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  • Analgesics and sedatives relieve pain and agitation and help facilitate mechanical ventilation. Pharmacokinetic and pharmacodynamic changes in critically ill patients can alter the profiles of these medications. Identifying these characteristics allows a patient-specific sedation and analgesia regimen.

  • Factors such as invasive catheters, mechanical ventilation, immobility, and underlying illness may contribute to overall pain and anxiety. Since pain is a significant contributor to anxiety, analgesics should be administered prior to the addition of sedatives (“analgosedation”).

  • Regional analgesia is useful in postoperative patients and in some nonsurgical patients (eg, thoracic trauma, acute pancreatitis). Epidural anesthetics and/or opioids are highly effective; however, coagulation abnormalities must be addressed to avoid epidural hematoma.

  • A validated sedation assessment tool such as the Richmond agitation sedation scale (RASS) should be utilized to assess the level of sedation. Sedatives should be titrated based on the scoring tool to optimize therapy and prevent adverse events.

  • There are different approaches to the administration of analgesia and sedatives such as intermittent boluses or continuous infusion. The doses required are based on patient-specific characteristics, which may range from no sedation to deep sedation. Sedation and analgesia regimens should be assessed frequently and a protocol for adjustment should be used.

  • Light sedation with a RASS goal of 0 to −2 is recommended over deep sedation. Protocolized light sedation or daily interruption of continuous infusions is recommended.

  • The ABCDEF bundle (Assess, prevent and manage pain, Both spontaneous awakening and breathing trials, Choice of analgesia and sedation, Delirium assess prevent and manage, Early mobility and exercise, Family engagement and empowerment) improves outcomes including survival and mechanical ventilation use. This bundle incorporates a multidisciplinary approach to patient care that focuses on assessment, prevention, and management and applies to all critically ill patients.

  • Neuromuscular blockade may be used for facilitating lung protective strategies and to reduce ventilator dyssynchrony. Due to the high risk of adverse effects associated with prolonged use of paralytics, they should be used sparingly.

  • Pain and agitation are common in the intensive care unit (ICU). Medications used to treat pain and agitation have altered pharmacokinetic and pharmacodynamic properties in the critically ill which can contribute to adverse events. A delicate balance is required to keep the patient calm and comfortable without oversedation. Recommendations for ICU analgesia and sedation have changed significantly over the past few decades, with an evidence-based focus on light sedation, daily awakenings, and bundle protocols.


Analgesia and sedation needs vary widely in intensive care unit (ICU) patients. Although nonpharmacologic means such as comfortable bed positioning and verbal reassurance should be considered, analgesic and sedative drugs frequently are needed. An effective approach to the use of these drugs begins with an understanding of their indications. Effective analgesia is extremely important and is discussed in detail in a later section of this chapter. Dyspnea is common in ICU patients and may be a ...

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