II. Precautions

  1. Analgesia (e.g. Fentanyl) should accompany sedation (e.g. Propofol) in intubated patients
    1. Concurrent analgesia relieves pain and decreases Ventilator bucking
    2. Concurrent analgesia allows for less Deep Sedation and reduced secondary Delirium
  2. Propofol and Dexmedetomidine are preferred sedatives
    1. Benzodiazepines (e.g. Lorazepam, Midazolam) in contrast result in longer intubation and ICU duration
    2. Fraser (2013) Crit Care Med 41(9 suppl 1): 830-8 [PubMed]
  3. Avoid longer-acting paralytics in general
    1. May be useful to reduce shivering in Induced Hypothermia protocol
    2. Do not use without sedation and Analgesics
    3. Vecuronium (Norcuron) 0.1 mg/kg IV
    4. Pancuronium (Pavulon) 0.1 mg/kg IV
  4. Post-Intubation Sedation and Analgesia is often inadequate
    1. Study of 10 interviewed patients, 5 patients could recollect their emergency intubation (including associated pain)
      1. Kinmball (2011) West J Emerg Med 12(4): 3655-7 [PubMed]
    2. Long-acting paralytics (recuronium) are associated with longer delays, too low dose of sedation and analgesia
      1. Paralysis outlasts induction agent leaving only indirect external cues (e.g. Sinus Tachycardia)
      2. Johnson (2015) J Emerg Med 49(1):43-9 +PMID:25797938 [PubMed]
      3. Korinek (2014) Eur J Emerg Med 21(3): 206-11 [PubMed]
    3. Sedation and analgesia is inconsistently used and at inadequate doses
      1. Bunomo (2008) Am J Emerg Med 26(4): 469-72 [PubMed]
      2. Kendrick (2009) Pediatr Emerg Care 25(6): 393-6 [PubMed]

III. Approach: Default strategy (Fentanyl with Propofol)

  1. Precautions
    1. See Propofol Infusion Syndrome
  2. Target
    1. Richmond Agitation and Sedation Scale (RASS): Alert and calm (0) to drowsy (-1)
    2. Modify with deeper sedation for Delirium or similar indications
  3. Analgesic: Fentanyl
    1. Bolus: Fentanyl 50 mcg IV as needed until patient appears comfortable
    2. Infusion: Fentanyl 1 mcg/kg/hour (or ~70 mcg/hour)
    3. May be administered in hypotensive patients (manage Hypotension with standard fluid boluses, Vasopressors)
  4. Sedation: Propofol (typically preferred)
    1. Infusion: 10-30 mcg/kg/min (low dose when used with Fentanyl)
    2. Avoid in hemodynamically unstable patients refractory to adequate fluid Resuscitation, Vasopressors
      1. Consider Ketamine as an alternative in these cases
    3. Risk of Propofol Infusion Syndrome
      1. Especially in the young, septic, Trauma or those on Corticosteroids or Vasopressors
  5. Sedation: Alternatives to Propofol
    1. Dexmedetomidine (alternative to Propofol)
      1. Central alpha-agonist sedative
      2. Less common use, and newly generic
      3. No respiratory depression
    2. Ketamine
      1. Consider in Asthma or COPD exacerbation
      2. Consider in hemodynamically unstable patients
      3. Less standardized protocols for prolonged sedation with Ketamine (and unclear longterm safety data)

IV. References

  1. Orman and Weingart in Herbert (2014) EM:Rap 14(4): 8-9
  2. Arora and Menchine in Herbert (2014) EM:Rap 14(9): 2-3

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