Contents
Analgesia-First (Analgosedation)
- Treat PAIN before adding sedation — untreated pain causes agitation
- Assess pain with a validated tool (CPOT or BPS in non-communicative patients)
- Goal is comfort with the LIGHTEST effective sedation
- Deep sedation prolongs ventilation, ICU stay, and delirium
The RASS Scale (Sedation Depth)
- Richmond Agitation-Sedation Scale ranges +4 (combative) to −5 (unarousable)
- Target is usually 0 to −2 (calm, awake, or lightly sedated)
- +1 to +4 = agitation; −3 to −5 = deep sedation
- Titrate sedation to a defined RASS goal, reassessed frequently
Sedative Agents
- Propofol: rapid on/off; watch hypotension, hypertriglyceridemia, and propofol-related infusion syndrome
- Dexmedetomidine: light, arousable sedation, minimal respiratory depression; causes bradycardia/hypotension
- Benzodiazepines: associated with MORE delirium — generally avoided for routine sedation
- Match the agent to the goal; favor non-benzodiazepine strategies
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Start Free Practice →Pain Management Agents
- Opioids (fentanyl, hydromorphone) are first-line for significant pain
- Use multimodal analgesia (acetaminophen, regional) to limit opioids
- Monitor for respiratory depression and ileus
- Reassess pain scores after interventions
Delirium: Recognition
- CAM-ICU screens for delirium: acute change + inattention + altered LOC or disorganized thinking
- Hypoactive delirium (quiet, withdrawn) is common and easily missed
- Hyperactive delirium (agitated) is more obvious but less common
- Delirium is linked to higher mortality and long-term cognitive impairment
Delirium: Risk Factors & Prevention
- Risks: benzodiazepines, deep sedation, immobility, sleep disruption, sepsis
- Prevent with early mobility, sleep hygiene, reorientation, glasses/hearing aids
- Minimize deliriogenic drugs; treat pain and underlying illness
- Antipsychotics do not prevent delirium — focus on non-pharmacologic measures
The ABCDEF Bundle
- A: Assess, prevent, and manage pain
- B: Both spontaneous awakening (SAT) and breathing (SBT) trials
- C: Choice of analgesia and sedation (light, non-benzo)
- D: Delirium assess, prevent, manage (CAM-ICU)
- E: Early mobility and exercise; F: Family engagement
Spontaneous Awakening & Breathing Trials
- Daily SAT: pause sedation to assess neuro status and readiness
- Pair the SAT with a spontaneous breathing trial (SBT) for ventilated patients
- Coordinated SAT + SBT shortens ventilator days
- Monitor for distress/agitation during the awakening trial and restart at a lower dose if needed
Withdrawal & Special Considerations
- Prolonged sedation/opioids can cause withdrawal — wean gradually
- Alcohol withdrawal: monitor (e.g., CIWA), treat with benzodiazepines
- Watch for oversedation masking neuro changes
- Balance comfort, safety, and the ability to assess the patient
Nursing Priorities
- Assess pain, sedation (RASS), and delirium (CAM-ICU) every shift and PRN
- Titrate to the lightest effective sedation; avoid routine benzodiazepines
- Implement the ABCDEF bundle — especially daily SAT/SBT and early mobility
- Promote sleep, reorientation, and family presence
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Premium Practice Question
According to best practice, what should be addressed FIRST in an agitated, intubated patient?
- Increase the propofol infusion
- Assess and treat pain (analgesia-first)
- Add a benzodiazepine
- Apply physical restraints
Rationale: An analgesia-first (analgosedation) approach treats pain before escalating sedation, because untreated pain is a common, reversible cause of agitation....
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Premium Practice Question
A nurse uses the CAM-ICU and finds an acute change in mental status, inattention, and disorganized thinking. This indicates:
- Adequate sedation
- Delirium
- Normal arousal
- Oversedation only
Rationale: A positive CAM-ICU (acute change plus inattention plus either altered level of consciousness or disorganized thinking) indicates delirium....
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Premium Practice Question
Which sedative is most associated with an increased risk of ICU delirium?
- Dexmedetomidine
- Propofol
- Benzodiazepines
- Acetaminophen
Rationale: Benzodiazepines are associated with a higher incidence of delirium and are generally avoided for routine ICU sedation in favor of propofol or dexmedetomidine....
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Related CCRN Guides
Frequently Asked Questions
What is the analgesia-first approach to ICU sedation?
Analgosedation means treating pain before adding sedatives, because untreated pain is a frequent and reversible cause of agitation. The goal is comfort using the lightest effective sedation, since deep sedation prolongs ventilation and increases delirium.
What is the RASS scale and the usual target?
The Richmond Agitation-Sedation Scale runs from +4 (combative) to −5 (unarousable). A target of 0 to −2 (calm and awake to lightly sedated) is usual for most ventilated patients.
How is delirium assessed in the ICU?
The CAM-ICU tool is used: delirium is present when there is an acute change or fluctuation in mental status plus inattention, combined with either an altered level of consciousness or disorganized thinking. Hypoactive delirium is common and easily missed.
Which sedatives are preferred to reduce delirium?
Non-benzodiazepine sedatives such as propofol and dexmedetomidine are preferred because benzodiazepines are associated with a higher risk of delirium.
What is the ABCDEF bundle?
It is a framework to improve ICU outcomes: Assess and manage pain; Both spontaneous awakening and breathing trials; Choice of light, non-benzodiazepine sedation; Delirium monitoring; Early mobility; and Family engagement.
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