ICU Map

ICU Sedation Titration & ABCDEF Liberation

From 'analgesia-first' multimodal pain control and light sedation targeting to daily SAT/SBT coordination, delirium screening, and early mobility.

RecognizeAssessDecideDifferentialInterveneReassess
Intubated ICU Patient Requiring Sedation & Analgesia
Clinical ActionAdopt 'Analgesia-First' approach: Assess pain using validated behavioral scalesExplore Topic
Use Critical-Care Pain Observation Tool (CPOT) or Behavioral Pain Scale (BPS). Treat pain prior to escalating sedatives with short-acting opioids (Fentanyl / Hydromorphone) and multimodal non-opioid adjuncts.
Clinical ActionSet target to Light Sedation: Richmond Agitation-Sedation Scale (RASS -1 to 0)
Avoid deep sedation unless specific clinical indication exists (severe ARDS with ventilator dyssynchrony, elevated ICP, therapeutic hypothermia, status epilepticus).
Decision PointSelect non-benzodiazepine sedative: Dexmedetomidine or Propofol
PADIS guidelines strongly recommend non-benzodiazepines over Midazolam/Lorazepam to reduce ventilator duration, ICU length of stay, and delirium incidence.
Clinical ActionExecute daily paired Spontaneous Awakening (SAT) & Breathing (SBT) TrialsExplore Topic
Every morning, turn off sedative and opioid infusions. When patient passes SAT, proceed immediately to spontaneous breathing trial (the 'Wake Up and Breathe' protocol).
Reassessment / LoopScreen for Delirium twice daily using CAM-ICU or ICDSC
Delirium increases mortality and long-term cognitive impairment. Identify underlying triggers: hypoxemia, sepsis, electrolyte derangement, anticholinergic medications.
Differential Branches (2)
1Branch
Clinical ActionCAM-ICU Positive: Non-pharmacologic bundle (Mobility, Sleep, Reorientation)
Implement ABCDEF bundle: daytime cognitive stimulation, night-time sleep promotion (dim lights, minimize alarms), early physical therapy, and family presence. Avoid routine antipsychotics.
2Branch
Reassessment / LoopCAM-ICU Negative: Continue progressive mobilization & extubation path
Progressive physical mobility protocol (sitting on bed edge, standing, transfer to chair) and plan for early ventilator extubation.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • Propofol Infusion Syndrome (PRIS) — suspect with otherwise unexplained metabolic acidosis, rhabdomyolysis, hyperkalemia, arrhythmia/bradycardia or cardiac failure during substantial propofol exposure. Higher dose and longer duration increase risk, but no single cutoff is diagnostic; stop propofol promptly when PRIS is suspected and provide urgent supportive care.
  • Benzodiazepine-heavy continuous sedation can delay awakening and is associated with delirium; favor non-benzodiazepine strategies when appropriate, while retaining midazolam/lorazepam for specific indications such as seizures, withdrawal or situations where they are otherwise clinically preferred.

Related Bedside Clinical Problems (17)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Acute Hypercapnia & Ventilatory Failure

Triaging rising PaCO2: distinguishing acute uncompensated acidemia from chronic compensation, identifying central vs pump vs dead-space failure, and titrating noninvasive ventilation.

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Sudden Ventilator Deterioration & High Airway Pressures

Algorithmic troubleshooting of acute patient-ventilator collapse: the DOPE framework, peak vs plateau pressure differentiation, auto-PEEP evaluation, and manual bagging separation.

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Linked Deep-Dive Topics (4)

Reference Knowledge
ICU Sedation, Analgesia, Delirium & Liberationneurology

Analgesia-first sedation, light sedation targets, ABCDEF bundle, spontaneous breathing trials, and non-pharmacologic delirium mitigation.

Explore Topic →
Altered Consciousness, Coma, & Delirium in the ICUneurology

ARAS neuroanatomy, structural vs toxic-metabolic coma, the comprehensive Coma Exam (pupils, cold calorics, posturing), FOUR score, and CAM-ICU delirium.

Explore Topic →
Invasive Mechanical Ventilationrespiratory

Complete clinical topic overview. For the full 10-level interactive course, visit Master MV. Covers core ventilator modes, respiratory mechanics (Cstat, Raw, driving pressure), waveform dyssynchrony analysis, VILI prevention, and liberation protocols.

Explore Topic →
Respiratory Failure: Basic Principlesrespiratory

Core taxonomy (Types I–IV), alveolar gas exchange physiology, work-of-breathing mechanics, and escalation thresholds in acute respiratory failure.

Explore Topic →

Evidence status

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