Intensive care unit (ICU) patients are often agitated, confused, and uncomfortable. They can become delirious (ICU delirium). These symptoms are unpleasant for patients and often interfere with care and safety. At worst, they may be life threatening (eg, patients dislodge the endotracheal tube or IV lines).
Etiology of Agitation and Confusion
In a critically ill patient, agitation, confusion, or both can result from the original medical condition, from medical complications, or from treatment or the ICU environment (see table Some Causes of Agitation or Confusion in Critical Care Patients). It is important to remember that neuromuscular blockade merely masks pain and agitation, it does not prevent it; paralyzed patients may be suffering significantly.
Some Causes of Agitation or Confusion in Critical Care Patients
Mechanism | Examples |
|---|---|
Underlying disorder | Head injury Toxin ingestion Pain and discomfort (eg, caused by injuries, surgical procedures, endotracheal intubation, IVs, blood drawing, or nasogastric tube) |
Complications | Hypoxia (see Oxygen Desaturation) Hypotension Organ failure (eg, hepatic encephalopathy) |
Drugs | Sedatives and other drugs active in the central nervous system, particularly opioids, benzodiazepines, H2 blockers, and antihistamines Withdrawal from alcohol, drugs, or both |
Intensive care unit (ICU) environment* | Sleep deprivation (eg, due to noise, bright lights, or round-the-clock medical interventions) Fear of death Anxiety about unpleasant medical procedures |
* Particularly a problem for older adults. | |
Evaluation of Agitation and Confusion
The chart should be reviewed and the patient examined before sedatives are ordered for “agitation.”
History
The presenting injury or illness is a prime causative suspect. Nursing notes and discussion with personnel may identify downward trends in blood pressure and urine output (suggesting hypoperfusion of the central nervous system [CNS]) and dysfunctional sleep patterns. Drug administration records are reviewed to identify inadequate or excessive analgesia and sedation.
Past medical history is reviewed for potential causes. Underlying liver disease suggests possible portosystemic encephalopathy (hepatic encephalopathy). Known substance dependency or abuse suggests a withdrawal syndrome.
Awake, coherent patients are asked what is troubling them and are questioned specifically about pain, dyspnea, and previously unreported substance dependency.
Physical examination
Oxygen saturation < 90% suggests a hypoxic etiology. Low blood pressure and urine output suggest CNS hypoperfusion. Fever and tachycardia suggest sepsis, drug withdrawal, or delirium tremens. Neck stiffness suggests meningitis, although this finding may be difficult to demonstrate in an agitated patient. Focal findings on neurologic examination suggest stroke, hemorrhage, or increased intracranial pressure (ICP).
Continuously assessing the degree of agitation and the need for sedation are key to preventing increased morbidity. The two most common sedation scales are the Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) (see table Riker Sedation-Agitation Scale). The Ramsay Sedation Scale is also sometimes used. Use of such scales allows better consistency between observers and the identification of trends. Patients who are under neuromuscular blockade are difficult to evaluate because they may be highly agitated and uncomfortable despite appearing motionless. It is typically necessary to allow paralysis to wear off periodically (eg, daily) so that the patient can be assessed.
The Confusion Assessment Method (see table Confusion Assessment Method for Diagnosing Delirium) can be used to screen for delirium as a cause of agitation.
Richmond Agitation-Sedation Scale
Score | Term | Description |
|---|---|---|
+4 | Combative | Overtly combative or violent; immediate danger to staff |
+3 | Very agitated | Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff |
+2 | Agitated | Frequent nonpurposeful movement or patient-ventilator dyssynchrony |
+1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
0 | Alert and calm— | — |
-1 | Drowsy | Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice |
-2 | Light sedation | Briefly (less than 10 seconds) awakens with eye contact to voice |
-3 | Moderate sedation | Any movement (but no eye contact) to voice |
-4 | Deep sedation | No response to voice, but any movement to physical stimulation |
-5 | Unarousable | No response to voice or physical stimulation |
Adapted from Sessler CN, Gosnell MS, Grap MJ, et al: The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. American Journal of Respiratory and Critical Care Medicine 166(10)1338–1344, 2002. doi: 10.1164/rccm.2107138 | ||
Riker Sedation-Agitation Scale
Score | Description | Explanation |
|---|---|---|
7 | Dangerous agitation | Tries to remove monitors and devices or climb out of bed; tosses and turns; lashes out at staff |
6 | Very agitated | Remains restless despite frequent verbal reassurance; bites endotracheal tube; requires restraint |
5 | Agitated | Anxious or restless; attempts to move; calms down with reassurance |
4 | Calm and cooperative | Calm; easy to arouse; able to follow instructions |
3 | Sedated | Difficult to awaken; responds to verbal prompts or gentle shaking but drifts off again |
2 | Very sedated | Incommunicative; responds to physical stimuli but not verbal instructions; may move spontaneously |
1 | Unarousable | Incommunicative; little or no response to painful stimuli |
The Ramsay Sedation Scale
Clinical Score | Patient Characteristics |
|---|---|
1 | Awake; agitated or restless or both |
2 | Awake; cooperative, oriented, and tranquil |
3 | Awake but responds to commands only |
4 | Asleep; brisk response to light glabellar tap or loud auditory stimulus |
5 | Asleep; sluggish response to light glabellar tap or loud auditory stimulus |
6 | Asleep; no response to glabellar tap or loud auditory stimulus |
Adapted from Ramsay MA, Savage TM, Simpson B, et al: Controlled sedation with alphaxalone-alphadolone. British Medical Journal 22;2(5920):656–659. doi: 10.1136/bmj.2.5920.656 | |
Confusion Assessment Method (CAM) for Diagnosing Delirium*
Feature | Assessment† |
|---|---|
Required features | |
Acute onset and fluctuating course | Shown by positive responses to the following questions: "Has the patient’s mental status changed abruptly from baseline?" "Did the abnormal behavior fluctuate during the day (ie, tend to come and go or increase and decrease in severity)?" |
Inattention | Shown by a positive response to the following question: "Did the patient have difficulty focusing attention (eg, was easily distracted or had difficulty following what was being said)?" |
One of the following features required | |
Disorganized thinking | Shown by a positive response to the following question: "Was the patient's thinking disorganized or incoherent (eg, evidenced by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?" |
Altered level of consciousness | Shown by any answer other than "alert" to the following question: "Overall, how would you rate this patient's level of consciousness?"
|
* The diagnosis of delirium requires the presence of the first 2 features plus one of the second 2 features. † This information is usually obtained from a family member or nurse. | |
Testing
Identified abnormalities (eg, hypoxia, hypotension, fever) should be clarified further with appropriate testing. Head CT need not routinely be done unless focal neurologic findings are present or no other etiology is found. A bispectral index (BIS) monitor placed on the head to capture cerebral cortex electrical activity may be helpful in determining the level of sedation/agitation of patients under neuromuscular blockade.
Treatment of Agitation and Confusion
Underlying conditions (eg, hypoxia, shock, sepsis, drugs, progression of traumatic brain injury) should be addressed. The environment should be optimized (eg, darkness, quiet, and minimal sleep interruption at night) as much as is compatible with medical care. Clocks, calendars, outside windows, and TV or radio programs also help connect the patient with the world, lessening confusion. Family presence and consistent nursing personnel may be calming.
Drug treatment is dictated by the most vexing symptoms. Pain is treated with analgesics; anxiety and insomnia are treated with sedatives; and psychosis and delirium are treated with small doses of an antipsychotic drug. Intubation may be needed when sedative and analgesic requirements are high enough to jeopardize the airway or respiratory drive. Many drugs are available; generally, short-acting drugs are preferred for patients who need frequent neurologic examination or who are being weaned to extubation.
Analgesia
Sedation
> > 400 mg/dL) may herald PRIS (1
< 48 hours).
Neuromuscular blockade
For intubated patients, neuromuscular blockade is not
Prolonged neuromuscular blockade should be avoided unless patients have severe lung injury and cannot do the work of breathing safely. Use for >
Treatment reference
1. Diaz JH, Prabhakar A, Urman RD, et alCrit Care Res Pract 2014;2014:346968, 2014. doi: 10.1155/2014/346968
Key Points
Agitation, confusion, or both can result from the original medical condition, from complications of the acute illness, from treatment, or from the ICU environment.
History and physical examination often suggest a cause and direct subsequent testing.
Neuromuscular blockade merely masks pain and agitation; paralyzed patients may be suffering significantly.
