Download current issues in agitation management

PROCEEDINGS
CURRENT ISSUES IN AGITATION MANAGEMENT*
—
I. Larry Cohen, MD, FCCP, FCCM
ABSTRACT
Managing the agitated patient is an important aspect of treating the critically ill. While no
comprehensive definition of agitation exists, it is
generally understood that it includes both physical and emotional distress. This article describes
the common signs of agitation, its major causes,
and practical courses of treatment. Several levels
of sedation can be achieved through proper
medication and monitoring. Selecting the appropriate medication, continuing close monitoring
throughout the sedation period, and conducting
a thorough follow-up will greatly improve the
patient’s chances for a better long-term outcome.
(Advanced Studies in Medicine 2002;2(9):332-337)
more drastically in the years to come as the evidence
base for practice matures. In the early 1980s, eg, the
goal of 67% of intensive care units (ICUs) was deep
sedation—a complete detachment of the patient from
the environment.1 Today, the more common goal is
maintenance of mild sedation with the patient lightly
asleep, yet responsive to stimuli and able to recover
rapidly following discontinuation of sedatives.1-3
Management of the agitated patient clearly has
become a major issue in critical care, with the growing
volume of interest illustrated by a drastic rise in the
number of journal articles on the subject over the past 3
decades.4 Simultaneously, sedation in the ICU has
become a powerful economic issue as research measures
its impact on overall costs, including length of time on
mechanical ventilation and days spent in the ICU.
DEFINITIONS
fundamental tenet of caring for the critically ill patient is relief of suffering;
maintenance of an optimal level of
comfort has long been a universal goal
of practitioners. Theories of management for the critically ill have changed considerably
over the last decade and are expected to evolve even
A
*This article is based on a presentation given by
Dr Cohen at a satellite symposium held at the Society of
Critical Care Medicine, January 27, 2002.
Address correspondence to: I. Larry Cohen, MD,
Roswell Park Cancer Institute, Department of Anesthesia, Elm
& Carlton Streets, Buffalo, NY 14263.
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While management of agitation is a critical issue,
no clear and concise clinical definition of “agitation”
exists. Simple dictionary descriptions of violent
motion and strong or tumultuous emotion can
encompass both the nonsedated paralyzed patient and
the comatose patient with patient-ventilator asynchrony. Most important, it covers both physical and
emotional distress—factors that contribute heavily to
agitation in the ICU.4
Levels of sedation have been defined as5:
• Minimal sedation (anxiolysis): a drug-induced
state during which patients respond normally to
verbal commands, either alone or accompanied
by light tactile stimulation.
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• Moderate sedation/analgesia (conscious sedation): a drug-induced depression of consciousness during which patients respond purposefully
to verbal commands, either alone or accompanied by light tactile stimulation.
• Deep sedation/analgesia: a drug-induced depression of consciousness during which patients cannot easily be aroused, but respond purposefully
following repeated or painful stimulation.
• Anesthesia: a drug-induced loss of consciousness
during which patients are not arousable, even by
painful stimulation.
lead, mercury, and manganese; brain injuries or
thrombotic strokes; and nervous system abnormalities
such as ischemia or malignancy. Alcohol, drug, or tobacco withdrawal may also contribute to agitation.4,7
Finally, the ICU environment itself can be a cause of
agitation. Sleep deprivation; constant bright lights; noise;
being restrained and/or lying in one position; frustration
with an inability to communicate or move; ventilator
malfunction or significant patient-ventilator desynchronization; and intubation can all contribute to agitation.
Sedation of the agitated patient should be initiated
only after reversible physiological causes have been
treated. When used appropriately, sedatives reduce the
risk of complications associated with the metabolic
response to an injury and improve tolerance for invasive interventions, such as intubation, mechanical ventilation, tracheal suctioning, and dressing changes.6
DIAGNOSIS OF AGITATION
Agitation has been described as the “motor restlessness that accompanies anxiety.”6 Continual movement,
often characterized by constant fidgeting, side-to-side
MONITORING
movement, pulling at dressings and/or bed sheets, and
attempts at self-extubation, is common, as is disorientaThe ever-changing condition and requirements of
tion to place, time, and even name. In nonventilated
sedated patients necessitate frequent assessment and
patients, conversation may be largely unintelligible and
include shouting, calling out, or moaning.
Commands frequently are not understood or
are misunderstood. An exaggerated sensation of
pain may be present, even though the actual
cause of the agitation may be the need to urinate
or have a bowel movement.4
Vital signs are frequently abnormal and
Table 1. Signs and Symptoms of Agitation
may include extremely high blood pressure,
elevated respiratory rate, increased heart rate,
and a high metabolic rate that results in an
increase in oxygen requirements and caloric
Common Descriptors of the Signs and Symptoms of Agitation
demand if left unchecked.4 Table 1 summarizes common descriptors of agitation.
Physical Signs
CAUSES OF AGITATION
• Restlessness
Agitation frequently is a manifestation of
an underlying disease or problem. While a
single, definitive cause of agitation is rarely
identified,7 patients should be evaluated for
reversible conditions such as hypoxemia,
pain, cerebral events, metabolic/electrolyte
imbalance, sepsis, hepatic encephalopathy, or
side effects from drug therapy.8 Other possible underlying causes of agitation include
hypotension; hyper- and hypoglycemia; uremia; elevated levels of heavy metals such as
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• Thrashing about in
the bed
• Pulling at catheters,
tubes, and restraints
• Overbreathing the
ventilator
• Asynchrony with ventilator settings
Vital Signs
• Elevated blood
pressure
• Elevated respiratory
rate
Emotional/
Mental Signs
• Disorientation
• Shouting, moaning,
calling out
• Increased heart rate
• Unintelligible
conversation
• Increased metabolic
rate
• Inability to follow
requests or commands
• Decreases in PO2
• Increase or decrease
in PCO2
• Tachycardia
• Tachypnea
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PROCEEDINGS
re-evaluation in order to ensure optimal patient management. A number of semiquantitative, subjective
monitoring scales have been developed and examined
for ICU use. An ideal scale should be easy to apply
and have clear gradations between levels, thereby
allowing for easier titration of interventions.4 As of
yet, no system has been tested for its ability to detect
a patient’s response to changes in therapy, dose, or
withdrawal.8 While a true “gold standard” in scales
does not exist, use of monitoring tools as a part of a
protocol-driven intervention plan has been shown to
improve patient outcomes regarding such issues as
reduced time on mechanical ventilation and shortened length of ICU stay.4,8
The most commonly used and investigated tool is
the Ramsay Sedation Scale, although it has been criticized for its lack of clear discrimination and specific
descriptors that differentiate between levels of sedation.8 The Ramsay Scale provides 6 levels of sedation,
including 3 levels of awake states and 3 levels of asleep
states (Table 2).
Other subjective scales include:
• Riker Sedation-Agitation Scale (SAS): The first
scale proven reliable and valid in the assessment
of critically ill adults, it identifies 7 levels, ranging from dangerous agitation to deep sedation.
• Motor Activity Assessment Scale: Similar in
structure to the SAS, it identifies 7 levels of agitation based upon patient behaviors, ranging
from “unresponsive” to “dangerously agitated
and uncooperative.”
• Confusion Assessment Method for ICU: This tool
for assessing delirium has been tested in combination with a sedation scale or the Glasgow Coma
Scale, and is currently undergoing validation. It is
easy to apply at bedside, with interrater reliability,
sensitivity, and specificity. The scale measures
acute onset of mental status changes or fluctuating
course, inattention, disorganized thinking, and
altered level of consciousness. As opposed to the
others listed above, it is more of a diagnostic tool
than a true monitoring one.
The development of quantitative monitoring
applications looks promising for the assessment and
management of sleep and in the use of deep sedation,
particularly when neuromuscular blockades are used.8
In current practice, objective scores are based on a
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patient’s electroencephalogram (EEG). The Bispectral
Index (BIS) incorporates several EEG components in
order to provide a discrete value ranging from 100
(completely awake) to <60 (deep sedation) and <40
(deep hypnotic state or barbiturate coma). While the
BIS has been shown to be reliable in the operating
room, it has not been thoroughly tested in the ICU.4,8
Bispectral Index scores may vary between different
patients at the same subjective level of sedation, and
other scales may be more reproducible.8 One study
found that the BIS is an accurate predictor of response
to verbal commands during sedation and hypnosis
with propofol, with accuracy maintained when drug
concentrations were increased or decreased.4 New BIS
software is currently undergoing testing for applicability in measuring sedation in the ICU.8
SYSTEMS MANAGEMENT:
THE NEED FOR STANDARDIZATION
Once pain has been alleviated, the primary goals of
sedation are anxiolysis, hypnosis, and amnesia4; in some
patients, respiratory depression and/or an antitussive
effect are also desired.2 Current choices for sustained
sedation include benzodiazepines and propofol in con-
Table 2. Ramsay Sedation Scale
Level
Response
1
Patient awake and anxious, agitated, and/or restless
2
Patient awake, cooperative, accepting ventilation,
oriented, tranquil
3
Patient awake; responds to commands only
4
Patient asleep; brisk response to light glabellar tap or
loud auditory stimulus
5
Patient asleep; sluggish response to light glabellar tap or
loud auditory stimulus, but does respond to painful stimulus
6
Patient asleep; no response to light glabellar tap or
loud auditory stimulus
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junction with opioids if analgesia is desired. The choice
total dose of midazolam by nearly 50%.13 Nonetheless,
of a specific sedative depends on the patient’s individual
the use of practice guidelines remains controversial across
requirements, including duration of sedation, need for a
hospital disciplines. To be effective, development of
rapid awakening, or presence of delirium. The patient’s
guidelines requires multidisciplinary input with agreeunderlying condition and anticipated length of stay in
ment among caregivers on monitoring scales and tools.
the ICU are also considered.2,4
Furthermore, it is essential that thought be given to the
It is estimated that sedatives and analgesics
system as a whole, since numerous factors affect the final
account for 10% to 15% of total drug costs in medeffect of any protocol.
ical and surgical ICUs.9 As a result, pharmacoecoThe Figure illustrates the factors that can lead to aginomics has become a key factor in sedative selection,
tation in critically ill patients. This cause-and-effect, or
with decisions based not solely upon acquisition cost,
“fishbone,” diagram should prove useful for performing
but on outcomes associated with sedation, such as
root cause analysis and developing strategies for systems
shortened time on mechanical ventilation, shortened
improvement in managing agitation in the ICU.
stay in the ICU, rapid awakening, and ease of titraFor any improvement strategy, such as protocols, to
tion. Consequently, the emerging standard of care is
be successful, additional and ongoing training is
the use of standardized protocols and clinical practice
required for all physicians, nurses, and other bedside
guidelines to assist in the selection of the most approcaregivers. It is also important to track and communipriate sedative.6
cate results in a simple, accurate, and timely manner.4
Three studies found that protocol-driven sedation
The American College of Critical Care Medicine
demonstrated significant reductions in duration of
first published practice parameters for the optimal use
sedation, time on mechanical ventilation, length of stay in the ICU and hospital, and in drug costs.10-12 Brook et al
conducted a randomized, controlled
trial of patients in a medical ICU, and
found that protocol-driven treatment
resulted in less time on mechanical venFigure. Factors That May Impact Agitation in Critically Ill Patients
tilation, shorter lengths of stay in the
ICU and the hospital, and fewer tracheostomies.11 Devlin et al found that
total sedation drug costs decreased
from $4515 to $1152 post-guideline
implementation (P = .081), while
median patient sedation cost decreased
from $11.27 (range $0-$1340) to
$3.55 (range $0-$250). A high degree
of guideline compliance was found to
decrease sedation drug costs by 75%.10
Mascia et al found that total sedation
costs were reduced from $4515 to
$1152 following implementation of
guidelines.12
Kress et al conducted a study of protocol-directed daily awakening of sedated patients. Daily interruption of
infusion was found to shorten the duration of mechanical ventilation by more
than 2 days and the length of stay in the
ICU by 3.5 days, as well as to reduce the
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PROCEEDINGS
of sedatives and analgesics in 1995; these guidelines
recently have been updated and rereleased, and recommend a tiered approach that is based largely on expert
opinion.8 The guidelines include recommendations on
sedation assessment and therapy.
predictability of drug action; risk for secondary drug
withdrawal and delirium; risk for post-ICU stress disorder or depression; immune compromise and antioxidant
properties; need for rapid awakening; drug acquisition
cost; and cost effectiveness. Drug selection is discussed
on page 343.
POST-ICU DEPRESSION AND STRESS SYNDROMES
CONCLUSIONS
Mental disorders, including anxiety, depression, and
posttraumatic stress disorder (PTSD), can arise following traumatic and stressful events. Indeed, stress from an
ICU stay can leave patients with psychological symptoms that can impair quality of life14; depression and
stress disorder symptoms have been found to last as long
as 6 to 41 months following ICU treatment.15
Schelling et al studied the incidence of PTSD in
patients discharged from the ICU and found that 27.5%
of patients suffered self-reported PTSD.16 Post-traumatic stress disorder scores were found to correlate to length
of ICU stay (higher scores/longer stay). Scragg et al
report that approximately 30% of discharged ICU
patients experience post-traumatic stress symptoms, and
about 15% meet the criteria for PTSD.14
Emerging evidence indicates that symptoms of stress
disorder and depression also are related to the use of sedatives.15 Further, stress disorder may be related to a patient’s
memories of the ICU. Patients not receiving sedative
therapy may recall an unpleasant or frightening ICU stay,
leading to symptoms of PTSD. Conversely, patients who
have clear, as opposed to delusional, memories of the
ICU—even if those memories are unpleasant—appear to
have a lesser risk for developing PTSD.4,17 As PTSD and
depression can have a great influence on post-ICU quality of life, their full socioeconomic impact needs to be better understood. It is quite possible that drug choice in the
ICU will ultimately be affected by this consideration.
SELECTING PHARMACOLOGICAL AGENTS
The ideal sedative agent would have a rapid onset;
provide adequate sedation; allow easy titration and
rapid recovery following discontinuation; be easy to
administer; lack drug accumulation; have minimal
adverse effects; and be inexpensive.3 Unfortunately, no
single drug has all of these characteristics.
When choosing a pharmacologic agent, the following issues should be considered: goal of individual
patient therapy; duration of treatment; cause and type of
agitation; mechanical versus nonmechanical ventilation;
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Agitation is an important issue for those concerned
about improving the quality, enhancing the outcome,
and the practice of evidence-based critical care.
Accurate diagnosis, diligent monitoring, and followup, as well as selection of an appropriate pharmacological therapy, are key to successful outcomes.
Systemizing the approach to management of agitation
through the use of protocols, objective and semiquantitative measurements, and study of the post-ICU
patient can lead to decreased lengths of stay, shortened
duration of mechanical ventilation, decreased drug
and care costs, and better long-term outcomes.
The topic of agitation is rapidly evolving for the
critical care practitioner. It is quite conceivable that
existing routine practices—especially in the area of
sedative use—will become obsolete over the next 5 to
10 years. These changes will be driven by better scientific evidence, increasingly sophisticated regulatory
guidelines, and, possibly, a more enlightened medicolegal community.
REFERENCES
1. Shafer A. Complications of sedation with midazolam in the
intensive care unit and a comparison with other sedative
agents. Crit Care Med. 1998;26. Available at: http://
home.mdconsult.com/das/article/body/1/jorg=journal&s
ource=MI&sp=1023692&si. Accessed January 16, 2002.
2. Swart EL, van Schijndel RJ, van Loenen AC, Thijs LG.
Continuous infusion of lorazepam versus midazolam in
patients in the intensive care unit: Sedation with lorazepam
is easier to manage and is more cost-effective. Crit Care
Med. 1999;27:1461-1465.
3. Ostermann ME, Keenan SP, Seiferling RA, Shibbald WJ.
Sedation in the intensive care unit: A systematic review.
JAMA. 2000;283:1451-1459.
4. Cohen IL. Management of the agitated intensive care
patient. Crit Care Med. 2002;30:S97-S121.
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5. Revisions to Anesthesia Care Standards: Standards and
intents for sedation and anesthesia care. Available at:
http://www.jcaho.org/standard/anesamb.html. Accessed
January 16, 2002.
6. Nasraway SA. Use of sedative medications in the intensive
care unit. Semin Respir Crit Care Med. 2001;22:165-174.
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haloperidol controls agitation in critically ill patients. Crit
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critically ill adult. Crit Care Med. 2002;30:119-141.
9. Papadakos PJ. The stress response and immunomodulation
in the sedated patient. Anesthesiol News. CME. 2001:1-8.
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sedation guidelines and pharmacist interventions on clinical
outcomes and drug cost. Ann Pharmacother. 1977;
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12. Mascia MF, Koch M, Medicis JJ. Pharmacoeconomic
impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care.
Crit Care Med. 2000;28:2300-2306.
13. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;
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of life and posttraumatic stress disorder in survivors of the
acute respiratory distress syndrome. Crit Care Med.
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