Sedation after Intubation

[Arcan57]

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What are you using for sedation after intubation in the hypotensive patient? Does anyone have any experience with using ketamine as a drip?

 

[EctopicFetus]

There was an EMRap about ketamine drips in trauma. In the end I used fentanyl and versed gtt. I would consider a ketamine gtt as well if needed.

 

[Greenbbs]

Fentanyl and versed gtt with intermittent bolus dosing prnT

 

[edgesofsanity]

I tried getting cute once with a ketamine drip in an asthmatic respiratory arrest; one mout foaming/restless/vent-bucking patient later who drank ativan like it was going out of style convinced me of the error of my ways...

I know, pleural of anecdote isn't data; but for my patient's money propofol vs versed drips with fentanyl as needed. Though the surgeons around here sometimes use benadryl in conjunction with ketamine successfully...

 

[Rendar5]

dexmedotomidine with other supplementation

 

[tkim]

dexmedotomidine with other supplementation

sounds expensive

 

[Rendar5]

sounds expensive

yeah it is a more expensive option. Interestingly though on a search for cost of the drug, I came across an article suggesting it's cheaper in the long run:http://www.medscape.com/viewarticle/721150

 

[jdh71]

Why is the patient hypotensive? That would be the first question I'd ask.

 

[doctorFred]

fent at 25, versed at 2, titrate per nursing, let me know if the pressure is <85 or so.

 

[FLTDOC1]

Ive used ketamine drips many times on long helicopter transports with intubated hypotensive or even normotensive trauma pts. You dont have to worry about analgesia.

Ive also used it on intubated cardiogenic shock pts ( on multiple pressors) with good results. On a few occasions the trauma team actually continued the drip in the ED during their eval. I typically use 1-2 mg/kg/hr augmented by small amounts of benzo.

 

[xaelia]

...if the OP was looking for a simple answer, it's safe to say there probably isn't one. As jdh alluded to, different sedation agents are going to have variable effects depending on the underlying physiology. Propofol and dexmedetomidine probably generally result in a greater degree of hypotension, whereas ketamine should tend to boost BP - though in theory has some depressant effects in decompensated heart failure. I agree with the initial infusion rate described above. I do encounter more paradoxical agitation in adults with ketamine if they aren't adequately bolused initially.

Depending on your nursing resources and clinical situation, some patients might be appropriate for a fentanyl gtt with PRN bolus sedation - shown to decrease ICU LOS, probably a good thing.

As an aside, our hospital has run out of etomidate - nice to have an excuse to get our residents experience with other induction agents.

 

[emergiQ]

I work as an ICU and an EM attending, so use a lot of these drugs in different situations. I think there are many ways to skin this cat, and all suggestions so far are reasonable. My own algorithm goes something like this (apologies to the OP: I know you said hypotensive patient, I'll get to that):

1st choice: Propofol and fentanyl infusion. These are both short-acting, and allow for serial neuro exams if necessary. Helps me keep the peace with the brain dentists if trauma is in the equation, the former are always harping not to give sedation until they do an exam. This is often unrealistic. And so I choose short-acting ones. Doesn't matter what you start it at, it's titratable. I usually bolus 25 of prop, 25 of fentanyl, start the drips at 20 and 25 respectively, and titrate from there. Often I find I need much less profpofol than this, but some seems to have a synergism with fentanyl allowing me to use less. I might use smaller boluses for elderly folks, etc.

Now, if my patient is hypotensive, propofol often will exacerbate the situation. I say OFTEN but not always. In other words, I don't automatically rule out prop like some folks will (Never say Never or Always in medicine), but I won't start with it. In the hypotensive patient, I'll give versed BOLUSES of 2-4mg as well as fentanyl BOLUSES until the rocking and rolling of the hypotension is over. Sometimes the hypotension is just due to your induction drugs. If so, the first bolus of versed and fentanyl buys you some time for this to resolve, then I go to prop and fent. Sometimes I continue the bolus strategy until fluids recover my pressure.

If my pressure still is low after a few rounds of versed/fent boluses, I start to call for the drip for versed and fent.... I've got a busy ED to run! 🙂 Note that there are certainly patients who go hypotensive with versed, too, it's just playing the odds that it doesn't seem to happen as often or as severe with versed.

By the way, sometimes if the ED is busy, hypotension is not an issue, but because the nurses are taking their time getting my prop and fent drip set up, I might use a versed/fentanyl bolus of 4mg here, too, to buy us some time until the prop/fent is up running.

A few other points:

-No matter what I choose as infusions, I like to use both a sedative and a pain reliever (i.e. prop+opiate or versed+opiate) because they seem to have synergy allowing less of both to be used, and ameliorating most of the hypotension). Dex doesn't need additional pain meds (has it as a component) and of course neither does the dissociative that someone mentioned (ketamine).

-Even if the prop/fent drip (or versed/opiate, whatever your poison) is set up quickly, I find an initial bolus is always helpful to make sure you don't have any fluctuations while the medicine works it's way through the pump, the lines, the patient's brain, etc.). Much calmer for everyone. The only downside is sometimes the bolus will cause hypotension. Usually transient.

-Someone mentioned Dex. Certainly an option, but the boluses don't work as well in my experience for rapid control as you are dealing with the chaos of the ED. I usually use this as my second line sedative, particularly in patients with an alcohol abuse or drug background as the alpha agonism chills 'em out without killing the resp drive (I actually routinely extubate people that are on dex without turning off the drip entirely, which is not the case for propofol).

-I do use ketamine sometimes, but find it less predictable. But it would probably be my 3rd choice in the ED (after the prop or versed) but my 4th choice in the ICU after the others.

-Ketamine myth of causing raised ICP has been debunked. It doesn't scare me off. It doesn't stop me from avoiding it whenever possible, however, in head injured patients as I don't usually want to re-educate the trauma team or NSG team. Like I said, never say never or always in medicine, but this particular piece seems to be stuck in the craw of many.

-If you get hypotension that you are almost sure is from your induction drugs or your propofol, it will wear off quickly, but if you want to fix it just as fast with a short-acting agent, have the nurse draw up phenylephrine in a concentration of 100mcg/cc. Note this is MCG and not MG. I have the nurse give me a 10- or 20- cc syringe at that concentration. I push 1-2 cc at a time, even through a peripheral. It is pure alpha and will cinch up the circulation without much (shouldn't be any, really) effect on the heart (you will often see a little decrease in the HR).

 

[deleted109597]

As an aside, our hospital has run out of etomidate - nice to have an excuse to get our residents experience with other induction agents.

As has ours. Unfortunately, they don't stock ketamine in the ED pyxis either. Or propofol (don't get me started). So I'm left with Versed. Awesome.