Choice of Analgesia and Sedation

Within the ABCDEF Bundle, the C Element refers to Choice of Analgesia and Sedation.

The C Element focuses on constructing a safe and effective medication regimen for the management of pain and agitation in critically ill adults, consistent with ICU pain, agitation and delirium (PAD) Guidelines recommendations.

Implementing the C Element of the ABCDEF Bundle.

Search C Element Resources
 
All ICU patients should be routinely assessed for pain using one of the following methods: 
  • Patient self-report, which is most reliable
  • Numeric Rating Scale (NRS), such as the Likert Scale self-report
  • Behavioral Pain Scale (BPS) or Critical-Care Pain Assessment Tool (CPOT) non-self-reports
Pain and discomfort should be treated first before considering sedative therapy.

All ICU patients should be assessed routinely for agitation and depth of sedation with one of the following tools:
  • Richmond Agitation-Sedation Scale (RASS) 
  • Riker Sedation-Agitation Scale (SAS) 
All ICU patients should be assessed routinely for delirium with one of the following scales: 
  • Confusion Assessment Method for the ICU (CAM-ICU)
  • Intensive Care Delirium Screening Checklist (ICDSC)
Properties of an ideal sedative include:
  • Rapid onset and rapid offset
  • Predictable dose-response relationship
  • Ease of administration
  • Lack of drug accumulation
  • Few side effects
  • Minimal drug interactions
  • Cost-effectiveness
  • Promotion of natural sleep
The interprofessional ICU team should reevaluate, at least daily, the appropriateness and the continued need for all pharmacologic interventions that have been initiated for treating pain and agitation.

Assessment Tools
Richmond-Agitation Sedation Scale
Sedation Agitation Scale

The PADIS guidelines recommend that depth and quality of sedation should be routinely assessed in all ICU patients. The Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) are considered the most valid and reliable tools for assessing adequacy and depth of sedation in critically ill patients who are not receiving neuromuscular blocking agents.
 
 
Oversedated
Ideal Wakefulness
Undersedated
RASS
2
 
Moderate Sedation (3): movement or eye opening to voice, but no eye contact
 
Deep Sedation (4): no response to voice, but movement or eye opening
 
Unarousable (5): no response to voice or physical stimulation
2 to 0
 
Light Sedation (2): briefly awakens with eye contact to voice (<10 seconds)
 
Drowsy (1): not fully alert, but has sustained awakening (eye-opening / eye contact) to voice (< 10 seconds)
 
Alert and Calm (0)
  > 0
 
Restless (+1): anxious but movements not aggressive or vigorous
 
Agitated (+2): frequent non-purposeful movement, fights ventilator
 
Very Agitated (+3): pulls or removes tube(s) or catheter(s), aggressive
 
Combative (+4): overtly combative, violent, immediate danger to staff
SAS
< 3
 
Very Sedated (2): arouses to physical stimuli but does not communicate or follow commands, may move spontaneously
 
Unarousable (1): minimal or no response to noxious stimuli, does not communicate or follow commands
 
3 to 4
 
Sedated (3): difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again
 
Calm and Cooperative (4): calm, easily arousable, follows commands
> 4
 
Agitated (5): anxious or physically agitated, calms to verbal instructions
 
Very Agitated (6): requires restraint and frequent verbal reminders of limits, bites endotracheal tube
 
Dangerous Agitation (7): pulls at endotracheal tube, tries to remove catheter(s), climbs over bed rail, strikes at staff, thrashes side to side
 

Pain

Nonpharmacologic strategies play an important role in managing pain and agitation.

IV opioids should be considered first-line analgesics for the treatment of non-neuropathic pain. Nonopioid analgesics should be considered to decrease the amount of opioids administered and thereby to decrease opioid-induced adverse effects.

Optimize opioid regimens by assessing the following considerations:

  • Is pain acute, persistent, or both?
  • Route of administration
  • Hemodynamic instability
Treatment of Pain


Agitation

When treating agitation, it is important to titrate sedative medications to maintain lighter levels of sedation; deep sedation or coma should be avoided.

Delirium

The PAD Guidelines suggest that, in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine (rather than benzodiazepine infusions) be administered for sedation to reduce the duration of delirium. Also, atypical antipsychotics may reduce the duration of delirium in adult ICU patients. Treatment with rivastigmine or haloperidol does not reduce the duration of delirium.

Nonpharmacologic strategies play an important role when preventing and managing delirium.
Before administering a medication to either prevent or treat delirium in the ICU:
  1. Consider nonmedication-related, reversible factors for delirium (e.g., hypoxemia, infection, electrolyte abnormalities).
  2. If possible, stop (or decrease the dose of) any medication that may increase delirium risk.
  3. Mobilize patients when possible.
  4. Optimize nonpharmacologic interventions that may reduce delirium incidence and/or burden (e.g., hearing aids, eyeglasses, reorientation, sleep protocols, music, noise control, family interaction).

 
A randomized trial of intermittent lorazepam versus propofol with daily interruption in mechanically ventilated patients
Citation: Crit Care Med. 2006 May;34(5):1326-32
Population: Adult
Bundle: C Element
View Reference
Improved analgesia, sedation, and delirium protocol associated with decreased duration of delirium and mechanical ventilation
Citation: Ann Am Thorac Soc. 2014 Mar;11(3):367-74
Population: Adult
Bundle: C Element
View Reference
Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials
Citation: Crit Care Med. 2013 Sep;41(9 Suppl 1):S30-8
Population: Adult
Bundle: C Element
View Reference
Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials
Citation: JAMA. 2012 Mar 21;307(11):1151-60
Population: Adult
Bundle: C Element
View Reference
Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS randomized controlled trial
Citation: Crit Care. 2010;14(2):R38
Population: Adult
Bundle: C Element
View Reference
Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients
Citation: Anesthesiology. 2006 Jan;104(1):21-6
Population: Adult
Bundle: C Element
View Reference
Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial
Citation: JAMA. 2009 Feb 4;301(5):489-99
Population: Adult
Bundle: C Element
View Reference
A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial
Citation: Lancet. 2010 Feb 6;375(9713):475-80
Population: Adult
Bundle: C Element
View Reference
Randomized trial of light versus deep sedation on mental health after critical illness
Citation: Crit Care Med. 2009 Sep;37(9):2527-34
Population: Adult
Bundle: C Element
View Reference
Is propofol a friend or a foe of the pediatric intensivist? Description of propofol use in a PICU
Citation: Pediatr Crit Care Med. 2014 Feb;15(2):e66-71
Population: Pediatrics
Bundle: C Element
View Reference