MIDAZOLAM VERSUS PROPOFOL FOR LONG-TERM SEDATION IN THE ICU - A RANDOMIZED PROSPECTIVE COMPARISON

Objective: To compare the efficacy, safety, and cost of midazolam and propofol in prolonged sedation of critically ill patients. Design: Ran domized, prospective study. Setting: General intensive care unit (ICU) in a 1100-bed teaching hospital. Patients: 67 critically ill, mechani cally ventilated patients. Interventions: Patients were invasively mon itored and mechanically ventilated. A loading dose [midazolam 0.11 +/- 0.02 (SEM) mg.kg(-1), propofol 1.3 +/- 0.2 mg.kg(-1)] was administere d, followed by continuous infusion, titrated to achieve a predetermine d sedation score. Sedation was continued as long as clinically indicat ed. Measurements and results: Mean duration of sedation was 141 and 99 h (NS) for midazolam and propofol, respectively, at mean hourly doses of 0.070 +/- 0.003 mg.kg(-1) midazolam and 1.80 +/- 0.08 mg.kg(-1) pr opofol. Overall, 68% of propofol patients versus 31% of midazolam (p < 0.001) patients had a > 20% decrease in systolic blood pressure after the loading dose, and 26 versus 45% (p < 0.01) showed a 25% decrease in spontaneous minute volume. Propofol required more daily dose adjust ments (2.1 +/- 0.1 vs 1.4 +/- 0.1, p < 0.001). Nurse-rated quality of sedation with midazolam was higher (8.2 +/- 0.1 vs 7.3 +/- 0.1 on a 10 -cm visual analog scale, p < 0.001). Resumption of spontaneous respira tion was equally rapid. Recovery was faster after propofol (p < 0.02), albeit with a higher degree of agitation. Amnesia was evident in all midazolam patients but in only a third of propofol patients. The cost of propofol was 4-5 times higher. Conclusions: Both drugs afforded rel iable, safe, and controllable longterm sedation in ICU patients and ra pid weaning from mechanical ventilation. Midazolam depressed respirati on, allowed better maintenance of sedation, and yielded complete amnes ia at a lower cost, while propofol caused more cardiovascular depressi on during induction.