Section 12. Critical Care

Pretreatment (not routinely indicated)

Lidocaine

100 mg

Elevated ICP

Protects from elevated ICP

Fentanyl

2–3 μg/kg

Elevated ICP, CVD

Decreases catecholamine surge

Induction

Etomidate

0.3 mg/kg

Emergency RSI

May cause adrenal insufficiency

Ketamine

1.5 mg/kg

RSI in patients septic or with reactive airways

Caution in CVD and in hypertensive patients. May pretreat with atropine

Propofol

1.5 mg/kg

RSI with reactive airway or status epilepticus

Negative effects on CV system; bolus dosing may cause hypotension

Midazolam

0.2–0.3 mg/kg

Alternative for RSI

Variable response

Paralytic

Succinylcholine

1.5 mg/kg

Agent of choice for RSI

Avoid in patients with hyperkalemia

Rocuronium

1 mg/kg

RSI when succinylcholine contraindicated

Duration up to 60 min; activity prolonged in patients with hepatic failure

Vecuronium

0.15 mg/kg

Used when succinylcholine and rocuronium not available

Duration up to 60 min; priming dose of 0.01 mg/kg give prior to RSI dose; activity prolonged in patients with renal and hepatic failure

Propofol

5–20 μg/kg/min

5 μg/kg/min Q 5 min

Max rate 50 μg/kg/min (institutional dependant); adverse effects: hypotension, high lipid content (1.1 kcal/mL), myocardial depressant. Sulfites in some formulations

Midazolam

1 mg/h

1 mg/h Q 15 min

CYP 3A4 interactions; benzyl alcohol in injection

Lorazepam

0.5 mg/h

0.5–1 mg/h Q 15 min

Propylene glycol and polyethylene glycol in injection. Reduce dose by 50% with concomitant valproic acid use. Use caution with renal and hepatic impairment

Dexmedetomidine

0.4 μg/kg/h

0.1 μg/kg/h Q 15 min

Max rate 0.7 μg/kg/h; dose-related bradycardia and hypotension; add adjunctive midazolam. FDA indicated for 24-h use; data available for 5-day use

Morphine

1 mg/h

1 mg/h Q 1 h

Prolonged activity in renal failure, hypotension, bronchospasm

Hydromorphone

0.2 mg/h

0.2 mg/h Q 1 h

Prolonged activity in renal and hepatic failure, hypotension

Fentanyl

25 μg/h

25–50 μg/h Q 15 min

Not prolonged in renal failure, chest wall rigidity with high-dose infusions