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Versed/fentanyl sedation

Discussion in 'ALS Discussion' started by StCEMT, May 15, 2017.

  1. SpecialK

    SpecialK Forum Captain

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    Oh Jesus tell me people aren't still trying to use midazolam for general anaesthesia? Why are you still doing this? And please stop doing this.
     
  2. Brandon O

    Brandon O Puzzled by facies

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    From an ICU perspective, it is done, but I see no advantage and tend to change it when I encounter it. Lorazepam has a long half-life, making it less titratable as a drip, and infusions are packaged in propylene glycol which can cause weird metabolic acidoses. Midazolam is better -- although frankly, all benzos can be rather deliriogenic and propofol is probably even better -- and simply minimizing sedation in general best of all.

    Ativan can make a decent choice for intermittent boluses, depending on what duration you're looking for.
     
    Summit likes this.
  3. Remi

    Remi Forum Deputy Chief Premium Member

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    Versed is an excellent drug. Why not use it?
     
  4. E tank

    E tank Forum Captain

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    Stop using versed with general anesthesia or for general anesthesia? I don't know anyone that uses it for general anesthesia and it is a valuable adjunct with general anesthesia.

    Using it as a hypnotic for intubation is not using it for general anesthesia.
     
    Summit, NomadicMedic and Remi like this.
  5. SpecialK

    SpecialK Forum Captain

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    Oh, rubbish. Taking somebody and making them unconscious so they can be intubated is .... general anaesthesia.

    Just because it's done outside of a traditional clinical setting by a non-anaesthetist doesn't make it any less of general anaesthesia.

    The doses of midazolam you'd need to achieve this are pretty high and then you get all the deleterious side effects, which in somebody who is being intubated say for severe traumatic brain injury is not a good thing.

    Why not just use ketamine (or in your part of the world where you have it - etomidate).
     
  6. StCEMT

    StCEMT Forum Deputy Chief

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    It might not have been clear in my initial post, but I have neither at my new service. I wouldn't ask this if I did. I am currently working on a proposition for Ketamine, but that is a long term project.

    All I have to work with is versed/fentanyl. I haven't used either of these meds enough to be as familiar with them, but I have used fentanyl on many occasions. Being a new medic, I recognize my knowledge and experience is not close to many members here. So I ask questions to have a better understanding of and best use what I am given, which will be happening a lot here soon since I have a lot of new meds and equipment that I am not all that familiar with.
     
    Remi and TXmed like this.
  7. Remi

    Remi Forum Deputy Chief Premium Member

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    It'd be nice to have ketamine and/or etomidate as options but really, versed & fent is a fine combo. Don't let the naysayers worry you.
     
    NomadicMedic likes this.
  8. StCEMT

    StCEMT Forum Deputy Chief

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    It's mostly just unfamiliarity making this outside my comfort zone. Never had to dose those meds like that for this purpose, not that I don't think I can manage other side effects adequately. In cases like this I want to be able to call a doc and know exactly what I want, why I want it, and how I want it done so I don't come off as a confused, bumbling fool when I do. Not having done this, that's where I rely on experienced folks like you. If it's a reasonable option, I'll just make sure I stay knowledgeable on it and proceed accordingly.
     
    Remi likes this.
  9. E tank

    E tank Forum Captain

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    Any hypnotic is chosen for the advantages it brings to the table and is weighed against potential risk which any of them bring. Propofol can have profound hypotension, etomidate, adrenal cortical suppression, ketamine a hyperdynamic response and dysphoria in some patients.

    Versed is also used in larger than common doses in cardiothoracic surgery with early extubation in procedures utilizing deep hypothermic circulatory arrest where neurological protection is a key objective.

    Versed is also routinely used in neuro intensive care units with propofol for sedation of ABI patients and they end up getting far more than an intubation dose, so while I get that there can be differing opinions on specific choices of hypnotics, I'm always a little surprised at out of proportion negative reactions to uses of some agents that may be unfamiliar to some.
     
  10. StCEMT

    StCEMT Forum Deputy Chief

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    Unfamiliarity is probably why it gets those reactions. I wish I could follow you two around for a week just for the variety of exposure. Admittedly my options don't make me too excited, but that's just due to my past experience with some meds and lack thereof with others.
     
    E tank likes this.
  11. Remi

    Remi Forum Deputy Chief Premium Member

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    We are really talking semantics so I don't want to get too far into the weeds over terminology, but induction for intubation is not necessarily the same thing as general anesthesia. It can be, sure, but it does't have to be. A mild-moderate level of hypnosis or anxioloysis with amnesia is all you really need in order to intubate someone humanely. "General anesthesia", however, always requires a much deeper and sustained loss of awareness, analgesia, and usually some loss of autonomic function. To put it another way, what I need to give you in order to humanely place an ETT in your trachea and allow you to tolerate mechanical ventilation is very different than what I need to give you in order to allow a surgeon to cut open your thorax or abdomen and start playing with your internal organs.

    Here's the thing about ketamine vs. versed vs. opioids vs. propofol vs. pentothal vs. brevital vs. etomidate vs. sevo for induction: any of those can work alone or in some combination with the others. None of them are without potential problems. Each one is maybe the best choice for a specific application and perhaps the worst choice for another. None of them are the best choice in EVERY situation. A big slug of ketamine may be the best all-around choice for prehospital use, but it would be my last choice in a fragile old patient with a sick heart. Not because it can't work, but because there are better options if you have the choice and know the drugs well. Being able to make that determination takes experience and is what they mean when they talk about the "art of anesthesia". It can't be distilled into a simple algorithm or explained with a clinical study. The same is true with paralytics (though less so, to be sure), and I've tried to explain that many times to paramedics who have been brainwashed into thinking that sux should never ever be used.

    In prehospital, since most of us don't have that kind of experience and knowledge of the drugs, we have a medical director who uses the best evidence (or dogma, or bias) to choose the drug(s) that he thinks are the best option for most of the scenarios we encounter in the field. If I were writing an RSI protocol for EMS, versed and fentanyl would probably not be my first choice, but honestly, you can make an argument for that combination over ketamine or etomidate. It may not be in style right now, but like I said before, it isn't a horrible choice by any means.

    "Never" and "always" are two of the most dangerous words in medicine.
     
    Last edited: May 20, 2017 at 5:02 PM
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  12. E tank

    E tank Forum Captain

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    Indeed...I don't personally, but I work with guys that put hearts off to sleep with 6 - 10 mgs of versed with some sufenta. Pretty stable induction and intubation, but just one way in many to put off a patient with a sick heart.
     
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  13. StCEMT

    StCEMT Forum Deputy Chief

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    Just out of curiosity, how would you form an RSI protocol if given free reign?
     
  14. E tank

    E tank Forum Captain

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    In a perfect world where practicality was not an issue, I'd have etomidate, propofol and ketamine for the hypnotics and succs and rocuronium for the muscle relaxants. There would be a specific pre-induction checklist and finally, because of the variety of possible combinations, the agents would be prescribed by medical control on a case by case basis.
     
    StCEMT likes this.
  15. SpecialK

    SpecialK Forum Captain

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    Medicine wise probably ketamine and rocuronium. Very common in Australasia. As a backup when ketamine is a bit suspicious to give, such as in somebody with massively uncontrolled hypertension or a crook ticker then something would be nice; can't say between for example propofol or etomidate. We don't have etomidate down here.
     
  16. StCEMT

    StCEMT Forum Deputy Chief

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    Is Ketamine the only thing used in Australia now? Kinda jealous, really wish it was still in my box.
     

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