sedation vacation

[VentdependenT]

Some attendings push for this on nearly every patient even though it is clear that the patient will not be taken off mechanical ventilation the day of the "vacation." Now with JAMA study how do you guys feel about this.

in addition do sedation vacations in themselves reduce VAP? How? If folks arent gettng off the vent quicker buy have daily termnation of vacation how does this strategy work.

Personally all the thrashing, tachycardia, tachpnea, hypertension, and further increased work of breathing on folks who already dont look clinically or physiologically ready for extubation makes application of this principle to ALL patients of dubious benefit. yes that was a long sentence.

N'joy

Also I learned that early tracheostomy does NOT decrease VAP. Had to correct an ID colleague.

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[Hernandez]

I firmly believe in sedation vacations, not necessarily for VAP but to assess neuro function on a daily basis (my definition of RASS -2 differs greatly from nurses definition) and I find that by for in this issue I can decrease sedation drips even when restarted which IMHO can decrease weaning times especially on those we have on benzo drips.

That being said, there are certain patients I feel it is appropriate to only cut sedation and not stop to assess and help guide nurses to a lighter degree of sedation.

Are y'all switching over to using opiates are the primary basis for sedation these days as well?

 

[Bostonredsox]

I firmly believe in sedation vacations, not necessarily for VAP but to assess neuro function on a daily basis (my definition of RASS -2 differs greatly from nurses definition) and I find that by for in this issue I can decrease sedation drips even when restarted which IMHO can decrease weaning times especially on those we have on benzo drips.

That being said, there are certain patients I feel it is appropriate to only cut sedation and not stop to assess and help guide nurses to a lighter degree of sedation.

Are y'all switching over to using opiates are the primary basis for sedation these days as well?

Yes. I am working with our intensivisit on a sedation/vent bundle here as the one they have, well, isnt even a bundle and has no sedation holidays at all. The vent days here are outrageous though improving monthly since the residency program began and we closed the ICU...as is mortality lol. Anyway, we are trying to use fentanyl as the primary sedative which is great given its shorter half life. If it is patient that I can tell early wont be really hard to keep calm I start them right off the bat with bolus regimen fentanly and versed. REALLY trying to avoid versed drips. I was very suprised that the propofol to benzo head t head did not have less ventilator days and less failed SBTs given the short half life of propofol and with the relative ease it can be weaned off and the patient woken up. Nevertheless If I can, I use prn fentanyl and a propofol gtt. The drunks end up with versed and are much tougher to liberate as it takes too much to sedate them. In general though I have found that the patients taking large doses of propofol/precedex/benzo here were just simply not given enough opiate and were in pain, thus dyssynchronus with the vent and combative. By giving more fentantyl I have found I can give less longer acting, harder to clear benzo, often on just a prn basis, even on the pts that I know will be on the vent 2-3 days. It is starting to spread amongst other people as well. Getting stuff ready for the IRB with the new protocol in a few months to see how it goes with respect to ventilator days, LOS and VAP rates, soon as I finish the current ICU QI project I have been working on. There was a good paper a few months back, I forget which journal, looking at doses of sedation given on a shift by shift basis by nursing...not surprising the night shift nurses gave a signficantly higher total dose of opiate and benzo on their shift. I agree with you, there version of RASS -2 is 'knocked out cold so I can facebook stalk".....

 

[redy]

Yes. I am working with our intensivisit on a sedation/vent bundle here as the one they have, well, isnt even a bundle and has no sedation holidays at all. The vent days here are outrageous though improving monthly since the residency program began and we closed the ICU...as is mortality lol. Anyway, we are trying to use fentanyl as the primary sedative which is great given its shorter half life. If it is patient that I can tell early wont be really hard to keep calm I start them right off the bat with bolus regimen fentanly and versed. REALLY trying to avoid versed drips. I was very suprised that the propofol to benzo head t head did not have less ventilator days and less failed SBTs given the short half life of propofol and with the relative ease it can be weaned off and the patient woken up. Nevertheless If I can, I use prn fentanyl and a propofol gtt. The drunks end up with versed and are much tougher to liberate as it takes too much to sedate them. In general though I have found that the patients taking large doses of propofol/precedex/benzo here were just simply not given enough opiate and were in pain, thus dyssynchronus with the vent and combative. By giving more fentantyl I have found I can give less longer acting, harder to clear benzo, often on just a prn basis, even on the pts that I know will be on the vent 2-3 days. It is starting to spread amongst other people as well. Getting stuff ready for the IRB with the new protocol in a few months to see how it goes with respect to ventilator days, LOS and VAP rates, soon as I finish the current ICU QI project I have been working on. There was a good paper a few months back, I forget which journal, looking at doses of sedation given on a shift by shift basis by nursing...not surprising the night shift nurses gave a signficantly higher total dose of opiate and benzo on their shift. I agree with you, there version of RASS -2 is 'knocked out cold so I can facebook stalk".....

Surprised by that as I have always been taught/always read that Fentanyl is mainly analgesic with some sedation. Am I wrong?

 

[MTGas2B]

Dexmedetomidine and propofol with vacations. Avoid benzos. If you need anything at all.

Not every patient needs sedation. People thought I was a bit cooky when I managed a non septic open belly patient with just fentanyl the other day. She was comfy. Sometimes analgesia is all you need.

 

[Hernandez]

Dexmedetomidine and propofol .

Dex - pharm has a special approval process an constantly says no due to "30% cardiovascular side affects"......and cost. Prop - our average vent days is about 7, so we have started sayin away from prop as we've seen lots of severe hypertryglidemja, pancreatitis and a few bad prop infusion syndromes. So we're going primary narc based with touch of benzo if needed but frankly that doesn't cut it on the really sick PTs.

 

[VentdependenT]

Surprised by that as I have always been taught/always read that Fentanyl is mainly analgesic with some sedation. Am I wrong?

You are correct. Fentanyl is NOT a sedative. It is an opiate. Regardless it is an integral part of the ICU sedation cocktail. Benzo's dont treat pain but decrease anxiety and induce amnesia. Fentanyl will make patients comfortable on the vent. A vast majority of ICU patients suffer from some amount of pain and thus fentanyl is very useful.

That being said I RARELY use ONLY fentanyl as my only mode of comfort on mechanically ventilated patients. Often I leave it on at a low dose when doing SBT's as it does keep patients more comfortable.

On folks who O.D. I use propofol ONLY and occasionally add in low dose fentanyl to titrate respiration/synchrony. Easy on/off.

Precedex is nearly useless at the recommended dose range by the manufacturer. I find that patients require HIGH doses of this drug and that it often must be supplimented by another agent...this COMPLETELY defeats the purpose of this drug.

Using opiate only "sedation" is new to me.

 

[Bostonredsox]

You are correct. Fentanyl is NOT a sedative. It is an opiate. Regardless it is an integral part of the ICU sedation cocktail. Benzo's dont treat pain but decrease anxiety and induce amnesia. Fentanyl will make patients comfortable on the vent. A vast majority of ICU patients suffer from some amount of pain and thus fentanyl is very useful.

That being said I RARELY use ONLY fentanyl as my only mode of comfort on mechanically ventilated patients. Often I leave it on at a low dose when doing SBT's as it does keep patients more comfortable.

On folks who O.D. I use propofol ONLY and occasionally add in low dose fentanyl to titrate respiration/synchrony. Easy on/off.

Precedex is nearly useless at the recommended dose range by the manufacturer. I find that patients require HIGH doses of this drug and that it often must be supplimented by another agent...this COMPLETELY defeats the purpose of this drug.

Using opiate only "sedation" is new to me.

This is also what I have seen. Plus as Hernandez mentioned, the cost is very high atleast at my shop. The general pt here is propofol + fentanyl or versed + fentanyl. And yes, fentantly is an opiod analgesic, not a sedative. However it has some sedative properties and many vented pts are suffering alot in terms of pain and irritation from the tube. Fentanly helps both of them, is short acting and is metabolized easily. I have been trying to use more of that and less sedative of late. Even the patients who are getting continuous fentanyl as primary analageia/sedation source, I have prn versed on board. I am atleast noticing a trend that these patients get less total doses of the prn benzo thus far. Not sure if it is translating to less vent days yet.

 

[OB1🤙]

Are we so sure fentanyl drips are short acting?

 

[VentdependenT]

so you suggest sufa drip. the only time i ran sufa was on TIVA and neuro cases. I never have seen it used in the SICU or MICU over the past 8 years. ive found it produces more bradycardia than fentanyl. What is the cost difference? Do you use it in your ICU? For your cases? How often?

So if i ran fentanyl at 1ucg an hour for 10hours it would take >>>>off the chart (hours? days?) to "recover"

 

[VentdependenT]

Are we so sure fentanyl drips are short acting?

same hold true for propofol....you suggest that its not short acting either?

context sensitive halflife

 

[OB1🤙]

Effect is much less for propofol.

I have always thought that ICU narcotic drips should be alfentanil, if the goal is "if I turn it off it goes away." But since I've never been an ICU attending, I've never had the opportunity to do that.

I'm not suggesting you guys not use fentanyl. But don't use it thinking that you turn it off and it goes away the same as a one-time bolus of fentanyl would.

Vent- you know this already from your anesthesia background. I bring it up purely as food for thought for those who haven't encountered context sensitive half-life graphs before.

 

[Bostonredsox]

We do not have sufenta, alfenta or remifenta as options. Community shops have much smaller formularys then academia.

 

[OB1🤙]

We do not have sufenta, alfenta or remifenta as options. Community shops have much smaller formularys then academia.

I'm not suggesting you change your practice, I'm just bringing up food for thought, because many people out there writing for ICU narcotic drips have never thought about this before. If you have, great. But maybe some residents or fellows out there just learned something or went to look it up.

Also, alfentanil is cheap. If my little community shop has it (it does), yours can too.

 

[Bostonredsox]

I'm not suggesting you change your practice, I'm just bringing up food for thought, because many people out there writing for ICU narcotic drips have never thought about this before. If you have, great. But maybe some residents or fellows out there just learned something or went to look it up.

Also, alfentanil is cheap. If my little community shop has it (it does), yours can too.

I am sure they can. But heres how this goes. I present data that alfenta is shorter acting and thus a better vent sedative/analgesic. I then show them it isnt more expensive. They set up 7 different committe meetings to see if they agree. Pharmacy then has there P and T meeing and says, well consider it. 8 months go by. I bring it up again. They say oh yeah let me see what our meetings minutes came up with. Pigs start to fly. By this time there is a newer drug on the market with superior data or the entire practice of sedeation will have shifted. They then will by the now obsolete and inferior product. I will be in my next job. And have a beard like Gandalfs.

In all seriousness though, thanks for the graphs, I was aware of Remi's t1/2 and clearance times, have never used much sufenta or alfenta so that was news to me and new knowledge is always good.

 

[redy]

I learnt a lot about context sensitive half life today. Thanks for that.

 

[VentdependenT]

good topic by our anesthesia colleague however