EMCrit Podcast 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare

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.

Additional References:

Payen JF, Chanques G, Mantz J, Hercule C, Auriant I, Leguillou JL, Binhas M, Genty C, Rolland C, Bosson JL. Current practices in sedation and analgesia for mechanically ventilated critically ill patients: a prospective multicenter patient-based study. Anesthesiology 2007; 106: 687–95.

Rozendaal FW, Spronk PE, Snellen FF, Schoen A, van Zanten AR, Foudraine NA, Mulder PGH, Bakker J. Remifentanil-propofol analgo-sedation shortens duration of ventilation and length of ICU stay compared to a conventional regimen: a centre randomised, cross-over, open-label study in the Netherlands. Intensive Care Med 2009; 35: 291–8.

Gelinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain 2007; 23: 497–505.

Gelinas C. Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive Crit Care Nurs 2007; 23: 298–303.

photo by brentbat

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  1. Mohd Anizan Aziz says

    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


    • emcrit says


      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.


  2. Sean Marshall says

    I’m listening to this podcast for a second time and I think it is very smart. I am wondering if you have any objective criteria of when you are happy with pain control and move on to a sedative. Do you aim for a RASS target with your fentanyl alone? I didn’t think RASS would be specific enough for physiologic signs of pain. I notice that there are tools similar to RASS which look at pain specifically such as CPOT but it looks a little less user friendly than RASS and I think using multiple overlapping tools would be cumbersome.

    I would also like to get your take on Freire AX. Crit Care Med.2002;30(11):2468. It seems to suggest that adding an analgesic infusion tends to commit the patient to increased monitoring and longer ICU stay. I’m not sure I buy this if drugs are titrated to a target.

    Thanks for all the great info.

  3. Gord Hannis, ER RN says

    Dear Scott,

    I recently discovered EMCRIT, and I LOVE your podcasts! I am an Emerg RN in British Columbia, and will heartily recommend the podcasts to my colleagues, nurses and docs.

    We always give prophylactic Dimenhydrinate (Gravol) before Morphine for acute pain management- however I’ve never seen anyone give Gravol post-intubation, before we hang the usual M&M infusion (Morph & Midaz).

    Do you think it’s worth adding an antihistamine/anti-emetic to your post-intubation sedation package?

    Best regards, Gord Hannis, ER RN

    • says

      If you use morphine, this might not be a horrible idea, though I have not seen data on this. However, no gain if you use fentanyl or hydromorphone.

  4. ByL says

    This is just an FYI from one who has been there, done that and refused the t-shirt:

    I am an RN and a former patient. I’ve worked in ICU and have been a patient in ICU, intubated many times r/t an issue I had at birth and multiple surgeries over my life to correct it. For me, the times I’ve awakened intubated were the absolute worst experiences I’ve ever had in my life. As an RN, I’ve seen pt’s handle being intubated quite well. I’m not one of those pt’s. And morphine or fentanyl didn’t work so well for me. Propofol and dilaudid did. Versed also works well to keep a patient from remembering the horrors of the experience. I know, some pt’s can’t handle such strong meds and each case can be unique but please don’t ever assume that your intubated pt is fine, mentally or physically. Pain, confusion, frustration, the need to use the bedpan but being too proud to want to go that route, being tied down and unable to communicate, not to mention that godawful tube in your trachea that can make you feel as though you’re suffocatiing even though you’re not. All this or even some of it can compound to make one horrendous experience for the patient that they may not fully come to terms with until they get out of ICU or even back home again, if they’re that fortunate. I’ve been that fortunate. I don’t think about how many bad experiences I’ve had. I think of how I got past them. Try to put yourself in their place. I know there are some wonderful nurses out there, but there are also some arrogant, ignorant people who are nurses who may well know the material but are terrible at relating to a patient. Try not to be one of those. You and your patient will feel better about it. :)

  5. Lakshay says

    Today I came across this patient, 34 years old male, florid septic shock on NORAD and Vasopression infusions with a BP of 60/40 (arterial line), of Course he was intubated and paralysed but no pain relief or sedation was given post intubation due to fear of hypotension. I noticed tears coming out of his eyes and a heart rate of 180/min but could not help. I would have started fentanyl drip for him but the consensus was not to give any pain relief, just lorazepam 4 mg IV.


    • Alan says

      Glad it wasnt me. Person responsible would have been in court for battery and false imprisonment. Thats whats wrong with the medical profession, there is very little concern for patiens as people.

  6. Lakshay says

    He also had 2 episodes of seizures Along with sepsis, and we were not sure about the possibility of raised ICP or a intracranial bleed secondary to thrombocytopenia (platelet count – 15000), so ketamine was not given.

    • says

      The idea that ketamine will negatively affect ICP in a normotensive or especially in a hypotensive patient has been debunked as a myth. See Minh’s recent PHARM podcast.

  7. Lakshay says

    Oops.. I was aware about the fact there is some conflicting data from human and animal studies ..but if its a myth I ll definitely keep ketamine as a option next time.


  8. Alan says

    I will never have Versed under any circumstances or for that matter any of the amnesiac drugs. They are dangerous and their only purpose is to make the patient “easier to handle” for the medical staff. I will also never permit intubation. If nature had intended me having tubes sticking out of me then I would have been born with them. I will allow non-invasive ventilation but nothing more.

  9. Kate says

    I disagree that there is little concern for patients as people. I think that two issues predominate here – first, the patient is unable to tell you about their pain or discomfort or demonstrate it. Therefore we need more education (thanks Scott for being a champion of these patients) at a baseline level – this should be hammered home in residency like “don’t lose the wire” in central lines!
    Second, we are scared to death of doing harm, ie, killing the patient. Again, this comes down to education and workarounds for specific situations as described above.
    I just don’t buy – “medical professionals don’t care about patients.” Please give us more credit than that. Hopefully we can improve this together.


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