Sedation

RASS = Richmond Agitation-Sedation scale - to measure agitation/sedation

  • Frequently RASS goal is 0 to -1
+4 Combative Combative/violent, danger to staff
+3 Very agitated Pulling on lines or aggressive to staff
+2 Agitated Frequent non-purposeful movement, or vent dyssynchrony
+1 Restless Anxious/apprehensive but not aggressive
0 Alert and calm Spontaneously pays attention
-1 Drowsy Awakens with eye contact > 10 seconds to voice
-2 Light sedation Awakens with eye contact < 10 seconds to voice
-3 Moderate sedation Any movement (but no eye contact) in response to voice
-4

Deep sedation

 Movement to physical stimulation, no response to voice
-5 Unrousable No response to voice/physical stimulation

Common sedation agents

Agent Mechanism Dose Indications Adverse effects
Precedex
(dexmedetomidine)

α2 agonist - anxiolytic, sedative, some analgesic

(inhibits NE in locus coeruleus)

 [0.2 - 1.5] mcg/kg/hr

Pts are more rousable and cooperative for neuro exam

No respiratory effects, so suitable for mech. ventilated pts

Bradycardia, hypotension (can be HTN at start of infusion)

Large volume infusion (100cc/hr) - caution with fluid balance
Propofol GABA agonist (anesthetic) [5 - 50] mcg/kg/min Rapid sedation/awakening (short duration) Hypotension
Fentanyl Opioid [50 - 250] mcg/hr Less hypotension  
Versed Benzo - anxiolytic, amnestic [2 - 8] mg/hr Short-term anxiolysis  

Acute agitation:

  • Be as sparing as possible with physical/chemical restraints
  • Treatment of delirium for further reading
  • Typical agents:
    • Haldol 5 mg IM - watch for EPS, long QT (have QTc on monitor and keep Mg > 3)
    • Ativan 2 mg PO - preferred for anxiety-related agitation, not for delirium
author: last edited: Oct. 20, 2018, 10:36 p.m. | pk: 86 | unpublished