Authors: Madkhali M M et al.
Cureus, Volume 18, Issue 1, Article e101790, January 2026. DOI: 10.7759/cureus.101790.
Summary
This systematic review evaluated analgesic and sedation strategies used in adult ICUs, comparing opioid-based regimens with non-opioid agents and protocolized approaches. Following PRISMA methods, the authors searched PubMed, Cochrane Library, Scopus, and Web of Science through October 2025 and included 11 eligible studies (randomized trials and observational designs). Study quality was appraised using a Modified Downs and Black checklist.
Across the included evidence, sedative selection and “how sedation is delivered” both mattered. Dexmedetomidine generally provided comparable or better sedation quality than benzodiazepines or propofol, with a consistent signal toward lower delirium rates and faster time to extubation in multiple ICU populations. Remimazolam showed sedation efficacy similar to propofol with fewer hypotensive events in the included trial, suggesting a hemodynamic advantage in selected settings.
The review also emphasized that protocolized, nurse-driven, or algorithm-based sedation strategies tended to outperform daily sedation interruption alone for operational outcomes such as ventilator-free days and ICU length of stay. In parallel, multimodal and non-opioid adjunct strategies reduced opioid requirements and opioid-related adverse effects (notably nausea) while maintaining hemodynamic stability. A recurring finding across studies was that light, cooperative sedation—paired with validated pain, sedation, and delirium assessment tools—was associated with better recovery profiles and fewer cognitive complications than deeper, benzodiazepine-forward approaches.
Overall, the authors concluded that the current evidence supports an analgesia-first, multimodal strategy that minimizes deep sedation and favors non-GABA-centric sedation when appropriate. Dexmedetomidine (and potentially remimazolam in certain contexts) stood out as options associated with improved delirium-related and recovery outcomes compared with benzodiazepines.
What You Should Know
The direction of travel in ICU sedation is toward light, cooperative sedation and analgesia-first strategies rather than deep benzodiazepine-heavy regimens.
Dexmedetomidine was associated across studies with better delirium-related outcomes and earlier extubation compared with benzodiazepines and sometimes propofol, with bradycardia/hypotension as the main predictable tradeoffs.
Remimazolam may provide propofol-like sedation with fewer hypotensive events in selected ICU/procedural contexts, based on limited included evidence.
Protocolized, nurse-driven sedation and consistent use of validated pain/sedation/delirium tools often perform better than daily interruption alone for ventilator and length-of-stay outcomes.
Thank you for allowing us to use and summarize this article from Cureus.