Sedation of choice

[placebo_B12]

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What sedating agents do you guys like to use for intubated patients in the ER?

I tend to use Propofol for neurologic patients (CVA, SAH, ICH, BHT) b/c I usually have a lot of pressure to burn and if neurosurg needs to get a neuro exam the sedation wears off quickly when infusion is held.

I tend to use Versed & Morphine for septic patients... but realize that the combo also tends to reduce BP significantly (but probably not as much as propofol).

 

[GeneralVeers]

Propofol on sedated patients. 90% of the intubated/sedated patients I see are hypertensive so propofol works well.

For procedures I love Etomidate. Lasts longer than Propofol, but not too long if you have to bag the patient.

 

[deleted65604]

I don't know why you would use morphine to sedate an intubated patient. Fentanyl is more titratable, and affects blood pressure less. Combined with versed, it works great. I'm no ICU doctor, and if I am worrying about their sedation, then they've been in the ER way too long. Having said that, I think propofol tends to be used for short periods of time. There is increased mortality after several days of use.

 

[WilcoWorld]

I find a little hypoxia + hypercarbia cocktail works great to keep patients sedated.

 

[placebo_B12]

So what do you guys give after RSI to keep septic patients down...

 

[waterski232002]

I give them a slug of Versed and Fentanyl (usually 4mg Versed and 100mcg Fentanyl), and then order a propofol gtt. The ICU can change it to whatever they want when they get the patient in a couple hours. But this way the Versed will keep the patient sedated for any CT scans we may order, Central line placement, and allow the nurses time to do their business before trying to set up their propofol gtt before the etomidate/succ wears off in 5 min.

 

[southerndoc]

There is actually evidence to support using PRN benzodiazepines instead of drips to keep intubated patients sedated. The evidence supports that doing so allows one to be extubated quicker.

I shy away from midazolam because of its "rapid in, rapid out" CNS effects. Of course lorazepam drips cause propylene glycol toxicity in up to 20% of patients (which is often unrecognized).

Propofol is a decent alternative, especially for head injured patients who need repetitive neuro assessments. However, it does have the potential for causing hypotension, which even one episode of hypotension worsens six month outcome in head injured patients.

 

[BADMD]

There is actually evidence to support using PRN benzodiazepines instead of drips to keep intubated patients sedated. The evidence supports that doing so allows one to be extubated quicker.

I shy away from midazolam because of its "rapid in, rapid out" CNS effects. Of course lorazepam drips cause propylene glycol toxicity in up to 20% of patients (which is often unrecognized).

I'm with you on this. PRN opiates and benzos using a sedation scale works well. I end up using Lorazepam and morphine. Fentanyl and midazolam work great, but both have the rapid in, rapid out effect and relatively long elimination half lives. Midazolam has active metabolites. I've seen a few patients on fentanyl/midaz drip take days to work all of that stuff out of their systems.

 

[DrQuinn]

Speaking of benzos, had my first really crappy reaction to valium. Had a pt come in with intractable back pain (real patient not percocetopenic), and gave him 2 of dilaudid and 5 of valium, one minute after the valium was given, tachycardic, acute bronchospasm, laryngospasm, and stridor, with muscular excitation. Pharynx normal. Scary as hell. Had to give him everything sans intubation (h1, h2, steroids, epi IM and epi IV, mag, neb treatments icluding alb/racemic epi). My third freakin shift out in the communtiy and I see something I"ve never seen in residency or in academia.

Weird.

Makes me respect the benzos.

Q

 

[roja]

propofol.

In patients who might be slightly hypotensive, I often augment it with fentanyl. It allows you to decrease the propofol needed and still get good sedation.

 

[kungfufishing]

I also favor propofol augmented by fentanyl or occasionally fentanyl/versed.

 

[Jeff698]

Out of habit, I do fentanyl/versed drips with propofol drip as a less used alternative.

Take care,
Jeff