• It is common to neglect post-intubation analgesia and sedation, especially among a multitude of other priorities.
• Rocuronium leads to a delay in post-intubation sedation, compared to its shorter-acting alternative Succinylcholine.
• Under-sedation of ICU patients is associated with an increased duration of mechanical ventilation, and increased the likelihood of delirium with its associated increased ICU stay, mortality, and long-term cognitive impairment.
• Over-sedation also increases risk of delirium.
• Deep sedation within 4 hours of commencing ventilation has been shown to be an independent negative predictor of time to extubation, hospital death, and 180-day mortality.
• Post-intubation Analgesia and Sedation in the ED can have long-lasting consequences and should be treated as an immediate priority after the tube is secured.

Analgesia First

• RSI drugs typically provide minimal analgesia.
• ICU patients treated with analgesia first, and no sedation, had a shorter ICU stay with fewer days on mechanical ventilation.
• Intubation should be immediately followed by an IV bolus of analgesia, particularly if induction was with a sedative (like Propofol) with no analgesic properties.
• Once able, bolus medications can be replaced with an infusion.

Common analgesic options (click image to enlarge):

When assessing the adequacy of analgesia, consider using a validated scale like the Behavioural Pain Scale, used for monitoring ICU patients.

• Some of these medications may cause hypotension, so it may be necessary to start a vasopressor infusion to allow for adequate analgesia.

Add Sedation

only once analgesia is addressed:

• Light sedation relieves discomfort, improves synchrony with mechanical ventilation and decreases oxygen requirements and overall work of breathing.
• Benzodiazepines have been associated with longer durations of mechanical ventilation and ICU stays, so are NOT recommended by the Society of Critical Care Medicine (SCCM) and other critical care experts. Short-term boluses may be appropriate, but avoid long-term benzodiazepine infusions.

For any of the drugs below, start with low boluses and titrate up:

• The goal should be to titrate to light sedation, such as -1 to -3 on the Richmond Agitation Sedation Scale below, provided that the patient was able to respond to voice prior to intubation:

Special Scenarios

Hypotension – Medical

• A patient’s low blood pressure should never limit adequate pain control; start and titrate up a vasopressor if necessary. Fentanyl, Ketamine or Midazolam have minimal hypotension.

Hypotension – Trauma

• If this patient has a very low MAP, Ketamine might be a reasonable first choice for its helpful side effect of hypertension and tachycardia.

Delirium Tremens, or Status Epilepticus

• Unlike the typical post-intubation patient, these patients need sedation with GABA agents; use benzodiazepines (BNZ) pre-intubation and add post intubation with a high starting infusion rate.  If already on such high doses of BNZ that more are unlikely to help, Propofol is a reasonable next option.

High Intracranial Pressure (ICP)

• Also require heavy sedation, to treat hypertension and limit CNS metabolic demand and rising ICP. Propofol and fentanyl are likely the best first options in these patients.

Pregnancy

• In general, the same strategy as for other critically ill patients.
• Fentanyl for analgesia is appropriate, even if delivery is imminent, to improve maternal hemodynamic stability and reduce risk of awareness, despite risk of fetal/neonatal respiratory depression.
• Ketamine would be appropriate as well.
• Propofol might be considered for low infusion dose post-intubation, due to its short duration, but should ideally be avoided for induction due to higher incidence of hypotension. Evidence is limited.

Treatment Summary

Analgesia first

• Consider Fentanyl 25-50mcg or Ketamine 20-30mg boluses, followed by IV infusion titrated to Behavioural Pain Score BPS.

Add light sedation

• If necessary, and especially if patient is still paralyzed, Propofol or Midazolam bolus or infusion, starting low and titrated to Richmond Agitation Sedation Score RASS.

1. Barr J, Fraser GL, 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 Jan;41(1):263-306

   
   

2. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet. 2010 Feb 6;375(9713):475-80

   
   

3. Fraser GL, Devlin JW, 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 Sep;41(9 Suppl 1):S30-8

   
   

4. Pisani MA, Kong SY, et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009 Dec 1;180(11):1092-7

   
   

5. Shehabi Y, Bellomo R, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012 Oct 15;186(8):724-31

   
   

6. Post-Intubation Sedation and Analgesia. Core EM.

   
   

7. A Bad Sedation Package Leaves your Patient Trapped in a Nightmare. (EMCrit Podcast)

   
   

8. Post-Intubation Sedation: The Tube Is In, Now What? (Emergency Physicians Monthly)