Sedation in Adult Patients

General Principles of Sedation

Nonbenzodiazepine sedatives, such as propofol or dexmedetomidine, are preferred over benzodiazepines for sedation in adult patients due to improved clinical outcomes, including shorter ICU length of stay and duration of mechanical ventilation, as recommended by the American College of Critical Care Medicine 1, 2, 3
Light levels of sedation should be maintained in adult patients unless clinically contraindicated, as this is associated with improved outcomes, including shorter duration of mechanical ventilation and ICU length of stay, with a strength of evidence rated as high 4, 5
Before administering sedatives, attempt non-pharmacological approaches, including providing adequate analgesia, frequent reorientation, and optimization of the environment to maintain normal sleep patterns, as suggested by the American College of Critical Care Medicine 4
The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable tools for measuring quality and depth of sedation in adult ICU patients, with a high level of evidence supporting their use 5
Sedation protocols designed to minimize sedative use are associated with improved outcomes, including decreased incidence of delirium and long-term cognitive dysfunction, with a moderate strength of evidence 4

Propofol is a preferred sedative agent due to its rapid onset and short elimination half-life, making it ideal for procedural sedation, with a recommended loading dose of 5 μg/kg/min over 5 minutes and maintenance dose of 5-50 μg/kg/min titrated to effect, as recommended by the American Society of Anesthesiologists 4, 6
Dexmedetomidine is another preferred sedative agent, with an onset of 5-10 minutes and a recommended loading dose of 1 μg/kg over 10 minutes, followed by a maintenance dose of 0.2-0.7 μg/kg/hr, as suggested by the American College of Critical Care Medicine 4, 6
Dexmedetomidine may have opioid-sparing effects, reducing opioid requirements in critically ill patients, with a moderate strength of evidence supporting its use 2

Daily Sedation Interruption (DSI) and Nurse Protocol (NP)-targeted sedation are both safe and effective in achieving and maintaining light sedation, with a high level of evidence supporting their use, as recommended by the American College of Critical Care Medicine 1
DSI protocols may be associated with increased nursing workload, and a brief DSI should not be used to justify deep sedation for the rest of the day when not indicated, with a moderate strength of evidence supporting this recommendation 1

Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients, with a moderate strength of evidence supporting this association 5
Objective measures of brain function, such as BIS, NI, and PSI, should not be used as the primary method to monitor sedation depth in non-comatose, non-paralyzed critically ill adults, with a high level of evidence supporting this recommendation, as suggested by the American College of Critical Care Medicine 5, 3