Analgesia → Sedation → Paralysis (always in this order)

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1. Sedation Goals

RASS Target

• Light sedation preferred: RASS –1 to 0

• Deep sedation only for:

  • Severe ARDS

  • ICP crises

  • Status epilepticus

  • Paralysis (mandatory)

  • Refractory agitation

Daily Requirements

• SAT (spontaneous awakening trial) every day

• Assess pain first, then agitation

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2. First-Line ICU Sedation Agents

A. Propofol

Starting Dose

• 5–10 mcg/kg/min

Titrate Range

• 5–50 mcg/kg/min

Pros

• Fast on / fast off

• Easy to titrate

• Good for neuro exams

• Anti-epileptic

• Decreases ICP

Cons

• Hypotension

• Hypertriglyceridemia

• Propofol Infusion Syndrome (PRIS) → rare

• Not ideal in shock

Monitoring

• Check triglycerides q3 days

• Watch MAP closely

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B. Dexmedetomidine (Precedex)

Dose

• 0.2–1.5 mcg/kg/hr

Pros

• Minimal respiratory depression

• Can use in non-intubated patients

• Helps with delirium

• Best for light sedation

• Allows patient to be arousable

Cons

• Bradycardia

• Hypotension (less than propofol)

• Cannot achieve deep sedation reliably

Best For

• Patients near extubation

• Delirium-prone patients

• Nighttime sedation

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C. Benzodiazepines (Midazolam, Lorazepam)

Midazolam

• Start 1–2 mg/hr, titrate to 2–7 mg/hr

Lorazepam (not preferred)

• 1–4 mg IV q2–6 hrs

  • Risk of propylene glycol toxicity with infusion

Pros

• Useful for seizures

• Useful when deep sedation is needed and pressors high

Cons

• Strongly associated with delirium

• Accumulates in renal/hepatic failure

• Slower weaning

• Prolonged extubation times

Best For

• Status epilepticus

• Severe alcohol withdrawal

• Deep sedation when propofol not tolerated

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3. Analgesia (Always Treat Pain First)

Fentanyl

• 25–100 mcg/hr, titrate up to 200+

• Fast onset

• Less hypotension

• Common for intubated patients

Hydromorphone (Dilaudid)

• 0.2–0.6 mg/hr

• Good for opioid-tolerant patients

• Longer half-life → accumulates

Morphine

• Rarely used in ICU

• Risk of histamine release, hypotension

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4. Paralytics (ONLY with deep sedation)

Never paralyze unless patient is:

• Adequately sedated

• Hydrated

• Monitored with TOF (train-of-four)

Common Agents

• Cisatracurium (preferred; Hoffman elimination)

• Rocuronium (renal/hepatic clearance)

Indications

• Severe ARDS

• Vent dyssynchrony despite sedation

• Elevated ICP

• Procedures

Important

ALWAYS use eye lubrication and deep sedation.

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5. Sedation Strategy by Clinical Scenario

A. Near Extubation

➡ Dexmedetomidine

B. Intubated, stable BP

➡ Propofol ± fentanyl

C. On multiple pressors / shock

➡ Fentanyl + midazolam (not preferred, but safest)

D. Neuro exam needed

➡ Propofol (fast on/off)

E. Delirium-prone

➡ Dexmedetomidine

F. Severe ARDS

➡ Propofol + fentanyl ± neuromuscular blockade

G. Alcohol withdrawal

➡ Midazolam infusion or phenobarbital protocol

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6. Monitoring Requirements

• RASS checks Q1 hr

• Daily SAT

• For propofol:

  • Triglycerides

  • CK if concern for PRIS

• For benzos:

  • Monitor for accumulation

• For paralytics:

  • Train-of-four

  • Eye care

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7. Sedation Intensivist Tips (What Fellows & Attendings Want You to Know)

• Light sedation improves mortality in ventilated patients

• Propofol is great, unless the patient is on high-dose pressors

• Dexmedetomidine is the best for weaning

• If agitation persists → treat pain first

• Don’t forget bowel regimen with opioids

• Keep sedation targeted — avoid overshooting

• Daily SAT + SBT dramatically reduces vent days

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