From the Guidelines
Hydromorphone is the recommended first-line intravenous (IV) analgesia for analgosedation in critically ill patients, particularly those undergoing extracorporeal cardiopulmonary resuscitation (ECPR) or extracorporeal membrane oxygenation (ECMO) 1. The goal of analgosedation is to manage pain, prevent and treat agitation, ensure ventilator synchrony, optimize ECMO flows, reduce metabolic demand, and enhance long-term functional outcomes.
- Key considerations for analgosedation medication selection include:
- Pharmacodynamics altered by severe critical illness and the ECMO circuit
- Bioavailability of drugs decreased by changes in volume of distribution and sequestration of lipophilic and protein-bound agents
- Preference for non-benzodiazepine sedatives such as dexmedetomidine and ketamine as adjunctive sedatives
- The first-line enteral agent for analgosedation is oxycodone, followed by oral hydromorphone, with adjunct gabapentin to reduce neuropathic pain 1.
- Propofol is not an optimal agent due to its high sequestration in the ECMO circuit, and fentanyl may not be an optimal agent as it is highly sequestered in the circuit 1.
- Regular assessment of the patient's pain and sedation levels using validated scales, such as the Richmond Agitation-Sedation Scale (RASS), is essential to adjust medication doses accordingly and prevent oversedation 1.
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.