What are the guidelines for initiating psych meds in an intubated patient on significant sedation?

Guidelines for Psychiatric Medications in Intubated Patients on Significant Sedation

For intubated patients on significant sedation, psychiatric medications should only be initiated after careful consideration of drug interactions, sedation depth, and the patient's underlying condition, with non-benzodiazepine sedatives (propofol or dexmedetomidine) preferred over benzodiazepines due to improved outcomes. 1

Assessment Before Initiating Psychiatric Medications

• Evaluate current sedation level using validated scales like Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS) to maintain light sedation when possible 1
• Assess for delirium using validated tools such as CAM-ICU or ICDSC before attributing symptoms to underlying psychiatric conditions 1
• Identify the specific psychiatric indication requiring treatment (agitation, anxiety, pre-existing psychiatric condition) 1
• Review all current medications for potential interactions with proposed psychiatric medications 1

Medication Selection Principles

• Maintain light sedation levels whenever clinically possible, as deep sedation is associated with worse outcomes including prolonged mechanical ventilation and ICU stay 1
• Prefer non-benzodiazepine sedatives (propofol or dexmedetomidine) over benzodiazepines for primary sedation 1
• Consider dexmedetomidine for delirious patients requiring sedation, as it's associated with lower delirium prevalence compared to benzodiazepines 1
• For patients with pre-existing psychiatric conditions, continue home medications when possible, with appropriate dose adjustments based on hepatic/renal function and potential interactions 1

Specific Medication Recommendations

For Agitation/Delirium:

• Avoid routine prophylactic use of antipsychotics to prevent delirium 1
• For treatment of delirium with agitation:
  • Consider dexmedetomidine (0.2-0.7 μg/kg/hr) as first-line sedative 1
  • Avoid benzodiazepines unless delirium is related to alcohol or benzodiazepine withdrawal 1
  • Monitor QT interval when using antipsychotics and withhold in patients with baseline QT prolongation or history of Torsades de Pointes 1

For Anxiety:

• Use small, incremental doses of sedatives titrated to desired effect 1
• For patients without IV access, consider alternative routes:
  • Intramuscular lorazepam (2.5-5 mg subcutaneously every 2-4 hours as needed) 2
  • Avoid intramuscular diazepam due to erratic absorption 2

For Pre-existing Psychiatric Conditions:

• Balance the risk of psychiatric medication discontinuation against potential drug interactions 1
• When initiating psychiatric medications, start at lower doses than typically used in non-critically ill patients 1

Monitoring and Safety Considerations

• Maintain continuous monitoring of vital signs, including respiratory rate, oxygen saturation, and level of consciousness 1, 2
• Have specific antagonists (naloxone for opioids, flumazenil for benzodiazepines) immediately available 1, 2
• Avoid combinations of three or more sedating medications, which are associated with adverse outcomes 3
• Be particularly cautious with medications that have long half-lives, as they may require prolonged observation periods 3

Special Considerations

• For patients nearing end-of-life care, opioids can be used to reduce dyspnea, sometimes in combination with benzodiazepines to reduce anxiety 1
• In hemodynamically unstable patients, use even smaller increments of sedatives and titrate carefully 1
• For patients requiring deep sedation, ensure adequate analgesia is provided alongside sedation 4
• Recognize that drug metabolism may be significantly altered in critically ill patients, potentially requiring dose adjustments 1, 5