# Post RSI Sedation



## fma08 (Nov 6, 2010)

Long time no see everyone.

Our service is looking into putting in an RSI protocol. Due to the possibility of longer transport times as we are a more rural service, we wanted something in place for continued sedation, not just random boluses as needed. Does anyone have a protocol for drips for continued sedation after intubation? Something like a midazolam/fentanyl drip for in the field? I know in hospitals, they often have propofol or something else, but I was trying to think of medications we'd already have for use in the field.

Any help would be appreciated. Thank you.


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## medicgene (Nov 6, 2010)

Vecuronium, lasts 35-45 mins per dose,
just have an airway before you use it!!


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## fma08 (Nov 6, 2010)

Looking for post RSI *sedation*. Vec is a paralytic, not a sedative 

Thanks for the reply though.


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## medicgene (Nov 6, 2010)

my mistake, we use versed/fentanyl. in the as you put it, random boluses


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## Smash (Nov 6, 2010)

fma08 said:


> Long time no see everyone.
> 
> Our service is looking into putting in an RSI protocol. Due to the possibility of longer transport times as we are a more rural service, we wanted something in place for continued sedation, not just random boluses as needed. Does anyone have a protocol for drips for continued sedation after intubation? Something like a midazolam/fentanyl drip for in the field? I know in hospitals, they often have propofol or something else, but I was trying to think of medications we'd already have for use in the field.
> 
> Any help would be appreciated. Thank you.



We use morphine/versed infusion, run through a syringe pump at rates between 1-10mg an hour or whatever the patient needs.  It is a good combination, providing sedation and pain relief and using drugs that we already have and that are cheap.  It is worth the outlay to get a syringe driver or two especially if you have long transports.  Avoiding peaks and troughs of sedation is vital in someone you have paralysed and intubated.


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## fma08 (Nov 6, 2010)

Smash said:


> We use morphine/versed infusion, run through a syringe pump at rates between 1-10mg an hour or whatever the patient needs.  It is a good combination, providing sedation and pain relief and using drugs that we already have and that are cheap.  It is worth the outlay to get a syringe driver or two especially if you have long transports.  Avoiding peaks and troughs of sedation is vital in someone you have paralysed and intubated.



Do they make prefilled syringes for these pumps at concentrations for continuous infusion?


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## Smash (Nov 6, 2010)

Not that I am aware of, however that is not to say that there isn't someone out there who does. We just draw up the drugs with D5W in a 50ml syringe to make 1mg/1ml concentration. The only prefilled syringe we have is naloxone.


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## FFMedic75 (Nov 6, 2010)

My current service uses a second dose of Etomidate.  Previously I have used Ativan.  I thought our Medical Director was crazy but the second dose of Etomidate actually works very well.  You have to be careful of Adrenal insufficiency but other than that there is very few side effects.  It also often prevents the need for a long term paralytic, which is positive.  There are definitely plenty of alternatives out there, but this one works, does not require additional drugs or equipment and has very little impact on the BP.


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## fma08 (Nov 6, 2010)

FFMedic75 said:


> My current service uses a second dose of Etomidate.  Previously I have used Ativan.  I thought our Medical Director was crazy but the second dose of Etomidate actually works very well.  You have to be careful of Adrenal insufficiency but other than that there is very few side effects.  It also often prevents the need for a long term paralytic, which is positive.  There are definitely plenty of alternatives out there, but this one works, does not require additional drugs or equipment and has very little impact on the BP.



Just another dose the same as the one for induction? 0.3mg/kg? How long does the sedation last?


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## usalsfyre (Nov 6, 2010)

FFMedic75 said:


> My current service uses a second dose of Etomidate.  Previously I have used Ativan.  I thought our Medical Director was crazy but the second dose of Etomidate actually works very well.  You have to be careful of Adrenal insufficiency but other than that there is very few side effects.  It also often prevents the need for a long term paralytic, which is positive.  There are definitely plenty of alternatives out there, but this one works, does not require additional drugs or equipment and has very little impact on the BP.




Using a very short acting sedative/hypnotic for ongoing sedation is crappy medicine. Etomidate provides roughly 5 minutes of sedation before emergence. On top of that a single dose of Amidate causes adrenal supression in HEALTHY people, two doses in soneone sick could prove fatal (though to be fair you seem to be aware of that).

So the real question is why does your medical director not trust your medics with better options? Is it poor education on y'alls or his part?


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## usalsfyre (Nov 6, 2010)

fma08 said:


> Long time no see everyone.
> 
> Our service is looking into putting in an RSI protocol. Due to the possibility of longer transport times as we are a more rural service, we wanted something in place for continued sedation, not just random boluses as needed. Does anyone have a protocol for drips for continued sedation after intubation? Something like a midazolam/fentanyl drip for in the field? I know in hospitals, they often have propofol or something else, but I was trying to think of medications we'd already have for use in the field.
> 
> Any help would be appreciated. Thank you.



Kudos for putting post-procedural sedation high on the priority list.

Your transport times play into this. If your transports are <1hr most patients can be managed fairly well with a healthy midaz/fent bolus immediately post intubation, followed by maybe one more dose PRN. Greater than that, they should really be on an infusion. Propofol is somewhat of a poor choice for transport medicine, as the doses required in a stimulus rich environment (like a 70mph ride down a pothole riddled dirt road) often lead to hypotension. Midaz/loraz and fent is a good choice, but you need to make sure it's carried in sufficent quantaties to set up an infusion. Another logistical issue is pumps, if your service doesn't have them this is a no go. These aren't drips you can titrate with a 60gtts and a second hand.


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## Smash (Nov 7, 2010)

FFMedic75 said:


> My current service uses a second dose of Etomidate.  Previously I have used Ativan.  I thought our Medical Director was crazy but the second dose of Etomidate actually works very well.  You have to be careful of Adrenal insufficiency but other than that there is very few side effects.  It also often prevents the need for a long term paralytic, which is positive.  There are definitely plenty of alternatives out there, but this one works, does not require additional drugs or equipment and has very little impact on the BP.



Long term paralytics and sedation are two very separate things.  One can have sedation alone, but there is no way you could ever have paralysis alone.  Well, I suppose you could, but you would deserve to have it done to you to see what it is like!

I agree with usalfyre in that etomidate is a poor choice of ongoing sedation, as is propofol.  We can use propofol for induction in some settings, but ongoing sedation is almost always with morphine and midazolam infusion.

We would be getting looked at VERY closely if we did not set up an infusion for almost any transport of a post-RSI patient unless we were very, very close to the hospital (like <10 minutes close).  Sedation is not optional.

RSI is something that should be done propery or not at all; there is no "near enough is good enough."  In fact pretty much all of the research that has shown a negative effect of RSI has only shown that a procedure done badly is bad for patients.  To this end, as usalfyre has already alluded to, unless your service is willing to spend money on proper equipment and stock levels, don't even bother trying to get an RSI program underway.


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## FFMedic75 (Nov 7, 2010)

With our transport times, the second dose of Etomidate works fine.  We normally induce while in route. If the 2nd dose is required it normally gets us to the hospital (lasts 8-12mins).  We have Ativan further down the protocol if we need, we also carry Fenanyl.  As far as the adrenal insufficiency our medics are smart enough to recognize a patient who is susceptible to it and seek online advice prior to post RSI care.  Does this mean it can never happen?  Of course not, but everything has a side effects.  Are you more worried about adrenal insufficiency in you patient with a head injury or dropping their blood pressure with Benzos?  The issue with RSI is there is no 1 recipe that works for every patient, every service and every situation.  For example a single dose of Etomidate is dangerous for a patient with suspected sepsis.  When you undertake an RSI program you have to move away from the cook book medicine and have medics who are experienced and smart enough to do it.  This is why most services don't let brand new medics RSI.  The process is actually pretty easy.  Give some weight dependent drugs and intubate.  Not rocket science.  The hard part is knowing when to do it, when not to, what drugs and procedures are appropriate for each set of circumstances and what to do when it all goes bad. 

We use the same .3mg/kg dose.


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## fma08 (Nov 7, 2010)

usalsfyre said:


> Kudos for putting post-procedural sedation high on the priority list.
> 
> Your transport times play into this. If your transports are <1hr most patients can be managed fairly well with a healthy midaz/fent bolus immediately post intubation, followed by maybe one more dose PRN. Greater than that, they should really be on an infusion. Propofol is somewhat of a poor choice for transport medicine, as the doses required in a stimulus rich environment (like a 70mph ride down a pothole riddled dirt road) often lead to hypotension. Midaz/loraz and fent is a good choice, but you need to make sure it's carried in sufficent quantaties to set up an infusion. Another logistical issue is pumps, if your service doesn't have them this is a no go. These aren't drips you can titrate with a 60gtts and a second hand.



Transport times could easily be an hour or more. I am liking the syringe pump idea. Easy to mix up and wouldn't have to worry about stocking more narcs than we already do (speaking strictly for the infusion part).

We are aware that this will be a lengthy and costly adventure regardless of what avenue we choose to go with. I'm just doing some preliminary research of a possible protocol to bring forth. We already stock morphine, midazolam, diazepam, and fentanyl. However, we don't stock enough fentanyl to set up an infusion for that.


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## usalsfyre (Nov 7, 2010)

FFMedic75 said:


> With our transport times, the second dose of Etomidate works fine.  We normally induce while in route. If the 2nd dose is required it normally gets us to the hospital (lasts 8-12mins).  We have Ativan further down the protocol if we need, we also carry Fenanyl.  As far as the adrenal insufficiency our medics are smart enough to recognize a patient who is susceptible to it and seek online advice prior to post RSI care.  Does this mean it can never happen?  Of course not, but everything has a side effects.  Are you more worried about adrenal insufficiency in you patient with a head injury or dropping their blood pressure with Benzos?  The issue with RSI is there is no 1 recipe that works for every patient, every service and every situation.  For example a single dose of Etomidate is dangerous for a patient with suspected sepsis.  When you undertake an RSI program you have to move away from the cook book medicine and have medics who are experienced and smart enough to do it.  This is why most services don't let brand new medics RSI.  The process is actually pretty easy.  Give some weight dependent drugs and intubate.  Not rocket science.  The hard part is knowing when to do it, when not to, what drugs and procedures are appropriate for each set of circumstances and what to do when it all goes bad.
> 
> We use the same .3mg/kg dose.


Still a couple of problems with this approach. Chief among them is that unless the receiving hospital has meds pulled and ready to administer your.ensuring a gap in sedation. I would also be more concerned with adrenal supression than hypotension, as if you choose the right agent/give it with some sense you won't cause hemodynamic changes that are significant. As opposed to adrenal supression that will occur no matter what I do.

I'm also not sure about intubating while enroute. If your performing RSI you should be doing everything to ensure succesful tube placement, and hitting a bump, swerving for traffic, ect is not doing that. Everytime I choose to place a tube in the field it is because I believe it is important to
the safety and treatment of the patient DURING TRANSPORT. Meaning I usually do it in the house or stationary at the scene. Usually the time added is clinically insignificant compared to the added safety of having the patient sedated and everything set prior to taking off.

Your right, no one recipe works for every patient. Which is why I dislike the Etomidate redose. It screams "just do this because it's really easy". Etomidate was never intended nor approved to be used in this manner, and is very likely to lead to suboptimal sedation as a result (not to mention your not treating the pain caused by the procedure). If your medics are not able to titrate other medications properly, than I question if they need to be doing RSI at all.


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## Smash (Nov 7, 2010)

usalsfyre said:


> Still a couple of problems with this approach. Chief among them is that unless the receiving hospital has meds pulled and ready to administer your.ensuring a gap in sedation. I would also be more concerned with adrenal supression than hypotension, as if you choose the right agent/give it with some sense you won't cause hemodynamic changes that are significant. As opposed to adrenal supression that will occur no matter what I do.
> 
> I'm also not sure about intubating while enroute. If your performing RSI you should be doing everything to ensure succesful tube placement, and hitting a bump, swerving for traffic, ect is not doing that. Everytime I choose to place a tube in the field it is because I believe it is important to
> the safety and treatment of the patient DURING TRANSPORT. Meaning I usually do it in the house or stationary at the scene. Usually the time added is clinically insignificant compared to the added safety of having the patient sedated and everything set prior to taking off.
> ...



I seem to be very agreeable today, not sure why that is.  Hopefully I'll snap out of it and return to my curmudgeonly ways.

RSI is something that needs to be done with care and precision.  This means setting up and carrying out the procedure in the best possible environment, which is not necessarily in the back of an ambulance, and certainly not whilst on the road.
It also needs the right drugs to be used, and I must say I agree with usalfyre regarding the etomidate.  It really does not seem to be an appropriate drug for ongoing sedation.  
Whilst benzos may have an effect on blood pressure, I have very seldom seen this presenting as a problem.  We expect it, we prepare for it and make allowances for it and it very, very seldom happens.  One of the things we do that minimizes potential hypotension is to ensure that adequate pain relief is given along with our benzos.  Sedation alone is not adequate or appropriate.  This means that lower doses of both can be used to maintain adequate sedation in the paralyzed patient.
It is unusual for me to titrate much more than 5mg/hour of morphine/midazolam to a patient who I have RSI'd.  I will of course give a small bolus when noxious stimuli is going to be higher, such as when I place the gastric tube, or suction the oropharynx, or move the patient, but generally these low doses are adequate.

It is also important that the patient is carefully packaged, with attention given to pressure points and padding, eyes being taped shut, limbs being carefully aligned and so forth.  Everything that we can do for the comfort of the patient reduces the amount of pharmacology we have to use, and is beneficial in reducing insults to the ICP.

All this takes time, but it is not a significant amount more time than would otherwise be spent and it makes all the difference in transit and at the other end.


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## Melbourne MICA (Nov 8, 2010)

*Your'e just a soft touch at heart*



Smash said:


> I seem to be very agreeable today, not sure why that is.  Hopefully I'll snap out of it and return to my curmudgeonly ways.
> 
> RSI is something that needs to be done with care and precision.  This means setting up and carrying out the procedure in the best possible environment, which is not necessarily in the back of an ambulance, and certainly not whilst on the road.
> It also needs the right drugs to be used, and I must say I agree with usalfyre regarding the etomidate.  It really does not seem to be an appropriate drug for ongoing sedation.
> ...



Excellent points Smash but I would suggest you don't have much choice when it comes to the environment for the RSI. Here in Aussie land Victoria we have been doing RSI's on a broad group of pt categories for a while now (2003) and if the pt needs an RSI they get one irrespective of the situation though I agree you make the best of it as you can. Our head injury pts are the most common candidates though given the success of our RSi trial which was exclusive to HI pts our scope has been broadened to include more pt events.

Our sedation protocol is both mandatory and entirely warranted as the RSI pt who is paralysed has sedation so they don't wake up and wonder why they can't move or talk or breath for that matter! The sedation is not a clinical necessity per say but rather something done for pt comfort and anxiety. This is standard in all anaesthetics. Paralysis to facilitate controlled ventilation and (in the case of the HI pt) MAP blood pressure control = ICP control plus sedation for humane purposes. Sedation especially with benzos needs to be offset by fluid management of blood pressure - this is done in our guidelines prophylactically at the start with fluid boluses before the induction commences (as well as pre-oxygenation).

We use a Morph and Midaz infusion 30 and 30 in 30 (mg in mls) titrated to response. We use Panc at the tail end of the RSI to cement paralysis - its the key induction agent relative to the goal being sought especially in the HI pt -ie to plateau blood pressure>>>MAP>>>ICP so they don't get those stimulus related ICP spikes which really don't help with reducing the impact of their intracranial bleed. 

It must be noted of course our RSI protocol opens with both sedation and paralysis - Fentanyl and Midaz plus Sux. Regarding pain relief - an excellent point I might add and all too overlooked because EMS types are looking at an unconscious pt and seem to forget that pain persists even in this state -as I stated our guideline include Fentanyl at the beginning and Morph included in the tail end sedation component.

So then - induction for the tube to deal with secondary brain injury issues via ventilation (ETCO2/O2 control) and then  ongoing paralysis plus sedation right through to the ED and beyond. It's not uncommon to see our ED docs leave our syringe pump of sedation still going whilst they organise for the longer term management of the pt including CT etc.

Great points Smash and spot on. What a delight to hear someone mention good packaging and the overall relief of pain and suffering as vital components - an approach as you pointed out actually reduces your reliance on pharmacology and all the inherent potential problems that comes with dumping in drugs.

Well done old boy!!! Very agreeable indeed.

MM

PS you're comment re RSI  - "near enough not good enough" - absoF*&%Kinglutely - In another thread I suggested RSI was not for ambos out playing ambulance - grown ups only please. Serious stuff.


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## usalsfyre (Nov 8, 2010)

Smash said:


> It is also important that the patient is carefully packaged, with attention given to pressure points and padding, eyes being taped shut, limbs being carefully aligned and so forth.  Everything that we can do for the comfort of the patient reduces the amount of pharmacology we have to use, and is beneficial in reducing insults to the ICP.
> 
> All this takes time, but it is not a significant amount more time than would otherwise be spent and it makes all the difference in transit and at the other end.



And here is a key point. RSI and transport of the sedated patient is not something that should be done with speed in mind. The only thing "Rapid" about RSI is the name.


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## MrBrown (Nov 8, 2010)

We use midaz


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## Smash (Nov 8, 2010)

Sorry, I didn't make myself very clear regarding controlling the environment. Obviously there is not often we can do to control environment, but sometimes the back of the rig may not be the best place. Depending on where it is it may be better to stay in the residence with more room, better light and so on. 



MrBrown said:


> We use midaz



Just midazolam? Infusion or boluses? Why no pain relief?


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## MrBrown (Nov 8, 2010)

Smash said:


> Just midazolam? Infusion or boluses? Why no pain relief?



We use midaz bolus ... Brown should have mentioned we can also use morph

Now, Brown is unsure how much morph somebody who has had a very large induction dose of ketamine requires hmmm where is that Consultant Anaesthetist when you need him?


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## Smash (Nov 8, 2010)

MrBrown said:


> We use midaz bolus ... Brown should have mentioned we can also use morph
> 
> Now, Brown is unsure how much morph somebody who has had a very large induction dose of ketamine requires hmmm where is that Consultant Anaesthetist when you need him?



IV ketamine used for induction has a relatively short duration of action - around 30 minutes, depending on various factors.  It would depend on how long your transport times are (bearing in mind how long it will actually take to get more drugs on board at the hospital, not just when you arrive at the bay) but I would still be adding morphine or fentanyl to the mix to ensure adequate analgesia is maintained.


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## fma08 (Nov 9, 2010)

How about a ketamine infusion after the procedure? Something like a ketamine/morphine or ketamine/fentanyl infusion? Anyone have a protocol for that?


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