No time for high fives…the initial management of mechanically ventilated patients matters! By Dr. Lou Argentine

You’ve just successfully intubated a critically ill patient in the emergency department….the nurse interrupts your celebration by asking if you would like any medications for sedation and/or pain management… does it matter?  YES!

  • Initial goal after intubation: analgesia
    • use quick acting medications such as fentanyl or remifentanil to avoid overmedicating
    • consider bolus adminstration immediately after tube secured
  • May also need low dose sedatives
    • the literature has consistently supported that minimizing sedation provides clinical benefit: fewer days on ventilator, fewer days in ICU, etc.
    • the initial level of sedation after intubation also influences these clinical outcomes, proving the importance of initial pharmacology in emergency department
    • important to remember that there are still indications for deeper levels of sedation: patients receiving neuromuscular blocking agents, status epilepticus, intracranial hypertension, etc.
  • Ordering post sedation medications while ordering RSI medications helps avoid delays and errors in post incubation analgesia/sedation

Bottom-line: minimizing sedation after first focusing on pain management will provide a clinical benefit to your recently intubated patients



  1. Barr, Juliana, et al. "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit." Critical care medicine 41.1 (2013): 263-306.
  2. Devabhakthuni, Sandeep, et al. "Analgosedation: a paradigm shift in intensive care unit sedation practice." Annals of Pharmacotherapy 46.4 (2012): 530-540.
  3. Reade, Michael C., and Simon Finfer. "Sedation and delirium in the intensive care unit." New England Journal of Medicine370.5 (2014): 444-454.
  4. Shehabi, Yahya, et al. "Early intensive care sedation predicts long-term mortality in ventilated critically ill patients." American journal of respiratory and critical care medicine 186.8 (2012): 724-731.