This document discusses options for analgesia and sedation in intensive care unit patients. It describes tools for pain assessment and factors that can reduce analgesic requirements. The main options for analgesia discussed are opioid analgesics like fentanyl, morphine, hydromorphone, and remifentanyl. Non-opioid options mentioned include ketorolac, ibuprofen, acetaminophen, and gabapentin. For sedation the document covers benzodiazepines like midazolam and lorazepam, propofol, dexmedetomidine, haloperidol, and their risks and benefits.

1. analgesia and sedation
in I.C.U
what is your options ?
Dr. Mohamed El Sayed
Lecturer of Anesthesia and intensive care
ALS provider –ACLS provider –ATLS provider

2. Sedation
Analgesia
Sedation
Analgesia

3. Analgeia
• Treating pain in critically ill patients reliable
pain assessment tool adequacy ofpain relief
A horizontal numeric rating scale
• 10 equally-spaced divider markings, numbered
• 1 (no pain) to 10 (maximal pain).
• The patient points to one of the numbered markings to
indicate the severity of pain.
• A score of 3 or less indicates adequate pain control.

4. Behavioral-pain
scale
• Patient cannot
express himself

5. Factors reducing analgesic requirements

6. Opoid analgesia
• Most popular  fentanyl – morphine –
hydromorphine - remifentanyl
• Sedation - euphoria – analgesia – no amnesia
• Morphine  potent +histamine +metabolites
• Fentanyl  600 more potent + no (metabolites-
histamine)
• Hydro-morphine  more potent + no
metabolite + safe in renal

7. • Remifentanyl
– Ultra-short acting
– Analgesia 8 – 10 min
– No dose adjustment in renal and hepatic
– Used in patients needing frequent evaluation of
brain functions TBI
– Combining remi-fentanil with a longer-acting
opioid. To safe guard against withdrawal .

8. Adverse effects of opioid
• Respiratory depression  dose dependant
• Hemodynamic adverse effects  rarly needs
treatment
• Decrease intestinal motility
• Nausea and vomiting CTZ ++

9. Dosing

10. Non-Opioid Analgesia
Few non-opioid alternatives
Ketorolac
• (NSAID) 350 times more potent thanaspirin
• side effects GIT blrrding + inhibition of platlet
aggregation limited to 5 days
Ibuprofen
• Like ketorolac
• short-term pain control 24–48 h
• No limit time for treatment

11. Acetaminophen
• short-term treatment of pain and fever in
postoperative patient
• opioid-sparing effect
• no anti-inflammatory activity = major disadvantage
• Daily dose limitation of 4 grams
Oral agents for neuropathic pain
• Non-opioid analgesia  gabapentin, pregabalinand
carbamazepine
Ketamine
• analgesic adjunct in cases where patients fail to
respond to escalating doses of opioids(e.g., in
chronic opioid users).

12. Sedation
• Exaggerated feelings of fear
• Absence sense of wellbeing
• Agitation  anxiety with increase motor
activity
• Delirium  acute confusional state that may,
or may not, have agitation as a component.
• Sedation-Agitation Scale (SAS) and the
Richmond Agitation-Sedation Scale (RASS)
 assess sedation

16. Benzodiazepines ( midazolam –lorazepam )
Midazolam
• Once the most popular sedative drugs in the ICU
• drug accumulation + prolonged sedation =
recently  less popular
• Midazolam  rapid onset 1-2 min
• Accumulation in tissues + short duration of action
• Continuous infusion  prolonged sedation 
limit its use to 48 h
• Midazolam  active metabolite kidneys

17. Lorazepam (Ativan )
• longer-acting drug than midazolam
lasting up to 6 hours after i.v injection
• intermittent IV injections, or by
continuous IV infusion
• dosing has a maximum allowable dose
(2 mg for bolus doses, and 10 mg/hr
for continuous infusions).
• no active metabolites.
• PROPYLENE GLYCOL added to
lorazepam to increase solubility in
plasma .

18. BZ advantages
• Amnesia  dose related + anti-grade
• Anticonvulsant effect
• Drug of choice in alcohol and opioid withdrawal .
BZ disadvantages
• Prolonged sedation
• Deleriuim  GABA receptors binding
• Withdrawal symptoms  not common in ICU
• PROPYLENE GLYCOL TOXICITY  Toxidrome
– Metabolic (lactic) acidosis,
– Delirium (with hallucination).
– Hypotension.
– (in severe cases) multi-organ failure.

19. Propofol
• Rapidly-acting general anesthetic
• GABA receptor binding
• Rapid onset and offset
• Infusion only  awakening after 10 -15 min
even with prolonged infusion
• Lipid emulsion = intralipid  1 kcal/ml
• Green urine  harmless phenolic metabolites

20. Adverse effect
• Respiratory depression = M.V
• Hypotension = carful in hypotensive patient
• Hyper-triglycemia  not harmful
• Anaphylactoid reaction
• Propofol infusion syndrome 
– poorly understood condition
– abrupt onset of bradycardic heart failure, lactic
acidosis, rhabdomyolysis, and acute renal failure
– high-dose Propofol infusions (>4–6 mg/kg/hr for
longer than 24–48 hrs)
– The mortality 30%

22. Dexmedetomidine
• Selectivealpha-2 adrenergic agonist that has
sedative,amnestic, and mild analgesic effects,
yetdoes not depress ventilation
• Arousal is maintained, despite deeplevels of
sedation. 6 – 10 min.
• Lower prevalence of delirium
• Adverse effect 
– Hypotension or hypotension
– Bradycardia

24. Haloperidol
• first-generation antipsychotic
• blocking dopa-mine receptor
in CNS.
• IV bolus dose sedation in
10–20 min,
• Lasts 3–4 hours
• No resp. Depression
• no hypotension
• Adverse effects 
– Extra-pyramidal
– Neuroleptic malig. Syndrome
– Prolongation of the QT interval

28. References
• Barr J, Fraser GL,PuntilloK, etal.Clinical practice
guidelines for the management of
pain, agitation, and delirium in adult
patients in the intensive care unit. Crit
Care Med 2013;41(1):263– 306.
• Critical Care Medicine at a Glance, Third Edition.
Richard Leach. © 2014 John Wiley & Sons, Ltd.
Published 2014 by John Wiley & Sons, Ltd.