Pain, Agitation, and Delirium (PAD) in the ICU

Addressing the ICU Triad (PAD) can be accomplished through the stepwise daily assessment of the ICU Liberation Bundle (A-F):

  A - Assess (CPOT), prevent, and manage pain

  B - Both Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT)

  C - Choice of sedation (see below)

  D - Delirium: assess (CAM-ICU), prevent, and manage

  E - Early mobility and exercise

  F - Family engagement

Critical Care Pain Observation Tool (CPOT) - Validated tool to assess pain control in critically ill patients. Total scores >2 indicate inadequate analgesia.

Richmond Agitation Sedation Scale (RASS) - Validated tool to assess level of sedation in the ICU. Target -1, but will vary with clinical scenario / sedation indication.

Opioids:

 • Fentanyl - Generally first line opioid in the ICU due to short half-life

 • Morphine - Slower on/off. Can also be dosed PO

 • Hydromorphone (Dilaudid) - Increased potency compared to morphine. Can also be dosed PO

Sedative (Non-Benzos):

 • Propofol (Diprivan) - 1st line non-benzo sedative: fast on/off. SE: HoTN, bradycardia. t triglycerides (monitor). Propofol infusion syndrome (PRIS) - acidosis, bradycardia. renal/liver failure, rhabdo (↑ CPK)

 • Dexmedetomidine (Precedex) - Can also be used as first sedative. okay to use in non-intubated patients (ie EtOH w/d), or to facilitate extubation, as it should not cause resp depression. SE: HoTN. bradycardia

 • Ketamine - A dissociative drug, it causes amnesia and analgesia w/out overt resp. depression. SE: hallucinations, sympathetic stimulation (including HTN), and ↑ oral/pulm secretions

Sedatives (Benzos):

 • Lorazepam (Ativan) - Propylene glycol (solvent) toxicity @ ↑ doses (ie. 20 mg/hr x > 6 hrs) can result in lactic acidosis. Can give in low doses (ie 0.5mg x1) for nausea, if you need a non-OTC prolonging agent.

 • Midazolam (Versed) - CYP3A4 metabolism (med interactions). Shorter t1/2 vs. lorazepam (2-6h vs. 14h). May see this used for moderate sedation for procedures as well.

Antipsychotics:

 • Quetiapine (Seroquel) - Often used QHS for insomnia/sleep-wake cycles. No pharmacologic therapy has been shown to be effective in preventing or treating delirium in the ICIJ. SE: prolonged QTC

 • Haloperidol (Haldol) - No pharmacologic therapy has been shown to be effective in preventing or treating delirium in the ICU. SE: prolonged QTC



- Dr. Meredith Greer @EmmGeezee



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