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

Patient Cases

A 48-year-old man with cirrhosis and now hepatorenal syndrome was intubated for respiratory distress. He

has been receiving midazolam 1 mg/hour and fentanyl 75 mcg/hour for 2 days; his RASS (−4 to −5) and

CPOT has been 1 for 24 hours. Oxygen requirements have decreased, and vital signs are normal. Which is

the most appropriate change in his medications?

T.L. is a 55-year-old woman intubated for respiratory distress for severe pneumonia. She is receiving

fentanyl 50 mcg/hour and dexmedetomidine 1.0 mcg/kg/hour. Her home medications are confirmed to

include esomeprazole 20 mg daily, lorazepam 1 mg three times daily, and citalopram 10 mg daily. The nurse

reports intermittent agitation with tachycardia and a negative pain score. Which is the most appropriate

recommendation?

process, store, or recall information. In the ICU, delirium may present as hyperactive (agitated and restless),

hypoactive (flat affect, apathy, lethargy, decreased responsiveness), or mixed hyper/hypoactive states.

Most common in the ICU are mixed and hypoactive states of delirium. Two screening tools are currently

recommended by the PAD guidelines: (1) the CAM-ICU and (2) the ICDSC. Both the CAM-ICU and the

ICDSC require a RASS (-2) or a SAS (3) or more alert to be completed.

The CAM-ICU assesses four features: (1) acute change or fluctuation in mental status from baseline,

(2) inattention, (3) altered level of consciousness, and (4) disorganized thinking. If features 1 and 2 plus

feature 3 or 4 are present, the patient is considered positive for delirium. Detailed training is available

at www.icudelirium.org.

are level of consciousness, inattention, disorientation, hallucinations-delusions-psychosis, psychomotor

agitation or retardation, inappropriate speech or mood, sleep-wake cycle disturbances, and symptom

fluctuation. A point is given for any symptom that is present during the previous 24 hours; a score of 4

or higher indicates the presence of delirium.

and the diagnostic method, yet assessment for delirium is still not routine in most U.S. ICUs. During a

patient’s hospitalization, the presence of delirium is associated with difficulty in weaning mechanical

ventilation and longer duration of mechanical ventilation, increased use of physical and chemical restraints,

longer duration of ICU stay, and additional stress to family and friends who may not understand the course