# Let's Talk About Sedation



## 18G (Nov 28, 2011)

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.


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## DrankTheKoolaid (Nov 28, 2011)

*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.


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## fast65 (Nov 28, 2011)

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*


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## HMartinho (Nov 28, 2011)

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.


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## Veneficus (Nov 28, 2011)

*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


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## Farmer2DO (Nov 28, 2011)

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).


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## usafmedic45 (Nov 28, 2011)

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



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



> 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*



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.


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## fast65 (Nov 28, 2011)

usafmedic45 said:


> 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.



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

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.


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## 18G (Nov 28, 2011)

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?



> 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.



Opinions? For IFT, do you prefer paralytic onboard or favor increasing dosage of the sedatives?


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## Veneficus (Nov 29, 2011)

usafmedic45 said:


> 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.



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?


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## Farmer2DO (Nov 29, 2011)

18G said:


> Opinions on transfers without a vent?



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.





> Opinions? For IFT, do you prefer paralytic onboard or favor increasing dosage of the sedatives?



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.


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## Farmer2DO (Nov 29, 2011)

Veneficus said:


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



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).


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## DrParasite (Nov 29, 2011)

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


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## Melclin (Nov 29, 2011)

usafmedic45 said:


> You can always tell medical professionals who have been tubed and vented because they are very liberal with sedation and pain control.



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.


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## Veneficus (Nov 29, 2011)

Farmer2DO said:


> 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).



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.


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## mycrofft (Nov 29, 2011)

*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:


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## boingo (Nov 29, 2011)

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.


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## usafmedic45 (Nov 29, 2011)

Veneficus said:


> 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?


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


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## usafmedic45 (Nov 29, 2011)

DrParasite said:


> 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.
> 
> ...



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.


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## medicsb (Nov 29, 2011)

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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## Veneficus (Nov 29, 2011)

medicsb said:


> 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.



I am not skeptical of pain management, quite the opposite. 

It is more of a go large or go home argument. Rather than give some sedation and analgesia using multiple agents, just use the propofol at the anesthetic dose. Nothing removes pain like general anesthesia. 

Joint commission is also guilty of taking away pain management options. For example, the use of benzos and opioids together is considered procedural sedation, not pain management. Which is totally BS and probably put into place for "safety" for substandard providers and institutions. 

But you can't have it both ways, you are either going to aggresively and properly manage pain or you are going to **** around with creating vague pain management guidlines while taking away the tools and techniques required to do just that.

It is also my opinion if providers are using outdated practices they are rightfully financially responsible for damages including pain and suffering.

There is a big difference between "do no harm" and "don't do :censored::censored::censored::censored:."


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## triemal04 (Nov 29, 2011)

Veneficus said:


> It is more of a go large or go home argument. Rather than give some sedation and analgesia using multiple agents, just use the propofol at the anesthetic dose. Nothing removes pain like general anesthesia.


True enough, but then the problem you still come across is dealing with the side effects; a transient drop in BP like you often get with induction via propofol can be tolerated  by many patients, but not all.  So you need a back up.  A maintanence infusion can be tolerated by most patient's without a change in pressure, but not all, and it can be dramatic in those ones.  So you need a back up.  It'd be the same with versed (much more common in EMS than propofol); feel free to use it for induction on ME, and don't worry about any pressure changes that may happen, but the patient with liver issues, or who is allready hypotensive or depending on preload and the sympathetic system to maintain an adequate BP...could be a problem.

There are cases when lower dose of several different drugs might be better then just 1 large dose, and other times when it wouldn't be needed.  It just depends...go figure, saying that in regards to medicine... 

Of course, there's also an education component that comes into play, and a shift in how prehospital medicine is practised, but that's just not worth talking about, right?


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## jjesusfreak01 (Nov 29, 2011)

boingo said:


> 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.



A "doctor" ordered a narcan drip for an intubated patient??? Why would you ever put narcan anywhere near an intubated patient. WHAT IS THE POINT???

Also, any ED doc that you would consider "old school" needs to get into a new field. Medicine evolves to fast for an ER doc to get behind the times.


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## mycrofft (Nov 30, 2011)

*The emphasis on conscious pain management went hot in the late Eighties.*

It remains tenebrous because of political issues, over- self-protective overprescribing, and the resultant uprush of Rx abuse. Also, because of drug abusers and their associates who are looking for loopholes for legal abuse. They have clouded what ought to be a medical scientific issue.


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## Veneficus (Nov 30, 2011)

triemal04 said:


> True enough, but then the problem you still come across is dealing with the side effects; a transient drop in BP like you often get with induction via propofol can be tolerated  by many patients, but not all.  So you need a back up.  A maintanence infusion can be tolerated by most patient's without a change in pressure, but not all, and it can be dramatic in those ones.  So you need a back up.  It'd be the same with versed (much more common in EMS than propofol); feel free to use it for induction on ME, and don't worry about any pressure changes that may happen, but the patient with liver issues, or who is allready hypotensive or depending on preload and the sympathetic system to maintain an adequate BP...could be a problem.



Or you can just add fluid?

Please see my earlier post in regards to liver issues.



triemal04 said:


> There are cases when lower dose of several different drugs might be better then just 1 large dose, and other times when it wouldn't be needed.  It just depends...go figure, saying that in regards to medicine...



I generally agree with this statement, but I don't think there is a need to play mad scientist by mixing multiple agents in a patient if you do not have to when one will do.


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## usalsfyre (Nov 30, 2011)

The biggest problem with propofol only intubation? In the US it's called "induction" and hoarded by anethistist. Even some hospital systems state no one outside of anesthesia is credentialed to give propofol as a bolus. Other services (including EMS) don't "induce anesthesia" we "consciously sedate the patient to perform a procedure". Which is massively stupid because the result is the same. Politics...

I'm not a big fan of propofol alone for transport, but it's not really the drugs fault. All too often the patients are not adequately volume resuscitated and on way too low a dose when anything other than laying in a ED bed is going on. As such during transport they do things like sit up, look at you and try to pull the tube (yes it has happened to me on more than one occasion). Up the dose and the get hypotensive due to volume state. Add a fent loading and infusion dose and these patients stay much more comfortable in a "stimulus rich environment". I've also taken to adding a liter bolus in my newly intubated patients on propofol, just in case.


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## Veneficus (Nov 30, 2011)

usalsfyre said:


> The biggest problem with propofol only intubation? In the US it's called "induction" and hoarded by anethistist. Even some hospital systems state no one outside of anesthesia is credentialed to give propofol as a bolus. Other services (including EMS) don't "induce anesthesia" we "consciously sedate the patient to perform a procedure". Which is massively stupid because the result is the same. Politics...
> 
> I'm not a big fan of propofol alone for transport, but it's not really the drugs fault. All too often the patients are not adequately volume resuscitated and on way too low a dose when anything other than laying in a ED bed is going on. As such during transport they do things like sit up, look at you and try to pull the tube (yes it has happened to me on more than one occasion). Up the dose and the get hypotensive due to volume state. Add a fent loading and infusion dose and these patients stay much more comfortable in a "stimulus rich environment". I've also taken to adding a liter bolus in my newly intubated patients on propofol, just in case.



It was specified in my education any patient on a propofol infusion should (as in, it is not a requirement, but a good practice to be in) have a liter of fluid hanging, with volume adjustment as needed in any environment.

I agree with you on the politics of it. Speaking from the standpoint of advocating patient care, if only anesthesia can use the required drugs and amounts during transport then anesthesia needs to start transporting too.

Patient transport is a required part of medical care in 2011 and the idea of 1/2 A$$ing it and forcing stopgap treatments in order to give a specific specialty an exclusive use of an optimum treatment or to make them feel superior is just the kind of behavior that invites outside regulation or excess litigation in medicine.

Just by the very nature of medicine, there is no perfect treatment that works safely and effectively in all patients. There is no procedure or protocol that will always prevent adverse effects. (perhaps arguably not treating at all, but that is not what medical providers are for. Anyone on the street can do nothing.)

Obviously if mixing meds is the only way to optimally treat your patients under your guidlines, then that is the right and proper thing to do, even when it is not the easiest or simplest method.


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## 18G (Dec 1, 2011)

usalsfyre said:


> The biggest problem with propofol only intubation? In the US it's called "induction" and hoarded by anethistist. Even some hospital systems state no one outside of anesthesia is credentialed to give propofol as a bolus. Other services (including EMS) don't "induce anesthesia" we "consciously sedate the patient to perform a procedure". Which is massively stupid because the result is the same. Politics...
> 
> I'm not a big fan of propofol alone for transport, but it's not really the drugs fault. All too often the patients are not adequately volume resuscitated and on way too low a dose when anything other than laying in a ED bed is going on. As such during transport they do things like sit up, look at you and try to pull the tube (yes it has happened to me on more than one occasion). Up the dose and the get hypotensive due to volume state. Add a fent loading and infusion dose and these patients stay much more comfortable in a "stimulus rich environment". I've also taken to adding a liter bolus in my newly intubated patients on propofol, just in case.



And this has been my experience. When the patient is completely still in an ED bed they are okay on the low dose of propofol as far as sedation goes, but soon as we get there and start doing things the patient becomes agitated, pulling at the tube, fights the vent, etc, etc. And if this is a head injured patient this is something undesirable as this agitation can increase ICP. And the studies I have read and position statements all pretty much say the same thing which is give these patients analgesia. These are evidenced based recommendations for pain control.  

I am not a fan of propofol only in the transport environment either. 




> It was specified in my education any patient on a propofol infusion should (as in, it is not a requirement, but a good practice to be in) have a liter of fluid hanging, with volume adjustment as needed in any environment.



I picked up an intubated patient on propofol with the line running directly into the IV catheter. No saline lock, no other IV access, no fluids at all. I was thinking wth? Really? Propofol on a critical patient and no fluids hanging?  This is what we deal with sometimes and adds to the time it takes to roll out the door with the patient.


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## Veneficus (Dec 1, 2011)

*food for thought.*



18G said:


> And the studies I have read and position statements all pretty much say the same thing which is give these patients analgesia. These are evidenced based recommendations for pain control.



I don't think anyone is disputing analgesia is needed.

I don't think anyone disputes that more medication is needed for transport compared to sitting in the ED or other non surgical environment.

The only thing being debated is how to go about providing the analgesia.  



18G said:


> I am not a fan of propofol only in the transport environment either..



Because of the limitations of the drug or the limitations of the dose?

Just to point out, at the proper dose you can cut open somebody's body with a razor blade and push, pull, press, and remove internal tissue. I am thinking that hurts more and causes more distress to a patient than transport? 




18G said:


> I picked up an intubated patient on propofol with the line running directly into the IV catheter. No saline lock, no other IV access, no fluids at all. I was thinking wth? Really? Propofol on a critical patient and no fluids hanging?  This is what we deal with sometimes and adds to the time it takes to roll out the door with the patient.



Ok, you are an expert at taking care of a patient during transport. The sending facility/physician probably is not. 

So if the patient needs an extra line, then start one. If the patient needs intubated, do it.

It adds time to transport? So what? Isn't the point of critical care to bring special knowledge and tools to a patient that needs them?

If getting out the door is the only measure of success, and added care is secondary, why not just put the patient in a BLS ambulance or a taxi?

Why should a service be reimbursed at a critical care rate if nothing more than ALS transport is provided?


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## 18G (Dec 1, 2011)

A great (short) podcast and points from Dr. Weingart from EmCrit.org on this very topic.

http://emcrit.org/podcasts/sedation-tirade/


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## 18G (Dec 1, 2011)

Veneficus said:


> Because of the limitations of the drug or the limitations of the dose?



Mainly limitation of dose. Granted in the one state I work I am permitted to titrate as needed but in the other state I work I am not even allowed to transport propofol and need an RN onboard. Not sure why, but that is the way it is. 

The standard dose for post-intubation sedation with propofol is 5-50mcg/kg/min. Even approaching 50mcg/kg/min I've had patient's that required Ativan in the transport environment. If they had fentanyl for pain I think we could have managed on a lower dose and not needed the Ativan but that was physician ordered. 

What dosage range are you referring to?


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## CANMAN (Dec 1, 2011)

I have seen patients on 100mcg/kg/min before without issues


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## Veneficus (Dec 1, 2011)

18G said:


> A great (short) podcast and points from Dr. Weingart from EmCrit.org on this very topic.
> 
> http://emcrit.org/podcasts/sedation-tirade/



Ok, I listened to it.

I didn't hear anything ground breaking.

He mentioned sedation and pain control in the ED environment. 

I am going to make a wild assumption that since general anesthesia is not provided routinely if it is permitted at all in US EDs, that he was speaking about environment specific techniques. He said multiple times using propofol for sedation, not for anesthesia. 

I then heard his opinion on a method he likes to employ in both the ED and ICU.

But here is the rub,

I spend a great deal of time with anesthesia and surgery. In this country, all intensivists are anesthesiologists. No surgical, pediatric, and for whatever reason EM intensivists. 

So I am going to share what I am constantly told. There is no one right method to provide anesthesia. There is only a goal. I have even heard of case reports of anesthesiologists providing regional anesthesia for cardiac bypass surgery with success.

Now I am going to deduce that provider comfort has a lot to do with choice of methods. 

I am of the mind that since the intensivists here provide general anesthesia for surgery all day long, they are quite comfortable doing it in all environments. Whether they are on an ambulance providing critical care or emergency response, whether in surgical theatre, whether in the ED, and/or ICU. (of course they are also big fans of barbiturates here too.)

So when you are constantly employ the same method and have no crazy restrictions from a joint commision on how you practice medicine and where, because you are an expert, not them, you tend to use and advocate what you are comfortable with.

Now I have experience in both the field and the hospital. One thing that I advocate in the field is: simple is better. Less batteries, less moving parts, less complex pharm calculations and administration, Less worrying about interactions, less long term effects and considerations of.

In summary, less is more.

Now I understand that there are limitations of what can be practiced, where, and how in the US. But it doesn't change my opinion or advocacy for making things less complex, even if it means going against convention.

I am sure if I thought it was better, I could argue for epidural anesthesia, but it is a bit more complex and risky procedure than a peripheral IV line.

But preference doesn't make any option less right.


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## Veneficus (Dec 1, 2011)

18G said:


> Mainly limitation of dose. Granted in the one state I work I am permitted to titrate as needed but in the other state I work I am not even allowed to transport propofol and need an RN onboard. Not sure why, but that is the way it is.
> 
> The standard dose for post-intubation sedation with propofol is 5-50mcg/kg/min. Even approaching 50mcg/kg/min I've had patient's that required Ativan in the transport environment. If they had fentanyl for pain I think we could have managed on a lower dose and not needed the Ativan but that was physician ordered.
> 
> What dosage range are you referring to?



For general anesthesia, the induction dose is listed as: 2-2.5 mg/kg. Anesthetic infusion at 100-300mcg/kg/min

sedation dose is listed as: 20-50% of the dose required for general anesthesia.


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## Veneficus (Dec 1, 2011)

I just confirmed with a US EM physician that the only thing preventing the use of anesthetic dose propofol is individual hospital policy and physician preference.


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## 18G (Dec 1, 2011)

Veneficus said:


> Ok, I listened to it.
> 
> I didn't hear anything ground breaking.
> 
> He mentioned sedation and pain control in the ED environment.



No, it wasn't ground breaking but for some it would probably be perceived as such. I just want to make sure my patient is comfortable and best managed. And I can tell you I would be shocked to see a patient on a propofol drip at 200-300mcg/kg/min for IFT. That's not gonna happen around here. 

Propofol and fentantyl seem to be the combo with best results.


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## CANMAN (Dec 1, 2011)

I have seen Fentanyl/Versed gtt more often then Propofol and Fentanyl and normally the main issue I see with hospitals not utilizing propofol is cost vs. fent/versed. Like I said I have transported a few 100mcg/kg/min patients on propofol IFT before so it does happen. I have also seen patients in the 1,000 to 2,000mcg/hr dosage range for Fentanyl gtt as well.


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## Veneficus (Dec 1, 2011)

18G said:


> Propofol and fentantyl seem to be the combo with best results.



Based on what?


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## usafmedic45 (Dec 1, 2011)

> And I can tell you I would be shocked to see a patient on a propofol drip at 200-300mcg/kg/min for IFT. That's not gonna happen around here.



I feel sorry for you. 



> Based on what?



Anecdotal evidence would be my guess.


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## Veneficus (Dec 2, 2011)

usafmedic45 said:


> Anecdotal evidence would be my guess.



Even still, wouldn't you have to try multiple ways to determine something is "best?"

or at least seek multiple opinions?


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## 18G (Dec 2, 2011)

Veneficus said:


> Based on what?



Based on the research I have done and studies on post-intubation sedation. The majority advocate strongly for analgesia and seem to recommend fentanyl as the initial drug of choice given it's good hemodynamic profile. That's not to say nothing else is superior or can work just as well. I'm definitely not saying that at all. 

I posed the question about how to best manage post-intubation in an IFT environment with the drugs and scope of practice we have as Paramedics. I admit I am still new at managing these patient types which is why I am desiring the knowledge from you guys. Everything I read on the subject says very strongly analgesia is not really an option and needs to be provided, yet ED practice around here foregoes the analgesia so I am confused as to why that would be. I'm gonna have to ask next case I get.  

And not much talk on use of a paralytic agent. What are common practices in the IFT world when deciding to use paralytics for intubated patients?


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## Veneficus (Dec 2, 2011)

18G said:


> Based on the research I have done and studies on post-intubation sedation. The majority advocate strongly for analgesia and seem to recommend fentanyl as the initial drug of choice given it's good hemodynamic profile. That's not to say nothing else is superior or can work just as well. I'm definitely not saying that at all.
> 
> I posed the question about how to best manage post-intubation in an IFT environment with the drugs and scope of practice we have as Paramedics. I admit I am still new at managing these patient types which is why I am desiring the knowledge from you guys. Everything I read on the subject says very strongly analgesia is not really an option and needs to be provided, yet ED practice around here foregoes the analgesia so I am confused as to why that would be. I'm gonna have to ask next case I get.
> 
> And not much talk on use of a paralytic agent. What are common practices in the IFT world when deciding to use paralytics for intubated patients?



If I could offer some perspective?

First off, evidence based medicine is BS. Rather, our implementation is BS. Some things simply cannot be studied. Some things have so few studies that when the subject is taken as a whole, there is no conclusive evidence. But the very worst of it is, most of the common practices are based off of expert opinion and there is a larger evidence requirement to change those expert opinion practices than there was to institute them.

When researching IFT, emergency medicine especially, and in general all forms of medicine, you must remember that none of these experts talk to each other regularly. 

This means nepho has things figured out than anesthesia doesn't and every combination of disease and specialty falls into this category. Without being derogatory of EM, I have noticed when looking at it from the outside, that they are guilty of the exact same sins as many paramedics. They don't think anyone else understands emergent patients or nothing done outside of the emergency realm applies.

This type of thinking is dangerously wrong. Principles of medicine do not change because of environment.

If you are truly interested in what is best practice, in therory or practice, you must investigate what others are doing and know that may be related. 

Said simply, you cannot do or conclude what is best by reading and listening only to EM. The type of medicine they practice is not exclusive and not comprehensive. It is the jack-of-all trades master of none. So you must look at what the masters say too.

Otherwise, you hold as gospel "best practice" without knowing what else is out there to really draw that conclusion.

As you further add restrictive criteria, you limit your knowledge, effectiveness, and usefullness.

an example:

Making sure patients are not in pain>making sure patients in ED are not in pain> making sure IFT patients are not in pain> making sure emergent patients are not in pain> making sure patients in your area are not in pain> making sure your patients in your area are not in pain based on your previous local practices.

If you really to get to the bottom of pain management, rather than looking at EM which has a culture or not managing pain properly, I really suggest you look to anesthesia or PM&R as that is their very focus. With a culture of making sure the patient is not in pain.

Is it your job to research and make recommendations to your medical director on managing pain? Some will say yes, some no. But isn't it your job to do what is best for your patient? Isn't that why they put their trust in you? 

What is best for them may be academic. It may be administrative. It may be doing the leg work so all of your future patients have better care than previous ones.

A professional constantly seeks to improve. A tech seeks to master what is currently being done. 

Which do you want to be? How about both?

The drugs and scope you have is easily changed. The obstacle is breaking down the barriers to change.

As a perfect example, 

perhaps you have been on a 911 call to a Dr. office. Said doctor may not know or want you to perform certain treatments, which you know will help and your medical director has standing orders for.

So when you get in the truck, the patient becomes indirectly that of your medical director. In absence of doctor to doctor consultation, i will bet my last $ you will follow your medical director's orders if you believe that treatment in the best interest of said patient.

In this discussion, if your medical director has authorized you to use propofol, there is nothing stopping her from ordering it at a more effective dose. If the transfering ED has an issue with it, as soon as the patient is in your care, they are in the care of your medical director, and her orders apply unless there is an extenuating circumstance or patient presentation.

I have heard of states that restrict paramedics from using certain medications. But I have never heard of any state restricting a dose.

Also specialty critical care transport falls under different guidlines than emergent EMS, which is what most state guidlines are for.


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## usafmedic45 (Dec 2, 2011)

> And not much talk on use of a paralytic agent. What are common practices in the IFT world when deciding to use paralytics for intubated patients?



Minimize their use whenever possible.  They honestly should never be used outside of the OR except when immediately intubating or as a last ditch adjunctive measure in status epilepticus (only in extremis, only in hospital, only in conjunction with EEG monitoring and with either propofol or barbiturates to bring the seizure activity to a halt).  They have no place in long-term ventilator patients for the most part because it's just going to make weaning the patient later more difficult.  If you have the "need" to paralyze, it means you need to go with a higher dose of sedation not a dose of paralytic.


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## usafmedic45 (Dec 2, 2011)

> I have heard of states that restrict paramedics from using certain medications. But I have never heard of any state restricting a dose.



Maryland.  Gotta love cookie cutter protocols.


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## usafmedic45 (Dec 2, 2011)

> The majority advocate strongly for analgesia and seem to recommend fentanyl as the initial drug of choice given it's good hemodynamic profile.



Are they recommending it as a combination with propofol or with a sedative like lorazepam? I've seen studying discussing its efficacy as a combo with benzos but not with propofol.


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## DV_EMT (Dec 2, 2011)

I had always heard that dilaudid and propofol was a main cause of "amnesia" effects ... hence where the name "milk of amnesia" care from. ^_^


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## triemal04 (Dec 4, 2011)

Veneficus said:


> Or you can just add fluid?
> 
> Please see my earlier post in regards to liver issues.
> 
> ...


Sure, there's things you can do to negate that; just saying that there are times when using just one drug is not the best course; if you can't use an anesthetic or sedative in the proper amounts then mixing in an analgesic, especially one with minimal effects on circulation seems quite appropriate.

And I believe propofol is notorious for causing liver problems, albeit in higher doses/over longer periods of time.


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## triemal04 (Dec 4, 2011)

usafmedic45 said:


> Are they recommending it as a combination with propofol or with a sedative like lorazepam? I've seen studying discussing its efficacy as a combo with benzos but not with propofol.


There's several studies that have looked at using propofol in conjunction with fentanyl/versed/narcotic or benzo x; generally they just say that it works well and often requires lower doses of each compared to using just one med.  I haven't seen or found any that explicitly say that it's better to use both or one, though a few studies have shown that there were fewer adverse effects with a combo.  

And some showed the opposite.  Go figure.

http://www.sciencedirect.com/science/article/pii/S0016510704003499    Looked at propfol vs a combo with lower propofol doses; no difference in outcomes/level of sedation.

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=344597  Same thing.  Don't have access to the whole study, so who knows if the dose of propofol was even appropriate.

http://www.medscape.com/viewarticle/750514  Actually looked at propofol vs versed, but both arms of the study were also fentanyl; no adverse outcomes or good levels of sedation.


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## boingo (Dec 4, 2011)

usafmedic45 said:


> Minimize their use whenever possible.  They honestly should never be used outside of the OR except when immediately intubating or as a last ditch adjunctive measure in status epilepticus (only in extremis, only in hospital, only in conjunction with EEG monitoring and with either propofol or barbiturates to bring the seizure activity to a halt).  They have no place in long-term ventilator patients for the most part because it's just going to make weaning the patient later more difficult.  If you have the "need" to paralyze, it means you need to go with a higher dose of sedation not a dose of paralytic.



I would argue that the asthma patient that is intubated would benefit from short term paralysis, let the vent do the work.  This is not a substitute for inadequate sedation, more to rest the patients muscles.


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## Veneficus (Dec 4, 2011)

triemal04 said:


> And I believe propofol is notorious for causing liver problems, albeit in higher doses/over longer periods of time.



Generally at the anesthetic dose >8 hours.

But in the EMS and transport environment, it is a non issue unless you are flying across an ocean. In which case other means will have to be used.


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## Basermedic159 (Feb 2, 2012)

18G said:


> 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.
> 
> 
> 
> ...



I think some docs don't provide analgesia sometimes, because their mindset may be-"Ah, they have versed on board and propofol, so by the time they wake up they wont even remember they were in pain." 

I have seen ED docs order nothing but sucs and a tube for combative and or non-compliant patients. I mean no versed, propofol, etomidate, fentanyl, nothing but a paralytic. I know we get pt's we just want to punch, but I cant imagine being paralized, knowing and hearing whats going on and then have a tube shoved down my throat.!.!

The docs later ordered versed, 'probably' for the amnesia effect....


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## jjesusfreak01 (Feb 22, 2012)

Somewhat related scenario/question: 

I had an IFT BLS level call the other day with an elderly DNR (new) post cath CVA patient being discharged to an SNF. He was in obvious pain when we moved him onto our stretcher, and as we walked through the hospital he was in obvious excessive (10/10 imo, he was posturing, grimacing, and yelling) abdominal pain (his report) every time we hit a bump in the hallway. He was able to answer questions appropriately and when asked whether he wanted to return to the ER (we hadn't left the ER bay) or take the trip, he only replied that he wanted to be left still to sleep. He appeared exhausted from the continued pain. I do not believe that he had been given any pain (or anxiety) meds prior to discharge or for use at the facility. It was obvious to me that transporting him in his condition would have led him to have about 40 minutes of excruciating pain. I took him back into the ER for re-evaluation of pain. He was re-discharged the following day, though I don't have any details about his care after I left him in the ER. 

So, here's the problem. I know I caused a @#$%storm in the ER, for the pts nurse, likely for the doctor, for myself, and for my company. In retrospect, I think I should have refused to take him out of his bed without something for pain/anxiety. I'm looking for some input on whether I should have just done the transport or whether I was right to take him back to the ER? This is the first call I have ever refused to transport, but in my mind I would have been causing him substantial harm by transporting him. Any and all thoughts welcome. Thanks.


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## TatuICU (Feb 23, 2012)

Different setting but in our ICU, pt's are typically put on a combo of versed and fentanyl.  

A high enough dose of propofol can have a potent anesthetic effect as well though. Typically we have our short timers on the diprivan with orders for morphine q whenever for a FLACC scale above whatever.


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## DrankTheKoolaid (Feb 23, 2012)

jjesusfreak01 said:


> Somewhat related scenario/question:
> 
> I had an IFT BLS level call the other day with an elderly DNR (new) post cath CVA patient being discharged to an SNF. He was in obvious pain when we moved him onto our stretcher, and as we walked through the hospital he was in obvious excessive (10/10 imo, he was posturing, grimacing, and yelling) abdominal pain (his report) every time we hit a bump in the hallway. He was able to answer questions appropriately and when asked whether he wanted to return to the ER (we hadn't left the ER bay) or take the trip, he only replied that he wanted to be left still to sleep. He appeared exhausted from the continued pain. I do not believe that he had been given any pain (or anxiety) meds prior to discharge or for use at the facility. It was obvious to me that transporting him in his condition would have led him to have about 40 minutes of excruciating pain. I took him back into the ER for re-evaluation of pain. He was re-discharged the following day, though I don't have any details about his care after I left him in the ER.
> 
> So, here's the problem. I know I caused a @#$%storm in the ER, for the pts nurse, likely for the doctor, for myself, and for my company. In retrospect, I think I should have refused to take him out of his bed without something for pain/anxiety. I'm looking for some input on whether I should have just done the transport or whether I was right to take him back to the ER? This is the first call I have ever refused to transport, but in my mind I would have been causing him substantial harm by transporting him. Any and all thoughts welcome. Thanks.



You did the right thing by bringing this patient back, IMHO.  I personally would have had him medicated prior to even accepting him, since I would not have been able to medicate him and then dump him onto a skilled unit.  DNR or not there is no excuse for a patients pain not to be addresses.


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## TatuICU (Feb 23, 2012)

Corky said:


> DNR or not there is no excuse for a patients pain not to be addresses.



Exactly. Hell, a DNR should give the provider a lot more leeway to be even more aggressive with pain management, not the other way around.


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## jjesusfreak01 (Feb 23, 2012)

TatuICU said:


> Exactly. Hell, a DNR should give the provider a lot more leeway to be even more aggressive with pain management, not the other way around.



I mentioned the DNR to give an idea of how his condition has been perceived by the doctors, IE, that he has moved from being functional to now essentially palliative. I agree that at this point they shouldn't have any reason not to snow him over with meds, at least for transport.


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## STXmedic (Feb 23, 2012)

Agreed with Corky. One of the first things I do on a patient discharge is ask them about their pain and get them pre-medicated by their nurse. Very rarely do I have a nurse object. In your patient, I'd side with you 100%. Over an hour of severe, unnecessary pain is just cruel. DNR or not.


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## MedicBrew (Feb 24, 2012)

Basermedic159 said:


> I think some docs don't provide analgesia sometimes, because their mindset may be-"Ah, they have versed on board and propofol, so by the time they wake up they wont even remember they were in pain."
> 
> I have seen ED docs order nothing but sucs and a tube for combative and or non-compliant patients. I mean no versed, propofol, etomidate, fentanyl, nothing but a paralytic. I know we get pt's we just want to punch, but I cant imagine being paralized, knowing and hearing whats going on and then have a tube shoved down my throat.!.!
> 
> The docs later ordered versed, 'probably' for the amnesia effect....



I’ve also seen this and I believe it to be criminally negligent!!  I’ve also seen the same said physician gag a patient with a stack of 4X4’s and 2” tape for cursing in HIS ED. 

Back on topic, what effects are you seeing or rather not seeing that would lead you to believe that you patients are not properly sedated? Elevated HR, B/P, EtCo2, excessive movement, etc? I’ve transported several vent patients on propofol and have never had an issue. Simply titrate to effect if you have the ability. 

I’ve also been a recipient of a propofol induced intubation and have zero recall of the incident.


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## Fish (Feb 24, 2012)

MedicBrew said:


> I’ve also seen this and I believe it to be criminally negligent!!  I’ve also seen the same said physician gag a patient with a stack of 4X4’s and 2” tape for cursing in HIS ED.
> 
> Back on topic, what effects are you seeing or rather not seeing that would lead you to believe that you patients are not properly sedated? Elevated HR, B/P, EtCo2, excessive movement, etc? I’ve transported several vent patients on propofol and have never had an issue. Simply titrate to effect if you have the ability.
> 
> I’ve also been a recipient of a propofol induced intubation and have zero recall of the incident.



THis sort of thing would have you in the Medical DIrectors office in no time, RSI without Sedatives is a no no no


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