Post intubation sedation

[StCEMT]

So came across a podcast (emcrit) that I will listen to after I get home from dinner with the family, but wanted to get wisdom/advice/suggestions/general bullshittery from you fine folks on this topic. The last two people tubed in my presence were just plain dead, so all I was pushing was epi, didn't really have to worry about sedation. Needless to say its a bit out of my bubble. I know what my protocols are for, but I still have other options in my box that I can probably try to call for under different circumstances if it seems prudent to do so. Curious as to what yalls thoughts are on the whole spectrum, from respiratory failure, post ROSC, hypovolemic trauma, etc. and just gonna let this roll where ever it leads.

 

[VFlutter]

My go to is Ketamine for most situations and always with hypotensive patients. Also supplement with Fentanyl and Ativan. We have Versed but I tend to avoid it.

 

[NomadicMedic]

...And we use versed. That's all I've got in my protocol.

Although, if I'm taking a transfer, I can take Ativan from the pharm and use that if needed.

 

[StCEMT]

Is Ativan a bit easier on the hypotensive folks Chase? Don't even have it and don't even think I ever gave it in the hospital.

I'm in the same boat as you DE. 2.5-5mg versed. I have Ketamine though, so I can at the very least give the doc a holler and ask.

 

[VFlutter]

Is Ativan a bit easier on the hypotensive folks Chase? Don't even have it and don't even think I ever gave it in the hospital.

I'm in the same boat as you DE. 2.5-5mg versed. I have Ketamine though, so I can at the very least give the doc a holler and ask.

Anecdotally I found Versed to frequently cause hypotension but most of my experience was sick cardiac patients. I do not think one benzo is clearly superior to the other in most situations. Pain control goes a long way and usually keeps most patients comfortable without needing much else. I am sure @Remi may be able to answer more

Interesting abstract. https://www.ncbi.nlm.nih.gov/pubmed/7943774

 

[Carlos Danger]

Scott Weingart is all about using fentanyl as your primary agent for post-intubation sedation. Which is fine - fentanyl is a great drug and it certainly works well for this purpose - but I think the reasoning behind why he thinks fentanyl is a better drug than other options is flawed.

Advocates of a "fentanyl first" approach to post-intubation sedation always say something along the lines of "having a rigid piece of plastic shoved down your throat is very painful, and therefore these people need analgesia more than sedation". As evidence, they will point to the fact that when people who are intubated get fentanyl, their HR and BP drops and they appear more comfortable.

The problem with that argument is that the premise is untrue. First, being intubated should not be especially painful. It is uncomfortable. It is unnatural. It is anxiety inducing. It will cause a sympathetic response. But none of those things are the same as pain. If an ETT is painful, them something is wrong. It is too large, or poorly positioned, or it is taped improperly, or the cuff is overinflated. There should be no overriding need for potent analgesics. Second, the reason their HR drops when they get fentanyl is because fentanyl has pretty potent sympatholytic properties, not because they were experiencing severe pain before they got it. Lastly, the reason they look more comfortable after you give them fentanyl is because you just gave them additional sedation (fentanyl is a GABA agonist, too). I assure you that you can make a patient just as comfortable with an adequate dose of sedative alone.

Despite what we've all had drilled into our heads, "tachycardia does not equal pain".

Now, there are good reasons to use fentanyl in the post-intubation setting. Primarily because it lets you cut way down on the dose of whatever other sedative you are using. Fentanyl is a "clean" drug, meaning that it wears off predictably and fairly quickly once you stop giving it, and has minimal lingering effects compared to other drugs. Propofol is clean too, as long as it isn't infused at high doses for a long period of time. Versed is a dirty drug. It's great in small doses for anxiolysis or brief, mild-moderate sedation but in large or continuous doses, it has some bad effects, especially in specific populations. Which is why it has fallen out of favor in the ICU world.

Versed is a fine drug to use after you've dropped a tube and you have a fairly short drive to the hospital and may need to repeat the dose once or twice. It works fine for that purpose in combination with an opioid. You just shouldn't use an infusion of it, or give many repeated doses, if you can help it. When I flew I used propofol and fentanyl or dilaudid. I think it is the best combination out there. Ketamine has its place too, but I don't think it is superior to propofol + fentanyl in the vast majority of cases.

I also think that the avoidance of NMB at almost all costs during transport is completely unnecessary.

 

[Carlos Danger]

Anecdotally I found Versed to frequently cause hypotension but most of my experience was sick cardiac patients. I do not think one benzo is clearly superior to the other in most situations. Pain control goes a long way and usually keeps most patients comfortable without needing much else. I am sure @Remi may be able to answer more

Interesting abstract. https://www.ncbi.nlm.nih.gov/pubmed/7943774

I don't know that it matters. All the benzos are remarkably hemodynamically stable in healthy patients. In fragile cardiac patients, all bets are off and it is hard to predict how they will react to these drugs, or which one will work better. I think the best approach is to use what you are most familiar with and give very small doses.

 

[SpecialK]

Morphine and midazolam, or fentanyl and ketamine if the patient has shock in combination with rocuronium.

Given routinely post-RSI and post-intubation without RSI only if there is clinically significant movement.

Withheld in patients who have a very poor prognosis if at all possible.

 

[NomadicMedic]

I don't know that it matters. All the benzos are remarkably hemodynamically stable in healthy patients. In fragile cardiac patients, all bets are off and it is hard to predict how they will react to these drugs, or which one will work better. I think the best approach is to use what you are most familiar with and give very small doses.

I think this is a key point. I'll admit, when I started tubing people, I was taught, and believed in, the "one size fits all" method of sedation. Every tube got a big slug of etomidate, a big dose of paralytic, fentanyl and more versed for post tube sedation. After seeing some bad stuff (precipitous drops in BP of fragile patients) I've learned that titrating to effect is a much better plan. If your protocol allows.

However, despite what we read here from the more forward thinking medics, most EMS systems haven't caught up with EBM, and we're still bolus dosing sedation and we're stuck using Versed as the only sedation option.

 

[VentMonkey]

I'm on board with @DEmedic's above post (shocking, I know). All we have is Fentanyl--->Versed for post RSI management. It works just fine and is always titrated to the patients tolerability of being intubated. We have all but moved away from Vec, and Roc post-RSI, though it's still in our nursing protocols.

Now, if we had Ketamine, I am more than willing to bet we would be using this more often than not. I know my CCP instructor was a big fan of Ketamine, and even supporting drips. I think push dose is fine for most scene flights especially with out flight times to our local ED's. Before my time at our CCT division we had Ketamine for a brief period, and everyone I have talked about it wishes we still had it, and/ or it comes back.

I don't know how well Propofol fits into the prehospital environment. I know "milk of amnesia" is a well like drug especially in neuro-ICU's what with "sedation vacations" and all, but most of the time in-flight I would imagine comfortable, tolerable, and relaxed are the way to properly manage one's airway post-RSI.

The hospital can reassess and see what all longer-acting agents they want, if they want or need for them to remain intubated.

 

[Carlos Danger]

I'm on board with @DEmedic's above post (shocking, I know). All we have is Fentanyl--->Versed for post RSI management. It works just fine and is always titrated to the patients tolerability of being intubated. We have all but moved away from Vec, and Roc post-RSI, though it's still in our nursing protocols.

Now, if we had Ketamine, I am more than willing to bet we would be using this more often than not. I know my CCP instructor was a big fan of Ketamine, and even supporting drips. I think push dose is fine for most scene flights especially with out flight times to our local ED's. Before my time at our CCT division we had Ketamine for a brief period, and everyone I have talked about it wishes we still had it, and/ or it comes back.

I don't know how well Propofol fits into the prehospital environment. I know "milk of amnesia" is a well like drug especially in neuro-ICU's what with "sedation vacations" and all, but most of the time in-flight I would imagine comfortable, tolerable, and relaxed are the way to properly manage one's airway post-RSI.

The hospital can reassess and see what all longer-acting agents they want, if they want or need for them to remain intubated.

Propofol works great in transport with an opioid or ketamine. I have always been a fan of using NMB, too. I think it is a shame that it's so frowned up these days.

 

[VentMonkey]

Propofol works great in transport with an opioid or ketamine. I have always been a fan of using NMB, too. I think it is a shame that it's so frowned up these days.

I don't know that's it's necessarily frowned up, to me it seems as though it is more along the lines (in my line of work anyhow) that they'll need to further assess, so let's focus our post-RSI efforts on comfort and/ or pain control so that the receiving ED/ EM's can further/ properly assess as they wish.

 

[TXmed]

I beleive the shift to ketamine for sedation pre-hospital is that most providers to contain the knowledge of the people in this forum, so it is safer to let them push ketamine than it is versed/fent/propofol with lesser education.

I love propofol+ketamine with small amounts of fentanyl pushed just prior to strenous movements if needed.

 

[StCEMT]

Remi: That's a good point. I do remember hearing the tachycardia being a potential sign of pain, but I see your point about the sympatholytic effects of fentanyl and properly sedating.

Ketamine might not be better than propofol+fentanyl, but propofol isn't an option for me so I gear my reading towards Ketamine as a backup. There are some instances our protocol says to use it over etomidate or we can consider it if we deem it more appropriate for patient condition. Still learning what some of those instances are, for example I believe an article I read stated etomidate was associated with a higher mortality rate in septic patients than Ketamine and considering my area, that is a very realistic possibility for me. Already had one of those patients, would have been tuned if the transport time wasn't <5 minutes.

For healthy patients, I wouldnt be worried about versed as much. As I said though, I seem to get a lot of not so healthy people some days. Having not given it enough in these cases, I would be a lot more cautious due to lack of exposure. Since I have no preference (yay for a clean slate?), would a small dose with preparation to support hemodynamics be your suggestion or is this where sedation with a gentler med like Ketamine comes into play?

I would have to get orders for Ketamine in this case, but trying to explore options my options for X situation.

 

[Carlos Danger]

I don't know that's it's necessarily frowned up, to me it seems as though it is more along the lines (in my line of work anyhow) that they'll need to further assess, so let's focus our post-RSI efforts on comfort and/ or pain control so that the receiving ED/ EM's can further/ properly assess as they wish.

It is frowned upon by lots of people. Probably 10 years or so ago it started to be the "progressive" thing to do to avoid NMB. I've still never heard a good rationale for avoiding it, and it was my practice right up until the last transport I did. I always thought that NMB interfering with neuro assessment was just like prehospital opioid interfering with abdominal assessment. These people are all getting scanned anyway and if I give 10 of vec at the beginning of a 30 minute transport, it will be wearing off by the time we get to the receiving, unload, get down to the trauma bay, etc. And if they really need to, it's not like it can't be reversed.

 

[VentMonkey]

It is frowned upon by lots of people. Probably 10 years or so ago it started to be the "progressive" thing to do to avoid NMB. I've still never heard a good rationale for avoiding it, and it was my practice right up until the last transport I did. I always thought that NMB interfering with neuro assessment was just like prehospital opioid interfering with abdominal assessment. These people are all getting scanned anyway and if I give 10 of vec at the beginning of a 30 minute transport, it will be wearing off by the time we get to the receiving, unload, get down to the trauma bay, etc. And if they really need to, it's not like it can't be reversed.

Trust me when I say, our CFN/ CBS has had many the same arguments with some of our receiving staff.

 

[MonkeyArrow]

Interesting that ketamine is first line for so many of you for post-ROSC sedation. For a purely respiratory issue, I see ketamine as a great option for post incubation sedation. However, I have always been taught that ketamine is a sympathomimetic, which would cause increases in myocardial oxygen demand and has excessive inotropic effects, which is bad for the "frail" heart, which for the sake of argument I am assuming most post-ROSC patients have. Also, ketamine has reported incidences of rebound hypertension, which can be rather interesting. Anecdotally, I have seen it given as induction/sedation in a hypotensive patient, who after induction, actually experienced a confirmed stretch of hypertension, so much so that we had to put away the levophed and start a cardene drip.

 

[Carlos Danger]

For healthy patients, I wouldnt be worried about versed as much. As I said though, I seem to get a lot of not so healthy people some days. Having not given it enough in these cases, I would be a lot more cautious due to lack of exposure. Since I have no preference (yay for a clean slate?), would a small dose with preparation to support hemodynamics be your suggestion or is this where sedation with a gentler med like Ketamine comes into play?

I would have to get orders for Ketamine in this case, but trying to explore options my options for X situation.

If someone is really hemodynamically unstable, then a small dose of ketamine is probably your safest bet. And then redose a little at a time as needed.

Versed is a good drug too, though. There aren't too many people who are so unstable that you need to worry about giving them any depressant at all. You'll know them when you see them.

 

[NomadicMedic]

I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly?

What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.

 

[E tank]

Sedation and amnesia being related but not the same things, remembering that being critically ill/injured is a powerful amnestic. I'm sure there are those outliers that "remember everything, but patients on deaths door don't need much to not rememer.