What is the recommended treatment for agitation in the Intensive Care Unit (ICU)?

Treatment of Agitation in the ICU

For the treatment of agitation in the ICU, a multimodal approach is recommended with dexmedetomidine as the preferred sedative agent for delirious patients, while avoiding routine use of antipsychotics unless specifically indicated for distressing symptoms. 1

Assessment and Identification of Causes

• Agitation in ICU patients should be routinely assessed using validated scales such as the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS) 1
• Identify and address underlying causes of agitation, including:
  • Pain (most common cause) 1
  • Delirium 1
  • Hypoxemia
  • Withdrawal syndromes (alcohol, benzodiazepines, opioids) 1
  • Medication side effects

Pharmacological Management

First-Line Approach

• For delirious ICU patients with agitation:

  • Dexmedetomidine is suggested as the preferred sedative agent over benzodiazepines to reduce the duration of delirium 1
  • Particularly beneficial when agitation is precluding ventilator weaning/extubation 1

• For pain-related agitation:

  • Use intravenous opioids as first-line analgesic therapy 1
  • Consider adding non-opioid analgesics to reduce opioid side effects 1

Antipsychotic Medications

• Haloperidol:

  • No published evidence that haloperidol reduces the duration of delirium in adult ICU patients 1
  • FDA-approved dosing for acute agitation: 2-5 mg intramuscularly, with subsequent doses as often as every hour (maximum 20 mg/day) 2
  • Not recommended for routine use to treat delirium 1

• Atypical antipsychotics:

  • May reduce the duration of delirium in adult ICU patients (evidence level C) 1
  • Quetiapine has shown some benefit in a small study 1
  • Not recommended for routine use to treat delirium 1

• Important safety considerations:

  • Do not use antipsychotics in patients at significant risk for torsades de pointes (baseline QT prolongation, concomitant QT-prolonging medications, or history of this arrhythmia) 1
  • Monitor for QT prolongation and rhythm disturbances when using antipsychotics 3

Benzodiazepines

• Generally not recommended as first-line agents for agitation in ICU patients except in:
  • Alcohol withdrawal syndrome 1
  • Benzodiazepine withdrawal 1
• Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients 1
• If required, midazolam dosing: initial infusion rate 0.02-0.10 mg/kg/hr (1-7 mg/hr) 4

Non-Pharmacological Interventions

• Early mobilization is strongly recommended to reduce the incidence and duration of delirium and associated agitation 1
• Optimize the patient's environment to promote sleep:
  • Control light and noise
  • Cluster patient care activities
  • Decrease stimuli at night 1
• Use sedation protocols and daily checklists to integrate and facilitate management of pain, agitation, and delirium 1

Special Considerations

• For mechanically ventilated patients:

  • Maintain lighter levels of sedation when possible 1
  • Consider daily sedation interruption or titrate sedatives to maintain light levels of sedation 1
  • Use analgesia-first sedation approach 1

• For patients receiving neuromuscular blocking agents:

  • Use brain function monitors as adjuncts to monitor depth of sedation 1

Medications to Avoid

• Rivastigmine (cholinesterase inhibitor) is not recommended for reducing the duration of delirium in ICU patients (evidence level -1B) 1
• Prophylactic use of haloperidol or atypical antipsychotics is not recommended to prevent delirium 1

Monitoring and Titration

• Assess sedation at regular intervals using validated scales 4
• Titrate medication doses to the desired level of sedation, adjusting by 25-50% of the initial rate 4
• Decrease infusion rates by 10-25% every few hours to find minimum effective dose 4
• Monitor for adverse effects including oversedation, QT prolongation, and respiratory depression 1

Remember that while antipsychotics are commonly used in clinical practice, the 2018 guidelines suggest not routinely using haloperidol, atypical antipsychotics, or statins to treat delirium due to lack of evidence for their effectiveness 1.