Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Patient Case

Questions 1 and 2 pertain to the following case.

T.O. is a 70-year-old man just admitted to the ICU with multiple fractures after a motor vehicle accident. His

medical history includes hypertension. He is now agitated after intubation. His laboratory values are normal,

and his vital signs include blood pressure 175/95 mm Hg and heart rate 110 beats/minute.

Which grouping of initial sedatives is most appropriate at this time?

drip with adequate pain control. Which is the best pain management regimen for chest tube removal?

challenging, requiring significant resources and daily discipline from the nursing, medical, and pharmacy

team. Ongoing research has improved our understanding of the consequences of either under- or overtreating

agitation in the ICU, and clinicians should continue to apply this knowledge to their daily selection and

titration of medications. Treatment of a patient who presents with agitation must always begin with attempts

to identify and correct the etiology of the agitation. Common causes of agitation in the ICU include pain,

delirium, hypoxia, hypoglycemia, dehydration, and drug or alcohol withdrawal. Close inspection of

significant patient variables will also help determine the appropriate sedative:

Pain control

Neurologic function: Baseline and acute mental status, history of seizure activity, dementia, psychiatric

history

Clinical variables: Blood pressure, heart rate, respiratory rate

Comorbidities (baseline and acute): Cardiac, renal, hepatic, gastric, pulmonary, pancreatic

Home medication use: Any medication from which a patient could withdraw: Benzodiazepines, opioids,

nicotine, antidepressants, other γ-aminobutyric acid (GABA) receptor agonists

benzodiazepines (usually lorazepam and midazolam) (Table 4). Benzodiazepines are first-line agents for

status epilepticus, alcohol withdrawal, benzodiazepine dependence or withdrawal, and are useful for deep

sedation or amnesia and with the use of neuromuscular blockade. Other indications for benzodiazepines

may exist, which must be scrutinized throughout the ICU stay.