What are the recommended post-sedation medication doses after intubation?

From the Guidelines

After intubation, the recommended post-sedation medication doses include fentanyl at 0.5-5 μg/kg/h, midazolam at 0.01-0.1 mg/kg/h, and propofol at 20-60 μg/kg/min, which should be titrated to achieve a Richmond Agitation-Sedation Scale (RASS) score of -2 to 0 for most patients. These doses are based on the most recent evidence from the European Heart Journal, published in 2023 1. The choice of medication depends on the patient's individual needs, with fentanyl providing potent analgesia, midazolam offering amnestic effects, and propofol allowing for rapid onset and offset.

Key Considerations

• Fentanyl is a potent analgesic, but it carries a risk of tachyphylaxis, accumulation, or withdrawal during prolonged infusion, as well as a risk of serotonin syndrome in combination with selective serotonin reuptake inhibitors 1.
• Midazolam can achieve deep sedation but may accumulate in kidney dysfunction, is highly deliriogenic, and can cause delayed awakening 1.
• Propofol provides a short duration of action, which may hasten awakening, but it also carries a higher risk of hypotension and propofol infusion syndrome at high doses 1.
• Daily sedation interruptions should be performed when appropriate to assess neurological status and prevent oversedation, as supported by evidence from Intensive Care Medicine, published in 2016 1.

Additional Recommendations

• For analgesia, hydromorphone (0.5-3 mg IV q1-4h) or morphine (2-10 mg IV q2-4h) should be administered regularly, as pain control reduces sedation requirements.
• Neuromuscular blockade with cisatracurium may be necessary for specific situations like severe ARDS, but it requires deep sedation and regular monitoring for awareness.
• The use of sedatives should be reduced, and strategies to reduce the incidence of oversedation should begin by making efforts to reduce doses of benzodiazepines and/or opioids, as recommended by Intensive Care Medicine, published in 2016 1.

From the FDA Drug Label

For maintenance of sedation, the usual initial infusion rate is 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr). The infusion rate should be titrated to the desired level of sedation, taking into account the patient’s age, clinical status and current medications. Assessment of sedation should be performed at regular intervals and the midazolam infusion rate adjusted up or down by 25% to 50% of the initial infusion rate so as to assure adequate titration of sedation level.

The recommended post-sedation medication doses after intubation are:

• Initial infusion rate: 0.02 to 0.10 mg/kg/hr (1 to 7 mg/hr)
• Titration: adjust infusion rate up or down by 25% to 50% of the initial infusion rate as needed
• Adjustment interval: every few hours, decrease infusion rate by 10% to 25% to find the minimum effective infusion rate 2

From the Research

Post-Sedation Medication Doses After Intubation

The recommended post-sedation medication doses after intubation vary depending on the patient's condition and the sedative used. Some studies suggest the following:

• Propofol and midazolam are commonly used sedatives in intensive care units (ICUs) for patients on mechanical ventilation 3, 4, 5, 6.
• The dosage of propofol can range from 2 mg/kg/h 4 to higher doses, while midazolam can be administered at 0.24 mg/kg/h 4 or higher doses.
• A combination of propofol and midazolam can be used for sedation in emergency critically ill patients on mechanical ventilation, with a decreased total amount of drug used 5.
• For post-intubation continuous sedation, a combination of propofol and fentanyl can be recommended for normotensive/hypertensive patients, while a combination of midazolam and fentanyl or ketamine alone can be considered for hypotensive patients 7.
• The specific dosage and choice of sedative should be tailored to the individual patient's needs and medical condition.

Factors Influencing Sedation

Several factors can influence the choice and dosage of sedation, including:

• Patient's medical condition, such as hypotension or hypertension 7
• Type of sedative used, such as propofol or midazolam 3, 4, 5, 6
• Duration of sedation, with longer-term infusions potentially leading to tolerance and tachyphylaxis 3
• Patient's response to sedation, with regular assessments of sedation level and vital signs necessary to adjust the dosage as needed 4, 6