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TICU Analgesia/Sedation Protocol

For Mechanically Ventilated Patients
Division of Trauma and Surgical Critical Care

Use clinical judgment to individualize therapy based on patient comorbidities, goals of care, and evolving clinical condition.

1. Initial Sedation & Analgesia

Initiate:

  • Fentanyl infusion: 50–200 mcg/hr
    AND
  • Propofol infusion: 5–50 mcg/kg/hr
    OR
  • Dexmedetomidine infusion: 0.1–1.5 mcg/kg/hr

    †Do not use dexmedetomidine in patients with: - Neurogenic shock
    - Bradycardia
    - Need for sedation for ICP control or ventilator synchrony

2. Pain Assessment

Is the patient in pain?

  • Yes:
  • Initiate or increase multimodal analgesia:
    • Acetaminophen
    • Gabapentin
    • NSAIDs
    • Muscle relaxants
    • PRN hydromorphone or oxycodone
  • Fentanyl bolus: 50–100 mcg IV

  • Increase fentanyl infusion by 25–50 mcg/hr

  • No:

  • Continue monitoring and reassess every 1–2 hours

3. Sedation Assessment

Is the patient at their goal RASS (Richmond Agitation-Sedation Scale)?

A. If Actual RASS < Goal RASS (Over-sedated):

  • Decrease sedative/analgesic dose to achieve target RASS
  • If severely over-sedated:
  • Hold sedative infusion
  • Restart at 50% of previous dose if clinically indicated

B. If Actual RASS > Goal RASS (Under-sedated or Agitated):

  • Administer propofol bolus and/or increase infusion rate if appropriate
  • If patient is agitated or delirious:
  • Initiate or escalate oral agents per Delirium/Agitation PMG
  • If propofol intolerance suspected (e.g., CPK ≥ 5000 or triglycerides > 500):
  • Consider:
    • Midazolam infusion: 0.5–10 mg/hr
    • Or Dexmedetomidine infusion

Reassess sedation every 1–2 hours

4. Daily Care Measures

  • Perform Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) daily
  • Consult Physical Therapy and Occupational Therapy as soon as patient is able to participate

5. References

  1. Devlin JW, Skrobik Y, Gélinas C, et al. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018; 46:825–873.

6. Last Updated

  • September 2021

7. Authors

  • Jill Streams, MD
  • Diana Hayes, AGACNP
  • Leanne Atchison, PharmD
  • Jennifer Beavers, PharmD, BCPS