Sedation & Analgesia study guide previews.

Key idea include Delirium is acute brain dysfunction - and it’s common in critical illness. You generally need the patient to be at least somewhat arousable. If RASS -4 or -5, patient is too deeply sedated to assess delirium. Examples include Normal this morning leading to confused tonight.

Key concept include Sedation ≠ analgesia and A patient can be “calm” and still be in pain. Each category is scored 0-2, total score 0-8.: Protective movements (slow, cautious, touching painful area). This is a big CPOT pearl include You actually check tone - it’s not just “looks stiff.” and Ventilator Compliance (or Vocalization if extubated). If intubated include Tolerating ventilator / no alarms.

These four agents cover two core jobs on the vent Analgesia (pain control) leading to fentanyl, ketamine (analgesic-dose), Sedation (anxiolysis/hypnosis) leading to propofol, dexmedetomidine (and ketamine as adjunct), and Analgesia first, sedation second. What each agent is “best for” (practical use-cases). Best when you want include light sedation (RASS -1 to 0), bradycardia with or without hypotension, and “analgesia base layer”. Best when you need include pain control (trauma, tubes, procedures, burns, ETT intolerance) and “adjunct when pain is tough or BP is fragile”.

bronchospasm/asthma context (often helpful)Watch for: tachycardia/HTN, secretions, psychomimetic effects. Always titrate to targets includes pain (CPOT/BPS) + Sedation (RASS). Common ICU titration range often ~5-50 mcg/kg/min (varies by protocol/patient). Key titration behavior includes quick adjustments q5-10 min are reasonable because onset/offset are rapid. Label dosing includes 2-0.7 mcg/kg/hr; may titrate up to 1 mcg/kg/hr per label language in ICU sedation. Practical pearl includes many clinicians skip the loading dose to avoid bradycardia/hypotension (policy varies).

Common ICU range includes 5-5 mcg/kg/hr, titrate to CPOT and procedural needs. Evidence shows wide dosing variability; most studies use <1 mg/kg/hr and many <0.5 mg/kg/hr. Practical “two-lane” concept include low dose (often ~0.1-0.3 mg/kg/hr in many protocols), commonly ~0.5-1 mg/kg/hr (center-dependent), and the “signature complications”.

Usually causes minimal respiratory depression (handy when we’re trying to lighten sedation and assess readiness). Not a primary analgesic (but does have some pain control).

What that does clinically include decreased sympathetic outflow (“sympatholysis”) leading to calmer, lower catecholamine tone, Sedation that resembles a sleep-like state (patients can often awaken and follow commands), Dex = α2 agonist leading to sympatholysis + arousable sedation, and When dex is especially useful on the vent.

From FDA labeling include 2-0.7 mcg/kg/hr, adjusted to desired sedation level, Label also describes initiating around 0.6 mcg/kg/hr and titrating, with doses up to 1 mcg/kg/hr in ICU sedation, Loading dose? (often skipped in ICU), Label includes a loading dose (1 mcg/kg over 10 min) in some contexts, and In real-world ICU/ED practice, many clinicians avoid the loading dose because it can trigger bradycardia/hypotension. (This is a practical pearl; policies vary.).

Key point includes fentanyl provides analgesia first and may provide some sedation, but it is not a primary sedative-hypnotic(like propofol). Critical care mantra includes analgesia-first (treat pain before escalating sedatives).

Fentanyl is a µ-opioid receptor agonist include decreased neurotransmitter release in pain pathways, increased pain tolerance + decreased pain perception, also contributes to respiratory drive suppression and sympathetic blunting, and When fentanyl is especially useful on the vent.

analgesia as the “base layer” while you titrate sedation separately. Dosing & titration (conceptual - not medical advice). A commonly referenced ICU range is include mcg/kg/hr (titrate to pain scores/comfort) and Clinical practice varies by unit and patient (opioid tolerance, shock physiology, deep sedation needs, etc.). Use your local protocol. Titrate in small steps (e.g., adjust infusion and/or add boluses for procedures). Good “score bundle” workflow include CPOT, RASS, and CAM-ICU.

Adjunct sedation (especially when hypotension limits other agents). A useful option in bronchospasm/asthma, opioid tolerance, and hemodynamically tenuous patients (with caveats). Key point includes ketamine can provide analgesia and sedation, but it’s often best thought of as an adjunct “bridge” or “booster” agent, not the only sedative for every patient. The headline mechanism include Noncompetitive NMDA receptor antagonism leading to analgesia + dissociation + anti-hyperalgesia effects.

Additional clinically relevant actions include Some activity at opioid receptors and other CNS pathways (contributes to analgesia/sedation), Sympathomimetic effects (often increased HR/increased BP) via catecholamine release/reuptake effects-BUT in catecholamine-depleted shock, BP can still fall, Ketamine = NMDA antagonist leading to analgesia + dissociation; often supports BP/bronchodilation, and When ketamine is especially useful on the vent.

Situations where ketamine often “makes sense” clinically Opioid-tolerant or hard-to-control pain patients (trauma, burns, chronic opioid use), Hemodynamic fragility where propofol escalation would tank BP, Severe bronchospasm (asthma) needing sedation + bronchodilation vibes, and When you want opioid-sparing analgesia (reduce total opioid burden).

What propofol is (and what it is not). Great for quick on / quick off sedation. Not an analgesic (it does not treat pain) leading to pair with analgesia when needed. RASS -1 to 0 (unless clear indication for deeper sedation). Neuromuscular blockade (paralysis) (requires deep sedation + analgesia). Dosing & titration (conceptual - NOT medical advice). Package labeling includes maintenance dosing ranges for sedation in monitored settings (e.g., commonly cited 25-100 mcg/kg/min depending on context and patient response).

Bolus dosing can rapidly deepen sedation but increases risk of hypotension/apnea. Check RASS frequently during titration (q5-15 min initially). Teaching pearl include Titrate to a target RASS, not to “no movement.” and What to monitor while on propofol.

Key idea include RASS is the “language” your ICU team uses to communicate sedation goals. Violent, danger to staff, pulling lines, fighting hard. Movement/eye opening to voice but no eye contact.