# Versed/fentanyl sedation



## StCEMT (May 15, 2017)

I will preface this with yes, I know this is not the most ideal combination out of the overall options, but new system, new way of doing things and this is one of many things I have to brush up on. 

Now, that being said, for the time being unless I can swing this proposal I was told to put together through the state level BS, it's all I got to work with (kind of, its a bit out of protocol, but not forbidden). I am most familiar with etomidate, but I haven't seen fentanyl or anything used except in the OR and there were a good 3-5 meds being pushed overall. That was also a case of you don't know what you don't know, I didn't really ask about it.

So. What are yall's experience with these meds in the process of sedation? What you have found to be a good starting place? What kind of changes to expect in vitals using this method? General considerations? Want to make sure I have done my homework on this before it is necessary since I haven't used this method or these meds combined.


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## E tank (May 15, 2017)

StCEMT said:


> I will preface this with yes, I know this is not the most ideal combination out of the overall options, but new system, new way of doing things and this is one of many things I have to brush up on.
> 
> Now, that being said, for the time being unless I can swing this proposal I was told to put together through the state level BS, it's all I got to work with (kind of, its a bit out of protocol, but not forbidden). I am most familiar with etomidate, but I haven't seen fentanyl or anything used except in the OR and there were a good 3-5 meds being pushed overall. That was also a case of you don't know what you don't know, I didn't really ask about it.
> 
> So. What are yall's experience with these meds in the process of sedation? What you have found to be a good starting place? What kind of changes to expect in vitals using this method? General considerations? Want to make sure I have done my homework on this before it is necessary since I haven't used this method or these meds combined.



It is my go-to sedation cocktail. I put 2mg/100 mcgs in a 5 cc syringe and give a cc at a time. I've been shying away from versed in the elderly because of the incidence of cognitive dysfunction associated with it, but I'll fudge on that from time to time if really necessary. 

That said, it is a very potent, synergistic combination with minimal respiratory/hemodynamic side effects. Short acting too.


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## Hold My Beer (May 15, 2017)

What are you sedating them for? RSI, cardioversion, pain?  I've used it with success for concurrent sedation for patients with larger injuries such as long bones, joints, backs. Have not used it with anything else.  Obviously watch for respiratory depression and a drop in blood pressure.  Using these together will potentiate their effects.  If its out of your protocol you probably want to call med control first.


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## StCEMT (May 15, 2017)

So for the sake of simplicity, 5mg/100mcg in a 10cc flush. Start with 5cc then move on to the last 5cc if needed? 

My bad, this would be intubation. Cardioversion etc are small doses of Versed only.


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## E tank (May 15, 2017)

Hold My Beer said:


> What are you sedating them for? RSI, cardioversion, pain?  I've used it with success for concurrent sedation for patients with larger injuries such as long bones, joints, backs. Have not used it with anything else.  Obviously watch for respiratory depression and a drop in blood pressure.  Using these together will potentiate their effects.  If its out of your protocol you probably want to call med control first.



Intubation, DCCV, major joint dislocation reduction requires more than 2 cc each of versed and fentanyl. I'm using if for procedural sedation. Putting needles in uncomfortable places after a generous local anesthetic wheal. Very good for anxiety and pre-existing pain.


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## Summit (May 15, 2017)

Monitor etco2


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## E tank (May 15, 2017)

StCEMT said:


> So for the sake of simplicity, 5mg/100mcg in a 10cc flush. Start with 5cc then move on to the last 5cc if needed?
> 
> My bad, this would be intubation. Cardioversion etc are small doses of Versed only.


 
I don't think that cocktail would be sufficient for direct laryngoscopy and intubation. Maybe DCCV. It would, however allow a smaller dose of hypnotic for DL and intubation.


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## StCEMT (May 15, 2017)

E tank said:


> I don't think that cocktail would be sufficient for direct laryngoscopy and intubation. Maybe DCCV. It would, however allow a smaller dose of hypnotic for DL and intubation.


And that was my concern. I have seen other sedatives used for intubation and know what to expect with them. Having never used this combo for that purpose, I am not familiar with what kind of range to work with or what to expect.

Now on the other hand, there is also the maintain what I can until I get to the hospital which is typically not too long. That is their reasoning behind not allowing RSI I am told. But, that isn't always how things work either, so prior planning...


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## Carlos Danger (May 16, 2017)

Versed & Fent is a great combo for almost any application requiring both sedation and analgesia. Titrate small doses for sedation, use a larger dose for induction. You can mix them in the same syringe like E tank described, or give 50-100 mcg of fent and then give small (1-2mg) boluses of versed on top of it until you get your desired effect.

Obviously watch respiratory status closely no matter who you are giving it to. Supplemental oxygen and Sp02 and Etc02 monitoring should go without saying. Older people require very little of this combo, and you don't want to give them much versed anyway, even if they seem to tolerate it well. Anyone with OSA or is heavy will obstruct easily and is also more susceptible to the resp depressant effects of the combo.

I don't use much versed at all in my anesthetic practice, but I sure would if I didn't have propofol available.

The induction dose of versed 200 - 300 mcg/kg, but you can cut that a little by adding 1-2 mcg/kg of fentanyl and 1.5 mg/kg of lido. The only reason versed isn't used more often in anesthesia for induction is because forever we had pentothal, and now we have propofol (which is hands down the best all around induction agent), and they both wear off quickly whereas such a large dose of versed lasts too long for most cases.


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## StCEMT (May 16, 2017)

@Remi what role does lido play in your example?


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## Carlos Danger (May 16, 2017)

StCEMT said:


> @Remi what role does lido play in your example?


Potentiates the effects of both versed and fentanyl. Decreases opioid requirements. Has analgesic and anti-hyperalgesic effects. Decreases ICP.

It's safe, and cheap. I use a lot of lidocaine in my practice. Boluses and infusions.


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## StCEMT (May 16, 2017)

Huh, I knew it was used for ICP, didn't know it was used to potentiate the other two. Good to know.


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## SpecialK (May 16, 2017)

It depends on what you want to use it for.  Ketamine (with or without a bit of midazolam) is a much choice if you want to do cardioversion or relocate somebodies fractured limbs or for severe pain.


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## StCEMT (May 17, 2017)

SpecialK said:


> It depends on what you want to use it for.  Ketamine (with or without a bit of midazolam) is a much choice if you want to do cardioversion or relocate somebodies fractured limbs or for severe pain.


I am in the process of trying to see if I can get Ketamine here. However, it will be many, many months before that ever happens just because the process of doing things can be slow. Have to get more familiar with other tools in the toolbox until then.


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## CTMD (May 17, 2017)

Does anyone use Fent/Ativan for post intubation sedation? Besides the longer lasting effect of Ativan, what would be the benefit of using Ativan over Versed in post intubation sedation?


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## E tank (May 17, 2017)

CTMD said:


> Does anyone use Fent/Ativan for post intubation sedation? Besides the longer lasting effect of Ativan, what would be the benefit of using Ativan over Versed in post intubation sedation?


 
You'd just be better off giving a good slug of versed with or without fentanyl for intubation. There is plenty of amnesia in an intubation dose of versed (around .3 - .6/ kg) to keep the patient amnestic for a couple of hours at least . There is no advantage of Ativan over versed for intubation because of the slower time to peak effect and blunting of effects of the DL. 

That said,  IV Ativan is a great amnestic and sedative. Just not the right tool for intubation.


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## CTMD (May 17, 2017)

E tank said:


> You'd just be better off giving a good slug of versed with or without fentanyl for intubation. There is plenty of amnesia in an intubation dose of versed (around .3 - .6/ kg) to keep the patient amnestic for a couple of hours at least . There is no advantage of Ativan over versed for intubation because of the slower time to peak effect and blunting of effects of the DL.
> 
> That said,  IV Ativan is a great amnestic and sedative. Just not the right tool for intubation.


So you would not continue to sedate someone after RSIing them? I could see this if it was a short transport but for transports over 20-40 mins wouldn't you run into problems with pt's bucking the tube?


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## StCEMT (May 17, 2017)

What kind of changes in bp can be expected with the intubation dose of versed combined with some fentanyl? I wouldn't push it with someone I thought this would cause more harm than good in, but I do have two good pressor options and a pump to work with now.


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## E tank (May 17, 2017)

CTMD said:


> So you would not continue to sedate someone after RSIing them? I could see this if it was a short transport but for transports over 20-40 mins wouldn't you run into problems with pt's bucking the tube?



Bucking on the tube doesn't necessarily mean they need sedation, if by sedation you mean amnesia and being unaware of what's going on. A large dose of versed like that might just be enough sedation for a couple of hours. If it isn't, I'd just give the patient what he needs. Ativan is a good choice for that. Paralyzing him would be the best option for what you're talking about.


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## E tank (May 17, 2017)

StCEMT said:


> What kind of changes in bp can be expected with the intubation dose of versed combined with some fentanyl? I wouldn't push it with someone I thought this would cause more harm than good in, but I do have two good pressor options and a pump to work with now.



Versed gives a very stable induction. You'd probably have more hypertension that the other way around, depending on why you're intubating the patient and if you didn't give it a few minutes to circulate well.


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## SpecialK (May 18, 2017)

Oh Jesus tell me people aren't still trying to use midazolam for general anaesthesia? Why are you still doing this? And please stop doing this.


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## Brandon O (May 18, 2017)

CTMD said:


> Does anyone use Fent/Ativan for post intubation sedation? Besides the longer lasting effect of Ativan, what would be the benefit of using Ativan over Versed in post intubation sedation?



From an ICU perspective, it is done, but I see no advantage and tend to change it when I encounter it. Lorazepam has a long half-life, making it less titratable as a drip, and infusions are packaged in propylene glycol which can cause weird metabolic acidoses. Midazolam is better -- although frankly, all benzos can be rather deliriogenic and propofol is probably even better -- and simply minimizing sedation in general best of all.

Ativan can make a decent choice for intermittent boluses, depending on what duration you're looking for.


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## Carlos Danger (May 18, 2017)

SpecialK said:


> Oh Jesus tell me people aren't still trying to use midazolam for general anaesthesia? Why are you still doing this? And please stop doing this.


Versed is an excellent drug. Why not use it?


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## E tank (May 18, 2017)

SpecialK said:


> Oh Jesus tell me people aren't still trying to use midazolam for general anaesthesia? Why are you still doing this? And please stop doing this.



Stop using versed with general anesthesia or for general anesthesia? I don't know anyone that uses it for general anesthesia and it is a valuable adjunct with general anesthesia. 

Using it as a hypnotic for intubation is not using it for general anesthesia.


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## SpecialK (May 18, 2017)

E tank said:


> Using it as a hypnotic for intubation is not using it for general anesthesia.



Oh, rubbish.  Taking somebody and making them unconscious so they can be intubated is .... general anaesthesia.

Just because it's done outside of a traditional clinical setting by a non-anaesthetist doesn't make it any less of general anaesthesia.

The doses of midazolam you'd need to achieve this are pretty high and then you get all the deleterious side effects, which in somebody who is being intubated say for severe traumatic brain injury is not a good thing.  

Why not just use ketamine (or in your part of the world where you have it - etomidate).


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## StCEMT (May 18, 2017)

SpecialK said:


> Why not just use ketamine (or in your part of the world where you have it - etomidate).


It might not have been clear in my initial post, but I have neither at my new service. I wouldn't ask this if I did. I am currently working on a proposition for Ketamine, but that is a long term project. 

All I have to work with is versed/fentanyl. I haven't used either of these meds enough to be as familiar with them, but I have used fentanyl on many occasions. Being a new medic, I recognize my knowledge and experience is not close to many members here. So I ask questions to have a better understanding of and best use what I am given, which will be happening a lot here soon since I have a lot of new meds and equipment that I am not all that familiar with.


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## Carlos Danger (May 18, 2017)

StCEMT said:


> It might not have been clear in my initial post, but I have neither at my new service. I wouldn't ask this if I did. I am currently working on a proposition for Ketamine, but that is a long term project.
> 
> All I have to work with is versed/fentanyl. I haven't used either of these meds enough to be as familiar with them, but I have used fentanyl on many occasions. Being a new medic, I recognize my knowledge and experience is not close to many members here. So I ask questions to have a better understanding of and best use what I am given, which will be happening a lot here soon since I have a lot of new meds and equipment that I am not all that familiar with.


It'd be nice to have ketamine and/or etomidate as options but really, versed & fent is a fine combo. Don't let the naysayers worry you.


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## StCEMT (May 18, 2017)

Remi said:


> It'd be nice to have ketamine and/or etomidate as options but really, versed & fent is a fine combo. Don't let the naysayers worry you.


It's mostly just unfamiliarity making this outside my comfort zone. Never had to dose those meds like that for this purpose, not that I don't think I can manage other side effects adequately. In cases like this I want to be able to call a doc and know exactly what I want, why I want it, and how I want it done so I don't come off as a confused, bumbling fool when I do. Not having done this, that's where I rely on experienced folks like you. If it's a reasonable option, I'll just make sure I stay knowledgeable on it and proceed accordingly.


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## E tank (May 18, 2017)

SpecialK said:


> Oh, rubbish.  Taking somebody and making them unconscious so they can be intubated is .... general anaesthesia.
> 
> Just because it's done outside of a traditional clinical setting by a non-anaesthetist doesn't make it any less of general anaesthesia.
> 
> ...



Any hypnotic is  chosen for the advantages it brings to the table and is weighed against potential risk which any of them bring. Propofol can have profound hypotension, etomidate, adrenal cortical suppression, ketamine a hyperdynamic response and dysphoria in some patients. 

Versed is also used in larger than common doses in cardiothoracic surgery with early extubation in procedures utilizing  deep hypothermic circulatory arrest where neurological protection is a key objective. 

Versed is also routinely used in neuro intensive care units with propofol for sedation of ABI patients and they end up getting far more than an intubation dose,  so while I get that there can be differing opinions on specific choices of hypnotics, I'm always a little surprised at out of proportion negative reactions to uses of some agents that may be unfamiliar to some.


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## StCEMT (May 19, 2017)

Unfamiliarity is probably why it gets those reactions. I wish I could follow you two around for a week just for the variety of exposure. Admittedly my options don't make me too excited, but that's just due to my past experience with some meds and lack thereof with others.


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## Carlos Danger (May 19, 2017)

SpecialK said:


> Oh, rubbish.  Taking somebody and making them unconscious so they can be intubated is .... general anaesthesia.
> 
> Just because it's done outside of a traditional clinical setting by a non-anaesthetist doesn't make it any less of general anaesthesia.
> 
> ...



We are really talking semantics so I don't want to get too far into the weeds over terminology, but induction for intubation is not necessarily the same thing as general anesthesia. It can be, sure, but it does't have to be. A mild-moderate level of hypnosis or anxioloysis with amnesia is all you really need in order to intubate someone humanely. "General anesthesia", however, always requires a much deeper and sustained loss of awareness, analgesia, and usually some loss of autonomic function. To put it another way, what I need to give you in order to humanely place an ETT in your trachea and allow you to tolerate mechanical ventilation is very different than what I need to give you in order to allow a surgeon to cut open your thorax or abdomen and start playing with your internal organs.

Here's the thing about ketamine vs. versed vs. opioids vs. propofol vs. pentothal vs. brevital vs. etomidate vs. sevo for induction: any of those can work alone or in some combination with the others. None of them are without potential problems. Each one is maybe the best choice for a specific application and perhaps the worst choice for another. None of them are the best choice in EVERY situation. A big slug of ketamine may be the best all-around choice for prehospital use, but it would be my last choice in a fragile old patient with a sick heart. Not because it can't work, but because there are better options if you have the choice and know the drugs well. Being able to make that determination takes experience and is what they mean when they talk about the "art of anesthesia". It can't be distilled into a simple algorithm or explained with a clinical study. The same is true with paralytics (though less so, to be sure), and I've tried to explain that  many times to paramedics who have been brainwashed into thinking that sux should never ever be used.

In prehospital, since most of us don't have that kind of experience and knowledge of the drugs, we have a medical director who uses the best evidence (or dogma, or bias) to choose the drug(s) that he thinks are the best option for most of the scenarios we encounter in the field. If I were writing an RSI protocol for EMS, versed and fentanyl would probably not be my first choice, but honestly, you _can _make an argument for that combination over ketamine or etomidate. It may not be in style right now, but like I said before, it isn't a horrible choice by any means.

"Never" and "always" are two of the most dangerous words in medicine.


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## E tank (May 19, 2017)

Remi said:


> In prehospital, since most of us don't have that kind of experience and knowledge of the drugs, we have a medical director who uses the best evidence (or dogma, or bias) to choose the drug(s) that he thinks are the best option for most of the scenarios we encounter in the field. If I were writing an RSI protocol for EMS, versed and fentanyl would probably not be my first choice, but honestly, you _can _make an argument for that combination over ketamine or etomidate. It may not be in style right now, but like I said before, it isn't a horrible choice by any means.
> 
> "Never" and "always" are two of the most dangerous words in medicine.



Indeed...I don't personally, but I work with guys that put hearts off to sleep with 6 - 10 mgs of versed with some sufenta. Pretty stable induction and intubation, but just one way in many to put off a patient with a sick heart.


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## StCEMT (May 19, 2017)

Just out of curiosity, how would you form an RSI protocol if given free reign?


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## E tank (May 19, 2017)

StCEMT said:


> Just out of curiosity, how would you form an RSI protocol if given free reign?



In a perfect world where practicality was not an issue,  I'd have etomidate, propofol and ketamine for the hypnotics and succs and rocuronium for the muscle relaxants. There would be a  specific pre-induction checklist and finally, because of the variety of possible combinations, the agents would be prescribed by medical control on a case by case basis.


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## SpecialK (May 20, 2017)

StCEMT said:


> Just out of curiosity, how would you form an RSI protocol if given free reign?



Medicine wise probably ketamine and rocuronium.  Very common in Australasia.  As a backup when ketamine is a bit suspicious to give, such as in somebody with massively uncontrolled hypertension or a crook ticker then something would be nice; can't say between for example propofol or etomidate.  We don't have etomidate down here.


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## StCEMT (May 21, 2017)

Is Ketamine the only thing used in Australia now? Kinda jealous, really wish it was still in my box.


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## Rialaigh (Jun 7, 2017)

We have ketamine and etomidate for RSI here, moving towards only ketamine for induction. Currently carry Succs but moving to Roc once we get everyone trained up on VL and get them on all the trucks.

Also will have a protocol for Ketamine for pain management (Dosed on top of fentanyl) for severe pain.


I am personally not a fan of Versed for induction. At my previous service it was our only option for induction and we did not carry fentanyl, it was versed and succs only. I am not a fan of using it in a lot of the hemodynamically unstable patients we end up tubing in rural areas. I think there are a number of better drugs out there for "general" use and ketamine tops that list currently.


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