What is the recommended approach for sedation in adults?

Recommended Approach for Sedation in Adults

Nonbenzodiazepine sedatives (propofol or dexmedetomidine) are preferred over benzodiazepines for sedation in adult patients due to improved clinical outcomes including shorter ICU length of stay and duration of mechanical ventilation. 1

General Principles of Sedation

• Light levels of sedation should be maintained in adult patients unless clinically contraindicated, as this is associated with improved outcomes including shorter duration of mechanical ventilation and ICU length of stay 1
• Before administering sedatives, attempt non-pharmacological approaches including providing adequate analgesia, frequent reorientation, and optimization of the environment to maintain normal sleep patterns 1
• The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable tools for measuring quality and depth of sedation in adult ICU patients 1
• Sedation protocols designed to minimize sedative use are associated with improved outcomes including decreased incidence of delirium and long-term cognitive dysfunction 1

Preferred Sedative Agents

First-Line Options:

• Propofol:

  • Rapid onset (1-2 minutes) and short elimination half-life making it ideal for procedural sedation 1, 2
  • Loading dose: 5 μg/kg/min over 5 minutes 1, 3
  • Maintenance dose: 5-50 μg/kg/min titrated to effect 1, 3
  • Adverse effects: Pain on injection, hypotension, respiratory depression, hypertriglyceridemia, and rarely propofol-related infusion syndrome 1, 2
  • For ICU sedation, most patients require 5-50 μg/kg/min (0.3-3 mg/kg/h), with administration not exceeding 4 mg/kg/hour unless benefits outweigh risks 3

• Dexmedetomidine:

  • Onset of 5-10 minutes 1, 2
  • Loading dose: 1 μg/kg over 10 minutes (avoid loading dose in hemodynamically unstable patients) 1, 2
  • Maintenance dose: 0.2-0.7 μg/kg/hr 1, 2
  • Adverse effects: Bradycardia, hypotension, and hypertension with loading dose 1, 2
  • May have opioid-sparing effects, reducing opioid requirements in critically ill patients 1

Second-Line Options:

• Midazolam:

  • Onset of 2-5 minutes, elimination half-life of 3-11 hours 1
  • Loading dose: 0.01-0.05 mg/kg over several minutes 1, 4
  • Maintenance dose: 0.02-0.1 mg/kg/hr 1
  • Adverse effects: Respiratory depression, hypotension 1, 4
  • Only recommended for short-term sedation due to risk of accumulation 5
  • Requires slow administration and individualization of dosage; 3-4 times as potent per mg as diazepam 4

• Lorazepam:

  • Onset of 15-20 minutes, elimination half-life of 8-15 hours 1
  • Loading dose: 0.02-0.04 mg/kg (≤ 2 mg) 1
  • Maintenance dose: 0.02-0.06 mg/kg q2-6 hr prn or 0.01-0.1 mg/kg/hr (≤10 mg/hr) 1
  • Adverse effects: Respiratory depression, hypotension, propylene glycol-related acidosis, nephrotoxicity 1

Special Considerations

• Elderly, debilitated, or ASA-PS III/IV patients:

  • Reduce propofol dosage to approximately 80% of usual adult dosage 3
  • Reduce midazolam dosage in patients with chronic obstructive pulmonary disease, higher risk surgical patients, and patients 60 or more years of age 4

• Monitoring requirements:

  • Continuous monitoring of respiratory and cardiac function (pulse oximetry) is required regardless of intended level of sedation 4
  • For deeply sedated patients, a dedicated individual other than the practitioner performing the procedure should monitor the patient throughout the procedure 4
  • Immediate availability of resuscitative drugs and appropriate equipment and personnel trained in airway management should be assured 4

• Daily Sedation Interruption (DSI) vs. Nurse Protocol (NP)-targeted sedation:

  • Both DSI protocols and NP-targeted sedation are safe and effective in achieving and maintaining light sedation 1
  • DSI protocols may be associated with increased nursing workload 1
  • A brief DSI should not be used to justify deep sedation for the rest of the day when not indicated 1

Cautions and Pitfalls

• Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients 1
• Excessive single doses or rapid intravenous administration may result in respiratory depression, airway obstruction and/or arrest, especially in debilitated patients 4
• Abrupt discontinuation of propofol prior to weaning may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation 3
• Objective measures of brain function (e.g., BIS, NI, PSI) should not be used as the primary method to monitor sedation depth in non-comatose, non-paralyzed critically ill adults 1
• For patients receiving neuromuscular blocking agents, objective measures of brain function can be used as an adjunct to subjective sedation assessments 1