N/IICU Clinical Pathway for Sedation/Analgesia
in the Mechanically Ventilated Patient
  • N/IICU Pillars of Sedation
  • Set SBS Goal Daily
  • Use Non-pharmacological interventions job aid - See Job Aid
  • Minimize use of benzodiazepines and barbiturates
  • Give 1 PRN sedation dose at a time
  • Convert to oral sedation when patient on full feeds/stable sedation regimen

Assess SBS and Pain Score
with cares (min Q6) and PRN
and documentation in EHR

SBS at Goal
SBS < Goal
  1. Contact FLOC
  2. Consider decreasing continuous sedation rate by 20% or by incremental infusion change, whichever is greater.
    Titrations should not occur more frequently than Q6.
SBS > Goal
  1. Assess SBS and Pain Q30 min
  2. Consider reversible causes:
    • Vent dyssynchrony
    • ETT placement appropriate
  3. Non-Pharmacological Interventions - See Job Aid
N/IICU Sedation Plan
Utilize interventions starting with 1st line and progressing accordingly
Document SBS and Pain scores in EHR 30 minutes after each intervention
Discuss with FLOC to consider sedation escalation if either is true:
  • Patient not at goal 30 minutes after intervention OR
  • > 3 doses of PRN sedation are administered within 8 hours
    (excludes those meant to facilitate procedures)
N/IICU Sedation Plan
1st Line Begin with starting dose of intermittent PRN opioid (morphine or fentanyl)

May increase opioid PRN to a maximum of morphine 0.15 mg/kg/dose IV or fentanyl 2 mcg/kg/dose IV to achieve goal SBS
2nd Line Consider starting an opioid infusion (morphine or fentanyl) if not responsive to maximum morphine or fentanyl PRN doses

Increase opioid infusion no more frequently than every 6 hours to achieve goal SBS
3rd Line Consider adding a starting dose of midazolam IV PRN if patient is needing additional sedation to achieve goal SBS

Increase midazolam PRN as needed to achieve goal SBS
4th Line Consider adding either a dexmedetomidine infusion or a midazolam infusion to achieve goal SBS. Titrate no more frequently than every 6 hours.
5th Line Consider addition of midazolam infusion OR dexmedetomidine infusion (whichever was not added in the previous step) if addition and titration of the second infusion has not achieved goal SBS.

May also consider opioid rotation if the patient is receiving a morphine infusion ≥ 0.15 mg/kg/hour or fentanyl infusion ≥ 5 mcg/kg/hour.
Please refer to Recommended Dosing Guidance table for guidance on dose titrations
Recommended Dosing Guidance
Initial PRN Doses (IV)
Fentanyl 1 mcg/kg/dose
Morphine 0.05 mg/kg/dose
Midazolam 0.05 mg/kg/dose
Note: The smallest dose of morphine or midazolam that can be accurately measured in an IV syringe is 0.1 mg.
Incremental PRN Dose Change (IV)
Fentanyl 0.5 mcg/kg/dose
Morphine 0.05 mg/kg/dose
Midazolam 0.05 mg/kg/dose
Hydromorphone 0.005 mg/kg/dose
Initial Medication Infusion Doses
Fentanyl 1 mcg/kg/hour
Morphine 0.01 mg/kg/hour
Midazolam 0.01 mg/kg/hour
Dexmedetomidine 0.3 mcg/kg/hour
Note: The lowest infusion rate that can be administered is 0.1 mL/hour.
Incremental Infusion Change
Fentanyl 0.5 mcg/kg/hour**
Morphine 0.01 mg/kg/hour**
Midazolam 0.01 mg/kg/hour**
Dexmedetomidine 0.1 mcg/kg/hour(to maximum rate of 1.5 mcg/kg/hour)
Hydromorphone 0.001 mg/kg/hr**
**Please note that the incremental infusion change recommendations for fentanyl, morphine,midazolam and hydromorphone are the minimum increases recommended. These infusions may be increased by higher amounts in certain clinical situations.
Posted: May 2015
Revised: August 2021
Authors: D. Munson, MD; H. Morris, PA; C. Franciscovich, CRNP; M. Fraga, MD; S. Gattoline, PharmD; A. Bustin, PharmD