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

Answer: D

This patient has a clear indication for intravenous pain

medication from his recent trauma and multiple frac-

tures. An “as-needed” opiate would likely not keep up

with his pain control needs (Answers B and C are incor-

rect). His age and history of hypertension place him at

risk of delirium; therefore, a benzodiazepine is not the

best initial choice for this patient. A fentanyl infusion

for pain with a propofol infusion if needed for sedation

is the most appropriate answer (Answer A is incorrect;

Answer D is correct).

Chest tube removal is specifically cited in the PADIS

guidelines as an indication for both preemptive analge-

sia and nonpharmacologic relaxation techniques. This

is given a “strong” recommendation, determining that

the benefits outweigh the risks of preemptive therapy

(Answer D is correct). Acetaminophen given just before

the procedure will most likely not adequately treat pain

associated with chest tube removal (Answer A is incor-

rect). Increasing an opiate infusion several hours before a

bedside procedure can expose the patient to substantially

higher amounts of drug than needed and cause delayed

awakening times or other significant adverse effects

from opiates (Answer C is incorrect). Extensive stud-

ies of appropriate preemptive analgesia for chest tube

removal have not been completed; however, administer-

ing an opiate appropriately timed before manipulation of

a chest tube is an accepted standard of therapy (Answer

B is incorrect).

Answer: B

This patient has end-stage liver failure and acute renal

failure; he will therefore not predictably clear mid-

azolam or fentanyl infusions. With a RASS of −4 to −5,

indicating no meaningful responsiveness to stimuli, all

sedatives should be held if the patient is otherwise clini-

cally stable to allow time for clearance of medications. If

the patient was to develop pain based on a CPOT of 3 or

more, then intermittent fentanyl is appropriate (Answer

B is correct). A decrease in sedative dose or changing to

a different sedative is not needed at this time based on

the deeply sedated RASS score and would only further

delay awakening time. Intermittent doses of benzo-

diazepines should avoided. (Answers A, C, and D are

incorrect).

Answer: B

Withdrawal from certain home medications may occur

if these medications are not reinitiated within a few

days of admission. The onset of withdrawal symptoms

will vary depending on the half-life of each medication.

Symptoms may include agitation, anxiety, psychosis,

insomnia, hypertension, and tachycardia and can occur

with medications such as opiates, GABA receptor ago-

nists, antiepileptics, antidepressants, and antipsychotics.

A pharmacist can assist the medical team by obtaining

a thorough medication history and assessment of home

medication adherence to help identify drug withdrawal

symptoms. Reinitiating these medications can be con-

sidered, unless contraindicated because of the clinical

scenario (e.g., drug-drug interactions, drug-disease state

interactions). The Agitation and Sedation section of the

PADIS guidelines discusses identifying and treating

the etiology of agitation before adding other medica-

tions; reinitiating the benzodiazepine and antidepressant

to treat withdrawal symptoms is the most appropri-

ate answer (Answer B is correct). Neither fentanyl nor

dexmedetomidine would treat withdrawal from a ben-

zodiazepine or antidepressant (Answers A, C, and D are

incorrect).

Answer: C

The PADIS guidelines stress using nonpharmaco-

logic means to manage delirium when it is safe for the

patient. Strong evidence for using dexmedetomidine

to treat delirium is still not available and the MIND

USA Study has shown that anti-psychotics are ineffec-

tive at treating delirium. This patient’s presentation of

“alert and calm with intermittent periods of agitation”

is a common scenario, and initial therapy should focus

on reorienting and getting the patient interactive and

mobile (Answers A and D are incorrect; Answer C is

correct). Dehydration is a common cause of agitation,

and it should be addressed; however, with normal lab-

oratory values and vital signs, this patient is unlikely

dehydrated at this time (Answer B is incorrect).

Answer: B

In the general population, systemic corticosteroids are

known to cause many neuropsychiatric events, includ-

ing hyperactivity and agitation; in a recent study of adult

ICU patients with acute lung injury, only age and use of

systemic corticosteroids in the preceding 24 hours were