When I first started working in the ICU, I was thrilled by the fact that ICU nurses have a very high level of autonomy when it comes to titrating drugs to keep the patients safe. High autonomy comes with high responsibility that we need to know out drugs well. Today, I would like to discuss about some of the sedative medications for intubated patients. The most common drugs are propofol (Diprivan) and dexmedetomidine (Precedex). Beside my bedside experience from handling these medications, I have used the AACN Essential of Critical Care Nursing by Suzanne M. Burns as my reference to make sure the information is correctly presented. So, let’s learning about some common sedative medications in the ICU and start saving lives!
Before we move on each specific medication, there are some general rules you should be aware.
- Patient still have pain even when they are appropriately sedated. ICU patients usually have tubes (endotracheal tube, NG tube, G tube, chest tube, Foley, etc) and lines (central line, dialysis, etc) so it is safe to say that almost all of them will experience some kind of discomfort and pain.
- Sedation can help the patient relax to prevent them from harming themselves from pulling tubes and lines. Sedation also keeps the patients who are on mechanical ventilators from fight the vent.
- Over-sedation in patients with mechanically ventilator will prolong the weaning process thus keep them on the ventilator longer. Also over-sedation will cause respiratory depression, decreased heart rate and blood pressure.
- Propofol is a central nervous system depressant. It has a rapid onset and short half life. It is one of the most common sedative medications for patients who is intubated and on the vent. The endotracheal (ET) tube constantly triggers the patients gag reflex which causes extreme discomfort. Therefore, most intubated patients need some sort of sedation to keep them calm and relax.
- Propofol also decrease cerebral oxygen consumption thus used in patients with traumatic head injury (increased ICP) or status epilepticus
- Main side effects of propofol include bradycardia and hypotension. Therefore, patients who is on propofol needs to have their vital signs taken every 15 minutes (mainly HR and BP)
- To appropriately sedate the patient to prevent under-sedation or over-sedation, we use Richmond Agitation Sedation Score (RASS) score to monitor the patient sedation level. We monitor the RASS score every 1 hour in my facility.
The Richmond Agitation and Sedation (RASS) Scale [Digital image]. (2015, March 23). Retrieved April 10, 2018, from https://pbrainmd.wordpress.com/2015/03/23/rass-scale/
It depends on how much the physician want the patients to be sedated, we usually titrate the propofol to the RASS -2 (patient appears to be asleep, opens eyes for less than ten seconds and looks at you when you shout his/her name then go back to sleep when is not stimulated. Patient is comfortable, normal heart rate, blood pressure, and not fighting the vent).
- Dosage 5-100 mcg/kg/min
- Propofol is formulated in fat-emulsion vehicle which increases growth of microorganism. Therefore, the medication and iv tubing needs to be changed every six to twelve hour (it is every twelve hours in my facility so I usually go ahead and change the whole tubing when I change the first new bag of my shift)
- High infusion rates (doses greater than 75mcg/kg/min over 48 hours) can cause a rear but serious adverse effect known as propofol infusion syndrome (PRIS). Signs and symptoms of PRIS include hyperkalemia, tachyarrythmia ST-segment elevation in the right precordial leads (V1-V3), bradycardia, rhabdomyolysis, and lactic acidosis (Burns, p.188).
- Propofol can turn your patient’s urine to green, especially if your patient has been on propofol continuous infusion for several days. This is a harmless side effect which doesn’t require any interventions.
My facility does not use this drug. Therefore, all information provided here came from the AACN Essential of Critical Care Nursing by Suzanne M. Burns. The reason why I decided to share with you because I learned that Precedex has become quite popular nowadays because it does not cause respiratory depression as much as propofol does thus patient is more awake and ready for weaning trial thus more cases of successful extubation.
- It is a Alpha 2 adrenergic agonist
- Used for short term sedation (<24 hours)
- Decreases HR and BP but does not cause respiratory depression
- Dose 0.2 to 1.5 mcg/kg/hr
(Burns, p. 188)
Burns, S. M. (2014). AACN essentials of critical care nursing. New York: McGraw-Hill Education.