analgesia post-intubation

You have a valid and important point:
Proper sedation for intubated patients in intensive care should definitely include analgesics added to a hypnotic agent like Propofol.
On the other hand we have to admit that we do many painful procedures on patients under straight Propofol sedation and we don't see significant sympathetic response to the painful procedure provided we give enough Propofol.
An example to that would be endoscopic procedures.
I still think that pain should be addressed separately in the intubated and sedated patient.

Our default is a fentanyl infusion without benzo. This works remarkably well. For patients we plan on extubating quickly (within a day or so) of ICU admission we sometimes use fentanyl gtt or propofol + fentanyl boluses prn.

12R34Y said:

So, in general you don't need analgesia for a typical tube for lets say respiratory failure or a combative trauma patient.

You just give them propofol by itself and sedate only?

What about when you use propofol for induction of anesthesia for an actual case in the OR.

do you just use propofol or are you also giving analgesia? Are you just giving a one time bolus of fentanyl or are you using some sort of continuous infusion?

thanks again.

later

Click to expand...

if an icu patient is vented b/c of resp. failure, pain med typically isn't used. if the patient is surgical and vented, i have found fentanyl infusions common. as for induction, it's not uncommon to couple propofol with fentanyl, as fentanyl helps suppress sympathetic stimulation with DL/intubation. this becomes more important in the cardiac-hx patient.

this is really a "if a tree falls in the woods..." argument. if a patient cant process pain or doesnt have a sympathetic response, then they probably arent in pain of clinical significance. if you have a patient sedated on propofol and their HR and BP arent significantly elevated, they arent diaphoretic, etc. then they probably dont need "pain medicine" so to speak. just my opinion.

one of our attendings here is doing work with longer-term precedex for sedation in the ICU, which would help to treat both issues.

12R34Y said:

So, in general you don't need analgesia for a typical tube for lets say respiratory failure or a combative trauma patient.

You just give them propofol by itself and sedate only?

What about when you use propofol for induction of anesthesia for an actual case in the OR.

do you just use propofol or are you also giving analgesia? Are you just giving a one time bolus of fentanyl or are you using some sort of continuous infusion?

thanks again.

later

Click to expand...

Who said don't give analgesia?
In the OR if we are giving GA, most of the time we are doing balanced anesthesia which includes Hypnosis, amnesia, analgesia, and muscle relaxation.
Analgesia could be provided by many different ways: Bolus, infusion, regional...... etc...
No one is saying you should not use analgesia of some kind in conjunction with sedation for intubated patients.

dfk said:

if an icu patient is vented b/c of resp. failure, pain med typically isn't used. if the patient is surgical and vented, i have found fentanyl infusions common.

Click to expand...

proman said:

Our default is a fentanyl infusion without benzo. This works remarkably well. For patients we plan on extubating quickly (within a day or so) of ICU admission we sometimes use fentanyl gtt or propofol + fentanyl boluses prn.

Click to expand...

Ditto.

-copro

12R34Y said:

The reason I'm asking about this is that I'm doing some research on sedation/analgesia practices for trauma patient. Bottom line as everyone probably knows there is gross under sedation/analgesia of these patients typically.

Click to expand...

Couldn't agree more.

One of my favorite examples: elective bedside trach on a young otherwise healthy pt in the trauma ICU. Surgeon verbally ordering midaz/fent boluses to the RN, who is administering via the IV pump (not a free-flowing IV w/ syringe boluses):

"1mg of versed, 50 of fentanyl"
...2 minutes later...
"The patient is still looking right at me. How about 1 more of versed and 50 more of fentanyl"
...repeat x3 and pt's eyes still open
I suggest propofol. "Ok, how about 20mg of propofol"

This is why it really, really helps when intensivists have anesthesia training and know appropriate doses and properties of the agents they use.

Another example is when ppl do a-lines w/o local just because the pt has a midaz or prop gtt going. I've had an a-line, they f***in' hurt!

To echo the if a tree falls in a forest argument... Propofol is a "brain scrambler." Although propofol has no analgesic properties, if a patient's brain is scrambled enough to not know they are experiencing discomfort and their autonomics are blunted enough not to respond, then maybe propofol is all you need for that patient.

12R34Y said:

First of all I appreciate all of the responses.



Every text, journal article, airway thing you read about states the following: "Being intubated is intensely stimulating and uncomortable/painful."

Click to expand...

Are these refering to the process of being intubated (i.e. having direct larygoscopy performed and a tube shoved in) or are they refering simply to having a tube in place? I feel that the initial act of intubation is stimulating enough to require narcotics but that once the tube is in the stimulation decreases and simple sedation to the point of lack of awareness is adequate. Don't get me wrong, I think that having a tube in place with no sedation is cruel and unusual punishment but I think that the initial stimulation from DL is much greater than a tube remaining in place.

Idiopathic said:

this is really a "if a tree falls in the woods..." argument. if a patient cant process pain or doesnt have a sympathetic response, then they probably arent in pain of clinical significance. if you have a patient sedated on propofol and their HR and BP arent significantly elevated, they arent diaphoretic, etc. then they probably dont need "pain medicine" so to speak. just my opinion.

one of our attendings here is doing work with longer-term precedex for sedation in the ICU, which would help to treat both issues.

Click to expand...

I agree with Idiopathic on this.

Furthermore, not to hijack the thread, but this is why I dont see why people use high dose narcotics for GETA when inhalation agent is used. I understand that during induction one should use an appropriate dose of narcotic because of the intense stimulation...but during maintenance, why not just titrate up and down on the gas. Then when it's time to extubate, get the pt to breathe on their own and titrate the narcs to the respiratory rate.

The whole point we're making is, if the patient is 'asleep' or 'sedated' and something painful is being done. Is it really 'painful' ? According to the definition of pain, it's not just a noxious stimulus, but also an 'emotional' experience. Well if you arent 'with it', then how can you have an emotional experience?

Just being devil's advocate.

As an anecdote, in our surgical ICU the preferred sedation chosen by most of our attending critical care physicians (the majority of whom are anesthesiologists) has been a combination of propofol and Dilaudid infusions. So although in many units critical care physicians choose Versed/fentanyl OR propofol, this is an institutional preference (or perhaps simply the pulmonologist's lack of expertise with sedation drugs) and you can certainly add a narcotic when using propofol -- you simply end up using less of each drug. And it can be any narcotic, whichever one your hospital has a sedation protocol for.

Propofol does not have analgesic properties but it can get a patient sedated enough that they tolerate an ETT without a cough reflex. Some people call this "general anesthesia."

There are a few issues that I think are pertinent that have not yet been mentioned, which you might consider with the intubated trauma patient in the ER.

1. Transport of an intubated critical patient. Transport of an intubated, critically ill or hemodynamically unstable patient is difficult and hazardous. Your intubated ER trauma patient is going somewhere else soon, whether it's to the OR or the ICU. For the sake of simplifying equipment for travel, one infusion is easier to manage than two. Propofol by itself works very well for this and also has a rapid onset should the patient need a bolus en route to the ICU or OR. Two infusions (Versed and fentanyl, or propofol and something else) make traveling more difficult.

2. Analgesia doesn't have to be an infusion. You absolutely can start a narcotic infusion and a propofol infusion at the same time in the ER. But to make things simple for whomever has to take the patient to the ICU, how about, ummm, hydromorphone 0.5-1mg IV x1? Or morphine 1-2mg IV x1? A single bolus of long-acting narcotic will last until the patient becomes someone else's responsibility.

3. The intubated hemodynamically unstable patient may need some sympathetic drive. An under-resuscitated trauma patient may not actually tolerate much sedation and analgesia. If you overshoot the sedation and analgesia you can also take away whatever sympathetic drive is keeping their blood pressure above 70/40. Obviously this problem is usually solved in other ways (further volume resuscitation, use of vasopressor) but oversedation complicates this picture. Conversely, in the ICU setting when you have a patient who doesn't have major pain issues, if you let the patient wake up a little more you frequently also lower your pressor requirement.

4. Propofol does not necessarily mean "sedation." Propofol is not "sedation" per se. For example, 3 mg/kg/hr is what I call a typical "sedation" dose for an adult. It may be higher or lower than you use for an intubated patient. However, if I increase it to, say, 9 mg/kg/hr for an adult, it is no longer sedation -- it's "general anesthesia." To "sedate" a 2-year-old so he doesn't move in the MRI scanner, I often give 15 mg/kg/hr. Again, there's no way in hell you could call that sedation -- it's general anesthesia.

5. The relative importance of ET tube tolerance. It depends how important this is to you in the greater context of the patient's situation. True, the ET tube is stimulating. However, if the patient was just in an MVA, something else hurts more (but you still may not necessarily want to treat the pain before you treat the hemodynamics).

12R34Y said:

...I asked an anesthesia attending yesterday in the unit and he said propofol by itself is probably fine, but I can't get past the fact that it is ONLY sedation and provides no pain relief.

Every text, journal article, airway thing you read about states the following: "Being intubated is intensely stimulating and uncomortable/painful."

The other weird thing is that when we use versed drips they are almost always accompanied by fentanyl drips.

so, I just can't get past the whole difference....

later

Click to expand...

Propofol will give a greater level of CNS depression (sedation, if you want to use that word) than Versed at the typically used doses. So I can understand giving only a propfol infusion, and then giving narcotics as prn boluses. It is very easy to produce general anesthesia with propofol. It's harder to do that with versed alone, because propofol is better at blunting the sympathetics.

An alternative way to infusion is to do what we did during my internal medicine year: the protocol was to give Ativan and Morphine alternatingly q3 hrs as a standing order. They probably chose this because they are both longer acting drugs and eventually build up in the system.

jennyboo said:

4. Propofol does not necessarily mean "sedation." Propofol is not "sedation" per se. For example, 3 mg/kg/hr is what I call a typical "sedation" dose for an adult. It may be higher or lower than you use for an intubated patient. However, if I increase it to, say, 9 mg/kg/hr for an adult, it is no longer sedation -- it's "general anesthesia." To "sedate" a 2-year-old so he doesn't move in the MRI scanner, I often give 15 mg/kg/hr. Again, there's no way in hell you could call that sedation -- it's general anesthesia.

Click to expand...

I thought everyone in the anesthesia world used mcg/kg/min when talking about Propofol, did that change recently?

Planktonmd said:

I thought everyone in the anesthesia world used mcg/kg/min when talking about Propofol, did that change recently?

Click to expand...

I don't think so plank, although in some literature you will see mg/kg/hr. I was also trying to do the conversion in my head as I was reading jennyboo's post.

Our Alaris pumps are programmed as mcg/kg/min for propofol.

I think in mcg/kg/min for propofol also.

Planktonmd said:

I thought everyone in the anesthesia world used mcg/kg/min when talking about Propofol, did that change recently?

Click to expand...

Yes, I converted some typical OR doses (50 mcg/kg/min, 150 mcg/kg/min, 250 mcg/kg/min) into a more typical ICU format.

You know what patients need post-intubation?

PUPPIES!

-copro

coprolalia said:

You know what patients need post-intubation?

PUPPIES!

-copro

Click to expand...