Re: Sedation vs. sedation/paralysis

["david lichtman" <davidlichtman@medscape.com>]

Scott brings out a very interesting point in regards to 
heavy sedation versus continued paralysis.  This has worked 
very well in numerous populations over the years, not just 
with pediatric patients.  Most patients, not all, are 
managed quite successfully with the use of sedatives 
without prolonged use of neuromuscular blocking agents.

As far as etomidate is concerned, it has a very good 
profile; however, patients vary and so do their clinical 
conditions.  This means that there is no one 
single "cocktail" that is ideal for initiating and/or 
maintaining all (or even most) patients.  There are 
numerous good sedatives available for use, and some of them 
provide excellent sedation without the possiblity of 
myoclonic activity, the need for refrigeration (as per 
manufacturer's instructions), or depressing cortisol 
levels.  For example, propofol has a very rapid onset (9-30 
sec.), relatively short duration of action, can be 
constantly infused for prolonged sedation, is able to be 
easily titrated to the patient's needs, can be stored at 
room temperature, can sit on the shelf with other non-
scheduled medications, and is cerebral protective in 
regards to seizures.  Ketamine is wonderful in the patient 
with severe bronchospasm.  Thiopental has been around 
forever and can be mixed on an as needed basis.

There are many others available as well, and all have their 
positive and negative attributes.  Pick meds based on 
patient needs and medication profile; so carry a few 
choices so you can appropriately treat all of your 
patients, not just some of them.

Sorry so preachy,
David

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