It can be applied in ICU patients who cannot use a numeric a scale such as the 0–10 NRS.

It measures pain intensity.

It consists of a 10 cm line, with two end points representing 0 (no pain) and 10 (worst possible pain or pain as bad as it could possibly be)

Ask the patient to rate their current level of pain by placing a mark on the line.

Indicator

Description

Score

Facial expression.

No muscular tension observed.

Relaxed, neutral.

0

Presence of frowning, brow lowering, orbit tightening.

Tense.

1

All of the above facial movements plus eyelid tightly closed.

Grimacing.

2

Body movements.

Does not move at all (does not necessarily mean absence of pain).

Absence of movement.

0

Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements.

Protection.

1

Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed.

Restlessness.

2

Muscle tension evaluation by passive flexion and extension of upper extremities.

No resistance to passive movements.

Relaxed.

0

Resistance to passive movements.

Tense, rigid.

1

Strong resistance to passive movements, inability to complete them.

Very tense or rigid.

2

Compliance with the ventilator.

OR

Vocalization (extubated patients).

Alarms not activated, easy ventilation.

Tolerating ventilator or movement.

0

Alarms stop spontaneously.

Coughing but tolerating.

1

Asynchrony: blocking ventilation, alarms frequently activated.

Fighting ventilator.

2

Talking in normal tone or no sound.

Talking in normal tone or no sound.

0

Sighting, moaning.

Sighting, moaning.

1

Crying out, sobbing.

Crying out, sobbing.

2

Total, range

0-8

Music

Cold ice packs

Massage

Relaxation techniques

Morphine can be used for both sedation and analgesia in ICU.

2 to 10 mg as loading dose and 1-5 mg/hr as intermittent or continuous infusion and reassess after every 30 minutes.

If inadequate pain control, re-bolus Inj. Morphine and increase infusion by 50%. And re-evaluate again in 30 minutes and increase or decrease dose by 50%.

Accumulation in patients with liver and renal dysfunction (morphine-6-glucuronide may cause respiratory depression and seizure), so dose adjustment and gradual titration is needed.

A good choice for analgesia and sedation for most critically ill patients.

1-2 mcg/kg (25 to 100 mcg) IV bolus.

If inadequate pain relief, re-bolus Inj. Fentanyl 50-100 mcg.

Use for sedation in patients planned to be weaned and extubated early.

Fentanyl infusion shall be used only for acute pain e.g., postoperative pain with dose of 25-50 mcg/ hr.

1-gram IV Q8H (due to its short elimination half-lives extra dose can be given after 4 hours), max dose ≤4 g/day.

First choice for treatment of mild to moderate acute pain and febrile conditions.

Adjunctive analgesics in critically ill patients to reduce opioid use and improve analgesic effectiveness.

Caution in hepatic dysfunction.

Initially 75mg once or twice daily, maintenance 150 to 300 mg twice per day.

Useful adjunct to other analgesics for treatment of neuropathic and postoperative pain.

Dose adjustment needed for renal impairment.

Adverse effects include sedation, blurred vision, dry mouth, dizziness, and ataxia.

Very good for sedation and analgesia

Dose: 50 mg IV bolus followed by 25-50 mg/hr

Adverse effects include delirium, hallucinations, and prolonged effects.

Light sedation is generally preferred in critically ill, mechanically ventilated adults.

A minority of ICU patients have an indication for continuous deep sedation, for reasons such as

● Treatment of intracranial hypertension.

● Severe respiratory failure.

● Refractory status epilepticus.

● Prevention of awareness in patients treated with neuromuscular blocking agents.

Every patient admitted to an adult ICU should undergo routine sedation assessment using standardized, validated assessment tools.

Nurse should perform and record the results of the Richmond Agitation and Sedation Scale (RASS) every 2 hours with vital Signs.

Each day during rounds, the team should set “target” RASS score for the patient for following 24 hours.

Each day during interdisciplinary rounds, the Nurse should inform the team of the patient’s actual RASS score and patient’s “Target” RASS score

Scale

Label

Description

+4

COMBATIVE

Combative, violent, immediate danger to staff.

+3

VERY AGITATED

Pulls to remove tubes or catheters; aggressive.

+2

AGITATED

Frequent non-purposeful movement, fights ventilator.

+1

RESTLESS

Anxious, apprehensive, movements not aggressive.

0

ALERT & CALM

Spontaneously pays attention to caregiver.

-1

DROWSY

Not fully alert, but has sustained awakening to voice (eye opening and contact >10 sec).

-2

LIGHT SEDATION

Briefly awakes to voice (eye open and contact <10 sec).

-3

MODERATE SEDATION

Movement or eye opening to voice (no eye contact).

If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?).

-4

DEEP

SEDATION

No response to voice, but movement or eye opening to physical stimulation.

-5

UNAROUSABLE

No response to voice or physical stimulation.

If RASS is -4 or -5 → STOP (patient unconscious), RECHECK later

Predominantly agonist at GABA receptor.

Hypnotic, antiemetic, and anticonvulsant.

No analgesic properties.

Onset of action 1–2 minutes, duration of effect 5–10 minutes.

Dose: 25-50 mcg/kg/min and titrate in increments of 25mcg/kg/min till desired level of sedation is achieved.

More appropriate for targeting deep sedation (RASS = - 2 / -3).

Should be used in Increment of 5 ml/hour.

Side effects

● Vasodilation and hypotension.

● Pancreatitis.

● Myocardial depression.

● Propofol infusion syndrome.

● Respiratory depression.

● Check Triglycerides after 72 hours.

● Pancreatitis.

● Watch for lactic acidosis and rhabdomyolysis.

Alpha‐2 receptor agonist.

Minimal respiratory depression.

Sedative and analgesic properties.

Prepare and administer as follows:

● Preparation available: 1 ml = 100 mcg.

● Add 2 ml Dexmedetomidine with 48 ml NS in 50 ml Syringe pump, so 50 ml = 200 mcg, 1 ml = 4 mcg.

● Give IV Bolus: 0.5-1 mcg/kg over 10 mins.

● Start infusion at 0.2 mcg / Kg / hr. = 3 ml / hour for 60 kg (12 mcg).

● Reassess over 5 mins and Increase Infusion by 3 ml / hour.

● Maximum infusion rate: 0.7 mcg / Kg / hr. = 20 ml / hour for 60 kg (60 mcg).

● Doses Used: 3 / 6 / 9 / 12 / 15 ml/hour.

● Titrate down the infusion rate and maintain at that rate when target RASS is achieved.

Side Effect:

● Bradycardia

● Hypotension

STOP if HR < 60 / min OR MAP < 65 mm Hg

Most preferable in case of seizure and Alcohol Withdrawal.

Used only for Anticonvulsant, and for Procedural Sedation, or Amnesia.

Use of Midazolam and Benzodiazepines in ICU is associated with increased length of ICU stay, increased length of mechanical Ventilation, increased delirium incidence and mortality.

Every patient admitted to an adult ICU should undergo routine delirium assessment using standardized, validated assessment tools.

Nurse should perform and record the results of the Confusion Assessment Method-ICU (CAM-ICU) twice a day and whenever a patient experiences a change in mental status.

Each day during interdisciplinary rounds, the nurse should inform the team of the patient’s CAM-ICU status and ongoing sedative and analgesic medications.

Ensure Daily Spontaneous Awakening Trial (SAT) performed.

Continually reorient patient to environment/surroundings.

Adequate pain management.

Perform Early mobilization:

● Out of Bed and Wheel Chair Mobilization for all

● Ambulation if OFF Inotropes and Low Ventilator Settings i.e., PEEP < 8 and FiO ₂ < 50%

Promote effective sleep/awake cycles.

Perform timely removal of catheters/physical restraints.

Ensure the use of eyeglasses, hearing aids.

Minimize continuous noise/stimulation at night.

Daylight exposure and orientation to Day and Night.

Minimize benzodiazepine for sedation – Consider Alcohol Withdrawal States in Chronic Alcohol Consumers.

Intravenous route is generally preferred among critically ill patient.

IV 5 mg Bolus, repeat every 3 – 5 mins till agitation settles down. If no response to cumulative dose of ~30 mg, then try a different medication.

QTc prolongation and torsade de pointes can occur. Contraindicated in patients with known QTc prolongation.

Tab. Quetiapine 25 mg BD / TDS and increase dose as required.

Metabolism may be slowed in patients with hepatic impairment, so exercise caution with repeated dosing, but not for renal dysfunction.

Caution is warranted in patients with QT prolongation.

Quetiapine has the lowest risk of extrapyramidal side-effects (compared to other antipsychotics).

Olanzapine PO 10 mg BD / TDS.

Rapidly absorbed, within about an hour.

Oral olanzapine can take several hours to reach peak effect. If prompt effect is desired, better options include oral Quetiapine.

Note that olanzapine doesn'tcause torsade de pointes. So, this is a useful agent if the QT interval is prolonged.

Higher risk of extrapyramidal effects, less powerful sedative effects.