"improving intensive care in Scotland"

Sedation and Analgesia in ICU

The assessment of anxiety/agitation, sedation and analgesia in ICU

Pain and anxiety are subjective and are thus difficult to measure. ICU patients may also have additional factors (e.g. endotracheal tubes and limb weakness reducing the ability to communicate) making assessment even more challenging. However, because of the consequences of suboptimal sedation/analgesia, frequent subjective assessment should be made.


Subjective assessment of anxiety/agitation and sedation:

  • This should be performed using a validated scoring system which can evaluate both anxiety/agitation and depth of sedation once a pharmacological agent has been started.

  • There are numerous scoring systems available including: the Ramsay Scale, Riker Sedation-Agitation Scale (SAS), Richmond Agitation Sedation Scale (RASS), Bloomsbury sedation scale, Motor Activity Assessment Scale (MAAS) and Vancouver Interaction and Calmness Scale (VICS).

  • The ICU in which you work will probably have chosen a sedation scoring system to use, you should find out and familiarise yourself with that system.

  • The Riker SAS scale is validated, easy to use and given as an example.


Subjective assessment of pain:

  • Patient self-report is valid, the most reliable and therefore should be used when available. Standard assessment tools (Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale) can be used.

  • Patient self-report, however, is frequently not available requiring other methods of assessing pain.

  • Behavioural-physiological scales including pain behaviours (movement, facial expression, posturing) and physiological indicators (heart rate, respiratory rate, blood pressure) are used but have been found to underestimate pain.

  • A family member's subjective assessment of a patient's pain has not been shown to be an accurate method of assessment.

Objective assessment of sedation:

  • Given there are limitations to the accuracy of subjective assessments of sedation, objective techniques can be used.

  • There are many available, including those analyzing components of the patient's EEG, e.g. BIS, and evoked potentials e.g. auditory evoked potentials.

  • None have been shown to be beneficial for routine use in the ICU and their routine use is thus not recommended.

  • However, they may be useful for helping monitor sedation during periods where deep sedation is required, e.g. neuromuscular blockade.

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