Weaning Drips

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Specializes in ED, ICU, PSYCH, PP, CEN.

I have a pt on Levo, Nimbex, Propofol and Fentanyl.  I was trying weaning the Nimbex down very slowly, and then I went down on the fentanyl from like 50 to 40.  So day shift comes in and says you can't wean sedation when someone is on Nimbex.  I postulate that you can, very slowly and carefully.  But they're saying the fentanyl and Propofol have to be running at max, because pt is paralyzed.  

So long story short, is it true that if pt is on Nimbex the other meds have to be run full bore.  I do realize the nimbex has to be weaned down first.  Advise please

Thanks from a crusty old bat

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Specializes in Critical Care.

You wouldn't touch the analgesia/sedation until the paralytic has been turned off and has worn off, deep sedation should be maintained until the patient is no longer under any paralytic effect.

If you have a way of measuring level of sedation, either BIS or continuous EEG, then you could titrate the analgesia/sedation so long as you could confirm the patient was still under deep sedation.

It's not uncommon though for paralytics to be given without a way of continuously monitoring sedation, the patient is sedated to a RASS of -4 prior to giving a paralytic, then those doses of analgesia/sedation is left alone for the duration of a paralytic infusion and action.

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Specializes in ED, ICU, PSYCH, PP, CEN.

Thank you for the information.  Still so much to learn

 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I'm somewhat surprised to see your dose of fentanyl (unless our units are very different), that seems like a very low dose for a paralyzed patient. I agree with MunoRN, because we cannot see anything like a RASS score in a paralyzed patient, there's no way to know if a patient is awake under the paralytic, which would have to be a terrifying situation. I do not ever titrate sedation down while patients are paralyzed. We recently got BIS monitoring and the values there will give us a better idea of sedation, but we still don't have titration orders to go with that endpoint so for now patients remain with the same sedation the whole time they are paralyzed. 

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Specializes in Nurse Anesthesiology.

In a way I'm glad you asked this question, but definitely think you asked it too late.  If you were that patient how would you feel if you were paralyzed on the outside but wide awake on the inside because he/she was not sedated.  Sorry to come off harsh but that is the reality.  You never want to have a patient paralyzed with no sedation.

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Specializes in Critical Care.
1 hour ago, JBMmom said:

I'm somewhat surprised to see your dose of fentanyl (unless our units are very different), that seems like a very low dose for a paralyzed patient. I agree with MunoRN, because we cannot see anything like a RASS score in a paralyzed patient, there's no way to know if a patient is awake under the paralytic, which would have to be a terrifying situation. I do not ever titrate sedation down while patients are paralyzed. We recently got BIS monitoring and the values there will give us a better idea of sedation, but we still don't have titration orders to go with that endpoint so for now patients remain with the same sedation the whole time they are paralyzed. 

I would typically be running the fentanyl at 100mcg/hr minimum, although I don't really have a scientific reason for that specific dose.  

This is one of those debates that's hard to put a correct answer on, it's the same basic debate as what portion of analgesia / sedation should be analgesia.  It does seem generally agreed upon that like pharmaceutical paralysis, we shouldn't just sedate someone without also giving analgesia, the exact ratio is debated based on the expected amount of pain a patient might encounter.  

But generally I agree with the rule that you can't really have too high a ratio of analgesia to pure sedation, but you can give inadequate analgesia relative to sedation.  

I would argue that for the purpose of analgesia / sedation, fentanyl may not be the best option.  Supposedly one of the advantages to fentanyl being synthetic is that there is more of a direct pain receptor blocking action relative to it's euphoric effects, but for this purpose I see no reason to try and limit the euphoric action of 'traditional' opiates.

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Does your facility not have a policy on paralyzed patients?  My other question is do you not use a BIS monitor to monitor the level of sedation on a patient?

You absolutely never wean your pain and sedation while a pt is paralyzed.  They are unable to give you any signs that the pain and sedation is not adequate because they are paralyzed.  50mcg of fentanyl is too low to be honest.

We uses dilaudid, propofol, and versed on paralyzed patients.  We also use TOF to ensure the pt is paralyzed and BIS monitoring to ensure the pt is adequately sedated.  BIS should be between 40-60 and I tend to keep mine right around 40.   
 

 The point of weaning sedation on any pt to to get them more awake and progress towards extubation in the near future.  Since that’s not the goal with a paralytic there is literally zero reason to wean the gtt.  
 

We get stuck in this thought process that your job as an ICU nurse is to get your patients weaned off all gtts on your shift.  We need to look at the clinical picture of the pt.  

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Specializes in ED, ICU, PSYCH, PP, CEN.

Thanks to everyone for their input.  That is the beauty of Allnurses.  In response to passingas (cute name).  It really wasn't necessary to be harsh, as I have been a nurse for 18 years.  We were having a discussion at work on the finer points of weaning etc, and I like to come on here for more information.  We do have parameters etc, and the pt was never in any chance of harm as our charge nurses keep track of and guide us in all we do, not matter how long we've been doing it.  Fortunately I work in a really awesome place.

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Specializes in Nurse Anesthesiology.
On 3/20/2021 at 3:47 PM, gonzo1 said:

Thanks to everyone for their input.  That is the beauty of Allnurses.  In response to passingas (cute name).  It really wasn't necessary to be harsh, as I have been a nurse for 18 years.  We were having a discussion at work on the finer points of weaning etc, and I like to come on here for more information.  We do have parameters etc, and the pt was never in any chance of harm as our charge nurses keep track of and guide us in all we do, not matter how long we've been doing it.  Fortunately I work in a really awesome place.

Don't take my criticism personal because I really don't mean them to be that way.  Sometimes points need to come across strong to make others understand how serious their consequences can be.  Nurses or anyone dealing with titration of medication that can affect a patient should know exactly what can happen prior to doing so in my opinion.

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Specializes in ED, ICU, PSYCH, PP, CEN.

a little update:

As a result of information gained on this post, our ICU has put me in charge of bringing in BIS monitoring to the unit.  

Allnurses doing what it does best, improving the lives of nurses and patients.

Thanks to all

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