Simple critical care question on sedation from a simple nose doc

[OtoRes]

Hey all,

I'm an surgical subspecialty resident with very little CC experience outside of intern year one month in SICU.

I've got a question on sedation. A patient's family keeps asking us about weaning sedation from the MICU COVID that is pending a trach, now on day 16 on the vent, with steadily improving ARDS. Now on PEEP 8 and FiO2 50% tolerating slow vent weaning, they want to wake him up a bit more as he tolerates the vent reasonably,

The MICU has been telling family about them weaning 20% by day on a patient currently on Fent 200 mcg/hour (from 300 last week) around the clock, now on nearly week 3 of using it. They did pull of the continuous Versed from 6 -> 4 -> 2 the past few days. The nurses seem to see a small amount of anxiety and keep pushing Versed 2 mg every 4-6 hours, of give a quick bolus (typically the night shift nurses I've noticed) of fentanyl. The patient is hardly responsive outside of sternal rub grimace and family are begging to see some slow weaning. The ICU team has started precedex to held bridge things, but the patient seems to be completely snowed all the time.

Is this a poor sedation weaning I am seeing? What about enteral meds to bridge the gap? Any advice?

Thanks.

---

Members don't see this ad.

 

[Katheudontas parateroumen]

Hi, I’ll take a stab at this. There are many sedation strategies. People can do drips, IV pushes, oral meds, etc to make a cocktail that works for the patient. Covid from my experience thus far for some reason requires a lot more sedation than any other disease process including other ARDS causes. Not sure why. So not surprising pt is on high doses of drips. Typically weaning sedation happens once the pt can tolerate some vent dysynchrony and make their own respiratory effort and such. They’ve probably been on drips for a while so coming off slowly with intermittent pushes isn’t so bad. I would supplementing with oral meds too at some point. Getting a trach has been shown to reduce sedation needs as it’s more comfortable for the pt.

 

[SurfingDoctor]

Why didn’t they start Methadone?

 

[OtoRes]

Why didn’t they start Methadone?

Not sure right now, but in your experience has Methadone helped? I've read some articles showing good results.

 

[SurfingDoctor]

Not sure right now, but in your experience has Methadone helped? I've read some articles showing good results.

That has been the standard weaning protocol I’ve seen at different institutions for over a decade.

 

[chessknt]

There isn’t an exact answer because it is all local. Is the nursing staff new or travelers? They dont win awards for getting people off sedation but they get in trouble if patients pull things out or flip out of bed so their preference is for everyone to be in a paralyzed coma unless the u it culture encourages this. Overcoming that is challenging and a huge portion of sedation issues in the icu.

 

[grt398]

There isn’t an exact answer because it is all local. Is the nursing staff new or travelers? They dont win awards for getting people off sedation but they get in trouble if patients pull things out or flip out of bed so their preference is for everyone to be in a paralyzed coma unless the u it culture encourages this. Overcoming that is challenging and a huge portion of sedation issues in the icu.

So much truth here...

 

[jdh71]

Hey all,

I'm an surgical subspecialty resident with very little CC experience outside of intern year one month in SICU.

I've got a question on sedation. A patient's family keeps asking us about weaning sedation from the MICU COVID that is pending a trach, now on day 16 on the vent, with steadily improving ARDS. Now on PEEP 8 and FiO2 50% tolerating slow vent weaning, they want to wake him up a bit more as he tolerates the vent reasonably,

The MICU has been telling family about them weaning 20% by day on a patient currently on Fent 200 mcg/hour (from 300 last week) around the clock, now on nearly week 3 of using it. They did pull of the continuous Versed from 6 -> 4 -> 2 the past few days. The nurses seem to see a small amount of anxiety and keep pushing Versed 2 mg every 4-6 hours, of give a quick bolus (typically the night shift nurses I've noticed) of fentanyl. The patient is hardly responsive outside of sternal rub grimace and family are begging to see some slow weaning. The ICU team has started precedex to held bridge things, but the patient seems to be completely snowed all the time.

Is this a poor sedation weaning I am seeing? What about enteral meds to bridge the gap? Any advice?

Thanks.

Without seeing the actually case . . . Smells like poor sedation weaning from what you’ve said.

As noted already some nurses aren’t great at this.

Sometimes you just have to take the drugs away from them. If it’s not on the MAR they can’t give it.

 

[Katheudontas parateroumen]

Just from what you've stated, i think methadone 10 q6, turn the fent drip 50%, then off after 24 hours. Use PRN bolus of dilaudid. Add some quetiapine or olazipine. Calculate the total versed dose and convert to lorazepam PO, turn off the versed drip, jave PRN pushes. Precedex isn't so bad (definitely much better if they can get away with it as single agent after implementing a PO/PRN bolus regimen), but tolerance happens and you're right back to max dose of precedex in no time if they aren't careful. This is super dependent on nursing as said above though so it's a lot harder than said. Common times I either have to take it off the MAR completely, limit the dosing or adjust it myself.

 

[OtoRes]

Thanks all for the replies. Sounds like some improvements can be made on this sedation plan as another RN came on and the events below are provided. Great notes I must admit but makes me laugh that she reports tachypnea when patients set vent rate is 35.

The patient was weaned yesterday PM to FiO2 40%, with toleration, and then the overnight RN comes on. Vent settings are set to 350 / 35 /+8 / 40% at 7pm shift change. EtCO2 40s.

She ended up again going up to Fent 235 mcg/hr around 4am and patient was thereafter snowed but HR 90s, saturating 95%.

2036 - Patient asynchronous with vent; ordered versed bolus given for same.
2136 - Patient tachypnic (RR 37) O2 sats 89%; patient asynchronous with vent; ordered fentanyl bolus given due to same.
2359 - Patient tachypnic (RR 38), O2 sats 87%. Fentanyl infusion increased to 187.5 mcg/hr.
0021 - RR 37, O2 sats 88%, patient asynchronous with vent. Ordered fentanyl bolus given due to same.
0103 - Patient tachycardic (HR 115) and tachypnic (RR 30). Ordered versed bolus given.
0106 - Versed infusion increased to 2.19 mg/hr.
0223 - Patient remains tachycardic (HR 114) and tachypnic (RR 35) but O2 sats presently 94% and patient does not appear to be asynchronous with vent.