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    Post-Intubation Analgesia and Sedation

    Critical Care / Resuscitation

    Last Updated Feb 14, 2021
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    Context

    • 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.

    Recommended Treatment

    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.

    Quality Of Evidence?

    Justification

    In general, evidence for this topic is substantial, including the impact of over- or under-sedation on ICU course. ED-specific evidence is less plentiful, but still of reasonable quality.

    Moderate

    Related Information

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

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    RELEVANT RESEARCH IN BC

    Procedural Sedation and Analgesia

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