This is the first guideline from a new project called Foundational Stabilization (FoundStab). The podcast goes into a more extensive introduction, but in short, I need your help to create a bedrock level of care across all venues in which a sick patient may show up. This should become the new foundation, the absolute lowest level of care that we deem acceptable. Even more advanced resuscitative and critical care can be built on top of this foundation. This is a crowd-sourced project–it only works if you comment, so please do!!!
Provisional FoundStab Guidelines for Post-Intubation Sedation for Adults
Note: This guideline is not applicable for crashing or exsanguinating patients
Sedation
1. Use Propofol over Benzos for sedation
2. Standard Propofol Dosing is 20-50 mcg/kg/min
2.5 If you intubated with rocuronium, use higher doses of propofol and/or administer midazolam 2-4 mg
3. Use a sedation scale to allow quantification and titration of sedation
If your hospital doesn't already have one, we recommend the RASS
Aim for sleepy, and arousable to voice (RASS -1 or -2) unless clinical circumstances dictate deeper sedation
Pain
4. Start with a bolus of opioid pain medication
e.g. 0.5-1 mg hydromorphone or 0.1 mg/kg of morphine
5. If transferring the patient, consider starting a fentanyl drip or administering a long-acting pain medication bolus just prior to transport
6. If keeping the patient, check for the need for additional intermittent boluses of pain medication q1 hour
7. Use a pain scale with hourly assessments for pain
If your hospital doesn't have one, we recommend the CPOT score
8. Do not titrate pain or sedation medications for hypotension
Misc.
9. Call for norepi to be hanging at bedside on pump after every intubation with a standing order to begin if MAP < 65
10. Intubated patients in the ED should have soft, wrist restraints places without the need for arduous, high-risk documentation or sitters
Additional New Information
More on EMCrit
- EMCrit 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium (PAD)
- EMCrit 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare
- EMCrit 331 – Awareness after Resus RSI and ICU Paralysis – It is Unacceptable!!!
- EMCrit 324 – Rural Resuscitation – Foundational Stabilization [Primer]
- EMCrit 330 – Rural Resus Explosion
Additional Resources
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 389 – Massive Transfusion Update and Hemostatic Resuscitation - December 1, 2024
- EMCrit 388 – Experts' Guide to the Bougie with Barnicle and Driver - November 22, 2024
- EMCrit RACC Lit Review – October/November 2024 - November 7, 2024
As a paramedic working in a primarily rural setting i really love this project. I like the idea behind the transfer recs. I’m not sure there can be a universal recommendation for a specific med. While some transport teams may be limited in the type/amount of pain medicine they can give, at this point, those teams are in the minority. Maybe the rec could read “If transferring, ensure adequate availability of enroute analgesia and sedation” I think a generic rec of a 2-3 times the anticipated transfer duration worth of meds is also reasonable. Perhaps also a note about many… Read more »
#1: 10mcg/kg/min of propofol seems very low…20-50mcg/kg/min as a suggested range?
#3: I don’t think a generic RASS target as you suggested in the podcast is adequate. Some pathology need a RASS of -5 initially: Raised ICP, Status epilepticus, severe bronchospasm, severe ARDS, etc…which ends up being a non-significant portion of the pts we intubate in the ED.
Love the idea. As a GFL flight medic, this info should also apply to paramedics, or at least IFT/CCT medics. Upstairs care downstairs translates directly into inside care outside. Prop over benzos…I understand it, but it’s tough to keep them down in a loud plane…which leads to pushes of either benzos or prop. Or reparalyzing, god forbid. Maybe instead, go with “no isolated benzos”? Mitigates the 5mg/hr versed drips by forcing a second drop of something. Worst case, it’s fentanyl. Best case, it’s fent/prop and no versed at all. I’m writing off ketamine entirely here cuz I just don’t see… Read more »
Love the idea Scott and given you know where I work and the very foundation I’ve been trying to build I would be happy to help in anyway needed Given the broad audience we’re shooting for, would it be helpful to assume some know less that what’s stated – ie #4 “ Start with a bolus of pain medication.” and provide even more foundational support such as pharmacological examples (drug name and starting doses etc)? I’d love to see this get to a “plug and play” level for the targeted audience. On #8 “ Do not titrate pain or sedation… Read more »
I love this concept of providing baseline guidelines for managing critically ill patients. I think this would be extremely helpful, especially in the rural setting. The transport guidelines are especially useful to safely get our patients to higher levels of care. Please let me know if I can be of assistance with this project!
2.5. place time cap on high dose propofol s/p rocuronium (~30-60min post intub) 3. Not sure goal rass in ED should be -1 to -2, that’s more of the end-goal once stabilized and in icu having had time to sort things out and decide it’s safe, appropriate and even possible (many delirious, intoxicated, brain injured, etc pts, esp early in their course, seem to be in much more of an all or nothing sedation category and those rass scores aren’t achievable at least not safely) to safely maintain that light of sedation. Always want to use least sedation necessary but… Read more »
We’re talking about sedation in the ED…But I can t see ketamine anywhere…
Seriously…why not starting a ketamine infusion post intubation in the ED? In many cases it’s the safest fastest easiest option in a crowded enviroment like the Resus room.
But I rarely see this strategy been adopted
Cant get why
There really isn’t much of any evidence out there re the use of ketamine infusions in intubated pts for sedation. We do it, but the evidence is so much more robust for propofol, dexmed, fentanyl that there really isn’t a need. Safety isn’t clear, some evidence of worsening hemodynamics in cardiogenic shock pts, unclear how to titrate/dose it (probably not simple linear dose-effect instead prob pain dose> recreational > subdissociated > dissociated, not like the others). At this point it’s adjunct to the others, or less evidence-based alternative to midazolam as 4th or so line.
Scott, have an agenda re: pediatric version? Could be helpful to offer best practice differentiators and when to go ahead with typical adult practices, whether for simplicity’s sake or bc adult practices don’t differ from that of peds. Happy to assist.
If you are paralysing and want amnesia… Midazolam is quite short… why not a longer agent eg clonazepam or lorazepam ?
Delirium and mentation impairment and failed extubation / prolonged intubation are all proportional to how much and how long benzodiazepines are used, all else being equal.
Not that they aren’t helpful. I usually have a Midaz 1-2 mg dose PRN on all my intubations, but it is limited to 5 doses before it needs an MD to renew. So the RN’s can use it while up-titrating drips.
Love this idea.
I’m an emergency physician as well as an administrator, running a rural hospital in Lithuania, Europe.
Having a concept of “what is a must” is so neccessary.
I’d love to contribute my time and resourses to making it happen.
Thank you for this! Especially not titrating your sedation to pressure. We know sedation drops BP, like you say, have levo ready. Its awful to have someone intubated and not well sedated. Hang your levo- Just do it, your patient will appreciate it.
I’m intrigued – and may have misheard (have never worked medically in The States). Was point 10 that all intubated ED patients should be mechanically restrained then leave them unattended except for a check-in by the nurse every 15 minutes, as a foundational standard of care?! And what is a ‘sitter’?
David Jarvis, MD – Wisconsin, USA Doesn’t mean no attention for 15 mins or longer. In my experience, RN(s) are usually 1:1 w pt for the first hour after intubation. But after that, they have to care for their other pt’s. The soft restraints are helpful for keeping the pt from hurting themselves for the 15 seconds it takes vent and bed alarms to get staff back into room. A ‘sitter’ is a 1:1 trained person sitting or standing next to the bed. Doesn’t have to be a nurse. Is often a Certified Nurses Aide or Medical Assistant. I’m lucky… Read more »
I realize for your listeners and readers it’s obvious but for the found stab project with regards to the pain tool should it be stated that any score above a 0 in any category is an indication for additional pain medication? Same with RASS? I guess we shouldn’t assume all providers know what to do with the numbers
This is a great project!
One addition I would make is that there should also be as needed boluses of propofol. People often use 100mg (or more) to sedate a patient then start them on 10mcg/kg/min only to have them quickly wake up. They then slowly up-titrate while the patient is waking up and fighting the vent (and occasionally restrain or paralyze them instead of adequately sedating them). This is especially true for young people with a substance use history. Adding a 50mg bolus of propofol with each up-titration helps gain rapid control while improving comfort and safety.
Hi Scott, Great Idea ! I think you intentionally made a few mistakes – so below are my suggestions for corrections: 1 *Except for patients in hemorrhagic shock (trauma, GI bleeding) – propofol may cause profound hemodynamic instability in those patients, even in “homeopathic” doses. Benzodiazepines or ketamine (my choice) in bolus or infusion form are much better options. 2 Midazolam 2-5 mg range, 2 mg is insufficient in many young patients and may not prevent recall. Hypertension and tachycardia may point out to those with awareness. 4 and 6 Fentanyl should be a drug of choice due to speed of onset… Read more »
Discuss with your transport team if they can take narcotics out of a sending facility, my team (big company) can not. We have to use our own CDSs so the fentanyl drip almost always turns into intermittent bolus. If this is the case spare yourself the trouble.
I’m an EM surgical critical care trained doc working in a rural ED and would love to join the team to review and create these policies
A few thoughts when intubating with Roc; Roc duration of action can be as long as 40-70min. In the first hour post RSI, RASS scale is not valid to asses sedation needs, as what we are seeing is likely still paralysis. Also, precedex alone is not deep enough sedation for a patient who still has paralytic on board. Guidance on how to titration these drips/goal rates during the 1hr post-Roc would be a great addition.
please see emcrit.org/331
Love the idea. One thing is that Fentanyl is rubbish for post-intubation sedation, Alfentanil is much better for ED sedation. Fentanyl acumulates so much (due to the context-sensitive half-time CSHT) alfentanil is a balance between fentanyl taking ages to wear off, and remifentanil wearing off immediately (well, over 5-10 minutes) so in ED there is enough time to make another syringe of alfentanil. Alfentanil is also available neat; so no dilutions needed improving safety!
Disclaimer: I’m practicing as an anaesthetist in the UK, not the US, but I assume you still have alfentanil infusions available.
nope, not available in any EDs or Crit Care Units in the US, though our anesthesiologists have it. I do not think it is available in UK EDs either though the ICUs there may have it
Regarding the analgesia in point 4: I assume you mean 0.1mg/kg for morphine, not 0.1mcg/kg
thank you