All patients should have attention to assure that they are comfortable. Critical illness is often accompanied by pain that MUST be treated. Delirium and patient ventilator dysynchrony are also very common. As a general rule, care-givers should seek to address the reasons for delirium and attempt titrations of ventilator settings to achieve better patient comfort BEFORE resorting to medications. However, medications are often required to achieve both analgesia (in all patients) and sedation (mainly for ventilated patients). In our MICU, we approach these issues as follows:

• Analgesia.

  Unfortunately, there is (as of April 2003) no objective pain scale for titration of medications. Since there are no standards of pain measurement in critically ill patients, there have not been well-controlled scientific studies to demonstrate superiority of one approach over another. Accordingly, in the absence of data, we have adopted the general strategy suggested by the Society of Critical Care.

  In intubated patients:

  MSO4 1-5 mg IV Q 1-5 hours PRN

  is the starting approach. Allowing the nurses to titrate pain medicine prevents over- and under-dosing. Well-trained critical care nurses administer narcotics for signs of catechol excess (that might suggest pain) and grimacing (especially during turning). Occasionally, a continuous drip of MSO4 can be used, especially in patients who are expected to have very severe pain (e.g. burns, meningitis etc.). In hemodynamically unstable patients fentanyl can be used as a patch or by continuous infusion, though continuous narcotic therapy may lead to greater tolerance and withdrawal.

  In non-intubated communicative patients:

  Acetominophen or acetominophen/narcotic oral combinations can be used every 4-6 hours.

• Sedation.

  Again, care-givers should always seek to understand the numerous factors that contribute to agitation and delirium in critically ill patients. Attempts to achieve comfort through ventilator manipulation, pain management and assessment (and reversal) of factors contributing to delirium should always precede use of sedatives that have numerous untoward side-effects (including causing delirium!).

  The approach listed below requires an intubated airway. When medications are needed, the available evidence suggests that intermittent boluses of sedatives are superior to use of constant infusions. In general, care-givers should "load" the patient with sedatives, following with a maintenance dose titrated to level of agitation using either the Ramsay or Richmond scoring systems.

  For patients expected to require ventilation for more than 48 hours:

  Loading: Lorazepam or midazolam given as follows:

  1-2 mg repeated every 5-10 minutes until patient becomes comfortable. If no improvement or worsening agitation, doses can be doubled (i.e. 4-5 mg) every 5-10 minutes as the blood pressure tolerates until patient is sedated.

  Maintenance: Lorazepam or midazolam 1-5 mg IV every 1-5 hours PRN titrated to Richmond or Ramsay scores.

  If more than 5 mg/H of intermittent bolus benzo (lorazepam/midazolam) is required, then we move to continuous infusions of benzo titrated to sedation scores AND with daily awakenings (when not contraindicated).

  For patients expected to require ventilation for less than 48 hours or who have neurologic injuries/illnesses requiring rapid wake-ups for neuro examinations:

  Diprivan (up to 20 ml/H) IV titrated to comfort

  In patients>60 years of age (who may have paradoxical agitation with benzos) and/or those with delirium haloperidol is the preferred drug and must be given around the clock:

  Haloperidol 1-5 mg IV every 4-6 hours

  The starting dose can be chosen based on the size of the patient and the degree of delirium/agitation.