Sedation, analgesia and delirium (PADIS)

Also known as PADIS guidelines · ICU delirium · CAM-ICU · ABCDEF bundle · Propofol infusion syndrome (PRIS) · Goal-directed sedation

The PADIS framework (Pain, Agitation/sedation, Delirium, Immobility, Sleep) guides ICU symptom management. Delirium affects 50-80% of ventilated ICU patients and is an independent predictor of mortality, longer ventilation, cognitive impairment. Assessment: pain (CPOT/BPS), sedation (RASS), delirium (CAM-ICU/ICDSC). Management: goal-directed light sedation (RASS -1 to 0), treat pain FIRST (analgesia-first), daily sedation interruption, ABCDEF bundle. Dexmedetomidine achieves arousable sedation with less delirium and earlier extubation than midazolam (SEDCOM); SPICE III found no 90-day mortality difference vs usual care. Haloperidol does NOT improve outcomes in ICU delirium. Propofol infusion syndrome (PRIS) is a lethal complication of high-dose, prolonged propofol (above 4 mg/kg/h for over 48 h).

high16 referencesUpdated 19 Aug 202614 min readSource-verified · Oct 2026

Checked against its sources on 14 Oct 2026

The exam answer

PADIS is the daily ICU symptom loop — Pain, Agitation/sedation, Delirium, Immobility, Sleep — driven by structured assessment every shift: pain with CPOT (or BPS) and NRS when the patient can speak, sedation depth with RASS, and delirium with CAM-ICU or ICDSC. Three rules do most of the work: analgesia-first (treat pain before adding any sedative), light goal-directed sedation (RASS -1 to 0 for most ventilated patients), and the ABCDEF bundle. Dexmedetomidine gives arousable sedation with less delirium and earlier extubation than midazolam (SEDCOM) and no 90-day mortality difference versus usual care (SPICE III) — while haloperidol does not improve outcomes in ICU delirium (MIND-USA, HOPE-ICU). The lethal pharmacological trap is propofol infusion syndrome (PRIS): propofol above 4 mg/kg/h for over 48 h causing metabolic acidosis, rhabdomyolysis and cardiac failure.^[1]^[13]^[14]

Meet the patient

An elderly woman is intubated for severe community-acquired pneumonia. It is day 3. She is on propofol plus a fentanyl infusion, her RASS is too deep, the CAM-ICU is positive, and the creatine kinase has crept upward with a raised lactate. The nurse asks whether to add haloperidol for the delirium.^[14]

Three questions decide her coming shift, and they are the three that decide every PADIS problem: is she too deeply sedated? (RASS -3 is too deep, and the propofol dose is creeping toward PRIS), is her pain controlled before you reach for more sedation?, and is there a reversible driver of the delirium — or are you about to prescribe a drug that changes nothing?^[7]^[14]

References16Show

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