Sedation, analgesia and paralysis
Pentobarbital (Nembutal) drip
Nembutal
Dosing
| Start | Refractory ICP (Eisenberg regimen): 10 mg/kg over 30 minutes, then 5 mg/kg/h for 3 hours, then 1 mg/kg/h. Refractory status epilepticus: load 5–15 mg/kg (5–10 more if needed), then 0.5–5 mg/kg/h (NCS 2012). Load no faster than 50 mg/min |
|---|---|
| Titrate | ICP: to ICP control, not EEG or levels; on EEG, go no higher once burst suppression appears (SIBICC; protocols aim for about 2–5 bursts a minute). Status epilepticus: to seizure cessation or burst suppression on cEEG; breakthrough seizures: 5 mg/kg bolus and 0.5–1 mg/kg/h more every 12 hours (NCS 2012) |
| Maximum | 5 mg/kg/h (NCS 2012). Held 24–48 hours after control (longer in TBI protocols), then weaned slowly, often halving every 12 hours |
| Common bags | 2,000 mg in 250 mL (8 mg/mL); 2,500 mg in 50 mL (50 mg/mL) |
| Dose units | mg/kg/h |
Line and administration
- Central line preferred: pH about 9.5 in 40% propylene glycol; extravasation or intra-arterial injection causes necrosis
- Own line: precipitates with acidic drugs. The label says not to admix with any drug or solution; 8 mg/mL bags are pharmacy practice
Watch for
- Hypotension and myocardial depression in about 1 in 4 (Cochrane 2012): arterial line, fluids and vasopressors ready
- Ileus, infection, hypothermia, low then rebound high K; propylene glycol acidosis with big doses
- Exam lost for days (half-life 15–50 h): small fixed pupils; brain death testing needs a level under 5 mcg/mL or a flow study
Pentobarbital: full drug monographIndications, mechanism, pharmacokinetics, cautions and every dose the app lists.
In the one-pagers
- Neuro: ICP and StrokeTBI and tiered ICP therapy: SIBICC avoids continuous mannitol, lumbar drainage, PaCO₂ below 30 and steroids. Pentobarbital (classic regimen 10 mg/kg over 30 min, 5 mg/kg/h for 3 h, then 1 mg/kg/h to burst suppression) causes hypotension, ileus, immunosuppression and hypothermia, and can leave pupils small and unreactive.
- End of Life, Brain Death and Organ DonationBrain death: physiology and the 2023 standard: Levels: Pentobarbital <5 mcg/mL; alcohol ≤80 mg/dL
- Pediatric Assessment and EmergenciesDKA, cerebral edema and status epilepticus: Over 40 min: Anesthetic infusion: Midazolam, pentobarbital or propofol, with EEG
Practice Neuro: ICP and Stroke questions free101 exam-style questions with rationales on the topic where pentobarbital comes up most. No account or download needed.
Other sedation, analgesia and paralysis
- Propofol
- Dexmedetomidine
- Midazolam
- Fentanyl
- Cisatracurium
- Ketamine
- Hydromorphone
- Rocuronium
- Vecuronium
- Remifentanil
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For education and exam preparation only. Follow your institution’s protocols. Study aid: check every dose against the order, the bag label, your pump library and your institution's protocol.