Ativan VS Versed Dosing

europeman said:

I thought you guys/gals in Anesthesia could help me with this please!

I'm a bit confused on pharmacology of versed vs ativan vs valium IV.

I'm sorta familiar, as a surgeon, to dosing versed clinically... but there are times where it's not available (post intubations on floor, or in ED, etc) where I have option of giving ativan or valium IV.

So what is the dose equivalent of versed 2mg to ativan? I know versed more rapid onset....what else should I know? Which one lasts longer?

Say I need to write for a drip that would be equivalent to 2mg versed an hour.... but i'm forced to do ativan... what do I write?

Obviously you titrate to clinical needs, but I just don't have a grasp of gross equivalents.

thanks!

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Not sure why you'd want an ativan drip, except for terminal sedation. I try to avoid benzos for ICU sedation, since they have been shown to increase time on vent, and delirium/coma (SEDCOM, MENDS trial). For EtOH withdrawal, I would use intermittent dosing based upon clinical variables.

europeman said:

At our institution, some ICU's use precedex, others use versed others use proipofol. In any regard, the reason I'd like to know the ativan dosing is simply because it's an AVAILABLE drug anywhere on the floors and in the ER at my institution.... so it's a nice drug to use as push doses for sedation in intubated patients before they are parked in the ICU.

Can anyone help with doses?

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Its a sort of tough question your asking. We all here believe propofol is a much better agent for ICU sedation.
But if I was forced to give ativan I'd mix 50mg in 100cc bag and I'd expect to be in the 1-10mg/hr range. The problem is that it accumulates and the longer the pt is on it the worse/longer it takes to go away

If you are trying to sedate a pt while traveling from ER to ICU, I guess it depends on how aroused they are. Little arousal may be treated with 1-2mg while a more aroused pt will need more.

Hope that helps.

As an intensivist, I suppose I can or should comment. It would be rare to use either midaz or loraz for routine ventilator sedation. I occasionally receive a patient from the outlying areas on continuous infusions of benzos, and I've seen anything from 1 mg/hr of lorazepam to 80 mg/hr midazolam (for status epilepticus). In general, midazolam has a shorter half-life, but there may be active metabolites, which, paradoxically, makes lorazepam shorter acting, the issues of IV incompatibility mentioned above, notwithstanding. The short answer is to titrate to effect and side effects. A typical range for either midaz or loraz might be 1-5 mg/hr, but this is a generalization; doses well above that may still be required and safe, although, as mentioned above, in 2012, most ICUs don't use continuous infusions of benzos at all, given the likelihood that these drugs cause delirium, which increases mortality.

It would also be unusual to "push" drugs for routine ICU sedation. In general, our goals for sedation are better achieved by continuous infusions. Perhaps you're referring to procedural sedation for typical procedures (intubation, lines, etc.) in the ICU, but that's another issue altogether.

The unit pts coming down for surgery at my hospital are generally on 2 mg/hr Ativan drips with some combo of fentanyl or propofol.

Sadly

europeman said:

Hi thanks.

Let me tell you my scenareos. I'm a surgical chief resident.

Patient gets sick during rounds. I call anesthesia to intubate. They are very kind to intubate using etomodate and succs or rocc, then they leave. Then I'm stuck there with the patient intubated, on a ventilator who needs sedation and analgesia while we wait for hi/sher ICU bed to become available. On our surgical ward, the nurses are simply NOT ALLOWED to hang fentanyl or benzo "drips". In fact, I can't even get fentaynl on the floor unless its for a PCA. Precedex and propofol are likewise not available. In the ICU great. On the floor, no.

So, i'm forced to come up with short term solutions. Generally, for a normal sized patient who isn't particularly narco/benzo tolerate/naive I will just load them with 5-10mg of morphine and 1-2mg ativan (pushed slowly) and then order 10mg morphine q1hr IV piggy back and 1-2mg ativan q1 hr with PRNS.

THat said, i'm much more familiar with push doses of versed just from my experience working the you guys in the OR and with ER docs who at my institution love versed. But on my floor we have ativan. Hence my question.

Any thoughts? thanks!

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Wow, so you'll have an intubated, ventilated patient who's stuck on the floor long enough to require sedation while waiting for an ICU bed? That sounds a little suspect/dangerous. What kinds of delays are you talking about here? 5 minutes or an hour? 5 hours? Who is monitoring and treating this patient while you wait? I think the regimen you describe, while certainly not the cutting edge of sedation practice, is, within the contraints that you have described, reasonable (it hurts a little to type that word). That said, once the load is in, I wouldn't think the average patient would require quite so much as 10 mg/hr of morphine or 2 mg/hr of lorazepam.

I should add, also, that this thread skirts a fine line between legitimate clinical discussion and "seeking medical advice," which is frowned upon here. So I will add that I am in no way recommending or sanctioning your chosen regimen, or suggesting you continue using it. It sounds like you've found yourself in a really tough spot and have chosen a reasonably safe solution.

I wonder what sorts of institutional changes you'd have to make in order to prevent this situation from occurring in the future. Aside from the issue of safety of sedation practice, I worry that whatever caused the patient to deteriorate in the first place is going untreated while the patient sits on the ward waiting for a bed. Trying to get a floor nurse to obtain stat labs, cultures, hang multiple Abx, assist with lines/procedures/transport for CT scans, etc. would be very difficult, I would think.

europeman said:

Hi thanks.

Let me tell you my scenareos. I'm a surgical chief resident.

Patient gets sick during rounds. I call anesthesia to intubate. They are very kind to intubate using etomodate and succs or rocc, then they leave. Then I'm stuck there with the patient intubated, on a ventilator who needs sedation and analgesia while we wait for hi/sher ICU bed to become available.

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I don't want to step on toes, but you need to have a discussion with your anesthesia colleagues and sort this out. It is inappropriate for them to leave you with a recently paralyzed patient and no sedation plan. It is the anesthesiologist responsibility to make certain that sedation is in process prior to transferring care back to the nursing staff. That doesn't mean that they order it or manage it, just that they confirm that a plan is in place and will be carried out before the patient's induction dose wears off.

I would recommend a discussion, at the attending level, including a representative from pharmacy, to hash this out. Come up with a mutually acceptable plan that addresses the specific needs and restrictions at your hospital.

When I had a similar scenario in residency, I used to carry a 100 cc bottle of propofol to hand off to the floor nurses since propofol was not available on the floor, and the ICU nurses since they had to wait for the order to clear pharmacy before they could check out a bottle for the patient. That way the floor nurses could get the drip running for transport to ICU, and the ICU nurses didn't have to wait for red tape.

This may or may not be an acceptable solution in your institution. I could recommend ativan/ morphine dosing, but it is a suboptimal regimen, and I think that it is a band-aid that does not answer your real problem, and it may run afoul of the restrictions on the forum.

- pod

once the floor patient is intubated and on the ventilator, you dont have to worry about apnea from overdosing of benzos. so dosing is not too much of an issue (if your not concerned abuot doing a neuro exam within a few hours). plus the high dose benzo may stop bucking and fighting the tube after induction wears off and if paraylyzed will give better amnesia. id give 5mg-10mg (if the vial came in 10mg form id just give the whole thing).. and i dont think 10mg of morphine is too high or a bad thing, but with higher does benzos you might not need it at all.

in the end i would ask a floor nurse to look at a vial of lorazepam next time you have the chance.in order to see how many total milligrams are in it.. if its total of 10mg ( in the whole bottle) i would just give the whole thing and order 10mg push in this situation... if its not and its like 2mg per bottle, i woud just stick with your 10mg of morphine because that definitely comes in one vial and is easy to access - you want something where the nurse just gets one vial and give the whole thing as the sole agent- quick and easy and unlikely for them to screw it up- the acute phase of being hit with either 10mg of ativan or morphine will control a situation/respiration/paralyzed patient for enough time to transport to the unit