ICU Sedation Overview 

• Goal: to ensure comfort with as minimal pharmacologic treatment as possible. 
• Indications: anxiety not due to delirium, ventilatory dyssynchrony, neuromuscular blockade, status epilepticus, severe respiratory failure, agitation when safety of patient or others is at risk, procedural sedation. 
• Adverse effects: delirium, hypotension, dependence with risk of withdrawal, prolonged ICU stay. 
• General principles: try PRN or bolus dosing before drips/continuous infusions, assess needs daily, perform daily sedation interruptions (DSI), use a target sedation as a goal (often RASS).  

Daily Sedation Interruption (DSI) 

• Daily, often nursing-driven protocols, to wean and/or turn off sedation unless contraindicated. 
• Daily arousal results in fewer days on the ventilator and in the ICU. 
• Enables assessment of baseline neurologic function as well as sedation needs. 
• Combine daily spontaneous breathing trials with sedation interruption for best chance at successful weaning. 
• Caring wisely: avoid deeply sedating mechanically ventilated patients without a specific indication (e.g. use of NMBA which requires RASS -5) and without daily attempts to lighten sedation. 

 Bolus versus Continuous Infusion 

• Bolus dosing should be attempted prior to starting an infusion in most circumstances. 
• A study of 157 pts showed bolus (PRN) sedation resulted in shorter ventilation and ICU stay. 
• If continuous infusions are used, adherence to principles of DSI and daily assessment of needs is crucial to patient safety.  

Monitoring Sedation 

• Numerous sedation scales exist and are institution-specific; however, RASS (Richmond Agitation-Sedation Scale) is a commonly used agitation and sedation scoring tool validated in ICU patients. 
• There is no universal RASS target. A patient-centered, individualized approach to choosing initial and subsequent sedation goals is required. 
• Generally, the goal is to target lighter levels of sedation, which corresponds to a target RASS of 0 or -1 so that patients are awake, comfortable, and without distress and able to engage with their care. 
• Former goal of RASS -2 is no longer promoted given risk of over-sedation.   
• At some hospitals (such as Moffitt-Long Hospital), nurses will titrate sedation to achieve a RASS within ±1 value of the selected target RASS in the core ICU order set. 
• Deeper levels of sedation (target RASS score -2 and below) should be reserved for those with indications for deeper levels of sedation. 
• In the ICU, patients who are paralyzed with NMBA require RASS -5. In these patients, sedation is not routinely down-titrated unless NMB is no longer acting. 

Sedation Agents 

Note: dosing provided here is meant to serve as a guide. Dosing should be a patient-specific choice taking into account drug-drug interactions and comorbidities (e.g. hepatic and renal impairment). Pharmacology resources should be referenced when administering medications to patients at the bedside. 

ICU Delirium 

• Definition: sudden, acute onset fluctuating changes in consciousness and cognition. 
  • Two subtypes: hypoactive or hyperactive. 
• Present in about 50% of ICU patients. 
• Delirium increases hospital LOS and mortality (~3x in mechanically ventilated patients), and long term cognitive function after ICU discharge.  
• Assessment: the Confusion Assessment Measurement for the ICU (CAM-ICU) was developed and validated for identification of ICU delirium and is an RN-driven protocol.  
• Risk factors for delirium:  
  • Non-modifiable: age, cognitive impairment/dementia at baseline, substance use. 
  • Modifiable: medications used, pain, AKI, critical illness, environmental factors, weakness, presence of drains/lines/tubes. 
• Management: 
  • First line is non-pharmacologic: 
    • Treat and reverse underlying causes. 
    • Re-orient frequently. 
    • Correct sensory deficits (glasses, hearing aids). 
    • Maximize restoration of sleep-wake cycle: melatonin qhs, up during the day with sunlight, promote nighttime rest with reduced VS and lab draws when appropriate.  
    • Avoid restraints: use sitters, coaches first. 
    • Limit unnecessary environmental stimulation. 
  • Pharmacologic if all else fails: 
    • Caution: no evidence that use of anti-psychotics reduces duration or mortality. 
    • Best indication is when safety of patient or staff is at risk of injury or patient is interfering with emergent care. 
    • Anti-psychotic agents include: haldol, quetiapine, risperidone.  
    • Side effects include prolonged QTc, extrapyramidal symptoms, and toxicity.