All the way back on Podcast 21, I advocated for better post-intubation sedation in the ED. Well, now it turns out that if you are still using just lorazepam and vecuronium you are now even further from the ideal.
2018 PAD Guidelines Update
It is all about Sleep and Orientation
Bad sedation strategies destroy sleep architecture and orientation, then patients become crazy.
Delirium=Death
- The impact of delirium in the intensive care unit on hospital length of stay. Intensive Care Med 2001; 27:1892–1900
- Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291:1753–1762
- Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med 2009; 35:1276–1280
- Delirium leads to long-term cognitive impairment (N Engl J Med 2013; 369:1306-1316) HT to @icudelirium
- Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009; 180:1092–1097
- Deep sedation associated with higher mortality (Critical Care 2015, 19:197 )
It doesn't matter if we screw it up Downstairs, they can Fix it in the ICU
Ummm, not so much if you believe the SPICE Study-In 251 critically ill patients at multiple centers, we identified deep sedation within 4 hours of commencing ventilation as an independent negative predictor of the time to extubation, hospital death, and 180-day mortality. The early phase of ICU sedation is usually unaccounted for in randomized controlled trials due to late randomization. (Am J Respir Crit Care Med Vol 2012;186(8):724–731)[cite source='doi']10.1164/rccm.201203-0522OC[/cite]
A1 Sedation – Analgesia First
Stick your finger down your throat–now leave it there
Strom et al. evaluated this: RCT of 140 patients-analgesia vs. analgesia+sedation. Analgesia only showed shorter vent time and ICU LOS.[cite source='pubmed']20116842[/cite]
Analgosedation: a paradigm shift in intensive care unit sedation practice,[cite source='doi']10.1345/aph.1Q525[/cite].
Just put patients on a fentanyl drip. If not go with dilaudad IV. When remifentanil is cheap, we'll switch to that in a bunch of patient categories.[cite]15329588[/cite]
Then evaluate pain and decide if the patient needs additional pushes of pain meds.
Consider using the Behavioral Pain Scale (Crit Care Med 2001;29(12):2258) HT to Nikolay Yusupov
Myth – We can prevent PTSD if we Black Out the ICU Experience
just the other way around
Myth – Benzos are just Swell
Not so much-Benzos lead to longer length of stay, longer vent time, and increased delirium.
Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials,[cite source='doi']10.1097/CCM.0b013e3182a16898[/cite].
Myth – Short-Acting Sedatives and Analgesics Go Away Quickly
You need a goal, like RASS
Here is the RASS Scale from the amazing ICU Delirium Site
Myth-Pain is a Great Pressor
Patients should never be undersedated due to hemodynamics
Patient Scenarios
Standard Critically Ill Patients
Fentanyl and Dexmedetomidine (or Propofol)
Neuro Patients/DTs
If you have ICP issues, propofol and fentanyl
Hemodynamically Compromised Patients
Fentanyl and then,
Ketamine drip or intermittent boluses
What are they doing in the ICU?
In patients with protocolized sedation, daily sedation interruptions (holidays) did not lead to demonstrable benefit. The SLEAP Study (JAMA 2012;308(19):1985)[cite source='doi']10.1097/CCM.0b013e3182a168c5[/cite]
The SCCM Guidelines
ICU Delirium Site Protocol
A Lecture on the SCCM Guidelines
By a masterful teacher, Dann Herr. Courtesy of the Maryland CC Project
Here is the Protocol
Dr. Herr created for the STC Center (STC Pain Sedation and Delirium Protocol)
Must Read Reviews
- Top 10 myths regarding sedation and delirium in the ICU,[cite source='doi']10.1097/CCM.0b013e3182a168f5[/cite]
- Sedation and analgesia in the mechanically ventilated patient,[cite source='doi']10.1164/rccm.201102-0273CI[/cite]
- Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies,[cite source='doi']10.1055/s-0033-1342983[/cite]
- An economic review of dexmedetomidine (Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care – an economic evaluation [cite source='doi']10.1186/s13054-015-0787-y[/cite]
Update
- Ketamine for Analgosedation
- Propofol doesn't seem to increase pressor requirements in this pilot study (prop and vasopressor use)
- Analgosedation practices and the impact of sedation depth on clinical outcomes among patients requiring mechanical ventilation in the emergency department: a cohort study. Chest. 2017 Jun 20. pii: S0012-3692(17)31076-0. doi: 10.1016/j.chest.2017.05.041. [Epub ahead of print] More on oversedation leading to badness in the ED
- ED-SED – A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients doi: 10.1097/CCM.0000000000003928
- Morphine vs. Fentanyl
Additional New Information
I have previously blogged about a study demonstrating that there are ED patients being intubated and then not sedated or pain-controlled.
So it was no surprise to see a new study showing the same thing:
Watt et al. Effect of paralytic type on time to post-intubation sedative use in the emergency department (Emerg Med J 2013;30:893-895)
If the patient received sux, they got their sedatives started at the 15 minute mark (still sucks), but if they got rocuronium (they won't be flailing about and alarming the vent) it took a mean of 27 minutes.
We can do better.
More on EMCrit
- Podcast 84 – The Post-Intubation Package(Opens in a new browser tab)
- EMCrit Podcast 21 – A Bad Sedation Package Leaves your Patient Trapped in a Nightmare(Opens in a new browser tab)
- EMCrit 331 – Awareness after Resus RSI and ICU Paralysis – It is Unacceptable!!!
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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You’re killing me, Scott….I just finished putting together lesson plans for our airway course! 🙂
My question…since I work in an EMS system where medics don’t have any form of RSI, is this post-tube package still appropriate for patients so obtunded they could be intubated without pharmacological assistance? Also, is this yet another reason for US EMS services to add ketamine to the drug box?
for those obtunded pts, I think you get a buy until they are in hospital. Ketamine would seem the ideal agent for most cases of post-intubation pain and agitation in prehospital arena.
Scott, Have to take a minor issue with your read of SPICE. I put together a very similar talk for AMTC2013 and our own ED group conference last year, hit most of the same points and even referenced your paper on the subject. The SPICE study enrollment scheme was a bit confusing. It is unclear from the way the data is presented if there really was an effect of “very early” sedation. Clearly at 48 hours, an effect was seen. I caution the interpretation of the “very early” group however. The Kaplan Meier curves are too coarse to really determine… Read more »
totally agree Mike. Curve scale makes that interpretation tough. From what I can piece together from the study, each deep RASS from 4-48hrs was independently assoc. with bad outcome, but even that is merely suggestive–we need a real trial to know for sure
Scott, happy new year mate! brilliant stuff. just emailed the link to this post to all my RFDS network. I have moved to doing a lot of these things in the last year as well so great to hear a peer validation! we get a lot of experience running ketamine drips in the aeromedical service here…in even the unintubated patients now…the sedation registry I run here is now 6 yrs old and we have found little problems with the ketamine drips. will be working on a second paper on this soon prob in a years time now. prob the only… Read more »
thanks for that Minh. Can’t wait for the paper.
s
Essentially we should be using BPS Scale (Behavioral Pain Scale) in conjunction with RASS Scale, as per the recommendations “The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for monitoring pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report” At least it offers objective approach when you find patient in restraints for their sedation package. http://www.consensus-conference.org/data/upload/consensus/1/pdf/1670.pdf (BPS scale in on the last page of that document) From 4th edition ICU Book: In a survey to the question “Does Diazepam… Read more »
I like it. I added BPS to the post with a hat tip to you
In patients with protocolized sedation, daily sedation interruptions (holidays) did not lead to demonstrable benefit. The SLEAP Study (JAMA 2012;308(19):1985) – The SLEAP study did have these findings; but the article that was referenced felt like there were some flaws in the SLEAP study (over sedation; drug dosing to average RASS of -3/-4 versus light sedation levels), some weird findings (increased sedation drug use in the daily sedation interruption group), and it was not consistent with previous studies and therefore future studies are required. I expect future studies may show that light protocolized sedation with daily sedation interruptions will show… Read more »
I look at SLEAP as a pragmatic trial. They messed up a bunch of stuff that I feel many units mess up as well. I don’t think targeted light sedation with agents like dexmedetomidine will have any difference in future trials with sedation holidays or no. I think a propofol sedation with RASS of 0 as goal will similarly have no difference between the groups. BUt agree, we need real trials to prove which of us is right.
thank you scott for your thoughtfully worded encouragement regarding studying ketamine for post-intubation sedation & analgesia. I have been using ketamine for years as my primary agent after ETI in all non-hyperdynamic patients. I should at least track outcomes for a case series, though I suspect K is often replaced as soon as the intensivist assumes care. agree that we do better for intubated patients to target more physiologic levels of arousal overall, however I would still say that for patients who are intubated in the ED and immediately after require painful procedures or transport (what I call the “just… Read more »
Yep, you’d be a great person to get this study done. Would need delirium assessments in these patients, preferably with a control group.
Of course, you can put patients deeper to do procedures, ct, etc. propofol is great for this as patients won’t be slogged for hours.
This is all good and well the majority of the time once they are intubated and have been for some while. With that said, using etomidate and rocuronium to intubate a patient, which is arguably the best combo for the majority of patients, and then NOT following it up with some form of deep sedation is cruel. Until the rocuronoium – which as we’re all aware outlast the etomidate – wears off, without adequate DEEP sedation and analgesia you are producing a patient who is fully aware of their surroundings, which, while paralyzed, is something that is not okay. I… Read more »
Jim,
Yes and yes. Though no reason to go the benzo route, propofol and fentanyl drip are ideal after roc and we”ll actually have the nurses starting them as we are intubating. Ketamine as an induction agent eases the transition and I’m not a big etomidate fan.
As Reuben mentioned above, transport and procedures: go as deep as you need.
is there any concern of hyperalgesia with remifentanil IVI? I’m working in theatres at the moment and lots of the anaesthesiologists worry about it post-op
would be wrong for me to comment as I’ve never played with the drug; as soon as I do for a while, I’m sure I’ll have an opinion
It has its advocates, but I can’t see the point really – it hasn’t conferred any benefit in sedation or length of ventilation or unit stay when we’ve tried it over our standard opiate (good old morphine). We already have the shortest length of stay in the county anyway. If you have a good targetted sedation and analgesia regime, with motivated and well trained nursing staff prepared to titrate, Remi has no advantage that I’ve seen for the vast majority of patients. Two additional other factors of important note: 1. It would cost us just under £1 million a year… Read more »
Thanks John!
OK Scott, You’ve got to stop doing this. Just as I get ready to roll out new guidelines, (this place has been a “Just turn up the Propofol” kind of place) Now I have to got back and see if I need to update anything. 🙂
What about for the overdose patient or drunk unruly patient or status patient- I have typically been starting propofol right away (though admittedly i have been using mega doses of propofol and have had a hard time achieving sedation), is my mistake not starting with fentanyl in these patients as well?
yes, you will need much higher doses of propofol without the fenatanyl for drunk, unruly, or ods. For status, we are shooting for v. deep sedation and we should be dosing based on EEG
Hello,
I enjoyed your podcast.
Have you come across any sedation research on critical care transport (ground and air)? I have looked but have had no luck. Most articles (Barr for example) have a hospital focus.
Personally, I have tried to keep the patients I transport lighter but change is difficult sometimes.
Thank you,
David
I would certainly like Dr. Weingart perspective on this. I also conduct ground critical care transport, and I do not know where this idea/paradigm of what is good critical care EBM medicine in hospital is all of a sudden crap medicine outside the hospital originated from. Good critical care EBM medicine is good medicine regardless of location! CCT is often conducted inside the hospital walls when a potentially unstable patient is taken to the CT scanner. However a good clinician would account and anticipate the possibility of hemodynamic collapse and resuscitate accordingly and take appropriate measures prior to transport: airway… Read more »
Great post as always Scott. Along with the paradigm shift comes a change in post-intubation “operations” such as longer amounts of time at the bedside to titrate to the target sedation level. This compared to the old practice of giving a propofol/fentanyl bolus, starting the drips, then having the nurses titrate. Would you say significantly longer? How have you and the other members of your team adapted?
As an FYI, I’ve been told that dexmedetomidine will go generic no earlier than December 2014.
So we have a year to wait. That’s ok low dose propofol works quite nicely.
I would say it adds about 5 minutes of bedside time to titrate in some fentanyl push. I think you could probably just give everyone a bolus of 2-3 mcg/kg automatically and you would be pretty close with no increase in time.
Speculative or not? There are many cofounders that may interact or produce delirium during ICU in a critically ill patient. Several items are commonly unreported in these studies that may creates major bias. Neurological status prior to intubation (was the patient presenting a septic encephalopathy or not, for example?) and what is the reason for intubation (respiratory failure, agitation)? These “details” are crucial. Secondly, new recommendations have emerged from major studies regarding the management of ARDS for example (NEJM PROSEVA and ACCURASYS) where “light sedation” cannot be performed because of the use of NMBs? This means that these patients should… Read more »
Scott, Thanks so much for bringing this often not so sexy part of critical care to the front of your listeners minds, and as always excellent podcast. I did have one question/suggestion. You mention using fentanyl infusions as your traditional opiate of choice in the podcast, and I agree that most critical care centers are using this as a first-line opiate for prolonged sedation. However, fentanyl has a relatively long context-sensitive half-life. If given as a single bolus it is rapidly metabolized by the liver and provides a duration of action much shorter than hydromorphone on the order of 30… Read more »
Dave,
so true and yet it is still the primary agent in most icus. I guess the saving grace is that long term analgesia is fine as long as the patient is kept rousable. it is when the pt gets a ton of sedation, and then the analgesia drip just runs with no assessment that fenanyl’s build-up becomes a big problem.
How are you training the nurses to assess and titrate as needed. We’ve been using RASS Scale for ages, but I keep finding nursing staff under dosing pt’s. Lots of unfounded fear about hypotension.
It is hard. We can’t educate the docs either as comments above demonstrate
Thanks Scott
Brilliant stuff as usual,
We just had a three badly burnt patients all whom needed packaged and sent to Oregon burn center. We did find that additional sedation was needed for procedures, after that we sent arousable intubated patients off to the Burn center.
I do have one question, Is there any concern for addiction or long term resetting of a patients pain tolerance after receiving days or more of opioid management?
Thanks
Brian Rapacz MD
Bend Oregon
I don’t think so if we are gearing the opioids to levl of current pain. I have heard of problems when stopping remifentanil.
Finally got around to listening to this… great podcast as always but I have two questions. 1. You said benzos contribute to delirium and should be avoided, yet if delirium is already present in DTs, then surely lots and lots of valium can’t cause much more harm, right? 2. I usually use ketamine either at low dose for analgesia or higher doses to dissociate a patient. I don’t really consider it titratable, so how do you go for a certain RASS using it? I’m guessing we would want to avoid dissociating a patient since that would likely contribute to delirium… Read more »
Josh,
Yes, you could conceivably use benzos in DTs as the delirium is actually from a shortage of GABA agents. Ketamine is not titratable past its sub-disassoc. range. Just give enough to disassociate, we will put the patient on a different regimen later if we can get them hemodynamically stable.
Hi Dr. Weingart,
Awesome Podcast 🙂
For fentanyl, what is your starting dose since you are starting with fentanyl alone and then adding in precedex, propofol, or ketamine? Do you start at 25 mcg/hr and titrate q 20 min?
If you use ketamine, are you using the 0.5 mg/kg/hr dose?
Thanks for all your help. Take care!!!
yes on the ketamine after achieving dissociation with bolus.
for fentanyl, after bolus, 1-1.5 mcg/kg/hr in general
So, what is your thoughts on RSI and Post-Intubation sedation in the field. We have a limited number of drugs, ie. Etomidate, Vec, Succs, Versed, Valium, Fentanyl… Are we doing harm by using Benzo’s (with a paralytic) to initially RSI? Some of us have a transport time of 20-30 minutes, our drugs start to wear off… How do we keep our patient’s sedated? Our medical control would frown on us giving copious amounts of Fentanyl to keep our patient comfortable/sedated. The gold standard, where I live (Central Ohio), is to continue giving the patient Benzo’s and a Paralytic, even in… Read more »
not sure why they would frown on opioids. short term benzos are fine, continued paralytics don’t make much sense unless you are in danger or the pt is about to extubate.
Side note:
Precedex is used widely in the Hospital that I work at. Every aggitated kid that goes on C-PAP or Bi-Pap automatically gets an order for “dex”. As far as I have seen, they keep the kids under heavy sedation while intubated and only use Precedex for light sedation. I haven’t seen it used in the adult hospitals, but I don’t see why not. We love it. Our patient’s are totally chill but easily arousable.
Food for thought.
Jodie, the reason is that the medication is insanely expensive.
Hi Scott
This is a great podcast.
As far as your ketamine drip goes, can you give a typical example of an infusion rate after they’re dissociated with a bolus?
We just had an email chain at work about sedation & the cost of Dexmetatomidine. Does the cost of the drug justify itself in saved bed days secondary to reduced delirium? Is there any data on this?
Any studies to support the use of ketamine in the hemodynamically unstable ICU pt for sedation? I have only found two studies that may be applicable and one is the evaluation of ketamine and versed, but in light of the move away from benzos, seems less applicable. We LOVE ketamine in the ED at University of New Mexico but our ICU does not. This issue came up on ICU rounds and I threw out the idea of using ketamine for sedation in a hemodynamically unstable pt on a versed drip with 4 pressors, after listening to this podcast and the… Read more »
Scott,
Thanks for all the great podcasts. Have there been any problems with opiate addiction and withdrawal in the analgesia first management of the intubated patient? Have you or others thought of using combinations of IV acetaminophen or toradol instead of opiates for this reason?
Thanks,
Dave ?Friedenson, MD
Attending Emergency Physician, North Suburban Medical Center, Colorado.
EMS Medical Director, Thornton Fire Dept.
Dear Scott,
I listened to this podcast when it first came out and am now revisiting it after reading SPICE itself. I scrolled through the comments and didn’t see this question addressed, but I apologize if it was touched upon. The SPICE trial saw an association with cumulative dose of fentanyl/midaz and delay in extubation. This was not seen with propofol or morphine. Why then make recs as fentanyl as your go-to drug in all of these cases? How do you take these findings into consideration?
accumulation is only an issue when the pt is not in an easily rousable state. If you are titrating to that, then accumulation will not occur. You can use what you want.
Current PGY-2 EM resident here. I’m interested in creating a QA/QI project at my hospital surrounding implementing part of these new guidelines on sedation and analgesia on our intubated patients in the ED. Do you think these guidelines apply to the very early post-intubated patient who is left in the ED for perhaps several hours before they get to the ICU? How feasible do you think some of these guidelines are to implement, such as titrating to RASS, using BPS, etc? Obviously daily sedation interruptions aren’t in the realm of discussion. EEG may even be a stretch. I can also… Read more »
this is all directly applicable to ED. Some of the studies mentioned looked at association with mortality for the first few hours of post-intubation time. Sedation holidays are no longer relevant in the ICU much less the ED just as you said. If I was doing a QA Project, I’d concentrate how many people got adequate analgesia & how many pts got roc as their intubation med but were started on inadequate analgosedation.
Hey Scott, I know I’m a bit delayed on this podcast. I am a new listener and find your podcast to be extremely helpful, so thank you!!! I am a flight paramedic, and recently I audited a chart and needless to say it was “one of those” critical care flights that when everything that could be wrong with the pt, was absolutely wrong. The pt, other than a history of opioid abuse, was a healthy young person. The pt had everything from sepsis to possible PE/cardiogenic shock, to flash pulmonary edema, hemodynamics, ventilatory compliance, ect.. Our protocols for post intubation… Read more »
Lets say you just intubated a Septic shock pt ”Hemodynamically compromised” what would be the best analgesia/sedation drugs along side a proper resuscitation?
Is there any merit for pre medicating with Fentanyl?