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Post intubation analgesia and sedation in the ED

You deftly sweep the tongue aside, slide into the vallecula, lift the epiglottis, and have a great view of the cords. You smoothly pass the tube, secure it, and walk away – a superstar. Meanwhile your nurses wonder “what now?” as your patient begins to wake up pulls their ET tube out.


Your job is not over after intubation – here we will go over how to keep your patients comfortable and safe.


Post-intubation Analgesia:

  • Being intubated is painful. So, all intubated patients should receive analgesia. 
  • Analgesia might be more important than sedation; in studies comparing analgesia-only to standard sedation, patients in the analgesia-only arm had better outcomes. 
  • Practically speaking: 
    • Use a pain scale validated in intubated patients (eg: Critical-Care Pain Observation Tool). 
    • User your preferred IV opioid. 
    • Boluses initially, and then start an infusion.
    • Remember to give boluses for painful procedures (eg: suctioning, wound exploration, repositioning, etc). 
  • For agitation/restlessness: titrate analgesia first, before increasing sedation. 


Post-intubation sedation: avoid benzodiazepines!

  • Benzodiazepines don't work as well as an infusion, as their half-lives increase significantly as the duration of infusion increases. 
  • Patients sedated with benzodiazepines had worse outcomes, including more days intubated, and more days in the ICU, when compared to patients sedated with other agents.
  • Good alternatives include; Propofol and Etomidate. 

Post-Intubation sedation: light sedation

  • In the ICU, light sedation resulted in better outcomes than deep sedation, and was at least as good as daily sedation vacations.
  • A recent study suggested that deep sedation within 4 hours of intubation was an independent predictor of increased mortality. Thus, our initial ED management has a larger impact than we likely perceive. 
  • Use a validated sedation scale; ideally patients should wake easily to verbal stimulus but remain calm.
  • Important exceptions include patients with: increased ICP, status epilepticus, ongoing paralysis, or patients undergoing transportation to another facility. These populations should all likely receive deep sedation.

Take home points:

  1. All intubated patients should receive analgesia. 
  2. Titrate analgesia first, then add sedation. 
  3. Avoid benzodiazepines for post-intubation sedation.
  4. Target light sedation in the majority of patients. 




Dr. Dewhirst is a 4th year Emergency Medicine resident at the University of Ottawa with a special interest in medical education and patient safety/quality improvement. 


Edited by Dr. Shahbaz Syed, 4th year Emergency Medicine resident at the University of Ottawa.

Comments

  1. Quick question - Can you comment more on your recommendation for etomidate in post-intubation sedation? Last I had heard, there is a real risk of adrenal suppression after even a single bolus.

    Also, what about ketamine? It provides both dissociation and analgesia. Are you aware of any literature on long-term sedation with ketamine and ICU delirium?

    ReplyDelete
  2. Hi Jeff, thank you for your questions. In regards to your comments here are my answers:
    1) As far as I am aware there are no definitive studies that show negative patient oriented outcomes with the use of Etomidate in sepsis. However, there is the concern of adrenal suppression and that it may lead to negative patients outcomes. For this reason, I would suggest propofol as the agent to use in the septic patient.
    2) I am not aware of any ICU literature on the use of Ketamine for long-term sedation in the ICU. I also discussed it with some ICU colleagues and they were not aware either. As for using Ketamine post-intubation from the ED to the ICU, it certainly seems like a reasonable choice as well.

    I will forward your questions to the author of the GR in case he has any other thoughts/comments.

    ReplyDelete
  3. Hi Jeff - great question. I agree with Hans' answer above. I would just add that in relation to ketamine for sedation in the ICU, while I'm not aware of studies looking at using it for long-term sedation, some guidelines and position papers talk about concerns for increased rates of ICU delirium because of the Ketamine's disociative properties. Also, it would be more difficult to titrate ketamine to a desired level of sedation because it is not a traditional sedative.

    Thanks,
    Sebastian

    ReplyDelete

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