The podcast doesn’t contain any profanity, but it may be difficult for some people to hear. Be kind to yourselves.
Paralysis and PAD–pain, anxiety, and delirium–protocols have consumed me lately. Notice pain comes before anxiety on the scale. Address your patient’s need for analgesics prior to adding sedation, or you are merely hiding their need for pain control beneath a blanket of lethargy.
I know it’s easier to hang propofol than administer bolus fentanyl doses, especially when you’re initiating hypothermia or sending your patient emergently to cath lab, or running to CT, but consider the process that brought them to the point where they required intubation. Trauma, hypoxia, acidosis, CPR–painful states.
I notice with a lot of PAD protocols that while the sedation is ordered as a continuous drip, the pain medication requires a certain number of bolus doses to be administered in a certain narrow timeframe to justify initiation of a drip. This is, to my mind, fucking stupid. This shows a certain lack of good clinical judgment on the part of the people who designed the protocol. It’s the opposite of a delirium-avoidance approach. And while I am by no means insisting that every single patient requires pain medication and sedation while on a ventilator, I am most definitely suggesting that each paralysis requires adequate narcotizing prior to sedation, and prior to placement on a maintenance drip.
With the new guidelines for ARDS and the renewed emphasis on therapeutic paralysis, it is vital that we understand the difference between pain control, sedation, and paralysis.
Another concept, and to me, one of even greater importance, is the care we show people who are undergoing therapeutic paralysis. This is the subject of my podcast. It’s a short listen, but important.
This was hard for me to say. I know I pause a lot. I considered editing those pauses out but decided to let them stand, so you could hear what I felt, trying to explain what it was like.