Analgesia, sedation and delirium

Pain assessment and analgesia-first sedation (PADIS, eCASH)

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

Assess pain with NRS, CPOT or BPS, treat pain first with multimodal opioid-sparing analgesia, and aim for calm, comfortable, collaborative patients.

Definition
PADIS/eCASH: early Comfort using Analgesia, minimal Sedatives and maximal Humane care - pain first, light sedation, and the ABCDEF bundle (Assess pain, Both SAT and SBT, Choice of sedation, Delirium, Early mobility, Family).

At the bedside

  1. 1

    Assess pain routinely

    Self-report (NRS 0-10) when possible; CPOT (0-8, > 2 = pain) or BPS (3-12, > 5 = pain) when the patient cannot communicate; assess at least every 4 h and before procedures.

  2. 2

    Analgesia first

    Treat pain before giving sedatives (analgosedation): fentanyl boluses/infusion titrated to CPOT/BPS.

  3. 3

    Multimodal, opioid-sparing

    Regular paracetamol; low-dose ketamine in surgical patients; neuropathic agents (gabapentin/pregabalin); regional blocks (epidural, erector spinae, serratus) for chest/abdominal trauma or surgery.

  4. 4

    Procedural analgesia

    Pre-emptive fentanyl bolus or local anaesthetic before chest drain removal, line insertion, turning and wound care.

  5. 5

    Humane care

    Explain, reorient, sleep promotion, hearing aids/glasses, family presence, music; treat thirst and anxiety.

Analgosedation

Fentanyl

IV
Dose
25-100 mcg bolus; 25-200 mcg/h infusion
Preparation
500 mcg in 50 mL NS = 10 mcg/mL
Worked example
70 kg: start 50 mcg/h = 5 mL/h; bolus 25-50 mcg for CPOT > 2
Open infusion calculator

Multimodal analgesia

Paracetamol

IV/oral
Dose
1 g every 6 h (max 4 g/day)

2-3 g/day in liver disease or < 50 kg.

Opioid-sparing adjunct

Ketamine

IV
Dose
0.1-0.5 mg/kg bolus, then 0.05-0.4 mg/kg/h
Worked example
70 kg: 0.1 mg/kg/h = 7 mg/h (0.7 mL/h of 10 mg/mL)

Alternative opioid

Morphine

IV
Dose
2-4 mg bolus; 2-10 mg/h

Avoid in AKI.

Critical-Care Pain Observation Tool (CPOT)

Domain012
Facial expressionRelaxed, neutralTense (frowning)Grimacing (eyelids tightly closed)
Body movementsAbsence of movements/normal positionProtection (slow, cautious movements, touching pain site)Restlessness/agitation, pulling tube, striking staff
Muscle tension (passive flexion/extension)RelaxedTense, rigidVery tense or rigid
Compliance with ventilator (intubated) OR vocalisation (extubated)Tolerating ventilator / normal toneCoughing but tolerating / sighing, moaningFighting ventilator / crying out, sobbing

Score 0-8; > 2 indicates significant pain.

Red flag · call your senior now
Agitation in a ventilated patient: first exclude pain, hypoxia, hypercapnia, tube displacement, full bladder, and withdrawal before deepening sedation.
Pitfall
Using vital signs alone to judge pain: they are unreliable.
Pitfall
Sedating instead of treating pain.
Pearl
A comfortable, awake, interactive patient on a ventilator is the goal, not an immobile one.

Calculators for this topic

Infusion rate from a fixed hourly or per-minute dose

Pump rate for non-weight-based infusions such as vasopressin (U/min), labetalol (mg/min) or amiodarone (mg/h).

References

  1. 1

    Devlin JW, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825-73.

  2. 2

    Lewis K, Balas MC, Stollings JL, et al. A focused update to the clinical practice guidelines for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2025;53:e711-27.

  3. 3

    Vincent JL, Shehabi Y, Walsh TS, et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med 2016;42:962-71.

  4. 4

    Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care 2006;15:420-7.

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Sedation targets, RASS and sedative choice

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.