Precedex vs. fentanyl/versed vs. propofol

canigraduate · Oct 30, 2016

You may get a better response in the ICU forum. You can go to the help desk and ask them to move it for you.

Trauma Columnist · Oct 30, 2016

Moved to Critical Care Nursing

core0 · Oct 30, 2016

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????
thanks!

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

http://www.learnicu.org/SiteCollectionDocuments/Pain,%20Agitation,%20Delirium.pdf

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.

offlabel · Oct 30, 2016

Caveat, I work in a surgical/transplant ICU so things may be different in other ICUs...

Great response...I'd only add that since the understanding of propofol infusion syndrome, although fairly rare, folks around here have been looking for ways not to use it, use it briefly or minimizing the dose through adding synergistic agents along with it. Giving smaller doses of two or three sedatives together can achieve the desired sedation without prolongation when it's time to wake up.

RNSAC, MSN · Oct 31, 2016

very detailed. thank you so much

RescueNinjaKy · Nov 4, 2016

Is it due to elevated CK and triglycerides. Those are signs of propofol syndrome and it calls for switching from propofol to another sedation. At least this is what I have seen at my work place.

ClauICURN · Nov 9, 2016

Hi,

It depends on the specific patient presentation and MD preference. Generally speaking, propofol and precedex are used for light to moderate sedation vs versed/fentanyl for deeper sedation. If the pulmonologist thinks the patient will improve and be extubated let's say 1-3 days, then they are more likely to go with propofol/precedex especially propofol because if you think the patient will stay on the vent for longer than that then propofol can have very serious adverse effects when used for that long. Precedex works great on a patient who is orientedx4 because usually they will be only minimally sedated and if they are cooperative, it makes weaning off and extubating so much easier. Also precedex provides some analgesic effects and doesn't cause significant respiratory depression. Versed/fentanyl you see on patients who are also on paralytics or who are anticipated to remain on the vent for more days and the patient will be deeply sedated. Weaning a patient off versed/fentanyl takes longer and the patient might fail the weaning trials due to too much respiratory depression for hours and hours after turning off the sedation.

delphine22 · Dec 1, 2016

In our MICU we use Precedex almost exclusively for the ETOHers, and they are always awake on it. I've never had someone fully sedated on just Precedex, and if I did I turned it right down, bc they are not tubed.

We love propofol because it works quickly and turns off quickly. The docs in our unit don't favor versed/fentanyl because they take longer to wear off. However if it's a chronic pain pt will will often add a fentanyl drip to propofol to cover their opoids.