Understanding different gtts for sedation: Propofol vs Precedex vs Versed vs Fentanyl, etc

  1. I'm new to critical care and what's confusing me is the different gtts used for sedation, mostly because all my patients are never on the same thing. So I was wondering what's the indication for each.

    Examples of Different Combinations of Sedation I've had:
    • Fentanyl and Versed gtt
    • Fentanyl and Precedex
    • Fentanyl and Propofol
    • Propofol and Precedex


    One case that confused me was a patient I had admitted with ARDS who was mechanically ventilated and on Versed gtt and Fentanyl gtt. Her respiratory rate was set at 28, however her breathing rate was between 30-50, and she was coughing over the vent it seemed. I gave 2mg IVP Versed x2, in addition to increasing her Versed gtt up, and then finally a dose of PRN Nimbex which appeared to work for like only 15 minutes. When I made the doctor aware, she said to switch her over to a Propofol gtt and off the Versed gtt if she could tolerate it. So again, my question is, why Propofol instead of Versed? I mean, it definitely worked after some titration, but I'm trying to understand why she was on Versed in the first place, and why Propofol was better for her?
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  2. 26 Comments

  3. by   ICUman
    PRN Nimbex, the paralytic? Could you explain the rationale? I've seen nimbex gtts. when the patient is overly tachypneic and on a vent., but never a prn push.

    As far as your question, I haven't used a versed gtt. but it seems like propofol really is stronger than versed and especially precedex.
  4. by   ArmaniX
    I've also never seen propofol and precedex together given their likelyhood to cause bradycardia and hypotension.
  5. by   ArmaniX
    Fentanyl gtt is for pain and has sedative effects
    Propofol gtt is pure sedation.. if the patient is in pain they will remain in it. It is cruel, in my opinion to have a patient on propofol only.
    Versed gtt will help with agitation and withdrawal. It is useful in patients in withdrawal or those difficult to ventilate. Again nothing for pain control.
    Precedex gtt is used for agitation, and in my practice, is used when we are attempting to extubate patients who do not tolerate low levels of sedation/previous gtts mentioned.

    A PRN paralytic is a ridiculous order and has the potential to be misused by staff with little knowledge of their gtts. I would never want someone to simply use a prn paralytic on me if I was awake and not appropriately sedated.
  6. by   Okami_CCRN
    Fentanyl (usual dosage 10-200mcg/hr) is an opiod medication often used as a gtt in critical care not only for its pain relieving properties, but its synergistic effects when combined with propofol and/or precedex. It is important to keep in mind that by its self fentanyl is not a sedative and should not be used as such.

    Propofol (max 50mcg/kg/min) is a powerful sedative with a short half life, most patients wake up within 30 minutes of turning the gtt off/down. At high doses propofol can cause propofol infusion syndrome, discoloration of the urine, and high triglycerides. It is great when used for short term sedation.

    Versed (max dose 10mg/hr) is a benzo and works well on patient who are withdrawing from ETOH and intubated. Versed at high doses also works almost like a hypnotic. Some physicians order it alongside fentanyl/propofol depending on how much sedation they need. I usually see versed/fentanyl/propofol on a patient who is chemically paralyzed.

    Precedex (usually max dose is 1.5 mcg/kg/min facility dependent); the hit or miss of sedative drugs, Neuro loves it, mainly because it does not sedate but calm. It does not affect respiratory centers of the brain but can cause bradycardia and should be stopped. I have seen people drop their HR to the 40-50 range on this gtt. Works well on patients who are withdrawing from etoh but don't quite need versed.

    and now let's talk about nimbex (1-10mcg), nimbex is a paralytic, it is very important that your patient be adequately sedated before beginning a nimbex gtt. bolus with versed and fentanyl, increase your propofol drip and then begin the nimbex infusion. If your facility uses a BIS monitor you want to have a BIS score of 40-50, also when doing TOF you want 1-2 twitches out of 4. Paralytic therapy is great when a patient is in ARDS and is requiring high levels of PEEP or an inverse I:E ratio that is unnatural to oxygenate the lungs, but remember you are paralyzing someone, if they are not adequately sedated then it is not only frightening but torturous. This is why pushing nimbex if someone isn't sedated is well, wrong. Also have the residents order lacrilube for their eyes and apply Q4h, you do not want their eyes drying up.
  7. by   ICUman
    Quote from ArmaniX
    I've also never seen propofol and precedex together given their likelyhood to cause bradycardia and hypotension.
    Really? I have patients on this combo all the time with little side effects noted other than occasional hypotension.
  8. by   MunoRN
    You generally want an analgesic component as part of vent sedation, which is what the fentanyl is for. Propofol is not an analgesic, so should not be used alone. Benzos should be used sparingly if possible, particularly versed since it is the most highly associated with delirium. The use of paralytics is becoming less popular due to more evidence on it's long term risks when used for vent compliance or other sustained uses. Precedex is an alpha agonist that is generally described as putting people in their "happy place" without the same level of CNS depression as other sedatives, making it possible to extubate someone with it still running, which may help speed up time-to-extubation and also decrease the need for other vent sedation.
  9. by   ArmaniX
    Quote from ICUman
    Really? I have patients on this combo all the time with little side effects noted other than occasional hypotension.
    I'll double check, but I'm almost certain it states it in the order set itself.
  10. by   William2
    Quote from ArmaniX
    Fentanyl gtt is for pain and has sedative effects
    Propofol gtt is pure sedation.. if the patient is in pain they will remain in it. It is cruel, in my opinion to have a patient on propofol only.
    Versed gtt will help with agitation and withdrawal. It is useful in patients in withdrawal or those difficult to ventilate. Again nothing for pain control.
    Precedex gtt is used for agitation, and in my practice, is used when we are attempting to extubate patients who do not tolerate low levels of sedation/previous gtts mentioned.

    A PRN paralytic is a ridiculous order and has the potential to be misused by staff with little knowledge of their gtts. I would never want someone to simply use a prn paralytic on me if I was awake and not appropriately sedated.
    Might add that I've seen Versed for seizure control in addition to your seizure meds. I've seen quadruple strength versed, 250mg/hr infusion for this post EEG.

    PRN paralytic for dyssynchrony or high peaking IF sedation increases haven't helped.

    Precedex is a word you never use around one of our docs for sedation/agitation. Better have exhausted all efforts before suggesting it.
  11. by   Dodongo
    I've worked for 2 institutions. The first really liked fentanyl and versed drips with propofol thrown in and a small amount of dex or even ketamine drips. The second really loves propofol with some fentanyl and versed thrown in and a small amount of dex. A patient in ARDS would really benefit from the fentanyl if she's coughing/breathing above the vent, but you want to make sure she is heavily sedated - at least in the very acute stages. Same thing with, say, hypothermia protocols. You want these patient profoundly sedated, even paralyzed, because you're attempting to rest the brain (or lungs in the OPs example). Sounds like she really did need a paralytic drip though. I've only given a bolus of vec when we made initial vent changes that weren't being tolerated (dysynchronous) and we needed an hour or so for the patient to adjust but didn't want to paralyze long term (risk of pna, etc). I think each provider or group of intensivists likes different sedation regimens, tbh. Provider preference. Dex is a nice light sedative as an alpha 2 agonist (think clonidine) but I've not seen it used as sole therapy for intubated patients. Ketamine is great for intractable pain (post surgical esp.).
  12. by   Dodongo
    Also, we have an anesthesiologist who likes to run prop and dex together on his mac cases. These patients aren't intubated and they seem to run pretty smoothly through the cases without significant cardiovascular depression.
  13. by   Burks21
    We frequently use the Fentanyl and Propofol combination for our intubated patients. Rarely due we used Versed. We will occasionally use Precedex for patients at risk of withdrawl from whatever (often think the med just plain doesn't work).

    Our docs want us to get Propofol off as soon as possible and continue using Fentanyl gtts and IV pushes to keep patients sedated but easy to arouse. It's a fine line.
  14. by   ICUman
    Quote from William2

    Precedex is a word you never use around one of our docs for sedation/agitation. Better have exhausted all efforts before suggesting it.
    Why's that?
    The intensivist group I work with prefers it as their top sedation choice. Personally I think it's hit or miss.

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