Run the List: Sedation and Anesthesia in the ICU

Host: Emily Gutowski (with co-hosts Walker Redd, Navin Kumar, Joyce Zhou, Blake Smith)
Guests: Dr. Maria Sinceri (Pulmonary & Critical Care Physician), Brynna Corvetto (ICU Pharmacist)
Date: September 8, 2025

Episode Overview

This episode addresses the nuanced management of sedation and anesthesia in the ICU, focusing on best practices for assessing agitation, choosing sedative and analgesic regimens, monitoring sedation levels, and safely weaning patients off mechanical ventilation. The discussion is anchored by a practical case—a 63-year-old man with septic shock from pneumonia, intubated for acute hypoxic respiratory failure.

Key Discussion Points & Insights

1. Understanding and Assessing Agitation in the Intubated ICU Patient

[02:19] Dr. Sinceri:

• Agitation is a nonspecific observed behavior (“psychomotor agitation”)—distinct from the underlying cause.
• Assessment must go beyond simply increasing sedation:
  • Potential causes: pain, delirium, withdrawal (e.g., alcohol, drugs), hypoxia, ventilator dyssynchrony, thirst, metabolic disturbances (e.g., hypernatremia).
• Approach:
  • Assess vital signs, ventilator settings, labs (electrolytes, ABG/VBG).
  • Physical exam: Look for pain (diaphoresis, grimacing), delirium, mechanical causes (bite tube, tube position).
  • “We really importantly need to also think about the underlying cause…only some of those things are treated by sedatives and analgesics.” — Dr. Sinceri [03:02]

2. Sedation Depth Assessment Tools

[05:35] Dr. Sinceri:

• Richmond Agitation and Sedation Scale (RASS)
  • Ranges: +4 (combative) to –5 (unarousable), with 0 as “alert and calm.”
  • Sedation typically targets 0 (calm/alert) to –1 (drowsy).
  • Deeper sedation (–2 to –4) is reserved for special scenarios (e.g., status epilepticus, ARDS requiring ventilator synchrony).
• Clinical Pearl: Target “the lightest level of sedation that is safe.” Deep sedation increases ICU/hospital length of stay, duration of ventilation, and delirium risk.
  • “We really do try to keep the sedation as light as possible in the conditions in which we safely can.” — Dr. Sinceri [10:47]

[07:12] Indications for deeper sedation:

• Status epilepticus
• Severe ARDS (lung-protective strategies needing paralytics)
• Status asthmaticus

3. Classes of Sedatives/Analgesics: Mechanisms & Clinical Pearls

[12:01] Brynna Corvetto:

• Analgo-sedation—prioritize pain control (typically opioids) to minimize need for sedatives.
  • Delirium and oversedation risks are lower when pain is controlled first.
• Opioids:
  • Fentanyl: Highly lipophilic, short onset/duration but accumulates with prolonged use; minimal hemodynamic effects; risk of serotonin effect and chest wall rigidity with high bolus.
  • Hydromorphone: Longer duration, less used on ECMO.
  • Morphine: Rarely used in ICU due to renal/hepatic accumulation, histamine-induced hypotension.
• Assessment Tool: CPOT (Critical Care Pain Observation Tool) for non-verbal patients.
• Dexmedetomidine (Precedex):
  • Prioritized (2024 update) over propofol for light sedation, but not suitable for deep sedation.
  • Benefits: No respiratory depression; risk: bradycardia, hypotension.
  • “It is a good option prior to extubation, which is where it got its fun name: Presidex precedes extubation.” — Brynna [16:41]
• Propofol:
  • Quick on/off, GABA agonist, NMDA antagonist; risk of hypotension, hypertriglyceridemia, propofol infusion syndrome.
• Midazolam (Versed):
  • Rarely used; increased delirium risk and prolonged awakening due to accumulation, especially in renal dysfunction.
• Ketamine:
  • NMDA antagonist, third-line for sedation, bronchodilation makes it first-line in status asthmaticus; increases BP/HR (“very lovely for status asthmaticus because of its bronchodilation” — Dr. Sinceri [20:04]).

4. Medication Combinations in Practice

[21:08] Dr. Sinceri:

• First-line: Fentanyl (except in ECMO, then hydromorphone).
• Propofol combined with opioid is common. In patients with risk for withdrawal (e.g., alcohol use), GABA agents (like propofol) are protective; dexmedetomidine alone may mask withdrawal.
• Midazolam (Versed) only used when necessary due to side effect profile.

5. Sedation Weaning and Extubation Preparation

[23:43] Dr. Sinceri:

• Only initiate sedation weaning if the primary cause for intubation is resolving (hemodynamics, hypoxia, airway protection).
• Daily sedation vacation/awakening trial + spontaneous breathing trial crucial for assessment.
• “Sometimes people can wean very smoothly off of the sedatives and wake up very calmly and nicely. Sometimes we have a rockier road with that.” — Dr. Sinceri [24:42]
• If delirium/agitation develops during weaning, may require re-sedation with careful titration. [25:59] Brynna:
  • If a sedation vacation fails, restart the sedative at 50% of the prior rate to avoid over-sedation.
  • Oral tapers may be needed for patients on high rates/prolonged infusions.

Notable Quotes & Memorable Moments

• Agitation as a signal, not a diagnosis:
  • “Agitation is a really nonspecific word…we're seeing an observed behavior…we're not necessarily describing the underlying issue that's driving it.” — Dr. Sinceri [02:27]
• Sedation targets:
  • “We really do try to keep the sedation as light as possible in the conditions in which we safely can.” — Dr. Sinceri [10:47]
• Administration pearls:
  • “It is a good option prior to extubation, which is where it got its fun name: Presidex precedes extubation.” — Brynna [16:41]
  • “Propofol can cause green urine, but that's a benign byproduct of hepatic metabolism.” — Brynna [15:26]
• Teamwork reminder:
  • “Do not ever initiate a sedation vacation on your own without your bedside nurse being aware and comfortable with it…you want to make absolutely sure your nurse is aware what's going on, that you're making the plans together.” — Dr. Sinceri [27:07]
• Pharmacist pearls:
  • “It's really important to bolus your patients…if you were trying to get to a serum concentration at a faster rate.” — Brynna [28:35]

Timestamps for Important Segments

• [02:19] Agitation in ICU: Dissecting causes and first steps
• [05:35] The RASS scale: Measuring and targeting sedation depth
• [07:20] When deeper sedation is needed (ARDS, status epilepticus, asthma)
• [12:01] Sedation pharmacology: Opioids, dexmedetomidine, propofol, midazolam, ketamine
• [21:08] Practical medication regimens and rationale for combinations
• [23:43] Safety steps and team approach to sedation weaning and extubation
• [26:57] Pearls for ICU learners: Safety, communication, drug administration tips

Take-Home Pearls & Final Advice

• Assess the why: Agitation is a symptom—work up the cause before reflexively increasing sedation.
• Lightest effective sedation: Reduces ICU stay, delirium, and time on mechanical ventilation.
• Daily awakening trials: Essential for evaluating readiness for weaning/extubation.
• Analgo-sedation (prioritize pain control): Use validated tools like CPOT.
• Communication and teamwork with nursing staff is critical at every stage of sedation management and extubation preparation.
• Pharmacokinetic tips:
  • Bolus before initiating drips to achieve faster effect (unless contraindicated).
  • Always ensure adequate sedation when paralytics are used.
• Know the side effect profile and metabolism of your sedatives.

Summary prepared for “Run the List” podcast, episode: “Sedation and Anesthesia in the ICU”
For further details, clinical context, and direct discussions, refer to the episode audio.