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.


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


  • Etomidate or ketamine


  • 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.




Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

One thought on “Sedation Guidance for Intubated COVID Patients”

  1. Great information as usual. A few words on dexmedetomidine and respiratory depression below.

    The traditional thinking that dexmedetomidine does not lead to respiratory depression may need to be re-evaluated based on the results of recent studies. At equi-sedative doses, dexmedetomidine and propofol exhibit similar degrees of pharyngeal collapsibility and reductions in ventilatory drive. When dose adjusted, dexmedetomidine does not offer increased protection against upper airway obstruction or ventilatory depression when compared to propofol. Further, light to moderate sedation with dexmedetomidine or propofol in adult volunteers caused similar reductions in ventilatory responses to hypoxia and hypercapnia with either drug.

    Lodenius Å, Maddison KJ, Lawther BK, et al. Upper Airway Collapsibility during Dexmedetomidine and Propofol Sedation in Healthy Volunteers: A Nonblinded Randomized Crossover Study [published correction appears in Anesthesiology. 2019 Dec 16;:null]. Anesthesiology. 2019;131(5):962–973. doi:10.1097/ALN.0000000000002883

    Lodenius Å, Ebberyd A, Hårdemark Cedborg A, et al. Sedation with Dexmedetomidine or Propofol Impairs Hypoxic Control of Breathing in Healthy Male Volunteers: A Nonblinded, Randomized Crossover Study. Anesthesiology. 2016;125(4):700–715. doi:10.1097/ALN.0000000000001236

    Liked by 2 people

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