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Renal Insufficiency: ICU sedation

Many patients in intensive care units (ICUs) have some degree of renal impairment prior to their ICU stay. Perhaps more significantly, a substantial portion of patients without pre-existing renal insufficiency will develop it at some point during their ICU course, which is a well known independent predictor of morbidity and mortality. It is important to consider renal function and protection.

Midazolam is commonly used in the form of IV boluses as well as a continuous infusion. When used as an infusion, it should be limited to less than 48 hours if possible and at a low dose as the drug is avidly taken up in tissue, which can lead to continued sedation long after the infusion is stopped. This effect is magnified in renal failure, as an active metabolite is 1-hydroxymidazolam, which is renally excreted.

Lorazepam is the preferred benzodiazepine as a continuous infusion for renal impairment, as its renally cleared metabolites are not active.

Propofol requires no adjustment in renal insufficiency. Compared to midazolam, propofol is also less likely to result in subsequent renal insufficiency in patients with previously normal kidney function.

Dexmedetomidine: studies have found no significant difference in plasma concentrations of dexmedetomidine following infusions in patients both with and without renal insufficiency.


  1. De Wolf AM1, Fragen RJ, Avram MJ, Fitzgerald PC, Rahimi-Danesh F. The pharmacokinetics of dexmedetomidine in volunteers with severe renal impairment. Anesth Analg. 2001 Nov;93(5):1205-9. PubMed Link

Other References

  1. Pharmacokinetics of dexmedetomidine administered to patients with end‐stage renal failure and secondary hyperparathyroidism undergoing general anaesthesia W. Zhong MD Y. Zhang PhD M.‐Z. Zhang PhD X.‐H. Huang PhD Y. Li MD R. Li MD Q.‐W. Liu PhD First published: 16 December 2017 Link
  2. Renal Outcomes in Critically Ill Patients Receiving Propofol or Midazolam Tacyano Tavares Leite, Etienne Macedo, Izanio da Silva Martins, Fernanda Macedo de Oliveira Neves and Alexandre Braga Libório CJASN November 2015, 10 (11) 1937-1945; DOI: Link