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ICU Sedation Management (PADIS Guidelines)

ICU Sedation Management (PADIS Guidelines): Ventilated adult in ICU who may need sedation → Treat pain first (analgesia-first) → Set sedation target: li...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    Ventilated adult in ICU who may need sedation

    Adults only. Treat pain and look for delirium and physical causes before you give a sedative.

  2. 02Action

    Treat pain first (analgesia-first)

    Assess pain before any sedative. Treat pain before you start or increase a sedative.

    • Able to self-report: 0-10 numeric rating scale
    • Unable to self-report: BPS or CPOT
    • Opioid is first-line; use the lowest effective dose
    • Renal impairment: avoid morphine (active metabolites accumulate); reduce opioid doses
    • Add paracetamol to reduce opioid need; low-dose ketamine after surgery
    • Also treat non-drug causes: position, tubes, bladder, bowels
  3. 03Action

    Set sedation target: light (RASS 0 to -2)

    PADIS: suggest light sedation for most ventilated adults (conditional, low certainty).

    • RASS 0: alert and calm
    • RASS -1: drowsy, sustained awakening to voice (eye contact 10 s or more)
    • RASS -2: light sedation, brief awakening to voice (eye contact less than 10 s)
    • Write the target RASS in the orders; reassess RASS often and after each dose change
  4. 04Action

    Deep sedation only if indicated (RASS -4 to -5)

    Indications: NMBA infusion, severe ventilator dyssynchrony, refractory raised ICP, status epilepticus, temperature control with shivering. Review every day.

    • NMBA: sedate deeply before and during paralysis; RASS cannot be assessed
    • During NMBA or deep sedation, consider BIS or processed EEG to titrate
    • Usually propofol plus opioid (see propofol cautions below); dexmedetomidine alone is often not enough
    • No SAT while NMBA, ICP control or status epilepticus continue
    • When the indication ends: lighten to RASS 0 to -2
  5. 05Warning

    Avoid benzodiazepine infusions for routine sedation

    PADIS: use propofol or dexmedetomidine over benzodiazepines (conditional).

    • Benzodiazepines: more delirium and longer ventilation
    • Alcohol withdrawal or seizures: benzodiazepine may be needed; use those pathways
  6. 06Action

    Light target, first choice: dexmedetomidine (PADIS 2025)

    Avoid or use with care in bradycardia, advanced heart block, severe ventricular dysfunction, hypotension or hypovolaemia. Age 65 or less: higher mortality with use over 24 h (AU PI, SPICE III).

    • Adult: start 0.4 microgram/kg/h; usual range 0.2-1 microgram/kg/h (AU PI)
    • Maximum 1 microgram/kg/h and 24 h (AU PI); beyond this is off-label
    • Loading dose usually omitted: more hypotension, hypertension and bradycardia
    • Reduce dose in hepatic impairment and age over 65 years
    • Dilute 100 microgram/mL concentrate to 4 microgram/mL in 0.9% sodium chloride
    • Often needs added propofol to reach target (SPICE III); no seizure protection
  7. 07Action

    Deep target, or dexmedetomidine unsuitable or not enough: propofol

    Not if allergy to propofol, egg lecithin or soya oil (AU PI). Causes hypotension. Adults only. If propofol and dexmedetomidine are both unsuitable: a benzodiazepine (for example midazolam) at the lowest effective dose.

    • Adult: usual 1-3 mg/kg/h (AU PI); titrate to the RASS target
    • Do not exceed 4 mg/kg/h (about 67 microgram/kg/min) (AU PI)
    • PRIS risk: high dose for more than 48 h, head injury, sepsis, vasopressors, inotropes or steroids
    • After 48 h or at high dose: check triglycerides, CK, lactate, potassium and ECG
    • PRIS signs (acidosis, rhabdomyolysis, arrhythmia): reduce or stop propofol; change to another sedative
    • Propofol 1% (10 mg/mL): change syringe and infusion set at least every 12 h
  8. 08Action

    Every day: SAT only if the safety screen is passed

    No SAT if: NMBA, treatment of raised ICP, active seizures, alcohol withdrawal, ECMO, myocardial infarction in past 24 h, or RASS above +2.

    • Screen passed: stop sedative infusions; keep the opioid only if pain needs it
    • SAT fails if for 5 min or more: RASS above +2, SpO2 below 88% or RR above 35/min; or new arrhythmia, ICP above 20 mmHg, or 2 or more of: tachycardia, bradycardia, accessory muscle use, abdominal paradox, sweating, marked dyspnoea
    • SAT failed: restart sedative at half the previous dose; titrate to target
    • SAT passed: do an SBT if the SBT screen is passed
    • Screen failed: no SAT today; lowest dose that meets the target; repeat screen tomorrow
    • Nurse-led titration to the target RASS is an alternative to SAT (PADIS)
  9. 09Decision

    Agitated (RASS +1 to +4) or SAT failed?

    Check RASS, pain score and CAM-ICU.

  10. If Yes
    1. 10Action

      Agitated: make safe, then treat the cause

      RASS +3 or +4, or risk to tube or lines: give an opioid bolus, or a propofol bolus if blood pressure allows, now. Do not bolus dexmedetomidine. Then look for the cause.

      • Pain: assess and treat (BPS or CPOT)
      • Delirium: CAM-ICU; use the ICU delirium pathway
      • Hypoxia, hypercapnia, ventilator dyssynchrony, tube position
      • Full bladder, constipation, hypoglycaemia, drug or alcohol withdrawal (use the withdrawal pathway)
    2. 11Decision

      Agitation continues after causes are treated?

      Reassess RASS, pain score and CAM-ICU.

    3. If Yes
      1. 12Action

        Still agitated: increase sedation carefully

        Only after pain and other causes are treated.

        • Increase the current agent within its maximum dose
        • Or add the second agent (dexmedetomidine or propofol)
        • Set a new RASS target and document the reason
        • Try to lighten again every day
      2. 13Outcome

        Deeper sedation in use: review every day

        Return to light sedation (RASS 0 to -2) as soon as possible.

      If No
      1. 14Outcome

        Agitation settled: light sedation achieved

        RASS 0 to -2, calm, pain controlled. Continue daily SAT screen, SBT and early mobilisation.

    If No
    1. 15Outcome

      Calm at target: continue the current plan

      RASS 0 to -2 and pain controlled. Continue daily SAT screen, SBT and early mobilisation. Reassess RASS, pain and CAM-ICU every shift.

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

DOI: 10.1097/CCM.0000000000006574View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only: propofol is contraindicated for ICU sedation at 16 years or younger (AU PI).
  • Does not cover alcohol withdrawal, status epilepticus or delirium drug treatment; use those pathways.
  • Doses follow Australian PIs: dexmedetomidine beyond 24 h or above 1 microgram/kg/h is off-label.
  • Does not address procedural sedation.
  • Local ICU sedation protocols and pharmacy concentrations take precedence.

Contraindicated Populations

pediatricchildren and adolescents 16 years or younger

Applicable Regions

AUUSEUGlobal

AU: Doses from Australian PIs: Diprivan (2025) and Precedex (2026). Precedex PI limits infusion to 24 h and states 0.2-1 microgram/kg/h.

Global: PADIS 2018 with the 2025 focused update. Dexmedetomidine labels differ by country.

Version 2Next review: 2027-09-30

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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: Adults only: propofol is contraindicated for ICU sedation at 16 years or younger (AU PI).; Does not cover alcohol withdrawal, status epilepticus or delirium drug treatment; use those pathways.; Doses follow Australian PIs: dexmedetomidine beyond 24 h or above 1 microgram/kg/h is off-label.; Does not address procedural sedation.; Local ICU sedation protocols and pharmacy concentrations take precedence.. Individual patient factors may require deviation from these recommendations.

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