You deftly sweep the tongue aside, slide into the vallecula, lift the epiglottis, and have a great view of the cords. You smoothly pass the tube, secure it, and walk away – a superstar. Meanwhile your nurses wonder “what now?” as your patient begins to wake up pulls their ET tube out. Your job is not over after intubation – here we will go over how to keep your patients comfortable and safe with appropriate sedation and analgesia.

Post-intubation Analgesia:

  • Being intubated is painful. So, all intubated patients should receive analgesia. 
  • Analgesia might be more important than sedation; in studies comparing analgesia-only to standard sedation, patients in the analgesia-only arm had better outcomes.
  • Practically speaking:
    • Use a pain scale validated in intubated patients (eg: Critical-Care Pain Observation Tool).
    • User your preferred IV opioid.
    • Boluses initially, and then start an infusion.
    • Remember to give boluses for painful procedures (eg: suctioning, wound exploration, repositioning, etc).
  • For agitation/restlessness: titrate analgesia first, before increasing sedation. 

Post-intubation sedation: avoid benzodiazepines!

  • Benzodiazepines don’t work as well as an infusion, as their half-lives increase significantly as the duration of infusion increases.
  • Patients sedated with benzodiazepines had worse outcomes, including more days intubated, and more days in the ICU, when compared to patients sedated with other agents.
  • Good alternatives include; Propofol and Etomidate.

Post-Intubation sedation: light sedation

  • In the ICU, light sedation resulted in better outcomes than deep sedation, and was at least as good as daily sedation vacations.
  • A recent study suggested that deep sedation within 4 hours of intubation was an independent predictor of increased mortality. Thus, our initial ED management has a larger impact than we likely perceive.
  • Use a validated sedation scale; ideally patients should wake easily to verbal stimulus but remain calm.
  • Important exceptions include patients with: increased ICP, status epilepticus, ongoing paralysis, or patients undergoing transportation to another facility. These populations should all likely receive deep sedation.

Take home points:

  1. All intubated patients should receive analgesia.
  2. Titrate analgesia first, then add sedation.
  3. Avoid benzodiazepines for post-intubation sedation.
  4. Target light sedation in the majority of patients.
Dr. Dewhirst is a 4th year Emergency Medicine resident at the University of Ottawa with a special interest in medical education and patient safety/quality improvement. 
Edited by Dr. Shahbaz Syed, 4th year Emergency Medicine resident at the University of Ottawa.