Sedation Strategies from the Emergency Interface to ICU Liberation: A Systematic Review of Agent Selection and Weaning Outcomes

Background: Sedation for mechanically ventilated adults begins at the emergency interface and continues through intensive care liberation, where depth, drug class, analgesia, delirium prevention, and awakening trials interact. Objective: This systematic review evaluated how sedative selection and sedation-minimization strategies influence delirium, ventilator liberation, intensive care duration, mortality, and adverse events. Methods: PubMed/MEDLINE, Scopus, Web of Science Core Collection, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews were searched for adult studies of invasive mechanical ventilation, emergency department or intensive care sedation, sedative agent comparison, sedation interruption, no-sedation protocols, and liberation outcomes. Original randomized trials and prospective cohorts were prioritized for the results synthesis. Results: Ten original studies were included in the qualitative results synthesis. Benzodiazepine-based sedation was consistently linked with less favorable delirium or extubation profiles than dexmedetomidine-based strategies in several randomized trials. Dexmedetomidine improved arousability and communication, reduced delirium in comparisons with benzodiazepines, and shortened extubation time in selected populations, although large trials showed similar mortality and ventilator-free outcomes compared with usual care or propofol. Daily awakening, paired awakening-breathing trials, no-sedation protocols, and targeted emergency department sedation reduced unnecessary deep sedation and aligned sedation with liberation readiness. Conclusion: The evidence favors early light sedation, avoidance of benzodiazepine accumulation, protocolized awakening, and agent selection matched to delirium and liberation goals.