Versed/fentanyl sedation

[StCEMT]

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.

 

[E tank]

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.

 

[Hold My Beer]

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.

 

[StCEMT]

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.

 

[E tank]

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.

 

[Summit]

Monitor etco2

 

[E tank]

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.

 

[StCEMT]

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...

 

[Carlos Danger]

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.

 

[StCEMT]

@Remi what role does lido play in your example?

 

[Carlos Danger]

@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.

 

[StCEMT]

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

 

[SpecialK]

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.

 

[StCEMT]

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.

 

[CTMD]

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?

 

[E tank]

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.

 

[CTMD]

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?

 

[StCEMT]

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.

 

[E tank]

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.

 

[E tank]

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.