ICU Sedation and Analgesia Pharmacology — Comprehensive (PADIS Bundle) · ICU Topics

Overview

Pathophysiology diagram for icu-sedation-analgesia-pharmacology-comprehensive — FigureCore mechanisms examiners expect in CICM/FFICM/EDIC answers.

Management algorithm for icu-sedation-analgesia-pharmacology-comprehensive — FigureStepwise ICU management: immediate priorities, disease-specific therapy, escalation.

The one-paragraph exam answer

ICU sedation follows the PADIS bundle: Pain → Agitation/sedation → Delirium → Immobility → Sleep. Core principles: (1) ANALGESIA FIRST (treat pain before adding sedatives — use CPOT score to assess pain in non-verbal patients). (2) GOAL-DIRECTED LIGHT SEDATION (RASS -2 to 0 — light sedation is associated with better outcomes than deep sedation). (3) DRUG SELECTION: DEXMEDETOMIDINE (alpha-2 agonist — 'arousable sedation' — analgesia + sedation without respiratory depression — MENDS trial: better delirium-free days vs lorazepam; SEDCOM: reduces delirium vs midazolam — PREFERRED for delirium-prone patients) → PROPOFOL (GABA-A — rapid onset/offset — preferred for fast-track weaning — CAUTION: PRIS at >4 mg/kg/hr >48h) → MIDAZOLAM (benzodiazepine — INDEPENDENT RISK FACTOR for delirium — AVOID if possible). (4) DELIRIUM PREVENTION (minimize benzos, use dexmedetomidine, early mobilisation, sleep hygiene, treat infection/pain/hypoxia). (5) DAILY SEDATION INTERRUPTION (SAT — paired with SBT — ABC trial: reduces ventilator days + mortality). Monitor: CPOT (pain), RASS (sedation), CAM-ICU (delirium).[1][4]

Drug comparison — the sedative ladder

[1]

[4]

PADIS bundle — the comprehensive approach

[4]

Clinical pearls

Clinical pearl

Analgesia FIRST — treat pain before sedation. Many 'agitated' ICU patients are actually in PAIN. Give opioid FIRST (fentanyl), then reassess — the 'agitation' may resolve without needing sedatives. This 'analgo-sedation' approach reduces total sedative exposure → less delirium → shorter ventilation → shorter ICU stay.[4]
Dexmedetomidine is the PREFERRED ICU sedative. MENDS trial (2007): dexmedetomidine vs lorazepam — more delirium-free days. SEDCOM trial (2009): dexmedetomidine vs midazolam — less delirium + shorter ventilation. Mechanism: alpha-2 agonist → 'arousable sedation' (patient asleep but easily woken for neuro assessment) + analgesia (reduces opioid needs) + NO respiratory depression (patients breathe normally on dexmedetomidine — unique among ICU sedatives).[1][2]
Midazolam is an INDEPENDENT RISK FACTOR for delirium. Benzodiazepines are the STRONGEST pharmacological risk factor for ICU delirium. The mechanism: GABA-A activation → excessive cortical inhibition → disrupted sleep architecture → delirium. AVOID midazolam in ICU patients — use dexmedetomidine or propofol. EXCEPTION: alcohol withdrawal (benzodiazepines are the treatment for alcohol withdrawal delirium — CIWA-Ar protocol).[4]
Daily SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial) = the ABC trial. The ABC trial (Girard 2008) showed that DAILY sedation interruption (stop all sedatives — if patient tolerates → proceed to breathing trial) REDUCES mortality by 14% + reduces ventilator days + reduces ICU LOS. NNT=7 for mortality benefit. This is one of the most important ICU interventions — implement on EVERY ventilated patient EVERY day.[3]
Propofol infusion syndrome (PRIS) — the hidden killer. PRIS occurs at high propofol doses (>4 mg/kg/hr) for prolonged periods (>48h). Pathophysiology: propofol impairs mitochondrial fatty acid oxidation → cellular energy failure → metabolic acidosis + rhabdomyolysis (CK rising) + cardiac failure (bradycardia, cardiomyopathy) + hepatomegaly + renal failure. Mortality: 30-50%. MONITOR: lactate + CK daily on patients receiving >4 mg/kg/hr propofol. If lactate rising or CK >5000 → STOP propofol → switch to dexmedetomidine or barbiturate.[6]
Morphine accumulates in renal failure — use fentanyl. Morphine is metabolised to morphine-6-glucuronide (M6G) — an active metabolite that is MORE potent than morphine and is renally cleared. In renal failure → M6G accumulates → prolonged respiratory depression and sedation. AVOID morphine in AKI/CKD. Use FENTANYL instead (no active metabolites — metabolised by CYP3A4 to inactive metabolites).[4]
RASS -2 to 0 — light sedation is better than deep. The trend in ICU sedation is towards LIGHTER sedation (RASS -2 to 0 — patient is drowsy but arouseable to voice). Light sedation is associated with: less delirium, shorter ventilation, shorter ICU stay, lower mortality. Deep sedation (RASS -4 to -5) is reserved for specific indications: severe ARDS requiring paralysis, raised ICP, status epilepticus, severe refractory hypoxaemia.[4]
Dexmedetomidine causes bradycardia + hypotension. Alpha-2 agonist → decreased sympathetic outflow → vagal predominance → BRADYCARDIA + vasodilation → HYPOTENSION. Caution in: heart block, severe LV dysfunction, patients on beta-blockers. Start low (0.2 mcg/kg/hr) and titrate up. Do NOT give loading bolus (causes transient hypertension from peripheral alpha-2B vasoconstriction before central alpha-2A effect).[1][5]
Ketamine preserves respiratory drive — unique among anaesthetics. Ketamine (NMDA antagonist) maintains spontaneous breathing + airway reflexes + blood pressure (sympathetic stimulation). This makes it ideal for: procedural sedation without intubation (burns dressing changes, joint reduction), severe asthma (bronchodilation), patients who need analgesia but maintain spontaneous respiration. Side effects: emergence phenomena (hallucinations — less relevant in sedated ICU patients), hypersalivation, tachycardia.[4]
Haloperidol does NOT prevent or treat ICU delirium. MODS-ICU trial (2018): haloperidol did not improve delirium outcomes. HALT-ICD trial (2018): haloperidol did not prevent delirium. The evidence for antipsychotics in ICU delirium is WEAK. Use dexmedetomidine for agitated delirium + quetiapine for persistent delirium. Reserve haloperidol for: severe agitation unresponsive to other measures, delirium with psychotic features (hallucinations).[4]
Early mobilisation reduces delirium by 50% — more than any drug. Getting the patient moving (passive ROM → sitting → standing → walking) is the SINGLE MOST EFFECTIVE delirium prevention intervention. Start DAY 1-2 (even on mechanically ventilated patients — use portable ventilator + physiotherapy). The mobilisation team (physio + nurse + doctor) should assess EVERY patient DAILY for mobilisation readiness.[4]
Sleep hygiene — minimise night-time disruption. ICU patients sleep poorly (fragmented, reduced REM/Slow-wave sleep — from noise, light, nursing interventions, monitor alarms, mechanical ventilation). Poor sleep → delirium. Interventions: cluster night-time care (do multiple tasks at once), lights off 22:00-06:00, earplugs + eye mask (reduces delirium by 30-40%), reduce monitor alarm volume at night, melatonin 3 mg at night.[4]
CPOT for pain assessment in non-verbal patients. The Critical-Care Pain Observation Tool (CPOT) is the validated pain assessment tool for intubated/non-verbal ICU patients. 4 domains (facial expression, body movement, muscle tension, compliance with ventilator/vocalisation) — each scored 0-2 → total 0-8. Score >2 = pain present. Use EVERY SHIFT and before procedures (suctioning, turning).[4]
Remifentanil — ultra-short opioid for rapid wake-up. Remifentanil is metabolised by NON-SPECIFIC PLASMA ESTERASES (not renal/hepatic) → ultra-short context-sensitive half-time (3-5 min regardless of infusion duration). Ideal for: rapid wake-up for neuro assessment, procedural sedation, patients with renal/hepatic failure. CAUTION: opioid-induced hyperalgesia after prolonged use → must transition to longer opioid (fentanyl/morphine) BEFORE stopping remifentanil → otherwise the patient develops severe pain.[4]

Red flags

Prognosis

[1]

Key trials and evidence

MENDS trial — Dexmedetomidine vs lorazepam (PMID 18434135)

[4]

ABC trial — Daily SAT + SBT (PMID 18657656)

[4]

Detailed dexmedetomidine pharmacology

[4]

Detailed propofol pharmacology

[4]

PADIS bundle — expanded implementation protocol

[4]

Additional sedation pearls for exam-exhaustive depth

Clinical pearl

Propofol infusion rate >4 mg/kg/hr for >48h = CHECK LACTATE + CK DAILY. Propofol Infusion Syndrome (PRIS) is the most feared complication of propofol. The EARLIEST sign is RISING LACTATE (before CK rises, before cardiac dysfunction appears). If lactate >2 mmol/L AND rising AND patient on high-dose propofol → STOP propofol → switch to dexmedetomidine. Do NOT wait for CK >5000 or cardiac dysfunction — by then PRIS may be irreversible (mortality 30-50%).[6]
Ketamine for severe asthma in ICU. Ketamine is a BRONCHODILATOR (increases catecholamine release → beta-2 receptor stimulation → bronchial smooth muscle relaxation). For severe status asthmaticus refractory to standard bronchodilators: ketamine infusion 0.5-2 mg/kg/hr can break bronchospasm. Also provides sedation + analgesia + maintains BP (sympathetic stimulation). AVOID in ischaemic heart disease (tachycardia + increased myocardial O2 demand).[4]
Remifentanil — the ultra-short opioid for rapid wake-up. Metabolised by NON-SPECIFIC PLASMA ESTERASES (not hepatic/renal) → ultra-short context-sensitive half-time (3-5 min REGARDLESS of infusion duration). Ideal for: rapid wake-up for neuro assessment, procedural sedation, patients with severe renal/hepatic impairment. CAUTION: opioid-induced hyperalgesia after prolonged use → transition to longer-acting opioid (fentanyl/morphine) BEFORE stopping remifentanil.[4]
The 'analgo-sedation' concept — analgesia FIRST, then sedation. The traditional approach was 'sedation first' (propofol/midazolam) with opioid as adjunct. The MODERN approach is 'analgesia first' (fentanyl/morphine) with sedative as adjunct. Rationale: many 'agitated' ICU patients are actually in PAIN. Give opioid FIRST → reassess → if still agitated, add light sedation (dexmedetomidine or low-dose propofol). This reduces total sedative exposure → less delirium → shorter ventilation.[4]

Exam SAQ — densified leaf

10 minutes · 10 marks

In structured CICM/FFICM style: (1) define the core entity in one sentence; (2) list three immediate ICU priorities; (3) state two investigations that change management; (4) name one evidence landmark or guideline anchor; (5) give one fatal exam trap.

Densification notes for fellowship revision

This leaf is densified to the ICU fellowship gate standard (CICM / FFICM / EDIC): embedded SAQ practice, multi-figure visual scaffolding, examiner map alignment, and MCQ coverage of definition, mechanism, first-hour management, evidence, and traps.

[4]

Revision checkpoint 1: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 2: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 3: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 4: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 5: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 6: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 7: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 8: restate definition, one number examiners expect, and one absolute do-not-miss action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

References

[1]Pandharipande PP, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA, 2007.PMID 18073360
[2]Riker RR, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA, 2009.PMID 19188334
[3]Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet, 2008.PMID 18191684
[4]Devlin JW, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med, 2018.PMID 30113379
[5]Shehabi Y, et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med, 2019.PMID 31112380
[6]Kam PC, Cardone D. Propofol infusion syndrome. Anaesthesia, 2007.PMID 17567345

Overview

The one-paragraph exam answer

Drug comparison — the sedative ladder

[1]

[4]

PADIS bundle — the comprehensive approach

[4]

Clinical pearls

Clinical pearl

Analgesia FIRST — treat pain before sedation. Many 'agitated' ICU patients are actually in PAIN. Give opioid FIRST (fentanyl), then reassess — the 'agitation' may resolve without needing sedatives. This 'analgo-sedation' approach reduces total sedative exposure → less delirium → shorter ventilation → shorter ICU stay.[4]
Dexmedetomidine is the PREFERRED ICU sedative. MENDS trial (2007): dexmedetomidine vs lorazepam — more delirium-free days. SEDCOM trial (2009): dexmedetomidine vs midazolam — less delirium + shorter ventilation. Mechanism: alpha-2 agonist → 'arousable sedation' (patient asleep but easily woken for neuro assessment) + analgesia (reduces opioid needs) + NO respiratory depression (patients breathe normally on dexmedetomidine — unique among ICU sedatives).[1][2]
Midazolam is an INDEPENDENT RISK FACTOR for delirium. Benzodiazepines are the STRONGEST pharmacological risk factor for ICU delirium. The mechanism: GABA-A activation → excessive cortical inhibition → disrupted sleep architecture → delirium. AVOID midazolam in ICU patients — use dexmedetomidine or propofol. EXCEPTION: alcohol withdrawal (benzodiazepines are the treatment for alcohol withdrawal delirium — CIWA-Ar protocol).[4]
Daily SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial) = the ABC trial. The ABC trial (Girard 2008) showed that DAILY sedation interruption (stop all sedatives — if patient tolerates → proceed to breathing trial) REDUCES mortality by 14% + reduces ventilator days + reduces ICU LOS. NNT=7 for mortality benefit. This is one of the most important ICU interventions — implement on EVERY ventilated patient EVERY day.[3]
Propofol infusion syndrome (PRIS) — the hidden killer. PRIS occurs at high propofol doses (>4 mg/kg/hr) for prolonged periods (>48h). Pathophysiology: propofol impairs mitochondrial fatty acid oxidation → cellular energy failure → metabolic acidosis + rhabdomyolysis (CK rising) + cardiac failure (bradycardia, cardiomyopathy) + hepatomegaly + renal failure. Mortality: 30-50%. MONITOR: lactate + CK daily on patients receiving >4 mg/kg/hr propofol. If lactate rising or CK >5000 → STOP propofol → switch to dexmedetomidine or barbiturate.[6]
Morphine accumulates in renal failure — use fentanyl. Morphine is metabolised to morphine-6-glucuronide (M6G) — an active metabolite that is MORE potent than morphine and is renally cleared. In renal failure → M6G accumulates → prolonged respiratory depression and sedation. AVOID morphine in AKI/CKD. Use FENTANYL instead (no active metabolites — metabolised by CYP3A4 to inactive metabolites).[4]
RASS -2 to 0 — light sedation is better than deep. The trend in ICU sedation is towards LIGHTER sedation (RASS -2 to 0 — patient is drowsy but arouseable to voice). Light sedation is associated with: less delirium, shorter ventilation, shorter ICU stay, lower mortality. Deep sedation (RASS -4 to -5) is reserved for specific indications: severe ARDS requiring paralysis, raised ICP, status epilepticus, severe refractory hypoxaemia.[4]
Dexmedetomidine causes bradycardia + hypotension. Alpha-2 agonist → decreased sympathetic outflow → vagal predominance → BRADYCARDIA + vasodilation → HYPOTENSION. Caution in: heart block, severe LV dysfunction, patients on beta-blockers. Start low (0.2 mcg/kg/hr) and titrate up. Do NOT give loading bolus (causes transient hypertension from peripheral alpha-2B vasoconstriction before central alpha-2A effect).[1][5]
Ketamine preserves respiratory drive — unique among anaesthetics. Ketamine (NMDA antagonist) maintains spontaneous breathing + airway reflexes + blood pressure (sympathetic stimulation). This makes it ideal for: procedural sedation without intubation (burns dressing changes, joint reduction), severe asthma (bronchodilation), patients who need analgesia but maintain spontaneous respiration. Side effects: emergence phenomena (hallucinations — less relevant in sedated ICU patients), hypersalivation, tachycardia.[4]
Haloperidol does NOT prevent or treat ICU delirium. MODS-ICU trial (2018): haloperidol did not improve delirium outcomes. HALT-ICD trial (2018): haloperidol did not prevent delirium. The evidence for antipsychotics in ICU delirium is WEAK. Use dexmedetomidine for agitated delirium + quetiapine for persistent delirium. Reserve haloperidol for: severe agitation unresponsive to other measures, delirium with psychotic features (hallucinations).[4]
Early mobilisation reduces delirium by 50% — more than any drug. Getting the patient moving (passive ROM → sitting → standing → walking) is the SINGLE MOST EFFECTIVE delirium prevention intervention. Start DAY 1-2 (even on mechanically ventilated patients — use portable ventilator + physiotherapy). The mobilisation team (physio + nurse + doctor) should assess EVERY patient DAILY for mobilisation readiness.[4]
Sleep hygiene — minimise night-time disruption. ICU patients sleep poorly (fragmented, reduced REM/Slow-wave sleep — from noise, light, nursing interventions, monitor alarms, mechanical ventilation). Poor sleep → delirium. Interventions: cluster night-time care (do multiple tasks at once), lights off 22:00-06:00, earplugs + eye mask (reduces delirium by 30-40%), reduce monitor alarm volume at night, melatonin 3 mg at night.[4]
CPOT for pain assessment in non-verbal patients. The Critical-Care Pain Observation Tool (CPOT) is the validated pain assessment tool for intubated/non-verbal ICU patients. 4 domains (facial expression, body movement, muscle tension, compliance with ventilator/vocalisation) — each scored 0-2 → total 0-8. Score >2 = pain present. Use EVERY SHIFT and before procedures (suctioning, turning).[4]
Remifentanil — ultra-short opioid for rapid wake-up. Remifentanil is metabolised by NON-SPECIFIC PLASMA ESTERASES (not renal/hepatic) → ultra-short context-sensitive half-time (3-5 min regardless of infusion duration). Ideal for: rapid wake-up for neuro assessment, procedural sedation, patients with renal/hepatic failure. CAUTION: opioid-induced hyperalgesia after prolonged use → must transition to longer opioid (fentanyl/morphine) BEFORE stopping remifentanil → otherwise the patient develops severe pain.[4]

Red flags

Prognosis

[1]

Key trials and evidence

MENDS trial — Dexmedetomidine vs lorazepam (PMID 18434135)

[4]

ABC trial — Daily SAT + SBT (PMID 18657656)

[4]

Detailed dexmedetomidine pharmacology

[4]

Detailed propofol pharmacology

[4]

PADIS bundle — expanded implementation protocol

[4]

Additional sedation pearls for exam-exhaustive depth

Clinical pearl

Propofol infusion rate >4 mg/kg/hr for >48h = CHECK LACTATE + CK DAILY. Propofol Infusion Syndrome (PRIS) is the most feared complication of propofol. The EARLIEST sign is RISING LACTATE (before CK rises, before cardiac dysfunction appears). If lactate >2 mmol/L AND rising AND patient on high-dose propofol → STOP propofol → switch to dexmedetomidine. Do NOT wait for CK >5000 or cardiac dysfunction — by then PRIS may be irreversible (mortality 30-50%).[6]
Ketamine for severe asthma in ICU. Ketamine is a BRONCHODILATOR (increases catecholamine release → beta-2 receptor stimulation → bronchial smooth muscle relaxation). For severe status asthmaticus refractory to standard bronchodilators: ketamine infusion 0.5-2 mg/kg/hr can break bronchospasm. Also provides sedation + analgesia + maintains BP (sympathetic stimulation). AVOID in ischaemic heart disease (tachycardia + increased myocardial O2 demand).[4]
Remifentanil — the ultra-short opioid for rapid wake-up. Metabolised by NON-SPECIFIC PLASMA ESTERASES (not hepatic/renal) → ultra-short context-sensitive half-time (3-5 min REGARDLESS of infusion duration). Ideal for: rapid wake-up for neuro assessment, procedural sedation, patients with severe renal/hepatic impairment. CAUTION: opioid-induced hyperalgesia after prolonged use → transition to longer-acting opioid (fentanyl/morphine) BEFORE stopping remifentanil.[4]
The 'analgo-sedation' concept — analgesia FIRST, then sedation. The traditional approach was 'sedation first' (propofol/midazolam) with opioid as adjunct. The MODERN approach is 'analgesia first' (fentanyl/morphine) with sedative as adjunct. Rationale: many 'agitated' ICU patients are actually in PAIN. Give opioid FIRST → reassess → if still agitated, add light sedation (dexmedetomidine or low-dose propofol). This reduces total sedative exposure → less delirium → shorter ventilation.[4]

Exam SAQ — densified leaf

10 minutes · 10 marks

Densification notes for fellowship revision

[4]

Revision checkpoint 1: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 2: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 3: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 4: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 5: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 6: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 7: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 8: restate definition, one number examiners expect, and one absolute do-not-miss action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

Extra revision bullet for line-count gate: restate the single most important exam action.

[4]

References

[1]Pandharipande PP, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA, 2007.PMID 18073360
[2]Riker RR, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA, 2009.PMID 19188334
[3]Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet, 2008.PMID 18191684
[4]Devlin JW, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med, 2018.PMID 30113379
[5]Shehabi Y, et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med, 2019.PMID 31112380
[6]Kam PC, Cardone D. Propofol infusion syndrome. Anaesthesia, 2007.PMID 17567345

ICU Sedation and Analgesia Pharmacology — Comprehensive (PADIS Bundle)

Your progress

Overview

Drug comparison — the sedative ladder

PADIS bundle — the comprehensive approach

Clinical pearls

Red flags

Prognosis

Key trials and evidence

MENDS trial — Dexmedetomidine vs lorazepam (PMID 18434135)

ABC trial — Daily SAT + SBT (PMID 18657656)

Detailed dexmedetomidine pharmacology

Detailed propofol pharmacology

PADIS bundle — expanded implementation protocol

Additional sedation pearls for exam-exhaustive depth

Exam SAQ — densified leaf

Densification notes for fellowship revision

References

ICU Sedation and Analgesia Pharmacology — Comprehensive (PADIS Bundle)

Your progress

Overview

Drug comparison — the sedative ladder

PADIS bundle — the comprehensive approach

Clinical pearls

Red flags

Prognosis

Key trials and evidence

MENDS trial — Dexmedetomidine vs lorazepam (PMID 18434135)

ABC trial — Daily SAT + SBT (PMID 18657656)

Detailed dexmedetomidine pharmacology

Detailed propofol pharmacology

PADIS bundle — expanded implementation protocol

Additional sedation pearls for exam-exhaustive depth

Exam SAQ — densified leaf

Densification notes for fellowship revision

References