Part 2 - Analgesia and Sedation in Intubated patient

No it's chris David.

Again we're continuing on with our analgesia and

sedation of the intubated patient post intubation.

We just reviewed a lot of different options that we

might have for analgesia and pain treatment immediately after intubation.

Now we're gonna move on with some sedative options.

Um What they mean what they can cause

we're gonna start with one of the more common um areas which is benzodiazepines.

You'll see a couple of them listed here.

I'm gonna break it down into a little bit more easy to read. Table

of the most common ones. We'll see. So diazePAM. Midazolam.

LORazepam also known as Valium for said and add a van respectively.

So we will typically in the intubated patient move to

Merced or midazolam because of its pharmacogenetics onset is quick,

Piques relatively quick and its duration is not that long. It's 30-120 minutes.

And that range you'll see is because it can be dependent on how much we're using.

If you're giving large doses over a long duration it

will take a long time for it to wear off.

So that's where you're going to get to a two hour time frame potentially

as you can see in a Valium and LORazepam they're not as

easily tight tradable as their duration is quite a lot longer.

Once you've got it on board, they may be sedated for a long duration,

which is why we don't typically use those

in for long duration sedation.

The other common one we use all the time.

And everybody's pulled it out at some some

time is the Gava agonist propofol Different category.

We love it because it's extremely quick and onset and short duration of 10 minutes.

We love that rapid onset and it's easily tie traded as a result

the risks.

It's not doing any pain control and it will cause some form of hypotension,

it will reduce the blood pressure to some degree.

Sometimes it's negligible. Other times that makes a big difference.

Mhm.

Now, importantly,

when you look at the actual people follow order and I

apologize that that is small and you probably can't read that,

but just so you know, it's a 0 to 50

micrograms per kilogram per minute dose is the actual tie tradable range.

When we look at

what that means, we're talking about a 70 kg patients. If you max out that drip rate,

it's 3.5 mg per minute.

When you do a sedation for a shoulder reduction or an arm fracture,

you're going to give 40 8100 and 20

and upwards of these bullets is for sedation of that patient.

Now we're getting pretty heavy sedation with those doses.

But still, if we start at 3.5 a minute and the patient starts pretty awake,

we're not going to get that cumulative effect for quite

a long time and they're going to be agitated.

That's why in the orders you will see

in order that comes up for 10 to 20 mg.

Bullis says,

pull the propofol from the bag when we actually put the vial in the RC kit,

so it's readily available for you to pull 10 to 20

mg bolus pushes to help keep your patient's sedated and comfortable.

If I have a young patient and I'm in that room with you which I typically am,

I'll even have you give a lot more of it

if we're not worried about hypertension as a secondary effect

and I may ask you to give a 40 or 60 mg bolus while we allow the titillation to occur,

you can also change the range.

So it could be a 5 to 100 micrograms per kilogram per minute

if the provider decides to change that range in the order itself.

So you have a little more variability or a little

higher doses you can give cumulatively if you go high,

you may end up with an over sedated patient

but that's going to be hours from the onset.

You have time to adjust and titrate.

Okay,

problems when we look at any of the stuff we've

been talking about in Part One or Part two,

we talk about midazolam and propofol.

One of the major issues you're gonna get with those

sedatives is hypertension and it happens with most sedation.

There's a few examples where it doesn't,

but we'll look at most of those like ketamine is one of those rare

instances that it's a category unto itself

and it doesn't often cause hypertension.

So we have to consider that and it's a

sedative and it's got some anthologies of properties,

but it is also cardiac stimulatory.

So you have to again, no,

these things as you're starting to try to pick and

choose what's the most appropriate sedation for your patient.

Everything causes respiratory depression that we're

talking about regarding benzodiazepines and opiates.

But thankfully we've intubated the patient and that's not a huge concern.

We still want them to match the event. We don't want to overdo it.

We do want them to inspire have their own inflammatory effort.

But in most cases, that's not a huge concern.

There's always side effects to all medications and it's a

good idea to review those on a regular basis.

Mhm.

Okay.

Another option that you will see for sedation will be precedent X.

Um it is related to cloNIDine if you will.

So that's an alpha two agonist, IQ like effect the same way cloNIDine works.

And we know that cloNIDine is often used

for blood pressure control or withdrawal symptoms from

alcohol in particular.

This acts as a sedative. And it is a short acting type medication when we drip this in.

It does not cause a lot of respiratory depression.

We like it for that reason.

I love to use this drug as a drip in the agitated patient that's hard

to control or that's going through some

form of withdrawal and agitated and tremulous.

This is a fantastic thing to get dialed in nicely where they are calm

sedated and when we do it right they have

no respiratory depression and they're still responsive to voice.

It has an ability to do that and find that nice sweet spot. We use it.

And intubated patients quite a bit more in the ICU.

Than in the er The major risks that you will see.

Not necessarily uncommonly is bradycardia and hypotension.

If it's very severe we have to stop the drug.

You know again you won't see much respiratory effect.

You will see that decreased sympathetic tone that

can cause the bradycardia and the hypertension.

Sometimes you will get a huge long sinus pause and I mean you see a beautiful Q. R. S.

And then there's just way too long between the next Q. R. S.

And you know that that is probably from your press index.

It's time to stop the drug if you see that in excess.

Otherwise it's an excellent medication for the integrated patient.

Again I think that's what I just emphasized.

Um despite our best efforts and dialing us in as

best we can go in with our analgesia first.

Sometimes we still have to avert and use some um vase oppressors

and it depends on the condition if you're treating septic shock.

I don't care what you put the patient on. You're gonna end up using

some form of of a suppressor on the patient

and there's other conditions that will happen as well.

But a lot of times we can avoid that.

Perhaps even avoid central line or more invasive procedures or arterial lines if we

dial this inappropriately and in a stepwise

fashion with constant reassessment of our patient

to sum up pains. Not likely well treated in the agitated intubation.

Intubated patient at all times.

If you're having trouble control them,

there's probably some pain that could be addressed better.

Seth angles early as early as you can.

When you know you're going to intubate a patient.

Push doses are highly likely to be needed and either both analgesia and sedation

Or at least one or the other.

The base rates for title tradable drips are small and they are cumulative.

They do offer sedation over time but

not always adequate immediately following intubation.

Yeah.

When we dial this in nicely it means that the patients, if they're going to recover,

they recover better and quicker and that's why we want to focus in on this.

Okay, let's do some briefcase uh evaluations. Just one or two of these

and we'll be done

case 1 29 year old female she presents with sepsis. She's in shock.

You can see she's tachycardic hypotensive febrile and has low oxygen saturation.

She doesn't prove after fluid bolus,

her heart rate still a little tachycardic but blood pressure is better,

Still has a respiratory rate that's elevated.

So she's compensating and she has sat sat around 90

the provider elects to intubate due to impending respiratory failure.

What can be safely used? What would be a good plan for the pain and sedation type

treatment of this patient? Give that some thought,

we'll move on to the conclusion and give some answers here.

There's a high likelihood for post intubation crash.

When you start with hypertension and tachycardia.

This is a young 29 year old who has a

lot of compensatory ability so they can really clamp down,

get that heart rate, squeezing with increased contract,

ill itty and great cardiac output

and when you relax them and paralyze them you take away quite a bit of that.

The kind of cola mean surges over and you will expect a potential precipitous drop.

You are a student have realized this already with some push doses

of niacin Ephron which is also in the Rs I box.

If you're not familiar with Neo Sin ephron,

it's usually given in 100 microgram pushes

for this kind of post intubation crash.

100 microgram pushes in our RSE box is the equivalent of one

ml and it says it right on the pre mixed syringes.

That brings her back up to pre intubation levels with her perfusion pressures

during your assessment.

You also heard some wheezing and roles are history also reveals some mild asthma.

You suggested the provider that a ketamine infusion might be a good

option for sedation and analgesia and is also a bronchodilator,

you realize starting this infusion will not be enough initially to

achieve your sedation Because remember when we calculated that out,

that was a small amount of overall academy.

You do a push dose of two mg per kilogram per the provider.

Get nice segmentation and adequate analgesia.

You hear no further weight wheezing.

And the patient responds well,

look how simple we just made that.

You may only need the single agent that acts as both an analgesic

and sedative and you're not having to do these oppressors or more invasive things

if it works

again,

everybody's an experiment doesn't always work beautifully exactly

how it's written down in the text.

But this would be a good option in this type of a patient

case. Number 2 84 year old. Presents with acute mental status acutely changes

and weakness on the left respiratory effort is minimal with cruise missiles,

respiratory pattern.

The blood pressure is 210 over 95. The heart rate is 67

temp is normal respiratory rate a little on the depressed side. Sats are 91%.

They did a brief history.

Uh, this reveals that the patient has end stage renal disease.

Not yet on dialysis coronary artery disease.

With open heart surgery one year prior we're going to move to intubate

orders are sectional cooling and midazolam.

You wisely suggests something different. What do you want to suggest and why?

Yeah.

Again, I'm giving you a little bit of a minute.

Moving on,

the provider changes his midazolam vecuronium based on your suggestions.

They're now using a non de polarizing paralytic vecuronium.

We would probably use rock your own ian regardless.

It's not going to release the potassium because

in an end stage of nearing dialysis patient who's

got altered mental status and altered profusion there is

a strong potential that this patient has hyper Colombia

and you will cause an immediate arrest if you use succinylcholine potentially.

And when we don't know we're going to go on

the safe side of using something that's non de polarizing

ct head is performed showing small right side and intra prank will bleed

on return from the C. T.

The patients biting at the two bucking and

posturing the provider orders of propofol drip.

You have it that and hang it but five minutes in

the patient is still biting at the two ventilating poorly.

But no longer posturing,

what do you want to do?

Mhm.

If you said

push doses of propofol and start some analgesia,

you'd be right on course here again we want to get analgesia on board early.

Sometimes before we do anything else regarding

sedation we don't mind the hypertension.

That's going to be caused by propofol.

We actually want that as a target because we now know

that the injury that is occurring in this patient is a hemorrhagic

Brain bleed. So we need to be aggressive about blood pressure control.

We start this after starting both of these and bowl

is saying we get a blood pressure of 90/60.

It's pretty big. Drop

well you go and talk to the provider and you

know that hypertensive brain cleans nia breast blood pressure control.

You also know that when you calculate the map out this is a map of 70.

This means we actually still have adequate perfusion.

After you discuss it with the provider,

you guys agreed to make a small reduction in propofol to

avoid further decreases and realizing that there will be cumulative effects.

So you're going to titrate that to the point where you still have some nation

still get blood pressure control.

But overall I find the best pathway forward for the patient.

Mhm.

I hope this helps clarify some of the highly

interactive approach that you have to take to

analgesia and sedation and the intubated patient.

Remember this is critical care, this is a lot of work.

This is constant reassessment of the patient, this is knowing what your drugs do.

This is knowing how fast they act.

This is knowing what your drip rates actually come

out to and what that means for the patient.

This is realizing that everything has its changes through time.

As you will see this developed from pre intubation, intubation,

post intubation and long term analgesia and sedation.

Over the next few hours for this page

Part 2 - Analgesia and Sedation in Intubated patient

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