ICU · pharmacology

ICU Sedation and Analgesia Pharmacology — Comprehensive (PADIS Bundle)

Also known as ICU sedation · PADIS guidelines · Dexmedetomidine · Propofol · Analgo-sedation · RASS · CAM-ICU · Propofol infusion syndrome · MENDS trial · SEDCOM trial

ICU sedation and analgesia pharmacology — the evidence-based approach to managing pain, sedation, and delirium in mechanically ventilated ICU patients following the PADIS (Pain, Agitation/sedation, Delirium, Immobility, Sleep) guidelines. Core principle: ANALGESIA FIRST (treat pain before adding sedatives) + GOAL-DIRECTED SEDATION (light sedation preferred — RASS -2 to 0) + DELIRIUM PREVENTION (minimize benzodiazepines, use dexmedetomidine) + EARLY MOBILISATION. Drug selection: DEXMEDETOMIDINE (alpha-2 agonist — unique 'arousable sedation' — analgesia + sedation WITHOUT respiratory depression — MENDS trial: better delirium-free days than lorazepam; SEDCOM trial: reduces delirium vs midazolam; preferred for delirium-prone patients) → PROPOFOL (GABA-A agonist — rapid onset/offset — preferred for fast-track weaning — caution: PRIS at 4 mg/kg/hr for 48h) → MIDAZOLAM (benzodiazepine — INDEPENDENT RISK FACTOR for delirium — AVOID if possible — reserve for alcohol withdrawal/seizures) → KETAMINE (NMDA antagonist — preserves respiratory drive — useful for procedural sedation + severe asthma). Analgesia: FENTANYL (first-line — rapid onset, short half-life), MORPHINE (active metabolite accumulates in renal failure — AVOID in AKI), REMIFENTANIL (ultra-short — ideal for short procedures or rapidly changing sedation needs). Monitoring: CPOT (Critical-Care Pain Observation Tool) for pain, RASS (Richmond Agitation-Sedation Scale) for sedation, CAM-ICU or ICDSC for delirium.