Management of critically ill patients difficult to sedate: Update and clinical strategies

One in every three critically ill patients who receive prolonged analgosedation may experience difficult sedation, negatively influencing their evolution and prognosis. Difficult sedation includes situations of therapeutic failure, tolerance or deprivation of analgesic and sedative drugs. Its origin is multifactorial and depends on the patient's characteristics, history of drug consumption, critical condition and the administration of drugs that alter the pharmacokinetics of the sedatives used. This update aims to describe the definition of difficult sedation, identify the group of critically ill sedated patients who can develop it, its etiology, and how it should be treated and managed. The difficulty in achieving an adequate level of sedation, increasing the dose of sedatives or adding new agents represents a challenge in daily practice in critical care units since it can increase the risks of toxicity and related complications. Prevention and early identification of difficult sedation situations are essential strategies to minimize their impact; hence nurses' autonomy in the management of analgosedation represents a primary intervention.