Quote from RNSAC
I recently transferred to ICU and in training right now. I just had a quick question about sedative medications. Why would doctors use some sedative medications over others. for example, Precedex vs. fentanyl/versed vs. propofol.
I understand precedex is used mostly for patients who are about to get extubated. But my patient who was on this medication wasn't even close to getting extubated. Im thinking its because he was on propofol for a while and they wanted to switch to precedex to switch it up????
Caveat, I work in a surgical/transplant ICU so things may be different in other ICUs.
Separate out the drugs by what they do. Fentanyl is an opiod so it affects the opiod receptors and provides pain relief with some sedation. Propofol and Versed work on the GABA receptors and provide sedation (although in my experience Propofol gives a little bit of analgesia). Precedex works on the Alpha 2 receptors producing sedation but without respiratory depression.
Then you have to look at the side effects
Fentanyl - primarily respiratory depression
Propofol - hypotension and respiratory depression
Versed - increased incidence of delirium
Precedex - bradycardia - also tends to have a higher incidence of breakthrough than the others.
Finally we use the PAD (pain agitation and delirium) guidelines
First treat pain then treat agitation finally avoid delirium by minimizing benzodiazopines (versded and ativan) while treating delirium (medically and environmentally).
So where I work everyone gets treated for pain - we start people on a fentanyl drip. This is titrated until the patients pain score of 3-4 and a RASS of -1 to -2. If the patient remains agitated after pain is controlled then check a CAM-ICU at this time (we check every 12 hours). If CAM-ICU + then treat delirium. If still agitated add another agent. We don't use benzos due to increased delirium so its Propofol if the blood pressure will stand it or Precedex if not. If the patient gets bradycardic on Precedex then we usually add Ketamine.
In my experience 80-90% of patients can be managed with Fentanyl alone. One issue comes around extubation. I usually stop Fentanyl and add PRN Dilaudid. If they get agitated some Precedex smooths things out here.
The other issue is inexperienced nurses using Fentanyl for sedation and then having to wait for it to wear off.
Sedation in the ICU is an art but using the PAD guidelines is a big start.