It is not uncommon to observe that, for some professionals involved in the care of the critically ill patient, sedation remains a low priority over other aspects of treatment such as respiratory, cardiac or renal function. 

Concepts as early resuscitation in sepsis or the strategy of lung protection in patients with respiratory distress syndrome are assumed, but with analgesia or sedation is another question.

Multiple studies have shown an insufficient monitoring of analgesia, sedation and delirium, inadequate analgesia in many patientes and how oversedation is still a problem in many ICU. However, the strategy of analgesia and sedation used will influence the evolution of the patient and growing evidence shows the relationship between unnecessary excessive sedation and adverse effects such as cognitive disorders, neuromuscular complications or increased mortality.

In the same path that SCCM recommendations (1) or the most recent made in Germany (2), Intensive Care Medicine has just published a review, proposing a new approach to the topic, called “eCASH concept” (early Comfort using Analgesia, minimal Sedatives and maximal Human care) (3). This concept perfectly summarizes what the current focus of any strategy of sedoanalgesia in the critical patient should be, and basically consists of the early implementation of a bundle in order to keep the patient comfortable, calm and cooperative.

1. The first priority is to achieve effective analgesia for the patient, using a multimodal strategy on which opioids are the mainstay of treatment. The choice of the drug will depend on factors such as the pharmacokinetic and pharmacodynamic properties, pain intensity or concomitant sedation regime.
2. Starting from this point, the next step is to establish a sedation protocol based on objectives, according to the patient’s clinical situation. These objectives must be clearly defined at the beginning of the treatment and daily revised, considering that most of patients can be kept, from the first moments, with a superficial sedation (RASS 0, – 1). When this is not feasible, as for example, patients with neuromuscular blockers, some cases with severe respiratory failure, intracranial hypertension, or status epilepticus, consider minimizing sedation as early as possible as soon as the clinical situation allows it. 

We can´t justify a deep sedation due to enough staff. In this context, the role of the interruption of sedation would be limited to a rescue measure in cases of drug accumulation. “Goodbye daily sedation stops: hello frequent titration protocols”.

In this strategy, it is essential to make an adequate choice of the sedative and evidence goes in favour of the use of drugs non-benzodiazepine (propofol, remifentanil, dexmedetomidine). Probably, benzodiazepines should be limited to selected cases as some patients requiring deep sedation, abstinence, or seizures.

Routine and frequent monitoring of pain, sedation and delirium with validated tools is required to achieve these objectives. Because of the interpersonal variability in the dosage of sedatives and analgesics for a same effect, it is mandatory to maintain a strict monitoring to manage the minimum effective dose to achieve the desired objective.

3. Patient-centered care. In this approach, even when the aim is to maintain a superficial sedation, not all are drugs. It is important to establish care based on the needs of the patient, and probably also of the family. Emotional support to the patient and the family are a fundamental part.

The inability to speak is stressful and inefficient communication impacts negatively on the patient, generating sensations such as helplessness, frustration, anxiety, or fear. It is important to try to optimize communication and work to find alternative methods to improve it.

We have to apply measures of reorientation and environmental stimulation, including clear explanations about the disease and the actions that will be performed, allowing the availability of familiar objects, etc.

In addition, it is important to adapt the environment, trying to make it more comfortable. Reducing noises, lights or unnecessary manoeuvres, especially during rest periods, to facilitate sleep. Improving the privacy and comfort of patients. Limiting the use of physical restraint and promote the early mobilization and collaboration of the patient in rehabilitation. Facilitating the family presence and their participation in care, always under adequate supervision.

Recently, the results of a study conducted in seven ICU in California has been published, including more than 6,000 patients: the application of similar measures, the “ABCDEF bundle”, is associated with an increase in the free days of delirium or coma, and an increase in survival, related to the degree of fulfilment of the same (4).

There are no excuses, it is time to change. Time to evaluate in every ICU, not only the analgesia and sedation practices, also other measures that imply that our units are no longer a hostile place. There is sufficient evidence to improve care, implementing strategies as the concept eCASH concept of the ABCDEF bundle. This is a challenge but the result can be very positive for the patient, improving not only the evolution, but also making their ICU experience more human and less traumatic.

To succeed, attitude and commitment of the whole team of professionals involved in the care is essential.

Dr. Miguel Ángel Romera
Hospital Universitario Puerta de Hierro-Majadahonda ICU


1.- Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306.

2.- Baron R, Binder A, Biniek R, Braune S, Buerkle H et al. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) -short version. Ger Med Sci 2015; 13: Doc19.

3.- Vincent JL, Shehabi Y, Walsh TS, Pandharipande PP, Ball JA et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med 2016 Apr 13

4.- Barnes-Daly MA, Phillips G, Ely EW. ICU liberation: using the ABCDEF bundle to improve outcomes in 7 California community ICUS. Crit Care Med 2015; 43 (Suppl): A41