Post – Intubation Analgesia and Sedation: Help from Dr. Weingart’s EMCrit #115

The podcast,Podcast 115 – A New Paradigm for Post-Intubation Pain, Agitation, and Delirium. January 13, 2014 by Scott Weingart is outstanding. The shownotes feature so much information that everything on the page should be studied carefully.

All the references on my page are from Dr. Weingart’s post. I placed them on my page just so I would have them right in front of me when I needed them.


These four links below are all from the shownotes of Dr. Weingart’s Podcast #115 :

Analgesia/Sedation Protocol for Mechanically Ventilated Patients from [This one page PDF gives you suggested medications and dosages for analgesia and sedation.]

UMMC Pain, Sedation and Delirium Guidelines For Ventilated Patients developed by the University of Maryland Medical Center Sedation Committee. [This two page PDF gives even more detailed information on medications for analgesia, sedation, and delirium then the first link – the go to resource.]

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit by the Society of Critical Care Medicine

A Lecture on the SCCM Guidelines [On Rx of Pain, etc.] by Dr. Dan Herr. Courtesy of the Maryland CC Project.


Dr. Weingart reminds us that having an endotracheal tube in your throat and airway is intrinsically very painful.

Therefore, every patient needs analgesia first even before they are given sedation. So here is what Dr. Weingart recommends:

Just put patients on a fentanyl drip. If not go with dilaudad IV. When remifentanil is cheap, we’ll switch to that in a bunch of patient categories.(Dahaba et al. 2004)*

Then evaluate pain and decide if the patient needs additional pushes of pain meds.

Consider using the Behavioral Pain Scale (Crit Care Med 2001;29(12):2258) HT to Nikolay Yusupov



So once you have the patient on adequate analgesia, then you may need to give them a sedative. And you need to have a goal for your sedation.

Use the Richmond Agitation-Sedation Scale (RASS) [link is to the PDF of Scale] to determine your level of sedation goal.

Dr. Weingart provides the link to The UMMC PAIN, SEDATION, AND DELIRIUM GUIDELINES FOR VENTILATED PATIENTS from expert Dr. Dann Herr. This is a two page PDF.

Be sure to study the great ICU Delirium Site of Vanderbilt University which has a large number of useful resources:

Assess, Prevent, and Manage Pain

Adult ICU patients routinely experience pain, both at rest and with routine ICU care such as procedures or wound care. Lack of treatment of pain can result in many complications including delirium. The PAD Guidelines (2013 PAD SCCM/ACCP Guidelines) suggest that pain be routinely monitored in all adult ICU patients. Self- reporting is the gold standard for assessment of pain. Vital signs should not be used alone for assessment of pain in patients that are unable to communicate. The Behavioral Pain Scale (BPS) [link to the PDF] and the Critical‐Care Pain Observation Tool (CPOT) [link is to the PDF] are the most valid and reliable behavioral pain scales for assessing pain in adult, ICU patients unable to communicate pain.

The CPOT includes evaluation of four different behaviors (facial expressions, body movements, muscle tension, and compliance with the ventilator for mechanically ventilated patients or vocalization for nonintubated patients) rated on a scale of zero to two with a total score ranging from 0 to 8. The CPOT is feasible, easy to complete, and simple to understand.

Choice of Analgesia and Sedation

The Pain, Agitation and Delirium (PAD) clinical practice guidelines of the Society of Critical Care Medicine (2013 PAD SCCM/ACCP Guidelines) emphasize management of pain first, followed by goal-directed delivery of psychoactive medications to avoid oversedation and to promote earlier extubation.               [Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. (PubMed Abstract) (Full Text PDF)]

In Dr. Weingart’s podcast  # 115 he gives us the following link: “Dr. Herr created for the STC Center (STC Pain Sedation and Delirium Protocol).”

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