Sedation Titration in Critical Care

Topic Progress:

Sedation Reduces Oxygen Demand by Decreasing Metabolic Demands

Sedation is primarily used to reduce oxygen demand (gray boxes).

Why Sedate?

  • COVID-19 causes hypoxemia, reducing oxygen supply.
  • The immune response increases metabolic demands causing increased oxygen demand.
  • This causes an imbalance of oxygen supply (from COVID-19) and oxygen demand (from the immune response).

Side Effects

  • Hypotension
  • Decrease respiration rate
  • Indirectly cause other problems, such as prolonged ICU stay, ileus, delirium among others

How to Titrate

  • Start low and go slow
  • Wait 15 minutes after each change to evaluate change in dose
  • Always change the DOSE of sedation medication – not the rate

Let’s Practice

55 year old patient admitted with respiratory failure secondary to COVID-19. They are intubated and mechanically ventilated.

A physician has written an order for Propofol 0-50 mcg/kg/min IV infusion prn for RASS goal -1 to keep the patient lightly sedated.
  • Does this order seem appropriate to the situation?
  • Does the medication ordered seem safe for the patient?
  • Assess the patient to see if the medication is needed.

  • Calculate the patient’s RASS score.
  • Start infusion.
  • Start low, and go slow.
  • Reassess your patient q5min prn until your goal is achieved
  • Stop infusion if the patient does not tolerate it (eg. hypotension).

72 year old admitted to ICU for hypoxemia and is intubated and mechanically ventilated. He has improved to the point where he only requires low amounts of oxygen. The patient is cooperative. All vital signs are normal. The physician states that he would like to get the patient “weaned off the ventilator” and transferred out of ICU. The patient is currently on sedation of Propofol 20 mcg/kg/min IV infusion. RASS is -1.

The physician writes RASS goal 0.
  • Does this order seem appropriate?
  • Does the medication ordered seem safe for the patient?
  • Assess the patient to see if the medication is needed.
  • Calculate the RASS score.
  • Slowly and methodically decrease the sedation infusion.
  • Assess the patient for 10-15 minutes after each change.
  • If the patient does not tolerate decreased sedation (eg. hypoxic, tachypneic), stop, re-assess and increase infusion back to previous rate if needed.
  • Always talk to your patient to comfort and reassure.

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