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. 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]

III. 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
    3. Sedation (added to the analgesia, wean as able)
      1. Choose one sedative (e.g. Propofol, Ketamine)
      2. Propofol is most commonly used
      3. Start immediately after intubation

IV. Preparations: Analgesics

  1. Analgesics are the core drugs in this regimen
    1. With adequate Analgesic use, sedation doses may be minimal
  2. Fentanyl (typically preferred)
    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
      1. Manage Hypotension with standard fluid boluses, Vasopressors
  3. Alternatives to Fentanyl
    1. Hydromorphone 1 mg IV initially, then 0.5 mg every 1 hour as needed
    2. Morphine 0.1 mg/kg up to 8-10 mg every 2 hours as needed

V. Preparations: Sedation

  1. 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
  2. Alternatives to Propofol
    1. Avoid Benzodiazepines
      1. Associated with prolonged Ventilator course
      2. Increased risk of Delirium
      3. Titration is difficult
    2. Dexmedetomidine or Precedex (alternative to Propofol)
      1. Central alpha-agonist sedative
      2. Less common use, and newly generic
      3. No respiratory depression
      4. Use other agents (e.g. Propofol) in the first hour after intubation (delayed effect with Dexmedetomidine)
    3. 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)

VI. 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
  3. Swaminathan and Weingart (2019) EM:Rap 19(3): 2-3

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window