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:

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