Understanding the differences/indications for different sedation gtts

[Samtansey]

I'm new to critical care and what's confusing me is the different gtts used for sedation, mostly because all my patients are never on the same thing. So I was wondering what's the indication for each.

Examples of Different Combinations of Sedation I've had:

• Fentanyl and Versed gtt
• Fentanyl and Precedex
• Fentanyl and Propofol
• Propofol and Precedex

One case that confused me was a patient I had admitted with ARDS who was mechanically ventilated and on Versed gtt and Fentanyl gtt. Her respiratory rate was set at 28, however her breathing rate was between 30-50, and she was coughing over the vent it seemed. I gave 2mg IVP Versed x2, in addition to increasing her Versed gtt up, and then finally a dose of PRN Nimbex which appeared to work for like only 15 minutes. When I made the doctor aware, she said to switch her over to a Propofol gtt and off the Versed gtt if she could tolerate it. So again, my question is, why Propofol instead of Versed? I mean, it definitely worked after some titration, but I'm trying to understand why she was on Versed in the first place, and why Propofol was better for her?

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[sluggs]

You may want to start by reading the SCCM guidelines on sedation and analgesia, as well as a basic pharmacology text.
In short:
1. There is almost NO INDICATION for versed drips anymore. Exceptions may include: you need to keep the patient in ARDSNET for a really long time and will switch to something less deleriumogenic soon. Ativan would be better if the patient has any liver/kidney issues, but is likewise a culprit in delirium, which is really BAD. Benzos are hemodynamically benign (usually) but cause delirium.
2. Nimbex is a paralytic and affords no sedation. You should not give it unless you know that your patient is sedated deeply. Imagine being paralyzed and not sedated!! Because nimbex stops you from breathing it should eliminate vent dys-synchrony. there is a trial of paralytics for 48 hours in patients with severe ARDS. Outcomes were improved.
3. Propofol is a great sedative, unless it drops patient BP or impairs cardiac squeeze. Using it long term can shoot up your triglycerides to infinity so you gotta check them periodically.
4. Precedex is a nice new(er) sedative, but can cause bradycardia. It also does not always work and some patients can be awake and dialed in at high does, even.
General thinking is analgesia first (fentanyl); then sedation; avoid benzos if possible.

 

[deleted547339]

You may want to start by reading the SCCM guidelines on sedation and analgesia, as well as a basic pharmacology text.
In short:
1. There is almost NO INDICATION for versed drips anymore. Exceptions may include: you need to keep the patient in ARDSNET for a really long time and will switch to something less deleriumogenic soon. Ativan would be better if the patient has any liver/kidney issues, but is likewise a culprit in delirium, which is really BAD. Benzos are hemodynamically benign (usually) but cause delirium.
2. Nimbex is a paralytic and affords no sedation. You should not give it unless you know that your patient is sedated deeply. Imagine being paralyzed and not sedated!! Because nimbex stops you from breathing it should eliminate vent dys-synchrony. there is a trial of paralytics for 48 hours in patients with severe ARDS. Outcomes were improved.
3. Propofol is a great sedative, unless it drops patient BP or impairs cardiac squeeze. Using it long term can shoot up your triglycerides to infinity so you gotta check them periodically.
4. Precedex is a nice new(er) sedative, but can cause bradycardia. It also does not always work and some patients can be awake and dialed in at high does, even.
General thinking is analgesia first (fentanyl); then sedation; avoid benzos if possible.

Let's not go too nuts with the anti-benzo sentiment. It shouldn't be your first (or second) choice, but there are plenty of reasons to use it.

It is great for alcohol withdrawal, status epileptics and a few others. Precedex isn't studied or indicated for long term sedation. You may not be able to get someone deep enough when they're paralyzed without adding benzodiazepines. You may have a patient with elevated triglycerides and bad ards you need to keep down - or they are really bradycardic or have heart block.

There are plenty of good reasons, but, like everything in critical care, you need to be thoughtful.

 

[sluggs]

It is not a benzo "sentiment". There is evidence that use of benzos for sedation causes harm. I acknowledge in my post that they have a role, albeit a limited one.

 

[Nephro critical care]

Benzos tend to hang around too long . Avoid at all costs unless you want to increase your ventilated days . Precedex I don't trust for sedation I think it's only good if you are near extubation and want something that keeps pts awake and yet calm. Should not be used in patients just intubated and in riproaring sepsis / shock . Causes too much hypotension and bradycardia which is of course expected as it is an IV analogue of clonidine.

Best drug for sedation I guess is propofol , causes some myocardial depression and hypotension but doesn't stick around or cause delirium. I feel the hemodynamic adverse effects of propofol are easily fixed with a little levophed. If you have a central and an arterial line as almost all of my vented patients do , should be just fine . Just check triglycerides periodically .

Only person I would go for the Versed / Fentanyl combo is the really high pressor requirements where it may cause less hypotension than propofol.

Anybody have experience with ketamine gotta for sedation ? One of my colleagues loves it but I feel people don't get properly sedated .

 

[deleted547339]

Benzos tend to hang around too long . Avoid at all costs unless you want to increase your ventilated days . Precedex I don't trust for sedation I think it's only good if you are near extubation and want something that keeps pts awake and yet calm. Should not be used in patients just intubated and in riproaring sepsis / shock . Causes too much hypotension and bradycardia which is of course expected as it is an IV analogue of clonidine.

Best drug for sedation I guess is propofol , causes some myocardial depression and hypotension but doesn't stick around or cause delirium. I feel the hemodynamic adverse effects of propofol are easily fixed with a little levophed. If you have a central and an arterial line as almost all of my vented patients do , should be just fine . Just check triglycerides periodically .

Only person I would go for the Versed / Fentanyl combo is the really high pressor requirements where it may cause less hypotension than propofol.

Anybody have experience with ketamine gotta for sedation ? One of my colleagues loves it but I feel people don't get properly sedated .

We use a good bit of ketamine. It's ok, not great.

I love ketamine for procedural sedation and induction, but it's marginal as a drip.

 

[G-Man82]

We use it quite often as an adjunct infusion anywhere from 0.1-0.5 mg/kg/hr. Rarely ever as primary. It goes well with fentanyl.


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[Samtansey]

What's behind the principal of analgesia first, then sedation?


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[deleted547339]

What's behind the principal of analgesia first, then sedation?


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Because you shouldn't sedate when pain is the problem.

 

[Samtansey]

But what if sedation is the goal? Do we assume pain is always a problem given the critical condition?


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[sluggs]

Hi Samtansey-- what literature have you read relative to this issue, thus far?

 

[Samtansey]

Only nursing pharmacology texts which don't help me understand indications for critical care sedation regimens, which appear to be very doctor-specific from my experience.


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[jdh71]

Propafed. Use it often enough.

I still defer to benzodiazepines when there is a lot of shock. Delerium is merely a marker of being sick as ballz. Benzos do make delerium worse but they can't kill anyone. Sicker people have worse outcomes, are more likely to have delerium, and if they were given benzodiazepines this was magnified.

I also use precedex a decent amount. I really like it for the those getting NIPPV. Started using it with bronchs.

 

[Femtochemistry]

if BP is OK and non-op patient, propofol only
if BP is OK and post-op patient, propofol plus fent

if BP is $hit and non-op patient, ketamine
if BP is $hit and post-op patient, ketamine plus fent

if nothing works, stun 'em with Nimbex and move on with your life. no time for mental masturbation here.....


no need for benzo's in icu. ever.

 

[deleted547339]

no need for benzo's in icu. ever.

I just disagree here. What do you do for your ards patient in bad shock on multiple pressors who is paralyzed and your trying to get volume off?

 

[jdh71]

disagree too

 

[Siggy]

if BP is OK and non-op patient, propofol only
if BP is OK and post-op patient, propofol plus fent

Stick your finger down your throat. Does it hurt?
Take 50mg of benadryl and stick your finger down your throat. Does the fact that you're drowsy change the fact that it hurts?

Pain control in intubated patients... every patient, every time.

 

[SurfingDoctor]

Stick your finger down your throat. Does it hurt?
Take 50mg of benadryl and stick your finger down your throat. Does the fact that you're drowsy change the fact that it hurts?

Pain control in intubated patients... every patient, every time.

Except with enough Propofol, you wouldn't respond and you wouldn't have a gag reflex.

 

[Siggy]

Except with enough Propofol, you wouldn't respond and you wouldn't have a gag reflex.

That doesn't mean that the patent isn't feeling pain/discomfort. Ever see how much opiates anesthesiology gives their adequately sedated patients during surgery (granted, we aren't cutting people)? Also, ideally, you can cut down the amount of propofol to keep the patient at a RASS of -1.

 

[chocomorsel]

That doesn't mean that the patent isn't feeling pain/discomfort. Ever see how much opiates anesthesiology gives their adequately sedated patients during surgery (granted, we aren't cutting people)? Also, ideally, you can cut down the amount of propofol to keep the patient at a RASS of -1.

Well, technically, if you have enough propofol to where the patient is unconscious, then no, they do not feel pain. Isn't that the definition of anesthesia?
Anyway I see your point about pain control.

 

[njac]

This is why I prefer fentanyl gtt to any sort of opioid pushes PRN when the patient is on a propofol gtt. You come in in the AM to find the propofol maxed out and no PRN pain Med's given for the last 18+ hours...

We did a very effective analgosedation education push with our RNs about a year ago. Initially giving pushes of fent and Midaz immediately after intubation and then starting PRN pushes of both, if needed adding on a fent gtt, and if that plus Midaz pushes isn't effective, adding a sedative gtt.


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[Samtansey]

I just disagree here. What do you do for your ards patient in bad shock on multiple pressors who is paralyzed and your trying to get volume off?

Can you elaborate on benzo use for the ARDs patient in bad shock and trying to get volume off?

 

[NontradICUdoc]

overdoses on TCAs or any other medications that increase the QTc, propofol can make the QT worse. Versed has no effect on the QT and thus would be a good choice. I would avoid propofol in patients on NMBA in the event that the nurses dont realize that the bottle ran out and the patient is paralyzed without sedation. Versed and fentanyl would be a good choice.

 

[Siggy]

overdoses on TCAs or any other medications that increase the QTc, propofol can make the QT worse. Versed has no effect on the QT and thus would be a good choice. I would avoid propofol in patients on NMBA in the event that the nurses dont realize that the bottle ran out and the patient is paralyzed without sedation. Versed and fentanyl would be a good choice.

I think once you get to needing paralytics for vent syncrony, you're at a position where the patient should probably be on propofol and versed.

 

[psychbender]

I would avoid propofol in patients on NMBA in the event that the nurses dont realize that the bottle ran out and the patient is paralyzed without sedation. Versed and fentanyl would be a good choice.

Quite frankly, that's a terrible reason to avoid propofol. Bags can run dry just as easily as bottles can empty, and pumps should be set to alarm 'infusion compete' while there is still volume left in the bottle, in the event there is any delay getting more from pharmacy or the pyxis is empty. You need competent nurses, not a different drug regimen.


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[deleted547339]

Can you elaborate on benzo use for the ARDs patient in bad shock and trying to get volume off?

One of the arguments for benzos making patients delirious is that it may be related to depth of sedation. There is a shift in culture to run people fairly light - essentially as light as you can and keep them safe. Benzos get people deep, which you need sometimes.

 

[CriTICAL]

agree with avoiding benzos, only indication imho is status and etoh w/d, I cringe when i see it used otherwise, they do indeed increase delirium and mortality independently of how sick the pt is
to the OP, do your pts a favor and read up on SAT/SBT and ABCDEF Bundle, simple effective ways of decreasing ICU Mortality

every pt is different but in general best to stick with propofol and/or precedex as your sedation base, very rarely have had any hemodynamic issues with precedex just dont let the nurses bolus it in the unit to avoid potential trouble, obviously if someone is already severly brady probably not the best choice, fyi almost every pt of mine ends up on precedex at some point, its an awesome drug

obviously if someone has legit pain issues fent gtt should be on board as well, precedex provides some analgesia as well

if pt is young and acutely ill with high resp drive lots of agitation/pain issues (ie; Septic, polytrauma, TBI) adding neuroleptics works well, never have i needed to resort to a benzo drip, can get almost any drug addict/polytrauma pt awake and comfortable with some combination of propofol/precedex/fent/neuroleptics

Severe ARDS trouble with vent synchrony/lung protection then reach for the NMB and likley will need to prone your pt, obviously make sure theyre well sedated prior to paralyzing, can use BIS if u have it, have never had to use NMB for more than 24 to 36hrs and if theyre so sick that your still having trouble then should probably be on ECMO if a good candidate

my 2cents

 

[AdmiralChz]

every pt is different but in general best to stick with propofol and/or precedex as your sedation base, very rarely have had any hemodynamic issues with precedex just dont let the nurses bolus it in the unit to avoid potential trouble, obviously if someone is already severly brady probably not the best choice, fyi almost every pt of mine ends up on precedex at some point, its an awesome drug

Big Precedex fan here, especially as a transition from the operating room to the ICU. Unfortunately, it's not readily available at all institutions and we have had to fight a ridiculous amount over the last 3 years to get more access to it. There are still very strict criteria for which it can be used here, but when they are satisfied almost all of our intensivists and anesthesiologists jump on it. The MICU guys aren't very keen on it, at all, though and have been on the opposing side of the P&T committee.

 

[Mad Jack]

if BP is OK and non-op patient, propofol only
if BP is OK and post-op patient, propofol plus fent

if BP is $hit and non-op patient, ketamine
if BP is $hit and post-op patient, ketamine plus fent

if nothing works, stun 'em with Nimbex and move on with your life. no time for mental masturbation here.....


no need for benzo's in icu. ever.

I'm really surprised at the resurgence of ketamine. It's a drug we always had great results with but we rarely saw employed aside from intubations of people with status asthmaticus and burn victims, good to see it getting more love for borderline patients.

 

[Vigileo]

What are you guys using for your cardiogenic shock patients or folks with EF < 20% that get intubated for respiratory failure and need sedation? My current site loves Versed gtt and pain meds for this, though the MICU rarely uses Versed and instead uses propofol or bolus/PRN sedation. The CVICU folks here don't like propofol due to its reduction in cardiac contractility


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[engineeredout]

What are you guys using for your cardiogenic shock patients or folks with EF < 20% that get intubated for respiratory failure and need sedation? My current site loves Versed gtt and pain meds for this, though the MICU rarely uses Versed and instead uses propofol or bolus/PRN sedation. The CVICU folks here don't like propofol due to its reduction in cardiac contractility


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With the patients in shock, be it cardiogenic or otherwise, the dosing requirements of propofol (or any other drugs for that matter) to achieve adequate sedation are much lower. While maintaining an analgesic drip in the background (fentanyl), I've found you need very little (if any) additional sedative. If so, the low dose of prop should be more than enough. Your patient in this scenario is likely to be on inotrops/pressors anyway which will offset the minimally negative hemodynamics of prop.

 

[Nephro critical care]

I like to use propofol as a default unless BP is really low in which case I would use lowest dose of midazolam. Usually the drop in BP with propofol is predictable and can be managed with a little norepinephrine. More annoying than the hypotension is the hypertriglyceridemia which is pretty common in the metabolic syndrome type of patients. Someone else in my group uses ketamine which may be OK but I always get the feeling that it's anesthetic effect is unpredictable.

When patients are agitated I will sometimes give a couple of bolus 2 mg doses of midazolam but not bump the propofol too high. Patients will then go off to sleep. Another challenging situation that I encounter is ventilator dysynchrony after intubation in a patient with PNA which is threatening to become ARDS . Seems to me if you give them a few doses of midazolam / fentanyl they will become really zonked out but still not synchronous . At this point I will give them 50 mg of rocuronium and obviously that will take care of the dysynchrony. And these patients then end up getting more synchronous and you do not need to put them on paralytic gtts.

 

[CanadianEM]

What are you guys using for your cardiogenic shock patients or folks with EF < 20% that get intubated for respiratory failure and need sedation? My current site loves Versed gtt and pain meds for this, though the MICU rarely uses Versed and instead uses propofol or bolus/PRN sedation. The CVICU folks here don't like propofol due to its reduction in cardiac contractility


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Similarly, what are you folks using in your post arrest/ROSC patients? I've tended to use midaz/fent gtt due to the just recently stunned heart and avoided propofol due to the myocardial depressant effects. Any thoughts?

 

[deleted171991]

Similarly, what are you folks using in your post arrest/ROSC patients? I've tended to use midaz/fent gtt due to the just recently stunned heart and avoided propofol due to the myocardial depressant effects. Any thoughts?

I would avoid sedation in those patients, until I have ascertained neurologic recovery. After that, fentanyl gtt is probably the best choice, with versed PRN. If they tolerate low dose propofol, plus/minus a bit of phenylephrine on top of it, that could be an alternative.

I would try to stay away from anything long-acting that could potentially alter mentation, such as versed gtt. But, being mostly a vasodilator, it's great for low EF patients who cannot tolerate the propofol + phenylephrine combo.

 

[SurfingDoctor]

I would avoid sedation in those patients, until I have ascertained neurologic recovery. After that, fentanyl gtt is probably the best choice, with versed PRN. If they tolerate low dose propofol, plus/minus a bit of phenylephrine on top of it, that could be an alternative.

I would try to stay away from anything long-acting that could potentially alter mentation, such as versed gtt. But, being mostly a vasodilator, it's great for low EF patients who cannot tolerate the propofol + phenylephrine combo.

We use Remifentanil in the neurologically injured patient. Quick on, quick off to assess neurological function.

But I agree, hypoperfusion is great sedative, no need to cloud the picture.

 

[njac]

Or PRN pushes rather than a gtt


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[Hamhock]

I would avoid sedation in those patients, until I have ascertained neurologic recovery. After that, fentanyl gtt is probably the best choice, with versed PRN. If they tolerate low dose propofol, plus/minus a bit of phenylephrine on top of it, that could be an alternative.

One comment and one question (more interested in answers to the question):

1. Phenylephrine seems like an odd choice is the ROSC patient, unless coronary disease is clearly not the the cause of arrest and afterload has been determined to be of no concern.

2. From the few comments above, it sounds like folks are running their ROSC "light". Assuming you are pursuing TTM 36 degrees, are you not "keeping them down" 24-36h for the potentially neuro-protective benefits that were confounding the earlier TTM (33 degrees) studies?

HH

 

[deleted547339]

hypoperfusion is great sedative, no need to cloud the picture.

So is hypoxia, but I try to avoid it....

 

[deleted171991]

One comment and one question (more interested in answers to the question):

1. Phenylephrine seems like an odd choice is the ROSC patient, unless coronary disease is clearly not the the cause of arrest and afterload has been determined to be of no concern.

2. From the few comments above, it sounds like folks are running their ROSC "light". Assuming you are pursuing TTM 36 degrees, are you not "keeping them down" 24-36h for the potentially neuro-protective benefits that were confounding the earlier TTM (33 degrees) studies?

HH

1. You are right. Afterload can be an issue with low EF. On the other hand, hypotension and coronary hypoperfusion are much worse; so is increased oxygen consumption in the heart.

When I say a bit of phenylephrine, I mean a low dose infusion, enough to maintain BP and not strain the heart. I have seen a good number of MI patients who did very poorly on dobutamine under cardiology care, while doing just fine previously on norepi in the MICU. People tend to focus on CO, and forget about coronary perfusion, cardiac oxygen delivery and consumption, and the big picture. I have seen proof again and again that pressors are better than inotropes in acute HF (unless the EF is really low).

I like phenylephrine as my first go-to pressor, because it can be given peripherally and easily titrated (it's an easy trial). I don't have much experience with stunned hearts, but I also feel the concerns with phenylephrine and afterload are somewhat overblown (except with truly low EF). Cardiac anesthesiologists use phenylephrine as a pressor in the OR all the time.

2. AFAIK, the neuroprotective benefits of hypothermia haven't been "proven" except after VFib. Anything else, and one is more in the realm of "it probably doesn't hurt".

Also, hypothermia at 33C is sedative by itself. Why muddy the waters with extra sedation that may linger around at the time of rewarming? In my book, sedation is something one does mostly PRN, especially for a patient who's almost in coma.

 

[njac]

Also, hypothermia at 33C is sedative by itself. Why muddy the waters with extra sedation that may linger around at the time of rewarming? In my book, sedation is something one does mostly PRN, especially for a patient who's almost in coma.

Unless you're giving paralytics?


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[engineeredout]

Unless you're giving paralytics?

You aren't mandated to use paralytics when doing TTM. If you can reach your target temperature without them, they aren't needed

 

[njac]

You aren't mandated to use paralytics when doing TTM. If you can reach your target temperature without them, they aren't needed

I agree, but my new institution wants them on board early and often (which I don't agree with)


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[engineeredout]

I agree, but my new institution wants them on board early and often (which I don't agree with)


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What's the justification? Again, if you can reach and maintain target temperature without paralytics, what's the point?

 

[Random Anesthesiologist]

We use Remifentanil in the neurologically injured patient. Quick on, quick off to assess neurological function.

But I agree, hypoperfusion is great sedative, no need to cloud the picture.

I like remi too. Can be problematic for use in a pat with chronic pain. Fentanyl is a pretty good choice, but sometimes a dilaudid pca with basal rate can work well too. Also, do not discount neuraxial or regional anesthetics from your anesthesiology colleagues if your patient is a candidate. Won't get rid of need for sedation but will cut back on amount required and lower amount of narcs.

Don't be fooled by "depth" of anesthesia with propofol. People vary in the amounts they need, and gag reflex may not always be abolished. (Ask any anesthesiologist that's experienced laryngospasm after "deep" extubation).


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