Sedation, Delirium, and Pain Management
0 to -2
RASS Target
Usual sedation goal
2
Delirium Types
Hyperactive and hypoactive
#1
Most Missed
Hypoactive delirium
PADIS Guidelines and Pain Assessment
Pain assessment comes FIRST. Use the CPOT (Critical Care Pain Observation Tool) or BPS (Behavioral Pain Scale) for patients who cannot self-report. Treat pain before reaching for sedatives. An analgesic-first approach reduces sedation requirements.
Hypoactive delirium is MORE common and easily MISSED. The CAM-ICU detects both types. Screen at least once per shift. A quiet patient is not necessarily a comfortable patient.
RASS Scale and Sedation Targets
RASS +4 to +1
Combative to restless
RASS 0
Alert and calm (ideal)
RASS -1 to -2
Drowsy to light sedation (acceptable)
RASS -3 to -5
Moderate sedation to unarousable (too deep)
Key Values to Memorize
RASS target 0 to -2
CAM-ICU every shift
No benzos per PADIS
CPOT/BPS for non-verbal
TOF 1-2 twitches for NMBAs
ABCDEF bundle daily
sedation and delirium questions appear throughout the CCRN
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Avoid benzodiazepines because they increase delirium
The PADIS guidelines recommend propofol or dexmedetomidine over benzodiazepines for sedation in mechanically ventilated adults. Benzodiazepines are independently associated with increased delirium, longer ICU stays, and longer ventilator days. The only exception is alcohol withdrawal or seizure management.
NMBAs require concurrent sedation because the patient may be aware
Neuromuscular blocking agents paralyze the patient but do NOT provide sedation or analgesia. A paralyzed patient who is not adequately sedated is fully conscious and aware but unable to move, speak, or signal distress. Always ensure adequate sedation BEFORE and DURING NMBA use. Monitor with train-of-four (TOF).
Hypoactive delirium is the most common and most missed type
The quiet, withdrawn, inattentive patient is often assumed to be "resting well." In reality, hypoactive delirium carries a WORSE prognosis than hyperactive delirium. The CAM-ICU assessment tool detects both types. Screen every shift.
Train-of-four monitoring is required during NMBA infusions
TOF monitoring uses peripheral nerve stimulation to assess the depth of neuromuscular blockade. The target is typically 1-2 twitches out of 4. Without TOF monitoring, you cannot titrate the NMBA appropriately and risk over-paralysis or under-paralysis.
No Benzos Rule
Propofol or dexmedetomidine for ICU sedation. Benzodiazepines = more delirium, longer stays. The guidelines are clear on this.
ABCDEF Bundle
Assess pain. Both SATs and SBTs. Choice of sedation. Delirium monitoring. Early mobility. Family engagement. Do it daily.
Think of the patient's consciousness as a radio. The RASS score is the volume knob. Too loud (positive RASS) = agitation, pulling at lines, fighting the ventilator. Too quiet (deeply negative RASS) = over-sedated, cannot assess neuro status, prolonged ventilation.
RASS 0 to -2 is the sweet spot. The patient is calm, cooperative or lightly sedated. They can participate in breathing trials, be assessed neurologically, and are not suffering. Light sedation improves outcomes across the board.
Delirium is like static on the radio signal. Even when the volume is right, the signal is garbled. The patient is confused, inattentive, has altered thinking. Hyperactive delirium is loud static (obvious). Hypoactive delirium is quiet static (easy to miss but just as dangerous).
Paralysis without sedation is like turning off the speaker but leaving the radio on. The patient is receiving every signal (pain, fear, awareness) but cannot respond or alert anyone. That is why sedation must ALWAYS accompany NMBAs.
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