Reducing Sedation, Improving Outcomes

Being on a ventilator can be a disturbing experience, causing many patients to show signs of agitation.1 When that’s the case, clinicians often turn to sedation.1 But depending on the cause, sedation might not be necessary.

Watch leading practitioners discuss why patients are over sedated.

CAUSES OF AGITATION

One first step is to examine the reasons why we turn to sedation, and then seek to manage the underlying causes.2

For more than a decade, ICU clinicians have studied the effects of sedation on the comfort and outcomes of their patients.2 Yet, even during clinical trials that closely implement protocol-driven sedation, 32% of patients were minimally- or non-arousable, but only 2.6% of these patients were given an oversedation rating. 

Causes of agitation can be fear and anxiety, delirium, pain and patient ventilator a-synchrony. By taking the time to evaluate each of these agitation causes, clinicians may be able to reduce the risk of oversedation.2  By using sedation more effectively, we can work together to potentially reduce ICU ventilation time.

Why is it important to understand the causes of agitation?

Agitation caused by fear and anxiety

The ICU can be a stressful environment for patients.4,5,6 Between their poor health and strange surroundings, being in the ICU can contribute to general feelings of fear and anxiety in patients, which in turn can manifest as agitation.2,4,5,6 Effective evaluation and treatment of anxiety can improve patients’ overall sense of well-being,2 and is another step that clinicians can take to reduce the overall use of sedatives.2

Agitation caused by delirium

While delirium may be an underlying cause of agitation in ICU patients, the more prevalent form of delirium is a quiet, hypoactive state that may result from sedation use.7 Regardless of the subtype, delirium is closely associated with poor patient outcomes, making identifying and managing delirium an important strategy for critical care clinicians.7

Agitation caused by pain

Identifying, evaluating, and treating underlying pain can be an important component of effective sedation management protocols.2  Pain, both procedural and at rest, is experienced by most patients in the ICU,2  potentially contributing to their overall levels of stress and anxiety.2 Effective management of pain may not only increase patient comfort by reducing pain, but also by reducing the additional factors that can lead to oversedation.2

In addition, protocolized pain assessment has been associated with reduced use of analgesics, reduced ICU length of stay, and reduced mechanical ventilation,2 which can all add up to improved patient outcomes.2

Agitation caused by patient ventilator asynchrony

Ventilation has been a life-saving tool for critically ill patients.8  But ventilation can be an uncomfortable experience due to the invasiveness of the tubing, and mismatches (or “asynchronies”) between the patient’s demand for breath and the ventilator-delivered breathing pattern.8

In the past, clinicians addressed ventilator-patient asynchrony through heavy sedation.8  However, recent studies have highlighted the negative consequences of oversedation for ventilatory patients, which include muscle atrophy from prolonged disuse and lengthened ventilation times.8

By evaluating and correcting ventilator-patient asynchrony, sedation use may be minimized, improving patient comfort and well-being.

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COVID-19 CRITICAL CARE / ICU TRAINING PRODUCT INFORMATION

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MANAGING THE CAUSES OF PATIENT AGITATION

Identification and management of the causes of patient agitation can be important for good patient outcomes.9

For some patients it will be enough to provide a quieter, more soothing ICU environment.9 Others will need pharmacological interventions or adjustment of their ventilator settings.2,8

By carefully considering when and why you use sedation and appropriately managing patient discomfort, you may be able to reduce unnecessary sedation.2

Click on each of the boxes below to learn more about the latest thoughts and practices on how to manage the ICU patient’s agitation and discomfort, while potentially improving outcomes.2,4,8

  • 1. Siegel MD. Management of agitation in the intensive care unit. Clin Chest Med.2003;24(4):713-725.

  • 2. Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

  • 3. Weinert CR, Calvin AD. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med. 2007;35(2):393-401.

  • 4. Wenham T, Pittard A. Intensive care unit environment. Continuing Education Anaesth Crit Care Pain. 2009;9(6):178-183.

  • 5. Pugh RJ, Jones C, Griffiths RD. The impact of noise in the intensive care unit. Intensive Care Med Yearbook of Intensive Care Med.  2007:942-949. Available at: http://link.springer.com/chapter/10.1007/978-3-540-49433-1_85. Accessed May 28, 2013.

  • 6. Biancofiore G, Bindi ML, Romanelli AM, Urbani L, Mosca F, Filipponi F. Stress-inducing factors in ICUs: what liver transplant recipients experience and what caregivers perceive. Liver Transpl. 2005;11(8):967-972.

  • 7. Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit.Crit Care. 2008;12 Suppl 3:S3.

  • 8. Epstein SK. How often does patient-ventilator asynchrony occur and what are the consequences? Respir Care. 2011;56(1):25-38.

  • 9. Cohen IL. Current issues in agitation management.Advanced Studies Med. 2002;2(9):332-337.

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