Quantcast

Sedation of choice

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

placebo_B12

Member
10+ Year Member
Joined
Feb 7, 2005
Messages
62
Reaction score
0

Members don't see this ad.
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

Socially Distanced
Removed
15+ Year Member
Joined
Mar 19, 2005
Messages
7,704
Reaction score
7,439
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.
 
D

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

Senior Member
15+ Year Member
Joined
Nov 2, 2004
Messages
4,073
Reaction score
4,163
I find a little hypoxia + hypercarbia cocktail works great to keep patients sedated.
 

placebo_B12

Member
10+ Year Member
Joined
Feb 7, 2005
Messages
62
Reaction score
0
So what do you guys give after RSI to keep septic patients down...
 

waterski232002

Senior Member
10+ Year Member
5+ Year Member
Joined
Sep 5, 2004
Messages
847
Reaction score
1
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

life is good
Volunteer Staff
Lifetime Donor
20+ Year Member
Joined
Jun 6, 2002
Messages
13,440
Reaction score
3,469
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

Full Member
15+ Year Member
Joined
Dec 28, 2006
Messages
856
Reaction score
34
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

My name is Neo
Moderator Emeritus
10+ Year Member
15+ Year Member
Joined
Dec 6, 2000
Messages
4,227
Reaction score
17
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

Full Member
7+ Year Member
15+ Year Member
Joined
Oct 20, 2003
Messages
6,040
Reaction score
21
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

Senior Member
7+ Year Member
15+ Year Member
Joined
Mar 7, 2003
Messages
1,053
Reaction score
7
I also favor propofol augmented by fentanyl or occasionally fentanyl/versed.
 

Jeff698

EM/EMS nerd
15+ Year Member
Joined
Aug 12, 2000
Messages
1,998
Reaction score
15
Out of habit, I do fentanyl/versed drips with propofol drip as a less used alternative.

Take care,
Jeff
 
Top