what's the preferred sedative in YOUR unit?

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europeman

Trauma Surgeon / Intensivist
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Our SICU routinely uses versed as a first line sedative, and fentaynl for analgesia. Sometimes we use other agents, but that's the first line.

Is it true this is old school? What are your units doing?

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Our SICU routinely uses versed as a first line sedative, and fentaynl for analgesia. Sometimes we use other agents, but that's the first line.

Is it true this is old school? What are your units doing?

just depends I think

I've been through 5 different ICUs this year, but most either use prop or versed, one preferred regular ativan boluses, the fentanyl is pretty industry standard though one month when I was we were short on the fent so we were using diluadid drips

Honestly, and I know some people get very aggressive about which is "best", but I don't really care much as long as my patient is comfortable
 
We (quaternary SICU) use propofol primarily and dexmedetomidine selectively. We use benzo's minimally/reluctantly (usually only in EtOH withdrawal). Most of our mechanically ventilated patients also receive fentanyl infusions.
 
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Dexmedetomidine, lots of dexmedetomidine. And occasional propofol.

How are you getting rid of the dex? I'm not an intensivist but work closely with them and they've reported significant difficulty weaning long term dex.

In my cardiac patients, I use propofol because I start with a fast-track approach in almost every patient. Obviously that doesn't pan out but I don't like burning bridges. I almost never give them midazolam. For the long term ICU patients, fentanyl infusion seems to be ideal. I don't think the benzos add much.
 
Dexmedetomidine, lots of dexmedetomidine. And occasional propofol.

How high are you going? 1.4 mcg/kg/hr? I've seen as high as 2 mcg/kg/hr used.

How are you getting rid of the dex? I'm not an intensivist but work closely with them and they've reported significant difficulty weaning long term dex.

At our unit, we don't wean dex for extubation, we keep it going. After, we usually don't have much trouble getting it off. In the rare cases, we slap on a clonidine patch or 3.
 
Found one reference on it related to bronchs, but would be interested to hear what the ICU experience is.

Transplantation. 2005 Oct 27;80(8):1081-5.

Sedative drug requirements during bronchoscopy are higher in cystic fibrosis after lung transplantation.

Chhajed PN, Aboyoun C, Chhajed TP, Malouf MA, Harrison GA, Tamm M, Leuppi JD, Glanville AR.

Source
Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia.

[email protected]

Abstract

BACKGROUND:
We noted that patients with cystic fibrosis tended to need higher doses of sedatives during bronchoscopy. We undertook this study to assess the sedative drug doses administered during bronchoscopy in lung transplant recipients and to assess if there is a change in the dosage requirements over time following lung transplantation.

METHODS:
In all, 773 transbronchial biopsy procedures performed via flexible bronchoscopy were analyzed in 140 consecutive lung transplant recipients. Conscious sedation was achieved with intermittent boluses of intravenous midazolam and fentanyl. Intravenous propofol boluses of 10 to 30 mg were administered when optimal sedation was not achieved with midazolam doses of 0.20 to 0.25 mg/kg and fentanyl 2 to 2.5 micrograms/kg.

RESULTS:
Mean doses of midazolam and fentanyl administered were 0.15+/-0.07 mg/kg (range 0.02 to 0.44 mg/kg) and 1.8+/-0.8 micrograms/kg (range 0.1 to 6.67 micrograms/kg) respectively. Midazolam and fentanyl doses administered to patients with cystic fibrosis were the highest compared to those with other disease types (P<0.0001). Examining the sedative doses administered over time following transplantation, there was a significant linear (P<0.001) and quadratic (P=0.0023) effect of time for midazolam and a significant linear (P=0.003) and a trend (P=0.08) for a quadratic effect for fentanyl. Propofol was effectively used in seven lung transplant recipients in whom adequate sedation could not be achieved with high doses of midazolam and fentanyl.

CONCLUSIONS:
There is an increase in sedative drug requirement with time for both midazolam and fentanyl after transplantation, which is significantly higher in patients with cystic fibrosis.

PMID: 16278589 [PubMed - indexed for MEDLINE]
 
As far as dosing we tend to stay on the lower side, in the package insert ranges, occasionally we push it. Our average length of mechanical ventilation is pretty short, and our accuity is pretty low. With that combinatination and being relatively new staff where I am now, so I really haven't had to deal with a lot of long term weaning, however I can't say I've noticed any issues related to it, even antecdotally.

In the unit I don't cover hearts, but coming out of the OR and in the unit we use dexmedetomidine, I had used mostly propofol in training, seems to be nice wake ups for the fast track folks.

Its interseting the differences. Where I trained dex was non-formulary and out pharmacists really put the squeeze on us to minimize use, so we used quite a bit of benzo for longer term folks. Seeing the differences I have become a dex fan.
 
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How high are you going? 1.4 mcg/kg/hr? I've seen as high as 2 mcg/kg/hr used.

At our unit, we don't wean dex for extubation, we keep it going. After, we usually don't have much trouble getting it off. In the rare cases, we slap on a clonidine patch or 3.

I've heard about significant rebound hypertension. When I plan on using it for post-op sedation I typically start at 0.3-0.5 mcg/kg/hr. I'm not sure how high the ICU will run it.

On a minor tangent, has anyone noticed very high sedation requirements in post-lung transplant patients?

I would agree with that.
 
Haven't seen any issues with discontinuing precedex infusion in our ICU folks, even those that have been on it at higher doses (>2mcg/kg/hr) or for prolonged periods of time. Our SICU pharmacist told me about one guy who was on 2mcg/kg/hr for three weeks, and was abrubtly taken off, with no rebound hypertension. Admitedly, most of the patients we see in our SICU are young multitraumas, so not your typical ICU player. When we use it in the sicker crowd, it seems to be for shorter periods, and still no significant difficulty with taking it away.
 
I've heard about significant rebound hypertension. When I plan on using it for post-op sedation I typically start at 0.3-0.5 mcg/kg/hr. I'm not sure how high the ICU will run it.

The stuff costs so much that all the places where I train have it restricted. And I think going forward with respect to costs that we'll all be using less and less of the stuff until it goes generic, unless of course, you're working at a money making machine like CCF ;)

I've run it very high up to 2.0 as long as the HR and BP don't tank.

Never used it long enough to see rebound.

My use of dex has been in patient's who freak coming off of sedation for weans or the EtOH w/d'er who I'm babysitting and trying to keep off the vent by decreasing the ativan/valium needs.
 
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