Sedation Guidance for Intubated COVID Patients

Today’s pearl provides some advice to more safely and efficiently intubate and sedate COVID patients.

Should they be treated differently than other intubations?

As you may be aware, post-intubation sedation has been quite challenging in COVID patients. After conferring with our EM and critical care physician and pharmacist colleagues, we have drafted interim recommendations that seem to work in most patients at our institution. Please note that any and all COVID recommendations are subject to change as we learn more about the disease and its management.

Pre-Induction

• Consider starting low-dose norepinephrine prior to intubation, or at least have it ready to go
• Have phenylephrine push-dose at the bedside

Induction

• Etomidate or ketamine

 PLUS

• Midazolam

Neuromuscular Blockade for RSI

• Rocuronium or succinylcholine

Post-Intubation Sedation

• Fentanyl infusion + propofol infusion
• Consider midazolam infusion if fentanyl + propofol is not sufficient

Post-Intubation Paralysis (when indicated)

• Vecuronium intermittent pushes
• Cisatracurium infusion

Important Notes

1. The addition of midazolam to RSI will provide sedation beyond the duration of effect of etomidate or ketamine and allow initiation and titration of continuous infusion sedatives and opioids.
2. We recognize we recently moved away from fentanyl infusions in favor of intermittent hydromorphone. However, we adding them back during COVID to minimize time going in and out of the room and provide a consistent level of pain control and sedation. These patients are getting hypotensive, in part due to the need for rapid propofol titration. If we can optimize fentanyl first and keep propofol at a middle-of-the-range dose, we may avert some of the hypotension. Midazolam during RSI should also help.
3. Fentanyl dosing should start at 1 mcg/kg/hr (generally 75-100 mcg/hr for most patients). We generally use up to 200 mcg/hr, but can allow higher doses if needed.
4. Titrate norepinephrine and add additional vasopressor support (e.g., vasopressin) as needed.
5. Dexmedetomidine has no respiratory suppression, so it is NOT ideal to foster synchrony with the low tidal volume ventilation required for ARDS patients.

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