Evidence-Based Management Of Pain, Sedation, and Delirium in the Intensive Care Unit and Clinical Pharmacists’ Contribution: A Practical Review

Abstract

Pain, anxiety, agitation, and delirium are common in intensive care unit (ICU) patients, particularly in those undergoing invasive procedures such as intubation and mechanical ventilation. Initiating sedation without first evaluating and treating pain is not rational, as it may mask underlying discomfort and delay appropriate management. Deep sedation, when applied without careful assessment, is associated with prolonged mechanical ventilation, extended ICU stay, and increased mortality; therefore, it should be reserved only for specific clinical indications, as emphasized in the Society of Critical Care Medicine Pain, Agitation, and Delirium Guidelines. Pain, a major trigger of agitation, requires systematic assessment and early, multimodal analgesia—combining opioid and non-opioid strategies—to reduce adverse outcomes, minimize opioid exposure, and support faster recovery. Agitation may otherwise result in complications including self-extubation, catheter dislodgement, and ventilator asynchrony, necessitating judicious use of sedatives and analgesics in ICU care. Delirium, characterized by disturbances in attention, consciousness, and cognition, is strongly linked to increased mortality and long-term cognitive impairment. Guidelines recommend routine delirium screening, environmental modifications, structured sleep protocols, and early mobilization, along with careful pharmacological strategies. Antipsychotics are not advised for prophylaxis, while dexmedetomidine may be considered in selected ventilated patients. Optimal triad management requires individualized drug selection, validated assessment tools, and minimal benzodiazepine use except in cases such as withdrawal. In addition to guideline-based strategies, growing evidence highlights the role of clinical pharmacists, whose interventions in drug selection, dose titration, monitoring, and interprofessional education have been shown to reduce sedative and opioid exposure, shorten mechanical ventilation and ICU stay, and improve cost-effectiveness. This review synthesizes guideline-based recommendations, recent evidence, and the expanding contributions of clinical pharmacists to provide practical, evidence-based strategies for clinicians managing pain, sedation, and delirium in the ICU.