Post-intubation Sedation – Tips for the Intubated Patient

You’ve just finished intubating your hypotensive, acute respiratory failure patient. Other than the pharmacologic and hemodynamic considerations, what other things should inform your choices for post-intubation sedation?

 

I thought I knew about post-intubation sedation since intern year; what’s new?

Though not brand new, the latest Society of Critical Care Medicine guidelines from Barr et al in 2013 on pain, agitation, and delirium place emphasis on analgesia-first sedation.(1) Furthermore, the risk of delirium with benzodiazepines should encourage sedation with other drug classes. Fraser et al in 2013 performed a meta-analysis of 1,235 patients comparing benzodiazepine and non-benzodiazepine sedation; length of stay and mechanical ventilation needs were greater with benzodiazepine paradigms.(2) Therefore, they should be avoided when possible.

 

What’s analgesia-first sedation and why should I care?

It is the concept of providing adequate analgesia before uptitrating sedation and has been shown to have shorter lengths of stay in the ICU as well as reduced times on mechanical ventilation.(3) In ICU populations during their first 48 hours of illness, analgesia-first sedation showed improved outcomes.(4) Though many critically ill patients do not spend 1-2 days in the ED, boarding times are increasing and ED interventions (including sedation choices) are often continued during the patient’s early ICU course.(5)

 

My patient is agitated; why can’t I just “snow them” with analgesia and sedation?

In addition to the association between benzodiazepines and worsened outcomes, deep sedation as quantified by RASS < -3 was shown by Shehabi et al to have increased time to extubation and worsened mortality.(6,7) Though the ED environment and high acuity often preclude lighter RASS goals, one should consider lighter sedation goals in the appropriate patients.

 

References

  1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.
  2. Fraser GL, Devlin JW, Worby CP, et al. Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials. Crit Care Med. 2013;41(9 Suppl 1):S30-8.
  3. Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother. 2012;46(4):530-40.
  4. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010;375(9713):475-80.
  5. Hung SC, Kung CT, Hung CW, et al. Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department. Crit Care. 2014;18(4):485.
  6. Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012;186(8):724-31.
  7. Shehabi Y, Chan L, Kadiman S, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med. 2013;39(5):910-8.