Sedation/Intubation

Interesting question. Our NICU gives very, very little in the way of sedation for vented kids from what I have observed. (I work in PICU and float to NICU). In PICU, we are fairly generous with sedation for our vented clients, regardless of age. So (and this happens) a kid was intubated in NICU no sedation, comes to us for whatever reason (possible ECMO, discharged and readmitted with RSV are the two most common things) and we sedate the same kid for mechanical ventilation.

The NICU nurses are horrified that we DO sedate, and we are horrified that they don't.

BIG disconnect between the two areas and providers.

We don't give any pain medicine unless it's necessary from a different point of view- like a patient is intubated because they are post-op from a surgery. It's not painful to be intubated. It may be uncomfortable, but the problem is that these drugs affect brain development. Versed alone causes neuron apoptosis- brain cell death. That is something hard for me to justify to a parent on her infant who doesn't really need it. When you think about the kids with chronic lung disease who are intubated for months before they end up getting a tracheostomy, all those months of drug sedation have compounded long-term effects. PICU is a different population and they generally don't keep kids intubated for months and months at a time.

I work at an academic center in the southwest and it is the same policy at the other academic center that I worked at on the east coast. And to be really honest, I didn't see signs of pain on infants as a RN on a patient who is just intubated with nothing else going on.

Unless the kid is wild or having really crappy gases, we use sedation pretty minimally. That being said, most oscillator kids get a low dose gtt of fentanyl or versed. We do give a dose of fentanyl prior to any intubation.

We start kids on a low-moderate morphine drip when they get intubated. If they're really snowed, we wean, and for some you can wean all the way off and they stay settled.

It's not painful to be intubated.

I understand this is objectively true, but I wonder about how a baby brain interprets it, especially a preemie for whom excessive light, noise, etc. translate as painful stimuli. Surely a tube down the throat would have a similar effect?

I understand this is objectively true, but I wonder about how a baby brain interprets it, especially a preemie for whom excessive light, noise, etc. translate as painful stimuli. Surely a tube down the throat would have a similar effect?

The truth is that we don't know (like most of neonatology). We do know signs/symptoms of pain.

Excessive light and noise which are "painful" & stressful stimuli to a baby usually manifest in a change of vital signs or physical signs, generally things like tachycardia, sometimes apnea in severe stress moments, splaying of fingers (the "stop" sign that they give us). But the infants that I have taken care of that are intubated with nothing else going on and are developmentally tucked in well and have strict hands on/off times, they are fine. They don't exhibit the typical pain signs that we recognize in infants.

There are some kids that are going to need sedation, plain and simple, to keep that tube in, of course. Those I don't argue about. But the universal usage of narcotics and sedatives on all infants *just* because they happen to be intubated is not best practice.

Very similar to NicuGal, we give a dose of fentanyl before intubation if it's not an emergent situation. Most kids on conventional ventilators don't get pain control, we use non-pharmacologic methods instead and most do just fine. Babies on a jet sometimes get a fentanyl gtt if they need it, but we try to stay away from it if possible. Versed gtts are fairly rare, but we do bolus some if the fentanyl isn't cutting it.

Not all intubation procedures are painless, I could probably safely say we have all witnessed multiple attempts and traumatic intubations. Once intubated and left to themselves it isn't.

For us, it depends on the infant. Sometimes there's just a one time dose for the actual intubation. If the kidlet is as NicuGal said, pretty wild or having unstable and crappy gasses, they will be sedated, otherwise, sedation will sometimes be ordered on a prn basis or not at all.

Case by case here, too. Most of our intubated patients have an order for fentanyl PRN and is up to the bedside nurse's discretion as to whether the baby gets it or not. We have some nurses that give it per the order around the clock, and others that treat symptomatically. I am the latter. That said, if I have a baby who has been given the med frequently I would never deny it if there is a risk for withdrawal. Anyway, I think this, like most things NICU, are institution based.

We definitely do if a baby is on high-frequency ventilation. And otherwise, it depends on the baby. Our nurses are good about advocating for pain control and/or control of agitation if it seems indicated, and our medical providers are pretty responsive to our requests.