Episode 61- PharmSoHard meets ER-Rx: ICU sedation
In case you missed our discussion on ICU sedation on the PharmSoHard podcast, we’re playing the episode on ER-Rx as well. Yes, it’s that important.
“PharmSoHard meets ER-Rx: ICU sedation:”
– The Pain, Agitation, and Delirium guidelines (PAD; 2013 and PADIS; 2018) are clear on their recommendations for managing post-intubation pain and sedation
– Pain is monitored by validated scales such as the visual pain scale (if patients can self report) or the critical care pain observation tool (CPOT) (in patients that cannot self report)
– Sedation is monitored using validated scales such the the RASS and SAS. Guidelines stress the importance of light sedation; with RASS goals of -1 – + 1 and SAS scores of 3-4. This corresponds to a patient that is drowsy and awakens to voice or is fully alert. Deeper levels of sedation lead to increased lengths of stay and worse patient outcomes
– Always start with “A-1” sedation, or analgesia-first sedation post-intubation. Remember that opioids have sedating properties!
– Agents such as fentanyl, hydromorphone, and morphine can be used first with an as needed, bolus dosing strategy followed by a continuous infusion if bolus dosing does not adequately sedate your patient
– If the patient is still uncomfortable on the ventilator, sedative agents such as propofol, dexmedetomidine (Precedex), and ketamine can be used as adjuncts to the opioid infusion
– Benzodiazepines are strongly recommended against as they increase the risk of developing ICU delirium and they have been associated with worse patient outcomes. Only use these agents for specific patients (ex. those with seizures or withdrawal from alcohol/ benzodiazepines) or those requiring deep sedation (ex. those on continuous paralytic infusions or those undergoing therapeutic hypothermia)