Management of the agitated intensive care unit patient.

Agitation: 1. Violent motion. 2. Strong or tumultuous emotion. Management of the agitated patient is fast becoming an area of major breakthroughs for critical care medicine. To illustrate, Figure 1 shows the total number of articles found on MEDLINE using a combination of search words related to sedation and critical care. This crude survey demonstrates an exponential rise in activity surrounding this topic and helps support the view that study of agitation in the critically ill patient is of rapidly expanding importance. Moreover, management of the agitated patient has developed into an economically powerful subject, both for pharmaceutical companies and for caregivers interested in improving the efficient use of intensive care unit (ICU) resources. It is increasingly apparent that outcomes are significantly influenced by the manner in which agitation is managed. The quantity of articles being published is only part of the picture. Investigations related to agitation in critical care are yielding a variety of intriguing observations including post-traumatic stress disorder and post-ICU depression, diagnosis of delirium, objective monitoring technology, sleep pattern changes, process/management strategies to enhance clinical and economic outcomes, scoring systems, tailorability of therapeutic approaches, and bronchodilatory, antioxidant, and immunosuppressive properties of sedative agents. Rather than simply discussing strategies for sedation, it is the deliberate intent of this continuing education program to focus on the specific topic of agitation (in the ICU patient). It is noteworthy that, although it is one of the most common issues facing critical care practitioners, agitation in the ICU has no clear and concise definition. The simple definition stated at the beginning of this article is from Funk and Wagnall’s 1982. This explanation of “agitation” has merit because it encompasses both physical and emotional distress. Under this characterization, either the nonsedated paralyzed patient or the comatose patient with patient-ventilator asynchrony can be considered agitated, even though the two may represent opposite ends of a spectrum. Accurate diagnosis of the cause of agitation frequently requires a careful analysis of the patient’s history and physical examination, review of laboratory and other diagnostic data, knowledge of the effectiveness of concomitant therapies, collaboration among members of the team and family, and a good deal of experience. The cause of agitation is often multifactorial (e.g., pain and confusion or delirium and withdrawal), and even with successful management it is difficult to be certain about precipitating factors in any single case. Anecdotes from patients and clinicians can serve as powerful tools for the critical care team’s armamentarium and help increase understanding from both sympathetic and empathetic perspectives. Pharmacologic management strategies for agitation include both prevention and treatment. Prevention commonly guides the hand of the critical care clinician when a patient is being stabilized and drips are ordered for analgesia and sedation in anticipation of agitation. Fine-tuning the therapy using agitation scales, daily awakening, and other strategies take on more of a treatment quality, as do pro re nata (PRN) agitation orders. Nonpharmacological approaches include a variety of environmental adjustments that are frequently underutilized. Yet, as obvious as these concepts for definition, diagnosis, and management may seem, it is difficult to consistently apply them to the literature (with the exception of short-term usage). There are a number of well-designed and wellexecuted studies in longer-duration agitation management but, excluding those in very focused populations (e.g., neurologic injury), most studies lump patients into groups for the purpose of assessing differing sedative regimens. Comparative pharmaceutical trials have been extraordinarily important to clinicians who deal regularly with agitation. These studies, as well as trials using innovative management techniques, are becoming increasingly sophisticated in the area of pharmacoeconomic assessment. There is still, however, a paucity of comprehensive studies evaluating the integration of economic, clinical, and humanistic outcomes of agitated ICU patients. Existing economic analyses include variables such as drug acquisition costs, ventilator duration, and ICU length of stay (LOS) to determine the “cost effectiveness” of one drug regimen over another; these are often only partial in their scope. Assigning or assuming costs for time in ICU or on a ventilator is fraught with the problems of evaluating the fixed and variable components. Opportunity costs are usually ignored, as they are exceedingly difficult to determine. And, failure to include post-ICU cost and outcome information ignores the post-ICU morbidity that appears linked to ICU sedation usage. These types of problems with economic analyses are widespread in the critically ill population and are not unique to the topic of agitation management. Notwithstanding, it can be said with a reasonable degree of confidence that the drug acquisition cost of various regimens is only one—often small—piece of the larger economic puzzle. Given the current tide of activity, it is conceivable that the approach to managing agitation in the critically ill patient will rise (or is rising) to a new level of sophistication. At this new level, pharmacologic and nonpharmacologic approaches will be highly selective and finetuned to more precisely address the Copyright © 2002 by Lippincott Williams & Wilkins