Pain Agitation/ Sedation Delirium

Description an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage
Complications Short-term: impair wound healing,
increased risk of infection, increased stress
response
Between 70-90% of ICU patients experience as the sudden severe confusion and rapid changes in brain function that
agitation occur with physical or mental illness
Injury to self or others
Dislodged tubes and lines

Long-term: chronic pain, post-traumatic Ventilator dyssynchrony

stress disorder, lower health-related quality
of life PTSD and other long-term cognitive deficits

Interference with patient care

Causes Mechanical ventilation Pain / withdrawal Immobility Restraints

Surgery or procedures Sleep disturbances / delirium Procedures Pain
Lines and tubes Lines and tubes Medications Withdrawal
Oncologic/chronic pain Medications Issues with environment Sleep wake issues
Immobility Hypoxemia
Assessment tools Numeric Rating Scale 0-10 is the gold RASS CAM-ICU
standard - Deep sedation -5 to -4 - Scored as + or –
- Moderate sedation -3
CPOT or BPS - Light sedation -2 to +1 ICDSC
- Scored between 0-8
SAS - 0 -no delirium
- Deep sedation 1-2 - 1-3 “subsyndromal delirium”
- Light sedation 3-4 - ≥ delirium
Frequency of Pain is assessed Q4H or is assessed Q4H or Patients should be screened for delirium once per nursing shift (~every 12
assessment w/ every dose titration w/ every dose titration hours)

Goals of CPOT goal 0-2 Light Sedation Deep Sedation

assessment - RASS -2 to +1 - RASS -4 to -5
BPS goal 0-3 - SAS 3 to 4 - SAS 1 to 2

Medication Opioids Benzos Benzos

options - MOA: μ opioid receptor agonist - MOA: acts on GABAa receptor
- Class SEs - Class SEs Anticholinergic medications
o Sedation o Respiratory depression - Metoclopramide
o Respiratory depression o Hypotension - H2 blockers
o NA/V/ Constipation o delirium o Famotidine// ranitidine
o hypotension o Phlebitis (Diazepam) - Antihistamines
o o diphenhydramine
Multimodal agents Others Corticosteroids
- various MOAs - propofol
Antipsychotics
- various SEs - dexmedtomidine
- first gen  haloperidol
- ketamine
- second gen (atypical)
 o quetiapine o risperidone
o olanzapine o ziprasidone

Overall summary - use validated tools for assessment

- pain addressed prior to sedation
o opioids are first line, but multimodal agents should be utilized as adjunct therapy to reduce opioid use
o intermittent dosing should be tried prior to continuous infusion
o ideal agent is rapid acting, has a short DUA, no active metabolites and unlikely to accumulate

- light sedation > deep sedation

o mech. Vented patients only use deep sedation if NECESSARY
o benzos limited due to risk of delirium, increased ventilation durations, and length of ICU stay
o nurse driven sedation protocols and spontaneous awakening trials can decrease duration of mech. Ventilation, sedation, and ICU stay
- delirium affects a significant number of ICU patients and is associated with worse outcomes

o prevention is key
o no meds improve outcomes for prevention or tx
o it may be appropriate to use antipsychotic to treat hyperactive delirium