Pain at rest is common in surgical, trauma, and medical ICU patients. Pain often goes unrecognized and is undertreated in the critical-care setting. The use of standard rating scales and unit-based guidelines form the foundation for the assessment and treatment of agitation with sedation. 4 Pain, delirium, and anxiety must all be assessed and treated to reduce the critically ill patient's agitation. In a prospective cohort study of a single medical ICU by Woods and colleagues, 23 of the 143 mechanically ventilated patients showed severe agitation that was associated with longer median ICU stay (12 d versus 5 d ), longer median mechanical ventilation (14 d versus 6 d ), and percent of self-extubations (26% vs 6%). Agitation alone is associated with more complications and longer stay. 3 The “triad of agitation” consists of pain, delirium, and anxiety, and each of these 3 internal discomforts can result in an agitated patient ( Fig. Agitation is extremely common in ICU patients of all ages, occurring at least once in 71% patients in medical-surgical ICUs. Agitation is a nonspecific symptom resulting from any type of internal discomfort. The ultimate goal of ICU sedation is to minimize agitation to allow the patient to be calm and comfortable throughout the ICU stay, while minimizing sleep/wake cycle disturbances and complications. 1 More recently, in a retrospective analysis of 549 patients with acute lung injury and acute respiratory distress syndrome enrolled in the Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury (ALVEOLI) trial, the use of benzodiazepines and opioids was associated with longer mechanical ventilation and time to successful 2-hour spontaneous breathing trial. Patients who received continuous infusion of sedatives had significantly longer mechanical ventilation, ICU stay, and hospital stay ( Fig. 1, 2 Kollef and coworkers demonstrated this problem in an observational study with 242 mechanically ventilated patients in a medical ICU, in which 38% of the patients received continuous infusions of lorazepam and/or fentanyl, 26% received intermittent bolus therapy, and 35% received no sedation. Mechanically ventilated patients receiving continuous intravenous sedation have a prolonged duration of mechanical ventilation, ICU stay, and hospital stay, when compared to those receiving no or intermittent sedation. The dilemma we face in caring for critically ill patients is the balance between treating agitation while minimizing the adverse outcomes from our therapies. Sedation has become an inseparable part of critical care practice in minimizing patient discomfort and agitation however, sedatives can have adverse effects that prolong mechanical ventilation and ICU stay. Utilization of these treatment modalities should be directed toward a specific indication, with the ultimate goal of achieving comfort and maintaining safety in the critically ill patient. Sedatives, opioids, and neuromuscular blocking agents (NMBAs) are commonly used in the intensive care unit (ICU).
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