Sedation Drugs for ICU Patients Handout
Pharmacologic Agents for Sedation in Intubated Adult PatientsDrug Class/Mechanism Dosing (per Carilion) Adverse Events Monitoring NotesFentanyl Opioid 25-50 mcg/hr, titrateevery 30-60 minMorphinePropofolOpioid, histaminereleaseShort-actinggeneralanestheticMax: 500 mcg/hr2 mg/hrMax: 10 mg/hr10 mcg/kg/min, titrate by5mcg/kg/min every 10minutes as neededMax: 50 mcg/kg/min• Respiratorydepression• Constipation• Respiratorydepression• Constipation• Hypotension,venodilation• Respiratorydepression• Hypotension• Hypertriglyceridemia• Pain on injection• Propofol-relatedinfusion syndrome(PRIS), usually seen atdoses >80 mcg/kg/min• Pain scale if pt canself-report• Critical Care PainObservation Tool(CPOT) for patientswho can’t self-report• RASS -1 to 0• Pain scale if pt canself-report• CPOT for patientswho can’t self-report• RASS -1 to 0• Triglycerides atbaseline and every 3-7 days after• CK• Lactatedehydrogenase• BP/MAP• RASS -1 to 0• CPOT goal <3• Has serotonergic property, usecaution in combination with otherserotonergic agents• Tachyphylaxis can develop arounddoses of 300-350 mcg/hr• CPOT goal <3• Can accumulate in renal dysfunction• 10% Lipid emulsion, 1.1 kcal/mL• Be cautious in patients withegg/soy/peanut allergyDexmedetomidineAlpha-2 agonist(same asclonidine)0.2 mcg/kg/hr, titrate by0.1 mcg/kg/hr every 30minutes as neededMax: 1.4 mcg/kg/hrMidazolam Benzodiazepine 1-4 mg/hr, titrate by 1mg/hr every 30 minutesas neededMax: 10 mg/hrLorazepam Benzodiazepine 1-2 mg/hr, titrate by 1mg/hr every 30 minutesas neededMax: 5 mg/hr• Hypotension• Bradycardia• HR• BP/MAP• RASS -1 to 0• Does not require intubation for use• Should not be used for deepsedation• Optional loading dose, usually causesbradycardia• $$$Respiratory depression RASS -1 to 0 • Can accumulate if used long-term,resulting in prolonged sedation(occurs more in renal dysfunction)Respiratory depression RASS -1 to 0 • Propylene glycol toxicity• Usually seen at doses >0.1 mg/kg/hrand/or renal impairment
- Page 2 and 3: General Tips• Analagosedation is
Pharmacologic Agents for Sedation in Intubated Adult Patients
Drug Class/Mechanism Dosing (per Carilion) Adverse Events Monitoring Notes
Fentanyl Opioid 25-50 mcg/hr, titrate
every 30-60 min
Morphine
Propofol
Opioid, histamine
release
Short-acting
general
anesthetic
Max: 500 mcg/hr
2 mg/hr
Max: 10 mg/hr
10 mcg/kg/min, titrate by
5mcg/kg/min every 10
minutes as needed
Max: 50 mcg/kg/min
• Respiratory
depression
• Constipation
• Respiratory
depression
• Constipation
• Hypotension,
venodilation
• Respiratory
depression
• Hypotension
• Hypertriglyceridemia
• Pain on injection
• Propofol-related
infusion syndrome
(PRIS), usually seen at
doses >80 mcg/kg/min
• Pain scale if pt can
self-report
• Critical Care Pain
Observation Tool
(CPOT) for patients
who can’t self-report
• RASS -1 to 0
• Pain scale if pt can
self-report
• CPOT for patients
who can’t self-report
• RASS -1 to 0
• Triglycerides at
baseline and every 3-
7 days after
• CK
• Lactate
dehydrogenase
• BP/MAP
• RASS -1 to 0
• CPOT goal <3
• Has serotonergic property, use
caution in combination with other
serotonergic agents
• Tachyphylaxis can develop around
doses of 300-350 mcg/hr
• CPOT goal <3
• Can accumulate in renal dysfunction
• 10% Lipid emulsion, 1.1 kcal/mL
• Be cautious in patients with
egg/soy/peanut allergy
Dexmedetomidine
Alpha-2 agonist
(same as
clonidine)
0.2 mcg/kg/hr, titrate by
0.1 mcg/kg/hr every 30
minutes as needed
Max: 1.4 mcg/kg/hr
Midazolam Benzodiazepine 1-4 mg/hr, titrate by 1
mg/hr every 30 minutes
as needed
Max: 10 mg/hr
Lorazepam Benzodiazepine 1-2 mg/hr, titrate by 1
mg/hr every 30 minutes
as needed
Max: 5 mg/hr
• Hypotension
• Bradycardia
• HR
• BP/MAP
• RASS -1 to 0
• Does not require intubation for use
• Should not be used for deep
sedation
• Optional loading dose, usually causes
bradycardia
• $$$
Respiratory depression RASS -1 to 0 • Can accumulate if used long-term,
resulting in prolonged sedation
(occurs more in renal dysfunction)
Respiratory depression RASS -1 to 0 • Propylene glycol toxicity
• Usually seen at doses >0.1 mg/kg/hr
and/or renal impairment
General Tips
• Analagosedation is a common approach to treat pain and to keep the patient sedated in the ICU
• Suggested to target light sedation (RASS -1 to 0), utilizing a sedation free period to assess level of sedation is beneficial
• Maintain a MAP of ≥65 mmHg
• For continuous infusion, have orders in for PRN boluses for management of breakthrough pain/agitation (midazolam/lorazepam, fentanyl/morphine), can
use boluses from the bag
• Propofol/dexmedetomidine is recommended over benzodiazepines as they have shown quicker time to light sedation and quicker time to extubation.
Benzodiazepines have potential to contribute to delirium as well
o Propofol and dexmedetomidine have been compared to each other with no noted clinically significant difference
• Patients may require more than one medication depending on their response and target level of sedation/pain control
• Pain, Agitation, Delirium, Immobility, and Sleep (PADIS) guidelines
• For patients on paralytics, both a pain medication and a sedative (not dexmedetomidine) are required. No sedation vacation is performed
Signs of Propylene Glycol Toxicity
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