What is the first line sedation for a newly intubated (insertion of an endotracheal tube) patient?

From the Guidelines

For newly intubated patients, fentanyl should be used as the first-line drug to achieve ventilator synchrony and suppress shivering, with propofol added as needed. This approach is based on the most recent and highest quality study available, which recommends an analgesic-first strategy for sedation of intubated patients 1. The use of fentanyl as a first-line agent is supported by its effectiveness in treating shivering and providing analgesia, as well as its ability to be used in combination with other sedatives such as propofol.

Key Considerations

• Fentanyl is effective for the treatment of shivering and provides analgesia, making it a suitable first-line agent for newly intubated patients 1.
• Propofol can be added as needed to achieve the desired level of sedation, particularly in patients who require deeper sedation or have severe ventilator dyssynchrony 1.
• Dexmedetomidine is another option for sedation, particularly in patients requiring lighter sedation or those at risk for delirium, and can be used in the latter stages of treatment 1.
• Regular assessment of sedation depth using validated tools is essential to maintain light sedation and reduce ventilator days and ICU length of stay.

Sedation Strategies

• Start with fentanyl at a dose of 25-100 mcg/hr for analgesia and sedation.
• Add propofol as needed, starting at a dose of 5-80 mcg/kg/min and titrating to achieve the desired level of sedation.
• Consider using dexmedetomidine at a dose of 0.2-1.5 mcg/kg/hr for patients requiring lighter sedation or those at risk for delirium.
• Regularly assess sedation depth using validated tools such as the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS), with the goal of maintaining a RASS score of -2 to 0.

This approach prioritizes the use of fentanyl as a first-line agent, with propofol and dexmedetomidine used as needed to achieve the desired level of sedation, and is based on the most recent and highest quality study available 1.

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. When indicated, initiation of sedation should begin at 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.

First line sedation for newly intubated patients can be achieved with propofol (IV) at an initial rate of 5 mcg/kg/min (0.3 mg/kg/h), with increments of 5 mcg/kg/min to 10 mcg/kg/min (0.3 mg/kg/h to 0.6 mg/kg/h) as needed to achieve the desired level of sedation, while minimizing hypotension 2.

• The dosage should be individualized and titrated to clinical response.
• Maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0.3 mg/kg/h to 3 mg/kg/h) or higher may be required.
• Administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks.

From the Research

Sedation Options for Newly Intubated Patients

• The choice of sedative agent for newly intubated patients is crucial, as it can affect the patient's hemodynamic stability, requirement for antihypertensive and analgesic medications, and duration of ICU stay 3, 4, 5.
• Dexmedetomidine has been shown to produce better hemodynamic stability and reduce the requirement for additional analgesics and antihypertensive medications compared to midazolam and propofol 3, 5.
• Propofol, on the other hand, has been associated with a lower risk of short-term death in ICU patients compared to midazolam when combined with fentanyl 4.
• Ketamine is another option for sedation, which provides analgesia with minimal respiratory and cardiovascular effects, but its use can lead to tachycardia and hypertension 6.

Considerations for Sedation in the ICU

• The goal of sedation in the ICU is to provide adequate comfort and reduce the patient's stress and anxiety while minimizing the risk of complications 7, 6.
• The choice of sedative agent should be tailored to the individual patient's needs and medical history, taking into account factors such as hemodynamic stability, respiratory function, and potential side effects 3, 4, 5, 6.
• A combination of sedative agents, such as ketamine and propofol ("Ketofol"), may be used to provide a balancing effect on hemodynamics without the side effects associated with the parent drugs 6.
• Awake intubation with the help of a fiberoptic scope or video laryngoscope may be considered in situations where a difficult airway is anticipated, with dexmedetomidine as a commonly used sedative agent for these procedures 6.