Nearly 400,000 patients per year undergo mechanical ventilation in the emergency department (ED).¹ An older report indicated that 2.8 percent of patients in the United States received mechanical ventilation following hospitalization, with a mortality rate of 3.5 percent.² Further, hospital and ED overcrowding has led to the boarding of critically ill patients in the ED waiting for ICU beds.³ Additionally, safety outcomes have historically been poorly reported in the post-intubation state, such as unplanned extubation and recall of events or awareness during paralysis.

For the purposes of this review, we shall discuss specific agents with complications only related to the medications themselves. Awareness with paralysis, length of hospitalization, and post-traumatic stress and cognitive dysfunction are outside the scope of this discussion. Some of these agents are more closely associated with post-intubation hypotension, which will be a topic of a future review.⁴

The Problem

Patients undergoing rapid sequence intubation (RSI) are at risk of being paralyzed without adequate post-procedural sedation and analgesia. The neuromuscular blocking agents most commonly employed in the emergency setting are rocuronium and succinylcholine. Literature suggests that patients paralyzed with succinylcholine receive post-intubation sedation more quickly than those paralyzed with rocuronium: median time to sedation was 9 minutes versus 14 minutes in one cohort study.⁵ Intubated and paralyzed patients who are under-sedated may be exposed to noxious stimuli, pain from invasive procedures, and a persistent gag reflex from the endotracheal tube. Given that patients who experience awareness with paralysis may develop post-traumatic stress disorder, depression, and complex phobias, the importance of sedation in this setting is underscored.⁶

Medications Employed

The medications used for post-intubation sedation vary widely. Propofol was the most commonly reported medication in one review, followed by benzodiazepines (most commonly midazolam), and opioids (most commonly fentanyl). Other agents reported in that review included ketamine, dexmedetomidine, etomidate, barbiturates, and antipsychotics. Studies have used various terms such as sedation, analgesia, analgosedation, and anxiolysis.⁷ What is clear is that medications for post-intubation sedation should be planned for and administered in a timely way (immediately) post intubation.

In this review, we shall examine the dosing and advantages of each respective agent, with the caveat that etomidate’s usefulness is limited due to its adrenal suppression, and that dexmedetomidine currently is likely underutilized. Doses listed are for suggestion only and may be titrated depending upon clinical response.

Fentanyl

This is a mu-opioid receptor agonist analgesic agent. Unlike other opioids, fentanyl does not induce histamine release and therefore is more hemodynamically stable.

• Suggested dose: 50-100 mcg bolus, followed by 0.25-1.5 mcg/kg/hour infusion
• Duration of action: 30 to 60 minutes

Recall that all opioids have been associated with an increased risk of delirium, ventilator-acquired pneumonia, and acute opioid withdrawal syndrome.⁸

Etomidate

This is mentioned in passing as an induction agent, not to be used on the post-intubated patient due to the risk of adrenal suppression. Etomidate works on gamma-aminobutyric receptors (GABA). It has no analgesic properties. It has been suggested to use cautiously in septic shock, and to add stress-dose hydrocortisone in patients with sepsis.

• Induction dose: 0.3-0.43 mg/kg.

No infusion exists; for the already intubated patient, we do not recommend its use.

Propofol

Propofol works on GABA receptors. It has no analgesic properties. Use of propofol and ketamine together has been well-described for procedural sedation dosing at 0.5-0.75 mg/kg for each agent (ketofol). Ketofol has not been well described for sedation post-intubation.

Of all agents used for sedation, propofol appears to be associated with the shortest recovery time, but also with higher rates of cardiac adverse events.⁹ These are related to its properties as a vasodilator and myocardial depressant. Avoid in patients with shock, hypovolemia, or reduced ejection fraction.

• Dosage: 0.3-1.7 mg/kg loading
• Infusion: 20-50 mcg/kg/minute in adults, 25-250 mcg/kg/minute in children

Midazolam

This agent, as with all benzodiazepines, works on GABA receptors. It is a short-acting sedative/amnestic and has no analgesic properties. As with narcotic agents, benzodiazepines may induce withdrawal symptoms.

Benzodiazepines may be more useful for patients with withdrawal syndromes or seizure history. They may be inappropriate for critically ill patients for long-term sedation.¹⁰

• Dosage: 0.03-0.1 mg/kg bolus
• Infusion: 0.03-0.08 mg/kg/hour in adults, 0.05-0.1 mg/kg/hour in children

Lorazepam

This is a long-acting sedative-hypnotic and as with other benzodiazepines, has no analgesic effects. Recall that benzodiazepines may cause untoward hemodynamic effects when used with opioids.

• Dosage: 1-4 mg bolus in adults, 0.05-0.1 mg/kg loading dose in children
• Infusion: 0.01-0.1 mg/kg/hour

Ketamine

Ketamine is a dissociative anesthetic that antagonizes glutamate NMDA receptors. It produces dissociative anesthesia, interrupting the thalamocortical system, producing analgesia and dissociation. It was first synthesized from phencyclidine and developed as a safer anesthetic with fewer hallucinogenic effects. It was approved for medical use in 1970.

This may be used as a single agent for post-intubation management. It has a rapid onset and generally causes little hypotension due to its endogenous release of catecholamines. One recent report indicates that ketamine is the most commonly used sedative in the ED to accomplish sedation in intubated patients.¹¹

Complications include hypersalivation, increased intraocular pressure, vomiting, delirium, hallucinations, and agitation. It has been associated with instances of atrial fibrillation.¹² Ketamine has been used in combination with atropine and midazolam in the pediatric population for procedural sedation for these reasons.¹³ The significance of its role in increasing intracranial pressure is unclear, and it may support cerebral perfusion pressure.

• Bolus: 0.1-1.4 mg/kg loading
• Infusion: 0.3-2.5 mg/kg/hour

As a bronchodilator, ketamine may be advantageous for severe asthma exacerbations requiring mechanical ventilation. Because it also has anticonvulsant properties, ketamine may be a potential choice for status epilepticus.

Dexmedetomidine

Dexmedetomidine is an alpha-2 agonist. It is a sedative, anxiolytic, and analgesic, which generally does not cause respiratory depression. It should not be used for patients with high-degree heart block (unless paced). As well, it should not be used for patients who are hypotensive or bradycardic (HR<50/minute).

It should be used with caution in patients with hepatic impairment and, in general, is not ideal for patients taking a beta blocker.

• Loading dose: 0.5-1 mcg/kg IV over 10 minutes
• Infusion: 0.2-0.7 mcg/kg/hour IV, titrate up to 1.5 mcg/kg/hour

Stop infusion for bradycardia, treat with atropine as needed. Stop for hypotension (SBP less than 90 systolic).

Dr. Glauser is a professor of emergency medicine at Case Western Reserve University and an attending faculty member at MetroHealth Medical Center Residency Program in Emergency Medicine.

Dr. Spalding is a senior resident in emergency medicine at MetroHealth Medical Center in Cleveland, Ohio.

References

1. Cairns C, Kang K. National Hospital Ambulatory Care Survey: 2020 Emergency Department Summary Tables; 2022. doi:10.15620/cdc:121911
2. Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010; 38(10):1947-1953
3. Saggaf AMO, Mugharbel A, Aboalola A, et al. Emergency Department Boarding of Mechanically Ventilated Patients. Cureus. 2022;14: e23990.doi:10.7759/cureus.23990
4. Pan E, Chen Y. Recent Advances in Understanding the Pathophysiology and Risk Stratification of Post-Intubation Hypotension. Asp Biomed Clin Case Rep. 2024;8(1):20-29.
5. Figueroa N, Wilson K, Hasara S, et al. Association Between Paralytic Agent Choice and Time to Post-Intubation Sedation in the Emergency Department. Emerg Care Med. 2026; 3(2). doi.org/10.3390
6. Wynia E, Baumgartner K, Yeager LH, et al. Postintubation sedation of pediatric patients in the Emergency Department. Pediatric Emergency Care 2025; 41(4): e19-e26
7. Baumgartner K, McElroy M, Weiss T, et al. Post-Intubation Sedation in the Emergency Department: A Scoping Review. Am J Emerg Med. 100(2026): 30-38
8. Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022 March 1:50: 108-126
9. Sadeghirad SS, Eltorki FS, Munshi l, et al. Procedural sedation and analgesia in the Emergency Department and Intensive Care unit: A systematic review and meta-analysis. Ann Emerg Med 2023;82(48): S29
10. Riker RR, Shehabi Y, Bokesch PM, et al. SEDCOM (Safety and Efficacy of Dexmedetomidine Compared with Midazolam) Study Group. Dexmedetomidine vs midazolam or sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5): 489-499
11. Sereeyotin J, Yarnell C, Mehta S. Sedation practices in patients intubated in the emergency department compared with those in patients in the intensive care unit. Crit Care Sci. 2025;37: e20250247
12. Maghraby N, Almulihi QA, Nemeth J, et al. Ketamine infusion as a single sedative agent for post-intubation management of critically ill patients: A systematic review and meta-analysis. Arch Acad Emerg Med 2025;13(1):e51
13. Soleimanpour H, Mahmoodpoor A, Eftekhari MF, et al. Effectiveness of oral ketamine, midazolam and atropine cocktail versus oral diphenhydramine for pediatric sedation in the emergency department. Iran Red Crescent Med J. 2014:16(9): e21366. Doi:10.5812