Management of Pain, Agitation and Delirium

Abstract

Pain and anxiety are almost universal feature of ICU patients. Clinically significant pain and anxiety have been reported in up to 70 % of ICU patients. Anxiety is often caused or exacerbated by uncontrolled pain. Severe anxiety is not limited to mechanically ventilated patients; indeed Treggiari-Venzi and colleagues demonstrated that up to 30 % of non-intubated SICU patients had severe anxiety [1]. Anxiety has numerous adverse effects, consequently, the control of anxiety is an integral component of the management of the ICU patient. Traditionally, the liberal use of sedatives was recommended in order to treat anxiety, with ventilated patients being heavily sedated with continuous infusions of sedative agents. The traditional approach to sedation in the ICU was one of deep sedation in which the patient was “snowed”. We now know that is approach to harmful and associated with numerous complications. Furthermore, ICU patients can be effectively managed with minimal or no sedation. Indeed, Strom et al. performed a RCT in which 140 mechanically ventilated patients were randomized to standard sedation or no sedation [2]. In this study patients were randomized to receive no sedation or sedation with propofol for 48 h. After 48 h the sedative was change to an infusion of midazolam. Both groups were treated with bolus doses of morphine (2·5 or 5 mg) as required for pain control. In cases in which delirium was suspected, intravenous haloperidol was given as bolus doses. Patients who received no sedation had greater ventilator and ICU free days with no apparent adverse events. This study dispels the common myth that all patients who require mechanical ventilation should receive sedative medications [3].