PAIN MANAGEMENT

In the Critically Ill

 Pain management is central to the care of the critically ill or
injured patient. Unfortunately critically ill patients may not be
able to self-report their pain management needs to their
healthcare team. Patients identify physical care that promotes
pain relief and comfort as an important element of their
hospitalization and recovery, especially while in the critical
care environment.

Providing optimum pain relief for critically ill patients not only enhances their psy- choemotional well-being, but can also help avert additional physiologic injury for a
patient who is already com- promised.

Using a multimodal approach, specific pharmacologic and non-pharmacologic pain management techniques are described, including the integral relationships among
relaxation, sedation, and pain relief. Strategies also are presented that promote comfort and are easy to incorporate into a plan of care for critically ill patients.
 Pain is…

•An unpleasant sensory and

emotional experience associated
with actual or potential tissue
damage, or described in terms
of such damage
•Can happen any where in our
body

If the patient complains of pain, then there is pain.

If the patients said no pain, then there is no pain

NO MATTER of your examination result

 80% of patients experience different intensities

of pain during their ICU stay and identify it as
one of the greatest sources of stress
Adam VN, Matolic M, Ilic KM, Grizelj-Stojcic E, Smiljanic A, Skok I. Pain management in critically ill patients. Periodicum Biologorum. Vol. 117, No 2, 225–230, 2015

Unrecognized and untreated pain have significant negative impact on outcomes

Access to Pain Management Is a Fundamental Human Right

Unrelieved pain may contribute to

inadequate sleep, possibly causing exhaustion and disorientation.

Agitation.

Stress response characterized by tachycardia, increased

myocardial oxygen consumption, hypercoagulability, immunosuppression, and persistent catabolism,

pulmonary dysfunction.

Recommendation: All critically ill patients have the right to adequate analgesia and management of their pain.

ICU patients commonly have pain and physical discomfort from obvious factors, such as

preexisting diseases,

Invasive procedures, or trauma.

Monitoring and therapeutic devices (such as catheters, drains, noninvasive ventilating devices, and endotracheal tubes)

Routine nursing care (such as airway suctioning, physical therapy, dressing changes, and patient mobilization)

prolonged immobility

The pain response is elicited with tissue injuries, whether actual or potential. Undifferentiated free nerve endings, or nocicep- tors, are the major receptors signaling tissue
injury. Nociceptors are polymodal and can be stimulated by thermal, mechanical, and chemical stimuli. Nociception refers to the transmission of impulses by sensory
nerves, which signal tissue injury.

At the site of injury, the release of a variety of neuro- chemical substances potentiates the activation of peripheral nociceptors. Many of these substances are also
mediators of the inflammatory response and they can facilitate or inhibit the pain impulse. These substances include hista- mine, kinins, prostaglandins, serotonin, and
leukotrienes (Figure 6-2).
 Types of Pain
Pain is defined as an unpleasant sensory and emotional experience associ- ated
with actual or potential tissue damage (APS, 2008). There are three main types of
pain that can occur alone or in combination:
•Acute pain from which the patient expects to recover
•Chronic pain that lasts beyond the normal healing period
•Neuropathic pain, a special type of chronic pain that is the result of nerve
damage
 Responses to Pain

• Blood shifts from superficial vessels to striated muscle, the heart, the
lungs, and the nervous system
• Dilation of the bronchioles to increase oxygenation
• Increased cardiac contractility
• Inhibition of gastric secretions and contraction
• Increases in circulating blood glucose for energy

The most reliable and valid indicator of pain is the patient’s self-report. The location, characteristics, aggravating and alleviating factors, and intensity of pain should be
evaluated.
*Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion or injury. Assess patients with hemiplegia on the unaffected side. ** This item
cannot be measured in patients with artificial airways.

How to Use the Pain Assessment Behavioral Scale:

1. Observe behaviors and mark appropriate number for each category.

2. Total the numbers in the pain assessment behavioral score column.

3. Zero = no evidence of pain. Mild pain = 1-3. Moderate pain = 4-6. Severe uncontrolled pain is > 6.

Considerations:

4. use the standard pain scale whenever possible to obtain the patient’s self-report of pain. Self-report is the best indicator of the presence and intensity of pain.

5. use this scale for patients who are unable to provide a self-report of pain.

6. In addition, a “proxy pain evaluation” from family, friends, or clinicians close to the patient may be helpful to evaluate pain based on previous knowledge of patient
response. 7. When in doubt, provide an analgesic. “If there is reason to suspect pain, an analgesic trial can be diagnostic as well as therapeutic.”

used with permission by the Detroit medical Center via margaret L. Campbell, PhD, RN.
As critically ill patients are often unable to communicate their level of pain if sedated, anesthetized, or receiving neuromuscular blockade.

BPS

Assess 3 domains

Validated in medical, surgical, and neurological critically ill adult patients

Simpler
CPOT

Assesses 4 domains

Validated in medical and surgical critically ill adult patients

Pre-eliminary phase on neurology/neurosurgery patients

More complex
 Evidenced-Based Practice: Pain Management

• Pain should be routinely monitored.

• Use the behavioral pain scale (BPS) or critical-care pain observation tool (CPOT) for patients who cannot self-report pain.
• Do not use vital signs alone for pain assessment in ICU patients.
• Use preemptive analgesia prior to procedures.
• Consider IV opioids as the first line to treat non-neuropathic pain.
• Non-opioids and co-analgesics such as gabapentin or carbamazepine be considered for use with opioids.
• Epidural analgesia is recommended for rib fractures and postoperative analgesia for abdominal aortic aneurysm
Today there are numerous approaches and modalities available to treat acute pain. Whereas pharmacologic techniques tradi- tionally have been the mainstay of
analgesia, other comple- mentary or nonpharmacologic methods are growing in their acceptance and use in clinical practice. Most modalities used in the treatment of
acute pain can be used effectively in the critically ill
Opioids are the primary medications for managing pain in critically ill patients because of potency, concomitant mild sedative and anxiolytic properties, and their ability to
be administered by multiple routes.

 NSAIDS

Nonsteroidal anti-inflammatory drugs (NSAIDs) target the peripheral nociceptors. The NSAIDs exert their effect by modifying or reducing the amount of prostaglandin pro-
duced at the site of injury by inhibiting the formation of the enzyme cyclooxygenase, which is also responsible for the breakdown of arachidonic acid. As prostaglandin
inhibitors, the NSAIDs have been shown to have opioid-sparing effects and are very effective in managing pain associated with inflammation, trauma to peripheral tissues
(eg, soft tissue injuries), bone pain (eg, fractures, metastatic disease), and pain associated with indwelling tubes and drains (eg, chest tubes).
 Ketorolac
NSAID

• Only parenteral NSAID preparation

available in the United States and can
be administered safely via the
intravenous (IV) route.
• Intramuscular administration is not
recommended due to the potential
for irregular and unpredictable
absorption
• Recommended dose 30 mg loading
dose, followed by 15 mg every 6 hours

One of the NSAIDs commonly used in the critical care setting is ketorolac tromethamine (Toradol). Ketorolac is currently the only parenteral NSAID preparation available in
the United States and can be administered safely via the intravenous (IV) route. Intramuscular administration is not recommended due to the potential for irregular and
unpre- dictable absorption. Recommended dosing for ketorolac is a 30-mg loading dose followed by 15 mg every 6 hours. Like all NSAIDs, ketorolac has a ceiling effect
where administra- tion of higher doses offers no additional therapeutic benefit yet significantly increases the risk of toxicity. Another non-opioid alternative to ketorolac is
acetaminophen IV (Orfirmev), for patients who can tolerate the drug and do not have liver disease or other potential contraindications. The Society of Critical Care
Medicine (SCCM) recommends the use of adjuvant analgesics such as NSAIDs to reduce opioid analgesic use and reduce opioid related side effects.
 SIDE EFFECTS
NSAID

• GI Irritation
• Bleeding problems
• Renal toxicity

The side effects associated with the use of NSAIDs relate to the function of prostaglandins in physiologic processes in addition to nociception; for example,
gastrointestinal (GI) irritation and bleeding may result from NSAID use because prostaglandins are necessary for maintaining the mucous lining of the stomach. Similarly,
the enzyme cyclooxygen- ase is needed for the eventual production of thromboxane, a key substance involved in platelet function. As a result, when NSAIDs are used
chronically or in high doses, platelet aggregation may be altered, leading to bleeding problems. NSAID use can also lead to renal toxicity.
 • NSAIDs should be avoided for
patients who have a history of
gastric ulceration, renal
insufficiency, and coagulopathies or
a documented sensitivity to aspirin
or other NSAIDs.
• Alternative to IV ketorolac is IV
acetaminophen

ibupro- fen, naproxen, indomethacin, piroxicam, aspirin

or these reasons, ketorolac and other NSAIDs should be avoided for patients who have a history of gastric ulceration, renal insufficiency, and coagulopathies or a
documented sensi- tivity to aspirin or other NSAIDs. In addition, NSAID use is not recommended in patients with heart disease, recent heart bypass surgery, or patients
with a history of ischemic attacks or strokes. An alternative to intravenous ketorolac for patients who are not good candidates for NSAIDs is intra- venous
acetaminophen, as noted above. The severity of all NSAID-related side effects increases with high doses or pro- longed use. For this reason, ketorolac and other such
drugs are designed for short-term use only.

Commonly Used Opioids

 OPIOIDS

• The principal modality of pain

management in the critical care
setting.
• Opioids are well tolerated by most
critically ill patients and can be
administered by many routes: IV, oral,
buccal, nasal, rectal, transdermal, and
intra-spinal.
• Morphine sulfate is still the most
widely used opioid
•

Traditionally referred to as narcotics, opioids produce their analgesic effects primarily by binding with specialized opiate receptors throughout the CNS and thereby
altering the perception of pain. Opiate receptors are located in the brain, spinal cord, and GI tract. Although opioids work primarily within the CNS, they also have been
shown to have some local or peripheral effects as well.

Opioids are well tolerated by most critically ill patients and can be administered by many routes including IV, oral, buccal, nasal, rectal, transdermal, and intraspinal.
Morphine sulfate is still the most widely used opioid and serves as the gold standard against which others are compared. Other opi- oids commonly used in the care of
the critically ill include hydromorphone (Dilaudid) and fentanyl (Sublimaze). Opioid polymorphisms may cause opioids to affect patients differently, thus careful use and
assessment of the drugs are necessary to determine optimal dosing.
 OPIOIDS
Side Effects

• Nausea and vomiting

• Pruritus
• Constipation
• Urinary retention
• Respiratory depression

Nausea and vomiting are distressing side effects often related to opioids that, unfortunately, many patients experience. Generally, nausea and vomiting result from
stimulation of the chemoreceptor trigger zone (CTZ) in the brain and/or from slowed GI peristalsis. Nausea and vomiting often can

be managed effectively with antiemetic medications. Meto- clopramide (Reglan), a procainamide derivative, works both centrally at the CTZ and at the GI level to
increase gastric motility.

Similar to other opioid side effects, the incidence and severity of pruritus is dose related and tends to dimin- ish with ongoing use. Another option to treat opioid-induced
pruritis is nalbuphine (Nubain), dosed at small doses of 2.5 to 5.0 mg IV every 6 hours as needed.

Constipation, another common side effect, results from opi- oid binding at opiate receptors in the GI tract and decreased peristalsis. The incidence of constipation may
be low in some critically ill patients, but it is important to remember that it is likely to be a problem for many patients after the critical phase of their illness or injury. The
best treatment for consti- pation is prevention by ensuring adequate hydration, as well as by administering stimulant laxatives and stool softeners, as needed.

Urinary retention can result from increased smooth muscle tone caused by opioids, especially in the detrussor muscle of the bladder.
 OPIOID
Respiratory Depression

• Earliest sign of respiratory

depression is an increased level of
sedation. OtherS/Sx include
decreased depth of breathing,
slowed respiratory rate,
constriction of pupils, hypoxemia,
and hypercarbia.
• Treated with IV Naloxone

Earliest sign of respiratory depression is an increased level of sedation, making this an important component of patient assessment. OtherS/Sx include decreased depth
of breathing, slowed respiratory rate, constriction of pupils, hypoxemia, and hypercarbia.

Clinically significant respiratory depression result- ing from opiate use is usually treated with IV naloxone (Narcan). Naloxone is an opioid antagonist; it binds with opiate
receptors, temporarily displacing the opioid and suspending its pharmacologic effects.
 Others

• Intravenous Opioids
• Patient-Controlled Analgesia
• Regional Anesthesia
• Switch from IV to Oral Opioid
Analgesia
• Epidural Analgesia

Many critically ill patients are unable to use the oral route, thus the IV route is used most often. One of the advantages of IV opioids is their rapid onset of action, allowing
for easy titration. Their rapid onset is beneficial during most inva- sive procedures in critical care. Loading doses of IV opioids should be administered to achieve an
adequate blood level of the drug. Additional doses can then be administered inter- mittently to maintain analgesic levels.

Some critically ill patients can benefit from the addi- tion of a continuous IV opioid infusion; for example, patients who are not able to communicate their pain
management needs effectively,

Patient-controlled analgesia (PCA) pumps can also be used effectively in the critical care setting with patients who are alert and able to activate the PCA button. With
PCA, patients self-administer small doses of an opioid infusion using a programmable pump. Assessing whether a critically ill patient is capable of using PCA is critical to
the success of this analgesic modality. PCA should not be prescribed for the patient who is unable to reliably self-administer pain medication (eg, a patient with a
decreased level of consciousness). A patient, however, who is cognitively intact but unable to activate the PCA button due to lack of manual dexterity or strength may
utilize a PCA device that has been ergonomically adapted to suit the patient with impaired motor abilities (eg, a pressure switch pad). Lastly, if PCA is prescribed,
patients, family members, and visitors should be educated that the patient is the only person to activate the PCA device. Family members and friends may think they are
helping by activating the PCA

device for the patient and not realize this can produce life- threatening sedation and respiratory depression.

Switching From IV to Oral Opioid Analgesia

Most often switching from IV to oral opioids is accomplished when acute pain subsides and the patient is able to tolerate oral or enteral nutrition. Patients who receive
analgesics by mouth or via the enteral route can experience comparable pain relief to parenteral analgesia with less risk of infec- tion and at lowered cost.
 Non-Pharmacologic Management

To apply or administer cutaneous stimula- tion, one simply needs to stimulate sensory fibers anywhere between the site of injury and the spinal cord, but within the

sensory dermatome (Figure 6-6). Massage, especially back massage, has additional analgesic benefits; it has been shown to promote relaxation and sleep, both of which
can influence patients’ responses to pain.

Distraction techniques such as music, conversation, televi- sion viewing, laughter, and deep breathing for relaxation can be valuable adjuncts to pharmacologic
modalities. These techniques produce their analgesic effects by sending intense stimuli through the thalamus, midbrain, and brain stem which can increase the
production of modulating substances such as endorphins.When planning for and using distraction techniques, keep in mind that they are most effective when activities
are interesting to the patient (eg, their favorite type of music, television program, or video) and when they involve mul- tiple senses such as hearing, vision, touch, and
movement.

Imagery is another technique that can be used effectively with critically ill patients, particularly during planned pro- cedures. Imagery alters the perception of pain stimuli
within the brain, promotes relaxation, and increases the production of endorphins in the brain. Patients can use imagery inde- pendently or use guided imagery where
either a care pro- vider, family member, or friend helps “guide” the patient in painting an imaginary picture. The more details that can be pictured with the image, the more
effective it can be.

RELAXATION TECHNIQUES

Because critically ill patients experience numerous stressors, most patients benefit from the inclusion of relaxation or anx- iolytic modalities. The use of relaxation
techniques can help interrupt the vicious cycle involving pain, anxiety, and mus- cle tension that often develops when pain goes unrelieved. The physiologic response
associated with relaxation includes decreased oxygen consumption, respiratory rate, heart rate, and muscle tension; blood pressure may either normalize or decrease.
Relaxation techniques are simple to use and can be particu- larly useful in situations involving brief procedures such as turning or minor dressing changes, and following
coughing or endotracheal suctioning or other stressful events.

Deep Breathing and Progressive Relaxation

Guided deep breathing and progressive relaxation can be incorporated easily into a plan of care for the critically ill patient. Nurses can coach patients with deep
breathing exer- cises by helping them to focus on and guide their breathing patterns. As patients begin to control their breathing, nurses

can work with them to begin progressive relaxation of their muscles. To do this, the nurse can say to the patient as he or she just begins to exhale, “Now begin to relax,
from the top of your head to the tips of your toes.” Change the pitch of the voice to be higher for “top of your head,” lower for “tips of your toes,” and be timed such that
the final phrase ends as the patient completes exhalation. This procedure capitalizes on the positive aspects of normal body functions, as the body tends to relax
naturally during exhalation. This process can and should be practiced during nonstressful periods to aug- ment its efficacy.

Presence

Probably the single most important aspect of promoting comfort in the critically ill or injured patient is the underly- ing relationship between the patient, the family, and his
or her care providers. Family presence at the patient’s bedside has been shown to decrease anxiety and promote healing. Including the people identified by the patient as
their family support (with a broad definition of family) can provide enor- mous comfort for the patient resulting in relaxation. Presence refers not only to physically “being
there,” but also to psy- chologically “being with” a patient. Although presence has not been well-defined as an intervention protocol, patients regularly describe the
importance of the support that their nurses render simply by “being there” and “being with” them.
 Non-Pharmacologic Management

• Cutaneous stimulation
• Distraction
• Imagery
• Relaxation Techniques
• Deep Breathing and Progressive
Relaxation
• Presence

To apply or administer cutaneous stimula- tion, one simply needs to stimulate sensory fibers anywhere between the site of injury and the spinal cord, but within the

sensory dermatome (Figure 6-6). Massage, especially back massage, has additional analgesic benefits; it has been shown to promote relaxation and sleep, both of which
can influence patients’ responses to pain.

Distraction techniques such as music, conversation, televi- sion viewing, laughter, and deep breathing for relaxation can be valuable adjuncts to pharmacologic
modalities. These techniques produce their analgesic effects by sending intense stimuli through the thalamus, midbrain, and brain stem which can increase the
production of modulating substances such as endorphins.When planning for and using distraction techniques, keep in mind that they are most effective when activities
are interesting to the patient (eg, their favorite type of music, television program, or video) and when they involve mul- tiple senses such as hearing, vision, touch, and
movement.

Imagery is another technique that can be used effectively with critically ill patients, particularly during planned pro- cedures. Imagery alters the perception of pain stimuli
within the brain, promotes relaxation, and increases the production of endorphins in the brain. Patients can use imagery inde- pendently or use guided imagery where
either a care pro- vider, family member, or friend helps “guide” the patient in painting an imaginary picture. The more details that can be pictured with the image, the more
effective it can be.

RELAXATION TECHNIQUES

Because critically ill patients experience numerous stressors, most patients benefit from the inclusion of relaxation or anx- iolytic modalities. The use of relaxation
techniques can help interrupt the vicious cycle involving pain, anxiety, and mus- cle tension that often develops when pain goes unrelieved. The physiologic response
associated with relaxation includes decreased oxygen consumption, respiratory rate, heart rate, and muscle tension; blood pressure may either normalize or decrease.
Relaxation techniques are simple to use and can be particu- larly useful in situations involving brief procedures such as turning or minor dressing changes, and following
coughing or endotracheal suctioning or other stressful events.

Deep Breathing and Progressive Relaxation

Guided deep breathing and progressive relaxation can be incorporated easily into a plan of care for the critically ill patient. Nurses can coach patients with deep
breathing exer- cises by helping them to focus on and guide their breathing patterns. As patients begin to control their breathing, nurses

can work with them to begin progressive relaxation of their muscles. To do this, the nurse can say to the patient as he or she just begins to exhale, “Now begin to relax,
from the top of your head to the tips of your toes.” Change the pitch of the voice to be higher for “top of your head,” lower for “tips of your toes,” and be timed such that
the final phrase ends as the patient completes exhalation. This procedure capitalizes on the positive aspects of normal body functions, as the body tends to relax
naturally during exhalation. This process can and should be practiced during nonstressful periods to aug- ment its efficacy.

Presence

Probably the single most important aspect of promoting comfort in the critically ill or injured patient is the underly- ing relationship between the patient, the family, and his
or her care providers. Family presence at the patient’s bedside has been shown to decrease anxiety and promote healing. Including the people identified by the patient as
their family support (with a broad definition of family) can provide enor- mous comfort for the patient resulting in relaxation. Presence refers not only to physically “being
there,” but also to psy- chologically “being with” a patient. Although presence has not been well-defined as an intervention protocol, patients regularly describe the
importance of the support that their nurses render simply by “being there” and “being with” them.
 Special Considerations

• Assessment
Elderly patients often report pain very differently from younger
patients due to physiologic, psychological, and cultural changes
accompanying age. Assure patients about the nature of their pain and
the importance of reporting any discomfort.

• Interventions
Critically ill elderly patients can benefit from any of the analgesic
modalities. Older patients can tolerate opioids well if the doses are
individualized and the patient is monitored for effect.

The pain experience of elderly patients has often been shad- owed by myths and misperceptions. Some believe that older patients have less pain because their extensive
life experi- ences have equipped them to cope with discomfort more effectively. This may be true for some individuals, to accept this generalization as truth for all elderly
patients is short sighted. In fact, the incidence of and morbidity associ- ated with pain is higher in the elderly than in the general population. Many elderly patients
continue to experience chronic pain in addition to any acute pain associated with their critical illness or injury. Major sources of underlying pain in the elderly include low
back pain, arthritis, head- ache, chest pain, and neuropathies.

Interventions

Critically ill elderly patients can benefit from any of the analgesic modalities discussed. Older patients can tolerate opioids well if the doses are individualized and the
patient is monitored for effect. However, it is important to recog- nize that medication requirements may be reduced in some elderly patients due to age related renal
insufficiency and the potential for decreased renal clearance of the drugs. In addi- tion, they have a reduced muscle-to-body fat ratio which affects the way that opioids
bind and activate in the body. Analgesic requirements are highly individualized and doses should be carefully titrated to achieve pain relief.

Assessment

Elderly patients often report pain very differently from younger patients due to physiologic, psychological, and cul- tural changes accompanying age. Some patients may
fear loss of control, loss of independence or being labeled as a “bad patient” if they report pain-related concerns. Also, for some patients the presence of pain may be
symbolic of impending death, especially in the critical care setting. In such cases, a patient may be reticent to report his or herpain to a care provider or family member as
if to deny pain is to deny death. For reasons such as these, it is important for nurses not only to assure patients about the nature of their pain and the importance of
reporting any discomfort. Nurses may also use a variety of pain assessment strategies to incorporate behavioral or physiologic indicators of pain.

Similar strategies are often needed to assess pain in persons who are cognitively impaired. Preliminary reports from ongoing work among nursing home patients suggest
that many patients with moderate to severe cognitive impair- ment are able to report acute pain reliably at the time they are asked. For these patients, pain recall and
integration of pain experience over time may be less reliable.
 SEDATION

Reasons:
• Amnesia
• Ventilator Tolerance
• Anxiety and Fear
• Patient Safety and agitation
• Sleep deprivation
• Delirium

The critical care environment can be uncomfortable and anxiety producing for patients. Once pain is addressed, anx- iolysis may be appropriate to enhance comfort,
decrease anxiety, reduce awareness of noxious stimuli, and induce sleep. In some cases the use of sedatives may be necessary to ensure tolerance of medical
modalities, clinical stability, and to protect patients from inadvertent self-harm. While the treatment of anxiety is an important aspect of the care of patients who are
critically ill, continuous use of sedatives as either an infusion or a bolus intravenous dosing method to induce a more depressed sensorium (ie, amnesia) in these patients
is discouraged.

The use of sedation infusions in mechanically ventilated patients has been associated with negative outcomes such as prolonged mechanical ventilation, increased
lengths of stay, and even death. In an attempt to improve these outcomes, studies have focused on how best to minimize infusion use. Daily interruptions of sedation
infusions have been associated with improved outcomes and do not appear to incur additional psychological stress. This finding is in direct opposition to the commonly
held philosophy that amnesia protects the patient from the psychological stress induced by the critical care environment. Further, there is a strong association between
sedation infusion use and delirium. Compounding the issue is the fact that those who develop delirium are then at risk for the development of long-term.

Reasons for Sedation

Amnesia

The goal of attaining amnesia is appropriate in the case of procedures, surgery, and other invasive critical care interven- tions. However, when used to create amnesia in
patients for extended lengths of time (> 24 hours), the patients may expe- rience the negative outcomes described previously. Amnesia may not be an appropriate reason
for prolonged sedation use, the absolute exception being when neuromuscular block- ade (NMB) is required. When paralytics are necessary, it is essential that both
comfort (with analgesics) and sedation are ensured.

Ventilator Tolerance

Ineffective, dyssynchronous, and excessive respiratory effort results in increased work of breathing and increased oxygen consumption. The reason for the
dyssynchronous breath- ing should be quickly assessed and managed. Efforts are made to improve tolerance by first treating potential pain and adjusting the ventilator
to optimize patient-ventilator interaction. Sedative use in the form of infusions or fre- quent IV bolus dosing in severe cases of patient/ventilator dssynchrony may be
necessary and in some cases lifesaving. (See Chapter 5, Airway and Ventilatory Management for more on patient/ventilator dyssynchrony and Chapter 20:

Advanced Respiratory Concepts: Modes of Ventilation, for more on specific characteristics of ventilator modes.)

Anxiety and Fear

Anxiety and fear are symptoms that can be experienced by critically ill patients who are conscious. However, these symptoms are often difficult to assess in critically ill
patients because many cannot adequately communicate their feelings secondary to the underlying condition, the presence of an arti- ficial airway, or a reduced
sensorium. When the patient can identify anxiety or fear, the treatment goals are clear. How- ever, in the patient who cannot, the presence of behaviors and signs that are
associated with anxiety and/or fear are often used as evidence and are the reason sedatives are provided. Manifestations of severe anxiety and/or fear include nonspe-
cific signs of distress such as agitation, thrashing, diaphore- sis, facial grimacing, blood pressure elevation, and increased heart rate. These nonspecific signs may also
be indicative of pain or delirium. Thus, an in-depth evaluation of the source of the distress (eg, pain, delirium, etc) is essential if the patient is to be appropriately and
adequately treated. Some studies have suggested the use of the GI tract (eg, oral and/or gas- tric tube) as vehicles for sedatives when needed to decrease anxiety.
Because gastric absorption of drugs is different from when they are provided intravenously, the steady state may be more reliably attained with less profound changes in
senso- rium (ie, peaks and valleys). As noted, in some cases sedatives are essential. However, the use of sedatives by infusion and/or repeated IV bolus for more than 24
hours is discouraged; they should be discontinued as early as possible.

Patient Safety and Agitation

Agitation includes any activity that appears unhelpful or potentially harmful to the patient. The patient may be aware of the activity and be able to communicate the
reason for the activity; more commonly they are not aware, making it difficult to identify the reason for the agitation. The patient appears distressed and the associated
activity includes epi- sodic or continuous nonpurposeful movements in the bed, severe thrashing, attempts to remove tubes, efforts to get out of bed, or other behaviors
which may threaten patient or staff safety. Reasons for agitation include pain and anxi- ety, delirium, preexisting conditions that require pharma- cologic interventions (ie,
preexisting psychiatric history), withdrawal from certain medications such as benzodiaz- epines (especially if they have been on them for a long time), and delirium
tremens secondary to alcohol withdrawal (see Chapter 11: Multisystem Problems, section on alcohol withdrawal). Patients who experience inadequately con- trolled
agitation face a high risk of morbidity and mortality. Thus, potential reasons for the agitation are explored so that appropriate therapy may be initiated.

Sleep Deprivation

Sleep deprivation is common among critically ill patients. Although patients may appear restful, physiologically they

may never experience stages of sleep that ensure a “rested” state (ie, rapid eye movement sleep, stages 2, 3, and 4). These restorative stages of sleep are adversely
affected by many fac- tors, including a wide variety of medications. Sleep depriva- tion is also common among those with pain, discomfort, and anxiety. Additionally,
sleep deprivation may be a result of the increased auditory, tactile, and visual stimuli ubiquitous to the critical care environment. The SCCM guidelines recommend the
use of non-pharmacologic interventions when possible. In some patients pharmacologic sleep aides may be prescribed.

Delirium

Delirium is said to be present in 50% to 80% of critically ill patients. Patients are especially at risk if they are elderly, have preexisting dementia, a history of hypertension,
and high severity of illness at admission. Coma is an independent risk factor for the development of delirium. As noted ear- lier, the risk of long-term cognitive dysfunction
is increased in patients who experience delirium. In the past, delirium was commonly associated with agitation.
Goals of Sedation, Monitoring, and Management

The goal of sedation administration is important to identify in order to determine the appropriate approach and drug. If the reason is to decrease pain and increase
comfort, the selection of an analgesic is indicated. If, however, pain has adequately been treated and the need for sedation is still pres- ent, a sedative and level of
sedation may be determined; for example, in the patient who is anxious and unable to sleep, the goal is very different than if the patient is unstable, on a ventilator, and
suffering from profound hypoxemia. Seda- tion scales have been developed in an effort to assist with the management of sedation and are helpful tools for the bedside
clinician.

Sedation scales allow the health-care team to select a level of sedation for the patient. Descriptors of each level of seda- tion are provided so that the sedative may be
adjusted appro- priately. Sedation monitoring is done at least hourly and the level of sedation achieved is recorded. Use of a valid and reli- able sedation assessment
scale is recommended (Table 6-6), rather than scales that are institutionally developed and lack proper testing. It is important for the interdisciplinary team to determine
the level of sedation daily so the infusion rate can be adjusted accordingly; however, addressing sedation level only once a day may not be often enough.

Sedation Management

Management of sedation is an essential step in attaining pos- itive outcomes for critically ill patients. Patients may require sedatives for the treatment of mild anxiety
while in the criti- cal care unit. Treatment of such anxiety is appropriate and rarely results in adverse effects. Generally the sedatives are provided orally. The doses are
adjusted to prevent excessive drowsiness or respiratory depression.
Midazolam is a popular benzodiazepine that fits in this category. It can be administered intermittently in a bolus IV form or as a continuous infusion. Long-term infusions
(> 24 hours) of midazolam are discouraged because the drug has an active metabo- lite that may accumulate in the presence of drugs, renal disease, liver disease, or old
age.

• Propofol is an IV general anesthetic designed for use as a continuous infusion. This drug is often preferred for short-term sedation use (< 24 hours) and when a very
rapid offset of effect is desired. An example is the patient requiring frequent neurologic assessments. Propofol is lipid based and serves as a source of calo- ries. It
should be used cautiously in those with high triglycerides and the drug is contraindicated in those with egg allergies. High doses of propofol should be cautiously used
with other lipid formulas. Frequent changes of the containers and tubing are required to prevent potential growth of microorganisms. The cur- rent evidence-based
guidelines recommend the use of propofol or dexmedetomidine (discussed below) over sedation with benzodiazepines (either midazolam or lorazepam) to improve
outcomes in mechanically ventilated patients.

• Dexmedetomidine is an alpha-2 receptor agonist that has been approved only for very short-term use (< 24 hours) in the ICU setting. Two of the rea- sons the drug may
be an attractive choice include the drug’s ability to either eliminate or decrease the need for other analgesic medications such as opi- oids, and the fact that it does not
produce respira- tory depression when used as designed (ie, boluses of the drug are not recommended). Further, patients on the drug are rapidly arousable and alert
when stimulated.

• Ketamine is an IV general anesthetic that produces analgesia, anesthesia, and amnesia without loss of consciousness. It may be given in an IV bolus form, intranasally,
or orally. Although contraindicated in those with elevated intracranial pressure, its bron- chodilatory properties make it a good choice in those with asthma. A well-known
side effect of ketamine is hallucinations; however, these may be prevented with concurrent use of benzodiazepines. It is rarely a first-line sedative of choice, but is
commonly used in patients requiring painful, frequent skin debridement procedures (eg, burn patients). The nurse needs to be aware of hospital policy for use of this
medication as some limit it to physician use only.
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