Analgesia / Sedation
Analgesia & Sedation in the Surgical ICU
Pain, agitation, and delirium management (PADIS) in the surgical ICU: analgesia-first approach, RASS sedation targets, SAT/SBT protocols, and multimodal pain strategies.
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Content Status
Guideline-supported example educational content* based on SCCM PADIS Guidelines (2018). Drug selection, dosing, and protocols are...Section
Content Status
Guideline-supported example educational content* based on SCCM PADIS Guidelines (2018). Drug selection, dosing, and protocols are...- 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.Section
Core Principle: Analgesia First
Address pain first before titrating sedation. Undertreated pain drives agitation and delirium.Address pain first before titrating sedation. Undertreated pain drives agitation and delirium.
Pain Assessment
Tool • Use Case • NRS (0–10)Section
Pain Assessment
Tool • Use Case • NRS (0–10)| 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 • DescriptionSection
RASS — Richmond Agitation Sedation Scale
Score • Label • Description| 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...Section
SAT / SBT — Wake and Breathe Protocol
SAT (Spontaneous Awakening Trial):* • Daily interruption of continuous sedatives/opioids • Safety screen first (no seizures, no...- 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 • NotesSection
Common Sedation Agents
Agent • Class • Notes| 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
Scheduled acetaminophen, NSAIDs (if not contraindicated) • Regional/neuraxial analgesia • Ketamine adjunctSection
Multimodal Analgesia
Scheduled acetaminophen, NSAIDs (if not contraindicated) • Regional/neuraxial analgesia • Ketamine adjunct- 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.*