Correctable Factors Causing Agitation

T he intensive care unit (ICU) is an extremely stressful environment where anxiety is prevalent, pain frequent, rest difficult, and sleep often impossible. Relief of pain and anxiety is often neglected while efforts focus on immediate life-threatening concerns. A growing awareness of ICU imposed stress and the increasing popularity of some modes of mechanical ventilation such as extended ratio ventilation have highlighted the need for effective sedation, analgesia, and occasionally, paralysis. The goal of therapy is to provide adequate analgesia, sedation, and anxiolysis without causing adverse autonomic or cardiopulmonary consequences. Above all, sedation and paralysis must be used for the comfort and well being of the patient—not that of the staff. Akin to the operating room setting, a balanced, multidrug approach is usually the best way to maximize patient comfort and minimize side effects. On the rare occasions when it is not possible to relieve discomfort, amnesia is desirable . Nonparalyzed patients should be sedate but sufficiently awake to communicate their needs to nurses and physicians; sedation to uncon sciousness is mandated during paralysis. The art of pain control is difficult at best in this setting, where patient comfort must be balanced against the numerous adverse drug effects. Unfortunately, concerns over safety often cause nurses and physicians to err on the side of insufficient relief of patient discomfort. The understandable reluctance to sedate patients who are not receiving mechanical ventilation for fear of producing respiratory depression often leaves nonintubated patients anxious and in pain. In addition to the discomfort itself, unrelieved pain can cause splinting that leads to atelectasis. Pain also discourages activity, promoting deep venous throm bosis and deconditioning. While every effort should be made to maximize patient comfort, excessive sedative or analgesic use can produce numerous complications. Excessive seda tion causes hypotension, gastrointestinal hypomotility, and masks the occurrence of intercurrent illnesses. Pharmaco logic obtundation also reduces tidal volume, vital capacity, minute ventilation, and inhibits forceful coughing.