Podcast 793: Postintubation Sedation and Analgesia

Contributor: Peter Bakes, MD

Educational Pearls:

• When intubating a patient, it is important to consider what medications will be used for post-intubation sedation and analgesia
• The common non-benzodiazepine sedating medications are propofol, precedex, and ketamine
• Propofol is frequently used in the emergency department, and it lowers ICP and MAP making it the preferred sedative for patients with intracranial bleeds
• Precedex is a milder sedative used in the ICU because it decreases time to extubation and reduces the risk of complications associated with long term intubation
• Ketamine should be used in hypotensive patients because it does not lower blood pressure, and its bronchodilatory effect is beneficial for asthmatic patients
• Versed and ativan are the most commonly encountered benzodiazepine sedatives, but they are infrequently used because they increase the risk of delirium and delay extubation
• Benzodiazepines are useful for sedation in patients with delirium tremens
• For post intubation analgesia, fentanyl is the drug of choice since it has a lower risk of hypotension than is seen in other narcotics
• In the emergency department, intubated and sedated patients should initially be sedated to a RASS of -2 while obtaining imaging, but aim for a RASS of -1 after to decrease side effects and promote earlier extubation

References

Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983-2991.

Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022.

Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015;75(10):1119-1130.

McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs. 2003;17(4):235-272.

Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. In: StatPearls. Treasure Island (FL): StatPearls Publishing. Copyright © 2022, StatPearls Publishing LLC.; 2022.

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD

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