Sedation, Pain & Delirium

Brain, Spine & Nerves · ICU Decoded chapter 31 · Locked — free with a referral

By Dr Javed Akhtar · Last reviewed 3 October 2026

Cited to SCCM PADIS 2018/2025.

Key points

Lead with analgesia (fentanyl), then target the lightest sedation (RASS 0 to −1); propofol or dexmedetomidine beat benzodiazepines, and dexmedetomidine is preferred when light sedation or less delirium is the priority (PADIS 2025).
Pair a daily spontaneous awakening trial with an SBT once safety screens pass; skip the interruption while deep sedation is still needed, such as for uncontrolled ICP or active seizures.
Screen for delirium once the patient is awake enough. ABCDEF: Assess and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium assessment and prevention; Early mobility; Family engagement. Treat causes and use non-drug measures; antipsychotics are not routine treatment for delirium.
Dexmedetomidine for agitated delirium/withdrawal; watch QTc with antipsychotics.

Investigations

First tests: Validated delirium and sedation assessment, Blood glucose.

Only if indicated: Sodium, potassium, bicarbonate, urea and creatinine, Source-directed infection tests, Noncontrast CT head, EEG.

Repeat monitoring: Validated delirium and sedation assessment.

Management pathways in this chapter

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

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The pathway step by step, with its decision points
Treatment orders with doses
Why and when to send each test

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