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What role does the choice of sedation in the field or ED play in the delirium that unfolds in the ICU? How can inter-departmental collaboration improve sedation practices and patient outcomes? How can the ICU better understand delirium and respond appropriately to new admissions from the other facilities and the ED? Jeff Polland, BS, NRP, FP-C, shares with us his work to avoid benzodiazepine abuse to improve patient outcomes.
Episode Transcription
Kali Dayton 0:00
In this podcast, I have advocated for seizing every possible opportunity to allow patients to wake up right after intubation, so as to prevent delirium altogether. In most cases, the less sedation a patient receives, the easier it will be for the ICU team and the patient. Yet not every intubation is in a controlled environment, with the opportunity to discuss intubation and sedation with the patient before and have the family and team present afterwards to help them acclimate to the ET tube and ventilator.
The cases in which patients are intubated in the field or ED. And especially when they spend hours or longer in the ED or in transportation to our ICU, can really impact the rest of their ICU stay. Just as twice of sedation indication for sedation, a combination and doses of sedation fluctuate drastically between ICUs. They can also vary among critical care, transportation, EMS and ers.
This podcast primarily focuses on the ICU side. But it is vital for the critical care side to really understand sedation and their domino effect so that we can better collaborate with our colleagues and other departments. We can also better prepare for and treat delirium when a patient has been given sedation, especially benzodiazepines, before arriving to our ICU. If our team has the goal of helping patients be awake, calm and mobile on the ventilator, then we will quickly wean them off of sedation as soon as they arrive to us if already intubated somewhere else.
We need to know what medications they have been given and for how long. For example, if a patient has been intubated with five milligrams or more of medazepam in the field, then Ana medazepam Er will falter up for a few hours in the ED. We need to factor in those medications. When they emerge from sedation with agitation consider the following:
For every one milligram of Lorazepam, there is a 20% increased risk of delirium within the following 24 hours. For every one milligram of midazolam, there is a seven to 8% increase in risk of delirium. This will impact how they come out of sedation. When we understand that they are at a 35% higher risk of having delirium because of the five milligram medazepam bolus they received at intubation, and then additional sedation during transportation.
We can be ready and eager to help them come out of that confusion and agitation through communication, family and even mobility. We can anticipate the causes of the response and seek to actually treat them if we are unaware of what they have received and consider the agitation we witnessed as a quote, failed sedation vacation unquote, and then rushed to resume and even increased the sedation. We have buckled them into the delirium ride and set them up for even worse and prolonged delirium, higher risk of death and hospital acquired disability.
What our colleagues do before the ICU, and how we respond upon arrival to the ICU in regards to sedation greatly impact our patients survival and quality of life as a European version of the ABCDE F bundle, e cash protocol states. Early comfort with minimal sedation should be provided as a clinical priority on a par with early resuscitation, early sepsis management, and an early lung protective ventilation strategy. So avoiding sedation, and those choices upon arrival to our ICU are just as important as which antibiotic and how much fluid we give them during those critical early phases of critical illness.
Fortunately, those of us on the ICU side are not the only ones realizing the role we play in patient mortality and suffering with our sedation choices. Even paramedic medicine is also having an awakening and movement to apply current research. I am excited to have an EMS expert share with us his expertise and work, Jeff, welcome to the podcast. Can you introduce yourself?
Jeff Polland BS, NRP, FP-C 5:04
Thank. Thank you. Yeah, so my name is Jeff Poland. I’m a paramedic in the US. I practice kind of all over and just about to start medical school.
Kali Dayton 5:15
Excellent. And we got connected because I think you had made some comments on a Facebook group about benzodiazepine use, I think it was a critical care group. And a provider had listed some of their station protocols, something like that. And we both said, why is that on there? Well, I don’t remember if Lorazepam was still on there, or if it was just burst said but we were, we were both pretty taken aback by that and we started chatting.
Jeff Polland BS, NRP, FP-C 5:44
Correct, correct. You know, I think it was one of those. I forget exactly which group it was. But yeah, you and I both had the same thought, you know, okay, well, why are we still, you know, listing…. like a like you said I can’t can’t remember which benzo it was why are we still listing this benzo as a sedative that’s appropriate for use it you know, in in intubated, and in ICU patients.
Kali Dayton 6:09
Yeah, it was it was nice to find validation. But we found that you have a very different perspective. In the ICU world. As I’m talking to people around the country, they’re saying, well, patients are showing up delirious. Because I I’m often referring to the situation which were explained to patients prior to intubation, that they’re needing to be intubated, like a lot of these COVID patients or patients that were intubated in the field and come and we pick up sedation right away.
But what it sounds like people are experiencing with patients that are already intubated, either in the field or in the IDI, they’re already delirious. And you gave some really interesting insights into how we’re using visit as opinions in the field. And there’s a study that shows that for every one milligram of Ativan, a patient is 20% more likely to develop delirium within the following 24 hours. So, we are using the desk in the field and what kind of contexts or what kind of scenarios are benzodiazepines being used?
Jeff Polland BS, NRP, FP-C 7:17
Yeah, no, and then that that’s a that’s a great point you make right there. And a lot of, you know, kind of what I what I seek reminder standing as you work primarily in a tertiary care facility, correct? Correct. Yes, so a lot of my experience has been either intubation in the field or picking up from some of the smaller either the critical access or even smaller than that hospitals, where, you know, the the care and the sedation.
And the the intubation that they get is widely variable. So, you know, on one of the expect about a spectrum, I’ll show up. And it’s been a patient who has been intubated, and I show up and there’s just, you know, puddles of tears in their eyes, and I start talking to the staff and oh, no, they’re fine. We induced with 10 of back and I just gave him another 1010 minutes ago, they don’t need anything else. Or you’ve got the opposite side, nothing else. Yeah, that’s, that happens more often than you, you’d think, unfortunately. And that’s an entirely entirely different topic, but that’s important.
Oh, it’s absolutely important to recognize and immediately I’ll usually typically reach for the the ketamine, but a lot of you know, my colleagues, they’ll recognize that kind of a scenario, or, you know, they’ll even do the innovation themselves, and they’ll immediately reach for something with which they’re familiar. And there aren’t a lot of EMS services, whether it’s critical care, inner facility or 911, or a mixture of both, that are used to some of the more, you know, typical sedative hypnotics. That might be a little bit more appropriate to the intubated patient, you know, your propofol, dexmedetomidine, ketamine, things like that.
And typically, because most you know, either family practice physicians working in the ER or ER physicians that maybe are a ways out of residency, they’re really familiar with verset. So a lot of times you’ll see okay, we’re going to intubate, give them five of her said 200 A sucks, or you know, it may be a terminate followed by sucks and then after that, it’s either ever said drip or intermittent versus boluses for for sedation, and it’s just a lot of people are very comfortable using the drug because they use it for seizures, they use it for, you know, some of the more milder you know, conscious sedation ‘s and things like that, that we do more in the in the ER and more in the emergency realm.
And, you know, you ask them to do something like, you know, initiate dexmedetomidine or initiate a propofol drip especially with somebody who maybe isn’t as hemodynamically stable as we’d like to see. And the fallback is always, you know, something that they’re familiar with. And that’s going to be either Ativan or ver said and typically without any sort of analgesia as well.
Kali Dayton 10:16
Wow. And why is that concerning to you? Why does that upset you?
Jeff Polland BS, NRP, FP-C 10:22
Oh, this is absolutely concerning you had brought up by, you know, the study about, you know, every milligram of Ativan, the one that I like to I like to reference is the one that found that, you know, any, even a single administration of a benzodiazepine was bound to be an independent predictor for ICU delirium. And we know how bad ICU delirium is, we know how it dramatically increases morbidity and mortality.
And it’s something I think we all should should strive to avoid. And a lot of I see from, you know, my colleagues is, oh, well, we we know that they’re under sedated. And there’s there’s a couple of different reasons for that I’ll get into in a bit. But you know, we know that they’re under sedated, we know that we need to give them give them something. So you know, fentanyl inverse said works really well. So we’re just going to, you know, I’m comfortable with that.
I’m used to that. So we’re just going to continue it, and then they can do whatever they want in the eye. Which I can I can understand that that line of thinking, but it’s flawed in a way because, like you said, and like I said, there’s even single administration of the these benzos. Can can have, I mean, I don’t want to say catastrophic, but almost catastrophic downstream effects, you know, for you in the ICU. And that’s just not something that we see not something that we deal with. So it’s not something that’s in the forefront of our mind. It’s something we see. Okay, cool. This works great right now. So we’re just going to continue, you know, continue to do this. And we don’t see that negative downstream effects.
Kali Dayton 11:56
It’s like this whole chain of dominoes that are all set up, the second patient comes to us, and maybe I see us somewhere towards the beginning in the middle Eltechs at the end, and there’s a whole another maze. After acute care, right?
Jeff Polland BS, NRP, FP-C 12:13
Absolutely.
Kali Dayton 12:13
And you as the EMS are even in the ED you hold that first…. that one domino, and you hit it. And then let’s say they get up to the ICU. So in the wake of what can I see if someone comes in and they’re on verse said, so let’s say that we started an outside facility coming on verse said, we’re going to take it off, because we want people to wait, right? But they’re going to come out cuckoo.
They’re going to come out agitated, thrashing, yet the waking walk in ICU, has the understanding the culture of hey, clearly, they’re delirious, we’re not going to give them something that’s going to make them more delirious, and make them delirious for longer. So we’re going to keep that off. That’s our culture, we are going to be super annoyed that you made them delirious, because that wasn’t nice. Right?
That was that was, in our mind, that’s a cruel thing to do to patients. And, and really inconvenient thing to do to us as a team. But that is an exceptional team. Most ICUs if they do, if they do sedation vacation, after you’ve started to verse that drip are given five milligrams of Ativan, whatever, when we, they see that agitation, they’re just going to turn that sedation right back on, higher, deeper, longer, they’re gonna be more determined and whatever agitation, they saw a product mission, or whenever they took it off, that they’re gonna have that label on that patient.
So the next shift is going to know this is a wild patient, keep that sedation on keep it higher. So now those dominoes keep on going and now we’ve all signed them up for delirium, cognitive deficits, infection, higher risk of mortality, longer time on the ventilator long time in the hospital, I mean, it but if if the IDI had let them wake up after intubation, how different would that had been? Where we’d prevented delirium, and then that patient rolls in and they are themselves the whole rest of the team everyone knows that this patient is okay and safe.
Jeff Polland BS, NRP, FP-C 14:10
Absolutely, absolutely. And you know, it’s it’s super interesting you know, kind of like that that would be the ideal world is if you know even if they’re you know, in the little you know two bed ED out in the middle of nowhere, even if they were, you know, appropriately intubated with you know, something short acting, given appropriate analgesia and allowed to, you know, kind of become more cognizant, had benzos withheld, there’s a lot that goes into being able to keep somebody awake and comfortable on on the vents.
And one of the things you know, as EMS one of the things that we we deal with is a lack of lack of budget, and we can we can almost break that that you know that that chain because once they once they get moved off of, you know, your guys’s I don’t know how many, you know, 10s or hundreds of 1000s of dollar ventilator over to, you know, hopefully, nobody’s still using, you know, pneumatic driven things, you know, like, like an auto event 4000 or, you know, even, you know, even some of the more common transport vents that, you know, may only run five or $10,000, those things aren’t comfortable.
So what we end up seeing is, we end up seeing somebody who is happy and comfortable on their, you know, real fancy, real gentle ICU style ventilator, and we move them over onto ours, and they can’t tolerate it. This is really prevalent, so patients who are going to Eltech, you know, they may need, you know, they they may be able to be off the vent for a little while, but they just need, you know, some some support intermittently, I’m sure you’ve had those those kinds of patients did you have to do your trade once, when we’re not been? Really, that’s probably goes,
Kali Dayton 16:10
When you have them up and walking, and they don’t atrophy, then they are able to be extubated, and they walk out the doors. So it is that at that point, someone’s transferring to LTACH, you would hope they would be off sedation by then. But that’s often not the case. Correct? Or they’re barely taken off?
Jeff Polland BS, NRP, FP-C 16:29
They’re either they’re just barely coming off or they’re on no sedation, but they’re able to tolerate that vent, and then I go to move them onto mine. And all of a sudden, they just can’t tolerate it. They become super uncomfortable. I mean, to the point where it’s pretty much okay, well, if you if you want this person to go to LTACH with me with a either needs to be able to manage off the vents or I need to either sedate or, you know, give them some sort of analgesia.
My preferred method is fentanyl, rather than sedation. But you know, if honestly, it all depends on the culture, it depends on the sending dock, it depends on the receiving dock, so many things. But more often than not, it’s Oh, yeah, they need to go give them a milligram or two milligrams Ativan, or give them two and a half or five of her said, and all of a sudden, we’re either starting down that delirium road again, or it’s just not super effective. And that’s kind of one of those, one of those things that, you know, that’s people going to El tack so you know, you throw on somebody who’s already maybe a little bit delirious, or somebody who’s new to being on the event, and they’re tolerating things, okay.
Even if they’re on something like a propofol drip or you know, some sort of appropriate sedation in the ICU or the ER, that we’re picking them up from, when you move them into the transport environment. Man, things are just there, they’re going from there, nice, comfy, quiet, you know, organized, everybody’s in a calm voice, there’s no weird vibrations, there’s no weird smells, there’s no weird sounds. Now all of a sudden, they’re going out into the harsh daylight, where temperature is maybe not, you know, controlled as as well as we’d like it to, there’s wrote noises, there’s vibrations, and all of a sudden, you know, I used to think it was just okay.
The, you know, all of a sudden, you’ve these patients, they need more sedation in a transport environment, because of just all the extra stimulus, they just can’t deal with it. And after talking with you a little bit, I’m wondering, and I don’t have any, any research one way or the other. But I’m wondering if we’re not just seeing a manifestation of some delirium already. And of course, as they’re delirious, what’s the first thing we’re gonna do? We’re, you know, maybe getting up a little bit on the protocol.
But as we have them on the protocol, their pressure is going to drop, so Oh, both their pressure drops the proper fall, I’m gonna turn pro fall down in here, I’m gonna give him two and a half or five ever set. And it’s, yeah, that this is this is one of those things, and I used to want it when I first started doing critical care. This is, you know, these are things that I thought, okay, yeah, you know, sure, no big deal. This is just how it’s done, you know, you, you’ve got a patient who’s agitated, the transport environment is definitely more stimulating, we need to be, you know, nice to these patients.
I don’t want them fighting the vent that want them to be nice and comfortable. And then when I actually started, you know, a couple of years ago, when I started taking a look at what these benzos are actually doing. It’s it’s crazy. And you know, I’ve kind of modified my approach a little bit to, you know, somebody who may be a little bit delirious, maybe it is, you know, some adverse effects of the transport environment, I really don’t know. But you know, my approach now is increase in the in the opioids and try to either bring the sedation down a little bit, or you know, stop benzos if they’ve got the benzos going, but I do just about everything I can now to avoid Using benzos and go with an analgesia first approach.
Kali Dayton 20:05
Thank goodness you do up to 80, at least maybe up to 80% of ICU patients have delirium. And there’s so many things that cause that, right. But we know that prolonged deep sedation causes delirium. I’m imagining these patients that are traits. And I’m sure the majority of them are because of prolonged time the ventilator. And the majority of that is because they have atrophied because they were deeply sedated. So it sounds like a lot of these patients that you’re transporting is not the majority of them, not all of them have, at one point been deeply sedated, likely for a prolonged period of time. So the risks of delirium are high.
And so maybe they were, you say calm, but I wonder if they’re maybe still having some hypoactive delirium. So they’re still pretty lethargic, pretty out of it, or just so weak, right? And they are in a more controlled environment, maybe they’re starting to come out of delirium. So I’m, I’m reflecting on the survivors that I’ve interviewed and what it’s like for them to start to kind of realize that they’re in the hospital, but they’re still seeing dogs or demons running around. They’re still trying to make sense of what’s going on. Now they’re being transported somewhere else. And they’re having this huge change of environment that you’re talking about.
And they’re if they don’t understand what’s going on, what is it like to suddenly? Do they think they’re in a spaceship, when they’re in your, your truck? Do they think that they’re going to be taken to jail? What do they think and of course, they get agitated and panicked. So it’s, it’s actually filling me with panic, to think of responding to that delirium, or that agitation, probably from delirium, be with benzodiazepines, that will just put them down deeper, they’ve already suffered so much. And then what happens in LTACH? When I have one nurse to 20 patients who have cleared him, how does that help their trauma? Well?
Jeff Polland BS, NRP, FP-C 22:07
No, absolutely. And and it’s one of those, you know, I mean, I don’t do a lot of critical care transport now, just because of the the environment that I’ve been in for the last year. But you know, back when I did do a lot of it, and when I was working on QI and training and all that, one of the things that you know, really push doesn’t matter whether, you know, you’re picking somebody up who’s been on the vent for 10 minutes or been on the vet for 10 days, you know, it’s always going with that.
That, you know, if you’re going to use, you know, pharmacologic methods, it’s going with that analgesia first. And, you know, kind of trying to break that whole benzodiazepine chain, it’s just so different in the transport environment and in the ambulance environment than it is anywhere, anywhere else, and ICU and ED, and a lot of that is just from a patient’s point of view, you know, like I said, it’s a completely different environment that’s not nearly as as controlled or as regulated. And, yeah, it’s gonna be tough for the for the patient. But the
Kali Dayton 23:18
30 minutes, hour, whatever quick period of time you have with them. Like you’ve said, the studies show that that can greatly impact their outcomes, their mortality, though REM all of it. And yet, I had never thought about what an EMS use. And when people say that patients show up to the ICU, delirious, granted, they mean telepathic from lots of things. But now I’m wondering, what did they use an AED? What did they use in the field?
Are we recognizing that delirium and clearing it out right away? Are we just adding on more of what caused it? Yeah, how much will that impact our outcomes if we really collaborated like this? We unified and said, We all know that benzodiazepines increased mortality, we are all part of this problem. We’re all accountable for it. How can we change together?
Jeff Polland BS, NRP, FP-C 24:08
Yeah, absolutely. And I think that’s a great, that’s a great place to start. So you actually just said something interesting. Right there. You said you don’t know what the IDI or what the prayer hospital use that actually. So, in you know, from, from my perspective, that kind of takes me back a little bit.
I thought that, you know, you guys, especially since you have access to all these other records, I mean, I’ll go through and I’ll read what sense you know, while I’m in the ambulance, and, you know, that’ll that’ll kind of help to alter my expectations and how I’m treating the patient. But you know, if you guys if that’s something that you just don’t know that that kind of strikes me as odd because I get it typically when, you know, every time I’ve given over a handoff report to somebody, you know, going up to the ICU, who’s vented.
There’s a bunch of different people there. You’re trying to Do everything that you need to do with you know, getting them set up getting them appropriately position getting, you know, everything that that’s super important for ICU care. And here I am, I’m spitting off some stuff that you’re half listening to. And again, I don’t I don’t mean any offense by that, but it’s just it’s the way that it goes. And
Kali Dayton 25:20
My connection with EMS is a little bit different. So, you’ve got you’ve given them if you’ve intubate in the field, right? You’ve already given them medications you brought them to the ED. I don’t know that we’re always aware of by the time they get to the ICU, what was given in the field as far as intubation, a lot of times what we hear is they were intubated in the field. And we don’t think about what was given them patient we do hear what it was given the ED, but if it’s like a tertiary hospital, so we’ve gone from EMS, to ED now, to a totally different facility.
We’ve played telephone down, though, down the road, and I think, my my culture like I am going to care about what was given, I’m gonna want to know what was going for sedation. I won’t necessarily know it was given for intubation in the field. I don’t know that I right. That’s it for protocol to really know.
Jeff Polland BS, NRP, FP-C 26:07
And, and, and it varies so much, even within states vary so much by county or by agency. You know, for, for example, out in in Washington, where I was at, we had the option of atomic ketamine and verset for induction. The next county over had the option of, I believe all they had was either verse said, or appropriate fall. But all the medics out there, they were uncomfortable with propofol, so propofol never got used, and their dosage strategy on the next county over was actually what I would consider, I mean, if you’re going to use preset for induction, which I would never recommend, but if you’re going to use it.
It’s got such a variable dose response curve, that the ideal dose is actually gonna be a little bit closer to one meg per kick. For induction with reset. If you go in you actually look yeah, back in the back in the 80s, when they when Bruce said was kind of just coming just coming out, they wouldn’t they did the study as your as a category one and two patients in order to achieve adequate depth of anesthesia required somewhere between point three and I think it’s like 1.1, or 1.3 makes for kick verse said,
You’re as a category three and four patients required I think was between point eight and two makes for KIG. Of versa. And I’ll I can edit that and look up the I don’t have the studies in front of me, but I’ll definitely include those as well. Yeah, absolutely. But it’s something ridiculous like that. I mean, one of my I mean, I’ve there’s a million reasons I hate Versa, and anybody that knows me will know that that’s kind of my thing. But one of the reasons is exactly that. Such an unreliable drug.
So you know, you may end up if you give them two and a half to 10, which is kind of what I’ve seen, as you know, most, er Doc’s and most EMS providers that will use for said for induction, that’s typically the dose range that they’ll use is Oh, give me two and a half and 200 A sucks or give them you know, five and 100 a rock. And, you know, yeah, you may get a little bit of that amnesia. But really, I’m wondering, are you really actually said, dating them?
Or are you setting them up for delirium in a couple of ways to where they’re going to remember feeling a little loopy, like they had one or two drinks, all of a sudden, they couldn’t move and somebody shoving stuff, you know, down their throat, I mean, in my view, and an unpleasant and you can please correct me if I’m, if I’m wrong on this, but an unpleasant uh, you know, experience like the act of actually being intubated.
You need sedation of some sort, or for that. Exactly. I mean, honestly, I’m gonna go out on a limb here and say you need general anesthesia for that even in, you know, everybody gets all medical, legal and worried about oh, we can’t do general anesthesia without an HSA board certification. No, you’re doing general anesthesia, when you’re doing an induction you’re not keeping them there for very long, but you’re you’re getting them to that adequate plane of of anesthesia.
And what I think we’re doing with a lot of people when we underdose, even when we give, you know, 10 of her said, for the induction, what I think we’re doing with a lot of people is we are giving them some vaguely dissociated, weird memories of you know, being paralyzed and pain and all of this and we are just going you know, we’re going up to the, you know, 20 foot diving board and pushing them off, you know, in the into this delirium cascade, because we’re are a we’re using the wrong med. But if you’re gonna use the wrong maybe use the wrong med in the right dose.
Kali Dayton 30:07
And in the right series, apparently addicts are not the standard drug of choice for intubations we can usually do nominate fentanyl we can we can get those Ella’s waking up nicely. So people say, Well, we start continuous sedation because we use paralysis for every patient that we intubate, which must be just, you know, part of their protocol. But I don’t know that that’s, that should be the exception there. And when it’s exception, it is necessary. But how much could we avoid? And how much better could we stay people if we weren’t paralyzing them?
Jeff Polland BS, NRP, FP-C 30:43
So So that’s interesting, do you vast majority, let’s see in my entire career, and I’ve done a lot of innovations, but in my entire career, I think I’ve only done maybe 30 medication on like, you know, induction only intubations. And the reason for that is in the kind of scenario that that I’m in, you know, if I’m doing an elective, urgent or an emergent intubation, I want to avoid hypoxia.
And I often don’t have time to properly pre oxygenate people, I can do my best. And, you know, I’ve discussed ad nauseam elsewhere, the strategies that I use for that, and you know, to optimize them, but what I really want is I want the best view possible in my best chance at a reduced time in laryngoscopy. And I want a first pass success. And for me, that’s, that’s always been, you know, look, I’m going to end up paralyzing just about all of my patients.
I’m not a huge fan of succinylcholine, largely because we get very, very limited histories in there, I don’t have a serum potassium, I don’t know if they’ve got a history of hyperthermia, and if they’ve got a history of malignant hyperthermia, cool, I’m gonna recognize it, and I’m 45 minutes to an hour and a half away from dantrolene. So you know, there’s a lot of, you know, downstream effects that that kind of go with the decision to use succinylcholine.
And it’s probably because the only agents that I’ve had available to me in the field are, you know, for said atomic date, and ketamine, ketamine is probably the best out of all of those in terms of muscle relaxation, and actually allowing an adequate view. But even then, it’s not, it’s not a great view, that’s Hamid a, you’re almost guaranteed to get some master spasm, or some trismus, at least in the way that I’ve used it. And versa. Like I said, I don’t I don’t touch it, if I can avoid it.
So yeah, I ended up actually giving a lot of my patients, it’s typically, you know, 95% of the time, it’s a ketamine and rock uranium induction rock at the higher dosage at about one MIG KIG. Because I want that quick onset, you know, to paralysis, I don’t want to sit and wait for the two to three minutes it’s going to take if we use, you know, the point 4.5.
So, you know, it’s a trade off, and I’m sitting here, I’m thinking, Well, you know, I guess in in selected patients, maybe succinylcholine might be appropriate, so I can try to win the sedation, but then it goes into, okay, well, if I’m putting them on this cheap, very, you know, rough for lack of a better term vents, they’re going to be upset anyway, so paralysis actually ends up benefiting us because a lot of the times and unless we’re intubating for airway protection, or intubating, for some sort of, you know, respiratory pathology, and we want, especially in the peri intubation period, we want good control over the patient’s done auditory status, because that is, you know, we can kind of precisely dial in.
It’s easier when you have ABGs I’ve unfortunately, never worked in a system that I could draw on AVG, but you know, we’ve got other ways I can approximate, you know, co2 off of, you know, entitled capnography and all that. And, you know, I can kind of make an educated guess at what the pathology and kind of titrate for that, but, you know, it’s, it’s kind of a gamble because we want that tight control so that the patient is not over breathing and not kind of undoing the health that we’re trying to do. So it gets really complex, you know, in the emergency scenario, you know, in the IDI or pre hospitably.
Kali Dayton 34:51
Absolutely. And you’re in a totally different setting. This is not a controlled environment. You have very little support. You’ve got that one shot you’ve got an emergency you That is a very appropriate setting for everything that you’re talking about. And I’m not, I don’t hate all sedation, I hate the way. So you Sorry, you’re, you’re mentioning, almost like a procedural sedation, even I would say that the transportation of a patient on transport vent during that kind of emergency.
That sounds like a procedure and that’s not going to have so that period of time on ketamine. That’s nothing compared to that period, like weeks on ketamine or weeks on verset or days. And, but yet, you’re still trying to have stewardship over their long term outcomes. And so by avoiding verse said, and being aware of delirium, I appreciate that because you’re making it so much safer for the patient down the road. So though, you have an appropriate use for sedation, you’re also using sedation appropriately and making wise choices.
Jeff Polland BS, NRP, FP-C 36:04
Yeah, absolutely. I mean, it’s, it’s one of those you don’t want to overstate and a lot of the times what, you know, we as as you know, in the emergency setting, like to think is the, you know, the sedation, you know, the the adverse effects of, of over sedation, pretty much, we think of it as Oh, well, if you sedate them too much, they’re going to have a human dynamic collapse or human dynamic instability. And it extends a lot more than just that.
It extends into, you know, the risks for delirium. The risks for atrophy though risks for prolonged weakness, you know, it’s it’s kind of rare, that will reduce paralysis. But no, I completely agree. I think that unless you’ve got like a Hamilton T one or one of the real, you know, luxury transport ventilators, thinking of it like procedural sedation is probably realistically going forward, going to be the best route. And we really need to plan and what I like to see is I’d like to see EMS work together with the ICUs to plan this procedural sedation. So that can be the best for the you know, for the patients.
Absolutely avoiding paralysis, avoiding benzos. A lot of times, this is outside of the scope of this, this podcast, but you know, we don’t have access to the drugs that I would love to see, available, you know, drugs like Remi, fentanyl, and dexmedetomidine, that I think would be absolutely appropriate for the transport environment. But there’s simply cost prohibitive for us to stock. So maybe planning for that kind of procedural sedation, and having those meds available for providers to use, and maybe switch them over to something like, you know, hey, for this transport, you know, here, here’s for me, fentanyl, here’s dexmedetomidine, here’s remifentanil, in propofol whatever.
You know, your preferred method, or whatever you think is going to be best for the patient, have that stuff ready for us, because we are more than happy to listen to everything that you guys, you know, have to have to say, you know, these patients are better than than we do. And if you guys have a plan that will help us to reduce the reduce delirium, we’d be more than happy to happy to vote, we’d be happy to chip in and uproot our thoughts as well. But often when we’re kind of left to left to our own devices, the majority of the country for sedation, it’s typically benzodiazepine only, or benzodiazepine, you know, opioid combination. And that’s kind of what we have to fall back on without something specific from the sending or receiving hospital.
Kali Dayton 38:56
So you have a culture of starting delirium. The ICU has a culture of 3d, no, but the ICU has a culture of treating delirium with sedation. Maybe there has been lightened up and then you’re reducing delirium on the way to LTACH, and I think LTACHs also are inclined due to their workload and maybe their culture as well, to continue visit as if he news for the agitation, delirium. So I think I’ll talk needs to be part of the discussion too. If you’re transporting these people to attack, you’re biting off the grenade or causing more explosions and then handing it off to them. They might have a word to say about it as well, right? Because they’re the ones that have to clean up the mess all of our mess. Well, yeah, absolutely.
Jeff Polland BS, NRP, FP-C 39:43
And you know, so I’m talking about, you know, yeah, either going to El tack or even, you know, going from community er to tertiary care, or, you know, ICU to ICU basically anytime there’s the transport of a patient’s on a ventilator, thinking of it, yeah, in terms of procedural sedation, and getting both facilities and the transport team involved is going to be the best option. And again, you know, there are some phenomenal transport vents out there, that can be just as comfortable as you know, the vents in the ICU. The thing is, it’s not realistic for most places, to have those events and and to use them. It would be awesome if it was, but it’s just, it’s cost prohibitive. So you’re local?
Kali Dayton 40:32
Well, you could change outcomes so much by choosing to do precedents Excellent. And determining, instead of versus set in that moment, for those that 20 minute drive, you could spare so much harm by having that available to you Houdini. Absolutely. So you’ve influenced change and different places that you’ve worked, how has that come about? And what barriers have you faced?
Jeff Polland BS, NRP, FP-C 40:54
So, you know, it’s, I’m, I’m pushy. And that’s how that’s come about? I mean, I, I Right, exactly. So, you know, when I was when I was first starting, it was it was one of those, I would, I would try to you know, consistently advocate for, okay, look, I’m not happy with with, with how this process is going. And I would try to take it up initially, with the, you know, providers at bedside at the at the sending to try to get something done for this patient.
After that, I tried to take things up to to management, and, you know, unfortunately, the vast majority of places, management is they’re very interested in in better clinical outcomes. But they’re also very interested in paycheck that bounce. And sometimes, you know, getting everything that we would like, is not really realistic from a budget standpoint. And I mean, you you’ve been around, you’ve been in medicine long enough, probably everybody in here listening has been in medicine long enough. The we all know that politics are a thing. And a lot of times, ideas that would be very beneficial, get hung up because of of politics.
So you know, for example, like trying to get certain things switched around when I was working, you know, doing training and Qi rather than kind of frontline as a, as a provider, for a company that did a lot of critical care transports. A lot of the resistance that I would run into is the ICU was largely uninterested in hearing from us, unless it was to say, Oh, hey, we can actually be 30 minutes early for that, you know, for that transport. Or, you know, basically, right now, I think the way that is viewed in a lot of allies, and again, I’m this I’m painting with a very broad brush, some areas have been nominal working relationships, and those really all it would take is, you know, a little bit of a conversation about, you know, hey, well, so this is what we’re doing on the way.
What do you guys think about that? What do you guys think about maybe, you know, we can try to reduce our benzodiazepine use, excuse me, I, you know, can we get a program where we can, you know, get some dexmedetomidine from you guys, for these patients? Or, you know, would you mind working with us a little bit on this. The other way to kind of really affect change is, you know, the EMS systems in and of themselves. Right now we in EMS have a have a culture of benzos first, and you know, oh, well, sedation.
That’s what benzos are for, or that’s what you know, a sedative is for and from all the research that I’ve read, and everything that I’ve looked into going with a more analgesia first modality can really help to not only reduce the incidences of of delirium, but reduce the overall sedation requirements, and keep people you know, nice and happy and much more aware and able to be you know, just overall. What’s the word I’m looking for? Just have an overall, you know, better experience that’s going to lead to in the end, less Stellarium?
Kali Dayton 44:43
Yeah, I think that I understand this discussions with critical care difficult. Men that I do all the time is tied to the research to attention and be convincing. And I think from your side, you can make the argument that supporting your Culture change within your discipline will make the ice team’s job easier. But to understand what delirium is, I think there’s a lot of lack of education that the apartment, but once I enter a room is how lethal it is how much work it is, they’re going to be very interested in preventing it. If they’re, if they’re wanting to keep patients awake and calm the ventilator, then they’re going to want to help people not bring them delirious to their door.
Jeff Polland BS, NRP, FP-C 45:28
Absolutely. And there’s also I mean, if you think that, you know, delirium is, is, you know, something needs to be educated on and the critical care meant, in EMS, and even in critical care transport, it’s just something that we don’t talk about. And, you know, like I had alluded to earlier, it’s largely because we don’t see a lot of that long term. So clearly, and a lot of the long term effects of what we do, and the biggest kind of cultural change that I think that would be most beneficial, you know, for us would be getting used to the idea that what we do, you know, matters beyond the time that we have the patient, and it’s got those long term effects. I know a lot of providers, and a lot of my colleagues that have that mentality that “well, you know, hey, I got them alive to the emergency department. I did my job. And what, yeah, yeah, but not really, you know”,
Kali Dayton 46:33
You would save them for that moment, that would also increase their risk of dying later.
Jeff Polland BS, NRP, FP-C 46:37
Exactly, exactly. And I mean, this, this is an argument that, you know, I think, all of kind of resuscitation and emergency Med, really to take to heart and I’m not going to bring up epinephrine and cardiac arrest in this. But you know, there’s, there’s, there’s a whole big culture thing beyond just the delirium when you look at a lot of these treatments that we’re using in any emergency med.
Yeah, we get dramatic results. And it makes things a little bit better for us in the moment. But why are we looking at these? I’m gonna borrow a term from the ABA, the late Dr. John Heinz, why are we looking at BSC bullshit surrogate endpoint data? Why aren’t we looking at patient important outcomes?
And that’s a huge thing that I think the you know, incidence of delirium, the prevalence of delirium, and the harm that it causes, could be a great catalyst and a great kind of concrete example of something that EMS and the emergency department and the critical care transfer teams, and the you know, community and critical access ICUs can all kind of get on board as a kind of a concrete example of Well, hang on, let’s take a look at the bigger picture overall, rather than what’s going to be best, most convenient in the moments for for a lot of things.
Kali Dayton 48:08
Oh, Jeff, you have captured the essence of this podcast, to look at the big picture and take accountability. No, we as we humanize our disciplines, at whatever point we’re touching a patient, we need to see them for who they are as a person, as their lives as a whole. And be darn sure that we’re doing everything in our power to make sure that they survive and thrive after they leave our hands. Thank you so much for all you’re doing out there, keep up the good fight. Let’s work together to help change the culture and bring in that big picture. I appreciate everything that you’re doing, and you aren’t good luck with medical school.
Jeff Polland BS, NRP, FP-C 48:46
Yeah, absolutely. Thank you so much. I’m thrilled to be on here. I’m thrilled to you know, kind of how to, you know, hopefully help you guys get at least a little bit of a window into what it’s like. And, you know, if you guys you know, anybody that’s listening, if you if you get a moment, you know, please next time you’re you’re sending out or receiving a patient, take a couple of minutes talk to talk to your local providers, because we’re very receptive to opening up that that dialogue. And you know, we want what’s best for the patients just like you want what’s best for the patients, and kind of I think coming to together on some common ground like that would be would be an amazing thing.
Kali Dayton 49:26
I had never thought about that. I think when especially lifelight bring someone and they’re never said drip. We quietly roll our eyes. But why not say how do you feel about verset? What do you have other options? What is available? What do we need to do to bring in policy changes? What how can we make better agents available to you? I never thought about actually communicating that. No, rather I was passive aggressive and just said, Well, great. We need to clean that up now. But you’re right. Everyone wants to do the right thing. We just need to communicate together and work together. Awesome.
Jeff Polland BS, NRP, FP-C 49:57
Absolutely.
Kali Dayton 49:58
Thanks so much, Jeff. Yep thank you if you want to join in on the conversation leave a voicemail at 801-784-0472 or reach out to me on Twitter
Transcribed by https://otter.ai
Jeff’s Resources
Wide dose-response variability with midazolam and amnesia.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095819/ — peds, benzos as an independant predictor for development of delirium.
lorazapam as an independent risk factor for delirium.
https://www.atsjournals.org/doi/full/10.1164/rccm.201312-2291oc — propofol better than benzos
Editorial, but well cited. https://journal.chestnet.org/article/S0012-3692(12)60436-X/fulltext
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316795/ — systematic review, fairly well conducted IMO,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2391269/ — another review article.
https://pubmed.ncbi.nlm.nih.gov/16394685/ — lorazapam as an independant predictor for delirium
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232258/ — survey, not hard data, but really interesting nonetheless. 82% of ICUs treat delirium with benzos only.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028734/ — no duh
https://www.sciencedirect.com/science/article/abs/pii/S0883944119304319?via%3Dihub — feasibility study on analgesia-first sedation, I’m trying to find my favorite study on analgesia first sedation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5237378/ — not addressing delirium in AFS, but a great bit about the feasibility and efficacy of an analgesia first approach.
Pandharipande, P., et al. (2006). Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 104(1). https://pubmed.ncbi.nlm.nih.gov/16394685/
Taipale, P., et al. (2012). The association between nurse-administered midazolam following cardiac surgery and incident delirium: an observational study. International Journal Nursing Student, 49(9). https://pubmed.ncbi.nlm.nih.gov/22542266/
Yang, et al. (2017). Risk factors of delirium in sequential sedation patients in intensive care units. Biomed Research International. https://www.hindawi.co
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