No time for high fives…the initial management of mechanically ventilated patients matters! By Dr. Lou Argentine
You’ve just successfully intubated a critically ill patient in the emergency department….the nurse interrupts your celebration by asking if you would like any medications for sedation and/or pain management… does it matter? YES!
- Initial goal after intubation: analgesia
- use quick acting medications such as fentanyl or remifentanil to avoid overmedicating
- consider bolus adminstration immediately after tube secured
- May also need low dose sedatives
- the literature has consistently supported that minimizing sedation provides clinical benefit: fewer days on ventilator, fewer days in ICU, etc.
- the initial level of sedation after intubation also influences these clinical outcomes, proving the importance of initial pharmacology in emergency department
- important to remember that there are still indications for deeper levels of sedation: patients receiving neuromuscular blocking agents, status epilepticus, intracranial hypertension, etc.
- Ordering post sedation medications while ordering RSI medications helps avoid delays and errors in post incubation analgesia/sedation
Bottom-line: minimizing sedation after first focusing on pain management will provide a clinical benefit to your recently intubated patients
- Barr, Juliana, et al. "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit." Critical care medicine 41.1 (2013): 263-306.
- Devabhakthuni, Sandeep, et al. "Analgosedation: a paradigm shift in intensive care unit sedation practice." Annals of Pharmacotherapy 46.4 (2012): 530-540.
- Reade, Michael C., and Simon Finfer. "Sedation and delirium in the intensive care unit." New England Journal of Medicine370.5 (2014): 444-454.
- Shehabi, Yahya, et al. "Early intensive care sedation predicts long-term mortality in ventilated critically ill patients." American journal of respiratory and critical care medicine 186.8 (2012): 724-731.