Pushing some ativan followed by vecuronium is no longer an acceptable strategy to manage post-intubation sedation. A good analgesia and sedation package is essential if you care about your patient’s comfort and well-being. We need to move to PAIN-FIRST paradigm. Optimize analgesia and then add in sedative agents as a bonus. In this episode of the EMCrit Podcast, I expand on a previous rant to discuss the optimal way to handle routine post-intubation patients and some special scenarios you may encounter.
The Routine
Here is the Lancet Article I mentioned:
(A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial)
Post-Intubation patients are in pain b/c they have a piece of rigid plastic jammed down their throats and b/c we do a lot of evil-seeming stuff to them in the ED.
Give them a bolus of fentanyl or morphine as soon as you complete the intubation (or better yet, with your RSI drugs)
Fentanyl Protocol
Morphine Protocol
Only when you have a calm, relaxed, but fully awake patient, add on a touch of sedative for hypnosis, amnesia, and anxiolysis.
Use a sedation scale like RASS.
Special Scenarios
1. Hypotensive Medical Patient-the patient’s blood pressure is never too low to get adequate pain control and sedation. Start them on a pressor and give them comfort. Fentanyl/versed is probably a good combination. Maybe in the future ketamine/versed.
2. Delerium Tremens-these patients need GABA first. My patients have already received 200-400 mg of diazepam before getting intubated so more benzos will probably not help. Use propofol/fentanyl. If propofol is not available, use versed/fentanyl/phenobarbital. Here is a DT protocol that encompasses phenobarb. Also see my DT Podcast.
3. Neurocritically Ill Patients-aka the head bleeds. This one is for Mike, a flight medic. Fentanyl/propofol is the way to go for these patients. Take them deep during the first 24 hours or so. Treat pain and sedation needs first, before add anti-hypertensives; their blood pressure may come down when you treat their pain. If you are transferring these patients, have a very low threshold to intubate, leaving them on propofol/fentanyl. WHen the receiving hospital gets the patient, they can easily extubate them if you used these medications.
Here is my extubation article.
4. Hypotensive Trauma Patients-this pertains to trauma patients hypotensive because of hemorrhagic shock. I get a bunch of ketamine and a bunch of fentanyl. If their MAP > 65 then I give 25 mcg of fentanyl. Wait a couple of minutes and if still > 65, give some more. If their MAP < 65, I give 10-15 mg of ketamine. Keep going with this until your patient looks good.
photo by brentbat
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{ 4 comments… read them below or add one }
Dear Scott,
Very remarkable stuff you did out there sir,
I heartily agree with you pertaining to extubating patient in ED. In place where I come from (Malaysia), We are definitely comfortable in intubation, but when it comes to extubation we tend to leave the headache to someone else. One of anest friends made a remark, that you guys are really quick in jamming tube to patient but when it comes to extubation, you leave the mess to us.
For your info sir, I tend to believe that not many of ED practioners in this country comfortable with idea of extubation in ED.
But If we were given enough training to do so, the trend will be changing.
I a great fan of your podcast, and this idea of extubation in ED serves as an opener to me.
Marvelous lecture pertaining to the management of post intubation sedation that you are given to us here sir. All the drugs that you have mentioned including the precedex are available in most hospital in this country. Availability in Ed though is another story. I believe, if there are effort to get accustom and to get familiar with the use of the drugs that you have mentioned, god willing it will be made available in ED soon.
Cant wait to listen you future podcast.
Thank you
MOHD
Mohd,
Thanks for your comments! ED extubation is a new frontier here in the states as well; hopefully that will change in the next few years.
Scott
Ativan followed by vecuronium is not post-intubation sedation. Do it right! EMCrit Podcast # 21. http://su.pr/2xFEXU
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@jdetrolio: RT @emcrit: Ativan followed by vecuronium is not post-intubation sedation. EMCrit Podcast # 21. http://su.pr/2xFEXU
This comment was originally posted on Twitter