1. A-1 (Analgesia First) Sedation for intubated patients

Practice Change:  WOW, we all need to be doing this TODAY. What we do in the ED DOES matter and is linked to a HUGE mortality benefit.  I will be using Fentanyl as the primary agent for pain control after intubation followed by low dose propofol and working to change our hospital’s sedated patient algorithm.

Background: Delirium is know to cause increased mortality in the ICU.  Deep sedation is thought to be a major contributor to the development of delirium.  If patients lose day-night cues, their sleep architecture becomes disordered.  If they lose their sleep architecture, they get delirious.  If they get delirious, they have increased mortality.

We have always assumed this was “An ICU Problem” and that care in the ED had nothing to do with these outcomes.  Then the SPICE trial was published…

The Spice Trial:

Early Intensive Care Sedation Predicts Long-Term Mortality in Ventilated Critically Ill Patients

Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators

Am J Resp Crit Care Med 2012


Design: Multicenter, prospective evaluation of Intubated patients and effects of early sedation on outcome

Patients: 251 Intubated Australian ICU patients from 25 centers.


RASS (Richmond Agitation-Sedation Scale)  (image from icudelerium.org)

May 1

LIGHT sedation in this study was +1 to -2,

  • Patients still needed to be able to make EYE CONTACT TO A CONVERSATIONAL VOICE.

Deep Sedation was -3 to -5

  • SO, Deep Sedation even included opening eyes to voice… generally lighter than we consider “deep sedation.”


  • Time until extubation
  • Mortality in the hospital and 180 days

Results: For EVERY RASS score of DEEP Sedation that was recorded at any time (even in the FIRST 4 HOURS) after intubation, there was a:

  • Delay to Extubation by 12.3 hoursMay6
  • 10% increase in Hospital Mortality
  • 8% increase in 6-month Mortality


Conclusion: Deep sedation at ANY time increases Duration of Intubation and Mortality.

This is the first paper to suggest that what we do in the ED DOES matter — if we sedate patients appropriately we can have a 10% mortality benefit for our patients.  

 Is there a better way to do sedations so that we can keep patients from hitting those deep levels of sedation?  

Yes, there is… and your ICU is likely already doing it… we just need to follow their lead.

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

 — Critical Care Medicine 2013


Society of Critical Care Medicine 2013 Sedation Guidelines — This is a long document, but one that has some very pertinent points for the state fo the art of sedation in the ER.

Question 3: DON’T sedate with Benzodiazepines

i. We suggest that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients (Level +2B).


Question 4:  Use Analgesia First Sedation (A-1) (p 28)

Question: Should analgesia-first sedation (i.e., analgosedation) or sedative-hypnotic-based sedation be used in mechanically ventilated ICU patients? (actionable)

Answer: We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B).

Four studies of 630 ICU patients shows decreased time to extubation in each study and shorter ICU Length of Stay.

Conclusions: Sedating intubated patients to the point they don’t make eye contact with a conversational voice volume question (ie anyone on Versed or propofol only) is BAD for patients. ANY drop to this level (even in the ED) increases in hospital mortality by 10%.  Use Fentanyl as your main sedative and propofol as an adjunct.  Don’t use Benzodiazepines.

Suggested Pathway For Sedation

  • Here is the pathway that I will be using: (From Emcrit.org)

After intubation, give:

  1. Boluses of 50-100mcg of FENTANYL, until patient is comfortable.

  2. Use a fentanyl gtt at 50-100 mcg per hour

  3.  THEN use low dose propofol (5mcg/kg/hr) to get MILD sedation.  To a max of 80 mcg/kg/hr.

  4. GOAL RASS should be +1 to -2

Other Resources:

  • Website dedicated to delirium research: icudelirium.org
  • Fantastic Podcast of this topic on EMCrit:  A New Paradigm for Post-Intubation Pain, Agitation, and Delirium.


  • Great Post Intubation Algorithms:

Click to access Pain-and-Sedation-from-STC.pdf



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