ICUs | Assessment tools | Common agents used | Sedation hold strategy/protocol | Practice and collaborations for ‘difficult-to-sedate’ patients | ||
Sedation score | Delirium | Pain | ||||
(ICU1) | RASS | CAM–ICU twice daily | No | Propofol Alfentanil Haloperidol | Sedation hold performed as part of VAP bundle. Not protocolised. Gradual reduction of sedation. Stop both the sedative and opiate agents simultaneously, which leaves patient with no pain relief. | Regular antipsychotic therapy discontinued while patient sedated—haloperidol used instead. Psychiatrist review. |
(ICU2) | Ramsay | No | No | Propofol Alfentanil Dexmedetomidine Remifentanil | Sedation hold as part of VAP bundle. Strictly performed at 8 am. Titrate the sedation dose gradually, and stop it when the patient is ready for extubation. | No specific approach. |
(ICU3) | RASS | CAM–ICU twice daily | No | Propofol Alfentanil Haloperidol | Individualised approach. Sedation hold performed as part of VAP bundle. Stop the sedative agent and retain the opiate for pain relief and endotracheal tube tolerance until the patient is able to be extubated. | Regular antipsychotic therapy discontinued while patient sedated—haloperidol used instead. Psychiatrist review. |
(ICU4) | RASS | CAM–ICU twice daily | VAS epidural tool Pain team involved. | Propofol Alfentanil | Individualised approach to sedation hold. Not protocolised. Sedation hold performed as part of VAP bundle. Stop the sedative agent and retain the opiate for pain relief and endotracheal tube tolerance until the patient is able to be extubated. | Psychiatrist review. |
(ICU5) | RASS | No | No Pain team involved. | Propofol Alfentanil | Individualised approach to sedation hold. Not protocolised. Sedation hold performed as part of VAP bundle. Titrate the sedation dose gradually, and stop when patient ready for extubation. | Substance withdrawal guidance available. |
(ICU6) | SAS | CAM–ICU not consistently | No | Propofol Remifentanil | Individualised approach to sedation hold. Not protocolised. Sedation hold performed as part of VAP bundle. Titrate the sedation dose gradually, and stop when patient ready for extubation. | Substance withdrawal guidance available. |
(ICU7) | RASS | CAM–ICU twice daily | No | Propofol Alfentanil Clonidine Haloperidol | Individualised approach to sedation hold. Protocolised. Sedation hold performed as part of VAP bundle. Stop the sedative agent and retain the opiate for pain relief and endotracheal tube tolerance until the patient is able to be extubated. | Substance withdrawal guidance available. Regular antipsychotic therapy discontinued while patient sedated—haloperidol used instead. Psychiatrist review. |
(ICU8) | RASS | CAM–ICU twice daily | VAS | Propofol Alfentanil Morphine Haloperidol | Individualised approach to sedation hold. Not protocolised. Sedation hold performed as part of VAP bundle. Stop both the sedative and opiate agents simultaneously, which leaves patient with no pain relief. | Regular antipsychotic therapy discontinued while patient sedated—haloperidol used instead. Psychiatrist review. |
CAM, confusion assessment method; ICU, intensive care unit; VAP, ventilator associated pneumonia; RASS, richmond agitation-sedation scale; VAS, Visual Analogue Scale; SAS, riker sedation-agitation scale