Sedation After Intubation

[UnderwaterDoc]

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After a week of many intubations in a very heterogeneous group of patients, I could use some pointers when it comes to post-tube sedation. I have so far used propofol and versed with fentanyl and I seem to always over, or undershoot my drips. I would really appreciate some pointers/pearls/sarcastic words of wisdom.

 

[ORL10]

Currently we are out of versed and ativan.

We are now using ketamine and propofol and if I beg we are using precedex, +/- fentanyl with these.

I think for post-intubation sedation there are many regimens and depending on whom you ask you will get different answers. There is some recent literature comparing benzodiazepenes to propofol and dexmedetomidine for sedation favoring the non-BZD in terms of time to extubation and ICU LOS. This is thought to be 2/2 delirium form BZD.

I have had little experience using continuous sedation with ketamine until our current drug shortages. So far so good in the septic/hypotensive patients.

As for some pointers you may or may not know:

If you are over or undershooting your drips an important thing to remeber is when starting sedation in order to reach steady state for example with a BZD you should BOLUS first, not go up on the drip. In general most versed drips start at 0.05-.0.1 mg/kg/hr. Boluses with 0.05mg/kg until they are sedated. For fentanyl its usually 0.5-1mcg//kg/hr with a bolus of a similar range. Remeber the old and young need less, and alcoholics and drug abusers need more.

Propofol is much shorter acting so often times you sedate for RSI with a dose and then start on a rate and titrate up as you need, its fast acting so boluses are not always necessary.

Play around some people like slugs of dilaudid/morphine instead of fentanyl drips

 

[UnderwaterDoc]

Thanks for the reply, I'll keep at it.

 

[Hernandez]

Dont be dogmatic, every patient is different.
Don't jump straight to drips, give small frequent pushes till you find the right combo, I frequently tell my nurses, give 1 of this, call me in 15 minutes if it doesn't work then I'll give larger dose. I that works I have them call me back when hat wears off and then I order it as a scheduled dose, if it doesn't, I either give even larger dose or switch agents.
Dont just expect to walk away abd forget your pt, Frequently reassess your pt.

Personally, I like a combo of low dose benzo and low dose opioid for sedation

 

[Tiger26]

Dont be dogmatic, every patient is different.
Don't jump straight to drips, give small frequent pushes till you find the right combo, I frequently tell my nurses, give 1 of this, call me in 15 minutes if it doesn't work then I'll give larger dose. I that works I have them call me back when hat wears off and then I order it as a scheduled dose, if it doesn't, I either give even larger dose or switch agents.
Dont just expect to walk away abd forget your pt, Frequently reassess your pt.

Personally, I like a combo of low dose benzo and low dose opioid for sedation

agreed--I like to go the fentanyl/versed route

 

[jdh71]

Dont be dogmatic, every patient is different.
Don't jump straight to drips, give small frequent pushes till you find the right combo, I frequently tell my nurses, give 1 of this, call me in 15 minutes if it doesn't work then I'll give larger dose. I that works I have them call me back when hat wears off and then I order it as a scheduled dose, if it doesn't, I either give even larger dose or switch agents.
Dont just expect to walk away abd forget your pt, Frequently reassess your pt.

Personally, I like a combo of low dose benzo and low dose opioid for sedation

I disagree. I think monkeying around with bolus dosing causes more problems than it worth, especially early on. Plus if I'm on a vent, or my mom's on a vent, don't spend a few hours trying to figure out what it takes to keep me from waking up and being uncomfortable with a tube crammed into my airway and my arms tied at my sides - put me down.

The sedative agent I choose is usually versed, unless we are out, and if we are out then something else, whatever, usually propofol. I also like an opioid, usually fentanyl, but when we are out of that then dilaudid.

If pressure drops a little, especially when using propofol, just give a little pressor.

 

[Hamhock]

I disagree. I think monkeying around with bolus dosing causes more problems than it worth, especially early on. Plus if I'm on a vent, or my mom's on a vent, don't spend a few hours trying to figure out what it takes to keep me from waking up and being uncomfortable with a tube crammed into my airway and my arms tied at my sides - put me down.

The sedative agent I choose is usually versed, unless we are out, and if we are out then something else, whatever, usually propofol. I also like an opioid, usually fentanyl, but when we are out of that then dilaudid.

If pressure drops a little, especially when using propofol, just give a little pressor.

I agree.

I think jdh's angle is better for the ED docs.

I say get them down with a bolus and then drip enough to keep them down. (remembering pain control with an opioid)

Then if you have time (once all studies and moving are complete) and want to monkey around in the ED, then you can start to lighten up on the drip.

I find the idea of small bolus - reassess - bigger bolus - reassess - rinse and repeat and repeat and reassess for an uncomfortable, fighting patient without adequate sedation or pain control to be bad for the patient, bad for completing the emergent work-up, and not practical in a busy ED.

HH

 

[Hernandez]

Drips other than propofol are not adequate for initiating sedation on the vent unless you are giving bolus anyways. In my institution, I end up using more meds upfront than anyone, but less in the long term. I can't tell you how many times I see people reflexively start an Ativan drip at 2mg/hour, then in 30 minutes it's been increased to 4 an hour, and then at an hour they may have received 3.67mg. While I'm giving blouses every 10-15 minutes.

Jdh, i don't just blindly put in orders for sedation and walk away, in all honesty, how often do you actually get to walk away from a freshly intubates pt in less than 20 minutes anyways? It's easy to sit there get things tidied up and titrate to control. As far as drips in general, my person bias is after titrating to control, my sedation requirements afterwards is significantly lower and mostly I can do with intermittent pushes

 

[Hernandez]

, and not practical in a busy ED.

HH

My ED will have already washed their hands of the pt by this point anyways and resumed to walking around talking to each other on walkie talkies

 

[jdh71]

Drips other than propofol are not adequate for initiating sedation on the vent unless you are giving bolus anyways. In my institution, I end up using more meds upfront than anyone, but less in the long term. I can't tell you how many times I see people reflexively start an Ativan drip at 2mg/hour, then in 30 minutes it's been increased to 4 an hour, and then at an hour they may have received 3.67mg. While I'm giving blouses every 10-15 minutes.

Jdh, i don't just blindly put in orders for sedation and walk away, in all honesty, how often do you actually get to walk away from a freshly intubates pt in less than 20 minutes anyways? It's easy to sit there get things tidied up and titrate to control. As far as drips in general, my person bias is after titrating to control, my sedation requirements afterwards is significantly lower and mostly I can do with intermittent pushes

I don't think anyone blindly puts in orders and walks away.

It's not like anyone (anecdotal outliers notwithstanding) is getting extubated any time soon after having been intubated, put em down, start a drip. Quit monkeying with the boluses every 15 minutes - patient wakes up, needs more, in the mean time nurses has been messing with the OG, and now needs to draw up more meds, once syringe in hand, then needs to alcohol wipe IV line, then giving the meds, then waiting for it to kick in . . . I'm not telling you, you are "wrong", but it's not my style.

Sedation vacation in the AM per usual.

 

[UnderwaterDoc]

If pressure drops a little, especially when using propofol, just give a little pressor.

Ran into this issue also, with an elderly woman that I intubated. I started with a 2mg Versed bolus and then dripped Propofol at 20mcg/kg/min, her pressure got soft quickly into the 80s/40s, attending didn't want a pressor so I ended up dc'ing the Propofol and bolusing Ativan Q30 mins. This worked but was much more labor intensive.

 

[jdh71]

Ran into this issue also, with an elderly woman that I intubated. I started with a 2mg Versed bolus and then dripped Propofol at 20mcg/kg/min, her pressure got soft quickly into the 80s/40s, attending didn't want a pressor so I ended up dc'ing the Propofol and bolusing Ativan Q30 mins. This worked but was much more labor intensive.

One attending I worked with jokingly called it "propofed". Usually if the soft pressures are simply from the propofol, it only takes a wiff of pressor to bring their pressures back up into the happy range. Old people can be sensitive to the prop. Though some of this is style related, if you can use another sedative without also needed to add a pressor, then that's probably the better way to go.

 

[ORL10]

In response to Hernandez's comments about going up on drips or starting drips without blousing, reread my initial reply:

"If you are over or undershooting your drips an important thing to remeber is when starting sedation in order to reach steady state for example with a BZD you should BOLUS first, not go up on the drip".

I wasn't being dogmatic, just giving an example of one way to obtain adequate sedation. I agree with the other sentiments above that suggests that as an ED doc drips are better. I don't usually intubate people that are getting extubated in a couple of hours (save for the drunk combative trauma patient), and I would rather err on the side of over-sedation than under sedation with boluses.

Just my opinion

 

[SoCuteMD]

Sedation on a vent is very different in the ED than in the ICU. Often, the ED patients need more sedation to facilitate their workup. There's a lot of activity/stimulation/moving involved - to CT, back from CT, getting their Foley, getting their central line, their xrays, etc. Once they are in the ICU, there tends to be less activity (with some notable exceptions). Plus, at least where I am, the ER nurses may have one intubated patient and then 2-3 other patients, so they can't be at the bedside as much as they would with an ICU patient load (2 patients max at my institution).

I always order a drip after intubation, usually start with Versed. I write for both the titratable drip and a generous frequency of bolus. If they were in pain prior to intubation, I give them pain meds as well. I do think the patients sometimes arrive in the ICU a little bit oversedated, but it's not like they are being extubated or trialed THAT DAY, so the ICU has some time to fine tune their sedation, and it's better than them self-extubating.