Current State of ICU Sedation-Analgesia: Insights from a National Survey

A nationwide study of over 2,000 ICU patients in France has uncovered a disconnect between advances in sedation practices and persistent gaps in managing patient discomfort—including pain, anxiety, and sleep disturbances. While the majority of critically ill patients are no longer deeply sedated, nearly half still experience at least one source of distress, suggesting that the shift toward lighter sedation has not been matched by sufficient improvements in comfort-focused care.

Conducted across 128 French ICUs, the cross-sectional study evaluated sedation, analgesia, and discomfort in adult patients on a single day in early 2024. Although 84% of patients were either lightly sedated or fully awake, 15% remained deeply sedated—and nearly two-thirds of these cases lacked a clear clinical justification, such as acute respiratory distress syndrome or intracranial hypertension.

Pain was assessed in 90% of patients at rest but dropped significantly during care procedures, with 38% receiving no pain evaluation at all during interventions. Notably, the likelihood of pain increased as sedation decreased: just 0.9% of deeply sedated patients were reported in pain at rest, compared to 15% among unsedated patients and 25% of those exhibiting agitation.

Forty-four percent of all ICU patients were found to experience at least one form of discomfort. Anxiety was the most common, followed by sleep disturbances and thirst. While pain at rest was relatively rare, pain during care procedures was significantly more prevalent and underassessed—highlighting a blind spot in current ICU routines.

Despite nearly two-thirds of ICUs reporting the use of written sedation-analgesia protocols, the presence of such protocols had no significant association with sedation depth, drug use, or the rate of misaligned sedation. However, these units were modestly more likely to conduct systematic pain assessments at rest.

Multivariable analysis pointed to illness severity, rather than institutional policies or staffing ratios, as the strongest predictor of deep or misaligned sedation. Higher Sequential Organ Failure Assessment (SOFA) scores were significantly associated with both phenomena, suggesting that entrenched clinical habits—rather than guideline adherence—continue to shape sedation decisions in the sickest patients.

The findings also call attention to underutilized tools for assessing psychiatric symptoms and discomfort. Delirium assessments were performed systematically in only 13% of ICUs, and the use of validated screening tools was inconsistent. For communicative patients, self-reported pain scales remain underused, with many providers relying instead on behavioral assessments that may miss or underestimate reported pain.