- Hey, everyone!
We're gonna do sedation and analgesia today,
because I got a request online for that.
But I want to start first
with doing a little bit of gratitude.
So, I have MD is gonna be my learner today,
MD what are you grateful for today?
- [MD] Today, I'm grateful for the Walter Reed team
and just the teamwork that I've seen.
- Yeah, me too.
So the biggest thing I'm really grateful for
that I want to make a point of is number one,
my colleagues all over.
The colleagues that are about to graduate,
the colleagues that I've been working with for years,
we have amazing teams working all over.
And I'm also really grateful for the people
that are watching these videos
to help us care for our loved ones,
our family members,
everyone out there who's suffering with this.
I'm also grateful for sedation and analgesia.
So that's what we're gonna to talk about today.
All right, so the first thing I want to start with
is whenever we have someone on pain medication
or sedation medication in the Intensive Care Unit,
we want to use a goal to titrate that medication to.
So what we usually use here is called a RASS,
Richmond Agitation and Sedation Scale.
It starts at zero,
zero is like hanging out chilling, normal,
just you and me hanging out almost about to fall asleep
just chillin' in our lives normally.
Negative one is like a little bit drowsy,
and then if we get to negative five,
negative five is like your out cold.
You can't function, nothin',
not even like,
can't even rouse you if I try, Okay?
The other side of this goes all the way up to positive four.
And this is like swinging atcha,
this like pissed off guy, Okay?
In general, when you look at protocols for sedation,
they generally talk about people
being like negative one to negative two.
I really like to keep my people right here,
we really want to focus on light sedation,
as much as possible for patients.
So, hanging out being comfortable,
we don't want people in pain, right?
So a little bit drowsy is fine,
maybe slightly lower than that,
but that's a pretty good range
to try to keep um in, okay?
So that's sort of starting point number one.
Use a scale,
doesn't have to be the RASS,
it's what we use, I'm comfortable with it.
There are other ones out there,
pick one, use it.
Have all of your nurses,
all of your doctors,
everybody being aware of what the goal is
and keeping it there, okay?
All right.
So, then I want to talk about both my sedatives
and my analgesicas, analgesics?
Analgesics.
And I want to keep them a little bit separate
in your mind upfront, okay?
What do you think of when you think of some medicines
that we use to control pain?
- [MD] I think of fentanyl.
- Okay, great.
So fentanyl's a great one.
What about if you have pain at home?
What do you use?
- [MD] Tylenol.
- Ah perfect. So Tylenol,
Paracetamol if you're across the pond,
but Tylenol is a great medication
to always think of starting with for pain in general.
Sometimes I take NSAIDs at home for pain.
In general in the intensive care environment,
we don't like using that anyway.
And now we have some questions about whether that
might make outcomes worse in COVID specifically,
so maybe avoid the NSAIDs,
but Tylenol is a pretty safe one to go with.
Okay, fentanyl, you know any others?
- [MD] Morphine.
- Perfect.
And then I'm going to add ketamine.
And then I'll put Dilaudid or hydromorphone,
it's also called down there.
I really almost never use this in an Intensive Care Unit,
unless I have someone who's on like
a Patient Controlled Analgesia pump a PCA pump,
then sometimes I use that,
I often stick with the other ones.
So, we'll talk some more about these in just a second.
I want to go over what our sedatives are.
So now we're talking about medicines that make you sleepy,
make you dissociate,
make you a little bit out of it,
things along those lines as opposed to
things that directly control the pain.
Do you know any of those?
- [MD] Propofol?
- Okay, great propofol.
Okay, some other ones
that we think of in the ICU, are Precedex,
now we think a little bit more about ketamine,
sort of falls in this as well.
And then we think about our benzos,
so benzodiazepines.
So, what I would tell you before,
of what my one regimen like,
what I would do for all of my,
my sort of my algorithm,
what I would do for all my patients in the ICU,
is a little bit different now,
in this age of COVID,
than it was before for,
for a couple of reasons.
But I want to teach you what I would have done before
and what I have in the back of my mind now.
- [MD] Okay.
- Okay, so if I was going to tell you before,
I would have told you
that pick one of these two
as your primary agent.
Propofol is a hypnotic,
the doses for that
are anywhere between five and 50
micrograms per K I think its per minute.
Sorry if it's slightly different than that,
I think it's mc's per K per minute.
And then Precedex, which is somewhere between .2 and 1.2,
I think that's mc's per K per minute.
Either of these is fine.
So propofol's just a non-benzo hypnotic.
Precedex is a centrally acting alpha two agonist.
So it's a little bit different.
And I would choose one of those
and then I would have added on fentanyl
as my pain medicine.
And my fentanyl dose would be somewhere between 25 and 100
micrograms per hour.
The reason that this would have been
what I would have done
is we know their studies had to have a propofol
and with Precedex against benzodiazepines,
and there's no benefit to benzodiazepines over those,
and there is more risk of delirium
and other adverse consequences.
So we put benzos lower on our list before.
We tried to avoid them if we could, okay?
I often went with propofol first
and the reason for that is sometimes I had difficulty
getting people comfortable and controlled
on Precedex alone.
So that was sort of the reason I would
choose propofol first,
but if there was someone who was easy to sedate,
no problems, I would choose Precedex, okay?
Some things I want you to know about those three medicines.
So propofol, side effects, do you know any?
- [MD] You can still get delirium
with propofol. - Yeah.
- [MD] But, I don't know any specific
side effects. - Okay,
so the big things we worry about here is that
you can get low blood pressure with propofol,
really low blood pressure,
it drops your blood pressure a lot.
And then the other downside of this is something called
propofol infusion syndrome,
which makes you get a really severe metabolic acidosis
that can cause problems.
To be honest with you,
I have used a lot of propofol
and I've never actually seen in real life
propofol infusion syndrome.
But we talk about it a lot as being a concerning problem.
Something else that happens with propofol
is your pee gets green.
That's okay.
It doesn't mean you're getting propofol infusion syndrome,
it just happens.
So, deal with it, okay?
Not a problem.
One other thing to know about propofol
is that it's in a lipid carrier,
so you can get high triglycerides from it.
It has to be refrigerated.
You have to make sure that the line doesn't get infected,
all sorts of things like that go along with propofol.
So have that in the back of your mind, okay?
Precedex or dexmedetomidine,
I try to always use generic names
but I always spell this one wrong so,
dexmedetomidine is the generic name,
Precedex, some people just call it Dex.
Downsides here is that
this can cause actually both hypotension and hypertension,
depending on the scenario.
But the thing that I've seen that's been really scary for me
is they get bradycardic.
And I've actually seen someone go a-systolic from it.
So if I have someone who has a heart rate in a 50-60 range,
I'm not going to reach for the Precedex.
- [MD] Okay.
- But in general before either of these
with fentanyl on top of it,
I would have been happy as a clam.
I wouldn't bother talking to you too much
about ketamine or benzos,
or any of the other pain meds,
other than Tylenol
is sort of our standing for everybody, Okay?
So that's pre-COVID, okay?
Now, if I'm talking COVID,
it's a little different.
And there's some reasons it's different.
And so I'm not telling you what regimen to use or not use.
I want you to have a lot of things
in your back pocket as options, Okay?
As we start running out of supplies,
we might run out of meds,
we may not have access to Precedex or propofol.
We may not have access to fentanyl.
So I want you to know others.
We may not have enough IV pumps,
so you're gonna have to figure out a drug
that you can just give in bolus dosing.
You can't really do that with these, okay?
You can do that with fentanyl,
so keep that in mind.
But you want to think about things
that maybe would be more long acting that you can just keep
in your back pocket,
go in and give it as needed.
And we also want to think about medicines
that might allow us to stay out of the room
as much as possible.
So all those things swirling around your mind,
make me want to teach you about some of these other ones.
So ketamine is an NMDA receptor antagonist.
It causes dissociative state,
so it sort of has some pain function
and some sedative function.
The dose range is somewhere
in the area of .5 to four mg's per K.
I'm not sure if it's minute or hour.
Something, some time.
I'm gonna say per time, sorry about that.
It's a great option with less effect
on blood pressure than some of the other medicines have.
It can cause a lot of hyper-salivation
that you want to think about.
It can cause laryngospasm,
so there are some downsides to this,
but in general, it's a great med,
that just sort of makes people chill out.
It can also cause tachycardia and hallucinations.
So sometimes we give it
in conjunction with benzos for people
if they're getting hallucinations with it, okay?
So another option in your back pocket.
Benzos, so when we talk about benzos,
there's sort of three big ones that I think about,
there's many others,
but I think of midazolam,
lorazepam, and diazepam.
And I write them in this order,
because this is the order of half life.
So the half life here is like,
two to six hours.
The half life here is like 10 to 20 hours.
And then the half life here, I don't know exactly,
but I'm gonna say like 40 to 80 hours,
something really long, okay?
So, if we can only give a patient one medicine
and then we're not gonna have time
to go back and see them for a long time,
this may be a good medicine to help keep them calm, right?
Or Ativan can be a good medicine to do that too.
The midazolam is gonna wear off more rapidly
so we think about the midazolam as being
more of a drip medicine,
that we have someone on like a milligram an hour
or two milligrams an hour as a drip.
We don't use lorazepam as a drip.
The reason we don't do that is it's carried in,
in a carrier that causes a metabolic acidosis.
So we don't want that carrier to build up.
It's not the drug itself that's the problem,
it's the carrier.
- [MD] Okay.
- Okay?
So other options that you want,
before I would have said,
the risk of delirium is too high,
too many problems with it, don't use benzos.
Think about having the option
of using benzos now, okay?
And then as far as the meds go,
same sort of issue.
So fentanyl is going to have
a shorter half life than morphine,
so you want to keep in mind having that morphine accessible
to use as needed.
I'm always a little bit hesitant to give
what the correct dose range of morphine is,
because there's such huge levels
of what affects people and what people's tolerance is
and all of that.
But in general, if I'm going to put someone on a drip,
I try to start it at like .5 milligrams an hour,
one milligram an hour
and titrate to as much as needed, okay?
We already talked a little about Dilaudid.
I don't use that too much.
But it's something else to keep in the back of your mind.
And then we talked about
sort of the the ketamine sort of falls
into both of these categories, okay?
The things I want you to think about,
one more important point is,
if you have your patient paralyzed
because they have respiratory failure.
And you're trying to minimize their oxygen consumption,
or trying to get them to become fine with the ventilator,
whatever the case may be.
If you have someone paralyzed,
you must also have them sedated, okay?
So please, please, please make sure you have them
on a sedative and an analgesic,
if they're paralyzed.
Because otherwise they could really be suffering
and not being able to tell you
in any way, shape or form, okay?
That's a big one that's really important to me.
Okay.
So I think now you have a plan in your back pocket.
You're gonna use a scoring system
to decide how much sedation someone needs.
You're going to keep that RASS zero,
negative one range, maybe negative two,
or some other scale.
Use a scale, make sure everyone's
on the same sheet of music with it.
If you have lots of supplies,
everything's cool, standard ICU patient,
pick one of these two.
Tack on fentanyl if they need something for pain, okay?
If not, then use what you can use from our list.
Keep in mind all of these things
are completely reasonable options
in the age of COVID, okay?
MD, are there any questions I can answer for you?
- [MD] I don't want to throw you off,
but where does Versed
fall? - Ah! midazolam is Versed,
- [MD] Is Versed , okay.
- Yup, great question. - [MD] Perfect.
- Yep, so Versed, Ativan, Valium,
are those three generic trade names.
- [MD] Okay, I'm tracking all that, okay.
- Perfect, awesome.
Thanks for your time today, I hope you
learned something. - [MD] I did.
- Go out and take good care of patients.
Have a good one.