My name is 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, control, power, and influence, making sure your loved one always gets best care and treatment, even if you’re not a doctor or a nurse in intensive care.

Today I have an email from one of our clients, Brett, who asks, 

“Hi Patrik, 

Just chasing up some questions about fentanyl. Why are they using fentanyl and not dexmedetomidine, dexmedetomidine is also known as Precedex? Would there be any reasons?
Does dexmedetomidine have a better profile regarding spontaneous breathing metrics? 

Why would they use fentanyl if she’s in ICU ventilated with a breathing tube for pneumonia, especially when we’re trying to avoid the tracheostomy, and she’s been ventilated with a breathing tube for 25 days now, trying to extubate her. 

Best wishes. 

–  Brett”

This is obviously an excellent and very relevant question for many families in ICU especially when it comes to long-term ventilation, sedation, and weaning from the ventilator and the breathing tube.

So, fentanyl versus dexmedetomidine in ICU. What’s the difference?

Fentanyl is obviously a powerful opioid painkiller that is often used in ICU for pain management and sometimes as part of the sedation regimen. It acts quickly and provides deep pain relief, but one of its main side effects is respiratory depression. Meaning, it can suppress breathing and make ventilator weaning much more difficult.

Dexmedetomidine, also known as Precedex, on the other hand, is a sedative that allows for lighter sedation while maintaining spontaneous breathing. It acts on alpha-2 receptors, not opiate receptors, and patients on dexmedetomidine or Precedex are often more awake, more cooperative, and easier to assess neurologically. This obviously make dexmedetomidine ideal for ventilator weaning and extubation because it supports patient comfort and calmness without suppressing their drive to breathe.

So why is ICU using fentanyl instead? There are several possible reasons.

Number 1 would be pain management. If your mom is experiencing significant pain from pneumonia, some procedures, or prolonged intubation, fentanyl may have been started primarily for pain control, not sedation.

Number 2. ICU protocol or habits. Some ICUs have standardized sedation protocols using fentanyl and midazolam rather than dexmedetomidine or propofol. Unfortunately, this can be a one size fits all approach, often delaying ventilator weaning.

Number 3. Cost and familiarity. Dexmedetomidine is more expensive in the short-term, and some ICU teams are less experienced or less comfortable using it.

Number 4. Unclear sedation goals. In many ICU sedation is clearly overused. Instead of targeting light sedation to promote weaning and extubation, patients are kept deeply sedated, which delays recovery and can lead to unnecessary and preventable tracheostomies.

And you know, also with pain management, for example, there may be no pain management needed if you’re moving towards extubation or if you’re moving towards a tracheostomy, if there is potentially no other option.

So, let’s keep it moving here. Does dexmedetomidine or Precedex have a better profile for breathing metrics?

Yes. Dexmedetomidine or Precedex supports spontaneous breathing, reduces the need for opiates and benzodiazepines, and allows for better neurological assessments. It can significantly improve the chances of successful ventilation, weaning, and extubation.

In a patient who’s been ventilated for 25 days with pneumonia in the breathing tube, and where the goal is to avoid a tracheostomy, switching to dexmedetomidine could absolutely help, provided the patient is hemodynamically stable and there are no contraindications.

So, what can you do next?

You should ask the ICU team what’s the current sedation goal. Why are they using fentanyl and not dexmedetomidine or propofol for lighter sedation and easier weaning? Can they trial dexmedetomidine to assess breathing and neurological function?

You should also insist on a daily sedation interruption, also known as sedation vacation, or spontaneous breathing trials if the goal is extubation. And this, once again, goes again hand in hand with what I’ve been saying here for over 10 years.

That the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask, they don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care.

That’s exactly what Brett is dealing with here. I imagine Brett would have had that information on day 3 or day 4, his mom might be extubated already.

In summary, but it’s never too late either, we can always help you here. If your loved one has been ventilated for over 25 days with pneumonia, the goal is to extubate without a tracheostomy. Fentanyl is not the best choice, most likely for sedation. Dexmedetomidine or propofol can facilitate spontaneous breathing trials, faster weaning, and better neurological recovery.

Always remember, you have the right to question and influence sedation and weaning strategies in ICU. If you need help with ventilator weaning, sedation strategies, avoiding tracheostomy, go to intensive care hotline.com and we can help you from there.

Contact us at intensivecarehotline.com.

I have worked in critical care nursing for 25 years in three different countries, where I worked as a nurse manager for over 5 years in intensive care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care. You can verify that on our intensivecarehotline.com testimonial section and also on our intensivecarehotline.com podcast section where we have done client interviews.

Because our advice is absolutely life changing, it is absolutely life changing. That’s why you can join a growing number of members and clients that we’re helping in intensive care. We’re improving their lives instantly, making sure families in intensive care can make informed decisions, have peace of mind, control, power and influence, making sure their loved ones get best care and treatment always.

Because the biggest challenge for families in intensive care is simply that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights, and they don’t know how to manage doctors and nurses in intensive care. That is exactly what you’re up against.

That’s why I do one on one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to doctors and nurses directly, which I do as well, you would see the dynamics change in your favor very quickly because you have someone on your team that understands intensive care inside out.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time, so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded that only our members have access to.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.