Pre-Hospital post intubation sedation

[18G]

Halothane. Sorry but have to disagree on all of your points. Sedated patients STILL FEEL PAIN. You're perpetrating a myth. Sedatives offer no analgesia. This is exactly like how a lot of nurses think because they lack understanding. Pain negatively effects the body.

I had a vent patient just the other day on a Versed drip who was NOT comfortable. I got an order for fentanyl q15 PRN and I had a comfortable patient. These patients appreciate having their pain treated! This isn't just an opinion it is evidenced based.

 

[Carlos Danger]

Halothane. Sorry but have to disagree on all of your points. Sedated patients STILL FEEL PAIN. You're perpetrating a myth. Sedatives offer no analgesia. This is exactly like how a lot of nurses think because they lack understanding. Pain negatively effects the body.

Oh, really? So if I go to paramedic school, I'll get the kind of in-depth education on pain and awareness pathways that it takes to provide anesthesia?

I guess I'll forget everything I learned in my tens of thousands of hours managing sedated, intubated patients in the ICU's, helicopters, and ambulances, and the hundreds of RSI's I did in the field, not to mention my hundreds of hours in the OR. I'll purge my brain of all the trash they shoved in there during my graduate level anatomy, physiology, pharmacology, and anesthesia courses. I'll throw away my medical physiology and anesthesia texts, my neuroanesthesia text, and my pharmacology texts.

Instead, I'll dig up my old 500 page paramedic text written at the tenth grade level and read it slowly.....maybe then and only then will I have an understanding as thorough as your own?

Or more likely, I'll just keep in mind that you really don't know what you are talking about, and ignore your attempted insult.

 

[VPIMedic]

You know, Halothane is right in all of his posts. This is not sarcasm. I'll say that the delivery on the last one is a bit rough though. Not trying to suck up here, but some good information is getting lost in this mess. I'm guilty of thumping the sedation/analgesia war drum, not fully explaining my rationale, nor differentiating between Halothane’s first response and all subsequent posts. This post is intended to offer an answer to the OP's question. The second will be to Halothane’s questions of me. I have an organic chemistry final that I really need to study for so that takes priority…unfortunately. In the meantime: yes, I read those papers. Otherwise I would not have posted them. You are right Halothane, your knowledge and experience dwarfs mine. I presume that applies to a few others here as well. Based upon the vernacular within your posts, in addition to the list of work experience, I presume that you are a CRNA. I freely admit that the attribute I respect most of CRNAs, AAs, and anesthesiologists is the in-depth knowledge that they possess of physiology, pathophysiology, and pharmacology. I can't really blame you for getting a little snippy at the end either. We're getting awfully close to Godwin's Law. Hopefully I can put it back on track. I'm sure most don't even care anymore, but apathy can be a terrible thing. Based upon your description of your experience, for all I know I could be arguing with my partner’s husband…he took the same route as you.

To the OP: intubation itself is not a painful procedure...I myself have had surgery and the only painful part was the burn of the propfol going into my arm. Now, this was in a controlled environment and performed by an individual that has thousands of intubations under her belt. This doesn't describe our practice. Any pain inflicted from intubation is a response to our poor technique or, in the absence of this, the fact that a piece of plastic is irritating the mucosal lining. The bougie and ET tube is not the time to practice form for muzzleloader season. I don't hunt so this could be an incorrect analogy. The thing is, pain is subjective and anxiety or poor sedation increases this perception to pain. Does adequate sedation treat the pain or does it inhibit the recall of the pain actually ever occurring? I think the latter, mainly for the exact reasons that Halothane cites: it puts to sleep the higher brain centers that are responsible for memory formation and recall.

I think the response to intubation that your OMD is concerned about masking is indeed hypotension. I also think your educator muddies the water here. What causes the hypotension? Physiologically, people suck and ventilators (BVMs) blow. This is why it is called “positive pressure” ventilation. The respiratory cycle is turned on its head, in essence, although not from intubation itself but rather from the transition to positive pressure ventilation. Intrathoracic pressure increases, which translates to a lower cardiac output. All of the medications used for induction, and post intubation care for that matter, can cause vasodilation. As Paracelsus said, “the dose makes the poison.” This is where I tip my hat to Halothane and his profession, because they comprehend this concept much better than any of us here. Read up on it, this forum is certainly not capable of explaining it well enough. If you are performing this procedure, I think it is your responsibility for knowing it. Or, at the very least, recognizing how complex of a topic it actually is. It is not as black and white as it may seem. This is probably the main source of Halothane’s frustration, although not the sole source either.

Regardless of my opinion, Halothane is again correct in stating that ketamine provides analgesia at the doses you describe. The subdissociative, pain management dose for ketamine is generally accepted to be 0.2mg/kg IV. Dissociation occurs around 2mg/kg. Ketamine is a versatile drug, but again, it is not the panacea of post intubation care. It is a bit more forgiving, although this characteristic is again dependent upon the patient’s underlying physiology and the pathophysiology of their illness. I realize I am a broken record here, but this cannot be stressed enough.

So a well sedated patient, absent a painful injury or procedure is not experiencing pain. This is the point that Halothane is really trying to make, I think. This is true. The stimuli of the transport environment are not present in an ICU, which increases the sedative requirements. The presence of an injury increases analgesic requirements. The KISS approach is accurate, but at some point it has its limitations. My main point, particularly by posting the ICU sedation article, is that even in controlled environments it would appear that we aren't as good as we think we are at inducing the level of sedation that Halothane refers to. This is a slippery slope for EMS as illustrated by our general lack of understanding of the process. Until later...

 

[Carlos Danger]

I appreciate the hat-tip, VPIMedic.

So a well sedated patient, absent a painful injury or procedure is not experiencing pain. This is the point that Halothane is really trying to make, I think. This is true.

That is indeed the main point I was trying to make. Even if there is some nociceptor activation (pain) involved, if they are indeed well-sedated, they should not be feeling the pain.

Nociceptor activation has two basic effects: 1) it causes an autonomic (sympathetic) response which manifests clinically as tachycardia and hypertension, and 2) it causes an unpleasant conscious experience, which we call pain.

One way to limit the effect of nociceptor activation is to administer opioids which block pain impulse transmission primarily in the spinal cord, keeping the pain impulse from reaching the upper spinal cord, where the reflex sympathetic stimulation is generated, and also from reaching the brain, where the pain experience is generated. Think of giving fentanyl as "blocking the road" that pain signal has to travel up the spinal cord in order to get to the brain.

When you adequately sedate someone, you do nothing to "block the road" that goes up the spinal cord, so the impulse is able to reach the parts of the spinal cord where a sympathetic response is generated. However, sedation shuts down the parts of the brain that turn that electrical "pain" stimulus into an unpleasant experience. This explains why giving fentanyl works so well to blunt the sympathetic response to intubation. It's not that the patient feels any less - after an adequate dose of propofol or etomidate, they weren't going to feel the intubation anyway. But the fentanyl blocks the signal much earlier in it's travels towards the brain before it can elicit a sympathetic response.

In addition to blocking pain transmission in the spinal cord, opioids also have sedative effects in the brain (same basic mechanism as etomidate or propofol or versed, just different receptors), and also blunt the respiratory drive.

So when your vent patient on a propofol drip is still breathing against the vent and tachycardic, and you give them 100 mcg of fentanyl and they stop fighting the vent and their HR comes down, it probably isn't because they were experiencing pain before the fentanyl, it's probably because the fentanyl further sedated them, slowed their respiratory drive, and blocked any sympathetic response that was occurring in response to inadequate sedation. You would likely have had similar results just by increasing the propofol infusion significantly, though there are obviously downsides to that.

As you can imagine, the neurophysiology of all this is actually pretty complex, but this is kind of the down-and-dirty about the differences between using opioids and sedatives for post-intubation patient comfort.

The reason you hear things lately on blogs like EMCrit about how much better "analgo-sedation" is as compared to benzo- or propofol- based sedation, has less to do with short-term patient comfort and more to do with vent weaning and long-term cognitive outcomes of patients who are on a vent for several days or longer. I'm not aware of any studies that show superior patient comfort with a narcotic-based technique, or that the outcomes are affected at all by a very short-term regimen of benzo-based sedation in the prehospital or ED setting.

A post-intubation cocktail of versed and fentanyl or morphine is a really good way to go. It's simple, safe, and effective, and it covers all the bases and is pretty hemodynamically stable.

But if for some reason your protocols don't allow opioids, or only allow very small doses of them, do not fret about being "cruel" to your patients. As long as you can give adequate sedation (the "adequate" part is important, mind you), your patients are probably not suffering.

 

[18G]

And just like a recent discussion that occurred on Facebook regarding abd pain and treating it with narcotics by EMS. A Medical Doctor (like yourself having completed thousands and thousands of hours of medical training) was advocating an incorrect and outdated practice of withholding analgesia despite tons of evidence to the contrary. Education doesn't automatically make you right (not saying you're totally wrong).

The common sedatives that are given lack analgesic properties. Yeah, if you're giving high doses the patient won't be feeling anything. But 2mg of Ativan or 1-5mg of Versed every 30-45mins??? It's not gonna achieve that effect. So yes, these patient's feel pain and remember it. The body responds to this painful stimuli negatively. I see it all the time. Maybe not in an OR, but in an ED, ICU, and field environment where sedation often lacks, pain control is necessary. Treat the pain, achieve some sedation at the same time, and pack on the sedative as a bonus.

That's just coming from a dumb Paramedic on a 10th grade level so take it for what its worth.

 

[FLdoc2011]

In an ICU where I have patients on vents for days I just don't see these folks needing lots of opioids for pain control while in the vent.

Usually if adequately sedated they may not need any. Even in the patients lightly sedated who can still follow commands they usually tolerate the tube well without much if any pain.

Do I still have something available for pain if needed? Of course. But in practice it just hasn't been a bug issue like it seems to have been made here, though granted these are different environments with somewhat of a different patient population I'm sure.

All drugs have side effects and there may be times when I would like to avoid any opiates.

 

[Nova1300]

I think you owe a patient (who is not in shock) analgesia after intubation.

3 points

1. The endotracheal tube may not cause pain, but it is highly stimulating. The sympathetic surge can be detrimental to some patients, especially those with ongoing myocardial ischemia or those with increased ICP. Which account for a good number of patients who get intubated in the prehospital world. Benzos do very little to blunt this response.

2. Again, while the tube does not hurt, you know what probably does? Being hand-ventilated in a fast-moving vehicle. We overventilate, we over-distend, we move the tube around; At least ICU/ER patients have a nice steady ventilator rate, or they set their own. And their tube is sitting still.

3. Heavy drinkers and patients on chronic benzos can often require huge doses of versed before you start to see clinical effect. If your patient falls into this category, when your induction drug wears off you have a paralyzed patient with little to no sedation. And no analgesia. That kinda makes you a jerk

I will always advocate for analgesia before sedation. Pain only makes patients combative and delirious. And throwing benzos at it only worsen the problem. I treat the pain, and if that doesn't work I move on to sedation.

 

[Sublime]

I want to thank everyone for their posts so far. I really do appreciate your input and opinions. However Halothane you have really persuaded me and changed my perspective on this topic. Posts like your last one are why I continue to use these forums. I really do feel enlightened on the topic.

Now if you don't mind I would like to further pick your brain.

In your first post you recommended 0.1mg/kg of versed as a post intubation dose. This seems like a pretty fair dose to me. Our protocol as I stated is 2.5 mg IV q10 to a max of 10mg. I'd say this is a rather small post intubation sedation dose. I'll admit though I have only been a medic a couple years and have very limited experience with this. If I was going to present to the education department and my medical director about increasing our flexibility with the dose or adding ketamine for post intubation purposes, what is your opinion on how to best approach this? I've googled for some papers or research I might use but I have found anything specific enough to apply to my argument. Not asking you to do the work for me, I just would like to hear your opinion, you obviously have much more experience and knowledge about this than I do.

Thanks!

 

[18G]

There is an article in this months issue of Emergency Physicians monthly on post-intubation sedation and advocates goal #1 being treating pain with fentanyl.

 

[Carlos Danger]

Now if you don't mind I would like to further pick your brain.

In your first post you recommended 0.1mg/kg of versed as a post intubation dose. This seems like a pretty fair dose to me. Our protocol as I stated is 2.5 mg IV q10 to a max of 10mg. I'd say this is a rather small post intubation sedation dose. I'll admit though I have only been a medic a couple years and have very limited experience with this. If I was going to present to the education department and my medical director about increasing our flexibility with the dose or adding ketamine for post intubation purposes, what is your opinion on how to best approach this? I've googled for some papers or research I might use but I have found anything specific enough to apply to my argument. Not asking you to do the work for me, I just would like to hear your opinion, you obviously have much more experience and knowledge about this than I do.

Thanks!

Well, to my knowledge there is unfortunately no research that shows that prehospital post-intubation sedation practices have any impact on outcomes, so you probably can't approach it from an EBM perspective.

I'd say, try to point out that the overall trend in EM is towards much better post-intubation comfort measures, for purely humane reasons. We are supposed to do what we can to make our patients comfortable. What would your medical director want his wife or daughter to have after intubation?

Increasing the dose of versed, adding fentanyl, repeating the ketamine, all are good options.

Honestly, I'd comb through the physician-led blogs and find the articles and podcasts that argue for better sedation practices and find a way to present those arguments. EMCRIT is a good place to start.

Feel free to PM me if you want. Good luck.

There is an article in this months issue of Emergency Physicians monthly on post-intubation sedation and advocates goal #1 being treating pain with fentanyl.

I saw that a few days ago and wondered whether someone would mention it in this thread.

Fentanyl for sedation is the hot thing right now in the "ED critical care"/FOAMed/EM blogoshpere. Last year it was ketamine. I understand why....fentanyl is a good drug, and it's cheap. It's sympatholytic properties certainly make us feel better, too, similar to how we feel better when we give a bunch of fluids to bring a trauma patient's SBP up to 100.

However, the article presented no evidence that fentanyl-based sedation provides better patient comfort that hypnotic-based sedation. It doesn't really address anything that has been discussed in this thread.

 

[MSDeltaFlt]

It's about time I read a thread here that peaked my interest. Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack. Keep it coming.

 

[FiremanMike]

It's about time I read a thread here that peaked my interest. Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack. Keep it coming.

Can you elaborate? I took a pretty decent airway class that made me a believer in SIMV>AC, I'd love to hear some counterpoints..

 

[VFlutter]

So yes, these patient's feel pain and remember it. The body responds to this painful stimuli negatively. I see it all the time. Maybe not in an OR, but in an ED, ICU, and field environment where sedation often lacks, pain control is necessary. Treat the pain, achieve some sedation at the same time, and pack on the sedative as a bonus.

Just some anecdotal observations. Most of our ICU patients have intermittent Fentanyl (50mcg q30 or 100mcg q1hr) orders but the majority of our post intubation care is sedative based (Intermittent Versed, Diprivan, Precedex). Most patients receive very little, if any, Fentanyl. We turn off all sedation and narcotics prior/during weans. I have never had a patient get extubated and tell me that they were in extreme pain or being tortured. Nor has anyone told me they remember their intubation or time after. Was it uncomfortable? Of course. But it is usually tolerated.

It would be great to snow every patient so there is absolutely no chance they would feel any sort of pain or discomfort. We would also be traching a lot of patients for failing to wean.

 

[Carlos Danger]

It's about time I read a thread here that peaked my interest. Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack. Keep it coming.

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..

Let's move this part of the discussion to the mechanical ventilation discussion I recently started. I copied these posts over there, hope no one minds.

 

[18G]

I'm talking about post-intubation analgesia in the pre-hospital, ED, and inter-facility transport setting. ICU care is a little different.

Just some anecdotal observations. Most of our ICU patients have intermittent Fentanyl (50mcg q30 or 100mcg q1hr) orders but the majority of our post intubation care is sedative based (Intermittent Versed, Diprivan, Precedex). Most patients receive very little, if any, Fentanyl. We turn off all sedation and narcotics prior/during weans. I have never had a patient get extubated and tell me that they were in extreme pain or being tortured. Nor has anyone told me they remember their intubation or time after. Was it uncomfortable? Of course. But it is usually tolerated.

It would be great to snow every patient so there is absolutely no chance they would feel any sort of pain or discomfort. We would also be traching a lot of patients for failing to wean.

 

[TransportJockey]

Our protocols are rather lax. They are: BIS readings of 40-60. That's it. We have our choice of medications (Propofol, Versed, Valium, Ketamine, Fentanyl) to use for it, with standard dosing of each. But the primary thing is a BIS of 40-60, we titrate meds to it, along with our other vital signs.

 

[Carlos Danger]

Our protocols are rather lax. They are: BIS readings of 40-60. That's it.

I'm suprised to hear that. Lots of research questioning the utility of the BIS - even in more controlled settings - while clinical signs are simple and reliable.

http://www.ncbi.nlm.nih.gov/m/pubmed/23708914/

 

[TransportJockey]

I'm suprised to hear that. Lots of research questioning the utility of the BIS - even in more controlled settings - while clinical signs are simple and reliable.

http://www.ncbi.nlm.nih.gov/m/pubmed/23708914/

We use the other clinical signs but we are doing a trial on the BIS.

 

[chaz90]

We use the other clinical signs but we are doing a trial on the BIS.

Is this a separate device that's able to monitor BIS in the field? Being mostly ignorant in the ways of CCT and IFT I hadn't even heard of this being done pre-hospitally before.

 

[TransportJockey]

Its made by covidien. Its a four channel monitor if I remember right.