Sedation in Intensive Care

• Indications for sedation in intensive care need to be defined for each patient, and may include one or more of: anxiolysis, analgesia, agitation control, or to help patients tolerate uncomfortable situations or procedures (e.g. intubation and ventilation).  
• Sedation requirements fluctuate rapidly and warrant regular review. 
• Individualised sedation objectives should be clearly defined, and level of sedation regularly recorded. 
• Sedation protocols that recognise the need for dose minimisation, weaning and sedation interruptions probably improve outcomes.

LoE:II¹⁰

• Adequate pain control is often more efficacious than sedatives for reducing agitation. 
• Delirium should be considered, and managed appropriately. 
• The doses listed apply to ventilated patients in whom short term respiratory depression is not a concern.

Short term sedation (less than 24 hours)

• Midazolam, IV infusion, 0.05–0.2 mg/kg/hour.

OR

• Propofol, IV infusion, 0.5 mg/kg/hour.

LoE:III¹¹

Longer term sedation (expected 72 hours or more)

• Lorazepam, IV, 0.1 mg/kg/hour.

OR

• Midazolam, IV, 0.2 mg/kg/hour.

Note

Lorazepam (0.1 mg/kg/hour) is as effective (and as easy to wean) as midazolam 0.2 mg/kg/hour) but more difficult to titrate. Due to high fat solubility, midazolam also becomes ‘long acting’ after infusions of more than 24 hours.

Supplemental analgesia:

Analgesia can be added to any of the above regimens:

• Morphine, IV infusion, 0.1–0.2 mg/kg/hour.

OR

• Fentanyl, IV infusion, 1 mcg/kg/hour (also becomes long acting after prolonged infusion due to fat solubility.)

LoE:III¹²

Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition