Sedation in ICU... your opinions/ experiences?

[IheartICUnursing]

Just wondering, how many of your vented pts are sedated, and with what? Are there certain pts that you always do or do not sedate, or is it always a case by case basis.

Most nurses on my unit would agree that we do NOT sedate people enough. Of course, I know we shouldnt be snowing every pt in the unit, lol. Nobody gets propofol, if they come in on it they have us stop it. They typically don't order anything continuous right off the bat... maybe they will order something Q1hr PRN and then when you explain how it doesn't make sense to be in there pushing fentanyl every hour, then you may get a continuous PCA dose.

We do end up with quite a few people on continuous Fentanyl, usually running at 50-100, maybe up to 200 after they are on it long enough and still sitting straight up in bed.

Rarely we might have a mg or two of Versed on board as well.

The only exception would be our pts on bilevel- most times they are very well sedated and paralyzed.

... they keep trying to make plans to help decrease our # of unplanned extubations (big problem in our unit) but none of these plans involve adequate sedation.

Ugh! Some nights I feel like I'm in the rodeo. Plus, we have all private rooms, so if I'm stuck in one, have no idea whats going on in the other until alarms are going off.

Opinions/ experiences/ advice??

[Sun0408, ASN, RN]

I would say 90% of our pts are sedated if on the vent. We either use diprovan, versed gtt, or something continuous. Rarely do we not sedate unless sedation is not needed. We also have PRN pain and anxiety meds

If I'm vented, sedate me please :)

[IheartICUnursing]

Exactly! I think its cruel not to be sedated unless you are about to be extubated. Some of our Drs feel the same but if they order sedation they know the medical director will question it. He feels it increases vent days or something. It seems to me that fighting the vent until you tear up your lungs would increase vent days as well.

[meanmaryjean, DNP, RN]

I was hoping this was about sedation for the staff. ......sigh

:)

[Always_Learning, BSN, RN]

We use propofol and fentanyl routinely, and Precedex alternatively and for weaning. However, studies have shown there are some adverse effects from longer-term propofol use. (I'm in class right now, though, so pardon me for not taking the time to find and post a link! ). I am inclined to think your medical director may have a point, though...we sedate vents pretty decently, and I have noticed quite a few patients recently with difficulty weaning off the vent, and they end up going for trachs. I know there are multiple factors involved in failed weans, but I need to research more the role of sedation in these instances. As you said, OP, we don't want folks bucking the vent and freaking out, but you don't want them totally snowed, either. That "happy medium" is often easier said than done, though.

I will say that sedation is always very individual. There are those little old folks where a tiny bit of fentanyl knocks them out, and then there are patients maxed out on everything and still kicking and trying to self-extubate (often these folks have a history of drug abuse or ETOH, so I sometimes think all the sedation in the world wouldn't cut it). Looking forward to seeing others' comments and experiences.

[mlykateRN]

How cruel!!!!!!!!!! We ALWAYS sedate. Most patients who require intubation will need at least 24hrs vent/rest time before even discussing wiening/extubation. I would fight this tooth and nail. Maybe you should intubate your medical director and then see what he thinks! Hope I don't have to be in your ICU!

Fight the good fight and keep advocating for your patients!

If we couldn't sedate our patients, most of them we couldn't get a decent enough ABG to start wiening. I HATE using fentanyl for "sedation". Fentanyl is for pain control and just like other narcotics, it sometimes has the opposite effect and instead of sedating, it causes aggitation.

Lord, I would have to be sedated if I couldn't help my patients be comfortable and heal!

[mlykateRN]

one more question/comment.....I bet your restraint use is outrageous! How are they handling that? The only way to decrease restraints is to adequately sedate!

[nurse in dallas]

If a patient is intubated and has NO plans for weaning, then we use versed gtts for sedation, and fentanyl gtts for analgesia. If using one, we usually have the other. We also use Precidex for weaning. This is a catch 22, b/c sedatives in patients are known to cause delirium, which increases morbidity and mortality in the long run (Vanderbilt study). If a patient is bucking and is trying to yank their tube, and they need to be intubuated, then advocate for your patient and get appropriate sedation. Thats just cruel.

[8jimi8ICURN]

Typically 1mcg/kg fentanyl /c a little versedOr propofol bonus on top of that.Plus or minus. Unless they are a ventilator PRO, one of the rare patients who doesn't mind and well tolerates alertness while intubated.

[lub dub]

Propofol, all the way!!!

[EMTtoRNinVA, MSN, RN]

We have nursing driven Sedation protocols (fentanyl, dilaudid, versed, diprivan), we use CAM-ICU, Richmond Agitation Scores, BIS monitoring, and a Train of Four to assess our paralyzed/sedated patients.

We have daily SBTs, and occasionally use Precedex, but it's crazy expensive. Our # of trachs has gone down dramatically in the last couple years.

[ckh23, BSN, RN]

Fentnyl,Versed, and restraints. Do they really need to investigate why you have and increase in unplanned extubations? Perhaps some protocols need to be put into place about sedating the patients on continuous gtts or more training to nurses.

I notice some nurses will titrate sedation gtts up with agitation, not realizing it will take some time for that increase to take effect. Next thing you know the patient is on 300 of Fentnyl and 5 of versed before adequate sedation is achieved. However, you can usually keep your continuous gtt rates lower and the patient well sedated by just giving prn boluses of a particular drug.