What are the guidelines for post-intubation sedation?

From the Guidelines

Critically ill, mechanically ventilated adults should be sedated with nonbenzodiazepine sedatives, such as propofol or dexmedetomidine, as they have improved short-term outcomes compared to benzodiazepine sedatives. When considering post-intubation sedation, several factors are crucial, including the sedation indication, goal, clinical pharmacology, and acquisition cost. The choice of sedative is vital, and according to the 2018 clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU 1, nonbenzodiazepine sedatives are preferable due to their improved short-term outcomes, such as reduced ICU length of stay, duration of mechanical ventilation, and delirium. Some key points to consider when sedating post-intubation patients include:

• Using propofol or dexmedetomidine as the primary sedative agents
• Titration of sedation to achieve a Richmond Agitation-Sedation Scale (RASS) score of -2 to 0 for most patients
• Daily sedation interruptions to assess neurological status and readiness for extubation
• Regular pain assessment using tools like the Critical Care Pain Observation Tool
• Consideration of adding neuromuscular blocking agents like cisatracurium for patients with severe ARDS or ventilator dyssynchrony
• Reassessment of sedation requirements at least every 24 hours, with medication doses adjusted based on the patient's response, organ function, and hemodynamic stability. The guidelines suggest that the separation of studies describing mechanically ventilated, routine cardiac surgical patients and critically ill, mechanically ventilated medical and surgical patients is essential, as elective cardiac surgical patients have different profiles compared to critically ill medical and surgical patients 1. Pharmacogenomic factors that may influence the response of sedatives and other medications in the critically ill should also be reviewed 1. By following these guidelines and using nonbenzodiazepine sedatives, clinicians can improve patient outcomes, reduce complications, and enhance the quality of life for critically ill, mechanically ventilated adults.

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. When indicated, initiation of sedation should begin at 5 mcg/kg/min (0.3 mg/kg/h). The infusion rate should be increased by increments of 5 mcg/kg/min to 10 mcg/kg/min (0. 3 mg/kg/h to 0.6 mg/kg/h) until the desired level of sedation is achieved. A minimum period of 5 minutes between adjustments should be allowed for onset of peak drug effect. Most adult patients require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) or higher. Administration should not exceed 4 mg/kg/hour unless the benefits outweigh the risks

The guidelines for post-intubation sedation with propofol are to:

• Initiate sedation slowly with a continuous infusion
• Start at 5 mcg/kg/min (0.3 mg/kg/h) and increase by increments of 5 mcg/kg/min to 10 mcg/kg/min
• Allow a minimum of 5 minutes between adjustments for onset of peak drug effect
• Maintain rates of 5 mcg/kg/min to 50 mcg/kg/min (0.3 mg/kg/h to 3 mg/kg/h) or higher, not exceeding 4 mg/kg/hour unless benefits outweigh risks 2

From the Research

Post-Intubation Sedation Guidelines

The guidelines for post-intubation sedation involve the use of various medications to ensure patient comfort and safety. Some key points to consider include:

• The use of propofol for sedation in intubated patients, which has been shown to have a rapid onset and offset of sedation, even after prolonged administration 3.
• The combination of propofol with other medications, such as opioids or low-dose ketamine, for procedural sedation in the emergency department 4.
• The use of fentanyl and propofol for analgesia and sedation in patients requiring intubation, as seen in a case study of a 67-year-old male presenting to the emergency department with respiratory distress 5.

Medication Options

Some medication options for post-intubation sedation include:

• Propofol, which has been shown to be effective for sedation in intubated patients 3, 6, 7.
• Midazolam and fentanyl, which have been compared to propofol and remifentanil in terms of time to wake up and extubation after stopping the medication 6, 7.
• Low-dose ketamine, which has been combined with propofol for procedural sedation in the emergency department 4.

Considerations

Some considerations for post-intubation sedation include:

• The risk of adverse effects, such as respiratory depression, agitation, and bradycardia 6, 7.
• The need for close monitoring of patients receiving sedation, particularly those with hemodynamic instability or disordered triglyceride metabolism 3.
• The potential for propofol to cause systemic vasodilatation and ventilatory depression, which may result in unwanted hypotension or respiratory complications 3.