Weaning off sedation

[Cadet133]

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What do you do when a patient has been maxed out on propofol and percedex for 7 days and for love of god can't wean him off because he starts bucking vent and gets agitated? Underlying cause has already resolved but he just wont get off sedation. We've tried giving him Seroquel, celexa but nothing. Have you guys encountered this before. What is your way of dealing with this

 

[jdh71]

What do you do when a patient has been maxed out on propofol and percedex for 7 days and for love of god can't wean him off because he starts bucking vent and gets agitated? Underlying cause has already resolved but he just wont get off sedation. We've tried giving him Seroquel, celexa but nothing. Have you guys encountered this before. What is your way of dealing with this

Does the patient have underlying chronic lung or heart disease? Especially heart failure?

 

[deleted171991]

What do you do when a patient has been maxed out on propofol and percedex for 7 days and for love of god can't wean him off because he starts bucking vent and gets agitated? Underlying cause has already resolved but he just wont get off sedation. We've tried giving him Seroquel, celexa but nothing. Have you guys encountered this before. What is your way of dealing with this

You want a patient who's awake, oriented, cooperative, able to protect his airway, able to function without PPV, and possibly easy to reintubate if needed.

First of all, putting somebody on high-dose propofol shoots you in the foot regarding precedex (the latter is a waste of money in this situation). As any other GABA medication, propofol can create delirium and confusion, and it's not your friend if infused at high dose for days. So that would be the first thing to take off or minimize.

Second, what does "maxed out" mean? You need to tell us more about the exact doses.

Third, get an anesthesiology-trained intensivist to help you. You guys sound like amateur hour, no offense. There is a reason anesthesiology residency is three years.

Fourth, in the meanwhile, get your vent settings in order (preferably PSV), and add some fentanyl if the precedex doesn't control bucking. Try to minimize further sedation with propofol (or anything that could disorient the patient), because you have done enough damage already apparently. It may take up to a day or two for that patient to be extubatable, depending on the cocktail of poisons administered. It sounds that you have been giving a bit of this, a bit of that.

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Also, use haldol if you need something to treat delirium with (if you're sure it's delirium); stop pussyfooting. It's not like you're putting the patient on it for life. Watch the QTc. And have your attending actually spend meaningful time weaning that patient at bedside.

Don't play with any of these without an attending at bedside.

If you're wondering why this post is not friendly is because I hate bad medicine, especially bad critical care. The patient should have never gotten this far. One doesn't need to be sedated into oblivion just because one has a tube. I had patients watch TV with the tube in, for DAYS. And I'm not even that good. Intubating a patient should be the exception, not the rule, and same goes for heavily sedating an intubated patient.

 

[IMGASMD]

Third, get an anesthesiology-trained intensivist to help you. You guys sound like amateur hour, no offense

Ouch.

 

[deleted171991]

Yep, Texas MICU. Probably community hospicetal, no anesthesiologist-intensivist in sight (and probably no attending intensivist either, leaving the PGY-3 in charge of a bad situation, except for the daily wiseguy, I mean rounds).

I also see this kind of muck up, in the CTICU, from cardiac surgeons playing intensive care.

 

[jdh71]

You want a patient who's awake, oriented, cooperative, able to protect his airway, able to function without PPV, and possibly easy to reintubate if needed.

First of all, putting somebody on high-dose propofol shoots you in the foot regarding precedex (the latter is a waste of money in this situation). As any other GABA medication, propofol can create delirium and confusion, and it's not your friend if infused at high dose for days. So that would be the first thing to take off or minimize.

Second, what does "maxed out" mean? You need to tell us more about the exact doses.

Third, get an anesthesiology-trained intensivist to help you. You guys sound like amateur hour, no offense. There is a reason anesthesiology residency is three years.

Fourth, in the meanwhile, get your vent settings in order (preferably PSV), and add some fentanyl if the precedex doesn't control bucking. Try to minimize further sedation with propofol (or anything that could disorient the patient), because you have done enough damage already apparently. It may take up to a day or two for that patient to be extubatable, depending on the cocktail of poisons administered. It sounds that you have been giving a bit of this, a bit of that.

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Also, use haldol if you need something to treat delirium with (if you're sure it's delirium); stop pussyfooting. It's not like you're putting the patient on it for life. Watch the QTc. And have your attending actually spend meaningful time weaning that patient at bedside.

Don't play with any of these without an attending at bedside.

If you're wondering why this post is not friendly is because I hate bad medicine, especially bad critical care. The patient should have never gotten this far. One doesn't need to be sedated into oblivion just because one has a tube. I had patients watch TV with the tube in, for DAYS. And I'm not even that good. Intubating a patient should be the exception, not the rule, and same goes for heavily sedating an intubated patient.

**** you and your "anesthesia only" bigotry bull****.

 

[deleted547339]

You want a patient who's awake, oriented, cooperative, able to protect his airway, able to function without PPV, and possibly easy to reintubate if needed.

First of all, putting somebody on high-dose propofol shoots you in the foot regarding precedex (the latter is a waste of money in this situation). As any other GABA medication, propofol can create delirium and confusion, and it's not your friend if infused at high dose for days. So that would be the first thing to take off or minimize.

Second, what does "maxed out" mean? You need to tell us more about the exact doses.

Third, get an anesthesiology-trained intensivist to help you. You guys sound like amateur hour, no offense. There is a reason anesthesiology residency is three years.

Fourth, in the meanwhile, get your vent settings in order (preferably PSV), and add some fentanyl if the precedex doesn't control bucking. Try to minimize further sedation with propofol (or anything that could disorient the patient), because you have done enough damage already apparently. It may take up to a day or two for that patient to be extubatable, depending on the cocktail of poisons administered. It sounds that you have been giving a bit of this, a bit of that.

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Also, use haldol if you need something to treat delirium with (if you're sure it's delirium); stop pussyfooting. It's not like you're putting the patient on it for life. Watch the QTc. And have your attending actually spend meaningful time weaning that patient at bedside.

Don't play with any of these without an attending at bedside.

If you're wondering why this post is not friendly is because I hate bad medicine, especially bad critical care. The patient should have never gotten this far. One doesn't need to be sedated into oblivion just because one has a tube. I had patients watch TV with the tube in, for DAYS. And I'm not even that good. Intubating a patient should be the exception, not the rule, and same goes for heavily sedating an intubated patient.

Sorry, bud, but I’ve seen anesthesiologists let the train get off the rails with stuff like this, too. Let’s not start that fight...

But To the OP, I agree with most of what FFP said. That’s a poor job and an intensivist should do better.

Think about why you’re sedating. Is it a painful condition or is it simply for vent compliance? Is this someone you need out (e.g. severe ARDS) or just someone who you need comfortable while the tube is in (e.g. CVA, myasthenic crisis, etc). Make sure your vent settings are reasonable (I.e. don’t sedate some that’s flow hungry), but don’t allow them to have damaged lungs because they “like” bad vent settings either. Give some baseline pain control. Prop + dex seems silly to me - I see it all the time, but it’s odd. Celexa makes no sense to me either. Treat delirium with haldol or seroquel. Provide good critical care otherwise and avoid delerium producing meds. Weaning takes care of itself most of them time if you get the other stuff right. Sometimes I’ll start orals if they’ve been sedated forever or precedex while I turn the prop off if I think they’re going to need something post-extubation.

 

[SurfingDoctor]

Why are you sedating him and keeping him intubation if his underlying medical problem is resolved?

 

[jdh71]

Why are you sedating him and keeping him intubation if his underlying medical problem is resolved?

Exactly

 

[CCM-MD]

Can't find any anesthesiology intensivists, they're too busy supervising CRNAs in the OR.

 

[CCM-MD]

I felt bad after writing my post above. I believe in multidisciplinary CCM fellowship training. I wish CCM was similar to pain management - where IM, EM, anes, surgery trained alongside each other and rotated equally in all types of ICUs under a unified set of training requirements.

This is how CCM training is in Canada. There’s no IM intensivists or anes intensivists or surg intensivists. Just intensivists.

 

[deleted171991]

I felt bad after writing my post above. I believe in multidisciplinary CCM fellowship training. I wish CCM was similar to pain management - where IM, EM, anes, surgery trained alongside each other and rotated equally in all types of ICUs under a unified set of training requirements.

This is how CCM training is in Canada. There’s no IM intensivists or anes intensivists or surg intensivists. Just intensivists.

You almost described my fellowship. And it was American. 🙂

I actually did more months of MICU than SICU in fellowship. My choice - I had seen enough SICU as a resident (plus I prefer the MICU). The main reason we don't have unified training is that ACGME's internal medicine RRC blocks it. I can't teach IM trainees (and there is so much I would), but any hospitalist with 3 years of training (instead of my 5) can.

So I am "just an intensivist". That doesn't change the fact that anesthesiologists are typically better at weaning, for the simple reason that it's part of our OR training. I wouldn't expect to be as good as Pulm-CCM at respiratory diseases; if I had a difficult lung patient, I would consult one of my pulmonary colleagues. Nothing to be ashamed of. (Still the case in this thread seems to have been managed poorly, for ANY type of intensivist.)

The easiest thing to do, in the OP's case, is to stop all drugs, and, if the patient gets agitated, load him up with haldol. Rinse and repeat, until his head clears. There.

 

[CCM-MD]

You almost described my fellowship. And it was American. 🙂

I actually did more months of MICU than SICU in fellowship. My choice - I had seen enough SICU as a resident (plus I prefer the MICU). The main reason we don't have unified training is that ACGME's internal medicine RRC blocks it. I can't teach IM trainees (and there is so much I would), but any hospitalist with 3 years of training (instead of my 5) can.

So I am "just an intensivist". That doesn't change the fact that anesthesiologists are typically better at weaning, for the simple reason that it's part of our OR training. I wouldn't expect to be as good as Pulm-CCM at respiratory diseases; if I had a difficult lung patient, I would consult one of my pulmonary colleagues. Nothing to be ashamed of. (Still the case in this thread seems to have been managed poorly, for ANY type of intensivist.)

The easiest thing to do, in the OP's case, is to stop all drugs, and, if the patient gets agitated, load him up with haldol. Rinse and repeat, until his head clears. There.

Agree. I did a similar fellowship also - in the US. We did near equal amounts of medical, surgical, CV and neuro-trauma. I always encourage people on this forum to go to fellowships like ours. But I don’t think that alone is good enough. I was never supervised by anes-CCM or surg-CCM folks, and I am sure anes-CCM fellows are rarely supervised by IM-CCM. Hopefully one day we will have anes, IM, EM, and surgeons training side by side, under one set of training requirements and cross supervision by attendings of various base training. I won’t be holding my breath though.

 

[deleted171991]

As I said, because of the IM RRC, you cannot be trained (extensively) by anesthesiologists or surgeons, but I can be trained by internists (which I was). If that's not stupid, nothing is.

 

[CCM-MD]

As I said, because of the IM RRC, you cannot be trained (extensively) by anesthesiologists or surgeons, but I can be trained by internists (which I was). If that's not stupid, nothing is.

Needs to change.

 

[deleted547339]

As I said, because of the IM RRC, you cannot be trained (extensively) by anesthesiologists or surgeons, but I can be trained by internists (which I was). If that's not stupid, nothing is.

My understanding is that non-internists can train internal med residents so long as they are not considered “core faculty.”

 

[BigRedBeta]

If you're wondering why this post is not friendly is because I hate bad medicine, especially bad critical care. The patient should have never gotten this far. One doesn't need to be sedated into oblivion just because one has a tube. I had patients watch TV with the tube in, for DAYS. And I'm not even that good. Intubating a patient should be the exception, not the rule, and same goes for heavily sedating an intubated patient.

Exactly. I've managed to have multiple kids under the age of 8 be able to play, color, and stand up at bedside with an ETT in (and it's only a matter of time before I think we'll be getting teenagers walking the halls while intubated). I try to get my teenagers on their phones and texting their friends while intubated. Is it every patient? No, but if you don't start with that goal in mind, you end up so heavily sedated as to be detrimental to all the outcomes we should be caring about - LOS, vent days, medication doses, etc.

 

[jdh71]

You almost described my fellowship. And it was American. 🙂

I actually did more months of MICU than SICU in fellowship. My choice - I had seen enough SICU as a resident (plus I prefer the MICU). The main reason we don't have unified training is that ACGME's internal medicine RRC blocks it. I can't teach IM trainees (and there is so much I would), but any hospitalist with 3 years of training (instead of my 5) can.

So I am "just an intensivist". That doesn't change the fact that anesthesiologists are typically better at weaning, for the simple reason that it's part of our OR training. I wouldn't expect to be as good as Pulm-CCM at respiratory diseases; if I had a difficult lung patient, I would consult one of my pulmonary colleagues. Nothing to be ashamed of. (Still the case in this thread seems to have been managed poorly, for ANY type of intensivist.)

The easiest thing to do, in the OP's case, is to stop all drugs, and, if the patient gets agitated, load him up with haldol. Rinse and repeat, until his head clears. There.

You sounded like an ass hole. I don't have any big problem with you and I actually basically enjoy your input almost every time. And even if I agree the case in the OP was sloppy I disagree strongly that you know better than I how to get the patient in the OP off of the vent because your initial training was in anesthesia. If your argument is because of post op management, I'd strongly disagree it's something that directly translates over into the case in the OP in an meaningful fashion that would require someone to track down an *anesthesia* trained intensivist.

 

[deleted171991]

My understanding is that non-internists can train internal med residents so long as they are not considered “core faculty.”

Only if their number is under 10%.

 

[deleted171991]

You sounded like an ass hole. I don't have any big problem with you and I actually basically enjoy your input almost every time. And even if I agree the case in the OP was sloppy I disagree strongly that you know better than I how to get the patient in the OP off of the vent because your initial training was in anesthesia. If your argument is because of post op management, I'd strongly disagree it's something that directly translates over into the case in the OP in an meaningful fashion that would require someone to track down an *anesthesia* trained intensivist.

It's not because of post-op management. It's because we wean thousands of patients during residency, which is part of emerging from general anesthesia or "sedation". And we get hands-on experience with all those psychotropic drugs like nobody else (except maybe EM). We are supposed to be able to time the wakeup with the end of the surgery ("drapes down, tube out"). So we become experts at this stuff.

Any CCM fellowship sedation and weaning experience is a much weaker sauce. It's like comparing my bronchoscopy skills with the ones of a pulmonary or thoracic surg guy.

I do sound like an ass hole, for the simple reason that I don't sugarcoat the truth for the babies, so that they learn something from the experience. Be nice to trainees when they do stupid things, and you can be 100% sure that they won't remember ****, and keep killing people.

 

[jdh71]

It's not because of post-op management. It's because we wean thousands of patients during residency. It's part of emerging from (general) anesthesia. And we get hands-on experience with all those psychotropic drugs. So we become experts in sedation. And our CCM fellowship and attending experience is built ON TOP of that. The IM/Pulm-CCM fellowship experience is way behind at that. It's like comparing my bronchoscopy skills with the ones of a pulmonary or thoracic surg guy.

Emerging from general anesthesia is not the equivalent of the difficult vent wean in the ICU. And even if I allow there may be some advantage early in fellowship training with sedating medications coming out of anesthesia residency. I doubt there is any serious qualitative differences in vent sedation and vent weaning by the end of fellowships and definitely after a few years of practice. At least for those who care and try to be good physicians.

I mean your recommendations above are not much off of what I'd suggest.

 

[CCM-MD]

Emerging from general anesthesia is not the equivalent of the difficult vent wean in the ICU. And even if I allow there may be some advantage early in fellowship training with sedating medications coming out of anesthesia residency. I doubt there is any serious qualitative differences in vent sedation and vent weaning by the end of fellowships and definitely after a few years of practice. At least for those who care and try to be good physicians.

I mean your recommendations above are not much off of what I'd suggest.

Extubating someone after a lap chole vs someone recovering from critical illness who was on the vent for days. Hardly comparable.

 

[deleted171991]

Extubating someone after a lap chole vs someone recovering from critical illness who was on the vent for days. Hardly comparable.

The skills are pretty much the same as in the OR (especially in the era of avoiding deep sedation in the ICU). We have a lot of long surgeries, too, especially in teaching hospitals. 😉

You guys (and most non-anesthesiologists) have no idea about our skills with medications such as propofol, fentanyl, midazolam, precedex, or with the vent, no offense. You may prescribe them, but we give them on a daily basis, for years, before we even start the fellowship. Plus many medical intensivists have no real airway/intubation skills, hence they suck at weaning and extubation (one has to accept a failure rate, and be READY for it, otherwise the patient will end up on the vent forever like the one in this thread.

Again, I am not comparing whose hands/balls are bigger, just pointing out that each specialty brings a certain set of expert skills to the table.

 

[CCM-MD]

The skills are the same (especially in the era of avoiding deep sedation in the ICU). We have a lot of long surgeries, too. 😉

You guys (and most non-anesthesiologists) have no idea about our skills with medications such as propofol, fentanyl, midazolam, precedex, or with the vent, no offense. You may prescribe them, but we give them on a daily basis, for years, before we even start the fellowship. Plus many medical intensivists have no real airway/intubation skills, hence they suck at weaning and extubation (one has to accept a failure rate, and be READY for it, otherwise the patient will end up on the vent forever like the one in this thread.

Again, I am not comparing whose hands are bigger, just pointing out that each specialty brings a certain set of expert skills to the table.

You’re making a lot of assumptions. I don’t know if you’re just purposely trying to piss people off and start an argument. Good job you push fentanyl and versed and propofol in the OR. I’m proud of you. Most “medical” intensivists i work with and trained with have great airway skills. Might not be as good as anesthesiologists, but we can always call your CRNAs to help us since you have done such a good job teaching them.

Oh yeah, I know you have long and complicated surgeries too. Because you send them to the ICU afterwards - intubated for me to wean them off.

 

[deleted171991]

You’re making a lot of assumptions. I don’t know if you’re just purposely trying to piss people off and start an argument. Good job you push fentanyl and versed and propofol in the OR. I’m proud of you. Most “medical” intensivists i work with and trained with have great airway skills. Might not be as good as anesthesiologists, but we can always call your CRNAs to help us since you have done such a good job teaching them.

Oh yeah, I know you have long and complicated surgeries too. Because you send them to the ICU afterwards - intubated for me to wean them off.

Great. Next time you have trouble weaning, you can call a CRNA. One doesn't need a physician for something so simple (to f*ck up, see above). 😛

I couldn't care less what you're proud of. I was just telling you the TRUTH, like it or not. If it hurts, not my fault. I still have to meet ONE internist-intensivist whose airway skills are even in the neighborhood of a fresh second year anesthesiology resident's. It's like me saying that I am as good at bronchs. Ridiculous!

And the reason we don't extubate at the end of certain long surgeries (e.g. with a lot of fluid exchange) is not incompetence, quite the opposite. As I said, people who don't know how to intubate will probably also suck at extubation (can they even do it without an RRT and other baby-sitters around?). The same way armchair civilian military "leaders" can't hold a candle to a war-hardened real one.

 

[jdh71]

The skills are pretty much the same as in the OR (especially in the era of avoiding deep sedation in the ICU). We have a lot of long surgeries, too, especially in teaching hospitals. 😉

You guys (and most non-anesthesiologists) have no idea about our skills with medications such as propofol, fentanyl, midazolam, precedex, or with the vent, no offense. You may prescribe them, but we give them on a daily basis, for years, before we even start the fellowship. Plus many medical intensivists have no real airway/intubation skills, hence they suck at weaning and extubation (one has to accept a failure rate, and be READY for it, otherwise the patient will end up on the vent forever like the one in this thread.

Again, I am not comparing whose hands/balls are bigger, just pointing out that each specialty brings a certain set of expert skills to the table.

I think when it comes to the vent and sedation in the critically ill patient you are simply talking nonsense here. I'll concede any point you want about the airway and putting tubes in. That doesn't make you "better" at extubation or wean from sedation.

 

[jdh71]

Great. Next time you have trouble weaning, you can call a CRNA. One doesn't need a physician for something so simple (to f*ck up). 😛

And I couldn't care less what you're proud of. I was just telling you the TRUTH. If it hurts, not my problem. I still have to meet ONE medical intensivist whose airway skills approach even a second year anesthesiology resident's.

It doesn't hurt. It's just incorrect. Don't double down on being wrong.

 

[deleted171991]

Emerging from general anesthesia is not the equivalent of the difficult vent wean in the ICU. And even if I allow there may be some advantage early in fellowship training with sedating medications coming out of anesthesia residency. I doubt there is any serious qualitative differences in vent sedation and vent weaning by the end of fellowships and definitely after a few years of practice. At least for those who care and try to be good physicians.

I mean your recommendations above are not much off of what I'd suggest.

You are comparing the average anesthesiologist-intensivist with the good internist-intensivist, no offense. 😉

I wouldn't say our skills are similar by the end of the fellowship, but the differences become insignificant after a number of years. I agree that a passionate doc will be a good doc regardless of the background. I was not talking about those of us. Some people never learn certain things for some reason (lack of exposure during fellowship, and life/shame/comfort getting in the way later).

Just think that a lot of Pulm-CCM programs have less than 18 months in the ICU (more like 12-15). During that time, one can't just catch up with the skills of somebody who has been doing them for 36 months before, AND more intensively. It's like me becoming an equal value internist in just 12 months; it's impossible.

Sedation is not rocket science, far from it, especially when there are no tight time constraints (i.e. you have 3 minutes to wake up the patient before you start looking incompetent). But I am still shocked how many people misuse drugs in the ICU, from sedatives to pressors, you name it, or how they can't fix a vent dissynchrony except by sedating the patient etc.

 

[deleted171991]

I think when it comes to the vent and sedation in the critically ill patient you are simply talking nonsense here. I'll concede any point you want about the airway and putting tubes in. That doesn't make you "better" at extubation or wean from sedation.

Agree, except in idiotic situations like the one in this thread. High dose propofol and precedex, for days, and nobody says a word that it's 2018, not even the nurses? As I said, not rocket science. But, trust me, there are docs that suck so much at airway stuff that any complicated weaning will get their patients in trouble.

Any good intensivist will be a champ at weaning and extubation. So will be any average anesthesiologist, even one who hasn't done ICU in ages. That was my main point here. Sorry if it came across differently. Let's just agree to differ (we must have had different experiences). This is turning into whose hands are bigger.

 

[jdh71]

Agree, except in idiotic situations like the one in this thread. High dose propofol and precedex, for days, and nobody says a word, not even the nurses? As I said, not rocket science. But, trust me, there are docs that suck so much at airway stuff that any complicated weaning will get their patients in trouble.

Any good intensivist will be a champ at weaning and extubation. So will be any average anesthesiologist, even one who hasn't done ICU in ages. That was my main point here. Sorry if it came across differently.

I don't think the wean of sedation after the OR in most situations and the wean of sedation in a critically ill patient are the same thing. At all. There are some things that seem to overlap but there is enough nuance to drive a truck through.

But I see the olive branch and I won't swat it away. Some docs. Too many docs. Don't do what they should for their patients. Poor training? Incompetence? Burn out? An unwillingness to keep up with practice strands and evidence?

 

[deleted171991]

There are patients who are difficult to wean in the OR, too. The elderly (and not only) can be as delirious/confused/agitated as some patients in the ICU. And most GA cases don't use precedex and other gentle drugs or doses, definitely not at RASS of -1, and there is much less time available for emergence and extubation.

Respectfully, nowadays, ICU sedation is much easier. In the last decade, we have replaced deep sedation with conscious sedation, as the standard of care. And weaning from a well-done conscious sedation, even for days, should be nothing like waking up from a long complicated surgery.

Just my last 2 cents.

 

[Psai]

If you deep extubate there will be no bucking 😉

Or you could be like these guys and do the boring thing like weaning sedation, putting the patient on proper vent settings, etc.

 

[coffeebythelake]

Extubating someone after a lap chole vs someone recovering from critical illness who was on the vent for days. Hardly comparable...... You’re making a lot of assumptions. I don’t know if you’re just purposely trying to piss people off and start an argument..... Oh yeah, I know you have long and complicated surgeries too. Because you send them to the ICU afterwards - intubated for me to wean them off.

Lot of that going around

 

[MirrorTodd]

I don't think the wean of sedation after the OR in most situations and the wean of sedation in a critically ill patient are the same thing. At all. There are some things that seem to overlap but there is enough nuance to drive a truck through.

But I see the olive branch and I won't swat it away. Some docs. Too many docs. Don't do what they should for their patients. Poor training? Incompetence? Burn out? An unwillingness to keep up with practice strands and evidence?

Honestly man, in my opinion...medical training has gotten far too soft. I get that we don't want physicians committing suicide etc but I was completely ****ing babied during this last intern year and that has nothing to do with getting time off or working less than 80 hours a week etc. I'm definitely a better doctor now that I've gone through internship, but I think I'd be better if I actually had more responsibility and more attendings breathing down my neck. I needed Drill Sergeants this year to burn **** into my brain. I didn't need noon academics talking about esoteric topics thrown in during lunch hour. That physician that never got a good sense of how to wean someone started during intern year when they weren't responsible for those things because the attending didn't want to teach them or couldn't or that was the job of respiratory therapy or nursing wasn't comfortable with the intern doing it. etc etc etc. Hell, it probably actually starts in medical school with new schools opening up without strong academic program attachments for the students to learn how to be doctors. It is my opinion that medical training is devolving to train followers and not leaders/free thinkers.

Caveat of course is that some physicians had just too many excuses to actually learn how to do things in residency and so they took the back seat and cruised through to graduation.

 

[Radetzky]

Trache...

 

[jdh71]

Trache...

I'm sure you're being facetious

 

[Radetzky]

I'm sure you're being facetious

Haha yes.

 

[vector2]

@FFP may be a bit rough around the edges, but he's not wrong in this regard. Extubating an ASA 1 lap chole and weaning a tough ICU vent may not be analogous, but during the course of anesthesia residency one learns how to extubate dozens and dozens of pts with reactive airway disease, AMS/delirium, kids, upper airway obstruction etc who have ventilator dyssynchrony, uncontrollable bucking, bronchospasm, or laryngospasm upon emergence and extubation. The average medical intensivist has never IV pushed 50mg propofol, 50mcg fent, 100mg lidocaine and immediately pulled the tube (to remove the bucking stimulus) and then gently mask assisted the pt until they were fully awake- mostly because they neither have the medication nor airway experience to do so.

IME (and this is just my generalization from ICU fellowship), other trained intensivists lean much more heavily towards leaving a pt intubated unless they look perfect with sedation off, whereas anesthesia intensivists will more frequently check to see if resp mechanics, oxygenation, ventilation look good sedated, and then just do a rip and run extubation if the pt starts bucking when sedation is off.

 

[CCM-MD]

anesthesia intensivists will more frequently check to see if resp mechanics, oxygenation, ventilation look good sedated, and then just do a rip and run extubation if the pt starts bucking when sedation is off.

Every intensivist I know who has ever extubated an agitated patient has done this before. You don’t think other intensivists look at respiratory mechanics, oxygenation, and ventilation? Do you think we trach all of our patients who start bucking the vent when sedation is stopped? You think we keep them intubated and sedated forever?

 

[vector2]

Every intensivist I know who has ever extubated an agitated patient has done this before. You don’t think other intensivists look at respiratory mechanics, oxygenation, and ventilation? Do you think we trach all of our patients who start bucking the vent when sedation is stopped? You think we keep them intubated and sedated forever?

Again, this has just been my general experience, and of course there are non-anesthesia intensivists who are facile and anesthesia ones who aren't. All intensivists look at resp mechanics, ox, and ventilation while the pt is sedated and during holidays. The point I'm making is that some intensivists will do something like check an ABG or look at the vitals during a holiday while the pt is bucking and then point to a one-time hypercapneic episode or tachycardia as some reason to resedate the patient because "they're not ready." Through hundreds or thousands of extubations, anesthesiologists simply have a better understanding of the gestalt of extubation that is independent of the typical critical care "can we check all the checkboxes on the weaning protocol?" mentality. Do I think medical intensivists trach all difficult pts or keep them intubated forever? No, I just think they probably stay intubated for a lot longer than they have to.

Ipso facto, I would bet dollars to donuts the OP was not referring to management that occurred by an anesthesia trained intensivist.

 

[CCM-MD]

Again, this has just been my general experience, and of course there are non-anesthesia intensivists who are facile and anesthesia ones who aren't. All intensivists look at resp mechanics, ox, and ventilation while the pt is sedated and during holidays. The point I'm making is that some intensivists will do something like check an ABG or look at the vitals during a holiday while the pt is bucking and then point to a one-time hypercapneic episode or tachycardia as some reason to resedate the patient because "they're not ready." Through hundreds or thousands of extubations, anesthesiologists simply have a better understanding of the gestalt of extubation that is independent of the typical critical care "can we check all the checkboxes on the weaning protocol?" mentality. Do I think medical intensivists trach all difficult pts or keep them intubated forever? No, I just think they probably stay intubated for a lot longer than they have to.

Ipso facto, I would bet dollars to donuts the OP was not referring to management that occurred by an anesthesia trained intensivist.

Not my experience. You have your bias and I have mine.

The physician mentioned by OP sucks. I would also bet that the intensivist mentioned by the OP was not anesthesia trained, but for a different reason - the vast majority of intensivists in the US are not anesthesia trained. In fact they make up less than 15% of intensivist workforce.

 

[chessknt]

Do you think surgeons are operating on patients intubated for 10 days with ards and critical illness induced myopathy or end stage lung disease? Do you think the risks and decisions involved in the or are comparable to the medically ill population who could never survive surgery?

Your experience in the or is inherently biased in that the population you take care of can survive general anesthesia and surgery. The Icu population is different and thus has different risks.

 

[IMGASMD]

I sincerely apologize for which I may have started.

Did IM at a ghetto Univeristy hospital then finished at a bougie community program. Worked for a few years as hospitalist. Entered and finished anesthesia at a community program. I moonlight during anesthesia training as nocturnists whenever I can.

I’ve had ~14 formal ICU months throughout my training. (CCU, MICU, SICU, CTICU). I’ve managed my own ICU patients in between my residencies.

My two cents. IM has absolutely no clue what anesthesia does and vice versa. And no matter how many intubations/extubations and even vent management IM had done, the numbers don’t compare.

I’ve administered thousands of anesthetics after three year of anesthesia training. I push any drugs, prop, benzo, and opioids without anyone verifying the dose, speed, or worried about penicillin or morphine allergies on daily basis. That’s not something most IM residents or surgical residents ever get to do. I’ve placed and took out thousands of tubes on elective/urgent/emergent basis.

Certainly I have not gone through CCM training, so I may be totally off base here; however, I think my anesthesia CCM trained colleagues are trying to say based on the “numbers alone”, IM residents, even fellowship CCM graduates are at a disadvantage. I’ve intubated more than the whole ENT residency program “combined” and that’s not an exaggeration. They are much more interested doing their surgeries than take care of airways. I certainly have extubated more times than any board certified pulmonologists. I’ve managed laryngospasms/bronchspasms on monthly basis. When was the last time CCM attending rushing a prego for crash C-section without pre-oxygenation, as soon as the facemask is off the patient, sats already down to 70s, oh and ob is already cutting? Or a 2 year old laryngospasm, unable to break and the sats now in the 30s and bradying down? Probably never, or very very very rarely. What I am trying to say is that these are the scenarios that anesthesiologists have to deal with confidently. So what if anesthesia CCM pulled the tube a little too early? We have the tools and trainings to deal with it. We don’t need to call someone when the airway “might” be difficult. Does that translate to vent management style? Sure it does. I don’t remember the last time I checked RSBI when I pulled the tube, the respiratory therapists freak out regularly when I just pull. The answer nowadays is, oh the patient looks good. Because I’ve seen thousands of patients that may or may not fly after extubation. I have the gestalt what the optimal condition suppose to look like. Do I get fool? Sure, but I’d guess my track record is pretty good. Maybe as good as someone who gets ABG, calculate out all the indices.

Regarding sick patients? I’ve done ASA 4,5,6. My experience in OR certainly translate whether they can be wean off the vent or not. If I try to extubate at the end of surgery/procedure or not. Heck, I’ve fought with surgeons not to bring OR, or tell them to finish the **** up, the patient is going to code on the table. Do I manage ARDS long term as well as IM, at this time, no.

My comprehension isn’t the best, but we are not saying one is bette than the other. What I heard is, anesthesia CCM do certain things better than IM CCM and vice versa.

It’s a numbers game after all. Just like I would not want an anesthesia CCM attending to manage my DKA. Because by my second month in ICU as a medical intern I’ve seen a dozen of them. During my IM residency, I’ve managed a couple hundred. I don’t think most anesthesiologists during their residency they actually manage any, other than the ones in their internship.

Lastly, I don’t appreciate the swipe taken with the CRNA comment. It feels a little personal. I’d rather have them intubate me than some of the CCM attendings ANY DAY. Since it is a numbers game after all. One of my attending told me that he could confidently teach a monkey to intubate; but anesthesia residency is three years for a reason.

Every speciality have their own strengths, vent/sedation/airway management in general, anesthesia comes out ahead.

 

[engineeredout]

When was the last time CCM attending rushing a prego for crash C-section without pre-oxygenation, as soon as the facemask is off the patient, sats already down to 70s, oh and ob is already cutting? Or a 2 year old laryngospasm, unable to break and the sats now in the 30s and bradying down? Probably never, or very very very rarely. What I am trying to say is that these are the scenarios that anesthesiologists have to deal with confidently.

Oh yeah? Well when was the last time an anesthesiologist flew the space shuttle? When was the last time they filled in a pot hole in the road? Modified the Large Hadron Collider?



Oh I'm sorry, are those irrelevant comparisons?

 

[SurfingDoctor]

Or a 2 year old laryngospasm, unable to break and the sats now in the 30s and bradying down?

Sounds like someone giving anesthesia for a deep sedation on a child and they weren't paying attention...

 

[jdh71]

I sincerely apologize for which I may have started.

Did IM at a ghetto Univeristy hospital then finished at a bougie community program. Worked for a few years as hospitalist. Entered and finished anesthesia at a community program. I moonlight during anesthesia training as nocturnists whenever I can.

I’ve had ~14 formal ICU months throughout my training. (CCU, MICU, SICU, CTICU). I’ve managed my own ICU patients in between my residencies.

My two cents. IM has absolutely no clue what anesthesia does and vice versa. And no matter how many intubations/extubations and even vent management IM had done, the numbers don’t compare.

I’ve administered thousands of anesthetics after three year of anesthesia training. I push any drugs, prop, benzo, and opioids without anyone verifying the dose, speed, or worried about penicillin or morphine allergies on daily basis. That’s not something most IM residents or surgical residents ever get to do. I’ve placed and took out thousands of tubes on elective/urgent/emergent basis.

Certainly I have not gone through CCM training, so I may be totally off base here; however, I think my anesthesia CCM trained colleagues are trying to say based on the “numbers alone”, IM residents, even fellowship CCM graduates are at a disadvantage. I’ve intubated more than the whole ENT residency program “combined” and that’s not an exaggeration. They are much more interested doing their surgeries than take care of airways. I certainly have extubated more times than any board certified pulmonologists. I’ve managed laryngospasms/bronchspasms on monthly basis. When was the last time CCM attending rushing a prego for crash C-section without pre-oxygenation, as soon as the facemask is off the patient, sats already down to 70s, oh and ob is already cutting? Or a 2 year old laryngospasm, unable to break and the sats now in the 30s and bradying down? Probably never, or very very very rarely. What I am trying to say is that these are the scenarios that anesthesiologists have to deal with confidently. So what if anesthesia CCM pulled the tube a little too early? We have the tools and trainings to deal with it. We don’t need to call someone when the airway “might” be difficult. Does that translate to vent management style? Sure it does. I don’t remember the last time I checked RSBI when I pulled the tube, the respiratory therapists freak out regularly when I just pull. The answer nowadays is, oh the patient looks good. Because I’ve seen thousands of patients that may or may not fly after extubation. I have the gestalt what the optimal condition suppose to look like. Do I get fool? Sure, but I’d guess my track record is pretty good. Maybe as good as someone who gets ABG, calculate out all the indices.

Regarding sick patients? I’ve done ASA 4,5,6. My experience in OR certainly translate whether they can be wean off the vent or not. If I try to extubate at the end of surgery/procedure or not. Heck, I’ve fought with surgeons not to bring OR, or tell them to finish the **** up, the patient is going to code on the table. Do I manage ARDS long term as well as IM, at this time, no.

My comprehension isn’t the best, but we are not saying one is bette than the other. What I heard is, anesthesia CCM do certain things better than IM CCM and vice versa.

It’s a numbers game after all. Just like I would not want an anesthesia CCM attending to manage my DKA. Because by my second month in ICU as a medical intern I’ve seen a dozen of them. During my IM residency, I’ve managed a couple hundred. I don’t think most anesthesiologists during their residency they actually manage any, other than the ones in their internship.

Lastly, I don’t appreciate the swipe taken with the CRNA comment. It feels a little personal. I’d rather have them intubate me than some of the CCM attendings ANY DAY. Since it is a numbers game after all. One of my attending told me that he could confidently teach a monkey to intubate; but anesthesia residency is three years for a reason.

Every speciality have their own strengths, vent/sedation/airway management in general, anesthesia comes out ahead.

You sound like a hero. But most of that is pretty irrelevant to the case in the OP. I bet you are correct that anesthesia experience leads you to get away with more cowboy nonsense as you have a more tools to deal with the bad outcomes of your decisions, espevislly if it was a hasty or risky decision. There is good amount of reasonable evidence here for what appears to be best practices when it comes to vent weaning and extubation. I think it's no crime to wander the well tread pathways in the critically ill. At some point in some situations it's clear that the patient's agitation is just the tube and if they don't have chronic lung disease or serious heart failure the best thing to do is to take out the tube.

 

[IMGASMD]

You sound like a hero.

Thank you.

 

[jdh71]

Thank you.

Calibrate your sarcasmeter.

 

[chocomorsel]

Sounds like someone giving anesthesia for a deep sedation on a child and they weren't paying attention...

Sounds like you know nothing about anesthesia.

 

[SurfingDoctor]

Sounds like you know nothing about anesthesia.

Done lots of deep sedation on kids. Also see lots of things go wrong. But thanks for your insight into my experience.