ICU Essentials · Sedation & Analgesia
ICU Sedation, Analgesia & Delirium
RASS Scale · A–F Bundle · Sedative & Opioid Dosing · PAD Guidelines 2018
🧠 Richmond Agitation–Sedation Scale (RASS) — Target: -1 to 0
Score
Level
Description
−5
Unarousable
No response to voice or physical stimulation
−4
Deep Sedation
No response to voice; any movement to physical stimulation
−3
Moderate Sedation
Movement/eye opening to voice, no eye contact
−2
Light Sedation
Brief eye opening/contact (<10 sec) to voice
−1
Drowsy
Eye opening/contact >10 sec to voice
0
Alert & Calm TARGET
Spontaneously awake and calm
+1
Restless
Anxious but movements not aggressive or vigorous
+2
Agitated
Frequent non-purposeful movement, fights ventilator
+3
Very Agitated
Pulls/removes tubes, aggressive
+4
Combative
Overtly combative, violent, immediate danger to staff
💊 ICU Sedatives & Opioid Dosing
Propofol
GABA-A agonist · Lipid emulsion
Infusion
5–50 mcg/kg/min
Onset
30–60 sec IV push
Use
Preferred for short-term sedation; awakening trials
Caution
Propofol infusion syndrome >48h at high doses; hypotriglyceridemia; monitor TGs >48h
Midazolam
Benzodiazepine · GABA-A
Bolus
1–5 mg IV q1–2h PRN
Infusion
0.01–0.1 mg/kg/h
Use
Acute agitation; procedural sedation; status epilepticus
Caution
Prolonged sedation, active metabolite accumulates (renal/hepatic failure); delirium risk
Dexmedetomidine
Alpha-2 agonist · "Cooperative sedation"
Load
0.5–1 mcg/kg over 10min (optional)
Infusion
0.2–1.5 mcg/kg/h
Use
Preferred for light sedation; reduces delirium; allows verbal communication; ICU agitation
Caution
Bradycardia, hypotension; avoid in heart block; does not prevent seizures
Ketamine
NMDA antagonist · Dissociative
Bolus
0.5–2 mg/kg IV (induction)
Infusion
0.1–0.5 mg/kg/h (analgesia)
Use
Bronchospasm; hemodynamically unstable; analgesia-based sedation; RSI
Caution
↑ secretions; emergence reaction; caution in raised ICP (older concern — reassessed); add midazolam to prevent emergence
Fentanyl
Opioid · μ-receptor · Analgesia-first
Bolus
25–100 mcg IV q1–2h PRN
Infusion
25–200 mcg/h
Use
First-line analgesia in ICU; hemodynamically neutral; renal failure safe
Caution
Chest wall rigidity at high doses; tolerance with prolonged use
Morphine
Opioid · μ-receptor
Bolus
2–5 mg IV q2–4h PRN
Infusion
1–5 mg/h
Use
Post-op analgesia; comfort care; acute pain
Caution
Avoid in renal failure (M6G accumulates); histamine release; hypotension
🏥 ABCDEF Bundle — ICU Liberation (Every Day)
A
Assess, Prevent, Manage Pain (CPOT/NRS)
B
SAT + SBT — Daily awakening trial → spontaneous breathing trial
C
Choose analgesia-first sedation; lightest effective level
D
Assess, Prevent, Manage Delirium (CAM-ICU)
E
Early Exercise & Mobility — PT/OT even intubated
F
Family Engagement — Include family in daily rounds
CCM Notes · FOAMed · Critical Care Clinical Reference
About
Based on SCCM PAD Guidelines 2018
Educational use only