What are the sedation options for patients on mechanical ventilation (MV)?

From the Guidelines

Sedation for mechanically ventilated patients should be individualized using the lightest effective sedation to maintain patient comfort while avoiding oversedation, with propofol or dexmedetomidine recommended over benzodiazepines. The choice between propofol and dexmedetomidine depends on the patient's specific needs, with propofol (starting at 5-10 mcg/kg/min, titrated to effect) suitable for short-term sedation and dexmedetomidine (0.2-0.7 mcg/kg/hr without loading dose) preferred for patients requiring lighter sedation 1. Benzodiazepines like midazolam should be reserved for specific indications such as alcohol withdrawal or status epilepticus due to their association with delirium and prolonged ventilation.

Key Considerations

• Daily sedation interruptions should be performed to assess neurological status and readiness for extubation, as this approach has been shown to reduce the time patients spend on the ventilator and in the ICU 1.
• Sedation should be titrated to target a Richmond Agitation-Sedation Scale (RASS) score of -2 to 0 (lightly sedated to alert and calm) for most patients.
• Pain should be addressed before escalating sedation, typically with fentanyl or hydromorphone, to minimize the need for deeper sedation and reduce the risk of complications like ventilator-associated pneumonia and ICU delirium.

Sedation Management

• Propofol and dexmedetomidine are preferred due to their shorter duration of action and lower risk of delirium compared to benzodiazepines 1.
• The use of protocolized sedation management, including daily sedation interruption or targeting light sedation levels, can lead to improved patient outcomes, including reduced time on the ventilator and in the ICU 1.
• Regular assessment and adjustment of sedation levels are crucial to balance the need for patient comfort with the risk of oversedation and its associated complications.

From the FDA Drug Label

For intubated, mechanically ventilated adult patients, Intensive Care Unit (ICU) sedation should be initiated slowly with a continuous infusion in order to titrate to desired clinical effect and minimize hypotension. Most adult ICU patients recovering from the effects of general anesthesia or deep sedation will require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) individualized and titrated to clinical response

Sedation for Mechanically Ventilated Patients:

• The recommended initial infusion rate for sedation in intubated, mechanically ventilated adult patients is 5 mcg/kg/min (0.3 mg/kg/h).
• The infusion rate should be increased by increments of 5 mcg/kg/min to 10 mcg/kg/min (0. 3 mg/kg/h to 0.6 mg/kg/h) until the desired level of sedation is achieved.
• Most adult patients require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) or higher, individualized and titrated to clinical response 2.
• Administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks.
• Evaluation of level of sedation and assessment of CNS function should be carried out daily throughout maintenance to determine the minimum dose of propofol required for sedation 2.

From the Research

Sedation for Mechanically Ventilated Patients

• Mechanically ventilated patients in the intensive care unit frequently require sedation and analgesia for anxiety and pain experienced during the time they are intubated 3.
• Strategies that optimize comfort while minimizing the predilection for sedative and analgesic drug accumulation with prolongation of effect have been shown to improve outcomes, such as decreasing mechanical ventilation duration, intensive care unit length of stay, and complications associated with critical illness 3.

Comparison of Sedation Agents

• Dexmedetomidine was not inferior to midazolam and propofol in maintaining light to moderate sedation in ICU patients receiving prolonged mechanical ventilation 4.
• Dexmedetomidine reduced duration of mechanical ventilation compared with midazolam and improved patients' ability to communicate pain compared with midazolam and propofol 4.
• Dexmedetomidine is safer and equally effective agent for the sedation of mechanically ventilated patients admitted to the ICU after cardiovascular surgery compared to the patients receiving propofol, with good hemodynamic stability, and equally rapid extubation time 5.

Clinical Outcomes

• Deep sedation was associated with higher mortality and a significant decrease in ventilator, ICU, and hospital free days 6.
• Agitation was also associated with higher mortality, and the use of haloperidol was associated with a 70% lower mortality 6.
• Deep sedation and benzodiazepine administration were frequent during critical care transport of mechanically ventilated patients, with 91.7% of patients being deeply sedated and 30.6% receiving benzodiazepines 7.

Sedation Practices

• The most commonly used sedatives were opioids and benzodiazepines, and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose 6.
• Sedation practices, including the use of benzodiazepines and deep sedation, can have significant impacts on clinical outcomes, such as mortality and duration of mechanical ventilation 4, 6, 7.