Agitation in critically ill patients can be a consequence of many factors including pain, delirium, anxiety, drug withdrawal syndromes and discomfort due to poor ventilator synchrony, bowel dysfunction or pressure areas (Vincent et al., 2016). Management of agitation in the ICU should focus on diagnosing and rectifying the cause of the agitation but will also typically involve keeping patients within a state of sedation (Barr et al., 2013; DAS Taskforce, 2015; Vincent et al., 2016).
A number of predictive risk factors for agitation have been identified and should be considered when creating a patient’s individual treatment plan. Factors found to significantly predict a risk for developing agitation include (Jaber et al., 2005; Grounds et al., 2014):
Table 1. Risk factors for the development of agitation. Adapted from Grounds et al., 2014.
Predictive risk factors
Use of sedatives in 48 hours before onset of agitation
Body temperature > 38.0°C
Sodium level < 134mmol/L
Sodium level > 143mmol/L
Long-term psychoactive drug user
Abbreviations: CI, confidence interval.
Although certain patients may require deep sedation, guidelines in recent years have advocated a shift towards the use of light sedation where possible and a target of patients being calm, comfortable and cooperative (the 3Cs) (Barr et al., 2013; DAS Taskforce, 2015; Vincent et al., 2016). In fact, the guidelines recommend a target of light sedation that is broadly equivalent to a Richmond Agitation-Sedation Scale (RASS) score of 0/-1 (DAS Taskforce, 2015; Vincent et al., 2016). In the 2018 update to the PAD guidelines, a conditional statement suggests that light suggestion, rather than deep sedation, should be used in critically ill, mechanically ventilated patients, although it does highlight that the quality of evidence remains low (Devlin et al., 2018b). Despite these guideline recommendations, it is apparent that deep sedation is still widely used (TEAM Study, 2015).