Let's Talk About Sedation

[18G]

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?

 

[Veneficus]

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.

 

[usafmedic45]

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.

 

[usafmedic45]

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.

 

[usafmedic45]

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.

 

[DV_EMT]

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

 

[triemal04]

Or you can just add fluid?

Please see my earlier post in regards to liver issues.



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.

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.

 

[triemal04]

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.

 

[boingo]

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.

 

[Veneficus]

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.

 

[Basermedic159]

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.





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.

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....

 

[jjesusfreak01]

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.

 

[TatuICU]

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.

 

[DrankTheKoolaid]

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.

 

[TatuICU]

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.

 

[jjesusfreak01]

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.

 

[STXmedic]

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.

 

[MedicBrew]

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.

 

[Fish]

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