Sedation, Analgesia, Delirium, and Toxicology
Sedation practice
Analgesia-first sedation with a light target (RASS −2 to 0) shortens ventilation. Assess pain with a behavioral scale (CPOT or BPS) in patients who cannot self-report. Use propofol or dexmedetomidine for short-term sedation; avoid benzodiazepines, which prolong ventilation and increase delirium. Daily spontaneous awakening and breathing trials, early mobility, family engagement, and sleep hygiene form the ABCDEF bundle. Delirium is diagnosed with CAM-ICU; treat nonpharmacologically first, since antipsychotics have not been shown to shorten delirium.
Toxicology essentials
- Acetaminophen: N-acetylcysteine, guided by the Rumack-Matthew nomogram from a level drawn at least 4 hours after ingestion.
- Salicylates: urinary alkalinization, hemodialysis for severe toxicity.
- Tricyclic antidepressants: sodium bicarbonate for QRS widening; avoid class IA/IC antiarrhythmics.
- Toxic alcohols: fomepizole plus hemodialysis for severe acidosis or renal failure.
- Opioids: naloxone titrated to respiratory effort, not full arousal.
- Methemoglobinemia: methylene blue. Digoxin toxicity: Fab fragments. Local anesthetic systemic toxicity: lipid emulsion.
Traps
Flumazenil in a mixed overdose (seizures); giving activated charcoal late or in an unprotected airway; assuming a normal anion gap excludes toxic alcohol; over-sedating to RASS −5 because the patient is "restless" (look for pain, delirium, hypoxia, urinary retention, withdrawal).
Worked example
A patient on high-dose propofol for 5 days develops rising triglycerides, acidosis, and rhabdomyolysis - propofol infusion syndrome. Stop propofol, switch agents, and support organ function.
Rule of thumb
Before deepening sedation, look for a cause: pain, delirium, hypoxemia, hypotension, retention, or withdrawal.