A 55 year old is intubated in your emergency department for a decreasing level of consciousness secondary to septic shock. The intubation was slick; there were no complications. The medications were administered at 1501 and they included ketamine 75 mg IV and rocuronium 100 mg IV. Once tube placement was confirmed with waveform capnography, the only person that remains with the patient is the Bedside Warrior.
The primary survey at 1621 is the following:
A – ETT in place, ETCO2 33
B – Mechanically ventilated on volume control, set respiratory rate 18 (actual 26), tidal volume 420 (IBW 70 kg), PEEP 8, FIO2 0.50.
C – MAP 68 on norepinephrine 0.1 mcg/kg/min, HR 145 (sinus tachycardia), peripheral capillary refill approximately 4 seconds.
D – Looks in distress. RASS +1, GCS E2 VET, M3. The patient is on propofol 10 mcg/kg/min.
E – Non contributory.
The good news is there are interventions the Bedside Warrior can do to provide quality patient care for patients who are intubated and mechanically ventilated in the ED.
First, ask for post-intubation analgosedation medications when rapid sequence intubation medications are ordered. By doing so reduces your cognitive load and clarifies the plan of care.
Second, ask for analgosedation goals. Establishing a clear, quantifiable goal among team members and allows the Bedside Warrior a target to reach for. Common goals include the Richmond Agitation Sedation Scale or Behavioural Pain Score. Recognize that if the patient is paralyzed that these analgosedation goals will not be appropriate. When using a long term paralytic, such as rocuronium, or MEGA-DOSE rocuronium, ensure deep sedation and analgesia for the duration of the paralysis.
Third, use a protocol or range of analgosedation doses to help identify what doses of analgosedation the Bedside Warrior can independently titrate. This frees up cognitive load among the prescriber and allows the Bedside Warrior to care for the patient.
Lastly, consider what the patient needs. For the above patient who was intubated for a decreasing level of consciousness secondary to septic shock, they may benefit from pure sedation alone (though some argue treating with analgesia first). If the patient has suffered traumatic injuries, it may be beneficial to prioritize analgesia and use a sedative in the background. Furthermore, if the paralytic has worn off, the patient has been settled with necessary imaging and medical procedures, it may be reasonable to assess the appropriateness of gradually lightening sedation. Shehabi et al. (2012) found that early light sedation over heavy sedation can reduce delayed extubation and mortality. That being said, it is wise to consider what the patient needs both from a medical perspective but also from a safety perspective; emergency departments are known for being unpredictable and have a much larger ratio of nurse to patient than intensive care units and lightly sedated patients may experience accidental extubations or removal of central venous access lines.
Back to the case: The Bedside Warrior realizes that the patient is in distress and decides to give the patient a bolus of analgesia then reassess the patient’s RASS and BPS in 10 minutes.
- Nurses have the most influence on post-intubation and sedation
- Ask for both analgesia and sedation medications and determine the dose titration range
- Assess what the needs for analgesia and sedation; if the patient is a trauma patient, chances are they would need higher doses of analgesia and sedation than a patient who is intubated for a medical reason
- Karamchandani, Kunal, et al. “Critical Care Pain Management in Patients Affected by the Opioid Epidemic: A Review.” Annals of the American Thoracic Society, vol. 15, no. 9, 2018, pp. 1016–1023., doi:10.1513/annalsats.201801-028cme
- Schweickert, William D, and John P Kress. “Strategies to optimize analgesia and sedation.” Critical care (London, England) vol. 12 Suppl 3,Suppl 3 (2008): S6. doi:10.1186/cc6151
- Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-480. doi:10.1016/S0140-6736(09)62072-9
- Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29(12):2258–2263. doi:10.1097/00003246-200112000-00004