Sedation, Analgesics, and Paralysis for MV Patients

Benzodiazepines Anesthetic agents

Propofol
- Sedative, hypotonic
- No analgesic effects
Diazepam (Valium) - Rapid onset 1-2 min
- Rapid onset 2-5 min - Duration up to 20-30 min
- Long duration 20-120 hrs - Major hemodynamic effects (↓ HR & BP)  ↓ CBF & ICP
- Not commonly used (good for head injuries pts)
- IV dose: 0. 5– 5 mg/kg/hr
Complications:
Prolong use of it  ↑ lipid in the blood (caloric overload)  Hyperlipidemia
Sedatives Ketamine
promote sleep, - Sedative, hypotonic
Lorazepam (Ativan)
reduce anxiety - Slower onset 5-20 min
- Some analgesic effect
and agitation - Duration up to 15-20 min (short term sedation)
- Duration of effect: 10-20 hrs
- Good choice for sedating MV pts longer than - ↓ CV effect + ↓ respiratory depression
24 hrs - Major CNS effects (nightmares, seizure, ↑ CBF & ICP)
- Has bronchodilatory properties (good for asthmatic pts)

Midazolam (Versed) Dexmedetomidine

- Rapid onset 2-5 min
- Duration of effect: 2-6 hrs
- Commonly used for MV pts
- Minimal hemodynamic effect
- IV dose: 0.04 – 0.2 mg/kg/hr
- Sedative
- Analgesic effect
- Duration up to 15-20 min (short term sedation)
- No respiratory depression (useful for awake intubation)
- Significant CV effects (↓HR & BP)

“Flumazenil”
Benzodiazepines
- When overdose of BDZ is suspected, it is given. Also, its competitively bind to GABA and BDZ receptors.
antagonist IV dose: 0.2 – 1 mg, every 20 min to max of 3 mg/hr.
 Opioids
Block )μ( receptors causing analgesia
Block (k) receptors causing sedation
Morphine Fentanyl
Onset: 6-20 mins Onset: 1-2 mins
Duration: 4 hrs Duration: 1 hr
Analgesics
- Most commonly used in ICU for long term
reduce pain - Can cause hypeotension at higher doses - 100X more potent than morphine
(Pain Killers) (include vasodilation) - Faster onset and shorter duration than morphine
- Alter CNS and could cause respiratory - Preferred for quick pain relief during short procedure
depression - Minimal CVS effect (opposite of morphine)
- Release histamine from mast cells - Doesn’t cause histamine release
(should be avoided with asthmatic pts) - IV dose: 0.5 – 1.5 mcg/kg/hr
- IV dose: 0.03 – 0.07 mg/kg/hr
“Narcan (Naloxane)”
- Used for opioids overdose
Opioids antagonist - Short onset of 30 secs, duration 30 mins
- Compete strongly with k receptors, weak at μ receptors
- IV or IM injection: 0.4 – 2 mg
Succinylcholine
Pancuronium
- Onset: 60 sec Vecuronium/ Atracurium/ Cisatracurium
- Slow onset: 4-6 mins
- Short acting in 5-10 mins - Intermediate duration: 30-60
Paralytics - Facilitate ET intubation
- Long duration: 1-2 hrs
- Prolonged paralysis after off mins
paralyze - Dose: 1-2 mg/kg - Most common used paralytic
muscles. Side effects: - Cause ↑ HR & BP (opposite of agents
1- Cardiac arrhythmias Succinylcholine) - Very minimal CV effects
2- Hyperkalemia - ↑ Histamine release
 Diazepam (valium) 2-5 m
Midazolam (versed) 2-5 m
Propofol 1-2 m
Rapid onset Fentanyl 1-2 m
Succinylcholine 60 secs
Narcan/Naloxane 30 secs
Lorazepam (Ativan) 5-20 m
Slower onset Pancuronium 4-6 mins
Diazepam (valium) 20-120 h
Long duration Pancuronium 1-2 hrs
Ketamine 15-20 m
Dexmedetomidine 15-20 m
Short duration Fentanyl 1 h
Succinylcholine 5-10 m
Good for asthmatic Ketamine
Fentanyl
patients
Should be avoided with Morphine
Pancuronium
asthmatic patients
Good for head injuries Propofol
patients
Midazolam (Versed)
Most common Vecuronium/ Atracurium/ Cisatracurium