Mechanically Ventilated Patient Requiring Sedation
Assess need for sedation after addressing pain, delirium, physiologic needs
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Critical CareManagement
ICU Sedation Management (PADIS Guidelines)
ICU Sedation Management (PADIS Guidelines): Mechanically Ventilated Patient Requiring Sedation → Address Pain FIRST (Analgosedation) → Set Sedation Targ...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Address Pain FIRST (Analgosedation)
Pain is primary driver of agitation - treat before sedatives
- Use validated pain scale (CPOT, BPS)
- Opioid analgesia as first-line
- Fentanyl preferred for hemodynamic stability
- Consider multimodal analgesia
03Action Set Sedation Target: LIGHT (RASS 0 to -2)
Strong recommendation for light sedation in most patients
- RASS 0: Alert and calm
- RASS -1: Drowsy, sustained awakening >10s
- RASS -2: Light sedation, brief awakening <10s
- Document target in orders
04Decision Special Deep Sedation Indication?
Most patients should target light sedation
- ARDS with ventilator dyssynchrony
- Therapeutic hypothermia
- Refractory ICP elevation
- NMBA use (must be deeply sedated)
05Action Deep Sedation (RASS -4 to -5)
Reserved for specific indications
- Target RASS -4 to -5
- Daily reassessment for lightening
- Monitor for over-sedation complications
- Plan for transition to light sedation
06Action Daily Sedation Assessment
Reassess sedation needs every shift
- Spontaneous Awakening Trial (SAT)
- Coordinate with SBT for ventilator weaning
- Reduce infusion to lowest effective dose
- Target lightest tolerated sedation
07Decision Breakthrough Agitation?
RASS +1 to +4
08Action Address Underlying Cause
Before escalating sedation
- Pain - treat with analgesia
- Delirium - CAM-ICU, non-pharm first
- Hypoxia, hypercapnia
- Full bladder, constipation
- Anxiety - consider dexmedetomidine
09Action Escalate Sedation
If agitation persists after addressing causes
- Increase current agent
- Add second agent
- Consider short-term deeper target
- Reassess daily for de-escalation
10Outcome Deep Sedation Required
Daily reassessment for lightening
11Outcome Light Sedation Achieved
RASS 0 to -2, awake for participation in care
- Path rejoins step 11Shared downstream outcome
12Decision Select Sedation Agent
Dexmedetomidine vs Propofol
13Action Dexmedetomidine (Precedex)
PADIS 2025: Suggest over propofol when light sedation or delirium reduction priority
- Load: 0.5-1 mcg/kg over 10-20 min (optional)
- Infusion: 0.2-0.7 mcg/kg/hr
- Max: 1.5 mcg/kg/hr
- ⚠️ Risk: Bradycardia, hypotension
- Benefit: Less delirium, better awakening
- Path rejoins step 06Shared downstream outcome
14Action Propofol
Alternative for lighter sedation, rapid awakening
- Start: 5-10 mcg/kg/min
- Titrate: 5-50 mcg/kg/min
- Max: 80 mcg/kg/min (PRIS risk)
- ⚠️ Monitor triglycerides if >48h
- ⚠️ PRIS risk at high doses/prolonged use
- Path rejoins step 06Shared downstream outcome
15Warning ⚠️ Avoid Benzodiazepines
Associated with worse outcomes
- Increased delirium risk
- Longer mechanical ventilation
- Exception: alcohol withdrawal, seizures
- PADIS: Suggest against routine use
Guideline Source
A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address procedural sedation
- Assumes mechanically ventilated patient
- Neurosurgical patients may need deeper sedation targets
- Drug dosing varies by institution and patient factors
- Does not address alcohol withdrawal requiring high-dose benzos
Contraindicated Populations
pediatric
Applicable Regions
USEUGlobal
Global: PADIS guidelines widely adopted
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the ICU Sedation Management (PADIS Guidelines)?
The ICU Sedation Management (PADIS Guidelines) is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
What guideline is the ICU Sedation Management (PADIS Guidelines) based on?
This algorithm is based on A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (DOI: 10.1097/CCM.0000000000006574).
What are the limitations of the ICU Sedation Management (PADIS Guidelines)?
Known limitations include: Does not address procedural sedation; Assumes mechanically ventilated patient; Neurosurgical patients may need deeper sedation targets; Drug dosing varies by institution and patient factors; Does not address alcohol withdrawal requiring high-dose benzos. Individual patient factors may require deviation from these recommendations.
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