Post-Intubation Sedation

RSI MedsAirway EquipmentPost-Intubation
Core principles
  • Analgesia first. Start an opioid drip (fentanyl) before titrating sedative.
  • Target light sedation (RASS −2 to 0) unless a specific indication for deeper.
  • Match the drug to the physiology — propofol for stable BP, ketamine for shock/asthma, benzo/propofol for status.
  • Anticipate hypotension at induction & shortly after — push-dose pressor at the bedside.
  • Daily SAT (sedation) + SBT (breathing) once stable. Reassess every 4 h at minimum.
  • Confirm delirium-prevention bundle: HOB 30°, oral care, early mobility plan, family presence.
Hemodynamically stable adult

Default post-intubation regimen.

First line
  • Fentanyl drip
    Drip: 25–100 mcg/hr (titrate)
  • Propofol drip
    Drip: Start 20–30 mcg/kg/min, titrate to RASS −2 to 0 (max ~80)
Pearls
  • Always pair an opioid (analgesia) with a sedative (analgesia-first sedation).
  • Target light sedation (RASS −2 to 0) unless deeper indicated.
  • Reassess every 30 min initially.

Hypotensive / septic shock

Avoid propofol — choose hemodynamically friendly agents.

First line
  • Fentanyl drip
    Drip: 25–100 mcg/hr
  • Ketamine drip
    Drip: 0.5–2 mg/kg/hr (start 1 mg/kg/hr)
    Preserves BP, mild sympathomimetic.
Alternatives
  • Midazolam drip
    Drip: 0.02–0.05 mg/kg/hr
    If ketamine contraindicated; cautious — accumulates.
  • Push-dose pressor
    Drip: Phenylephrine 50–200 mcg or epi 5–20 mcg q1–5 min
    Bridge while titrating norepinephrine.
Avoid
  • Propofol bolus or high-dose drip (vasodilation, myocardial depression)
Pearls
  • Resuscitate BEFORE/DURING induction — push-dose pressors ready.
  • Start norepinephrine early; sedation depth follows BP.

Status epilepticus

Sedation that is also anticonvulsant.

First line
  • Midazolam drip
    Load: 0.2 mg/kg IV bolus
    Drip: 0.05–2 mg/kg/hr (titrate to seizure suppression / burst-suppression on EEG)
  • Propofol drip
    Load: 1–2 mg/kg IV
    Drip: 30–200 mcg/kg/min
    Powerful anticonvulsant; watch BP and PRIS at >80 mcg/kg/min >48 h.
Alternatives
  • Ketamine drip
    Load: 1.5 mg/kg IV
    Drip: 1–5 mg/kg/hr
    Refractory / super-refractory status, especially if hypotensive.
  • Pentobarbital
    Drip: Coma induction — ICU only
Avoid
  • Dexmedetomidine alone (not anticonvulsant)
Pearls
  • Continue scheduled AEDs (levetiracetam, fosphenytoin, valproate).
  • Get continuous EEG once intubated — paralysis masks seizures.
  • Avoid long-acting paralytics post-intubation so seizures remain visible.

Head injury / ↑ ICP

Maintain CPP; avoid agitation, hypotension, hypoxia, hypercapnia.

First line
  • Fentanyl drip
    Drip: 25–150 mcg/hr (analgesia first)
  • Propofol drip
    Drip: 20–60 mcg/kg/min
    ↓ CMRO₂, ↓ ICP. Maintain MAP ≥ 80 (CPP ≥ 60).
Alternatives
  • Ketamine drip
    Drip: 1–2 mg/kg/hr
    Modern data: safe in TBI, may ↓ ICP. Use if BP marginal.
Avoid
  • Excessive midazolam (delays neuro exam, accumulates)
Pearls
  • HOB 30°, normocapnia (PaCO₂ 35–40), SpO₂ ≥ 94%, MAP ≥ 80.
  • Hypertonic saline / mannitol for herniation signs.
  • Brief sedation holds for serial neuro exam if safe.

Severe asthma / status asthmaticus

Bronchodilation + deep sedation + permissive hypercapnia.

First line
  • Ketamine drip
    Load: 1–2 mg/kg IV
    Drip: 1–3 mg/kg/hr
    Bronchodilator; preserves drive.
  • Fentanyl drip
    Drip: 50–150 mcg/hr
Alternatives
  • Propofol drip
    Drip: 30–80 mcg/kg/min
    Mild bronchodilation; watch BP.
  • Cisatracurium drip
    Drip: 1–3 mcg/kg/min
    Only if dyssynchrony despite deep sedation. Steroid co-treatment ↑ myopathy risk.
Avoid
  • Morphine and atracurium boluses (histamine release)
Pearls
  • Vent: low RR (8–10), Vt 6 mL/kg IBW, long expiratory time, permissive hypercapnia (pH ≥ 7.15).
  • Continue β-agonists, steroids, magnesium.
  • Watch for breath stacking / auto-PEEP — disconnect circuit if sudden hypotension.

ARDS / lung-protective ventilation

Deep sedation early to tolerate low-Vt, then lighten quickly.

First line
  • Fentanyl drip
    Drip: 50–200 mcg/hr
  • Propofol drip
    Drip: 20–80 mcg/kg/min
Alternatives
  • Cisatracurium drip
    Load: 0.15 mg/kg IV
    Drip: 1–3 mcg/kg/min × 48 h
    Severe ARDS (P/F < 150) with dyssynchrony.
  • Ketamine drip
    Drip: 1–2 mg/kg/hr
    Adjunct to reduce propofol/fentanyl needs.
Pearls
  • Daily SAT / SBT once stable; avoid over-sedation.
  • If paralyzed, MUST be deeply sedated — RASS −5.
  • Prone positioning for refractory hypoxemia.

Post-arrest / TTM

Sedation + analgesia + shiver control.

First line
  • Fentanyl drip
    Drip: 25–100 mcg/hr
  • Propofol drip
    Drip: 20–50 mcg/kg/min
Alternatives
  • Midazolam drip
    Drip: 0.02–0.1 mg/kg/hr
    If hemodynamically marginal.
  • Cisatracurium boluses or drip
    Drip: 0.15 mg/kg or 1–3 mcg/kg/min
    For shivering refractory to meperidine/Mg/buspirone.
Pearls
  • Target temperature 32–36 °C × 24 h per local protocol.
  • Avoid prolonged neuromuscular blockade — masks seizures and exam.
  • Continuous EEG; up to 25% of post-arrest have non-convulsive seizures.

Pregnancy

Most agents acceptable short-term post-intubation.

First line
  • Fentanyl drip
    Drip: 25–100 mcg/hr
  • Propofol drip
    Drip: 20–50 mcg/kg/min
Alternatives
  • Ketamine drip
    Drip: 0.5–2 mg/kg/hr
    Avoid in severe pre-eclampsia (BP).
Avoid
  • Prolonged benzodiazepines if delivery imminent (neonatal sedation).
Pearls
  • Left lateral tilt if > 20 weeks.
  • Maintain MAP ≥ 65; uterine perfusion follows maternal BP.
Drip reference (adult)
DrugClassDrip doseBPNotes
PropofolSedative-hypnotic5–80 mcg/kg/min (start 20–30)↓↓ BPFast on/off; ideal in stable BP. Watch TG, PRIS.
KetamineDissociative0.5–2 mg/kg/hr (start 1)Neutral / ↑Best in shock, asthma, status epilepticus. Bronchodilator.
MidazolamBenzo0.02–0.1 mg/kg/hr↓ BP (mild)Active metabolite — accumulates with renal/hepatic failure.
Dexmedetomidineα2-agonist0.2–1.4 mcg/kg/hr (no load in ED)↓ BP, ↓ HRLight sedation; not for deep sedation alone.
FentanylOpioid25–200 mcg/hr (0.5–3 mcg/kg/hr)NeutralPair with sedative. Chest wall rigidity at high bolus.
HydromorphoneOpioid0.5–3 mg/hrMild ↓Alternative to fentanyl, longer-acting.
RASS targets
  • RASS 0: alert, calm — most stable patients.
  • RASS −1 to −2: light sedation, drowsy but rousable — default goal.
  • RASS −3: moderate sedation — short-term tolerance of vent.
  • RASS −4 to −5: deep / unrousable — needed for paralysis, status, severe ARDS, ↑ICP.
Push-dose pressorsRSI medsBiPAP / CPAP

Educational reference only. Doses are typical adult ranges — verify with institutional protocol and pharmacy.