One that made me happy, One that made me sad

I recently came across two articles pertaining to the peri-intubation; one made me very happy (b/c it reinforces my prejudices) and the other made me quite upset (b/c it reinforces my prejudices).

Let’s start with good tidings first:

(PMID: 22610185)

In this prospective, observational trial the use of NMBAs was associated with a lower incidence of hypoxemia and complications. NMBAs also led to better intubating conditions. Now during the debate with Dr. Paul Mayo I showed a bunch of articles that said the same thing, so why is this one so important? Because this was done in a setting that really matters to EMCrit readers: the ICU. What we have known for at least a decade is that ED/ICU intubations are an entirely different animal than OR intubations. So now we have further proof of what I have always believed–if you are a skilled airway operator, paralytics will improve your intubating conditions.

Now the not so great:

Note: I am not the author of this paper, nor am I related to him.

Thanks to Minh of the Pharm for pointing this one out to me.So here is the paper’s conclusion: Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers. Now I’m not sure if some of these patients were so deeply comatose that the team felt no sedation was necessary, but I can’t imagine it is a huge fraction of the patients that did not get sedation. This makes me so sad. The relief of pain and suffering should be our first priority as doctors. How can this still be going on?

(PMID: 22770915)

Update: This article in-press says the same thing–frown

(Chong ID. Long-acting neuromuscular paralysis without concurrent sedation in emergency care. American Journal of Emergency Medicine 2014;In-Press)

Tell me how these articles make you feel (b/c EMCrit cares) in the comments:

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Comments

  1. I’m with you r/t the articles. I have been using muscle relaxants intubating in the ICU for the past 10 yrs, never regretted it yet! Being on the anesthesia side of the fence, I think it’s cruel not to sedate before intubating almost anyone, ED or elsewhere.

    • Brian, thanks for commenting. Despite their misleading title, that 2nd article was actually dealing with post-intubation sedation. I would say close to 100% of patients with any mental status get pre-intubation sedatives.

  2. Scott,
    Working at an University Flight/Critical Care shop, we tend to do a lot of IFTs from smaller community hospitals. I can recall at least 4 instances in the past 6-8 weeks where we’ve been sent for patients who’ve received no sedation at all during their ED stay. At bedside, a referring ED attending told me (when asked about sedation) that “we’ve been giving Vec boluses every hour.” We’ve made sure to establish proper analgesia/sedation for these patients, while also trying to educate. These patients underwent pre-intubation, NMBAs and the post-intubation period with no analgesia or sedation, while being A&O prior to the procedure. Few things make me as sad as arriving to the bedside of a patient who’s intubated, restrained, tachycardic, eyes taped shut, and following commands. But it’s happening…..

    • Aaaagggggghhhhhhh!

    • Rebecca says:

      Unfortunately you aren’t the only one who is seeing this. I used to see it on a fairly frequent basis when I worked on the adult side of critical care transport (although it was usually only the post-intubation sedation and analgesia that was missing). When I switched to pediatric critical care transport I saw an even higher rate of absent pre- AND post-intubation sedation and analgesia. It’s one of the most aggravating things to deal with because it would have been so easy to have prevented needless suffering.

    • Don Diakow says:

      Have to chime in here as well. Have flown a few missions landing in small centres where we received what we call here in Alberta a patient “Buried alive”. Never forget a ped patient we had from a MVC etube laying on a backboard in a small ER and the Doc telling me he has maintained sedation with a NMBA? Poor kid was tachy, hypertensive tears streaming down his face. We immediately went the Fent/Midaz route. Happens more times then I would like to mention………..

  3. Absolutely with you on these issues. My perception is similar on both, too little use of NMBAs (curiously overused postintubation with CMV instead of A/C) and bad/no sedation. Absolute lagunas in postintubation analgesia – sometimes arriving at retrieval and wonder if my high BP and tears top patient’s.
    On that issue about RSI & NMBAs, our patients mostly needed ETI 5 to 15 minutes ago so there’s no time to play around: optimize organisation, team, drugs, skills and give it your best (first) shot…

  4. I forgot:
    In total balance still is too sadness: second article way more depressing than first.
    But remember: Sisyphus didn’t stop pushing that boulder uphill neither!!!

  5. Cory Brulotte says:

    I am a regular listener Scott but cannot recall a full length episode discussing the basics of post intubation sedation and management (but I haven’t had a chance to look them all over recently)… med doses (sedatives and analgesics), regimens, specific to case scenarios (altered NYD, stable VS, unstable VS, asthmatics / COPDers, etc). It sounds like a great potential podcast and opportunity to reinforce proper post intubation management with the listeners.

  6. I’m only a nurse, so can’t speak from the same perspective as MD’s, but nothing quite breaks my heart like looking after a paralysed but not sedated patient. The amount of time we spend bolusing vec, trying to stabilise BP/HR and wiping away tears…yet some still refuse to consider sedation. It feels like a little part of me dies every time someone is so callous towards their fellow human beings…

    • xerxes1279 says:

      Is there some school of thought out there are certain patients who should not receive sedation? I’m only a resident, but I have never seen or heard of this, and frankly it’s kind of scary. I thought the people who think that propofol provides analgesia were being cruel!

      • Even in high-level academic centers there is still this ridiculous meme saying a patient with borderline blood pressure is “too unstable” for sedation and analgesia. These bad doctors are forcing the patient to maintain their BP by pain/misery induced endogenous catecholamines. All of these patients could get put on an external pressor drip and have their pain fully relieved with the SAME blood pressure as they were generating.

        • Craig Button says:

          Not only Bad Docs, but bad nurses also. Well at least nurses without a solid education. In the ED there is so much focus on the BP, that they don’t pay to much attention to anything else. One of the flaws of nursing education is that it scares nurses, and makes them scared to combine a “low” BP and opiates or anxiolitics.

  7. minh le cong says:

    morphine and midazolam infusion is pretty standard fare for post intubation care in Australia. 50mg of each made up to 50ml syringe, 1:1:1 ratio, starting rate of 5mls/ hr. thats a de rigeur Happy Meal sedation/analgesia package for those of us trained in Oz. Occasionally I use fentanyl in generous doses by itself, perintubation. ..and some times an infusion. but thats reserved for cases I am not sure what the haemodynamics are going to do post intubation, even with ketamine. guillain barre comes to mind. I dont understand this research findings out of US EDs . and the followup comments from US crit care providers.

  8. Elisha T says:

    Scott, thanks for sharing these articles and your opinion. I think pre + post-intubation checklists can potentially help circumvent the issue. When there are docs, nurses and RTs at the bedside, there is no excuse for forgetting/?neglecting to sedate. A preprinted checklist/ppo for ED intubations would be a useful reminder, with suggested sedation regimens like most ICUs have.

  9. Oliver Hawksley says:

    I’m amazed that patients are paralysed without sedation. If I saw or heard of that in the UK I’m sure all hell would break loose. Propofol / alfentanil or morphine and midazolam would be standard for most cases. Surely it’s a basic standard of care?

  10. Minh Le Cong says:

    YoU folks doing CCT in USA have a term for this ? Don’t you need to do an anesthesiology term before you are accredited to RSI? I mean ED training etc not just CCT

    • Don’t have to do CCT to do RSI in some of the USA. A service may require only continuing education, medical director sign-off and 2 RSI signed-off paramedics be present. Our State does require all RSI’s be reviewed at the local and state level though.

  11. James French says:

    This really happens? In the UK we have a nasty habit of justy giving propofol and no anagesia which drives me nuts. I actually cant think of anyone that wouldnt get vitamin F (fentanyl)…..if they were flat from a palliative process they’d get it anyway to “rule out” pain perception. If they are “too shocked” from bleeding, they would get Duttonesque delviered fentayl to reverse vasoconstriction in a titrated way and then fill the space. The only time they wouldnt get fentanyl is if they were a crashing asthmatic and they would get ketamine to reduce Histamine secretion (which is a local preference)….but that’s it!
    This is medically sanctioned torture and is illegal. Im serious! I think you are commiting a criminal offence by not analgesing your patients that are paralysed! I can feel a session on the heavy bag coming on…..

    • L. Murphy says:

      It happens in the US, too. I’ve seen entirely too many patients intubated in Resus and then placed on a propofol drip with no regard given to pain control. Apparently there’s another meme going around among ED personnel that propofol is the perfect sedative and completely provides for all patients’ needs on the vent – and when it doesn’t, you just re-paralyze. Sigh…

  12. The hesitation to properly sedate patients is especially apparent in the neuro population. During EVD placement I frequently hear, “Let’s turn the propofol down, she’s getting hypotensive” Leaving a chemically paralyzed patient possibly awake.

    As a result of EMCrit I have been advocating for keeping the sedation at an appropriate level and giving a couple push doses of phenylephrine (to keep MAP >65) while the drain is being placed, maintaining adequate sedation and perfusion.

  13. Just saw an intubation today with paralytics/ no sedation. I am at a large level 1 trauma teaching hospital. We had 2 trauma alerts and one medical code all at the same time while the other attending was tied up in a procedure. We had a sick blunt trauma,hypotensive, pale as a ghost pt with a positive fast. Em is supposed to do all trauma airways. I went to check on the medical arrest with the plan to return and assist the resident in intubating this guy. In the brief time I was gone anesthesia swooped in and then refused to give us back the airway. At that point I did not want an argument to endanger the life of this critical pt so i decided to watch. First they did not actually( just 2 l nasal cannula) pre oxygenate the guy and they gave roc without sedation. I was shocked. I would have much rather us manage the airway, I would have at least used ketamine ( and actually preox as well). They said they did not want to give him meds due to his bp.

  14. This could be an interesting topic for research. What physician factors are associated with no or sub-optimal sedation pre or post intubation. When was their training, what were they trained to do, where were they trained, etc. The emphasis on pain management is still relatively new; it wasn’t long ago that docs were taught to withold pain meds for abdominal pain because it “hindered diagnosis” among others (actually there is still an abundance of docs who believe this). And if anyone is familiar with Dax Cowart (the subject of many medical ethics lectures), you might recall that when he was treated for ~70% BSA burns, he was given little to no analgesia or sedation during the many treatments and debridements, which were carried out at one of the most famous burn centers in the US. Sure, it was the 70s, but how long did it take for that practice to die out? Maybe it is time to institute quality measures for sedation. My most recent horror story was a Pulmonary & Critical Care physician not giving sedation to an intubated patient and then proceeding to perform a bronchoscopy. Half way through the procedure he ordered 1mg of versed. *facepalm*

  15. Ed Valentine says:

    Like everyone else I’m stunned that this practice goes on! Here in the UK if a patient was left paralysed and with no sedation that would be viewed as a critical incident and taken very seriously. (We’re not entirely blameless in the UK though – I’ve lost count of the number of times I’ve seen propofol alone used post intubation in patients with multiple painful injuries, with no attempt at any actual analgesia).

  16. Mike Jasumback says:

    Scott,

    Great timing, I’ve been asked to give a presentation on this topic at the CEP America CME conferences in spring 2013. Hope to get to 600 practitioners and stomp out this despicable practice (or lack thereof)

    Mike

  17. Hi Scott – I’ve been looking back at your posts on post-intubation care, again frustrated with no sedation/ no analgesia/ started too late/ or just too little. Finished nights where my colleague was looking after an intubated patient – & transferred her to CT, where she promptly sat up – too little of everything! On arrival the following night, another pt self-extubated. I recall another pt last year I was called to on an ever increasing propofol infusion (with nil analgesia), still agitated and producing tears, to which I was asked “shall we increase the propofol, or give muscle relaxants”.
    We seem to dedicate a lot of training (rightly) to RSI, but the approach and effectiveness of ongoing analgesia and sedation is patchy and inconsistent. I think I might borrow some of your rants for a teaching session.

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