What is the recommended sedation regimen for patients still intubated?

From the Guidelines

The recommended sedation regimen for patients still intubated is to use either propofol or dexmedetomidine as the primary sedative, combined with fentanyl for pain control, with a target sedation score of RASS -2 to 0, as this approach is associated with shorter duration of mechanical ventilation and ICU stay, and less delirium, as supported by the most recent and highest quality study 1.

Sedation Regimen

The sedation regimen should be individualized based on the patient's clinical condition, hemodynamic stability, and the expected duration of mechanical ventilation.

• Propofol (starting at 5-50 mcg/kg/min) or dexmedetomidine (0.2-1.5 mcg/kg/hr) can be used as the primary sedative.
• Fentanyl (25-200 mcg/hr) can be used for pain control.
• Midazolam (1-10 mg/hr) may be used instead of propofol for patients requiring deeper sedation or those with hemodynamic instability.

Sedation Management

• Daily sedation interruptions should be performed when clinically appropriate to assess neurological status and readiness for extubation.
• Sedation should be titrated to a target sedation score (such as RASS -2 to 0) rather than keeping patients deeply sedated.
• Regular assessment of pain, agitation, and delirium using validated tools should guide medication adjustments.

Rationale

The use of non-benzodiazepine sedatives, such as propofol and dexmedetomidine, is preferred over benzodiazepines due to their association with less delirium and shorter mechanical ventilation times, as supported by studies 1.

• A study published in 2023 1 suggests that fentanyl can be used as the first-line drug to achieve ventilator synchrony and suppress shivering, with propofol added as needed.
• Another study published in 2018 1 recommends using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults, as it is associated with a shorter time to extubation and reduced tracheostomy rate.

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. A minimum period of 5 minutes between adjustments should be allowed for onset of peak drug effect. 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.

Administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks

The recommended sedation regimen for patients still intubated is propofol (IV), initiated at a rate of 5 mcg/kg/min (0.3 mg/kg/h) and titrated to the desired clinical effect, with maintenance rates ranging from 5 mcg/kg/min to 50 mcg/kg/min (0.3 mg/kg/h to 3 mg/kg/h) or higher, not exceeding 4 mg/kg/hour unless the benefits outweigh the risks 2.

• Key considerations:
  • Initiate sedation slowly with a continuous infusion
  • Titrate to desired clinical effect and minimize hypotension
  • Monitor patients continuously for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation
  • Adjust infusion rates downward in the absence of clinical signs of light sedation to avoid sedative administration at rates higher than clinically necessary
  • Evaluate level of sedation and assess CNS function daily throughout maintenance to determine the minimum dose of propofol required for sedation 2.
• Warning: Abrupt discontinuation of propofol injectable emulsion prior to weaning or for daily evaluation of sedation levels should be avoided, as it may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation 2.

From the Research

Sedation Regimens for Intubated Patients

The recommended sedation regimen for patients still intubated can vary depending on several factors, including the patient's medical condition, age, and the duration of mechanical ventilation.

• Propofol is a commonly used sedative for intubated patients due to its rapid onset and offset of sedation, even after prolonged administration 3.
• A study published in 1996 found that a descending propofol dosing strategy, which maintains the propofol concentration constant in the central compartment, is necessary for effective propofol sedation in pediatric ICU patients 4.
• Another study published in 2004 compared the efficacy and safety of remifentanil and fentanyl for ICU sedation and analgesia, and found that remifentanil provided effective sedation and rapid extubation without the need for propofol in most patients 5.
• A study published in 1999 found that a propofol-based sedation and ICP control regimen is a safe, acceptable, and possibly desirable alternative to an opiate-based sedation regimen in intubated head-injured patients 6.
• A randomized controlled study published in 2011 compared the value of bispectral index (BIS) monitoring and sedation agitation scale (SAS) in guiding ICU sedation therapy, and found that BIS monitoring is better in sedative control than SAS assessment for ICU patients undergoing short-term mechanical ventilation 7.

Key Findings

• Propofol is a commonly used sedative for intubated patients due to its rapid onset and offset of sedation.
• The choice of sedation regimen depends on several factors, including the patient's medical condition, age, and the duration of mechanical ventilation.
• BIS monitoring may be a useful tool in guiding sedation therapy for ICU patients undergoing short-term mechanical ventilation.
• Remifentanil and fentanyl are also effective sedatives for intubated patients, but may have different advantages and disadvantages compared to propofol 3, 5.