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

Learning Objectives

Develop a management strategy for the preven-

tion and treatment of pain, agitation/sedation, and

delirium, immobility, and sleep disruption (PADIS)

in an intensive care unit (ICU) patient with various

comorbidities.

namic considerations of PADIS medications as they

pertain to disturbances in critical care physiology.

Identify relevant adverse effects, drug interactions,

and drug withdrawal syndromes in the management

of PADIS.

Evaluate patients in the ICU for PADIS using a vali-

dated screening tool.

Construct a plan for the management of delirium.

Identify the long-term effects of critical illness in

adult ICU patients.

Create a management strategy for PADIS-related

medications that are continued beyond ICU dis-

charge.

Describe a treatment and monitoring plan for criti-

cally ill patients receiving neuromuscular blockade.

Acute respiratory distress syndrome

BPS

Behavioral Pain Scale

intensive care unit

CPOT

Critical-Care Pain Observation Tool

GABA

γ-Aminobutyric acid

ICDSC

Checklist

ICP

Intracranial pressure

ICU

Intensive care unit

NMBA

Neuromuscular blocking agent

PAD

Pain, agitation, and delirium

PADIS

Pain, agitation/sedation, delirium,

immobility, and sleep disruption

PRIS

Propofol-related infusion syndrome

RASS

Richmond Agitation Sedation Scale

SAS

Sedation-Agitation Scale

SAT

Spontaneous awakening trial

SBT

Spontaneous breathing trial

SCCM

TOF

Train of four

Self-Assessment Questions

Answers and explanations to these questions may be

found at the end of this chapter.

P.J. has been receiving propofol 50–60 mcg/kg/

minute and fentanyl 75–100 mcg/hour for 4 days.

She has no significant medical history. Laboratory

results today show that transaminases have

increased to 5 times baseline, lactate is increased to

5 mmol/L, and triglyceride concentration is 450 mg/

dL. No new medications have been added. Given

these laboratory values, which complication would

be most appropriate to address?

severe alcohol withdrawal. His medical history is

otherwise unknown. Laboratory values are within

normal limits on admission. He has been receiv-

ing a lorazepam infusion 6–8 mg/hour for active

alcohol withdrawal. On day 4, his blood pressure is

130/75 mm Hg, oxygen saturation is 98% on 2 L

of oxygen, blood urea nitrogen (BUN) is 50 mg/dL,

and serum creatinine (SCr) is 2.0 mg/dL; he has a

new anion gap of 20 mEq/L, an osmolar gap of 18

mmol/L H2O, and a fractional excretion of sodium

of 0.2. Which is the most likely cause for his clinical

presentation?

R.B. is a 25-year-old man admitted to the ICU for

acute pancreatitis and sepsis. He is intermittently

agitated on hydromorphone 2 mg/hour and mid-

azolam 6 mg/hour (Richmond Agitation-Sedation

Scale [RASS] score of –1 to +2) and is not oxygen-

ating adequately after adjustments on the ventilator.

The physician would like to initiate therapeutic

paralysis. Which is the next best step in the treat-

ment of this patient?