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?

[guest769224]

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.

[Lev, MSN, RN, NP]

Precedex doesn't work on all patients. Also to avoid the hypotension/bradycardia, titrate slowly.

[Julius Seizure]

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. I have seen it used in patients that had lung issues that sometimes made it almost impossible to ventilate them due to muscle spasms, and all the sedation in the world couldn't break the cycle once it started.

Yes, certainly it is important to sedate first - and the nursing staff should be educated on that. But that is just as true with gtts.

Paralytic gtts have downsides - they make a good neuro assessment impossible, they have the potential to prolong intubation by deconditioning the respiratory muscles (and other muscles). In general, the less paralytic use that you can get away with, the better.

I will say, though, that Nimbex is maybe not the best choice for PRN dosing, as it has a relatively long onset of action and if you are using PRN "rescue" doses of paralytic, you probably need it to work faster. We use vecuronium for this, usually.

[Julius Seizure]

We sometimes will also use a morphine/ativan combination. Sometimes, in a patient that has been intubated for a long time and their gtt doses keep needed to be increased, the docs will change them from fentanyl/versed over to morphine ativan just to "reset" (that seems to be their idea). Can't say for sure if it works.

I think sometimes, the sedation gtt of choice comes down to physician preference.

[/username, BSN, RN]

Dex is expensive as ****.

[RescueNinjaKy]

Fentanyl is a narcotic that is used for pain. It also has a synergistic effect with sedatives. Typically a patient should be on a pain control drip in addition to their sedative. It is inhumane to just sedate a patient that is having pain.

Propofol is a powerful drug used for inducting and continuously sedating a patient. It is used for procedures or for keeping vent synchrony. It usually doesn't last too long and the patients will wake up shortly after turning it off, however there are exceptions. In particular, patients who receive high continuous doses of propofol for prolonged periods can wake up slower when finally turning it off. It is recommended to have sedation vacations for patients to help with weaning and to do assessments. With propofol look at their ck and triglycerides to watch out for propofol infusion syndrome. A patient that receives propofol should have an airway(intubated) as they're likely to not breath. In my icu we used rass (Richmond agitation sedation score) from -5(they're completely out and no response) to +4 (they're batshiz cray). Doctors might order titration on propofol for a score of whatever.

versed is benzo that is used for calming down patients and as a sedative. It can be pushed or used in a drip. I have seen versed used in replacement of propofol for patients who have elevated triglycerides or ck(think propofol syndrome). Typically I find that it doesn't work as well as propofol for patients who are in ards and bucking the vent. In the case in which they shouldn't get propofol due to propofol syndrome, they might be indicated for a paralytic. it's been a while but I kind of remember that the patient getting a paralytic drip should be getting pain management (fentanyl) and possibly a sedative (versed) as an adjunct, as you don't want your patient to be in pain and paralyzed. Or in pain and awake and anxious.

For paralytics it paralyzes the patient like the name suggests. I think it's mainly the ards patient that you will see this on. Especially those that will need an oscillator I believe. Since their lungs will be paralyzed, they will definitely need to be ventilated. There's an induction agent like roc/vec and then a maintainence agent (which I don't remember). For the patient being paralyzed you should be doing a train of 4 with your assessment to ensure that they're not under or over paralyzed. The train of four is basically electric shocks that causes their fingers to twitch per shock. If they don't twitch at all then they're probably too paralyzed. If you're getting 4 twitches then it might be under. There's a specific guideline/titration on it usually. Then there's BiS monitoring which kind of measures activity in the brain. DO NOT USE THIS TO SAY THE PATIENT IS BRAIN DEAD (you don't use this for that) if their BiS is high you might want to go up on the sedative and if it's low then lighten it.

Finally precedex, which is used to calm the patient down with a sedative/hypnotic effect. I hardly ever seen it used but it was usually for the agitated delirious patient that we are trying to extubate (like detox/etoh withdrawal).

As a disclaimer, all of this is just off the top of my head and I no longer work icu nor do I remember much about it. The information is just a general way of how I saw things in the icu that I worked (5 months) at, and could absolutely be wrong so don't take this as an absolute. Each icu might do things differently. Some docs have a preferred sedative and pain management drip. I do want to go back to the icu one day but I'm going to be working cath lab instead for now.

[jaicu]

Hmm, I suspect this is different for all authorities but also physicians will

have their preference.

We use propofol primarily as it works quickly, and it works well. It's also incredibly quick to wear off so it is is GREAT in neuro ICU where you need to be able to do sedation vacations to assess their status. Long term use can be liver toxic so there's that problem, but we rarely see it. It's definitely our first line sedative for intubated patients.

Precedex. It works well on non-intubated patients. Patients who are difficult to manage due to anxiety, behaviour, aggression, delirium, seem to get this when we are having a hard time caring for them. We rarely find it works on intubated patients to keep the coughing and discomfort at bay. It also often makes patients profoundly bradycardic and hypotensive. We do run it with propofol sometimes when we are planning on war if the propofol in order to extubate.

Midaz we use mostly as a prn for intubation or agitation, or when propofol is not sufficient to keep people sedated. We don't use it that often as a drip though when we receive patients from smaller centres, they are often on it.

Fentanyl gtt for pain on a variety of patients. We often don't run it when we use propofol, depends on the patient and the likelyhood of pain issues. Ie a trauma would get it, but an influenza is usually good with propofol.

[EllaBella1, BSN]

There's some really good responses in this thread. My 10 cents is that we usually use versed gtts on patients whose BP is not tolerating propofol or whose HR is not tolerating precedex. Also all of our patients who are seizing or are in status typically are put on versed drips, though sometimes neuro requests that we use both versed running at around 2-3 mg/hr plus propofol. We use precedex a lot on our non-intubated patients, and a combo of precedex and fentanyl on our intubated patients. I'd say like 90% of our intubated patients are on fentanyl running at at least 50 mcg/hr- don't forget that propofol/precedex/versed sedate but don't do anything for patient pain.

I also think that PRN push nimbex is kind of crazy. Any time we nimbex someone it's a big setup- Train of four, BIZ monitor, etc. We have pushed Roc for patients who are really dyssynchronous, etc, but if they require more than one dose then they would be put on a nimbex gtt for sure.

[BSN16]

Really? I have patients on this combo all the time with little side effects noted other than occasional hypotension.

Precedex and propofol combo is really great for those patients who arent tolerating coming off of sedation very well. Usually we try to wean off the propofol while increasing the precedex.

[Dodongo, APRN, NP]

Also all of our patients who are seizing or are in status typically are put on versed drips, though sometimes neuro requests that we use both versed running at around 2-3 mg/hr plus propofol.

This is a good point. You can use ativan/versed or propofol (or a combo) for seizing patients. All have anticonvulsant properties.

Also, I work in IR and we have typically mostly used versed and fentanyl for our conscious sedation, however, we are going to start using precedes drips for our longer procedures.

[cdibley]

We use a lot of precedex in my CVICU of course because we want to extubate quickly, if complicated and we know they will be intubated longer than a day we'll add propofol with the Dex, if longer than 24hrs, we'll take off the Dex and add fent. Each intensivist has their preference. Haven't seen a lot Brady episodes with Dex and propofol, usually if we do, we'll back up pace (already have epicardial wires hooked to a box) until Extubated but very rare.

[offlabel]

Dex is expensive as ****.

Not nearly expensive as being intubated in the ICU.