Sedation, Pain & Delirium

• Lead with analgesia (fentanyl), then target the lightest sedation (RASS 0 to −1); propofol or dexmedetomidine beat benzodiazepines.
• Pair a daily SAT (spontaneous awakening trial) with an SBT to shorten ventilation and reduce delirium.
• Screen with CAM-ICU; delirium means treating causes (ABCDEF bundle: Awakening, Breathing, Coordination, Delirium monitoring, Early mobility, Family engagement), not reflex haloperidol; avoid benzodiazepines.
• Dexmedetomidine for agitated delirium/withdrawal; watch QTc with antipsychotics.

CAM-ICU (Confusion Assessment Method for the ICU) Flowsheet

• 1. Acute change or fluctuating course of mental status: has mental status changed acutely from baseline? OR fluctuated over the past 24 hours?
• CAM-ICU negative — NO DELIRIUM
• 2. Inattention: "Squeeze my hand when I say the letter 'A'" — read out SAVEAHAART; ERRORS: no squeeze with 'A' plus squeezing on other letters (letters impossible → pictures)
• >2 errors — proceed
• 0–2 errors: CAM-ICU negative — NO DELIRIUM
• 3. Altered level of consciousness: current RASS level
• RASS other than zero: CAM-ICU positive — DELIRIUM PRESENT
• 4. Disorganized thinking (RASS = zero): ask — 1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail? · Command: "Hold up this many fingers" (hold up 2 fingers), "Now do the same thing with the other hand" (without demonstrating) OR "Add one more finger" (if the patient cannot move both arms)
• >1 error: CAM-ICU positive — DELIRIUM PRESENT
• 0–1 error: CAM-ICU negative — NO DELIRIUM