Sedation Selection

Document a target using RASS or the Riker Sedation-Agitation Scale (SAS), then titrate to that target rather than to an unstructured impression of comfort. RASS ranges from +4 (combative) to -5 (unarousable), whereas SAS ranges from 7 (dangerous agitation) to 1 (unarousable). For many mechanically ventilated adults, a RASS target of -2 to 0 or SAS 3 to 4 is appropriate. ScienceDirect+1ScienceDirectComparison and Agreement Between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in Evaluating Patients' Eligibility for Delirium Assessment in the ICU - ScienceDirectPubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf

Reassess sedation at least every shift and whenever agitation, ventilator dyssynchrony, hypotension, neurologic change, or a weaning transition occurs. A bundle implementation that increased RASS assessments and reduced benzodiazepine infusion use was associated with lower ICU delirium prevalence, 0.6 fewer ventilator days, and 0.5 fewer ICU days, although these observational implementation data do not establish an agent-specific causal effect. Wolters KluwerWolters KluwerImproving Outcomes in Mechanically Ventilated... : Critical Care Explorations

Before escalating a hypnotic infusion for agitation, reassess pain and delirium. Use a structured delirium screen such as CAM-ICU when the patient can be evaluated; ICU practice data describe daily delirium screening, most commonly with CAM-ICU, alongside daily consideration of sedation holds. PubMedPubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf

In critically ill mechanically ventilated adults, the Society of Critical Care Medicine guideline suggests either propofol or dexmedetomidine instead of benzodiazepines. The recommendation is conditional and based on low-quality evidence, but it directly supports a nonbenzodiazepine default when no patient-specific indication favors another strategy. Wolters KluwerWolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...

Propofol is an appropriate option when a continuously titratable infusion is needed. Its FDA labeling directs slow initiation in intubated, mechanically ventilated adults to minimize hypotension and calls for individualization using clinical response, vital signs, and blood lipid profile. accessdata fda+1accessdata fdaDIPRIVAN (propofol) injectable emulsion, USPdailymed nlm nihThese highlights do not include all the information needed to use PROPOFOL INJECTABLE EMULSION safely and effectively. See full prescribing information for PROPOFOL INJECTABLE EMULSION. PROPOFOL INJECTABLE EMULSION, USP, for intravenous use Initial U.S. Approval: 1991

Dexmedetomidine is FDA-indicated for sedation of initially intubated, mechanically ventilated adults in an ICU setting. Its central tradeoff is cardiovascular intolerance: hypotension, bradycardia, and dry mouth are the most frequent adverse reactions in the label. dailymed nlm nih+1dailymed nlm nih[PDF] dexmedetomidine injection, solution - DailyMeddailymed nlm nihDEXMEDETOMIDINE INJECTION

Reserve a benzodiazepine infusion for situations in which the anticipated advantage outweighs the guideline preference for propofol or dexmedetomidine. Do not use a benzodiazepine solely because deeper sedation is desired without first confirming the intended target and assessing whether the depth is still required. Wolters Kluwer+1Wolters KluwerClinical Practice Guidelines for the Prevention... : Critical Care ...PubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf

For ICU sedation of an intubated, mechanically ventilated adult, start propofol at 5 mcg/kg/min (0.3 mg/kg/h) when initiation is indicated. Increase by 5-10 mcg/kg/min (0.3-0.6 mg/kg/h) per adjustment, allowing at least 5 minutes between changes for peak effect. Most adults require 5-50 mcg/kg/min (0.3-3 mg/kg/h), although some require higher rates. accessdata fda+1accessdata fdaDIPRIVAN (propofol) injectable emulsion, USPdailymed nlm nihThese highlights do not include all the information needed to use PROPOFOL INJECTABLE EMULSION safely and effectively. See full prescribing information for PROPOFOL INJECTABLE EMULSION. PROPOFOL INJECTABLE EMULSION, USP, for intravenous use Initial U.S. Approval: 1991

Avoid routine infusion rates above 4 mg/kg/h unless the benefit outweighs the risk. Titrate slowly, particularly in a patient with limited hemodynamic reserve, because the label specifically frames gradual initiation as a strategy to minimize hypotension. accessdata fda+1accessdata fdaDIPRIVAN (propofol) injectable emulsion, USPdailymed nlm nihThese highlights do not include all the information needed to use PROPOFOL INJECTABLE EMULSION safely and effectively. See full prescribing information for PROPOFOL INJECTABLE EMULSION. PROPOFOL INJECTABLE EMULSION, USP, for intravenous use Initial U.S. Approval: 1991

Check vital signs continuously or at ICU-standard intervals during initiation and rate changes, and incorporate blood lipid profile into ongoing individualized management. If blood pressure falls after an escalation, reduce the propofol rate toward the lowest dose that maintains the prescribed RASS or SAS target and reassess whether the target depth remains necessary. accessdata fda+2accessdata fdaDIPRIVAN (propofol) injectable emulsion, USPdailymed nlm nihThese highlights do not include all the information needed to use PROPOFOL INJECTABLE EMULSION safely and effectively. See full prescribing information for PROPOFOL INJECTABLE EMULSION. PROPOFOL INJECTABLE EMULSION, USP, for intravenous use Initial U.S. Approval: 1991PubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf

Do not abruptly discontinue propofol before a planned weaning attempt or daily sedation-level evaluation. The label warns that abrupt discontinuation may produce rapid awakening with anxiety, agitation, and resistance to mechanical ventilation; instead, adjust the infusion to maintain the minimum sedation needed during weaning and assessment. accessdata fdaaccessdata fdaDIPRIVAN (propofol) injectable emulsion, USP

Dexmedetomidine is indicated for sedation of initially intubated and mechanically ventilated adults during ICU treatment. Use a prescribed RASS or SAS target to judge effectiveness rather than escalating solely for an isolated episode of restlessness. dailymed nlm nih+2dailymed nlm nihDEXMEDETOMIDINE INJECTIONScienceDirectComparison and Agreement Between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in Evaluating Patients' Eligibility for Delirium Assessment in the ICU - ScienceDirectPubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf

Before initiating or increasing dexmedetomidine, review baseline heart rate, blood pressure, recent vasopressor requirement, and whether the patient has already developed clinically meaningful bradycardia or hypotension. In adult ICU sedation populations treated with dexmedetomidine, hypotension was reported in 24%-28% and bradycardia in 5%-7%; these labeled adverse-event frequencies make a worsening hemodynamic trajectory a practical reason to avoid escalation or select an alternative. dailymed nlm nihdailymed nlm nih[PDF] dexmedetomidine injection, solution - DailyMed

If clinically significant bradycardia or hypotension develops temporally with dexmedetomidine titration, reassess infusion necessity and dose immediately while evaluating concurrent causes such as hypovolemia and other medications. The label also reports hypovolemia among treatment-emergent adverse events, reinforcing the need to distinguish drug-associated hemodynamic intolerance from an evolving shock state. dailymed nlm nihdailymed nlm nih[PDF] dexmedetomidine injection, solution - DailyMed

For patients approaching liberation, coordinate sedation management with daily consideration of a sedation hold and ventilator-weaning assessment. ICU practice data report that 94% of units considered a daily sedation hold for sedated patients, and a mechanically ventilated patient workflow described daily interruption of continuous sedation paired with respiratory-therapist-managed weaning. PubMed+1PubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI BookshelfclinicaltrialsStudy Details | NCT02528513 | Midazolam Used Alone or Sequential Use of Midazolam and Propofol/Dexmedetomidine in Mechanically Ventilated Patients | ClinicalTrials.gov

For propofol, do not equate sedation assessment with abrupt cessation. Maintain the minimum level of sedation needed through weaning and sedation-level assessment to avoid rapid awakening, anxiety, agitation, and ventilator resistance. accessdata fdaaccessdata fdaDIPRIVAN (propofol) injectable emulsion, USP

A failed wake-up or breathing evaluation should prompt reassessment of the sedation target, pain, delirium screen, and ventilator requirements before returning automatically to the prior infusion rate. RASS-guided protocols and CAM-ICU screening are practical tools for separating agitation, oversedation, and delirium-related barriers to liberation. Wolters Kluwer+2Wolters KluwerImproving Outcomes in Mechanically Ventilated... : Critical Care ExplorationsScienceDirectComparison and Agreement Between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in Evaluating Patients' Eligibility for Delirium Assessment in the ICU - ScienceDirectPubMedBackground and research question - Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review - NCBI Bookshelf