What are the recommended post-intubation sedation medications and their dosages?

From the Guidelines

Dexmedetomidine is the recommended post-intubation sedation medication, which can be administered at a dose of 0.2-1.5 mcg/kg/hr without a loading dose, due to its sedative, analgesic/opioid sparing, and sympatholytic properties with minimal respiratory depression 1. The use of dexmedetomidine for post-intubation sedation has been supported by clinical practice guidelines, which highlight its unique properties that allow for easy arousability and interaction in patients, with minimal impact on respiratory function 1. Some key points to consider when using dexmedetomidine include:

• Onset of sedation occurs within 15 minutes, with peak sedation achieved within 1 hour of starting the infusion 1
• The elimination half-life is approximately 3 hours in patients with normal liver function, but may be prolonged in those with severe hepatic dysfunction 1
• Common side effects include hypotension and bradycardia, and continuous respiratory monitoring is recommended, especially in nonintubated patients 1
• Dexmedetomidine's opioid-sparing effect may reduce opioid requirements in critically ill patients, making it a valuable option for post-intubation sedation 1

From the FDA Drug Label

2.6 Intensive Care Unit (ICU) Sedation of Intubated, Mechanically Ventilated Adult Patients

Dosage:

• For intubated, mechanically ventilated adult patients, propofol should be initiated at a continuous rate of 5 mcg/kg/min (0.3 mg/kg/h) through a central venous catheter or a peripheral vein.
• The rate of administration should be titrated to achieve the desired level of sedation, as assessed by the clinical response (e.g., patient comfort, tolerance, and lack of response to verbal commands).
• Most adult patients require propofol doses between 5 to 50 mcg/kg/min (0.3 to 3 mg/kg/h) when used for ICU sedation.

Dose Titrations:

• Dose titrations should be made in increments of 5 to 10 mcg/kg/min (0.3 to 0.6 mg/kg/h) until the desired level of sedation is achieved.
• The clinical effects of the dose titration should be assessed after waiting for a few minutes to allow the effects of the dose change to be fully established.

The recommended post-intubation sedation medication is propofol, with a dosage of 5 to 50 mcg/kg/min (0.3 to 3 mg/kg/h) for intubated, mechanically ventilated adult patients, titrated to achieve the desired level of sedation, as assessed by clinical response 2.

• Key points:
  • Initial dosage: 5 mcg/kg/min (0.3 mg/kg/h)
  • Titration increments: 5 to 10 mcg/kg/min (0.3 to 0.6 mg/kg/h)
  • Desired level of sedation: patient comfort, tolerance, and lack of response to verbal commands

From the Research

Post-Intubation Sedation Medications

The following medications can be used for post-intubation sedation:

• Dexmedetomidine: a loading dose of 0.5 μg/kg over 10 min followed by a continuous infusion of 0.25 μg·kg-1·h-1 3
• Midazolam: 0.02 mg/kg as premedication, with additional doses of 0.5 mg at 2-min intervals as needed 3
• Propofol: dosing protocols can achieve optimal sedation in a large fraction of patients 4
• Sufentanil: a loading dose of 0.2 μg/kg over 10 min followed by a continuous infusion of 0.1 μg·kg-1·h-1 3
• Lorazepam: currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but may contribute to acute brain dysfunction 5

Dosage Considerations

When using these medications, the following dosage considerations should be taken into account:

• Dexmedetomidine: 0.2-1.4 microg/kg per hour 6
• Midazolam: 0.02-0.1 mg/kg per hour 6
• Propofol: dosing protocols can vary, but a faster and more reliable wake-up time can be achieved with propofol compared to midazolam 4
• Sufentanil: 0.2 μg/kg over 10 min followed by a continuous infusion of 0.1 μg·kg-1·h-1 3
• Lorazepam: dosing can vary, but may be associated with a higher risk of acute brain dysfunction 5

Comparison of Sedation Medications

Studies have compared the efficacy and safety of these sedation medications, including:

• Dexmedetomidine vs midazolam: dexmedetomidine was associated with less delirium and a shorter duration of mechanical ventilation 6
• Dexmedetomidine vs propofol: dexmedetomidine was not inferior to propofol in maintaining light to moderate sedation, and was associated with improved patient comfort and reduced duration of mechanical ventilation 7
• Midazolam vs propofol: propofol had a faster and more reliable wake-up time, but both medications achieved optimal sedation in a large fraction of patients 4