Intensive Care Med
DOI 10.1007/s00134-017-4992-9
WHAT’S NEW IN INTENSIVE CARE
Ten tips for ICU sedation
Sangeeta Mehta1* , Claudia Spies2 and Yahya Shehabi3,4
© 2017 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
Introduction
Addressing critically ill patients’ pain, anxiety, distress
and sleeplessness is paramount, but can be challenging
given their severity of illness and life-support technolo-
gies. Ideally, patients should be able to communicate
their symptoms and severity, so that clinicians can use
appropriate symptom-based non-pharmacologic and
pharmacologic therapy. We provide ten suggestions
for the management of sedation in critically ill patients,
targeted at optimizing patient comfort while avoiding
over-sedation.
1. Prioritize pain assessment and management
Pain is a strong driver of distress and agitation. Pain con-
trol should be a first priority in the care of critically ill
patients. Effective analgesia will obviate or reduce the need
for sedation [1], and may attenuate the metabolic and car-
diovascular burden of pain-induced sympathetic overdrive.
Pre-emptive multimodal analgesia can enhance analgesic
efficacy, reduce opioid requirements, and may reduce opi-
oid dependence.
2. Target an awake, interactive patient shortly after
intubation
Deep sedation, particularly within the first 48 h after ini-
tiation of mechanical ventilation (MV), is associated with
delayed time to extubation and increased risk of death [2].
Keeping patients awake, calm and interactive shortly after
intubation and initial stabilisation should be the target [3].
While agitation can be a challenging consequence of lighter
sedation; adjuncts such as atypical antipsychotics or clo-
nidine [4] may be useful. When needed, short-acting and
*Correspondence: Geeta.mehta@utoronto.ca
1
Department of Medicine and Interdepartmental Division of Critical
Care Medicine, Mount Sinai Hospital, Sinai Health System, University
of Toronto, 600 University Ave, Suite 18‑216, Toronto, ON M5G1X5, Canada
Full author information is available at the end of the article
easily titratable sedatives such as propofol or dexmedetomi-
dine may help achieve an awake, interactive patient.
3. Multimodality symptom-based management: use
appropriate non-pharmacologic and pharmacologic
interventions for different symptoms, ideally with
patient input
Pain, anxiety and sleeplessness are common, and cause
profound distress to patients and family members. The
ideal situation is an awake patient who can communicate
her symptoms so that clinicians can provide reassurance,
and if needed, the appropriate medication to treat the
specific symptom. No medications address all of these
symptoms, thus several medications (i.e., analgesic, anxio-
lytic, hypnotic for sleep) in combination may be required.
While pharmacological agents are often necessary to
manage pain and anxiety, their use may be reduced and
effectiveness enhanced by multi-faceted non-pharmaco-
logic interventions (Fig. 1).
4. When deep sedation is indicated, de-escalate as soon
as possible
Some critically ill patients require deep sedation to facili-
tate specific interventions such as management of intrac-
ranial pressure, prone position, neuromuscular blockade,
and controlled MV. The need for deep sedation should be
assessed frequently, at least daily. Once the indication for
deep sedation has resolved, medications should rapidly be
reduced and stopped.
5. For patients receiving opioids/sedatives, use vali-
dated tools and explicit targets
Patient-centred therapy relies on regular assessment of
pain, sedation, and delirium using validated tools [5]. At
least every shift, the healthcare team should reassess and
document the target level of sedation. There are several
validated and reliable sedation assessment tools, includ-
ing the Richmond Agitation-Sedation Scale (RASS), and
the Sedation Agitation Scale (SAS). Patient self-report is
 PAIN ANXIETY AGITATION SLEEPLESSNESS
ASSESSMENT

NRS Paent report

RASS
TOOLS

BPS Faces Anxiety Scale Nursing report

SAS
CPOT Other Acgraphy
Other
Other Other
NON-PHARMACOLOGIC

Paent and family-centered, culturally sensive, Ear plugs

INTERVENTIONS

communicaon, reassurance, family presence, open vising Headphones

hours, maintenance of circadian rhythm, relaxaon techniques, Noise reducon
music therapy, spiritual care, distracon acvies, pet therapy, Eye masks
acupressure, acupuncture, others Light therapy

Opioids,
PHARMACOLOGIC
INTERVENTIONS

Non-opioid Benzodiazepines Alpha 2 agonists, Melatonin and

analgesics, (intermi„ent), Propofol, analogues,
Ketamine, Non- Benzodiazepines, Others
Regional benzodiazepines Anpsychocs
Blockade

Fig. 1 Management of pain, anxiety, agitation and sleeplessness is tailored on frequent individualized patient assessment. Non-pharmacologic
intervention depends on the context, environment and extent of family engagement, as well as patient and family values and beliefs. Pharmaco-
logic management should be used sparingly, at the lowest effective dose and for the shortest possible duration. NRS Numerical Rating Scale, BPS
Behavioural Pain Scale, CPOT Critical Care Pain Observation Tool, VAS Visual Analogue Scale, RASS Richmond Agitation Sedation Scale, SAS Sedation
Agitation Scale (Riker Sedation Scale)

best for pain assessment; for non-communicative patients
The Behavioral Pain Scale and Critical-Care Pain Obser-
vation Tool (CPOT) are valid and reliable. In most cases,
it is desirable that patients are awake and cooperative, as
reflected by RASS 0 or − 1, or SAS 3–4.
6. Use non-pharmacologic interventions for patient
comfort and engagement
Survivors of critical illness frequently report noise, diso-
rientation, lack of privacy, and sleep deprivation during
their ICU stay [6]. These stressors generate discomfort,
anxiety, and may promote delirium. Non-pharmacological
measures are relatively low-cost and safe, and may reduce
patient and family anxiety and stress. Natural light expo-
sure and a stimulating environment during the day; a quiet
and dark night-time environment can contribute to main-
tenance of circadian rhythm. Glare-free LED lighting may
promote maintenance of circadian rhythm via melatonin
suppression [7]. Reassurance, conversation, music, family
presence, relaxation therapy, and personal mementos, may
be calming. Early removal of drains, initiation of enteral
nutrition, and mobilization also improve patient comfort.
7. Avoid benzodiazepines, particularly infusions
Compared with non-benzodiazepine sedatives, a benzo-
diazepine strategy is associated with longer durations of
MV and ICU stay [8–10]. Continuous benzodiazepine
infusions have been associated with a higher risk of death
compared with propofol in a large, propensity-matched
population [9]. While avoidance of benzodiazepines is
generally recommended, specific indications for their use
include palliation, seizures, procedural amnesia, and alco-
hol withdrawal [11].
8. Identify iatrogenic benzodiazepine and opioid with-
drawal
Prolonged treatment with these drugs results in physi-
ologic dependence, and rapid tapering or abrupt discon-
tinuation can precipitate iatrogenic withdrawal syndrome
[12], which may be associated with adverse outcomes,
including agitation, delirium, and prolonged MV. There
are validated opioid withdrawal scales for pediatric criti-
cally ill patients; however, scales for adults are lacking.
Deliberate slow tapering of parenteral opioids and ben-
zodiazepines, bridging with enteral agents, and monitor-
ing for symptoms, may prevent withdrawal syndromes.
Adjuncts such as methadone and alpha-2 agonists may be
useful for withdrawal symptoms [4].
9. Remove catheters (vascular, gastric, urinary) as soon
as possible, and avoid physical restraint (PR)
Removing unnecessary catheters and drains improves
patient comfort, may reduce agitation, and facilitates
mobilization. PR use should be avoided or minimized, as
it is causes patient injury, increased agitation, psychologi-
cal distress for patients and family members, and may not
prevent unplanned device removal [13, 14]. For agitated
patients, consider non-pharmacologic and pharmaco-
logic alternatives to PR. If PR is used, frequent and regular
assessment of ongoing need and adjunctive management
is essential.
10. Be attentive about night-time sedation
Several studies show that mechanically ventilated patients
receive higher doses of opioids and benzodiazepines at
night; and higher nocturnal doses are associated with
failure to pass a spontaneous breathing trial, as well as
delayed extubation [15]. Sedation-minimization should be
the goal at night as well as during the day, and sedation
should not be increased at night for the purpose of pro-
moting sleep. Melatonin or non-benzodiazepine hypnot-
ics can be considered for sleep promotion in addition to
non-pharmacologic measures.
Conclusion
A priority for intensivists is patient comfort, while keep-
ing them awake and interactive so that they can par-
ticipate in their care. Avoiding excessive sedation is
associated with reduced MV duration and ICU stay, and
may reduce mortality. With engagement of the patient,
family, and interprofessional team, patient-directed,
symptom-based comfort management can be achieved.
Author details
1
Department of Medicine and Interdepartmental Division of Critical Care
Medicine, Mount Sinai Hospital, Sinai Health System, University of Toronto,
600 University Ave, Suite 18‑216, Toronto, ON M5G1X5, Canada. 2 Department
of Anesthesiology and Critical Care Medicine, Charité-University Medicine
Berlin, Berlin, Germany. 3 Critical Care and Perioperative Medicine, School
of Clinical Sciences, Monash University, Melbourne, Australia. 4 Clinical School
of Medicine, University of New South Wales, Sydney, Australia.
Received: 10 August 2017 Accepted: 2 November 2017
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