Post Intubation in ED

[studyinghard]

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Didn't pay a lot of attention to post intubation orders on people in the ED on my rotations. What do you (residents and attendings) like to write for to keep a patient sedated, not moving, and pain free while intubated in the ED?

 

[kungfufishing]

propofol, fentanyl, reparalyze if needed.

 

[Arcan57]

Mostly propofol titrate to sedation. Pretty much all the sedatives are going to drop your BP (except ketamine), so the patient in septic shock may need the tank filled more or a bump in their pressors to tolerate it.

 

[po' boy]

Mostly propofol titrate to sedation. Pretty much all the sedatives are going to drop your BP (except ketamine), so the patient in septic shock my need the tank filled more or a bump in their pressors to tolerate it.

agree

 

[EctopicFetus]

If good BP.. propofol.. if not versed and fentanyl gtt.

 

[Jeff698]

Keep in mind that all of us are creatures of habit and there are many ways to skin a cat....

My default combo is fentanyl/versed, titrated to effect. I'll change this up based on the needs of the patient but that's what I start with.

I haven't used a ketamine drip yet but one of my partners had a case that got me thinking about it. A truly sick asthmatic he had no choice but to intubate. Seems like ketamine would have been a good option there. Neither of us knew how to use it as a drip, though. Any thoughts?

Take care,
Jeff

 

[Apollyon]

Keep in mind that all of us are creatures of habit and there are many ways to skin a cat....

My default combo is fentanyl/versed, titrated to effect. I'll change this up based on the needs of the patient but that's what I start with.

I haven't used a ketamine drip yet but one of my partners had a case that got me thinking about it. A truly sick asthmatic he had no choice but to intubate. Seems like ketamine would have been a good option there. Neither of us knew how to use it as a drip, though. Any thoughts?

Take care,
Jeff

First of all, as my best friend's wife says as a corollary - "yes, but, why would you want to skin a cat?"

Used a ketamine drip for the first time last month, when we had a rotating senior EM resident with us. As we're standalone, the patient had to be transferred. The doc in the ED at the other hospital apparently really didn't like the ketamine drip (for unknown reasons), and turned it off and started something else (pt also coincidentally with a pretty good asthma history). I wonder what, though, considering this lady had no blood pressure.

 

[leorl]

anyone else have trouble getting propofol in the ED? for some reason anesthesia want to be the ones to control proprofol usage. We can get short doses but wouldn't be able to get it for a drip. Which is a shame...

 

[Stitch]

anyone else have trouble getting propofol in the ED? for some reason anesthesia want to be the ones to control proprofol usage. We can get short doses but wouldn't be able to get it for a drip. Which is a shame...

We can't get it easily, which is a shame, because I can think of a lot of good uses for it. Anesthesia controls it, but the PICU also has access.

We use versed/fentanyl or sometimes a big dose of ativan post intubation. Also a big fan of a ketamine drip for the asthmatics, but we use a lot of ketamine in general here.

 

[canjosh]

anyone else have trouble getting propofol in the ED? /

Approved for intubated ED pts here. Can't use it for procedural sedation though.

As an aside, they tried (unsuccessfully) to take etomidate away. The compromise is that physician must be the syringe monkey.

 

[Jeff698]

Also a big fan of a ketamine drip for the asthmatics, but we use a lot of ketamine in general here.

How do you dose your ketamine drips?

Take care,
Jeff

 

[Stitch]

How do you dose your ketamine drips?

Take care,
Jeff

Usually start at 1mg/kg/hr, but can go as high as 2-3mg/kg/hr. One study used that higher dose in a non intubated patient in order to avoid intubation, but I've never tried that.

You can add some versed and use lesser doses as well. They do this in the PICU sometimes, especially in older patients. The younger kids seem to have less emergence reactions in my experience, but require higher dosing to knock them out.

 

[roja]

Propofol.

If BP problems, will try to titrate propofol down and add fentynl to augment.

If septic with crappy bp, appropriate volume resusc, then will add pressors, often needed anyway.

 

[southerndoc]

We're having trouble getting propofol from the supplier (national shortage I think). We can only use it for procedural sedation and neuro patients at the moment. Once our supplies are replenished, then we can use it for all intubated patients.

 

[Jeff698]

Usually start at 1mg/kg/hr, but can go as high as 2-3mg/kg/hr.

Sweet. Thanks.

Take care,
Jeff

 

[Apollyon]

Sweet. Thanks.

Take care,
Jeff

But remember he's a pediatrician. In the one lady that I used ketamine as an infusion for sedation, it was 25mg/hr, and she was MUCH larger than 25kg. Worked just fine.