Post Intubation Sedation (pre-hospital)

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Rialaigh

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Recently I have been finding myself questioning more and more the post-intubation sedation protocols or guidelines that most systems use for pre-hospital management. Where I currently work we have the option of either Ketamine or a Fentanyl/Versed combo. I am finding Ketamine to be a poor agent for post-intubation (More specifically post-RSI) sedation. I have had to use repeated doses (IV) with little success in keeping the patient comfortable with good ventilation compliance for more than 5-10 minutes. We also have the option of Vec although I am not sold that we should be routinely using that pre-hospital on your "every day" RSI.

My basic understanding is that due to the nature of the environment we are operating in we have several unique challenges for keeping a patient adequately sedated that the ER generally does not have. One being extra stimulation (lights, sirens, being moved or poked). Another being the difficulty of bagging someone with spontaneous respiration's (matching inspiration and expiration in someone after that initial paralytic is worn off). I feel like the second is more of a difficulty now (at least in my personal experience). I currently do not have a vent available to me much less any form of assist control.

So I guess long story short, in an optimal world without a vent (not optimal I know...) what should or could I be using for post-RSI sedation. I am trying to improve my own practice as well as make some changes with our current protocols, several options that have been discussed is adding fentanyl with the ketamine, upping the dosage of ketamine, and utilizing Vec more frequently as a service if the expected time to hospital after the RSI is complete is greater than lets say 20 minutes.


Any advice, comments, knowledge, articles, or otherwise would be greatly appreciated.
 
I am curious as well. I do have a vent available, so I can use assist modes, but I typically use the fentanyl/versed combo as needed. My protocols don't give an exact "give this often" so I just give what I think the patient needs based on his activity. ie if he starts coughing and moving a lot, he needs more sedation.
 
The last three RSI's I have had have required repeat doses post intubation and I do not seem to be getting more than about 8 minutes of sedation per dose, I don't know if this is an anomaly or due to the unique challenges we have.
 
Rialaigh said:
The last three RSI's I have had have required repeat doses post intubation and I do not seem to be getting more than about 8 minutes of sedation per dose, I don't know if this is an anomaly or due to the unique challenges we have.
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8 minutes doesn't sound unreasonable. When I worked ground I would typically give fentanyl after intubation with Ketamine and Roc. Follow up sedation was typically every 5 minutes, fentanyl->fentanyl-> ketamine-> repeat. I had good success.
 
What is your dosing? What are your adjuncts? Why do you not want to use paralytics? What are your goals of sedation? What do you consider non-compliant to ventilation?

Why have your patients been RSI'd, are they respiratory failure who is hypoxic or hypercapnic, are they traumatic head bleeds, are they on stimulant medications?

Certainly this is most relevant to inpatient critical care, less to the ED, and much less in pre hospital, but sedation simply to be intubated and vented does not mean complete unconsciousness and unresponsiveness. Take the following with a grain of salt, I don't worry about this for the short period patients spend with EMS, but over sedation leads to all kinds of problems down the road from VAPs to poor body habitus requiring far more PT and OT to get a patient back to a functional level.

I also wouldn't be as hesitant to consider a paralytic as long as the patient has appropriate sedation/pain management, especially for a short period of time. It is not uncommon for us to roc a patient before/during transport, during procedures (imaging, line placement, bronchs...), or to promote vent compliance in the ED. While I don't love keeping patients on paralytics quite a few of my unit patients get vec drips, especially those with ARDS and don't have reasonable vent compliance. Paralytics do require some special considerations, but they are not some awful class of drug.
 
I guess the first questions is what is the dosing protocol you are currently working with. Any combination of Versed, Fentanyl and Ketamine should be adequate. Ketamine isn't always the greatest as a sole agent, add narcotic and/or benzos as needed. You really shouldn't be needing to routinely paralyze patients.
 
Sounds like you are using suxamethonium. This is good for elective anaesthesia requiring neuromuscular blockade but personally I think it's a poor choice for pre-hospital use.

Why not use rocuronium (or another long-acting neuromuscular blocker) and a combination of midazolam and fentanyl?
 
We use a Ketamine Succs Ketamine method, Ive had very good experience with it. We also have options for Roc, Versed and Fentanyl depending on the patients taking to ketamine
 
Rialaigh said:
Recently I have been finding myself questioning more and more the post-intubation sedation protocols or guidelines that most systems use for pre-hospital management. Where I currently work we have the option of either Ketamine or a Fentanyl/Versed combo. I am finding Ketamine to be a poor agent for post-intubation (More specifically post-RSI) sedation. I have had to use repeated doses (IV) with little success in keeping the patient comfortable with good ventilation compliance for more than 5-10 minutes. We also have the option of Vec although I am not sold that we should be routinely using that pre-hospital on your "every day" RSI.

My basic understanding is that due to the nature of the environment we are operating in we have several unique challenges for keeping a patient adequately sedated that the ER generally does not have. One being extra stimulation (lights, sirens, being moved or poked). Another being the difficulty of bagging someone with spontaneous respiration's (matching inspiration and expiration in someone after that initial paralytic is worn off). I feel like the second is more of a difficulty now (at least in my personal experience). I currently do not have a vent available to me much less any form of assist control.

So I guess long story short, in an optimal world without a vent (not optimal I know...) what should or could I be using for post-RSI sedation. I am trying to improve my own practice as well as make some changes with our current protocols, several options that have been discussed is adding fentanyl with the ketamine, upping the dosage of ketamine, and utilizing Vec more frequently as a service if the expected time to hospital after the RSI is complete is greater than lets say 20 minutes.

Any advice, comments, knowledge, articles, or otherwise would be greatly appreciated.
Click to expand...

What about using vec aren't you "sold" on? I have always advocated for maintaining paralysis in the transport setting. I've been told by many people over the years that that's "not necessary" or "not optimal care", but I have yet to hear a good, well reasoned argument against it. As you've seen, it can be hard to give enough sedation to keep them still and compliant. Why fight that battle? There's no reason not to keep them relaxed, yet several potential benefits.

For sedation, fentanyl and versed is an excellent combo. It always was and still would be my go-to for post-intubation sedation with a short transport time. Ketamine as a sole agent isn't a good choice. The only time I'd use ketamine for post-intubation sedation would be in a very hemodynamically unstable patient. And even then I'd do my best to work some versed in with it.
 
@Rialaigh The nice part about ketamine is that it is extremely reliable when dosed appropriately. There is some variation between patients but if you are in the 1-2 mg/kg of IBW range patients will almost always become dissociated. It they don't just give more. Ketamine has an extremely wide safety margin when it comes to dosing. However, ketamine does not typically cause respiratory depression. This means you may have trouble with ventilator compliance as patients are able to spontaneously breath if they are not paralyzed. There are a few ways to combat this. You can switch the patient to an SIMV, pressure support, or CPAP mode if appropriate. You can also give a paralytic (while ensuring sedation is also maintained). You could also add fentanyl or midazolam to suppress respiratory drive.
 
Ketamine is a wonderful drug but always remember it is not perfect. Some people rely on it as a crutch when patients are under-resuscitated. It will cause apnea when pushed too fast and can also cause hypotension and cardiac depression in catecholamine depleted or high shock index patients.

Retrospectively, a lot of our peri-intubation arrests were induced with Ketamine. Doesn't necessarily save a shocky patient
 
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