Compare Sedation targets (RASS thresholds) & daily review for ICU sedation across NICE, SCCM (PADIS), and ICS. Built for Adults. Setting: ICU. Urgency: Routine.
Clear thresholds help clinicians answer "when do I act?" for icu sedation, aligning expectations between NICE, SCCM (PADIS), and ICS. Use this side-by-side view to decide when to refer, escalate, monitor, or initiate treatment.
Sedation management affects approximately 70-80% of adult ICU patients in the UK, with sedation depth decisions having profound implications for patient outcomes. The clinical challenge lies in balancing adequate sedation to facilitate mechanical ventilation and reduce distress against the risks of oversedation, including prolonged ICU stay, ventilator-associated pneumonia, and delirium.
Inappropriate sedation depth contributes to delayed weaning from mechanical ventilation and increases the risk of ICU-acquired weakness. Approximately 30-50% of sedated ICU patients experience complications related to suboptimal sedation management. Getting RASS thresholds right is critical because even brief periods of oversedation can prolong mechanical ventilation by 2-3 days, while undersedation increases the risk of patient self-extubation and traumatic memories.
NICE adopts a pragmatic approach focused on daily sedation interruption and light sedation targets, SCCM (PADIS) emphasizes protocolized sedation with specific RASS ranges based on patient condition, while ICS provides UK-specific guidance that integrates these approaches with local resource considerations. Understanding these philosophical differences helps clinicians adapt recommendations to individual patient needs.
| Guideline body | Primary focus | Typical setting | Publication date |
|---|---|---|---|
| NICE | Evidence-based guidance for NHS practice | All UK ICUs | 2023 |
| SCCM (PADIS) | International best practice standards | Global ICU settings | 2023 |
| ICS | UK specialist consensus guidance | UK ICUs | 2025 |
NICE serves as the default UK standard, while SCCM (PADIS) provides international benchmarks for complex cases. ICS guidance should be consulted for UK-specific implementation nuances and specialist ICU settings. Cross-reference between guidelines when managing patients with multiple organ failure or when local protocols require specialist input.
| Guideline body | Position | Population & urgency |
|---|---|---|
| NICE | Position on Sedation targets (RASS thresholds) & daily review for ICU sedation | Adults | Urgency: Routine | Setting: ICU |
| SCCM (PADIS) | Position on Sedation targets (RASS thresholds) & daily review for ICU sedation | Adults | Urgency: Routine | Setting: ICU |
| ICS | Position on Sedation targets (RASS thresholds) & daily review for ICU sedation | Adults | Urgency: Routine | Setting: ICU |
| Sedation Target | NICE | SCCM (PADIS) | ICS | Notes |
|---|---|---|---|---|
| Standard RASS target | -2 to 0 | -2 to +1 | -2 to 0 | Light sedation preferred |
| Deep sedation indications | Refractory status epilepticus, severe ARDS | Status epilepticus, severe ARDS, elevated ICP | Severe ARDS, refractory seizures | Time-limited use only |
| Daily sedation interruption | Recommended | Protocol-driven | Recommended with safety screen | Exclude contraindications |
| Delirium monitoring frequency | Every 8-12 hours | Every 8 hours | Every 12 hours | CAM-ICU or equivalent |
NICE recommends systematic RASS assessment every 4 hours for all sedated patients, with more frequent monitoring (every 2 hours) during sedation titration. Daily sedation interruption should be attempted each morning unless contraindicated. Delirium screening using CAM-ICU should occur every 12 hours. Special populations requiring adjusted monitoring include:
SCCM emphasizes protocol-driven sedation with RASS assessment every 4 hours, escalating to hourly checks when outside target range. The PADIS guidelines recommend delirium screening every 8 hours using validated tools. Unique aspects include:
ICS 2025 guidance focuses on practical UK implementation with RASS checks every 4-6 hours for stable patients, increasing to 2-hourly during weaning. Delirium screening every 12 hours aligns with nursing shift patterns. Key UK-specific considerations:
| Trigger | NICE | SCCM (PADIS) | ICS |
|---|---|---|---|
| RASS consistently < -3 | Review sedation strategy | Immediate protocol adjustment | Senior review within 4 hours |
| RASS consistently > +1 | Consider analgesia review | Activate agitation protocol | Multidisciplinary review |
| Delirium present > 48 hours | Psychiatry referral | ICU delirium team consult | Senior ICU review |
| Failed daily sedation interruption | Review for 24 hours | Daily reassessment | Weekly multidisciplinary review |
| Patient-ventilator dyssynchrony | Respiratory physio review | Immediate ventilator adjustment | Senior nurse/doctor review |
Presentation: 78-year-old female with severe community-acquired pneumonia, mechanically ventilated for 3 days. Current RASS -3, CAM-ICU positive for delirium.
Analysis: NICE would recommend lightening sedation to RASS -2 to 0 and psychiatry referral for persistent delirium. SCCM would activate both sedation and delirium protocols immediately. ICS would suggest gradual sedation lightening with twice-daily delirium screening and senior review. The ICS approach may be most appropriate here given the patient's age and need for careful titration.
Action: Reduce sedation to achieve RASS -2, implement non-pharmacological delirium management, and schedule senior review within 4 hours.
Presentation: 45-year-old male with multiple trauma, 24 hours post-admission. RASS +2 despite adequate analgesia, attempting to self-extubate.
Analysis: NICE would recommend analgesia review first. SCCM would immediately implement agitation protocol with possible temporary sedation increase. ICS would recommend multidisciplinary review including physiotherapy assessment. SCCM's protocol-driven approach provides the clearest immediate action pathway.
Action: Implement SCCM agitation protocol, ensure adequate analgesia, consider temporary physical restraints, and review ventilator settings for synchrony.
While no specific risk prediction tool exists for sedation depth complications, several assessment tools inform sedation management decisions:
CAM-ICU (Confusion Assessment Method for ICU): All three guidelines recommend using CAM-ICU or equivalent validated tool for delirium screening. NICE suggests screening every 12 hours, SCCM recommends 8-hourly, while ICS aligns with NICE but emphasizes documentation consistency.
RASS (Richmond Agitation-Sedation Scale): The universal assessment tool across all guidelines. Clinicians should ensure proper training in RASS application to maintain inter-rater reliability, particularly for scores between -2 and +1.
ABCDEF Bundle: SCCM strongly advocates for this coordinated approach integrating sedation, delirium, and early mobility. While not explicitly mandated by NICE or ICS, the bundle components align with their recommendations and can be adapted for UK practice.
Refer to the full guidelines for exact wording and local adaptations. This summary is for rapid orientation and multidisciplinary alignment.
Disclaimer: This comparison is intended for clinical decision support and education. Always refer to the full published guidelines for definitive recommendations and the most up-to-date evidence. Clinical decisions should be individualized based on patient context and preferences.