CURRENT Essentials of Critical Care.pdf

Chapter 1 Monitoring & Support 3■■■Anxiety and SedationEssentials of Diagnosis• Distress, often expressed as fear, agitation• Tachycardia, hypertension, diaphoresis• May manifest as pain, restlessness, discoordination with mechanicalventilation• Frequent complaint of patients, sometimes misinterpreted• Contributing factors include stressful ICU environment, excessivenoise, sleep deprivation, painful procedures, mechanicalventilation, medications, anticipation of surgery, fear• Mechanical ventilation may contribute, especially low tidal volume,permissive hypercapniaDifferential Diagnosis• Hypoxemia• Alcohol or drug withdrawal• Hyperthyroidism• Beta-agonist excess• Infection, sepsis• Psychiatric illness, including severe situational reaction to ICUenvironmentTreatment• Exclude medical conditions, including pain, especially if patientshows delirium• Explain anticipated events, procedures, current condition to patient;provide orientation to date, time; include family membersin discussions, encourage visitation• Anticipate and control pain; avoid sleep interruptions• If sedation needed, objective scales for measuring effects of sedationuseful; target sedation: follows verbal commands• For most patients, lorazepam recommended for long-term use;midazolam, propofol useful for short-term sedation■ PearlDaily interruption of sedation reduces duration of mechanical ventilation,length of ICU stay, and number of diagnostic studies for unexplainedaltered mental status.ReferenceKress JP et al: Daily interruption of sedative infusions in critically ill patientsundergoing mechanical ventilation. N Engl J Med 2000;34:1471. [PMID:10816184]