From the Guidelines
Hydromorphone is the recommended first-line intravenous (IV) analgesia for patients requiring analgesia/sedation medication. This recommendation is based on the most recent and highest quality study available, which prioritizes pain management before the introduction of sedatives 1. The goal of analgosedation in these patients includes managing pain, preventing and treating agitation, ensuring ventilator synchrony, optimizing ECMO flows, reducing metabolic demand, and enhancing long-term functional outcomes.
When considering analgesia/sedation medication, it is essential to note that:
- Fentanyl may not be an optimal agent due to its high sequestration in the circuit 1
- Oxycodone is the recommended first-line enteral agent, followed by oral hydromorphone with adjunct gabapentin to reduce neuropathic pain 1
- Non-benzodiazepine sedatives such as dexmedetomidine and ketamine are preferred as adjunctive sedatives 1
- Propofol is not an optimal agent due to its high sequestration in the ECMO circuit 1
The selection of analgesia/sedation medication should be individualized based on the patient's condition, with consideration of hemodynamic stability, kidney and liver function, and the desired depth and duration of sedation. Regular assessment using validated tools is essential to titrate medications appropriately and prevent oversedation, ultimately minimizing delirium, reducing ventilator days, and improving outcomes by maintaining comfort while allowing for daily awakening trials when appropriate.
From the FDA Drug Label
The decision as to when patients who have received injectable midazolam, particularly on an outpatient basis, may again engage in activities requiring complete mental alertness, operate hazardous machinery or drive a motor vehicle must be individualized. Although all of these anomalies were not present in the concurrent control group, they have been reported to occur randomly in historical controls. Abrupt discontinuation of propofol injectable emulsion prior to weaning or for daily evaluation of sedation levels should be avoided.
The analgesia/sedation medications are:
From the Research
Analgesia/Sedation Medication
The following medications are used for analgesia and sedation:
- Midazolam 5, 6, 7, 8, 9
- Propofol 5, 7, 8, 9
- Fentanyl 5, 6, 7, 8, 9
- Sufentanil 5
- Morphine 5
- Remifentanil 5, 9
- Alfentanil 6
- Benzodiazepine 6
- Pentazocine 6
Combination of Medications
The combination of a sedative agent and an opioid is usually used for sedation-analgesia in critically ill patients 5. The combination of midazolam and fentanyl 6, 7, 8, or propofol and fentanyl 7, 8 is commonly used. The combination of alfentanil and midazolam is also used for analgosedation during painful interventions 6.
Comparison of Medications
The quality of sedation with midazolam and propofol is comparable, but propofol allows for a more rapid weaning process from mechanical ventilation 5. However, the implementation of algorithms to adjust drug dosages reduces ventilator days and limits the kinetic differences between propofol and midazolam 5. Propofol combined with fentanyl can reduce the risk of short-term death in ICU patients compared to midazolam combined with fentanyl 8.