LITERATURE
- There is no superior sedative. You must take into account the patient’s current clinical condition, past medical history, and drug pharmacology. However non-benzodiazepine sedatives are preferred, as benzodiazepines are associated with long-term dysfunction of patients after ICU stay not to mention ICU LOS
- Use sedation scales to monitor your patient’s level of sedation– Richmond-Agitation-Sedation Scale (RASS) and Riker Sedation-Agitation Scale (SAS) are recommended
- Less is more – sedation scales/weaning protocol as well as bolus sedation v. continuous sedation are associated with shorter mechanical ventilation time.
- Daily interruption of sedation is key (if on a continuous gtt) –associated with decreased duration of mechanical ventilation and decreased length of stay in ICU
Richmond Agitation and Sedation Scale (RASS) Goal: Usually 0 to -1
| Scale | Item | Descriptions |
| +4 | Combative | Violent, immediate danger to staff |
| +3 | Very Agitated | Pulls or removes tubes or catheters; aggressive |
| +2 | Agitated | Frequent non-purposeful movements, fights ventilator |
| +1 | Restless | Anxious, apprehensive but movements not aggressive or vigorous |
| 0 | Alert and Calm | |
| -1 | Drowsy | Not fully alert, but has sustained awakening to voice (eye opening and contact > 10 sec) |
| -2 | Light Sedation | Briefly awakens to voice (eye opening and contact < 10 sec) |
| -3 | Moderate Sedation | Movement or eye-opening to voice (no eye contact) |
| -4 | Deep Sedation | No response to voice, but movement or eye opening to physical stimulation |
| -5 | Unarousable | No response to voice or physical stimulation |
| Medication | Dosing | Pharmacology | Side Effects |
| Dexmedetomidine (precedex) | Load: 1 mg/kg over 10 min Rate: 0.2 -1.5mg/kg/hour | a2 agonist, t1/2: 2 hr hepatically metabolized | Bradycardia, loss of airway reflexes. Rebound hypertension when discontinued. Do not load in hemodynamically unstable patients |
| Diazepam IV (Valium) | Load: 5- 10 mg Rate: 0.03-0.1 mg/kg q 0.5-6 hr PRN | GABAA agonist. t1/2: 20-120 hr, hepatically metabolized | Respiratory depression, hypotension, phlebitis. Active metabolite accumulates in renal failure. risk of delirium |
| Fentanyl (Sublimaze) | Load: 1-2 mg/kg Rate: 1-2 mg/kg/hour | m opioid agonist, t1/2 = 1.5-6 hr, hepatically metabolized CYPA4, very fat soluble | Nausea/constipation, respiratory depression, ¯K+, skeletal muscle rigidity |
| Hydromorphone (Dilaudid) | 0.2-0.6 mg IV q1-2 hour PRN | m opioid agonist w. k,d effect, t1/2 1.5- 3.5 hr, 7-11 x more potent morphine | Nausea/constipation, respiratory depression, accumulates in hepatic/renal impairment |
| Lorazepam IV (Ativan) | Load: 1-4 mg Rate: 1-5 mg/hour | GABAA agonist , t1/2: 8-15 hr, hepatically metabolized, slower onset compared to valium/versed | Respiratory depression, hypotension, propylene glycol metabolic acidosis, nephrotoxicity. risk of delirium |
| Midalozam (Versed) | Load: 1-5 mg Rate: 1-5 mg/hour | GABAA agonist t1/2: 3-11 liver met./renal excreted. More lipid soluble compared ativan | risk of delirium, active metabolites, respiratory depression |
| Morphine | 2-4 mg IV q1-2 hour | m opioid agonist w. k,d effect , t1/2: 3-7 hr, H20 soluble, hepatically metabolized/renal excreted | Nausea/constipation, respiratory depression, histamine release hypotension, pruritus. accumulates in hepatic/renal impairment |
| Propofol (Diprivan) | Load: 5 mg/kg/min over 5 mins Rate: 5-50 mg/kg/min | GABAA, glycine, nictonic, M1 agonist. t1/2: 30-60 min, lipid soluble so t1/2 ▲w. ▲infusion time | Hypotension/bradycardia 2/2 vasodilation & ▼inotropy. Hypertriglyceridemia, pancreatitis, myoclonis. PROPOFOL INFUSION SYNDROME**, avoid egg/soy allergy |
** Propofol infusion syndrome (PRIS) – seen in prolonged infusion rates > 4-5 mg/kg/hr. characterized by lactic acidosis, hypotension, arrhythmia; kidney or liver injury, and rhabdomyolysis may also occur. Incidence 1%, but high mortality ~33%