Let's Talk About Sedation

[Veneficus]

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It is also my opinion if providers are using outdated practices they are rightfully financially responsible for damages including pain and suffering.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

 

[triemal04]

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?

 

[jjesusfreak01]

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.

 

[mycrofft]

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.

 

[Veneficus]

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.

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.

 

[usalsfyre]

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.

 

[Veneficus]

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.

 

[18G]

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.

 

[Veneficus]

food for thought.

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.

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?

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?

 

[18G]

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

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

 

[18G]

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?

 

[CANMAN]

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

 

[Veneficus]

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.

 

[Veneficus]

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.

 

[Veneficus]

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.

 

[18G]

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.

 

[CANMAN]

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.

 

[Veneficus]

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

Based on what?

 

[usafmedic45]

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.

 

[Veneficus]

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?