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Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from our readers and the question was
My Dad is in ICU Ventilated with Tracheostomy. Will it Be Safe to Move Him Out to LTAC?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED”, I I am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all time. And today’s live stream is about, My Husband’s in ICU in an Induced Coma on Midazolam, He’s Not Waking Up, Should He Have Propofol?
My Husband’s in ICU in an Induced Coma on Midazolam, He’s Not Waking Up, Should He Have Propofol?
Welcome to another Intensive Care Hotline and Intensive Care at Home livestream. Good evening to our viewers in the United States and North America. Good morning to our viewers in Australia and New Zealand. I don’t know whether we’ll have anyone here from the U.K. today or from Ireland. It’s in the middle of the night there. Nevertheless, welcome to today’s livestream.
Today’s livestream is about, “My husband’s in intensive care in an induced coma on midazolam. He’s not waking up. Should he have propofol instead?” That’s what I want to focus on today, on different sedatives in ICU. Obviously, this is a question that we get quite frequently if people have done a little bit of research. I mean, many families in intensive care are oblivious to the things that are happening. They are oblivious to the questions they should be asking. Obviously, this reader has done some research in order to even get to that question. It’s a very intelligent question to ask and it’s a question that many clinicians in ICU ask as well.
Now, before I go into today’s topic, just a few housekeeping issues. Please type your questions into the chat pad. Keep them to today’s topic, if you can. If they are not on today’s topic, please type them in anyway and I’ll get to them towards the end of the presentation.
Before I go into today’s topic, I just want to make a quick introduction about myself. You might wonder what makes me qualified to talk about this topic. I have worked in intensive care for over 20 years in three different countries. Out of those more than 20 years, I have worked as a nurse unit manager in intensive care for over five years. I have also been an in-charge nurse on shifts. I have been consulting and advocating for families in intensive care all around the world since 2013 as part of my intensivecarehotline.com blog. I also own and operate a service, Intensive Care at Home, where we look after predominantly long-term ventilated intensive care patients, where we bring the intensive care into the home. That’s a little bit about me.
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Let’s dive into today’s topic. Reader writes, “My husband’s in intensive care in an induced coma on midazolam. He’s not waking up, should he have propofol?” Especially for our viewers in North America, midazolam is also known as Versed. You might have heard of Versed instead of midazolam. The terms are interchangeable. It’s just one is the generic name, one is the brand name. At the end of the day, it’s the same medication that we are referring to.
Now, let’s just set the scene here. When someone is in intensive care on a ventilator with a breathing tube or an endotracheal tube, they are going into an induced coma. First-line sedative is often propofol and which goes hand-in-hand with fentanyl or morphine. Those are standard sedatives and opiates in intensive care for an induced coma. Also, when patients come back from surgery to intensive care, they’re often sedated with propofol and fentanyl or morphine. Fentanyl or morphine, obviously the pain medicine also known as opiates.
Then, if someone stays in an induced coma for a few days and the propofol has undesired side effects such as hypotension, which means low blood pressure, if someone is not responding favorably to propofol, which means they might be having high doses depending on their weight. For someone with 60 or 70 kilos, you might be okay with 100 milligrams an hour of propofol. For someone with 100 kilos, you might be needing 200 milligrams an hour of propofol in order to sedate them.
Now, again, one of the main side effects of propofol is hypotension or low blood pressure. If that is the case, you have to counteract that in intensive care. You have to counteract that with what’s known as inotropes or vasopressors. They’re a classification of drugs that maintain a blood pressure that’s sustainable with life. If the propofol is inducing low blood pressure, that’s not sustainable with life, you have to start inotropes or vasopressors such as norepinephrine, epinephrine, vasopressin, Levophed, or noradrenaline, adrenaline, then you’re having a problem on the other side. That combined with issues such as after surgery you might have bleeding or after a trauma, you might have bleeding, and that could cause low blood pressure as well.
The combination of propofol and for example bleeding could quite quickly spiral out of control where blood pressure is dropping to a dangerously low level and then you have to start those inotropes or vasopressors. You have to keep blood transfusions and so forth.
Then the question is being asked, should you start using midazolam? When midazolam is being used, it’s often for long-term sedation. Propofol is often short-term acting whereas midazolam is more for long-term sedation, but it also comes with undesired side effects.
Let’s just say that someone needs at least seven days of an induced coma, you might consider using midazolam because on the one hand, you can use less of it compared to propofol. You can just use maybe 5 mls an hour, which is 5 milligrams an hour. That might be sufficient to keep a critically ill patient safely in an induced coma.
When someone is on propofol, because it’s short-term acting, when you wake them up, patients should wake up very quickly. Whereas on the other hand, if you use midazolam and you stop it, patients do not wake up immediately because it’s long-term acting and the half-life is much higher. It stays in the body system for much longer. Therefore, you’re not getting a quick wake-up time.
If you’ve done enough research, you would know by now that the longer someone stays in an induced coma, the more undesired side effects there are, such as deconditioning, muscle wastage, confusion, delirium, ICU psychosis, and the list goes on. Whereas if you’re using propofol and you stop the propofol, critically ill patients should wake up pretty quickly. That doesn’t mean they’re not going to be confused.
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When you wake someone up from an induced coma, you can often see confusion, aggression, and agitation. You can still see ICU delirium or ICU psychosis depending on how long someone has been in an induced coma for, or if there are other complications. Maybe someone is going through withdrawal when they’re waking up, maybe they’ve taken drugs beforehand, maybe they were abusing alcohol beforehand. There are all sorts of situations that could contribute to confusion, aggression, when someone is waking up after an induced coma that you might observe.
There are situations where midazolam is clearly preferred over propofol, for example, when someone is coming into ICU with multiple traumata. They might be having rib fractures, they might be having leg fractures, they might even have a traumatic brain injury. Then midazolam can be the preferred sedative over propofol simply because you don’t get the hypotension or the low blood pressure that you get with propofol.
If someone is coming in with multiple trauma, they are prone to hypotension or low blood pressure to begin with, therefore, you might start off with a midazolam infusion instead of the propofol. Again, midazolam, the other term that it’s being known as is Versed. Again, Versed is the term for midazolam that’s being used mainly in North America.
Other situations where midazolam might be the better option is when patients have a traumatic brain injury . ICPs (intracranial pressures) are monitored, intracranial pressures are monitored because the brain had a traumatic injury. If that is the case, midazolam is often being used over propofol because it’s just a smoother sedative to use when it comes to those situations where patients have traumatic brain injuries with an intracranial pressure monitor in the brain where you might have to look at things such as giving a mannitol infusion. You might have to look at things like giving hypertonic saline. You might have to look at things such as venting and extra ventricular drainage or extra ventricular drain and that is where you might see midazolam being used over propofol.
Should midazolam or Versed be changed to propofol as soon as you can? I would argue yes, because it takes a lot longer for patients to wake up after midazolam or Versed. Again, the half-life is a lot longer and again, it stays in the body system for much longer. Therefore, the sooner you can wean off midazolam, the better it is.
Now, here is another issue with midazolam or Versed. Midazolam or Versed is classified as a benzodiazepine. I don’t know how much you know about benzodiazepines such as lorazepam, temazepam, diazepam, also known as Valium, those drugs are all classified as benzodiazepines.
One nature of benzodiazepines is simply it’s addictive. If a patient is on a midazolam infusion for many days to keep them in an induced coma, you don’t want to just switch off the midazolam or the Versed like you can with the propofol, and someone is going to wake up quickly. When you switch off the midazolam or Versed, especially after long-term use, patients might go through withdrawal because again, benzodiazepines are addictive in nature.
How can you counteract that? One way to reduce or take off midazolam or Versed to get someone out of an induced coma is simply by weaning it off. If someone is on 10 milligrams an hour of midazolam for many days, maybe you turn it down to 8 milligrams an hour and then the next day you turn it down to 6 milligrams an hour and the next day you turn it down to 4 milligrams an hour. The next day you turn it down to 2 milligrams an hour and then you switch it off. Hopefully then patients won’t go through massive withdrawals.
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There are strategies in ICU how you can manage withdrawal from a medication. The same applies to morphine or fentanyl. They’re highly addictive opiates and the same applies there. You can now see why you want to minimize sedatives in intensive care as much as you can.
Other things that are important to know when it comes to using midazolam versus propofol in ICUs, and I have seen patients going into ICU for example, with a drug addiction, with an alcohol addiction and we often have found that if you start them on propofol, it may not be enough. You may have to use midazolam instead. It is the better drug in those situations from my experience.
Then once you’ve got the addiction and the withdrawal under control, then you can slowly reduce the midazolam and then, maybe you can introduce propofol instead of midazolam. There are also situations where you need to use both midazolam and propofol, again, probably more like when it comes to trauma in ICU, when it comes to traumatic brain injuries in ICU. I’ve seen many times where you actually need to use both to keep a patient under sedation so that they can tolerate the ventilation and the breathing tube.
There is research out there that suggests that the longer and the more midazolam or Versed you use, the less likely it is that a patient gets discharged home eventually. That is certainly concerning to see, but I’m also not surprised to see that this research is confirming that because it’s just a long-term sedative, even if you stop midazolam or Versed today, patients often don’t wake up as quickly as they do with propofol.
If they don’t wake up, then there are delays in recovery. There are delays with physiotherapy, there are delays with mobilization. As I’ve been saying over and over again, the longer someone is in an induced coma and is not being mobilized, the deconditioning happens very quickly. There is muscle wastage. When people wake up, eventually, there’s a higher chance that people are having or going through agitation, are being confused, are being delirious, or have ICU psychosis. You want to avoid that at all costs. The long-term damage from a long-term ICU stay is huge and therefore, as much as you can shorten the time spent in an induced coma under sedation, the better it is for all parties involved.
There’s also studies out there that suggests that if you are using propofol over midazolam, that ventilation time can be reduced. Again, I’m not surprised there at all, because it takes longer for patients to wake up after they have midazolam versus propofol.
You have someone on 100 milligrams an hour of propofol for two days, you switch off the propofol, assuming that kidneys and liver are working, those patients can wake up, I’d say within less than an hour, sometimes even less. Whereas you do that with midazolam and there are often delays because the half-life is much longer. Again, it’s a long-term acting sedative. Propofol it’s a short-acting sedative.
Same with time to extubation. There are studies out there that if propofol is being used versus midazolam or Versed, the time from intubation, breathing tube in to breathing tube out is shortened in comparison to midazolam or Versed.
Now, so in order to answer our reader’s question, “My husband is in ICU in an induced coma on midazolam or Versed. He’s not waking up, should he have propofol?” Absolutely, if it can be facilitated, if your husband is not addicted to alcohol, if he’s not addicted to drugs, if he doesn’t have a traumatic brain injury, where ICPs or intracranial pressures or brain pressures need to be monitored and managed. You haven’t shared with me what your husband’s condition is, but as a rule of thumb, yes.
Let’s just say your husband is in ICU with pneumonia, should he be changed from midazolam to propofol? My answer would be a clear yes if it’s a ‘straightforward’ situation where pneumonia needs to be managed with antibiotics and there’s no other issues happening. For example, you take a COVID pneumonia, someone might need to be proned, might need to go into prone position, that’s when you would most likely use midazolam as opposed to propofol. It always depends on the situation, what should be used in terms of a sedative.
Now also, other studies have shown that I mentioned that propofol shortens the time from intubation to extubation and it also shortens the time when it comes to removal of a tracheostomy, removal of tracheostomy, decannulation. I’ll tell you what I’ve seen over and over again to illustrate everything that I’ve been saying. Someone is in the prolonged induced coma in ICU, especially with midazolam. They’re then having a tracheostomy for example, and they continue mechanical ventilation on the tracheostomy.
A lot of patients wake up being confused. One of the main major advantages of a tracheostomy is that you can stop sedation. One of the main reasons sedatives are being used or opiates are being used is simply that if someone has a breathing tube down their throat, it’s so uncomfortable, people need to be induced into a coma. Once someone has a tracheostomy, sedatives and the opiates can be stopped, assuming there is not multiple trauma that need to be managed with an induced coma that don’t need to be managed with opiates. Assuming it’s a straightforward tracheostomy, stop sedation.
Then if someone is on propofol, they wake up pretty quickly. If someone is on midazolam, they may not wake up very quickly. Again, patients on midazolam or Versed may go through withdrawal from the drug and that needs to be managed too. Clearly studies have shown that the time from intubation to extubation is shortened on propofol as opposed to midazolam and that the time to discharge ICU… Not to discharge ICU, but to discharge home is also shortened with propofol.
It looks like the mortality rate for patients on midazolam or Versed is also higher compared to propofol. That’s probably because the conditions when midazolam or Versed is being used are probably having a higher acuity compared to the conditions where propofol is used. I’m not overly surprised to see that.
Another option when someone is in an induced coma and the questions are being raised whether one should use propofol versus midazolam is also whether there are other options besides the propofol and the midazolam.
Now, there is now a third option. It’s called dexmedetomidine, also known as Precedex. Basically, Precedex is a combination of the two. It’s a combination of sedative and an opiate. In theory, if you have a patient on propofol and fentanyl, you can change that to dexmedetomidine or Precedex. Dexmedetomidine and Precedex has sedative effects, and it also has opiate effects. In theory, you’re killing two birds with one stone.
Does it always work? What I’ve seen over the years is you take someone from propofol and fentanyl over to dexmedetomidine to assist them in waking up. For some patients it works like a treat and for others it doesn’t work at all. In my experience, I can’t speak about other people’s experience, but I haven’t been a huge friend of the Precedex. If it works, I think it’s fantastic.
I would argue that if it does work, waking up is quicker, but I just haven’t seen it work with all patients. Same is applicable when you have a patient on midazolam, Versed, and fentanyl or morphine and you change it over to Precedex, again, it might certainly assist in the waking up process and also managing a potential withdrawal from midazolam or from managing a withdrawal from morphine or from fentanyl because dexmedetomidine or Precedex also has clonidine in it and clonidine has been used in the past to manage withdrawal situations in ICU.
That’s the quick overview, and I might in the future do an episode about a live stream about comparing propofol, midazolam, and dexmedetomidine, combine the three together. I think it’s still standard at the moment to start off with propofol and midazolam in combination with fentanyl or morphine. The dexmedetomidine, even though it’s been around now for over 15 years, it’s sort of still making its way into mainstream ICU. I think it is way more mainstream than it was 10 years ago, but I think it’s still not quite mainstream yet.
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Now, I want to open up the floor for any questions, whether they are related to today’s topic or whether they’re related to any other questions you might have about ICU. I would welcome any questions. While I’m waiting for you to type them into your chat pad, I also want to let you know that I’m doing those live streams regularly. I’m doing them every Saturday at 8:30 PM Eastern Standard Time, which is 5:30 PM Pacific Time, which is 10:30 AM on a Sunday, Sydney, Melbourne time, and it’s in the middle of the night in the U.K. unfortunately. If you have any topics that you would like me to talk about on those live streams, please, you can email them to me at [email protected].
You can also leave a comment below the videos, and you can type in there what you want me to talk about. I’m always open to suggestions and I always want to make it around what you want to know.
If there are no questions today, and that is absolutely fine, I want to thank you for coming onto the live stream today. I want to thank you for your support. I haven’t got next week’s topic yet, but I do have so many topics that I want to talk about that I will be having something that is client-centric, that someone has emailed me or a client that we worked with. There will be something that is highly relevant for families in intensive care.
Sometimes I also do the live streams about Intensive Care at Home. You can check out intensivecareathome.com for more information there. If you have a loved one in intensive care that you think should go home rather than staying in intensive care, you should definitely check out intensivecareathome.com.
I do also offer one-to-one consulting and advocacy where you can have time with me over the phone via Zoom, via Skype, via email. I do that for a fee and if you are interested, just send me an email again to [email protected] and I can send you my fees. I can send you my options. We also have a membership for families of critically ill patients in intensive care where you have access to me in a membership area or via email. I have several options how you can access me.
You can also call me on one of the numbers on the top of the website, intensivecarehotline.com. You can get me directly there and then we can look into your loved one’s situation and how I can help you.
If you like this video, give it a thumbs-up. Subscribe to my YouTube channel for updates for families of critically ill patients in intensive care. Comment below what you want to see next, or what questions or insights you have, and click the notification bell.
I guess today, there are no questions.
I wanted to thank you for joining this live stream and I will see you all again next week at the same time. Watch out for the announcement this week what the live stream will be all about.
Thank you so much and have a wonderful weekend and I wish you and your families all the very best.
Take care.
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