What is a good sedative for a hypotensive patient?

[nursingdude78]

I had a patient that was dropping her pressure on propofol, switched her to ativan and fentanyl drips, and it was just as bad. She was on 20 mcg dopamine and 250 mcg of neosynephrine, definitely was not hypovolemic. Would you try ativan alone, or fentanyl alone, or something else? I know ativan and fentanyl work synergistically to create sedation, do they do the same to blood pressure when they are combined?

[TakeBack]

Fentanyl has less histamine release than other narcotics and is the textbook answer for that class.

You will need a combo for adequate sedation in most.

Dexmedetomidine is another choice.

[NtannRN]

What about Versed (midazolam) and Fentanyl?

[nursingdude78]

For some reason our hospital does not do Versed drips, just Ativan. I kind of assumed that Versed would act similarly to Ativan when combined with Fentanyl.

[TakeBack]

Midaz is more expensive than loraz.

[CABGx4, ASN, BSN, MSN, CRNA]

Most of our critical care MD's use fentanyl/versed combo if propofol is contraindicated. Precedex has been used but long-term use has not been studied. If volume is not your issue, then adding a pressor at small doses may be necessary if you want you patient to be comfortable.

[TakeBack]

Re dexmed, It depends on what you mean by long term. The drug is not approved for more than about 24 hrs, in but in real practice it is being used for 1-2 weeks without any established complications.Fent-midaz is a good combo and even in refractory pts the dilation can be counteracted w/ neo, vaso, norepi etc.

[meandragonbrett]

A lot will be patient dependent.

Precedex, Fentanyl, low dose lorazepam, dilaudid, low dose diazepam, etc can all be great options depending on your patient and what's going on with them.

Sometimes it is necessary to bump your pressors in order to keep the patient adequately sedated.

Fentanyl is going to be the best opiate hemodynamically speaking because it does not involve as much of a histamine mediated hypotension as other opiates.

What was the etiology of your patients hypotension?

[HyperTension]

I absolutely echo previous the responses regarding etiology of the hypotension at hand. As a general statement, sedation is not a "one size fits all" type of therapy (not much is in critical care, minus celestial transfer).

Lately I'm finding that with patients that don't evolve well with either precedex or diprivan have done better with combination of both. If the goal is vent. weaning I have a tendency to go heavier with the precedex (our hospital / anesthesia protocol allows for up to 1mcg/kg/hr and suppliement with diprivan, vs. more of a generalized sedation where the roles may be better reversed (heavier on diprivan with precedex as a suppliment). Also bear in mind that precedex has a tendency to potientiate co-administered central nervous system depressants. I've read various studies / drug-rep's that have stated by a factor of 1.5 - 2X. Not sure if there is a solid number to state, but It's something I am aware of while medicating my patient.

Now add narcotic / opioid therapy. Fentanyl may be ideal due to it's lower incidence of induced hypotension / decreased histamine release vs. morphine / dilaudid, and shorter half-life, but it's far more expensive vs. the other 2 mentioned. Add any hepatic / renal impairement to murky up the waters as well.

Ativan / valium (old school) are also a valid option but they have a far greater half-life / clearence, especially with long term usage. I personally prefer to use them as PRN suppliments, but will absolutly advocate for a ativan drip if events / needs dictate.

Now lets talk about your stated dosing of dopamine / Neo. If your not getting the effect you want (or need), it's time to advocate for different flavor (similar to sedation no?). Your maxed on dopamine, and very maxed out on the traditional dosing of Neo. It's time to add Levophed and possibly look at the usage of vasopressin (last on, first off). However, a lot needs to be considered with this, ie: etiology of the hypotension (septic, post bypass pump, etc, etc, etc). Whats your heart-rate at, especially considereing your at 20mcg/kg/min of dopamine, volume (you stated that volume was not an issue, but I'm mentioning it as a general consideration).

I'd say it's time to try a few different flavors to get your BP in line (inferred), then worry about sedation. (I'd would have advocated of precedex and suppliment with diprivan / fentanyl)

And this is just over the few minutes I have left on my break to answer.

[scoochy]

Sounds like a volume issue to me...does the patient have S/G catheter? If so, what are the numbers, so to speak?

[CTURN]

go up on pressors or start dex.

[wakaro]

I would echo my collegues above. Just wondering whats the cause of hypotension? You stated not hypovolemia? Patient already maxed on dopamine and neo?

Anyway, sometimes you will need to use a combo of sedatives, i do like an idea of versed + fentanyl if there are no contraindications to this. Some folks would love haldol, i do not know whats the age of your patient. I talked with one geriatric doc and do agreee with him if you have an elderly patient try to avoid ativan it makes this population crazy!

You probably need more pressors on board though to continue sedating this patient. May be levo, vosopressin??

Hope this helps. 