Sedation in ICU... your opinions/ experiences?

07302003, ASN, RN · Sep 5, 2012

95% of patients where I work are intermittent sedation - Morphine 2-4 and Ativan 2-4 Q 15min-2 hours prn MAAS (very nurse driven). Of course, if the patient is hard to sedate it's easy to get an order for a continuous fentanyl + versed gtt or propofol + versed if needed. Intermittent sedation has been shown to decrease vent days, and I'd agree, because I've seen the patients who have had a hard time waking up from continuous drips. And with intermittent sedation, we're using much less meds per day, especially in the elderly, who have a hard time clearing the meds from their system.

AICU RN · Sep 11, 2012

I had a pt over the weekend who was nasally intubated after a radical neck surgery. ENT wanted him pretty snowed but that was easier said than done. First night I had him we were up to 150mcg of Fent per hour and 50 of Propofol/hr. He was still sitting straight up in bed and trying to kick his feet over the siderails. I had to wrist restrain him unfortunately. Finally talked the docs into believing it wasn't working and the next night I had him on the same dose fo Fent with 12 of Versed. That didn't touch him. The next night I had him we were trying boluses of KETAMINE...that didn't work either. Finally started Precedex but after 24h that started making him brady (of course). So the last night before I was off they had me wean him off Precedex before I left and ordered bolus doses of Haldol. Sheesh....don't know how it finally worked out. No history of drug abuse either.

Honestly, in our ICU, I'd say it's about 50/50 as far as whether our patient's are sedated while intubated. If they are, Prop is usually our first choice. We have been using Precedex more. Also started using the Fent/Versed combo someone talked about earlier. The people who are vented but NOT sedated that amaze me. Just lying in bed all calm, just amazing. Not me. If I'm tubed I better have some major sedation on board :geek: .

Anyway, we did just start using the ABCDE bundle. It seems pretty useful so far.

tenman11 · Sep 12, 2012

In the hospital where I worked we often used a mix of Propofol and Fentanyl. We also had a sedation protocol in place which allowed for other alternatives. On patients who could tolerate weaning, we would do daily sedation vacations with spontaneous weaning parameters. This seemed to help get them off faster. It was always a balancing act between actively weaning (fio2/peep) and adequate sedation and pain control. Our Intensivists were pretty good at letting nursing and respiratory therapy play an active role managing the vent. There are many studies about sedation vacations, and reduced vent days, perhaps your physicians would be open to this type of strategy or you could do your own study of your units incidence of average vent times, self extubations, reintubation, invasive line removal by patients, restraint days, etc. Real numbers are a powerful motivator for change.

reyfresco · Sep 12, 2012

What may be more cruel is the damage we are doing to our patients in the long term. By over sedating our patients studies have shown poorer outcomes in these patients. Over sedation leads to ICU delerium which causes increased risk of dementia, depression, STM loss, variety of mental health disorders, and a four fold risk of mortality (yes, death) in the next 10 years, due to over sedation. Benzos are enemy number one, they have the worst long term effects. Using a valid and reliable tool such as the ABCDE type bundle we can improve patient outcomes. I was a hard and fast believer in sedation, diprovan was my best friend. Despite it being more work for us, and the patient being more aware, we have duty to act and implement evidence-based best practice. There is a lot of current information out there on ICU delerium and ventilator sedation management. When patients are sedated they are not "resting", and when there are lying in bed and not moving they are not "heal[ing]". It is a cultural shift from how critical care nursing used to be, to what it must become.

justatraveler · Nov 14, 2012

I work in a 23 bed micu/sicu at one of the largest hospitals in Denmark. It is a university hospital/learning hospital. The approach here is that NONE of our intubated patients are sedated. There are exceptions ofcourse. For those who absolutely cannot tolerate it and fx. I recently had a patient who had a bleed in his naso/pharynx and they had to pack with gauze for 3 or 4 days to stop the bleed. That would have been intolerable ofc. and he was kept sedated. There are other reasons for why we might choose to sedate, but my mind is on the fritz right now. However, sedation is really a rare thing for us. Neuro patients are sedated obviously, but we don't have those, they are at our NICU .

Conscious patients have better outcomes, fewer days on vent, shorter stays in icu and fewer instances of PTSD. Not to mention fewer instances of VAP and the list goes on and on. One of our dr.s has done groundbreaking research in this area and it is the norm at my hospital.

Now all that being said, we do have a 1:1 ratio, which is the only reason this can be done successfully.

PMFB-RN, RN · Nov 14, 2012

Where I work all vented patients are sedated automaticaly. When the provider enters the vent orders s/he MUST choose one of several sedation protocols or the computer won't take the vent orders. The protocols range from propofol with fentanyl gtt down to q1 versed IV push. Occasionaly there are patients that do not need to be sedated. In that case there will be no gtt but the nurse will have versed IV push orders (or for certain patients Ativan IV push), even if nobody is using them.

Speaking as a person who had been intubated twice, once for almost a week, I find the idea of not sedating vented patients barbaric. Naturaly there can be no one-size-fit-all answer for every patient but in principal the questions should never be "does this patient need sedation". We should alwasy start out with the assumtion that of course vented patients need to be sedated and take the exceptions on a case by case basis.

That said the dangers of over sedation are very real and there is some great litature out there about the dangers of oversedation of ICU patients and resulting poor outcomes. In my view many places are not sedating enough and those that do are often oversedating. There are a variety of tools for assessing sedation out there but what I usually teach my students and residents is that a sedated patient should open their eyes if you say their name and remain awake when you are stimulating them, then drift off when the stiumation stops.

We have this thing in nursing called evidence based practice. Tell your manager and medical director to get with the program.

PMFB-RN, RN · Nov 14, 2012

Neuro patients are sedated obviously, but we don't have those, they are at our NICU .

This was making no sence to me. I just realized that you are calling neuro ICU NICU. Here in the USA NICU refers to Neonatal ICU. I though what are the neuro patients doing in the baby ICU? I got it now:)

justatraveler · Nov 14, 2012

lol... yes, I can see where that would be confusing. Unfortunately, I cannot go back and correct it.

And just for the record, our practices here are evidence based.

http://www.biostat.sdu.dk/courses/f11/Biostatistics/papers/No-sedation.pdf

There is a higher incidence of agitated delirium in these patients, which we treat with bolus Midazolam PN, which is given following a protocol.

I cannot argue with your personal experiences, but there is also evidence for a lower incidence of PTSD associated with this practice. If I can find the evidence I will link it.

PMFB-RN, RN · Nov 14, 2012

lol... yes, I can see where that would be confusing. Unfortunately, I cannot go back and correct it.
And just for the record, our practices here are evidence based.
http://www.biostat.sdu.dk/courses/f11/Biostatistics/papers/No-sedation.pdf
There is a higher incidence of agitated delirium in these patients, which we treat with bolus Midazolam PN, which is given following a protocol.
I cannot argue with your personal experiences, but there is also evidence for a lower incidence of PTSD associated with this practice. If I can find the evidence I will link it.

*** I will tell you this. The first time I was intubated for several days and I have no memory of it except for just a few hours before they pulled the tube out. It was a not unpleasent floating feeling.

The second time I was wide awake and have nothing but horrible and tramatic memories. If I have to go though that again I will make myself a DNI........

justatraveler · Nov 14, 2012

So sorry your experience was so horrible. If you wouldn't mind telling about it, I would be very interested to learn about your experience.

On our unit, we do not use restraints. If patients are anxious we will stay by their side, hold their hands, explain everything that is happening. Much effort is spent informing them and making them as comfortable as possible. It is not unusual to see patients sitting up in a chair, watching TV or visiting with their families while intubated. Their families can be with them almost all the time.

http://www.kristeligt-dagblad.dk/artikel/476628:Danmark--Henning-kaempede-for-livet-med-aabne-oejne

This a picture of Henning, who was admitted in our icu. The link is to a danish article about Henning's experiences with being awake while intubated, while not always pleasant, he was glad to be able to remember his stay in icu. Sry, there is no english translation available.

hodgieRN · Nov 15, 2012

Studies are showing that awake pt have better outcomes. There's less delerium, lower VAP's, and shorter days on the vent. We basically sedate all of our pts, but some doc's are moving toward prn meds unless the pt isn't tolerating. Our hospital is looking into ambulating intubated pts. Some major hospitals are already doing this. There is exclusion criteria, but studies are proving the benefits of ambulating ventilated pts. The nurse, PT, RT are walking pts while bagging them or having the vent on a rolling table. There are videos of this on Youtube. It's pretty wild. There they are, walking in the room with an ET tube.

brandi-lynn · Nov 15, 2012

One of the Intensivists in our unit trialled all of the nurses on our unit on the vent. We each had a nose plug and a tube that we put in our mouth. He ran us through all of the vent settings. It was really interesting. Some of the nurses immediately yanked the tube from their mouths, it just freaked them out. Others, like myself, had no issues with it. So, I think sedation should be individualized. Just like pain meds, if someone looks liked their freaking out, bucking the vent or indicating that they're not doing well, by all means advocate to sedate. But, if someone's doing fine, why keep them down? I would hate to be sedated. But you would never know that I would do fine if you never gave me the chance to ask... Also, studies do show less days on the vent/delerium/PTSD/VAP...