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Let's Talk About Sedation

Discussion in 'ALS Discussion' started by 18G, Nov 28, 2011.

  1. 18G

    18G Active Member

    I have been receiving patients from ED's lately that are intubated and sedated with a combination of propofol and boluses of Ativan but with no analgesea provided.. AT ALL.

    This is contrary to everything I have been taught and read in the journals, position papers, and other articles. I have been spending a good bit of time researching best practices and everything I have came across strongly say's to provide analgesia ALONG with the sedation and never to provide only sedation especially when the patient receives a paralytic.

    The one patient I had was a 20 something male kicked in the head with a sub-arachnoid hemorrhage, was seizing on arrival at ED, was RSI'd and sedated with propofol and boluses of Ativan along with titrating propofol up. This patient received no analgesia.

    Another pt. I had a few day's ago was a 20 something drug OD. Pt. was intubated and was receiving propofol and Ativan boluses. I asked if pt. had anything for pain and the RN literally chuckled when I asked so I gave a brief reason why I was asking. The RN was clueless as to why this pt. should have analgesia. Despite my asking the pt. did not get analgesia but did get vecuronium for transport and I increased the propofol.

    What are the current practices of ALS providers on the forum when treating and transporting intubated patients? If the patient is fighting the vent however so mildly, do you favor giving a NMBA to better manage ventilations during the 45min-2hr transport? I have found that works well (obviously, right) but without analgesia onboard I am more hesitant to do that.

    Why are these ED docs not realizing the need for analgesia?

    I think a lot of people see a sedated/unconscious patient and think that they have no perception of pain and the body is not experiencing any sympathetic surge or other physiological response to the pain. Just having an ETT and a metal blade rammed down your throat is uncomfortable and not to mention the inflammatory response and injury that causes chemical mediator release that enhances pain transmission and perception.

    Any guidance is greatly appreciated. I really need to advocate for my patients when they have not received analgesia and need to be prepared to make my case when doing so which I am prepared to do now but additional ammunition and points to make is always a plus.
  2. DrankTheKoolaid

    DrankTheKoolaid Active Member

    Location:
    NorCal
    re

    They should absolutely receive analgesia along with sedation. Paralysis does nothing for the discomfort related to the garden hose in their throat, nor will it blunt the effect of hypercarbia and whatever else is going on. Keeping down with benzo's will keep them down but studies have show sedation only also does nothing for pain. If you happen to be transporting on Versed infusions make note that it has been found to make patients hyperalgesic.

    Help your Doc's come out of the stone age and either recruit your local CRNA / MD to come in and talk about it with them or bring in liturature.
  3. fast65

    fast65 Doogie Howser EMTP

    Location:
    Oregon
    Out of the 20 or so intubated patients I've taken out in the last six months, none of them have had any sort of analgesia. Hell, very rarely are they on anything other than a propofol drip and it seems to be a challenge for me to get the hospital to even give me an extra bottle for the trip. That being said, I will usually end up hitting them with some Versed.

    I have tried discussing analgesia in the intubated patient with a couple of nurses and coworkers, but they all seem to believe that intubated patients don't require analgesia. They chuckle about it and claim that the benzo's take care of that...*le sigh*
  4. HMartinho

    HMartinho Member

    Location:
    Leiria, Portugal
    EMS Training:
    EMT-Basic
    In Portugal, all of our Pre-hospital Nurses, Pre-hospital physicians and CRNA's provide analgesia with sedation/paralysis in ET intubation. Obviously it's uncomfortable to have a tube down the throat, and here there are no discussions about it. All agree. At least its what I see.
  5. definition of anesthetic state

    A collection of component changes in behavior or perception.

    Components include:

    amnesia
    immobility in response to noxious stimuli
    attenuation of autonomic response to noxious stimuli
    analgesia
    unconsciousness



    Sedating dose of propofol is: 20-50% of the dose required for general anesthesia. So you must first differentiate what the purpose and dose propofol was used for. ;)



    The Oxford American Handbook of Anesthiology also lists propofol as the only induction agent needed for RSI at the anesthetic dose.

    Most anesthesiologists I know like a smaller number of chemicals in the mix.

    In addition to anesthesia and sedation. Propofol can also be used to maintain anesthesia begun with other agents.

    It is possible you will find find patients who are on a maintenence of propofol after another agent was used. (like fent or morphine)

    Doctors can be so stupid :)
  6. Farmer2DO

    Farmer2DO New Member

    Location:
    Western New York
    EMS Training:
    Critical Care Paramedic
    I'm actually quite lucky. We have our standard protocols, and our IFT critical care transport protocols. Both actually REQUIRE an intubated patient to receive sedation and analgesia unless specifically contraindicated. One of the nice things is that once the patient is under our care, the decision of how to treat rests with us and our medical control physician, and we are generally given a fair amount of latitude in our treatment plans.

    Just recently had a similar episode: 11 year old patient from a VERY outlying facility, intubated with versed and roc for a cerebral lesion with status seizures. I walked in and asked what he was being sedated with, and the reply was "rocuronium". He had been intubated nearly an hour before and they were still doing BVM ventilations; no vent had been set up. There had been nothing given AT ALL post intubation, because "he's not moving; he's sedated just fine". I had to ask for propofol and dilantin; I had to make my own vent settings. The kid started to wake up before I had sedation and analgesia on board, and guess what? Seizing. Which had probably been happening for quite a while. Propofol (with multiple titrations), and multiple boluses of midazolam and morphine during the trip.

    We only have midazolam and morphine; no fentanyl yet. I generally prefer the 2 agent system: either midazolam and an opiate, or propofol and an opiate. We can usually get fentanyl from the sending facility, which I prefer if I'm doing infusion analgesia. But if I'm using boluses, I prefer morphine, because it lasts longer (assuming they can tolerate it hemodynamically).
  7. usafmedic45

    usafmedic45 New Member

    Location:
    Indiana
    But private duty physicians prefer their Michael Jackson brand Nighty-Night Juice with a larger number of medications.

    Your coworkers and those nurses are :censored::censored::censored::censored:ing morons. Unless the patient is completely under (which they really should be only for a minimal amount of time after intubation), they need pain control. You can always tell medical professionals who have been tubed and vented because they are very liberal with sedation and pain control.
  8. fast65

    fast65 Doogie Howser EMTP

    Location:
    Oregon
    I'm glad you picked up on what I was implying with the last part of my post :p

    I mean, don't get me wrong, I'm a really new provider, so I try not to cast such judgement; but when you're capable of doing a procedure and you're unaware of what the drugs involved in such a procedure actually do, it's just sad and pretty scary.
    Last edited by a moderator: Nov 28, 2011
  9. 18G

    18G Active Member

    I see I'm not the only one that has been experiencing these types of situations with intubated patients. It is really amazing how RN's and physicians aren't aware of the need for analgesia when a patient is sedated and/or paralyzed.

    We have morphine and fentanyl available and most of the recommendations and research I have read seem to prefer fentanyl due to its good hemodynamic profile especially when used with other sedative and anesthetic agents that can effect B/P.

    And kind of a side note, we tend to transport patients without a ventilator on a frequent basis. Our transports range anywhere for 45mins to 2hrs. I had a patient that was bagged for literally 2hrs during a transfer. I believe these patient's need to be transported on a ventilator for optimal management. Granted, BVM ventilations can be performed okay when guided by EtCO2 but in a critical care setting I don't see an excuse for not having these patients on a vent. Again, quite a few people think that squeezing a bag to deliver oxygen every so many seconds is providing optimal care of which I strongly disagree.

    Opinions on transfers without a vent?

    Opinions? For IFT, do you prefer paralytic onboard or favor increasing dosage of the sedatives?
    Last edited by a moderator: Nov 28, 2011
  10. My point was you can use propofol in large enough quantities to induce an anesthetic state.

    Unless discharging home or to the MJ ranch, why not use more of the same drug instead of a mix?
  11. Farmer2DO

    Farmer2DO New Member

    Location:
    Western New York
    EMS Training:
    Critical Care Paramedic
    I think an agency that lets patients be bagged for 45-120 minutes is doing their patients a huge disservice. It can be difficult, often downright impossible, to manage the finer points of mechanical ventilation with a BVM: fine tuning FiO2, RR, TV, PEEP, PS, mode, I time, etc. You need a ventilator to manage breaths in synch with a patient. Often times, in my experience, these patients need to be paralyzed, and that's sometimes not in their best interests. At my current job, we use a ventilator for a 1.4 mile IFT.



    If a paralytic is going to be used, sedation and analgesia should be optimized first. I understand that sometimes it's a patient safety issue and may need to be done with sub-optimal sedation and analgesia. I try to avoid routine paralysis. I've been shown the IVC on US of a trauma patient who is intubated and paralyzed, and you can see the IVC collapse with every breath.
  12. Farmer2DO

    Farmer2DO New Member

    Location:
    Western New York
    EMS Training:
    Critical Care Paramedic
    Less side effects when you use lower doses. And you get the benefits of both agents, like sedation, pain management, reduction of MAP (if you want it).
  13. DrParasite

    DrParasite Ambulance Driver

    you know, as someone who has never intubated someone, the thought of giving analgesea has never crossed my mind. Sedative + paralytic = RSI, and I don't think I ever heard pain medication given. and most unconc people who get tubes don't get analgesea either (although they tend to be pretty messed up for us to tube them anyway). ditto someone is is RSIed, odds are if you are being tubed, you have bigger problems than if the tube is causing the patient pain, and are trying to keep the person alive until they get to the hospital.

    granted, our transport time for 911 jobs can be between 4 min and 30 minutes depending on where in our coverage area we are, but I don't think I've ever heard any paramedic push pain meds.

    I think I'm gonna ask some of the ALS providers I know, as well as some of the ER docs what they think of it.

    thanks
  14. Melclin

    Melclin New Member

    Location:
    Melb, Australia.
    I was tubed in ED and spent a short while in the unit..once upon a time. I can't remember any details obviously but I have this odd and vague memory of having been in pure agony for a few days.

    For some completely unrelated reason, I am very passionate about post tube analgesia.

    Go figure.
  15. So you get the side effects of multiple drugs?

    Plus propofol depresses CMRO2, fent does not.

    It decreases cerebral blood flow, ICP, and intraoccular pressure.

    Has no clinically significant side effects on renal, hepatic or endocrine organs.

    Let's compare it to fent?

    Side effects common: nausea, vomiting, itching.

    Muscle rigidity more common in induction doses.

    as an analgesic and not an anestetic agent patient can be immobilized and aware.

    Over saturation of hepatic and renal metabolism with prolonged or high doses.

    I think I will stick with higher dose propofol given the choice.
  16. mycrofft

    mycrofft Still crazy but elsewhere

    Location:
    Central California
    They used propafol and ativan on me for cardioversion

    Other than the first degree burns around the patches, no issues, other than I felt about 5 points lower on the IQ scale for the next week.
    Just saying. I am remembering the old days of scopolamine for childbirth, it still hurt like hell and they hallucinated, but they forgot it all afterwards.

    Hey, wait a minute!:glare:
  17. boingo

    boingo New Member

    Propofol is generally not available to EMS except in the IFT arena, for those patients a benzo/opiate combination is what you have to work with.

    In my experience, analgesia is woefully under used during induction or the short term post intubation period, both in and out of the hospital. I'm not sure why that is, but I see it daily.

    A case from 2 weeks ago, R/O head bleed that we RSI'd in the field, Fentanyl, Etomidate, Sux for induction, Versed/Fentanyl for post intubation sedation. Pt had about 40 minutes between induction and ED arrival, old school ED doc who studied and worked in New Orleans for most of her career (graduated in 1973) was horrified that we gave Versed/Fenanyl. Her first comment was that since the pt recieved Etomidate there was no reason for Versed. When I stated that the induction dose of Etomidate lasts about 5 minutes her comment was "Versed doesn't last any longer". Her next problem was Fentanyl. She doesn't use it, and the 200 mcg the pt recieved was apparently way above any dose of Fentanyl she had ever heard of, and promptly ordered a Narcan drip. This is a true story, not from some deserted island but a large medical facility in a city full of academic medical centers.

    Pt was inducted w/150 mcg Fentanyl, 20 mg Etomidate and 120 mg Sux, post intubation recieved 5 mg Versed x 2 and 50 mcg Fenanyl.
  18. usafmedic45

    usafmedic45 New Member

    Location:
    Indiana
    That was my thought too. I was just too loaded on USAFMedic45 brand Nighty Night Juice (Benadryl) to formulate a good argument for it.:p
  19. usafmedic45

    usafmedic45 New Member

    Location:
    Indiana
    Which is one reason why I've always argued that ketamine is a damn near ideal medication for RSI in the field. A lot of times you can intubate with it alone and do not need to give a paralytic which negates that tiny issue of stopping whatever respiratory effort the patient may have going on which makes a failed airway situation a little less Under-roo ruining in nature. You get pain control, don't have to worry about drops in BP, it has a bronchodilatory effect and there are some apparent neuroprotective effects from its use. Other than the patient drooling some with it and emergence reactions, there really isn't a better drug out there for this purpose.
  20. medicsb

    medicsb Member

    Location:
    PA/NJ/DE area
    I think it should be remembered that the emphasis on pain management in awake patients is still relatively new and often poorly done, still. It can take decades to overturn old/bad practices. It doesn't surprise me that many RNs and physicians think analgesia isn't needed in these situations where patients are usually heavily sedated. It really wasn't too long ago that it was common knowledge that morphine was detrimental to the physical exam of the patient complaining of abdominal pain (and there are plenty of people who are still misinformed about this). At one point, it was standard practice to NOT give analgesics (or only very low doses) to BURN patients (look up Dax Cowart if you're curious). Anyhow, there is a reason JHACO had to set pain management standards in 2000. Opiates still carry a stigma, especially fentanyl, which many older physicians are only familiar with as a drug used by anesthetists. Additionally, there are a lot of physicians practicing EM and critical care that were not formally trained in such practices, thus there is a bigger disconnect between what is taught and what is practiced in some places.

    From what I've read, there have been a couple cases of physicians being sued for inadequate pain management. There is at least one study where patients who underwent ED RSI were interviewed about their experience and about 1/2 had some sort of recall and most reported experiencing pain. These two things might help in persuading the skeptics or gaining the attention of those who don't want to take the time to listen.

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