Management of agitation in the intensive care unit
Section snippets
Characteristics and causes of agitation in the intensive care unit
Agitation is characterized by excess motor activity and is driven by internal factors, such as disease, pain, anxiety, and delirium [11], [12]. Activity may be purposeless or, more dangerously, self-destructive. Consequences include removing or disconnecting catheters, self-extubation, ventilator dysynchrony, and increased oxygen consumption [13], [14], [15], [16], [17], [18]. Agitation may also lead to detrimental long-term outcomes that range from unpleasant memories to posttraumatic stress
Treatment of agitation
Compared with life-threatening problems, such as shock and respiratory failure, the treatment of agitation receives little attention. A recent systematic review found only 15 prospective, randomized studies that investigated successful sedation as a primary outcome in mechanically-ventilated patients [26]. Effective management, however, in addition to providing comfort, is indispensable in helping patients tolerate sometimes noxious treatments and procedures.
Consideration of nonpharmacologic
Treatment goals (objective measurements of sedation and agitation)
Sedation goals should meet individual patient needs. Most patients should be kept comfortably awake or lightly asleep but easily arousable. A few patients need deeper sedation, particularly those who require neuromuscular blockade or those who are undergoing difficult-to-tolerate mechanical ventilation, such as inverse ratio or permissive hypercapnia.
Since the 1970s, several investigators designed scales to allow clinicians to objectively measure and describe agitation and to guide therapy [82]
Protocols and guidelines
There is growing concern that many patients in the ICU are too sedated, which leads to complications, such as prolonged mechanical ventilation, increased length of stay, delirium, and cognitive impairment. In one study, the use of continuous IV sedation correlated with an increased duration of mechanical ventilation and longer lengths of stay in the ICU and hospital [8]. In a prospective, randomized, controlled study, daily interruption of sedation was associated with decreased duration of
Special considerations
Several special situations pose unique challenges to the intensivist, particularly patients who are experiencing withdrawal from benzodiazepines and narcotics, those who require treatment with neuromuscular blockade, and those who require palliative care.
Summary
Although the effective evaluation and management of agitated patients often receives less attention than other aspects of critical illness, it is among the most important and rewarding challenges that face critical care physicians. Key features of effective management include a thorough, organized search for potentially dangerous and correctable causes; a sound understanding of the pharmacology of analgesics and sedatives; and keeping a steady eye on appropriate management goals. In turn, the
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