From the Guidelines
The patient's agitation during CPAP transition to a tracheostomy collar is most likely due to alcohol withdrawal syndrome, given their history of ethanol use, and this should be promptly addressed to prevent progression to delirium tremens. Considering the patient's history of ethanol use, untreated withdrawal can progress to delirium tremens, which can be life-threatening 1. Other possible causes of agitation include hypoxemia from inadequate ventilation during the transition, discomfort from the tracheostomy tube, inability to communicate effectively, anxiety about breathing changes, pain, or an underlying medical condition like infection or electrolyte imbalances.
Possible Causes of Agitation
- Alcohol withdrawal syndrome
- Hypoxemia from inadequate ventilation
- Discomfort from the tracheostomy tube
- Inability to communicate effectively
- Anxiety about breathing changes
- Pain
- Underlying medical conditions like infection or electrolyte imbalances I recommend checking vital signs, oxygen saturation, and performing a CIWA-Ar assessment to evaluate for withdrawal symptoms 1. If withdrawal is suspected, discuss with the physician about implementing a symptom-triggered benzodiazepine protocol (such as lorazepam 1-2mg IV every 1-2 hours based on CIWA scores) despite the initial reluctance for sedation, as untreated withdrawal poses greater risks. Non-pharmacological interventions should include clear communication with the patient, maintaining a calm environment, having family present if possible, and ensuring adequate pain control. The respiratory therapist should also verify proper tracheostomy tube positioning and consider a more gradual weaning process from ventilatory support.
From the Research
Possible Causes of Agitation
The patient's agitation could be caused by several factors, including:
- Alcohol withdrawal symptoms, as the patient has a history of ethanol (ETOH) use 2, 3
- Delirium or confusion, which can be exacerbated by the patient's critical illness and the intensive care unit (ICU) environment 4
- Pain or discomfort, which can contribute to agitation and distress 4
- Fear or anxiety, which can be triggered by the patient's situation and the inability to communicate effectively 4
- The patient's dependence on others for care and the loss of control, which can incite agitation and distress 4
Neurobiology of Agitation
The neurobiology of agitation is complex and involves multiple neurotransmitter systems 5. The patient's agitation could be related to the neuropharmacological aspects of alcohol withdrawal, including the sensitization of the patient to future episodes of withdrawal 2.
Management of Agitation
The management of agitation in critically ill patients requires a comprehensive approach that takes into account the patient's medical and psychological needs 6, 5. The use of benzodiazepines, such as lorazepam, may be effective in managing alcohol withdrawal symptoms and agitation 2, 3. However, the patient's cortical doctor has expressed concerns about sedation, and alternative strategies may need to be considered 5.