Analgosedation: a paradigm shift in intensive care unit sedation practice

Ann Pharmacother. 2012 Apr;46(4):530-40. doi: 10.1345/aph.1Q525. Epub 2012 Apr 10.


Objective: To critically evaluate the use of analgosedation in the management of agitation in critically ill mechanically ventilated patients.

Data sources: Literature was accessed through MEDLINE (1948-November 2011) and Cochrane Library (2011, issue 1) using the terms analgosedation, analgosedation, or analgesia-based sedation alone or in combination with intensive care unit or critically ill. Reference lists of related publications were also reviewed.

Study selection and data extraction: All articles published in English were evaluated. Randomized controlled trials examining critically ill mechanically ventilated patients older than 18 years were included.

Data synthesis: Limitations of current sedation practices include serious adverse drug events, prolonged mechanical ventilation time, and intensive care unit (ICU) length of stay. Studies have demonstrated that analgosedation, a strategy that manages patient pain and discomfort first, before providing sedative therapy, results in improved patient outcomes compared to standard sedative-hypnotic regimens. Nine randomized controlled trials comparing remifentanil-based analgosedation to other commonly used agents (fentanyl, midazolam, morphine, and propofol) for ICU sedation and 1 trial comparing morphine to daily sedation interruption with propofol or midazolam were reviewed. Remifentanil is an ideal agent for analgosedation due to its easy titratability and organ-independent metabolism. When compared to sedative-hypnotic regimens, remifentanil-based regimens were associated with shorter duration of mechanical ventilation, more rapid weaning from the ventilator, and shorter ICU length of stay. Compared to fentanyl-based regimens, remifentanil had similar efficacy with the exception of increased pain requirements upon remifentanil discontinuation. Analgosedation was well tolerated, with no significant differences in hemodynamic stability compared to sedative-hypnotic regimens.

Conclusions: Analgosedation is an efficacious and well-tolerated approach to management of ICU sedation with improved patient outcomes compared to sedative-hypnotic approaches. Additional well-designed trials are warranted to clarify the role of analgosedation in the management of ICU sedation, including trials with nonopioid analgesics.

Publication types

  • Review

MeSH terms

  • Analgesia / adverse effects
  • Analgesia / methods
  • Analgesics / administration & dosage
  • Analgesics / adverse effects
  • Analgesics / therapeutic use*
  • Critical Illness
  • Humans
  • Hypnotics and Sedatives / administration & dosage
  • Hypnotics and Sedatives / adverse effects
  • Hypnotics and Sedatives / therapeutic use*
  • Intensive Care Units*
  • Length of Stay
  • Piperidines / administration & dosage
  • Piperidines / adverse effects
  • Piperidines / therapeutic use
  • Randomized Controlled Trials as Topic
  • Remifentanil
  • Respiration, Artificial / methods
  • Treatment Outcome


  • Analgesics
  • Hypnotics and Sedatives
  • Piperidines
  • Remifentanil