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

cal state.

P.V. is a 70-year-old woman (weight 50 kg,

decreased from 60 kg 2 months ago) admitted to the

ICU in ARDS. She has a history of cirrhosis and

is currently fluid overloaded (net positive 5 L). She

has been on a continuous infusion of fentanyl and

propofol for 5 days. Which pharmacologic factor

would best be considered with respect to her analge-

sics or sedatives?

propofol.

L.B. is a 38-year-old woman intubated in the neu-

rosurgery ICU for 72 hours receiving propofol. The

nurse is requesting medications for “severe agitation

and hallucinations.” Her heart rate and blood pres-

sure have steadily increased since admission, and

a chart review reveals years of chronic pain while

receiving oxycodone and tramadol at home. Her

laboratory values are normal, but she is not toler-

ating enteral-route medications. Which is the most

appropriate recommendation at this time?

S.P. has just been intubated in the ICU and is in

severe alcohol withdrawal. He has a history of

frequent delirium tremens and alcohol withdrawal

seizures. Which medication is most appropriate to

begin initial management of pain, agitation, and

delirium (PAD) in this patient?

H.F., a 65-year-old man admitted to the ICU from

home for aspiration pneumonia requiring intubation,

is initiated on levofloxacin and metronidazole. Other

medications include fentanyl and dexmedetomidine

infusions as well as amiodarone, a home medica-

tion. His last RASS was -2, and he has intermittent

agitation. Vital signs and laboratory values are nor-

mal, and corrected QT (QTc) is 550 milliseconds.

Which is the most appropriate recommendation at

this time?

nonpharmacologic

management

of

agitation/delirium.

prolonged QTc.

S.V., a 70-year-old woman with a history of hyper-

tension, is transferred from the floor to the ICU for

worsening pneumonia and new-onset hypoactive

delirium. She has been nil per os (NPO) since admis-

sion 3 days prior. She remains febrile (temperature

102°F [38.89°C]) with decreased urine output; other

vital signs and laboratory values are within normal

limits. Her medications include ceftriaxone, hepa-

rin, and hydrochlorothiazide. Which best represents

the most important set of considerations regarding

her delirium?