Pre-Hospital post intubation sedation

[Sublime]

I know this has been discussed here, previously, but I wanted to bring it up in hopes that someone can help me convince my medical director to change his mind. Our current protocol for PAI (we don't rsi) is Ketamine 0.5-1.5 mg/kg for induction.

Post intubation sedation is versed 2.5 mg every 10 minutes as required. Max 10mg.

People as such as myself have considered intubation a painful procedure and thus felt necessary to add fentanyl to post intubation sedation. We recently received a updated pearl and message from our medical director about this. He states "intubation followed by immediate opiate analgesia can mask how the patient is responding to the intubation. So give the patient time to react to the Ketamine and see how they respond to it and see how they respond to the intubation procedure itself. If pain is suspected post intubation call med control for pain management guidance".

In the same message an educator at my service writes "our medical director has clearly stated that a triple drug cocktail of Ketamine, versed, and fentanyl is unacceptable and can be dangerous to your patient".

I am guessing the concerns here are hypotension. I'm not sure what he means by mask how the patient is responding to the intubation.

Either way I've searched through literature today and can't find anything that states not to use these drugs together for sedation purposes. I've recently listened to the EMcrit on post-intubation sedation where fentanyl is discussed as the a go to agent and has better outcomes for intubated patients. I know this is talking about ICU and ER care but I don't see why it couldn't apply to us as well.

Anyone have thoughts, recommendations, or supporting literature that I could use to persuade my medical director? Or if I'm way off base in my thinking I'll welcome your opinion on that as well.

 

[Medic Tim]

My CQI would be reaming me a new one if I only gave versed post intubation.
Our maintenance of paralysis / sedation guideline suggests we use 0.5 mg/kg ketamine q 10 prn or 2-5 mg midazolam and 50-100 mcg fentanyl q 10 prn

 

[Carlos Danger]

Ketamine at those doses is a potent analgesic. No need to add an opioid immediately.

I disagree that intubation is painful. It is uncomfortable. It is anxiety-inducing. It should not be painful, however; that's different. If it is, something is wrong.

Versed alone is a pretty poor agent to use, I would agree. Versed + fentanyl is a good combo, because they potentiate each other and "cover all the bases". Personally, I feel strongly that every intubated patient should be paralyzed for transport. But that is another topic.

I don't understand why your MD is concerned about "masking" the "response" to intubation. The response is ugly. Masking it is the whole point.

I am not unaware of any reason not to give versed and ketamine and fentanyl together. I almost never give ketamine WITHOUT the other two - plus other meds - and have never seen an issue.

Why not a repeat dose of ketamine, if nothing else?

Don't even get me started on "PAI" vs. "RSI" in the prehospital realm....that is also a whole different topic.

 

[Sublime]

Ketamine at those doses is a potent analgesic. No need to add an opioid immediately.

I think Ketamine alone is sufficient for PAI induction purposes, don't have a problem with this portion of the protocol.

I disagree that intubation is painful. It is uncomfortable. It is anxiety-inducing. It should not be painful, however; that's different. If it is, something is wrong.

I see what you're saying. I don't disagree either but when you're only allowed to use fentanyl for pain management purposes and want to ensure your patient is comfortable.... You have to use the "pain" protocol to justify the fentanyl in these scenarios.

Why not a repeat dose of ketamine, if nothing else?

That could be argued for as well, and I believe is probably a more likely to go over well with the Medical director than fentanyl. He seems to have his mind set about that.

Don't even get me started on "PAI" vs. "RSI" in the prehospital realm....that is also a whole different topic.

Agreed. Don't want to start down that road... Different can of worms.

 

[Rialaigh]

Our protocol goes to hefty doses of Versed, and Vec for long term paralytic post intubation.

We can call for orders for morphine, don't currently carry fent, and have the option to use ativan or valium in addition to versed. We are suposed to be getting ketamine shortly

 

[Sublime]

What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?

 

[Handsome Robb]

I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care.

I don't see why we can't alternate fentanyl and versed q5-10.

 

[FiremanMike]

I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care.

I don't see why we can't alternate fentanyl and versed q5-10.

That's what we do in my critical care gig.. Works pretty great!

 

[Carlos Danger]

I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care.

I don't see why we can't alternate fentanyl and versed q5-10.

Why do you want to have to give drugs every 5 minutes though? Why not just give them together and give enough that you don't have to repeat it every time you turn around?

What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?

I am a strong believer in the KISS principle, especially in the prehospital realm.

I would advocate for a protocol that calls for something along the lines of:

1 mcg/kg of fentanyl (simply their estimated weight in kg, rounded to the nearest 10kg)
0.1 mg/kg of versed (the fentanyl dose / 10 and given in mg)
0.1 mg/kg of vecuronium (same as the versed dose)

- Give the first doses immediately post-intubation
- Repeat Q30 min, earlier only if there are objective signs of them needing more sedation
- Repeat the vec only earlier if they start to move
- If the pressure is low, give half the versed dose
- If you give fentanyl prior to intubation, omit it from the first round of post-intubation dosing
- As an alternative to fentanyl, a healthy dose of morphine immediately post-intubation should cover you analgesia-wise for the duration of the transport.

Ketamine is a great option to have but I think is probably superior to versed & fentanyl combo only in select circumstances. I think it is a bit overhyped these days.

What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?

The only advantage an infusion offers over boluses is a more precise ability to titrate over time, and more stable serum concentrations which potentially leads to lower total doses over time. And of course it frees the bedside nurse from having to administer a bolus every 30 minutes or so. But in the prehospital phase, we are not concerned with stable serum concentrations or 24-hour opioid totals, and it takes more time to set up an infusion than it does to give a couple boluses. Plus, even with an infusion you usually start off with an initial bolus anyway. Personally, I would not bother with an infusion prehospital, unless the transport was going to be very long.

What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?

In all actuality, yes, versed probably is perfectly adequate for most patients post-intubation, providing of course that they don't have a painful injury or condition to begin with, and assuming that you didn't mangle their airway during the intubation. That said, adding an opioid only makes sense, both to cover any pain and to potentiate your versed.

 

[FiremanMike]

Why do you want to have to give drugs every 5 minutes though? Why not just give them together and give enough that you don't have to repeat it every time you turn around?

Because then we'd be sitting around and twiddling our thumbs for 10 minutes instead of 5...

As for your vec opinion, I'm only a fan of vec if you're doing hypothermia protocol or don't have a vent. IMHO, a vent patient should really be on SIMV as much as possible..

 

[Handsome Robb]

That's a very valid point Halothane...I didn't even think of that. Most every protocol I've seen calls for alternating doses, I was wondering if there was an issue just giving both concurrently...they're intubated and ventilated I'm not worried about their respiratory drive.

 

[Carlos Danger]

Because then we'd be sitting around and twiddling our thumbs for 10 minutes instead of 5...

As for your vec opinion, I'm only a fan of vec if you're doing hypothermia protocol or don't have a vent. IMHO, a vent patient should really be on SIMV as much as possible..

I cannot think of a single reason not to paralyze for transport, but I can think of several why you should.

You can still put them on SIMV if you really want to. in my last couple years of flying I always used SIMV, whether paralyzed or not.

There are good reasons why patients who are intubated for prolonged periods should be encouraged to breathe spontaneously as much as possible, but none of them are relevant to the emergent prehospital setting any more than they are to the OR, where we paralyze people all the time for elective surgeries. It just isn't an issue for an hour or two at a time.

If you have someone well sedated enough that they tolerate not only intubation/mechanical ventilation but also the high-stimulus transport environment, chances are very good that they won't be breathing well enough to reap the benefits of SIMV or any support mode - they are going to require pretty much full support anyway.

In the short-term prehospital setting with an emergent patient, the advantages of paralysis easily outweigh the potential/theoretical risks of it, IMO.

 

[18G]

If you want a comfortable patient post-intubation and want them to do well on the vent.... TREAT THEIR FREAKING PAIN!!!! Not providing post-intubation analgesia is asinine to me. I hate walking into EDs and finding out the patient received no post-intubation analgesia and has only been receiving a push dose benzo.

Yes, intubation is a very uncomfortable and painful experience. The patient is already feeling horribly bad as it is given the underlying condition that warrants intubation. So, now we ran a metal blade into their mouth and place a rigid piece of plastic through their vocal cords and leave it there. Next, we subject them to the unnatural and uncomfortable sensation of positive pressure ventilation via the ventilator. This is all on top of being poked and prodded with NG tubes, IV catheters, central lines, foley catheter, and being bounced around down the road with this piece of plastic vibrating through the vocal cords. And what about some meds that may be infusing that are irritating at the infusion site? I think analgesia is a priority!

When I give my vent patients fentanyl... it works amazing to provide a comfortable and well sedated patient. It also prevents having to up the dose on the propofol. I give fentanyl as needed and use the propofol or a benzo on top just as additive.

Patient's who are critically ill can experience allodynia which is pain due to a stimulus that does not normally cause pain.

I highly recommend this podcast from EMcrit.org (A Bad Sedation Package Leaves Your Patient Trapped in a Nightmare):

http://emcrit.org/podcasts/post-intubation-sedation/

 

[Carlos Danger]

If you want a comfortable patient post-intubation and want them to do well on the vent.... TREAT THEIR FREAKING PAIN!!!! Not providing post-intubation analgesia is asinine to me.

No one is advocating withholding analgesia where it is needed. People experiencing pain should have their pain treated. We all get that.

What needs to be understood, though, is that a well sedated patient isn't "experiencing" pain. An adequate dose of versed or propofol puts the higher centers of the brain to sleep and the patient consciously experiences nothing. You could saw their leg off with a hacksaw and they wouldn't "feel" it at all. You will still have signs of sympathetic stimulation (tachycardia, etc.), but that does not indicate that the patient is experiencing pain or discomfort; it is simply a reflexive response to nociceptor activation that is separate from awareness pathways.

When I give my vent patients fentanyl... it works amazing to provide a comfortable and well sedated patient. It also prevents having to up the dose on the propofol. I give fentanyl as needed and use the propofol or a benzo on top just as additive.

Of course they do better with fentanyl + propofol than with propofol alone. When you give the fentanyl, you are essentially doubling their dose of propofol without having to deal with the hemodynamic consequences of actually doing so. You are also blunting their respiratory drive to a greater degree than the propofol alone, which makes it easier to synchronize them with the vent (assuming they are still even breathing on their own).

Patient's who are critically ill can experience allodynia which is pain due to a stimulus that does not normally cause pain.

This is actually an argument AGAINST using an opioid-based sedation strategy. Google "opioid induced hyperalgesia".


I am not making these points to argue that intubated patients shouldn't be given analgesia; I am simply pointing out that a protocol based on benzos or propofol, while probably not ideal, does NOT equate to "abusing" or "torturing" your patients (assuming, of course, that adequate doses are used). No one is committing an ethically questionable act by following a protocol that calls for propofol or versed and omits fentanyl.

I do think that an opioid-based vent sedation is a much better choice than a benzo or hypnotic based one - especially in the field - but that primarily has to do with hemodynamic stability rather than improved comfort; it is simply easier to keep a good BP and a low HR with opioids than it is with large doses of versed or fentanyl. Other advantages of opioids include duration of action, synergism with the benzos, and (in the ICU) lower rates of pneumonia and improved weaning from the vent.

 

[VPIMedic]

Most every protocol I've seen calls for alternating doses, I was wondering if there was an issue just giving both concurrently...they're intubated and ventilated I'm not worried about their respiratory drive.

This is actually a much more complex topic. There are two reasons why this approach is a poor practice IMO. First: it promotes, and reinforces, the appropriately admonished practice of "cookbook medicine." No single agent, nor any broad combination of agents, applies to every patient. Each patient needs to be approached individually because the effect of each drug is different. Everybody knows this but the very nature of protocols promotes this thinking. Concomitant administration of medications at specific intervals for this circumstances appears to eliminate critical thinking by the provider. Again, my opinion.

Why? This creates an excellent segue into the second problem with concomitant administration. You are correct that depressed respiratory drive is not a concern for intubated patients. But this is not the only effect. It is known that the specific combination of midazolam and fentanyl, or benzos and opiates in general, cause a decrease in hemodynamics. A modest drop is not an issue, and this is sometimes desired. But the underlying pathology of the disease (ex:trauma/hypovolemia) as well as the physiologic state of the individual (ex: geriatrics, renal failure etc) can exacerbate the effects and consequences of this practice. One episode of hypotension has significantly deleterious effects on morbidity and mortality in TBI.

The cornerstone of post-intubation care is understanding that it is multifaceted and illness dependent. You must ask yourself three basic questions each time. What is wrong with the patient? Where do they need to be? How am I going to get there?

 

[VPIMedic]

What needs to be understood, though, is that a well sedated patient isn't "experiencing" pain.

Wrong See these papers:
Pain from ET tube alone--at it's most: 8. At it's least:5! Rotondi AJ, Chelluri L, Sirio C, et al. Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30(4):746-52.
Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994; 51:1539.

You could saw their leg off with a hacksaw and they wouldn't "feel" it at all. You will still have signs of sympathetic stimulation (tachycardia, etc.), but that does not indicate that the patient is experiencing pain or discomfort; it is simply a reflexive response to nociceptor activation that is separate from awareness pathways.

Wrong again. Probably more egregious than the first inaccuracy. Too much literature to list, but sedatives and hypnotics do not provide analgesia. Clearly established fact.

Hyperalgesia is real. Yet it is from chronic use of opiates. In the acute setting, such as this...nah. More harm from not treating pain.

Treating with benzos or propofol alone is unethical because it is not the currently accepted medical standard of care. See Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263.

Yes we are talking about prehospital care...but these patients are critically ill and destined for an ICU. Not an elective gallbladder removal that is sent home two hours after the procedure.

 

[rmabrey]

Good thread. We dont give pain meds with intubation and ive been meaning to ask why.

 

[Rialaigh]

Good thread. We dont give pain meds with intubation and ive been meaning to ask why.

For a lot of agencies it gets all the way back to the most basic debate of all, and that is what our "job" is. Fact is prehospital pain medication post intubation does not reduce mortality or morbidity in any condition period. If you go back to the mentality that some people have, that all treatments that we do need to be justified by reduced mortality, morbidity, or reduced hospital stay times, then pain medication is no where to be found...along with most other prehospital ems treatments.

 

[Carlos Danger]

Wrong See these papers:
Pain from ET tube alone--at it's most: 8. At it's least:5! Rotondi AJ, Chelluri L, Sirio C, et al. Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30(4):746-52.

Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994; 51:1539.

Did you even read those papers? They have nothing at all to do with what I wrote. The first one simply shows that under-sedated patients who receive mechanical ventilation in the ICU are uncomfortable and sometimes have stressful recollections of the event, and the second one describes negative physiologic responses to untreated severe pain. Neither piece of info is breaking news, and neither one addresses awareness of pain in well-sedated patients, or establishes the necessity of an opioid-based sedation strategy in the prehospital environment.

Wrong again. Probably more egregious than the first inaccuracy. Too much literature to list, but sedatives and hypnotics do not provide analgesia. Clearly established fact.

Did I say that sedatives provide analgesia? No, I didn't....I'm not sure why you are barking up that tree.

Treating with benzos or propofol alone is unethical because it is not the currently accepted medical standard of care. See Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263.

So the current accepted standard of care is the only arbiter of what constitutes proper care? "If it's in the protocol it's right, if it isn't it's wrong?" Isn't that exactly the kind of thinking that kept rigid backboards in everyone's protocols for so long?

I wonder if you've read this document, too, because it doesn't really say what you seem to think it says. It addresses many issues but when it comes to pain, it basically says "assess for pain frequently, treat it aggressively, tailor it to the patient's needs, and use multi-modal therapy where appropriate".


Look man, I know a thing or two about analgesics and sedatives and how to use them so that patients can tolerate painful procedures. I think you are misinterpreting what I wrote partly because it's not what you've been taught, and partly because you don't have much understanding of sensory pathways and mechanisms of awareness or the way they are affected by these drugs, so what I wrote didn't make sense to you. Sorry you weren't able to follow.

Just to keep you happy, I'll say it again for the 3rd or 4th time in this thread: People in pain should receive analgesia. I do not nor have I ever advocated withholding analgesia in any case.

 

[rmabrey]

For a lot of agencies it gets all the way back to the most basic debate of all, and that is what our "job" is. Fact is prehospital pain medication post intubation does not reduce mortality or morbidity in any condition period. If you go back to the mentality that some people have, that all treatments that we do need to be justified by reduced mortality, morbidity, or reduced hospital stay times, then pain medication is no where to be found...along with most other prehospital ems treatments.

That is the answer I expect