Revel alarm question/with scenario.

[Tigger]

Would you stay to titrate the patient back to their original RASS goal once you complete the transport?

Often sedation doesn't get adjusted for hours once a new accepting team or even oncoming bedside RN after shift change starts caring for the patient. As a result some of the hard work to reduce ICU length of stay, ventilator days, cognitive dysfunction, and delirium gets negated.

If I was doing real IFT work where the sending facility had some idea of what they were doing, possibly? But we're doing scene calls or rescue missions to the local critical access facility that rarely uses a ventilator and only occasionally sedates patients pre and post intubation.

 

[Carlos Danger]

Would you stay to titrate the patient back to their original RASS goal once you complete the transport?

Often sedation doesn't get adjusted for hours once a new accepting team or even oncoming bedside RN after shift change starts caring for the patient. As a result some of the hard work to reduce ICU length of stay, ventilator days, cognitive dysfunction, and delirium gets negated.

But is it the responsibility of the transport team to attempt to prophylactically negate whatever poor care might be provided by the receiving ICU staff? I feel like attempting to move a sick patient between facilities is challenging enough in itself.

The flip side of this coin is that without NMB, the transport environment often requires WAAY more sedation than an ICU bed does. How does that affect length of stay, ventilator days, and delirium? I don't think anyone knows because it has never been looked at. I think a reasonable assumption is that minimizing hypnotics during transport is as good of a practice as is minimizing hypnotics in the ICU, and that is much easier done with NMB.

Maybe it doesn't matter in terms of outcomes for a 1-2 hour tranport? I don't imagine it really does. But with NMB at least you have a compliant patient during transport requiring less sedation and less fiddling with the vent. If nothing else, I think there's a lot to be said for just making things a little easier on the providers.

I'm definitely not saying that every vent patient should necessarily be paralyzed for transport. Just that we should recognize the benefits and lack of risk in doing so, and thus have a low threshold for giving some NMB vs. increasing the sedation.

 

[Tigger]

But is it the responsibility of the transport team to attempt to prophylactically negate whatever poor care might be provided by the receiving ICU staff? I feel like attempting to move a sick patient between facilities is challenging enough in itself.

The flip side of this coin is that without NMB, the transport environment often requires WAAY more sedation than an ICU bed does. How does that affect length of stay, ventilator days, and delirium? I don't think anyone knows because it has never been looked at. I think a reasonable assumption is that minimizing hypnotics during transport is as good of a practice as is minimizing hypnotics in the ICU, and that is much easier done with NMB.

Maybe it doesn't matter in terms of outcomes for a 1-2 hour tranport? I don't imagine it really does. But with NMB at least you have a compliant patient during transport requiring less sedation and less fiddling with the vent. If nothing else, I think there's a lot to be said for just making things a little easier on the providers.

I'm definitely not saying that every vent patient should necessarily be paralyzed for transport. Just that we should recognize the benefits and lack of risk in doing so, and thus have a low threshold for giving some NMB vs. increasing the sedation.

I think I have personally moved away from "paralytics are bad," which in itself was a 180 from how I originally learned. The sedation needed to get a patient on our vent was outrageous and I am happy we are swinging back into a more do what is right situation. We just got Zoll Z's so now I need to actually understand a real vent and challenges like what the OP is facing.

 

[medichopeful]

I think someone already mentioned it, but with the ReVel if the patient is taking in huge volumes it can fool the machine. With patients that are taking stupidly large breaths (neurogenic, metabolic acidosis, etc) I'll usually just switch it to AC/PC. Patients seem to like it a lot better. In fact, I'll put a lot of my patients on AC/PC for the same reason(s).

While I'm a huge fan of ketamine, I would consider propofol/versed and fentanyl for this patient, especially due to the risk of seizures which propofol and versed can help with. But I don't see anything wrong with your treatment either, just a difference in opinion!

Nice job with what seems like a trainwreck.

 

[medichopeful]

I never have and never will understand the reluctance in the transport community to use NMB. In nearly every case the advantages of it easily outweigh any downsides or risks.

Me neither. I'll absolutely try pain meds followed by sedation, but if that doesn't work I have a pretty low threshold to paralyze. For really sick respiratory patients, a lot of the time I'll just go straight to a sedative/analgesic/paralytic combo to just completely take them out of the equation so the ventilator can do everything.

Prone transports get paralyzed no questions asked, in addition to rather generous sedatives and analgesics.

 

[StCEMT]

Would you stay to titrate the patient back to their original RASS goal once you complete the transport?

Often sedation doesn't get adjusted for hours once a new accepting team or even oncoming bedside RN after shift change starts caring for the patient. As a result some of the hard work to reduce ICU length of stay, ventilator days, cognitive dysfunction, and delirium gets negated.

No. If I am going to a higher level of care, I shouldn't have to. Nor do I think the hospitals here want be to. If I do change sedation, I inform them of why and what changes were made. If the receiving teams are leaving stuff unchecked for hours and it actually is impacting patients, that sounds like a systemic change that needs to happen in hospital.

 

[silver]

But is it the responsibility of the transport team to attempt to prophylactically negate whatever poor care might be provided by the receiving ICU staff? I feel like attempting to move a sick patient between facilities is challenging enough in itself.

The flip side of this coin is that without NMB, the transport environment often requires WAAY more sedation than an ICU bed does. How does that affect length of stay, ventilator days, and delirium? I don't think anyone knows because it has never been looked at. I think a reasonable assumption is that minimizing hypnotics during transport is as good of a practice as is minimizing hypnotics in the ICU, and that is much easier done with NMB.

Maybe it doesn't matter in terms of outcomes for a 1-2 hour tranport? I don't imagine it really does. But with NMB at least you have a compliant patient during transport requiring less sedation and less fiddling with the vent. If nothing else, I think there's a lot to be said for just making things a little easier on the providers.

I'm definitely not saying that every vent patient should necessarily be paralyzed for transport. Just that we should recognize the benefits and lack of risk in doing so, and thus have a low threshold for giving some NMB vs. increasing the sedation.

I don't think you should prophylactically, but in the same vein no one should automatically sedate deeper just because keeping RASS -1 to -2 is perceived as too hard in transport. 100% agree that no one knows how sedation during transport affects outcomes, but we do know how sedation in the ICU does and its unlikely that transport contradicts it.

Anecdotally as someone who both drops patients off in ICU and takes patients as ICU provider, patients stay overly sedated following transitions of care. Often when transporting patients in the hospital I rely on residual NMB or give additional doses, and agree giving PRN doses of analgesia, sedation, and NMB prior to stimulation or if patient demonstrates need for. However, the evidence we have in critical care supports continuing minimizing sedation if safe (specifically standing doses) and no evidence contradicts that, which is why medical directors will push that.

 

[Comfort Care]

I've seen the "pt circuit" alarm due to flow sensor problems, due to the pts neuro status,, maybe APV/CMV mode would have been more appropriate than AC mode?

 

[DesertMedic66]

I've seen the "pt circuit" alarm due to flow sensor problems, due to the pts neuro status,, maybe APV/CMV mode would have been more appropriate than AC mode?

With the revel your only options are AC or SIMV

 

[GMCmedic]

I like the direction this went.

There has already been mention in our program that ketamine is beginning to be preferred over propofol. We know that sedation needs can increase by 25% in transport and hemo dynamics don't often support 25% more propofol.

@silver what are your thoughts on routinely paralyzing patients in transport? As @Carlos Danger already said, transport vents tend to me more finicky with alarms and a RASS of -1 or -2 doesn't always do the trick. While alarms are mostly an inconvenience, there are cases where alarms lock out certain operations till addressed or cleared.


As an aside, we're free to sedate from a -1 to -5 by guidelines.

 

[silver]

I like the direction this went.

There has already been mention in our program that ketamine is beginning to be preferred over propofol. We know that sedation needs can increase by 25% in transport and hemo dynamics don't often support 25% more propofol.

@silver what are your thoughts on routinely paralyzing patients in transport? As @Carlos Danger already said, transport vents tend to me more finicky with alarms and a RASS of -1 or -2 doesn't always do the trick. While alarms are mostly an inconvenience, there are cases where alarms lock out certain operations till addressed or cleared.


As an aside, we're free to sedate from a -1 to -5 by guidelines.

If attempts to provide more analgesia/sedation are unsuccessful or if one feels like transport is going to be unsafe then NMB is ideal. Certain patients don't really need to even prove themselves in my mind like ARDS patient already on high doses of multiple sedatives (think needing fent/dilaudid, midaz, propofol, and ketamine drips) who is already dyssynchronous on the ICU ventilator. Another example, mechanical circulatory support patients may often benefit from PRN NMB during transport.

 

[VFlutter]

Did you switch the sensitivity to P? And consider switching to SIMV?