Sedation on the vent...

[SCER2005]

OK so you've expertly initiated RSI and deftly passed your ET tube. Your atient who was previosuly in respiratory dire straits is now securely on the ventilator. What now? What drugs and dosages do you guys and gals like to use for continued sedation? I've messed around a little with versed and fentanyl and some with propofol. In a time where it seems like we are boarding ICU patients more and more this definitely becomes an issue. This is an issue that I'm just now starting to get faced with regularly and it's one that I'm not all that comfortable with yet. Appreciate all the input.

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[bulgethetwine]

OK so you've expertly initiated RSI and deftly passed your ET tube. Your atient who was previosuly in respiratory dire straits is now securely on the ventilator. What now? What drugs and dosages do you guys and gals like to use for continued sedation? I've messed around a little with versed and fentanyl and some with propofol. In a time where it seems like we are boarding ICU patients more and more this definitely becomes an issue. This is an issue that I'm just now starting to get faced with regularly and it's one that I'm not all that comfortable with yet. Appreciate all the input.

Lots of regimens! Important way to think about it to go component by component, i.e. sedative, pain control, paralytic (if necessary).

Versed and fentanyl is a popular combo -- I start with 4 of Versed and 50 of fentanyl (generally, of course, extremes of weight require re-thinking of my knee-jerk doses). Can add another 2 of Versed when they get light if they are, for example, headed for the scanner and I don't want to paralyze them. If they thrash and buck, could use a longer acting paralytic then sux such as rocuronium. Don't forget that if you paralyze someone, though, you need sedatives and pain control or you can imagine the nightmare that could ensue for the patient!

Propofol is a great agent if you are planning on extubating within 24-48 hours, but if I know they are gonna be vented for a long time, I usually just skip to the other stuff all together. Unless it's a case of I'll-give-what-I-want-short-term and the ICU can transition from the propfol to their longer acting agent du-jour as they see fit.

There is a good section in the Icu Book (Mariino) if you use it, that details post intubation sedation.

 

[southerndoc]

I use propofol for patients requiring frequent neuro exams. Vecuronium is reserved almost (almost) exclusively for trauma patients heading to CT scan or for medical patients that cannot lie still for diagnostic imaging. I ensure they have adequate sedation though.

For nearly all medical patients, I use midazolam and fentanyl. I try to avoid drips if possible since our MICU director hates them with a passion. Research shows that those who are on sedation/pain management drips have longer vent weaning times when compared to those who receive boluses.

 

[sdn1977]

On the other hand.....our ICU director prefers drips & so do the nurses....so we use lorazepam & fentanyl. Midazolam is more expensive for us (this varies with contractual agreements) so we prefer lorazepam.

But.....your protocol has to be clearly defined so the nurses start to wean early in the AM so whichever physician who is assessing mental status can do so when he/she rounds.

The nurses like it because it is smooth, requires fewer assessments & dose adjustments & we like it because its less expensive. However, we don't convert someone over unless they've been on the vent for > 48h. Until that time, we assume it will be short term, so don't mind midazolam, propofol,etc..

 

[MasterintuBater]

I like Versed and Fentanyl as well. THe nurses are comfortable titrating Versed to moderate sedation. I try to avoid paralyzing these patients as well but if I have to, 10 mg of Vecuronium will usually last until they get to the unit.

 

[roja]

We use propofol almost exclusively- except when the pressures don't tolerate it. Our ICU directors like it and they can always switch over to something else.

Other option is ativan drips. Fentynyl is great when you are having trouble with pressures.

Really there are so many options, much of it is dependent on your institution.


We tend to only use paralytics when it is someone that is bucking the vent alot (asthmatics that are hard to control with sedation, etc) and we are worried about barotrauma

 

[basementbeastie]

propofol -> yes!
ativan - bolus or drips -> yes!
vec -> usually a one time shot after tube is in, sedation is in and patient is getting scanned, lines, whatever...
fentanyl -> yes

 

[The White Coat Investor]

Am I the only one who just connects the budweiser in their pocket to their IV for sedation? Why mix agents?

Alternatively, I call in Nurse Norris for a roundhouse...

 

[basementbeastie]

Am I the only one who just connects the budweiser in their pocket to their IV for sedation? Why mix agents?

Alternatively, I call in Nurse Norris for a roundhouse...

the bud is for ME!

 

[docB]

I have found that the preferences for vent sedation are nurse and institution dependent. Around here I order, and the unit nurses are comfy with, propofol gtt and versed 1-5 / hr PRN breakthrough sedation. I avoid paralytics unless the patient is moving and needs a study.

And BTW Chuck does NOT use the roundhouse for sedation. His icy stare is enough for that.

 

[GeneralVeers]

My personal favourite is the propofol drip. It's easy to titrate, and short acting, the nurses will love you for it. Most of my colleagues try to manage intubated patients with ativan Q4h, the problem being that if you forget to give it, the patient may self-extubate.

 

[beyond all hope]

I don't understand using Versed when you've already got someone down, as it's more vasoactive than Ativan and shorter-lasting. Once they're down, I'm all about the Ativan and Vecc.

People who are agitated often drop their pressures just after tubing them. They can also get stacking on the vent, drop their preload, and drop their pressures. Why drop it with a short-acting benzo?

Agree with Propofol if you want to turn it off for neuro exams (like head bleeds). However, can be tough to get the titration just right, so I start with my handy Ativan/Vecc and get my Propofol drip running at the same time. Only got 10 minutes with Succ, and often by the time the Propofol is hung the person is sitting up clawing at the tube.

Unfortunately, I find myself using noninvasive ventillation a lot lately, so a lot of the people I tube don't require anything.

Resp distress -> BiPAP trial
Shock -> Tube

 

[basementbeastie]

agree with using ativan instead of versed for vent sedation....use versed for procedures mostly.....

 

[bartleby]

Propofol is great for all the reasons mentioned above. Particularly in the emergency department it is helpful because one the patient is chilled out, they tend to be on autopilot on a steady infusion.

Fentanyl/versed are acceptable for unstable patients who need small doses of short-acting meds. But when you are boarding someone on a vent in the ED and the nurse taking care of them has five other patients, it is too easy for their doses to get spaced out too far so the patient alternates between comatose and bucking the vent.

Paralytics should not be used for "keeping a patient down" except in a addition to a healthy dose of a sedative (propofol or benzo) freshly tubed trauma patient heading the the scanner. Otherwise, if you're needing to paralyze you are likely undersedating them. Using a short active sedative with a long acting paralytic agent is torture. I can always tell when one of the residents has done this because the nurse comes to find me what I want to give the paralyzed intubated guy who's gotten progressively more tachycardic and hypertensive 45 minutes after his last dose of sedative. Ativan + morphine or dilaudid is a better choice for people you want to go down and stay down.

 

[VentdependenT]

there is a definite relationship between long term use of a muscle relaxant and myopathy. If we need to use them for decreasing work of breathing or ablation of shivering (while warming of course) then they need to be used with a twitch monitor and be put on "holidays." You can get screwed big time if your patient has renal or hepatic failure with vec. Nimbex is the way to flow but it costs about 8x more than vec.

Propofol is the schnizzle. Flip it off in the am, shes gone in 30 min, do yer neuro checks and whatever, flip her back on. You need fentanyl or morphine for pain.

Dex is the new kid on the block. Has favorable profile for zero respiratory depression, lowering of blood pressure, sedation, some degree of analgesia, and a short half life.

Ativan = versed in my opinion. However ativan is better in liver failure I believe due to some metabolite in versed. I can't remember what exactly.

Everone needs an am ween. titrate down narcs if you can't turn em all the way off.

 

[Apollyon]

Dex is the new kid on the block. Has favorable profile for zero respiratory depression, lowering of blood pressure, sedation, some degree of analgesia, and a short half life.

I take it that, when you say "dex", you mean "dexmedetomidine" (a/k/a "Precedex").

Just need to clarify, as I might guess that most people think of "dexamethasone" when you say "dex".

 

[BeardieDoc]

Trauma patients with stable BP going to CT: Vecuronium + Ativan + fentanyl (don't forget to treat the pain). If patient spending night in busy ED. Propofol drip.

 

[VentdependenT]

I take it that, when you say "dex", you mean "dexmedetomidine" (a/k/a "Precedex").

Just need to clarify, as I might guess that most people think of "dexamethasone" when you say "dex".

You be correct. I mean preceDEX.