High dose narcotics FIRST for sedation in the ICU

Discussion in 'Critical Care' started by chocomorsel, Jan 8, 2019.

  1. chocomorsel

    chocomorsel Senior Member
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    Are you guys doing this? I am an anesthesiologist rotating in the MICU and this is what I am seeing. Patients on 200-300mcg/hr of Fentanyl or Dilaudid 3-5mg/hr IV before propofol/precedex. And attendings are like "treat pain first" before adding sedation drugs. So on top of the drips, there are pushes.

    I guess this is en vogue since "pain" is the fifth VS and all that jazz, but really, why are these patients needing such large doses of narcotics? For the ETT pain? Is it really that uncomfortable?

    In the SICU and NICU we are still old school I and running propofol/precedex first and adding Fentanyl and Dilaudid for pain if there's a known surgical/pain issue. And our Fentanyl drips rarely go above 100mcg/hr.

    Personally, I am not buying into the whole, narcotics first in medical patients without a known pain issue because I think it's creating tolerance, withdrawal, possible neuroexitation, and probably other things that we have yet to research and figure out. Especially when it's most likely unnecessary. Yes, there are papers, but we all know how research changes over time when we discover we are harming patients.

    Has the pendulum swung too far? What do y'all think?
     
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    #1 chocomorsel, Jan 8, 2019
    Last edited: Jan 9, 2019
  2. Hernandez

    Hernandez Paranoid and Crotchety...
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    http://www.learnicu.org/SiteCollectionDocuments/Pain, Agitation, Delirium.pdf

    “analgesia-first sedation (e.g. fentanyl) be used in mechanically ventilated adult ICU patients (+2B ) and that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes”


    My experience is that what you’re seeing, opiate first strategies decrease time on vent and have better outcomes
     
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  3. AdmiralChz

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    Wow, I thought everyone was on the propofol/precedex train. Sounds like a return to the 80s or 90s for sedation if true?

    I would worry about opiate tolerance after a few days?
     
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  4. TimesNewRoman

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    I wouldn’t say that it’s high dose narcotics first and I don’t think it’s going back to the 90s.

    The goal is the lowest possible sedation, but starting first with opiates. If that doesn’t do the trick, then escalate and/or add a sedative.
     
  5. Hernandez

    Hernandez Paranoid and Crotchety...
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    In my experience, precedex has a high rate of not working for sedation as a monotherapy. I like fent w/ precedex but that’s not my go to combo. There are lots of things I look at before deciding what I’m using but I probably use fent drip w/ q4 benzo push the most. And like tnr says, lowest dose possible.

    But did they die......
     
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    chocomorsel

    chocomorsel Senior Member
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    Well, I am not talking about benzos. Talking about combo of propofol/fentanyl or precedex/fentanyl and sometimes sedation first alone with fentanyl pushes instead of fentanyl first and prn benzos.

    What I am really concerned about is the high levels of fentanyl and dilaudid I am seeing in a couple of our ICUs. While I am not denying that an ETT/Foley/Vascath/PEG are uncomfortable, are they really 300mcg/hr uncomfortable?
     
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  7. CCM2017

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    That seems like too much opiate. I like precedex/propofol infusions with fentanyl as needed.

    Unless patient is in bad shock... might rely more on opiates then
     
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  8. Siggy

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    To be honest, I just start out all of my ventilators with propofol and fentanyl. The combination of both results in a lot of patients on fentanyl 25 and propofol 5-10.
     
  9. lymphocyte

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    The "analgesia-first" approach is supported by several prospective RCTs, including the Strom trial, which is probably the most cited trial when it comes to this approach.

    200mcg/kg/hr is bananas. It's not "analgesia-first." It's analgo-sedation; It's using a fentanyl infusion to sedate. And that's not supported by any literature. The Strom trial, for example, only used a median dose of 10 mg IV morphine/day in the intervention arm. Plus, fentanyl isn't a great drug. It accumulates in fat with a context-sensitive half-life, causes hyperalgesia, and sometimes even induces rigid-chest.

    PulmCrit- Fentanyl infusions for sedation: The opioid pendulum swings astray?

    Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014;370(5):444-54

    Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010;375:475-480
     
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    #9 lymphocyte, Jan 9, 2019
    Last edited: Jan 9, 2019
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  10. Psai

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    I like to start prop 50 and fent 50 mcg/h or so on normal people. If you're doing fentanyl only, people still get agitated and pull things until youre at about 200 mcg/h and more for drug users. Are you sure it's mcg/kg/h?
     
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    chocomorsel

    chocomorsel Senior Member
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    My bad, I meant 200 to 300 mcg/hr which is still a lot IMO.
     
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  12. psychbender

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    A lot of this is going to be population and situation dependent. 200-300mcg/hr fentanyl in a opioid-naive, MICU population without painful surgical or traumatic insult as primary sedative is rather crazy. If the GI tract works, I often utilize that for analgesics, and encourage them to be aggressively used, as needed. Nurses like to set it and forget it with moderate to high dose fentanyl infusions (makes for a really quiet shift). Change it to max at 50mcg/hr, and they're forced to actually look to see if their pt appears uncomfortable, and if so, give 5-10mg oxycodone down the dobhoff.

    Sent from my SM-G930V using SDN mobile
     
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  13. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    OpiOIDs guiz.

    Anyway. I use a low dose of fentanyl on vented patients, 25-50 mikes per hour, and then propofol or precedex.
     
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  14. TimesNewRoman

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    Same. Usually everyone gets 50 of fent, if that doesn’t do it I’ll start prop. Once I get to 20-30 of prop, I’ll go up on the fent. I usually won’t go above 150 of fent unless I’m up to 50 on prop.

    I’m not as big a precedex fan as a lot of people. Angioedema and need 24-48h to chill - yea, sure, precedex. But septic shock will be on the vent 5 days? Nah...
     
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  15. lymphocyte

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    I never understood fentanyl infusions. Still don't. It's lazy and low-value. Trials don't support it. Pharmokinetics doesn't support it. Generally, people become more hyperalgesic, need more sedation, and who knows what the offset time will be after a few days.
     
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    #15 lymphocyte, Jan 9, 2019
    Last edited: Jan 9, 2019
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  16. Hamhock

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    For me it depends on the patient, of course -- and so I won't go into that (surgical vs medical vs neuro)...and what "sub-type" of patient.

    In general, however, I think that timing is important.
    Just intubated and basically neuro intact before intubation? Then Precedex 0.5 just ain't going to cut it. However, after 24-36 hours of precedex/fentanyl or propofol/fentanyl, I find most patients can be transitioned to moderate precedex (0.3-1.0) alone or with low fentanyl (25-50) or intermittent opioids IVP (fentanyl or ideally q2-4h dilaudid IVP prn...I try to avoid the drip or scheduled opioids, tbh).

    And nowadays, especially in the surgical patients, I am throwing in early ketamine. In the first 24-36h, some other agent is usually required...but then very often ketamine 0.3 infusion is sufficient.
    (or toss in intermittent enteral ketamine for pain with your precedex or low propofol sedation)

    Overall, as long as we get away from fentanyl 300 drips or versed infusions, I think we are making progress.

    HH
     
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  17. anbuitachi

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    that sounds really ******ed. 300 mcg/hr? treat pain first? what were the patients pain scores?
     
  18. MoMoGesiologist

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    Those are crazy high doses. Post intubation we always do fent and propofol until sure the paralytic has worn off. Then we titrate down sedation (and analgesic) with goal RASS -1 to 0. Are the drip orders titratable in your unit and what's the goal?

    Is your unit doing daily awakening and breathing trials? That's what has been shown to improve mortality and get people off the vent and out the ICU faster:
    -"Efficacy and Safety of a Paired Sedation and Ventilator Weaning Protocol for Mechanically Ventilated Patients"
    -Original article: https://www.thelancet.com/article/S0140-6736(08)60105-1/fulltext
    -Quick summary: ABC Trial

    This trial used the following protocol which we use in our ICU:
    -Every day sedation (sedatives and analgesics) halted. Analgesia for pain control was continued
    -If not tolerated, sedatives restarted at half the previous rate and titrated back up

    Daily turning off the sedation and then titrating back up seems to stop the nurses from leaving the fent gtt at 200 (though it sometimes still takes some reminding to bring the drips down). Some nurses really love snowed patients and take 12 hours to bring the drip down 25mcg... like I literally don't understand.
     
  19. MoMoGesiologist

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    chocomorsel

    chocomorsel Senior Member
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    Well, seems like trying to do daily awakenings on these patients proved to be a bit of a challenge. Very agitated, or HTN and tachycardia that's out of control and would scare the nurses. Rightfully so. I mean B/Ps in the 220's, HR in the 130's, physically agitated, etc.

    Hmm, I wonder why? So no, these patients stayed snowed for days. And then finally when they woke up they were doing nothing. Or they didn't wake up. Of course, I came in in the midst of their hospitalization, so I don't know if they would have been different had they not used such high doses of narcs, but these were sick patients to begin with.

    I do believe the reason these patients were so hard to wean off these narcs is due to hyperalgesia, or neuro-excitation. But they never woke up enough to tell us anything. And again, these are medical patients without any surgical incisions nor known triggers for pain besides Foley, ETT and PEG tube.

    The patients on lower doses of narcs, like in the SICU and the MICU patients on bolus fentanyl and precedes/propofol somehow seemed to do OK with daily awakenings.
     
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  21. MoMoGesiologist

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    Per what I could find in SCCM guidelines (2013 and 2018 update), in general it sounds like treat pain first before starting sedation, but if there's continued agitation, titrate sedative/hypnotics to light sedation. The 2013 guidelines (http://www.learnicu.org/SiteCollectionDocuments/Pain, Agitation, Delirium.pdf) do a good job of expanding on why:
    "Providing analgesia-first sedation for many ICU patients is supported by the high frequency of pain and discomfort as primary causes of agitation and by reports implicating standard hypnotic-based sedative regimens as having negative clinical and quality-of-life outcomes."
    -In the same section it goes on to say there are no consistent advantages of analgesia-first sedation over sedative-hypnotic-based sedation. Optimal analgesia and sedation were achieved during 97% of the time with either strategy. Possible pain recurrence and withdrawal upon analgesic discontinuation should be anticipated (130). Furthermore, 18-70% of patients treated with analgesia first strategies will require supplementation with other traditional sedative agents.

    Basically, seems like the MICU docs are right to try narcotics first, but once pain is treated (like you are saying), then pts should be supplemented with sedatives. Do the medicine docs in your unit have some studies they are looking at that support their high-narcs strategy? I would imagine at some point they add alternatives or transition to different agents to wake up the patients and get them to SBT to extubate... The definition of crazy is doing the same thing over and over again expecting different results.
     
  22. Siggy

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    We did that study for journal club earlier this year. For better or worse, Precedex has become my standard answer to the agitated patient now.
     
  23. SurfingDoctor

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    We use Precedex as a first line treatment, Benzos as second line now that it’s generic and the cost has dropped.

    I think the delirium thing is the next tight-glycemic control personally in critical care, but if Precedex is better than Benzos... great.
     
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  24. TimesNewRoman

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    You use benzos before opiates or propofol??
     
  25. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    We don’t use Propofol typically in Pediatrics except for moderate sedation and sedative washouts for 24 hours.

    The opiates versus benzos depends on the reason for intubation (and the age). If they are post-surgical, more opiates, if they aren’t, more sedatives. We have a protocol, but there are often deviations because not every patient fits into the same box.
     
  26. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    Wait?! Daily sedation vacation gets people off the vent faster?!

    Since when?!
     
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  27. SurfingDoctor

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  28. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    I'm with you. My guess is the more seriously sick require more sedation and have more delirium rather than we are giving sick prople delirium with benzodiazepines . How to tease that out? :shrug:

    Benzos do make vent weaning longer though because of metabolism. I'm a firm believer in that. Hell. I'll even run a bit of "propaphed" as long as I'm not needing more than a few mikes per kilo per minute (0.2-0.4) instead of benzos if they didn't tolerate dex well.
     
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  29. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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  30. SurfingDoctor

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    I mean, it was randomized. But in my experience there is always the question of too sick for sedation holiday. And if too sick, then longer vent days, yadda yadda...
     
  31. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    I was joking.

    Sedation vacation is gospel.
     
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  32. SurfingDoctor

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    Way too many cofounders in “delirium” and personally, I think people have found an association between delirium and “X” and because so, have decided to apply bad hypotheses to it. I’m sure after decades of research and expensive clinical trials... we’ll finally come to concrete conclusion that really sick people don’t come out right on the other end despite our best efforts. I’ll be happy to be wrong... waiting with bated breath...
     
  33. SurfingDoctor

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    Ah :thumbup:
     
  34. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    I thought obvious troll would be obvious. :D
     
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  35. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    My wife says I'm not funny. So. It could just really all be my fault.
     
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  36. MoMoGesiologist

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    Are people starting oral benzos and narcs just to get patients off drips if they are gonna be on the vent for a while? We do it but I’m not really a fan of scheduled oral benzos but meh
     
  37. SurfingDoctor

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    Your wife too huh? The unfunny gene must be on the Y chromosome...
     
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    chocomorsel

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    I knew you were joking. Figured everyone did. But I guess not. Hard to decipher on the Internet sometimes.
     
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    chocomorsel

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    @MoMoGesiologist, there was precedex or propofol on top of that. I was just amazed at the high narcotic dose. And then sometimes
    it would be 5 to 6 an hour of dilaudid if Th Fentanyl wasn’t cutting it.

    Some of the patients though would have just PRN Fentanyl pushes along with Precedex or propofol so it was definitely one extreme to another.
     
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  40. TimesNewRoman

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    Do they all get together and have a club or something?
     
  41. jdh71

    jdh71 epiphany at nine thousand six hundred feet
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    If they do they aren't letting me in on the details!!
     
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  42. Hamhock

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    Deleted.

    HH
     
    #42 Hamhock, Feb 6, 2019
    Last edited: Feb 6, 2019
  43. turkeyjerky

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    I don't have access but seems interesting. What type of patients were included, were they all vented? Abstract says that preexisting sedative infusions were halved during the study infusion, so I don't how you could state that precedex reduces delirium vs the possibility that withdrawal of nocturnal sedation causes delirium...unless the abstract isn't stating the methods correctly?
     
  44. leviathan

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    I also do 25-50mcg/hr of fentanyl, more if they legitimately seem to be in pain, / CCPOT score is high. Sometimes I'll try hydromorphone instead. Add propofol for sedation after if still agitated. Never do propofol alone. If you have a good ICU then the SLEAP study suggests no benefit to sedation vacation. But if you work in an ICU with nurses who snow their patients then it helps.
     
  45. WheezyBaby

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    My general approach for an opioid naive patient is initial regimen of 25 - 50 mcg/hr fentanyl, prn bolus liberally for the first hour or so to get a sense of their requirements, add precedex if needing more than 50 of fentanyl. Alternatively ketamine if hemodynamics aren't tolerating it, or propofol if someone needs to be deep. Obviously some variability based on what seems like agitation vs pain, but I don't think a neurologically normal individual should need more than that in fentanyl to tolerate a tube from an analgesia standpoint. I love precedex but it seems like there's a subset of people it doesn't do much for and they'll just sit at 1.5 shaking their restraints.

    Do any of y'all do bolus for induction or prn bolus with precedex? I've only seen it for procedural sedation
     
    #45 WheezyBaby, Feb 11, 2019
    Last edited: Feb 13, 2019
    abolt18 likes this.
  46. jdh71

    jdh71 epiphany at nine thousand six hundred feet
    Physician 10+ Year Member

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    I don't bolus it. Really the only time I see it cause hypotension is when bolused and then no one wants to use it because: zomghypotension!! Takes a lot longer to kick in that way though. You can also push a few mg of versed in that situation.

    Many ways to skin a cat here.
     
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  47. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
    Physician Faculty 10+ Year Member

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    I don’t bolus Precedex however Precedex is quite well tolerated.
     

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