# Sedation after ROSC



## harold1981 (Nov 10, 2016)

How do you feel about sedating a patient who is waking up post-CPR with 2,5 to 5mg Versed?

The rational behind this would be to reduce anxiety, reduce oxygen consumption, reduce awareness and prevent memories from the resuscitation setting. 
I know that there are a few contraindications, eg hypotension, shock, brain injury, drugs/alcohol intox and muscular weakness.
I have had different medics disagree with the suggestion of sedating the awakening patient after ROSC, stating that I don´t want to knock down their respiratory drive. However, if respiratory depression or apnea reoccurs, we are there to resume ventilations with a BVM immediately (besided the patient is often still intubated). 
Also, if need arises, the effect of the midazolam can be antagonized in the ED. And...we are giving a small dose, I believe they use 25mg in the OR as an anesthetic induction. 

Please share your thoughts on this matter. Also, how do you feel about Midazolam in combination with IV fentanyl post-ROSC for the purpose of reducing the pain and discomfort of an AMI and chest compessions?


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## VFlutter (Nov 10, 2016)

I do not think I would be giving a patient who just had cardiovascular collapse Versed. And I have never seen anyone induce anethesia with 25mg of Versed. There are better options like ketamine.


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## NomadicMedic (Nov 10, 2016)

For a patient that had ROSC and is now agitated, not receiving a vasopressor and if you don't have Ketamine, a _judicious_ use of Versed and Fentanyl seems entirely appropriate. 

Hell, I'd like some sedation and analgesic on board if I was just resuscitated.


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## Summit (Nov 10, 2016)

Uh... what??? 25mg?

And we do not give any med under the operating philosophy of "don't worry they can reverse that in the ED."

Determine the actual need to sedate. Just waking up after ROSC does not constitute a need and we do not blanket issue sedatives to prophylacticly reduce metabolic demand. We do in some circumstances.


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## VentMonkey (Nov 10, 2016)

harold1981 said:


> How do you feel about sedating a patient who is waking up post-CPR with 2,5 to 5mg Versed?


I feel like if it was me waking up I would want some sedation.


harold1981 said:


> I believe they use *2.5mg* in the OR as an anesthetic induction...Also, how do you feel about Midazolam in combination with IV fentanyl post-ROSC for the purpose of reducing the pain and discomfort of an AMI and chest compessions?


Perhaps you heard it wrong, or forgot the period. Us medical folk tend to be kinda stickler-ish about these sort of dosing errors, especially something such as 2.5 vs. 25 mg of Versed.

Anyhow, my service currently doesn't carry Ketamine, but like @Chase mentioned, assuming there's no cardiovascular collapse present, and the patient is hemodynamically stable, beginning to buck/ over breathe the ETT, tear, their HR spikes, etc., etc., etc., it seems inhumane _not _to provide proper/ adequate sedation and pain management.


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## Handsome Robb (Nov 10, 2016)

If they're intubated you damn well better be sedating them. 


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## VFlutter (Nov 10, 2016)

Handsome Robb said:


> If they're intubated you damn well better be sedating them.
> 
> 
> Sent from my iPhone using Tapatalk



I totally agree however with a post-arrest patient I would be extremely cautious. A little temporary discomfort may be preferable to another arrest. Post ROSC patients can be like those patients whom arrest immediately upon induction, they may be dependent on their sympathetic tone. I would choose the most cardiac stable agent I had available and Versed does not fit that role.


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## Summit (Nov 10, 2016)

Chase said:


> I totally agree however with a post-arrest patient I would be extremely cautious. A little temporary discomfort may be preferable to another arrest. Post ROSC patients can be like those patients whom arrest immediately upon induction, they may be dependent on their sympathetic tone. I would choose the most cardiac stable agent I had available and Versed does not fit that role.



Agree with this. 2 days ago saw this exact thing. ROSC now starting to move around a bit with ET tube in... 2mg of versed and  next thing you know we are pushing 0.5mg epi  in the CT scanner and starting a levophed drip.

In this case the justification was the necessity for a good CT study (pt needed it).

Remember, we would like some assessment of the type of responsiveness if possible, particularly if they have purposeful movement. This drives the decision to cool the patient.

Plenty of intubated ROSC patients have very little agitation and wouldn't need sedation (and get cooled).

Some didn't get tube and wake up and don't need sedation.

And everything inbetween, some warran sedation.


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## Handsome Robb (Nov 10, 2016)

Chase said:


> I totally agree however with a post-arrest patient I would be extremely cautious. A little temporary discomfort may be preferable to another arrest. Post ROSC patients can be like those patients whom arrest immediately upon induction, they may be dependent on their sympathetic tone. I would choose the most cardiac stable agent I had available and Versed does not fit that role.



I definitely agree with you there. I am not a fan of versed. 

We actually have an SOC and people have had to use it for intra-arrest ketamine for awareness during resuscitation with the Lucas. 


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## Carlos Danger (Nov 10, 2016)

I'm aware of the trend of using versed even intra-arrest in order to induce amnesia. There have been more than a few case studies of patients having distressing memories of their resuscitation, even while pulseless. I think it is a really bad idea, personally. I cannot see how it would not negatively affect the perfusion pressure your are trying to get the sick heart to generate and maintain in the coronaries and the brain, in at least some patients. 

Post-arrest? I mean if they need it, sure. If they are tubed and hemodynamically stable and showing signs of awareness and agitation, treat them like any other sick, intubated patient. But like Summit explained above, you have to assess each patient's individual needs. You wouldn't go blindly giving every ICU patient that you transport the same exact sedation regimen, why would you do it in the immediate post-arrest setting? 

Versed is actually very cardio stable - probably the most stable choice, in fact (ketamine is actually a direct myocardial depressant, and is not a reliable amnestic in small doses). The problem is that these patients are often so tenuous that even "stable" drugs can threaten their ability to maintain perfusion. 

Go spend a day in the electrophysiology suite and watch how little sedation people get for cardioversions and pacemaker placements and battery changes. If you are there for a busy day you'll see at least one patient almost arrest (or actually do so) after 0.5mg of versed. You'll see lots of other patients squirming and moaning but have their BP drop dramatically from even very small doses of sedatives.


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## Carlos Danger (Nov 10, 2016)

Also not to get off topic, but I felt like it was only fair to the OP to mention that 25mg of versed actually would be a reasonable induction dose. 0.2 - 0.3 mg/kg is the dose that you see in the books. That could easily work out to around 25mg, depending on the patient weight.

Bear in mind, *no one* uses versed for induction anymore, for numerous reasons. I don't even know if it was ever really common, but I think the setting it may have been used in at least occasionally was sick cardiac patients, precisely because it is so cardio stable.

So technically, the OP isn't wrong about that


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## Nova1300 (Nov 10, 2016)

One more point here.  Generally, hypothermia protocols have only been shown to benefit patients who suffer out-of-hospital cardiac arrest and subsequently remain comatose after resuscitation.   

If you load a patient up on versed simply because you resuscitated them, you take away the ability of the physician to make the call about hypothermia.  

If the patient needs it because they are obviously agitated or have discomfort, I would be supportive.  If you are giving versed to a patient simply because you are worried about post-resuscitation recall, I think you may be interfering with future medical decision making.  

And not the "don't give pain meds to abdominal pain and skew the exam" nonsense type of medical decision making.  


This is something that could potentially matter.


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## VentMonkey (Nov 10, 2016)

Sort of still on topic, and perhaps @Nova1300 or somebody can elaborate, but this can also dictate one's decision to perform, or with hold an RSI in the field.  If said patient is on the cusp of being able to protect their own airway, it may inhibit a proper neuro assessment on arrival at the ED.

Oftentimes we as providers, especially when newer, and/ or less experienced may not factor in the need for the receiving facility to perform such an assessment over the "sexiness" of performing an RSI in the field.

Now clearly, there are times when it's very much warranted, just keep in mind there are times when it can very much wait. I think this is worth mentioning, but again, boils down, and reflects a strong clinical assessment when to know with hold any procedure versus when not to.


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## StCEMT (Nov 11, 2016)

Remi said:


> Versed is actually very cardio stable - probably the most stable choice, in fact (ketamine is actually a direct myocardial depressant, and is not a reliable amnestic in small doses). The problem is that these patients are often so tenuous that even "stable" drugs can threaten their ability to maintain perfusion.


Never have had to sedate someone since the only pt with ROSC I have had was already in the ER. So when it comes to sedation and K vs V, what would your (slightly expanded on the above quote) thoughts be? I carry both.


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## Carlos Danger (Nov 11, 2016)

StCEMT said:


> Never have had to sedate someone since the only pt with ROSC I have had was already in the ER. So when it comes to sedation and K vs V, what would your (slightly expanded on the above quote) thoughts be? I carry both.



I think in the small doses that you'll probably be using in this setting, versed is probably a more reliable amnestic.


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## medichopeful (Nov 11, 2016)

Remi said:


> Versed is actually very cardio stable - probably the most stable choice, in fact (*ketamine is actually a direct myocardial depressant*, and is not a reliable amnestic in small doses).



My understanding was that in general, that the opposite was in fact true: most of the time, it acted as a stimulant, causing tachycardia and hypertension, along with increased CO.

http://reference.medscape.com/drug/ketalar-ketamine-343099#4

Of course, in the spirit of medicine contradicting itself, another source seems to suggest that hypotension and bradycardia are COMMON side effects, along with hypertension and tachycardia:

https://online.epocrates.com/drugs/196905/ketamine/Adverse-Reactions

Do you have sources that discuss this more?  Or that discuss the direct myocardial depressant properties?  I had always been under the impression that ketamine didn't (generally) depress anything cardiovascularly.


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## Carlos Danger (Nov 11, 2016)

medichopeful said:


> My understanding was that in general, that the opposite was in fact true: most of the time, it acted as a stimulant, causing tachycardia and hypertension, along with increased CO.
> 
> http://reference.medscape.com/drug/ketalar-ketamine-343099#4
> 
> ...



_Most _of the time it does act as a stimulant. Ketamine acts directly on the myocardium to cause a negative inotropic effect. I don't recall the mechanism. It also acts as a central stimulant and reduces the re-uptake of norepi. This sympathetic stimulation usually has more of an effect than the myocardial depression, so the net result is usually the  increase in HR and BP that we are all familiar with.

However, someone who is in shock may already be "maxed out" on the support that their endogenous catecholamine stores can provide. In this setting, the decreased re-uptake of norepi may not result in increased concentrations, and you get a crashing patient.

This is not a common result of ketamine administration, but in some populations it should definitely be a consideration. Anyone with severely depressed myocardial function or who has been critically ill for several days are the ones I would be hesitant to use a large dose of ketamine in.

I know this is covered in some detail in some anesthesia and anesthesia-oriented pharm texts. I just did a quick Google search and didn't see much that discusses this thoroughly.


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## harold1981 (Nov 12, 2016)

On our side of the pond Midazolam is widely used as an pre-induction agent in the OR. The dosis is 0,2 to 0,3 mg/kg. As it is a cardiopulmonary stable drug, it tends to be a good option in patients with pre-existing cardiopulmonary disease. 
In the prehospital setting our protocols provide for 2,5 to 5mg of midazolam IV after ROSC in case of agitation, in combination with fentanyl if pain from mechanical compression is suspected. We don´t practice cookbook-medicine, so offcourse we will be looking at the heamodynamic stability and respiratory state of each patient vs the benefits of sedation and/or analgesics. However many medics are reluctant to sedate post-resus.  
We also have a protocol for terminal asphyxia, where we give 25mg midazolam IV, for example in the case of massive lungbleed or carotid blow out syndrome, in the context of terminal sedation.


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## SpecialK (Nov 12, 2016)

I have only seen one or two people completely regain consciousness after ROSC and they've had very short resuscitations.  

If the patient fully wakes up and is in pain, agitated or restless then I don't see a problem with titrating 10-20 mcg of fentanyl with 1-2 mg of midazolam to settle them.

Patients who remain unconscious are generally intubated and will be given sedation and long acting neuromuscular blockade routinely if intubated with RSI, or if they begin to wake and haven't been intubated with RSI.


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## VFlutter (Nov 12, 2016)

harold1981 said:


> We also have a protocol for terminal asphyxia, where we give 25mg midazolam IV, for example in the case of massive lungbleed or carotid blow out syndrome, in the context of terminal sedation.



Just curious how often are you seeing CBS that you actually need a protocol for it? I am very surprised you give terminal sedation. Who makes the decision what is "terminal"?


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## NomadicMedic (Nov 12, 2016)

Mechanical CPR devices often provide sufficient perfusion that a high quality CPR recipient will awaken enough to answer questions with blinks and track the team around the room.

_"A patient making purposeful movements, even being awake and alert while in cardiac arrest, can have profound emotional and psychological implications on the patient as well as the paramedic providers caring for them."_

I believe not sedating these patients is cruel, akin to a paralytic with no concurrent sedation and analgesic.


Rice DT, et al. CPR induced consciousness: It’s time for sedation protocols for this growing population. Resuscitation (2016), http://dx.doi.org/10.1016/j.resuscitation.2016.02.013


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## harold1981 (Nov 12, 2016)

I have never seen it in nine years, and only once did I do an interfacility transfer in which the attending physician instructed us (on a writen statement) that a carotid blowout was imminent and that sedation was going to be the only course of action. Our protocols cover 17million people at a national level, so I can imagine that it happens quite a few times a year. We have three criteria: there must be a individual treatment plan in place, which is signed by the attending physician. People with terminal cancer in the lungs, head and neck, who have a high risk for CBS or lungbleeds tend to have these documents with them, which also include a DNR/NTBR-order and a statement that the prognosis is infaust. Second, based on our assessement we must establish that the patient is asfyxiated and will die as a result of this. Third, we must establish that the patient is suffering unbearably. If all three criteria are satisfied we can proceed and provide acute palliative care by sedating the patient while he dies.

Emergency care is provided by us (EMS). Primary health care is provided primarily by GP´s, 24/7. GP´s on duty have emergency vehicles too. In the unlikely event that that we arrive at an emergency situation requiring palliative sedation, and no individual treatment plan is in place, we may call in the help of a GP, while we push 5mg midazolam based on our agitation-protocol, and repeat with a 2,5mg dose every five minutes untill a GP arrives. In every case, the call will be evaluated by our medical director.


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## RRTMedic (Nov 13, 2016)

harold1981 said:


> How do you feel about sedating a patient who is waking up post-CPR with 2,5 to 5mg Versed?
> 
> The rational behind this would be to reduce anxiety, reduce oxygen consumption, reduce awareness and prevent memories from the resuscitation setting.
> I know that there are a few contraindications, eg hypotension, shock, brain injury, drugs/alcohol intox and muscular weakness.
> ...



Sedate the patient if they are combative with altered mental status or not sedating them would potentially result in an extubation.  Had a situation like this....post cardiac arrest after 30 minutes of V-fib... patient started sitting up and swinging his arms and was obviously out of his mind... My partner gave him 5 mg of versed and that put him down nicely.... then he coded again 5 mins later. Then again he was having a huge anterior-septal STEMI.


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## Carlos Danger (Nov 13, 2016)

DEmedic said:


> Mechanical CPR devices often provide sufficient perfusion that a high quality CPR recipient will awaken enough to answer questions with blinks and track the team around the room.
> 
> _"A patient making purposeful movements, even being awake and alert while in cardiac arrest, can have profound emotional and psychological implications on the patient as well as the paramedic providers caring for them."_
> 
> ...



Whether or not it is "cruel" depends on the specifics of the situation. Of course we should try to make folks comfortable where possible, but it isn't always the top priority, especially when you are talking about brittle patients in true life-and-death scenarios. Even in elective anesthesia there are times when the patient just has to endure some discomfort. Verbal reassurance actually tends to go a long way. Also, just because someone has some awareness doesn't mean they are necessarily even distressed by it.


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## Summit (Nov 13, 2016)

If we sedate people during resuscitation, it complicates post ROSC neuro assessment so we could end up cooling people who don't need to be cooled, or delaying cooling.

I've had times where I swear the patient was looking at me during compression... not sure if it was really so. It's weird, like that scene in Bringing Out the Dead.

Hard to figure where to draw the line for comfort. It is easy to draw it at protecting interventions and care. I'd err towards that because a bad memory is something worth living with so you don't lose brain function d/t delayed cooling in order to allow proper neuro assessment, or the complications of unnecessary cooling.


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## TomB (Nov 13, 2016)

It's unnecessary and confounds the neuro exam at a very important time. If there is a return of airway reflexes, extubate.


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## Summit (Nov 13, 2016)

TomB said:


> It's unnecessary and confounds the neuro exam at a very important time. If there is a return of airway reflexes, extubate.


I'd include purposeful movement (which would mean no cooling) and put a caveat for the etiology of the arrest (likely to lose airway again?).


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## TomB (Nov 14, 2016)

We use "obeying commands" rather than "purposeful movement". Too much gray area for the latter. Is grabbing for a tube purposeful? Perhaps, but it's primitive. We've withheld cooling for these patients and they ended up trying to shave with the TV remote (borderline CPC 3 -- long term care arranged at discharged).


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## Summit (Nov 14, 2016)

It depends on who the ICU team is... I've seen this point debated and don't have a solid answer... but now we have TTM at 36C which is easier, has fewer complications, and fewer patients excluded without being inferior to 33C so it is a lot easier to lean towards cooling the neurologically borderline.


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## SpecialK (Nov 14, 2016)

Agreed.  Ideally to avoid neuromuscular blockade in patients who are post-ROSC however if the balance of risk is in favour of doing it, then do it.  A single dose of rocuronium  only lasts about 40 minutes and the time you get the patient off the floor, onto the bed, into the ambulance, drive to hospital, unload, get them inside and everything set up that's 20 to 30 minutes used right there.  A single dose can be reversed in ED too, although I am not a fan of the "it can be undone or wear off" motto but in this case, it's not so bad.


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