Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade
can be considered 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
medications; fentanyl should treat this patient’s chronic
pain and treat opiate/tramadol withdrawal (Answer B
is correct). Adding quetiapine or lorazepam for agita-
tion would not address or treat the underlying etiology
of potential opiate/tramadol withdrawal (Answers A
and C are incorrect). Patient-controlled analgesia with
an opiate would help treat opiate withdrawal; however,
this patient is not alert enough to use it (Answer D is
incorrect).
Answer: D
Up to 30%–60% of ICU patients may go through alcohol
withdrawal on cessation of alcohol use. The presence of
alcohol withdrawal in ICU patients may prolong their
ICU stay, increase hospital costs significantly, and lead
to other complications during the hospital stay. Early
and aggressive symptom-triggered management with a
benzodiazepine, particularly in a patient with a history
of alcohol withdrawal, is a key element in management.
There is no otherwise published protocol for alcohol
withdrawal in ICU patients. In this case, although dex-
medetomidine is useful as an adjunctive agent to help
decrease sympathetic storm and agitation secondary to
alcohol withdrawal, it is not currently recommended for
use as a single agent for alcohol withdrawal (Answer
A is incorrect). Opiates do not treat alcohol withdrawal
(Answer C is incorrect). Phenytoin is a known anti-
epileptic for use in epilepsy; however, it has not been
shown to be effective in preventing or treating alcohol
withdrawal (Answer B is incorrect). Benzodiazepines
are the drugs of choice for alcohol withdrawal seizures;
therefore, midazolam is the most appropriate drug for
this patient, whose medical history is significant for
recurrent alcohol withdrawal seizures (Answer D is
correct).
Answer: B
This patient is at risk of delirium given the patient’s age
and being critically ill in the ICU. Avoiding medications
that may cause or worsen delirium, such as benzodiaze-
pines, is a strong recommendation in the PAD guidelines
(Answer D is incorrect). With a QTc of 550 millisec-
onds, increasing the quetiapine dose for agitation could
further increase the QTc and put this patient at high risk
of cardiac arrhythmias. Starting quetiapine would not
be the best option (Answer A is incorrect). Starting non-
pharmacologic management of agitation/delirium is the
best option (Answer B is correct). Dexmedetomidine
does not prolong the QTc and should be continued in the
setting of agitation (Answer C is incorrect).
Answer: D
Dementia is a progressive and chronic state of cognitive
impairment that worsens over weeks to months; this dif-
fers from the acute onset characteristic of ICU delirium
(Answer A is incorrect). Alcohol withdrawal should
always be a consideration for patients who become
altered or agitated in the ICU. This patient’s vital signs
are normal, and she is presenting in a hypoactive state;
these findings are not typical for acute alcohol with-
drawal, and alternative causes for her decline in mental
status need to be considered (Answer B is incorrect).
Adrenal insufficiency in the ICU usually presents
with abnormal laboratory values and/or hemodynamic
instability. This patient’s laboratory values and hemo-
dynamics are reported as normal; therefore, adrenal
insufficiency is unlikely (Answer C is incorrect). Both
iatrogenic and non-iatrogenic causes for delirium are
well documented in the literature. Dehydration and
infection are common causes of delirium, particularly
in the older adult population. This patient has several
reasons for being dehydrated in the hospital: NPO sta-
tus, persistent fevers, and taking hydrochlorothiazide.
Untreated infection or lack of source control is also a
concern with the presence of persistent fever, even while
the patient is taking antibiotics (Answer D is correct).