What is the recommended dosing regimen for fentanyl (Fentanyl) IV push with vecuronium (Vec) and propofol (Propofol) for analgesia and sedation?

Recommended Dosing Regimen for Fentanyl IV Push with Vecuronium and Propofol

For analgesia and sedation, fentanyl should be administered at 1-2 mcg/kg IV initially, followed by propofol 1 mg/kg, with subsequent propofol doses of 0.5 mg/kg as needed, and vecuronium 0.08-0.1 mg/kg for neuromuscular blockade. 1

Fentanyl Dosing

• Initial dose: 1-2 mcg/kg IV push (typically 50-100 mcg for adults) 1
• Timing: Administer fentanyl first, 3-5 minutes before propofol and vecuronium to allow peak analgesic effect to coincide with intubation/procedure 1
• Supplemental dosing: Additional doses of 25 mcg every 2-5 minutes until adequate analgesia is achieved 1
• Duration of action: 30-60 minutes for a single dose 1

Propofol Dosing

• Initial dose: 1 mg/kg IV push following fentanyl administration 2
• Subsequent doses: 0.5 mg/kg as needed for sedation maintenance 2
• Average total dose: 2.2-2.4 mg/kg for most procedures 3

Vecuronium Dosing

• Standard dose: 0.08-0.1 mg/kg IV for intubation 3, 4
• Onset of action: 2-3 minutes
• Duration: 25-40 minutes
• Note: Females may require approximately 22% less vecuronium than males for equivalent neuromuscular blockade 4

Administration Sequence

1. Fentanyl IV push (1-2 mcg/kg)
2. Wait 3-5 minutes for peak analgesic effect
3. Propofol IV push (1 mg/kg)
4. Vecuronium IV push (0.08-0.1 mg/kg)
5. Additional propofol doses (0.5 mg/kg) as needed for sedation maintenance

Monitoring Requirements

• Continuous monitoring of:
  • Heart rate
  • Blood pressure
  • Oxygen saturation
  • Respiratory rate
  • Level of sedation 2, 1

Potential Adverse Effects and Management

• Respiratory depression: Most common with fentanyl/propofol combination (up to 31% may experience transient desaturation) 2

  • Have naloxone readily available (0.2-0.4 mg IV) 1
  • Ensure airway management equipment is accessible

• Hypotension: More common with rapid propofol administration

  • Consider fluid bolus for transient hypotension
  • Administer propofol slowly to minimize hemodynamic effects 1

• Myoclonus: May occur with propofol administration

  • Usually self-limiting and brief
  • May be mistaken for seizure activity but is benign 2

Special Considerations

• Elderly patients: Reduce fentanyl dose by 50% (0.5-1 mcg/kg) 1
• Renal impairment: Fentanyl is preferred over morphine due to less accumulation of neurotoxic metabolites 1
• Hepatic impairment: Consider dose reduction of all agents due to altered clearance 1

Efficacy Considerations

• The combination of fentanyl and propofol provides effective sedation and analgesia for most procedures 2, 5
• Compared to midazolam/fentanyl combinations, propofol/fentanyl allows for shorter recovery times 5
• Ketamine may be considered as an alternative to fentanyl when combined with propofol, as it has been shown to have fewer respiratory adverse events 6

This regimen provides effective analgesia and sedation while minimizing adverse effects through careful dosing and monitoring. The sequence of administration is critical to ensure peak analgesic effect coincides with the most stimulating parts of the procedure.