This document provides guidelines for sedation, analgesia, and neuromuscular blockade in the adult intensive care unit (ICU). It describes the benefits of daily awakening and sedation titration programs. It discusses assessing and treating pain, and the consequences of untreated pain. It reviews sedation and analgesia options like opioids, benzodiazepines, propofol, and neuromuscular blocking agents. It also addresses delirium screening, risk factors, and treatment options. The optimal level of sedation allows for patient interaction while maintaining comfort. Daily awakening and titrating sedation to the minimum required level can reduce ICU and ventilation times.

1. Sedation, Analgesia, and Neuromuscular Blockade in the Adult ICU Dalhousie Critical Care Lecture Series

12. Overview of SCCM Algorithm 1 2 3 4 Jacobi J, Fraser GL, Coursin D, et al. Crit Care Med. 2002;30:119-141.

14. Address Pain

16. Opiate Analgesic Options: Fentanyl, Morphine, Hydromorphone * Offset prolonged after long-term use ** Active metabolite accumulation causes excessive narcosis 10 mg 1.5 mg 100 mcg Equivalent doses X Avoid in hemodynamic instability X Preload reduction X** Avoid in renal disease X* Rapid offset X Rapid onset Morphine Hydromorphone Fentanyl

17. Fentanyl half life over time

18. Sample Analgesia Protocol Numeric Rating Scale

19. Address Sedation Yes

21. Why Does Midazolam Change From a Short- to a Long-acting Benzodiazepine When Given for a Prolonged Period of Time? Hours Duration of midazolam therapy Chest. 1993;103:55.

22. Context Specific Half-life Accumulation in a deep compartment is a function of fat solubility and may explain the long duration of action of midazolam after long-term use.

25. Sample Sedation Protocol Sedation-agitation Scale Riker RR et al. Crit Care Med. 1999;27:1325.

45. Sample NMBA Protocol