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

[Catticus11]

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?

[calivianya, BSN, RN]

I don't think that PRN paralytic doses are a ridiculous order in all cases. Some experts actually say that intermittent dosing is the preferred method.

Love this post!

Sometimes a paralytic is the only thing that will break the patient out of being asynchronous. I've had patients on 200mcg/hr of fentanyl, 100mcg/kg/min propofol, 10mg/hr versed, all running together - and we still can't get them to breathe. I'd rather give PRN paralytics than start a drip if we can get the patient to be synchronous with the ventilator with just a push.

Most of these patients are real "touch me nots" - the asynchronous episodes usually only happen when we mess with them. When these patients are lying perfectly still and not being suctioned/turned, they are breathing OK. Why paralyze them when they're doing okay instead of just paralyzing them when they're not?

Which would you guys prefer - being on a paralytic drip for days, and for sure developing the deconditioning that's arguably the worst part of paralytics, or only having it pushed when nothing else works? I'd much rather have as much muscle function as possible. I'm all for PRN paralytics.

[MYSTICOOKIEBEAR]

The quick down and dirty is as follows:

Fentanyl- Opiod analgesic that is used to decrease pain, usually but not limited to post operative pain.

Propofol- Sedative hypnotic that is used for sedation.

Versed- Benzodiazepine that is use to decrease anxiety.

Precedex- A2 specific adrenergic agonist that decrease pain, has an anxiolytic effect, but does not decrease respiratory drive

Nimbex- Neuromuscular blocker that blocks the stimulation of skeletal muscles

So in a patient with raging ARDS that needs complete ventilator syncrhony I usually advocate for

-Nimbex , propofol, and fentanyl to start

-Fentanyl and propofol when we no longer need nimbex for complete vent synchrony

-Fentanyl and versed when we no longer need propofol for hard sedation

-Precedex if the pt has a hard time coming off of fentanyl/versed/propofol

It is not a perfect science but it really just depends on what your goals are for that hour/shift/day. I hope this helps you when putting patients to sleep!

[BellsyNurse]

All depends on what your patient needs. Most often analgesic + sedative (fentanyl + prop or versed... sometimes all three...! Is your patient 22 with a crazy metabolism?!). Prop clears the system typically faster than versed [versed can be a nightmare for renal pts and/or those we're trying to assess for cns function post-arrest) and makes sedation vacations easier, but can cause bradys and high triglycerides. Some people just respond better to certain drugs. All generally can cause hypotension. Precedex hardly ever seems to work - aside from causing bradys or heart blocks even-but ?unfortunately? í ½í¸‚ there will be that random rarity that it works for, allows them to extubate calmly, and then your intensivist will order it all the time. Eye roll. Paralytics are for sedated pts needing 1) complete control by the vent (ards-y guys),

2) pts being cooled post-arrest whom are

shivering/not ventilating well, or 3)for short but difficult procedures like intubating or traching . We tend to use rocuronium (for 1&2) and succs for 3 (shorter acting than roc).

Ketamine seems to make an occasional appearance as

an infusion (mg/hr)... but we use it rarely; moreso

as an adjunct bolus for tubing.

[LovingLife123]

I've seen lots of different combos. But never propofol and precedex. It would also seem to me to cause hypotension. Just because I see these drugs do the often individually, so to me combining them could be an issue. But if people on here use it without issues, who am I to question?????

Our main workhorse is the fentanyl and propofol combination. It comes out of the system so quickly that we can get accurate neuro assessments and try to wean from the vent easily.

Sometimes, we go to Ativan but that's kind of last resort for sedation. We use roc as a paralytic with fentanyl and prop. Precedex we use more for straight agitation issues. Usually people who are now off the vent, but not fully there and super agitated to the point they become a danger to themselves. It doesn't always work and it can make the patient even more agitated. But when it works, it's a blessing.

We can also use dilaudid and Ativan. Propofol can be toxic if used to long or the rate too high. We only go up to fifty of propofol but I've seen it toxic on people especially after being on it too long.