The intravenous route is not FDA approved and is generally not recommended except when no other alternatives are available. Intravenous administration appears to be associated with a higher risk of QT prolongation and torsade de pointes (TdP) than other forms of administration. The manufacturer recommends ECG monitoring for QT prolongation and arrhythmias if IV administration is required. A dose in the range of 1 to 5 mg IV has been suggested, with the dose being repeated at 30 to 60 minute intervals, if needed. A maximum IV dose has not been established. The lowest effective dose should be used in conjunction with conversion to oral therapy as soon as possible.
The PAD guidelines recommend either daily sedation interruption or a light target level of sedation be routinely used (+1B). Interrupt sedation completely on a daily basis whenever possible (sedation vacation). Restart the dose at half the previous rate, if the patient becomes agitated. Sedation vacations have been shown to reduce ventilator days and length of ICU stays. Pair the daily sedation interruption with a spontaneous breathing trial, when possible. This led to reduced ventilator days and 1 year mortality in a randomized trial.