How should anxiety be managed in intensive care unit patients?

Managing ICU Anxiety

Implement ICU diaries immediately and provide psychological interventions during the ICU stay, combined with a multimodal approach including early mobilization, family contact, environmental optimization, and stress reduction—while ensuring professional psychological support continues for 12 months after discharge. 1

During ICU Stay: Core Interventions

ICU Diaries (Highest Priority)

• ICU diaries should be implemented as a Grade A recommendation to reduce anxiety, depression, and PTSD symptoms after ICU discharge. 1
• Diaries are written by nurses, therapists, or family members to document events during the period patients cannot remember, including photographs and psychoeducational information about visits and patient progress. 1
• Patient-centered editing with trained personnel enhances effectiveness, helping patients better understand their experience and develop effective coping strategies. 1

Psychological Interventions

• Offer psychological interventions to critically ill patients with anxiety and depression during ICU stay and early rehabilitation, extending support to family members when possible. 1
• A multidisciplinary approach should include mobilization, facilitation of communication, information provision, and resilience training. 1
• Resilience training reduces anxiety and depression with effects stable over 12 weeks. 1

Multimodal Sensory and Cognitive Stimulation (ABCDEF Bundle)

• Implement the ABCDEF bundle with regular delirium assessments using CAM-ICU or ICDSC, as delirium prevention directly reduces anxiety development. 1
• Early mobilization (from sitting on bed edge to walking with therapist) and family contact significantly reduce delirium incidence and mortality. 1
• Cognitive programs including orientation aids and improved communication reduce delirium frequency and duration. 1

Environmental Optimization

• Control light and noise levels, cluster care activities, and protect sleep cycles during 2-4 AM or 12-5 AM periods when uninterrupted sleep is most likely. 2
• Turn down lights and reduce ambient noise during designated quiet periods. 2
• Avoid routine procedures during protected sleep periods to reduce sleep disruptions. 2
• Environmental modifications (noise reduction, ear-plugs, eye shields, light management) reduce delirium and improve outcomes. 1

Stress Reduction Strategies

• Address underlying stressors before escalating to sedation: treat constipation or urinary retention, reposition the patient, and consider drug withdrawal, pain, or dyspnea as causes of agitation. 1
• Use communication aids (letter boards, tablets, tracheostomy tubes with speaking valves) to reduce isolation and disorientation. 1
• Control concurrent symptoms including pain, hunger, thirst, anxiety, dyspnea, and depression. 1

Non-Pharmacological Adjuncts

• Incorporate distraction techniques, music therapy, and environmental optimization (sunlight exposure, art) to support anxiety management. 1
• Massage, relaxation techniques, and meditation can reduce anxiety without medication side effects. 1
• Ventilator optimization to improve synchrony and repositioning to alleviate discomfort reduce the need for sedation. 1

Pharmacological Considerations

What NOT to Use

• Do not use prophylactic haloperidol for ventilated patients, as it shows no effect on delirium incidence, severity, duration, or outcome compared to placebo (Grade B recommendation). 1
• Avoid benzodiazepines when possible, as they are associated with deeper sedation, prolonged mechanical ventilation, delirium, and worse outcomes. 1

Analgesia-First Approach

• Prioritize analgesia-first sedation strategies (analgosedation) targeting light sedation when possible, using short-acting sedatives. 1
• Use multimodal analgesia including acetaminophen, NSAIDs (with caution), gabapentinoids, and regional techniques to minimize opioid requirements. 1
• Ketamine at subanesthetic doses provides opioid-sparing effects with reduced risk of delirium and nightmares compared to higher doses. 1

Sedation Management

• Target light sedation using validated tools (Richmond Agitation-Sedation Scale or Sedation Agitation Scale) with daily reassessment of sedation goals. 1
• Implement daily sedation interruptions paired with spontaneous breathing trials when appropriate. 1
• Allow patients to be more awake to participate in early mobilization and family interactions, which reduces anxiety and improves outcomes. 1

Post-ICU Discharge: Continuation of Care

Professional Follow-Up

• Provide access to professional psychological support and follow-up care targeting psychological stabilization for the first 12 months after discharge (Grade B recommendation). 1
• Refer patients to specialized psychiatric services for ongoing management of anxiety and depression symptoms. 1
• Regular psychiatric consultation may be helpful in detecting and managing persistent anxiety symptoms. 3

Psychotherapeutic Interventions

• Offer psychotherapeutic interventions after discharge, as systematic reviews demonstrate PTSD-reducing effects. 1
• Cognitive-behavioral approaches show significant reduction of PTSD symptoms and improvement in psychological stabilization. 1

Common Pitfalls to Avoid

• Do not rely solely on structured information programs during ICU stay, as single-episode interventions show no additional benefit over standard communication. 4
• Anxiety management requires continuous approaches rather than one-time information delivery. 4
• Recognize that anxiety ratings decline slowly over time (-.53 points per day), requiring ongoing assessment and intervention throughout mechanical ventilation. 5
• Anxiety is an individual experience requiring daily assessment rather than assuming improvement occurs automatically. 5
• Do not mistake agitation for need for deeper sedation—assess and treat underlying causes (pain, delirium, dyspnea, constipation) first. 1

Assessment Requirements

• Use validated anxiety assessment tools regularly throughout ICU stay, as anxiety levels vary significantly between patients and over time. 5
• Screen for anxiety sensitivity—the fear of anxiety symptoms themselves—which can be a barrier to weaning from mechanical ventilation and requires specific intervention. 6
• Assess for physical, social, and cognitive domains of anxiety sensitivity using the Anxiety Sensitivity Index. 6