Pain · RASS · delirium

Analgesia & Sedation

Pain control, sedation goals, opioid conversion caution, delirium prevention, and ventilator comfort.

Attribution: SurgCritCare handbook
Updated: 5/29/2026

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At a Glance

Focus on analgesia-first care, sedation targets, opioid caution, delirium prevention, and ventilator comfort.

Analgesia firstTreat pain before deepening sedation when clinically appropriate.

Define target RASS.
Use multimodal analgesia when safe.
Reassess after every dose change.

Pain, Sedation, And Delirium Topics

Analgesia-first care, sedation goals, opioid caution, delirium prevention, and ventilator comfort.

Analgesia & Sedation in the Surgical ICUPain, agitation, and delirium management (PADIS) in the surgical ICU: analgesia-first approach, RASS sedation targets, SAT/SBT protocols, and multimodal pain strategies.

Content Status

Guideline-supported example educational content* based on SCCM PADIS Guidelines (2018). Drug selection, dosing, and protocols are institution-specific. Always follow institutional order sets and attending guidance.

The SurgCritCare. org Analgesia page had no extractable clinical content at the time of access (navigation/shell only). This content is based on SCCM PADIS Guidelines.

Core Principle: Analgesia First

Address pain first before titrating sedation. Undertreated pain drives agitation and delirium.

Pain Assessment

Tool	Use Case
NRS (0–10)	Patients who can self-report
CPOT	Patients unable to self-report
BPS	Mechanically ventilated patients

RASS — Richmond Agitation Sedation Scale

Score	Label	Description
+4	Combative	Violent, immediate danger to staff
+3	Very agitated	Pulls/removes tubes
+2	Agitated	Frequent purposeless movement
+1	Restless	Anxious, not aggressive
0	Alert and calm
−1	Drowsy	Eye opening > 10 sec
−2	Light sedation	Brief awakening < 10 sec
−3	Moderate sedation	Movement/eye opening, no contact
−4	Deep sedation	No response to voice
−5	Unarousable	No response to any stimulus

Target for most ventilated patients: RASS −1 to 0*

SAT / SBT — Wake and Breathe Protocol

SAT (Spontaneous Awakening Trial):*
Daily interruption of continuous sedatives/opioids
Safety screen first (no seizures, no agitation requiring sedation, no FiO₂ escalation, no increasing vasopressors)

SBT (Spontaneous Breathing Trial):*
Pair with SAT
Pressure support ≤ 8 cmH₂O, PEEP ≤ 5 cmH₂O for 30–120 min
Extubate if trial passes

Common Sedation Agents

Agent	Class	Notes
Fentanyl	Opioid	Primary analgesic; short-acting
Propofol	Sedative	Titratable; monitor for propofol infusion syndrome
Dexmedetomidine	Alpha-2 agonist	Less delirium vs. benzos; preserves arousability
Lorazepam/Midazolam	Benzodiazepines	Avoid/minimize — associated with delirium
Ketamine	NMDA antagonist	Analgesic; preserves airway; useful adjunct

Multimodal Analgesia

Minimize opioid use by combining:

Scheduled acetaminophen, NSAIDs (if not contraindicated)
Regional/neuraxial analgesia
Ketamine adjunct
Gabapentin/pregabalin (selective use)

Guideline-supported example educational content based on SCCM PADIS Guidelines 2018. Do not use without attending guidance and institutional review.*

SurgCritCare

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