Sedation Management for Tetanus

Initial Sedation Strategy

• The Anaesthesia society recommends starting at the lower end of the midazolam dosing range (0.04-0.05 mg/kg/hr) given the respiratory compromise, and titrating upward in 25% increments every 15-30 minutes until adequate sedation is achieved (patient quiet but responsive to stimuli) 1

Addressing the Metabolic Alkalosis and Tachypnea

• The Anaesthesia society suggests monitoring for hypoxemia and hypercapnia, as excessive sedation can worsen respiratory mechanics through airway depression and vasodilatation 1
• The American society recommends combining midazolam with morphine infusion at 1-2 mg/hr for additional muscle relaxation and analgesia, allowing for lower doses of each agent, reducing individual drug-related side effects, and better control of autonomic instability 1

Monitoring Parameters

• The Praxis Medical Insights society recommends reassessing sedation level every 15-30 minutes during initial titration, then hourly once stable, and monitoring specific parameters such as respiratory rate and pattern, oxygen saturation, blood pressure and heart rate, sedation depth, and arterial blood gases 2
• The Anaesthesia society suggests targeting reduction in tachypnea without causing hypoventilation, maintaining oxygen saturation >90%, watching for autonomic instability, and ensuring the patient is quiet but arousable to verbal/painful stimuli 1

Critical Pitfalls to Avoid

• The Gastroenterology society recommends avoiding the use of ketamine as primary sedation despite its cardiovascular stability, as it can increase sympathetic tone and worsen autonomic instability common in tetanus 3