Therapeutic options for agitation in the intensive care unit

Patient Agitation in the Intensive Care Unit: A Concept Analysis

AIM

Exploring the concept of patient agitation in the intensive care unit.

BACKGROUND

Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management.

DESIGN

Concept Analysis.

METHOD

Walker and Avant's eight-step concept analysis approach.

DATA SOURCES

A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation.

RESULTS

Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff.

CONCLUSION

Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours.

IMPLICATIONS

A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research.

PATIENT OR PUBLIC CONTRIBUTION

This concept analysis was developed with input from a patient representative.

Clinical profiles, treatment adherence, and quality of life in patients with severe mental disorders treated with cyamemazine: A real-world observational study

BACKGROUND

Cyamemazine, a phenothiazine antipsychotic with anxiolytic and sedative properties, is commonly used in the management of severe mental disorders (SMDs) such as schizophrenia, bipolar disorder, and major depressive disorder. Despite its unique pharmacological profile, the impact of cyamemazine on clinical outcomes, treatment adherence, and quality of life (QoL) remains inadequately studied. This study addresses the significant gap in understanding the clinical impact of cyamemazine, a widely used yet under-researched antipsychotic.

METHODS

This observational study was conducted at a university psychiatry unit in Marseille, France, involving patients with SMDs. Sociodemographic, clinical, and comorbid characteristics were assessed, along with treatment adherence, QoL, and side effects using validated instruments including the Medication Adherence Rating Scale (MARS) and the Schizophrenia Quality of Life Scale (SQoL-18). Multivariate analyses were performed to explore the associations between cyamemazine use and clinical outcomes.

RESULTS

A total of 1,248 patients were included with 55 (4.4%) using cyamemazine. Cyamemazine users presented more severe clinical profiles, with higher anxiety, more hospitalizations, and poorer functioning. Although cyamemazine's anxiolytic effects may improve adherence, its sedative and metabolic side effects were associated with reduced QoL and functional impairment.

CONCLUSIONS

The study highlights the need for personalized treatment strategies that weigh the benefits of cyamemazine against its potential risks. Integrating pharmacological and non-pharmacological interventions could enhance patient outcomes.

A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

RATIONALE

Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

OBJECTIVES

The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

PANEL DESIGN

The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

METHODS

The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

RESULTS

The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

CONCLUSIONS

The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

Incidence and factors associated with agitation in patients on mechanical ventilators in Amhara Region, North-West Ethiopia: a multi-center study

Agitation is a common psychomotor disorder among critically ill patients on mechanical ventilators, posing significant risks to patients and adding strain to clinical services. Despite its importance, there is a lack of data on the incidence and contributing factors of agitation in the study area and across Ethiopia. This study, therefore, aims to assess the incidence and factors associated with agitation in patients on mechanical ventilators in the intensive care units of comprehensive specialized hospitals in the Amhara Region, North-West Ethiopia. A multi-center prospective follow-up study was conducted among 253 critically ill adult patients on mechanical ventilators in the Amhara region of Ethiopia from April 17, 2024, to July 16, 2024. Data were collected using a semi-structured questionnaire through chart reviews, observations, and interviews. Participants were selected using a consecutive sampling technique. The data were entered into Epi-Data version 4.6 and transferred to Stata version 17 for analysis. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with agitation. Variables with a p value of less than 0.2 in the bivariable analysis were included in the multivariable analysis. Crude and adjusted odds ratios with 95% confidence intervals were used to identify factors associated with agitation. The results were presented in the form of text, tables, and figures. In the multivariable analysis, variables with a p value of less than 0.05 were considered statistically significant predictors. The overall incidence of agitation among patients on mechanical ventilators in intensive care units was 87.35% (95% CI 82.6, 91.2). Anxiety (Adjusted Odds Ratio (AOR) 3.5; 95% CI 1.28, 9.45), delirium (AOR 3.01; 95% CI 1.13, 7.97), pain (AOR 3.23; 95% CI 1.18, 8.85), hyperthermia (AOR 3.49; 95% CI 1.004, 12.15), hyponatremia (AOR 3.64; 95% CI 1.009, 13.11), and the use of restraints (AOR 3.49; 95% CI 1.11, 8.67) were statistically significant factors associated with agitation. In this study, the majority of participants experienced agitation. To reduce the incidence of agitation, we recommend addressing or preventing the development of anxiety, pain, delirium, hyperthermia, and hyponatremia, as well as minimizing the use of restraints in intensive care units.

Understanding the use of sedation boluses in the intensive care unit: A mixed methods study

BACKGROUND

To better understand the impact of sedations in the intensive care unit (ICU), an accurate understanding of the clinical practices surrounding sedation bolus use is essential.

OBJECTIVES

Our primary objectives were to describe how sedation boluses are administered, and to compare observed and nurse-reported practices.

METHODS

We conducted a mixed methods study comprising 150 quantitative observations in a large university-affiliated ICU and 10 semi-structured interviews with nurses recruited in the same ICU and from others in the Province of Quebec (Canada).

RESULTS

During 150 observations, nurses administered 197 boluses. Nurses mostly administered boluses with a volumetric pump (76 %, 95 %CI 69-81 %). In interviews, all nurses expressed favoring volumetric pumps to administer boluses. Nurses documented bolus use in 58 % of observations (58 %, 95 %CI 50-66 %). Propofol and fentanyl were the most frequently used drugs, and all nurses reported that they were the "classic" bolus drugs. The median cumulative propofol and opioid bolus doses given by nurses were respectively 30 mg (95 %CI 25-30), and 50 µg in fentanyl-equivalent (95 %CI 50-50). We observed that nursing or medical interventions were the most common trigger for bolus use (63 %, 95 %CI 55-71 %), and these were among the main reason for bolus use reported in interviews (n = 9, 90 %). Increasing norepinephrine was observed (19 %, 95 %CI 13-26 %) and reported by all nurses as the most frequent interventions after boluses.

CONCLUSIONS

Nurses favor volumetric pumps to administer boluses and propofol and fentanyl were the most used drugs. Documentation of boluses was suboptimal. Sedation boluses often led to norepinephrine titration.

IMPLICATIONS FOR CLINICAL PRACTICE

Sedation boluses administered to patients with continuous infusions of sedations often led to norepinephrine titration, suggesting that they may have implications for patient safety and outcomes. Merging electronic health records entries and volumetric pump data logs or data feeds may be essential to properly capture the exposure of ICU patients to sedation.

Acute Management of Moderate to Severe Traumatic Brain Injury

The focus of this article is on the acute management of traumatic brain injury. The article focuses on the classification of traumatic brain injury, general acute management of traumatic brain injury, the role of the physiatrist on this team, and lastly, behavioral and family considerations in the acute care setting. The article includes a focus on physiologic systems, strategies for the management of various aspects of brain injury, and consideration of factors associated with the continuum of care. Overall, the article reviews this critical period of brain injury recovery and provides a primer for the physiatrist.

How are agitated patients dealt with in internal medicine departments?

Background

Studies on agitation in internal medicine departments are scarce, especially regarding how doctors and nurses act in these situations. The objective of this study was to clarify how agitation is dealt with in these departments.

Methods

This prospective observational study was performed in the internal medicine departments of four Portuguese hospitals. The researchers at each hospital contacted the nursing team that identifies patients who were agitated in the previous shifts. The researcher reviewed these patients' files, recording the research protocol's parameters.

Results

During the study period, 331 patients were observed; 177 (54%) were female, and the median age was 80 years (19-99). Episodes of agitation occurred in 69 patients (21%); of them, 44 (64%) were female, and the median age was 84 years (31-98). In the first episode of agitation, the doctor on duty was called in 49 times (71%). These doctors prescribed a new medication for the crisis in 30 cases (43%). After the crisis, the assistant doctor recorded the episode in the patient file in 41 cases (59%). According to the medical notes, after the acute phase, in only 21 patients (30%), there was an attempt to clarify the cause of agitation. The prescription after the crisis was regular medication in 32 cases (46%), rescue medication in 27 (39%), and physical restraint in 9 (13%), isolated or in various combinations.

Conclusion

This study suggests that there is room to improve how agitated patients are managed in internal medicine departments.

Effect of a physician-nurse integrated lung protection care model in neurocritical patients

Background

Lung injury resulting from diffuse pulmonary interstitial and other lung-related complications is a significant contributor to poor prognosis and mortality in patients with critical neurological diseases. To enhance patient outcomes, it is essential to investigate a lung protection model that involves the collaboration of doctors, nurses, and other medical professionals.

Methods

Patients receiving different care styles were divided into two groups: routine care (RC) and lung function protection care (LFPC). The LFPC group included airway and posture management, sedation and analgesia management, positive end-expiratory pressure titration in ventilation management, and fluid volume management, among others. Statistical analysis methods, such as chi-square, were used to compare the incidence of acute lung injury (ALI), neurogenic pulmonary edema (NPE), ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS), and length of stay between the RC and LFPC groups.

Results

The RC group included 68 patients (33 males; 34-74 years of age). The LFPC group included 60 patients (29 males; 37-73 years of age). Compared with the RC group, the LFPC group had lower occurrence rates of ALI (20.0 % vs. 38.2 %, P = 0.024), NPE (8.3 % vs. 23.5 %, P = 0.021), VAP (8.3 % vs. 25.0 %, P = 0.013), and ARDS (1.7 % vs. 16.2 %, P = 0.015). The length of hospital stay was shorter in the LFPC group than in the RC group (11.3 ± 3.5 vs. 14.3 ± 4.4 days, P = 0.0001).

Conclusion

The physician-nurse integrated lung protection care model proved to be effective in improving outcomes, reducing complications, and shortening the hospital stay length for neurocritical patients.

Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults

BACKGROUND

Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature.

AIM

The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC).

METHOD

This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill.

RESULTS

One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC.

CONCLUSION

Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.

Critical Issues in the Management of Agitation, Aggression, and End-of-Life in Delusional Disorder: A Mini-Review

Background: Compared to other psychotic disorders, there is little information about staging care in delusional disorder (DD). Unlike schizophrenia, this is a disorder that begins in middle age, a time at which chronic medical comorbidities have already begun to impact global functioning. With age, the combination of psychological and somatic conditions leads to new behaviours, e.g., agitation, aggression, and behaviours that require specific preventive and interventive measures. With further age, knowledgeable end-of-life care becomes necessary for this population. Aim: The aim of this article was to review existing evidence on the management of these successive phases. Methods: We conducted a narrative review using PubMed and ClinicalTrials.gov and searched for the following terms: (agitation OR aggressivity OR aggression OR palliative OR "end-of-life") AND ("delusional disorder"). Results: We found that the literature was sparse. Existing evidence suggests that medical causes are frequently at the root of agitation and aggression. With respect to management, de-escalation strategies are generally preferred over pharmacotherapy. Specific delusional syndromes, e.g., de Clérambault, Othello, Capgras, Fregoli, as well as folie à deux, are associated with aggression. The somatic subtype of DD is the one most often requiring palliative care at the end of life. Conclusions: We conclude that insufficient attention has been given to the care needs of the accelerated aging process in DD.

Efficacy and safety of ciprofol for agitation and delirium in the ICU: A multicenter, single-blind, 3-arm parallel randomized controlled trial study protocol

Background

Agitation is very common in the intensive care unit (ICU). The causes include pain, delirium, underlying disease, withdrawal syndrome, and some drug treatments. The practical goal of ICU treatment is to find an appropriate sedation regimen to reduce pain, restlessness, and delirium. Previous trials have examined the use of dexmedetomidine, but no trials have evaluated the efficacy and safety of ciprofol, a new sedative drug.

Methods

This study was a multicenter, single-blind, 3-arm parallel randomized controlled trial. ICU patients aged ≥ 18 years with agitation and delirium who met the eligibility criteria were included. The main outcome was the proportion of patients who needed additional study medication or midazolam due to agitation within 4 h after the first intravenous injection of the study medication. The secondary outcomes included the pass rate as indicated by a Richmond Agitation-Sedation Scale (RASS) score < +1, the effectiveness rate of improving delirium symptoms, the number of recurrences of agitation within 24 h, the incidence of rescue treatment, the dose and cost of analgesic and sedative drugs, the length and cost of ICU stay, and the 30-day survival period. The safety evaluation included the incidence of adverse events (hypotension, bradycardia, hypoxia, etc.) and the rate of endotracheal intubation. The subjects were randomly assigned to receive ciprofol, dexmedetomidine, or normal saline at a ratio of 1:1:1. The rates of additional drug administration within 4 h after the first injection of the study drug in the three groups were 40, 50, and 90%, respectively. A total sample size of 81 subjects was required to reach 90% power and an α of 0.05. Considering a 20% loss rate, 102 patients were enrolled and randomly assigned to the three groups in equal proportions.

Ethics and communication

This trial was approved by the Ethics Committee of Dalian Municipal Central Hospital. The communication plan includes presentations at scientific conferences, scientific publications, and presentations to the public through non-professional media.

Clinical trial registration

www.ClinicalTrials.gov, identifier ChiCTR220006 2799.

The effect of Shiatsu massage on agitation in mechanically ventilated patients: A randomized controlled trial

BACKGROUND

Patients admitted to the intensive care units encounter many complications due to the nature of the disease and invasive medical procedures such as intubation and mechanical ventilation. Among these complications, agitation is a frequently-observed and serious problem.

OBJECTIVES

This study aimed to investigate the effect of Shiatsu massage on agitation in mechanically ventilated patients.

METHODS

In this randomized controlled trial, a total of 68 mechanically ventilated patients were selected and then randomly assigned to two groups of intervention and control. Patients in the intervention group received three 5-minute periods of Shiatsu massage with a 2-minute break between them, while patients in the control group only received a touch on the area considered for the message. Data were collected before and after the intervention using the Richmond Agitation-Sedation Scale (RASS) and then analyzed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA).

RESULTS

The results showed that the level of agitation significantly decreased in the intervention group compared to the control group (p=.001).

CONCLUSION

Application of shiatsu massage seems to be effective in managing agitation in mechanically ventilated patients. Further studies with greater sample size and longer follow-up period are needed to confirm the current findings.

The Effects of Lavender and Citrus aurantium on Anxiety and Agitation of the Conscious Patients in Intensive Care Units: A Parallel Randomized Placebo-Controlled Trial

BACKGROUND

Conscious patients admitted to intensive care units (ICU) suffer from anxiety and agitation for various reasons, which can affect their recovery processes.

AIMS

To compare the effects of lavender and Citrus aurantium essential oils on anxiety and agitation of conscious patients admitted to ICUs.

DESIGN

A randomized parallel placebo-controlled trial.

METHODS

One hundred and fifty conscious patients admitted to ICUs were selected by convenience sampling and were randomly divided into three groups, groups of lavender aromatherapy and Citrus aurantium aromatherapy, in addition to the routine care and inhalation of five drops of lavender or Citrus aurantium essential oils for 30 minutes. The placebo group, in addition to routine care, was provided with 5 drops of normal saline for 30 minutes. Anxiety was assessed with the state subscale of State-Trait Anxiety Inventory, and agitation was examined with Richmond Agitation-Sedation Scale before, immediately, one hour, and three hours after the intervention.

RESULTS

All three groups suffered from relatively severe state anxiety before the intervention. The level of anxiety in the lavender and Citrus aurantium groups was significantly lower than that of the placebo group immediately and three hours after the intervention (P < 0.05). No significant difference was observed between the two groups of lavender and Citrus aurantium. The majority of the samples in all three groups were agitated before the intervention, but agitation of all three groups decreased after the intervention. Restless/agitation reduced significantly in all three groups. Although restless/agitation of the lavender and Citrus aurantium groups reduced more than that of the placebo, no significant difference was found between the three groups.

CONCLUSION

The results of the present study showed the positive effects of lavender aromatherapy and Citrus aurantium aromatherapy on reducing the anxiety of patients admitted to ICUs. Relevance to Clinical Practice. Aromatherapy can be used as an effective and safe intervention to reduce anxiety in ICUs.

Late Presentation of Linezolid-Induced Serotonin Syndrome After Maprotiline and Mirtazapine Therapy: A Case Report

OBJECTIVE

This report describes a 45-year-old man who developed serotonin syndrome on day 13 of linezolid therapy. This is unusual as it typically appears within 24 hours of linezolid initiation.

METHODS

The patient did not receive any serotonergic agents concurrently with linezolid; maprotiline and mirtazapine were stopped 17 days before the development of serotonin syndrome. On day 13 of linezolid administration, the patient exhibited diaphoresis, fever, confusion, agitation, disorientation, anxiety, and restlessness. His blood pressure was elevated with persistent tachycardia. He was then diagnosed with serotonin syndrome using the Hunter criteria.

RESULTS

Linezolid was discontinued and supportive measures were initiated, which resulted in the complete resolution of the syndrome.

CONCLUSIONS

This case report highlights that linezolid-induced serotonin syndrome can occur late in the course of therapy and the importance of the serotonergic agent washout period before the introduction of linezolid. A multidisciplinary team is important for optimal diagnosis and management of such cases.

Calming the Agitated Patient: Providing Strategies to Support Clinicians

Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity. Agitation often delays treatment onset, potentially impacting morbidity and mortality, and may require emergency interventions. Management of acute agitation centers around three main goals: early recognition and treatment of the underlying etiology, rapid control of the behavior, and prevention of harm to the patient and personnel. Nurses should increase use of validated techniques, including frequent and sufficient reality orientation, validation therapy, and strategies that improve the individual's quality of life.