Pulmonology Book


Post-Intubation Sedation and Analgesia

Aka: Post-Intubation Sedation and Analgesia, Sedation and Analgesia in Ventilated Patients, Sedation and Analgesia in Intensive Care, Insomnia Management in Critical Care
  1. See Also
    1. Intubation
    2. Advanced Airway
    3. Rapid Sequence Intubation
    4. Endotracheal Intubation Preparation
    5. Critical Care Pain Observation Tool (CPOT)
    6. Endotracheal Tube
    7. Endotracheal Intubation Preoxygenation (and Apneic Oxygenation)
    8. Direct Laryngoscope
    9. Video Laryngoscope (e.g. Glidescope, C-MAC, MacGrath)
    10. Extraglottic Device (e.g. Laryngeal Mask Airway or LMA)
    11. Tactile Orotracheal Intubation (Digital Intubation)
    12. Nasotracheal Intubation
    13. Cricothyrotomy
    14. Needle Cricothyrotomy
  2. Precautions
    1. Analgesia (e.g. Fentanyl) should accompany sedation (e.g. Propofol) in intubated patients
      1. See Critical Care Pain Observation Tool (CPOT)
      2. Concurrent analgesia relieves pain and decreases Ventilator bucking
      3. 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. Critical to have adequate analgesia and sedation started from the time of intubation
        3. Johnson (2015) J Emerg Med 49(1):43-9 +PMID:25797938 [PubMed]
        4. 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]
  3. Approach: Default strategy (Fentanyl with Propofol)
    1. Precautions
      1. See Propofol Infusion Syndrome
      2. Hypotension risk (esp. with Propofol)
        1. Fluid boluses as needed
        2. May require initial Norepinephrine
    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. Protocol: Analgesia AND Sedation
      1. Approach: Lead with analgesia and titrate sedation as needed
      2. Analgesia (primary medication)
        1. Choose one Analgesic (e.g. Fentanyl, hydomorphone, Morphine)
          1. Dose immediately after intubation
          2. Reassess every 1-2 hours for additional doses
        2. Fentanyl infusion is most commonly used
          1. Give Fentanyl bolus, Hydromorphone bolus or Morphine bolus until infusion Running
          2. However, losing favor due to adverse effects and recommended to wean to other agents
      3. Sedation (added to the analgesia, wean as able)
        1. Choose one sedative (e.g. Propofol, Ketamine)
        2. Propofol is most commonly used (however, risk of Propofol Infusion Syndrome)
        3. Start immediately after intubation
  4. Preparations: Analgesics
    1. See Acute Pain Management
    2. See Opioid Analgesic
    3. See Regional Anesthesia
    4. Analgesics are the core drugs in this regimen
      1. With adequate Analgesic use, sedation doses may be minimal
      2. However, Analgesics should specifically target pain and should not be used for sedation
        1. See Critical Care Pain Observation Tool (CPOT)
    5. Fentanyl (typically used as initial agent)
      1. Bolus: Fentanyl 50 mcg IV as needed until patient appears comfortable
      2. Infusion
        1. Typical dosing: 25-50 mcg/hour
          1. Fentanyl 25 mcg/h is equivalent to Oxycodone 120 mg per day
        2. High dose: 1 mcg/kg/hour (or ~70 mcg/hour)
          1. Risk of Opioid-induced hyperalgesia
      3. May be administered in hypotensive patients
        1. Manage Hypotension with standard fluid boluses, Vasopressors
      4. Precautions
        1. Risk of Opioid tolerance within days of continuous use with risk of Opioid Withdrawal on stopping
        2. Attempt to wean dose on each day of infusion, and switch when able to other agents (see below)
    6. Alternative Opioids to Fentanyl
      1. Hydromorphone (Dilaudid) 1 mg IV initially, then 0.5 mg every 1 hour as needed
        1. Lower doses of 0.2 to 0.4 mg every 1 hour are often effective
      2. Morphine 0.1 mg/kg up to 8-10 mg every 2 hours as needed
        1. Lower doses of 2 to 4 mg every 1 hour are often effective
      3. Oral Opioids (via Enteral Tube in stable patients with moderate persistent pain)
        1. Oxycodone 5-10 mg every 4-6 hours as needed
        2. Hydromorphone (Dilaudid) 2-4 mg every 4-6 hours
        3. Morphine Sulfate Immediate Release (MSIR) 15 to 30 mg PO q4 hours
    7. Non-Opioid Analgesics
      1. Acetaminophen
        1. Consider scheduled dosing every 6 hours, via Rectum or Enteral Tube
        2. Safe in most patients, aside from acute hepatic injury
        3. Typical dosing: 1000 mg every 6 hours (max 4000 mg/day)
          1. Reduce to 650 mg every 8 hours in Chronic Liver Disease or Alcohol Abuse (max 2000 mg/day)
      2. Ketamine
        1. Moderate analgesia
        2. Decreases Opioid requirements, tolerance and adverse effects (Opioid-induced hyperalgesia, Vomiting)
        3. Dosing: 0.1 to 0.3 mg/kg/hour (sub-dissociative dose)
          1. Exercise caution above 0.2 to 0.3 mg/kg (risk of Hallucinations, flashbacks, Agitation)
          2. Stop infusion for 1 hour if psychotropic effects, and restart infusion at 0.1 mg/kg/h
        4. Consider with adjunctive agents that potentiate Ketamine effects (avoid in Hypotension, Bradycardia)
          1. Dexmedetomidine or Precedex
          2. Clonidine
    8. Agents to avoid
      1. Avoid Tramadol
        1. See Tramadol
        2. Weak Opioid with risk of Serotonin Syndrome, Delirium and Seizures
      2. Avoid NSAIDs
        1. See Nephrotoxicity due to NSAIDs
        2. See NSAID Gastrointestinal Adverse Effects (Peptic Ulcer Disease)
  5. Preparations: Sedation
    1. See Procedural Sedation and Analgesia
    2. Targets
      1. Richmond Agitation and Sedation Scale (RASS)
        1. Goal RASS: Alert and calm (0) to drowsy (-1)
      2. Critical Care Pain Observation Tool (CPOT)
        1. Target analgesia first (see above), then sedation
        2. Goal CPOT <=2
    3. Propofol (typically preferred)
      1. Infusion: 10-30 mcg/kg/min (low dose when used with Fentanyl)
        1. Less adverse effects (including Propofol Infusion Syndrome) with dosing <50 mcg/kg/min
      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
      4. Risk of Hypertriglyceridemia (and Acute Pancreatitis)
        1. Propofol is a lipid-based infusion that contains 1 kcal/ml
    4. Alternatives to Propofol
      1. Dexmedetomidine or Precedex (alternative to Propofol)
        1. Central alpha-agonist sedative that is generic
        2. Dosing
          1. Load: Start high dose infusion 1 to 1.4 mcg/kg/hour without bolus
            1. Decrease infusion rate in the first 30-60 minutes to maintenance dose
          2. Maintenance: 0.2 to 0.7 mcg/kg/hour
        3. No respiratory depression
          1. Very effective in the Ventilator Weaning process (also reduces associated anxiety, Tachypnea)
        4. Use other agents (e.g. Propofol) in the first hour after intubation (delayed effect with Dexmedetomidine)
        5. Risk of Bradycardia and Hypotension (avoid bolus dosing)
          1. Low dose Epinephrine infusion may be used to counter Dexmedetomidine effects if needed
        6. Risk of tolerance (within 4-5 days of starting)
          1. Results in less sedation and risk of withdrawal
          2. Transition to Clonidine if Dexmedetomidine tolerance develops
      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)
      3. Avoid Benzodiazepines
        1. Reserve for Status Epilepticus, continued chronic Benzodiazepine, Alcohol Withdrawal, Ketamine re-emergence
        2. Effective only initially and transiently
        3. Associated with prolonged Ventilator course
        4. Increased risk of Delirium (increased risk with cummulative dosing)
          1. Pandharipande (2006) Anesthesiology 104(1):21-6 +PMID:1639485 [PubMed]
        5. Titration is difficult
        6. Risk of Lactic Acidosis (propylene glycol related)
    5. Options for Agitation and anxiety
      1. See Agitated Delirium
      2. See Agitation in Dementia
      3. Haloperidol
      4. Olanzapine
      5. Ketamine
  6. Management: Insomnia (and Delirium prevention)
    1. See Insomnia
    2. General measures
      1. Avoid sleep interruption (minimize lab testing, Blood Pressure cuff, examination overnight)
      2. Apply eye shades and ear plugs overnight
      3. Assist with daytime reorientation and activity (eye glasses, lighting, early mobilization)
    3. Medications
      1. Avoid Benzodiazepine and Nonbenzodiazepine Hypnotic Agent or Z-Drug (e.g. Zolpidem or Ambien)
      2. Melatonin 3 mg (or Ramelteon 8 mg) scheduled dosing at night
      3. Quetiapine 25-50 mg orally (or via Enteral Tube) in early evening
      4. Clonidine 0.2 to 0.3 mg in evening (avoid in Hypotension or Bradycardia)
      5. Dexmedetomidine with dose increased in evening and decreased significantly during daytime
      6. Trazadone (other agents are preferred)
  7. Resources
    1. Internet Book of Critical Care (EMCRIT.org)
      1. https://emcrit.org/ibcc/guide/
  8. References
    1. Marino (2014) The ICU Book, p. 901-22
    2. Orman and Weingart in Herbert (2014) EM:Rap 14(4): 8-9
    3. Arora and Menchine in Herbert (2014) EM:Rap 14(9): 2-3
    4. Swaminathan and Weingart (2019) EM:Rap 19(3): 2-3

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