From the Guidelines
Post-intubation sedation should prioritize the use of nonbenzodiazepine sedatives, such as propofol or dexmedetomidine, over benzodiazepine sedatives like midazolam or lorazepam, due to improved short-term outcomes including reduced ICU length of stay, duration of mechanical ventilation, and delirium 1. When selecting a sedative agent, it is crucial to consider the sedation indication, goal, clinical pharmacology, and acquisition cost. The choice of sedative should be tailored to the individual patient's needs, taking into account their hemodynamic status, organ function, and the anticipated duration of mechanical ventilation.
- Key considerations for post-intubation sedation include:
- Using a combination of sedatives and analgesics to ensure patient comfort and prevent complications
- Regularly assessing sedation levels using validated tools like the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS)
- Targeting a light sedation level (RASS -2 to 0) for most patients
- Performing daily sedation interruptions when appropriate to assess neurological status and prevent oversedation
- Individualizing the choice of agents based on the patient's clinical condition and response to treatment, as suggested by 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.
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. Most adult ICU patients recovering from the effects of general anesthesia or deep sedation will require maintenance rates of 5 mcg/kg/min to 50 mcg/kg/min (0. 3 mg/kg/h to 3 mg/kg/h) individualized and titrated to clinical response. With medical ICU patients or patients who have recovered from the effects of general anesthesia or deep sedation, the rate of administration of 50 mcg/kg/min or higher may be required to achieve adequate sedation.
Post-intubation sedation with propofol should be initiated at a rate of 5 mcg/kg/min and titrated to effect, with most patients requiring 5-50 mcg/kg/min for maintenance. The dosage should be individualized based on the patient's condition, response, and vital signs 2.
- Key considerations:
- Initiate sedation slowly with a continuous infusion to minimize hypotension.
- Titrate the dosage to the desired clinical effect.
- Monitor the patient's condition and adjust the dosage as needed.
- Be cautious when using higher rates of administration, as they may increase the likelihood of hypotension 2.
From the Research
Post-Intubation Sedation
- Post-intubation sedation is crucial for patient comfort and to prevent complications such as self-extubation 3.
- The choice of sedative and analgesic agents is important, with common options including benzodiazepines, opioids, and propofol 4.
- The goal of post-intubation sedation is to achieve a level of sedation that is comfortable for the patient while minimizing the risk of adverse effects such as respiratory depression or hypotension.
Sedation Regimens
- A study comparing ketamine-dexmedetomidine and ketamine-propofol combinations for periprocedural sedation found that the ketamine-dexmedetomidine combination was associated with lower pain scores and fewer adverse events 5.
- Another study found that standard dosages of analgesic and sedative drugs in intensive care resulted in a low incidence of potentially toxic blood concentrations, with 97% of concentrations being below the upper limit of the therapeutic interval 6.
- A randomized, prospective, double-blind trial comparing ketamine/propofol with midazolam/fentanyl for procedural sedation and analgesia in the emergency department found that the ketamine/propofol combination provided adequate sedation and analgesia with fewer adverse effects 7.
Monitoring and Titration
- Close monitoring of the patient's level of sedation and clinical responses, such as using the Richmond Agitation-Sedation Scale (RASS) and Numeric Rating Scale (NRS), is essential to ensure that the patient is comfortable and safe 4, 6.
- Titration of sedative and analgesic agents to achieve the desired level of sedation while minimizing adverse effects is critical 3, 4.