Comparative effectiveness data for one analgesia/sedation strategy versus another are lacking. The principles of medication use in the PFC setting include:

- Consider pain in three categories:

1. Background: the pain that is always present because of an injury or wound. This should be managed to keep a patient comfortable at rest but should not impair breathing, circulation, or mental status.
2. Breakthrough: the acute pain induced with movement or manipulation. This should be managed as needed. If breakthrough pain occurs often or while at rest, background pain medication should be increased.
3. Procedural: the acute pain associated with a procedure. This should be anticipated and managed periprocedurally.

- Analgesia is the alleviation of pain and should be the primary focus of using these medications. In other words, treat pain before considering sedation. Remember, not every patient needs (or should receive) pain medication at first, and unstable patients may require other therapies or resuscitation before the administration of pain or sedation medications.
- Sedation is used to relieve agitation or anxiety and, in some cases, induce amnesia. The most common causes of agitation are untreated pain or other serious physiologic problems like hypoxia, hypotension, or hypoglycemia. Sedation is used most commonly to ensure patient safety (e.g., when agitation is not controlled by analgesia and there is need for the patient to remain calm to avoid movement that might cause unintentional tube, line, dressing, splint, or other device removal or to allow a procedure to be performed) or to obtain patient amnesia to an event (e.g., forming no memory of a painful procedure or during paralysis for ventilator management).
- Each patient responds differently to medications, particularly with respect to dose. Some individuals require substantially more opioid, benzodiazepine, or ketamine; some require significantly less. Once you have a “feel” for how much medication a patient requires, you can be more comfortable giving similar amounts during redosing. In general, a single medication will achieve its desired effect if enough is given; however, the higher the dose, the more likely the side effects. Additionally, ketamine, opioids, and benzodiazepines given together have a synergistic effect: the effect of medications given together is much greater than a single medication given alone (i.e. the effect is multiplied, not added. Go with less than what you might normally use if each were given alone).
- PFC requires a different treatment approach than TCCC. Go slow, use lower doses of medication, titrate to effect, and redose more frequently. This will provide more consistent pain control and sedation. High doses may result in dramatic swings between oversedation with respiratory suppression and hypotension alternating with agitation and emergence phenomenon.