, your attending ordered the the worst combination of drugs for both muscle relaxation and sedation; whether you find it irritating or not. And if this pt. were my mom who was hypotensive, on pressors and septic and I found these gtts hanging; I would be ******. Furthermore, If I were working alongside an ER attending and he ordered these drugs for the pt., I would call him out on it and politely ask what his rationale is for using those gtts. As far as what is on formulary at your institution, I highly doubt that Atricurium is the only muscle relaxant that you have "in house." This is the 21st century and a 10 mg single use vial of Vecuronium would have kept your pt. relaxed all the way to the ICU and then some, without the histamine release. This dose would have set your pt. back roughly..... 10 cents.

As far as the SVR being elevated due to a "later form of septic shock" from the picture you have painted in your posts, you are wrong. Please don't get angry again, remember you wrote, "If I am wrong please correct me." Your pts. SVR was in the toilet.... Identifying what is "wrong" does serve a purpose. This is how professionals grow and learn from their mistakes. You have pts. lives in your hands. Don't you want to give them the best care that they deserve?

[Anna Flaxis, BSN, RN]

A patient in septic shock needs aggressive fluid resuscitation, which 2L is not. You have to dump those fluids in as fast as you can; worry about fluid overload later.

I agree, Fentanyl and Versed is a nice combo, and it wouldn't have hurt to get an order for a single dose of Vec.

We use a LOT of Propofol in my ED; but, if the patient's pressure can't handle it, we have to look at alternatives.

I'll never forget the kiddo with the skull fracture and head bleed I had to get to the OR with his ET tube still in place. I started the Propofol gtt at the pediatric dose, but it wasn't cutting it, and I had to keep bolusing the kid. I tried titrating the gtt, but our pumps have hard limits that you can't override, and I couldn't override the limit on the peds setting. I was bolusing the kid all the way from the ED to the OR to keep him from pulling out his tube (even with soft wrist restraints on, his efforts were admirable), and the anesthesiologist met us at the door to the OR with a syringe of Vec. It was like one of those moments where the clouds part and the shaft of light shines down. Lesson learned, do NOT use the pediatric settings on the IV pumps, and ask for an order for Vec prior to transport!

Anyway, I agree, bad choice of drugs for the situation, but it sounds like you did a good job dealing with what you had to deal with. The fact that a lot of us have to do our learning on the job, in the moment, is unfortunately the nature of the beast. Better clinical education would help immensely!

[Esme12, ASN, BSN, RN]

crna, and gilda are some pretty smart people....they know their stuff. i'd listen to them if they were talking to me......

septic shock is a medical emergency caused by decreased tissue perfusion and oxygen delivery as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. it can cause multiple organ dysfunction syndrome (formerly known as multiple organ failure) and death. its most common victims are children, immunocompromised individuals, and the elderly, as their immune systems cannot deal with the infection as effectively as those of healthy adults. frequently, patients suffering from septic shock are cared for in intensive care units. the mortality rate from septic shock is approximately 25-50%.

in humans, septic shock has a specific definition requiring several criteria for diagnosis:

• first, sirs (systemic inflammatory response syndrome) must be met by finding at least any two of the following:
  

tachypnea (high respiratory rate) > 20 breaths per minute, or on blood gas, a pco2 less than 32 mmhg signifying hyperventilation.white blood cell count either significantly low, 12000 cells/mm³.heart rate > 90 beats per minutetemperature: fever > 38.5 °c (101.3 °f) or hypothermia

• second, there must be sepsis and not an alternative form cause of sirs. sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest x-ray, or other radiologic or laboratory evidence of infection
  
• third, signs of end-organ dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate.
  
• finally, septic shock is diagnosed if there is refractory hypotension (low blood pressure that does not respond to treatment). this signifies that intravenous fluid administration alone is insufficient to maintain a patient's blood pressure from becoming hypotensive
  

a subclass of distributive shock, shock refers specifically to decreased tissue perfusion resulting in ischemia and organ dysfunction. cytokines released in a large scale inflammatory response results in massive vasodilation, increased capillary permeability, decreased systemic vascular resistance, and hypotension. hypotension reduces tissue perfusion pressure causing tissue hypoxia. finally, in an attempt to offset decreased blood pressure, ventricular dilatation and myocardial dysfunction will occur.

"the syndrome of septic shock supervenes; the same cytokine and secondary mediators, now at high levels, result in systemic vasodilation (hypotension), diminished myocardial contractility, widespread endothelial injury and activation, causing systemic leukocyte adhesion and diffuse alveolar capillary damage in the lung activation of the coagulation system, culminating in disseminated intravascular coagulation (dic)."

http://www.oucom.ohiou.edu/dbms-witmer/downloads/goodrum%20septic%20shock%2002-26-02.pdf

the hypoperfusion resulting from the combined effects of widespread vasodilation, myocardial pump failure, and dic causes multiorgan system failure that affects the liver, kidneys, and central nervous system, among others. unless the underlying infection (and lps overload) is rapidly brought under control, the patient usually dies.

treatment primarily consists of the following.

1. volume resuscitation
   
2. early antibiotic administration
   
3. early goal directed therapy
   
4. rapid source identification and control.
   
5. support of major organ dysfunction.
   

among the choices for vasopressors, norepinephrine is superior to dopamine in septic shock. both however are still listed as first line in guidelines.

antimediator agents may be of some limited use in severe clinical situations however are controversial:

1) low dose steroids (hydrocortisone) for 5 - 7 days led to improved outcomes.

2) recombinant activated protein c (drotrecogin alpha) reviews comment that it may be effective in those with very severe disease.

http://www.umm.edu/ency/article/000668.htm

http://ccn.aacnjournals.org/content/25/2/14.full

the drug choice for sedation, however, contributed to your patients instability and inability to be sedated effectively. i have worked at many facilities over the years and i have to say i am still amazed at what still goes on in some facilities to this very day in smaller corners of the united states that are sitting right in the middle of the research mecca in the northeast and i shake my head everytime i put someone in an ambulance for their 45 min ride for an angiogram and the tenacity if some phycisians that are the big fish of their little sea to absolutely refuse to reliquish their beliefs, preferances and control and that the only reason they haven't been eaten alive by the staff is that they are local(and the doctor is right) and usually (and that's a big usually) have never worked elsewhere.

so for drug choice you are pretty stuck. i would ask for the fentanyl and ativan/versed the next ime this situation arises and avoid propofol unitl the patient has been properly fluid resuscitated. but given the circun=mstances i'd still say good job!!

[Dempather, RN]

"The fact that a lot of us have to do our learning on the job, in the moment, is unfortunately the nature of the beast. Better clinical education would help immensely! "

I agree with this!

I spoke with a couple nurses from the hospital regarding Fentanyl gtts-- which they state do happen, but with less frequency in this ER d/t a specialized pump that's used for controlled substances (that you have to be trained in to use?). Fantastico. As a traveler, I'm not sure if I'll be seeing one before my assignment is up.

Thanks for your knowledge!

[Anna Flaxis, BSN, RN]

And this, my friends, is what is wrong with nursing today.

*Anybody* can bring an extra pillow. *Anybody* can serve a turkey sandwich.

Graduating nursing school and passing the NCLEX is a *starting point*. Nurses need continuing education from the time they graduate until the time they retire.

ACLS, PALS, TNCC? These do not count as clinical education! They are a *starting point*. Just passing the TNCC does NOT a competent Trauma Nurse make! Checking RNs off every year on how to read hemoccult cards and check CBGs does NOT count as clinical education!

Sadly, when we refer to the knowledge that the experienced nurse has gained, that knowledge may well have been gained at the expense of the patient.

In the scenario I previously referenced, the child had a good outcome, and the parents were happy with the care their child received. But imagine how much better the care would have been, had I had the benefit of better (or how about ANY) education in managing ventilated pediatric trauma patients.

Yeah, I learned a lot, and I'll do better next time. But the patients deserve better. The nurses deserve better!

If I ever leave acute care, it will be because I am sick of being treated like a handmaiden with no brain in my skull, my most important functions related to patient satisfaction, yet entrusted with human lives and expected to possess knowledge and skills that my employer is not willing to nurture and advance.