Providing sedation and comfort for intensive care patients has evolved in the last few years. New approaches to improving outcomes for intensive care unit (ICU) patients include providing analgesia before adding sedation and recognizing dangerous adverse effects associated with sedative medications, such as prolonged effects of midazolam, propylene glycol toxicity with lorazepam, propofol infusion syndrome, the deliriogenic effects of benzodiazepines and propofol, and bradycardia with dexmedetomidine. There are now reliable and valid ways to monitor pain and delirium in ICU patients. Dexmedetomidine reduces the incidence of delirium, reduces the duration of mechanical ventilation, and appears to be cost effective.