From the Guidelines
Sedation in the ICU should prioritize nonbenzodiazepine sedatives, such as propofol or dexmedetomidine, over benzodiazepines to improve clinical outcomes in mechanically ventilated adult patients. The choice of sedative agent should be driven by specific indications and sedation goals for each patient, the clinical pharmacology of the drug, and the overall costs associated 1.
Sedation Options
- Propofol (starting at 5-80 mcg/kg/min) provides rapid onset and offset, making it ideal for neurological assessments but can cause hypotension and propofol infusion syndrome with prolonged use.
- Dexmedetomidine (0.2-1.5 mcg/kg/hr) allows for an "arousable sedation" where patients can communicate when stimulated and has less respiratory depression, though it can cause bradycardia.
- Midazolam (1-4 mg/hr continuous infusion) offers amnesia and anxiolysis but may lead to delirium and prolonged awakening.
- Opioids like fentanyl (25-200 mcg/hr) are often combined with other sedatives for pain control.
Sedation Management
- Daily sedation interruptions, protocolized approaches using validated assessment tools like RASS or SAS, and targeting light sedation when appropriate can reduce ventilator days and ICU length of stay 1.
- Non-pharmacological approaches such as reorientation, noise reduction, and maintaining day-night cycles should complement medication strategies.
- The ideal approach individualizes sedation based on the patient's medical condition, ventilator synchrony needs, and goals of care while minimizing delirium risk and facilitating recovery.
Key Considerations
- Sedation should only be used with close monitoring, especially when using infused sedative/anxiolytic drugs in an HDU or ICU setting 1.
- Sedation/anxiolysis is indicated for symptom control in the distressed or agitated patient if intubation is not intended should non-invasive ventilation (NIV) fail.
The most recent and highest quality study 1 supports the use of nonbenzodiazepine sedatives as the preferred choice for sedation in the ICU, which aligns with the goal of minimizing morbidity, mortality, and improving quality of life.
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. Most adult ICU patients recovering from the effects of general anesthesia or deep sedation will require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) individualized and titrated to clinical response.
The options for sedation in the Intensive Care Unit (ICU) include:
- Propofol (IV): can be administered as a continuous infusion to titrate to desired clinical effect and minimize hypotension.
- Combination with other medications: propofol can be supplemented with opioid and/or benzodiazepine medications, but this may increase the sedative and respiratory effects of propofol and result in a slower recovery profile 2. It is essential to individualize and titrate the dosage to the desired effect, according to clinically relevant factors, including the patient's underlying medical problems, preinduction and concomitant medications, age, ASA-PS classification, and level of debilitation of the patient 2.
From the Research
Options for Sedation in ICU
The following are options for sedation in the Intensive Care Unit (ICU):
- Propofol: a phenolic derivative with sedative and hypnotic properties, which has a rapid onset and offset of sedation, allowing for greater control over the level of sedation and more rapid weaning from mechanical ventilation 3, 4
- Midazolam: a benzodiazepine that has been traditionally used for sedation in the ICU, but has been associated with longer recovery times and more adverse effects compared to propofol 4, 5
- Dexmedetomidine: an α(2)-agonist that provides effective sedation with a lower risk of respiratory depression, and has been shown to reduce the duration of mechanical ventilation and improve patient comfort 6, 7
Comparison of Sedation Options
A comparison of the sedation options is as follows:
- Propofol vs Midazolam: propofol has a faster recovery time and is associated with fewer adverse effects, but is more expensive 4, 5
- Dexmedetomidine vs Midazolam/Propofol: dexmedetomidine is not inferior to midazolam and propofol in maintaining light to moderate sedation, and reduces the duration of mechanical ventilation and improves patient comfort, but is associated with more adverse effects such as hypotension and bradycardia 6
- Dexmedetomidine vs Propofol: dexmedetomidine is associated with a lower risk of respiratory depression and is generally well tolerated, but may cause hypotension and bradycardia 7
Considerations for Sedation in ICU
When considering sedation options in the ICU, the following factors should be taken into account: