Pain, Agitation, Delirium, and Immobility in the ICU

  • Juliane JablonskiEmail author


Surgical critical care patients may endure numerous invasive procedures in addition to the primary surgical intervention that led to hospitalization. Examples include the placement of chest, endotracheal, tracheostomy, and surgical drainage tubes, urinary catheters, blood draws, suctioning, and wound care. Such treatments in the intensive care unit (ICU) increase patients’ vulnerability to experiencing pain, as well as physical and psychological distress.

Critical care specialists are responsible for evaluating and managing all of the symptoms associated with pain, agitation, and delirium (PAD). Sedatives and analgesics are among the most commonly administered medications in the intensive care unit (ICU) especially for mechanically ventilated patients. Intensive care physicians must carefully address patient distress and agitation while simultaneously avoiding oversedation.

In the mission of providing comfort exist the potential unintentional harms of oversedation, delirium, and immobility leading to longer ventilator days, longer hospital stays, and increased mortality rates. ICU survivors can endure long-term, new, or worsening impairments in physical, cognitive, or mental health status persisting beyond acute care hospitalization. This phenomenon is termed post-intensive care syndrome.

In efforts to improve patient outcomes, a multidisciplinary approach is needed for the implementation of an evidence-based, goal-directed approach to managing pain, agitation, and delirium in the ICU. Pain, agitation, and delirium have come to the forefront as modifiable interventions in the care of the critically ill. The incidence and specific management of all three of these clinical entities have been shown to have a significant impact on outcomes related to mortality, length of stay (LOS) in the ICU and hospital, as well as post-neurological outcomes.


Pain Agitation Delirium Sedation Immobility Post-intensive care syndrome 


  1. 1.
    Jackson DL, Proudfoot CW, Cann KF, Walsh TS. The incidence of sub-optimal sedation in the ICU: a systematic review. Crit Care. 2009;13:R204. doi: 10.1186/cc8212.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.CrossRefGoogle Scholar
  3. 3.
    Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled Trial): a randomized controlled trial. Lancet. 2008;371:126–34. Barr.CrossRefGoogle Scholar
  4. 4.
    Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009;373:1874–82.CrossRefGoogle Scholar
  5. 5.
    Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized trial. Lancet. 2010;375:475–80.CrossRefGoogle Scholar
  6. 6.
    Mehta S, Burry L, Cook D, et al. Daily interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):9.CrossRefGoogle Scholar
  7. 7.
    Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.CrossRefGoogle Scholar
  8. 8.
    Resar R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf. 2005;31(5):243–8.CrossRefGoogle Scholar
  9. 9.
    Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42(5):1024–36. doi: 10.1097/CCM.0000000000000129.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Balas MC, Vasilevskis EE, Burke W, et al. Critical care nurses role in implementing the “ABCDE” bundle into practice. Crit Care Nurse. 2012;23(2):35–47.CrossRefGoogle Scholar
  11. 11.
    Petty LT. Suspended life or extending death. Chest. 1998;114(2):360–1.CrossRefGoogle Scholar
  12. 12.
    Kollef MH, Levy NT, Ahrens TS, et al. The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest. 1998;114(2):541–8.CrossRefGoogle Scholar
  13. 13.
    Augustes R, Ho KM. Meta-analysis of randomized controlled trials on daily sedation interruption for critically ill adult patient. Anaesth Intensive Care. 2011;39(3):401–9.PubMedGoogle Scholar
  14. 14.
    Karlsson V, Forsberg A, Bergbom I. Communication when patients are conscious during respirator treatment – a hermeneutic observation study. Intensive Crit Care Nurs. 2011;28:197–207.CrossRefGoogle Scholar
  15. 15.
    Mehta S, McCullagh I, Burry L, Epstein SK, Devlin JW. Current sedation practices: lessons learned from international surveys. Crit Care Clin. 2009;25:471–88.CrossRefGoogle Scholar
  16. 16.
    Tanios MA, DeWit M, Epstein SK. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care. 2009;24:66–73.CrossRefGoogle Scholar
  17. 17.
    Patel RP, Gambrell M, Speroff T, et al. Delirium and sedation in the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37(3):825–32.CrossRefGoogle Scholar
  18. 18.
    Weinert CR, Calvin DC. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in medical and surgical intensive care unit. Crit Care Med. 2007;35(2):393–401.CrossRefGoogle Scholar
  19. 19.
    Samuelson K. Unpleasant and pleasant memories of intensive care in adult mechanically ventilated patients-findings from 250 interviews. Intensive Crit Care Nurs. 2011;27:76–84.CrossRefGoogle Scholar
  20. 20.
    Egerod I. Uncertain terms of sedation in ICU, how nurses and physicians manage and describe sedation for mechanically ventilated patients. J Clin Nurs. 2002;11:831–40.CrossRefGoogle Scholar
  21. 21.
    Guttormson JL, Chlan L, Weinert C, Savik K. Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive Crit Care Nurs. 2009;26:44–50.CrossRefGoogle Scholar
  22. 22.
    Brook AD, Ahrens TS, Schaiff R, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27:2609–15.CrossRefGoogle Scholar
  23. 23.
    Robinson BR, Mueller EW, Henson K, Branson RD, Barsoum S, Tsuei BJ. An analgesia-delirium-sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J Trauma Inj Infect Crit Care. 2008;65:517–26.CrossRefGoogle Scholar
  24. 24.
    Awissi DK, Begin C, Moisan J, et al. I-SAVE study: impact of sedation, analgesia, and delirium protocols evaluated in the intensive care unit: an economic evaluation. Ann Pharmacother. 2012;46:21–8.CrossRefGoogle Scholar
  25. 25.
    Erstad BL, Puntillo K, Gilbert HC, et al. Pain management principles in the critically ill. Chest. 2009;135(4):1075–80.CrossRefGoogle Scholar
  26. 26.
    Stanik-Hutt JA, Soeken KL, Belcher AE, et al. Pain experiences of traumatically injured patients in a critical care setting. Am J Crit Care. 2001;10:252–9.PubMedGoogle Scholar
  27. 27.
    Gelinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the critical-care pain observation tool and physiologic indicators. Clin J Pain. 2007;23:497–505.CrossRefGoogle Scholar
  28. 28.
    Reade MC, Phil D, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014;370:444–54.CrossRefGoogle Scholar
  29. 29.
    Honiden S, Siegel MD. Managing the agitated patient in the ICU: sedation, analgesia, and neuromuscular blockade. J Crit Care Med. 2010;25(4):187–204.Google Scholar
  30. 30.
    Ely WE, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(4):1753–62.CrossRefGoogle Scholar
  31. 31.
    Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012;186(8):724–31. doi: 10.1164/rccm.201203-05220C.CrossRefPubMedGoogle Scholar
  32. 32.
    Gelinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care. 2009;24:628.e7–17.CrossRefGoogle Scholar
  33. 33.
    Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med. 2001;29:2258–63.CrossRefGoogle Scholar
  34. 34.
    Siegel MD. Management of agitation in the intensive care unit. Clin Chest Med. 2003;24(4):713–25.CrossRefGoogle Scholar
  35. 35.
    Sessler CN, Gosnell MS, Grap MJ. The Richmond agitation-sedation scale, validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338–44.CrossRefGoogle Scholar
  36. 36.
    Riker RR, Fraser GL, Cox PM. Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med. 1994;22(3):433–40.CrossRefGoogle Scholar
  37. 37.
    Riker RR, Fraser GL, Simmons LE, et al. Validating the sedation-agitation scale with the bispectral index and visual analogue scale in adult ICU patients after cardiac surgery. Intensive Care Med. 2001;27:853–8.CrossRefGoogle Scholar
  38. 38.
    Riker RR, Picard JT, Fraser GL. Prospective evaluation of the sedation-agitation scale for critically ill adults. Crit Care Med. 1999;27:1325–9.CrossRefGoogle Scholar
  39. 39.
    Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM-ICU). Crit Care Med. 2001;29:1370–9.CrossRefGoogle Scholar
  40. 40.
    Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27(5):859–64.CrossRefGoogle Scholar
  41. 41.
    Brummel N, Vasilevskis E, Han J, Boehm L, Pun BT, Ely EW. Implementing delirium screening in the ICU: secrets to success. Crit Care Med. 2013;41(9):2196–208.CrossRefGoogle Scholar
  42. 42.
    Dimitri Gusmao-Flores D, Salluh JI, Chalhub RA, Quarantini LC. The confusion assessment method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for diagnosis of delirium: a systemic review and meta-analysis of clinical studies. Crit Care. 2012. doi: 10.1186/cc11407.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    American Psychiatric Association. Diagnostic and statistics manual of mental disorders, 4th edn text (text revision). Washington, DC: American Psychiatric Publishing; 2000.Google Scholar
  44. 44.
    Ali S, Patel M, Jabeen S, et al. Insight into delirium. Innov Clin Neurosci. 2011;8(10):25–34.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Salluh JI, Wang H, Schneider EB, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015;350:h2538. doi: 10.1136/bmj.h2538.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis, and treatment. Crit Care Clin. 2008;24:657–722.CrossRefGoogle Scholar
  47. 47.
    Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the intensive care unit. Crit Care Clin. 2008;24(1):45–65.CrossRefGoogle Scholar
  48. 48.
    Duppils GS, Wikblad K. Patients’ experiences of being delirious. J Clin Nurs. 2007;16:810–8.CrossRefGoogle Scholar
  49. 49.
    Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology. 2006;104(1):21–6.CrossRefGoogle Scholar
  50. 50.
    Khan BA, Zawahiri M, Campbell NL, et al. Delirium in hospitalized patients: implications of current evidence on clinical practice and future avenues for research- a systematic evidence review. J Hosp Med. 2012;7(7):580–9.CrossRefGoogle Scholar
  51. 51.
    Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012;307(11):1151–60.CrossRefGoogle Scholar
  52. 52.
    Frazier GL, Devlin JW, Worby CP, et al. Benzodiazepine versus non-benzodiazepine-based sedation for mechanically ventilated critically ill adults: a systematic review and meta-analysis of randomized controlled trials. Crit Care Med. 2013;41(suppl):S30–8.CrossRefGoogle Scholar
  53. 53.
    Pisani MA, Murphy TE, Araujo KLB, et al. Benzodiazepine and opioid use and the duration of ICU delirium in an older population. Crit Care Med. 2009;37(1):177–83. doi: 10.1097/CCM.0b013e318192fcf9.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010;38(2):419–27. doi: 10.1097/CCM.0b013e3181b9e302.CrossRefPubMedGoogle Scholar
  55. 55.
    Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions, a meta-analysis. JAMA. 2015;175(4):512–20. doi: 10.1001/jamainternmed.2014.7779.CrossRefGoogle Scholar
  56. 56.
    Abraha I, Trotta F, Rimland JM, et al. Efficacy of non-pharmacological interventions to prevent and treat delirium in older adults: a systematic overview. The SENATOR project ONTOP series. PLoS ONE. 2015. doi: 10.1371/journal.pone.0123090.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Dijkstra BM, Gamel C, Van Der Bijl JJ, Bots ML, Kesecioglu J. The effects of music therapy on physiological responses and sedation scores in sedated, mechanically ventilated patients. J Clin Nurs. 2012;19:1030–9.CrossRefGoogle Scholar
  58. 58.
    Van Rompaey B, Elseviers MM, Drom WV, Fromont V, Jorens PG. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Crit Care. 2012;16:R73. Retrieved from Scholar
  59. 59.
    Bloomfield SA. Changes in musculoskeletal structure and function with prolonged bed rest. Med Sci Sports Exerc. 1997;29(2):197–206.CrossRefGoogle Scholar
  60. 60.
    Lee SM, Schneider SM, Feiveson AH, et al. WISE-2005: countermeasures to prevent deconditioning during bed rest in women. J Appl Physiol (1985). 2014;116:654–67.CrossRefGoogle Scholar
  61. 61.
    Lee SM, Moore AD, Everett ME, et al. Aerobic exercise deconditioning and countermeasures during bed rest. Aviat Space Environ Med. 2010;81:5–63.CrossRefGoogle Scholar
  62. 62.
    Herridge MS, Cheung AM, Tansey CM, et al. One year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348:683–93.CrossRefGoogle Scholar
  63. 63.
    Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5–13.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill patients. Crit Care. 2014;18:658.CrossRefGoogle Scholar
  65. 65.
    Malkoc M, Karadibak D, Yildirim Y. The effect of physiotherapy on ventilator dependence and the length of stay in an intensive care unit. Int J Rehabil Res. 2009;32:85–8.CrossRefGoogle Scholar
  66. 66.
    Li Z, Peng X, Zhu B, et al. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94(3):551–61. doi: 10.1016/japmr.2012.10.023.CrossRefPubMedGoogle Scholar
  67. 67.
    Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238–43.CrossRefGoogle Scholar
  68. 68.
    Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139–45.CrossRefGoogle Scholar
  69. 69.
    Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010;38:2089–94.CrossRefGoogle Scholar
  70. 70.
    Wunsch H, Linde-Zwirble WT, Angus DC, et al. The epidemiology of mechanical ventilation use in the United States. Crit Care Med. 2010;38:1947–53.CrossRefGoogle Scholar
  71. 71.
    Bienvenu OJ, Gellar J, Althouse BM, et al. Post-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal study. Psychol Med. 2013; available on CJO. doi: 10.1017/S0033291713000214.CrossRefGoogle Scholar
  72. 72.
    Bienvenu OJ, Colantuoni E, Mendez-Tellez, et al. Cooccurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury: a 2-year longitudinal study. Crit Care Med. 2015;43(3):642–53.CrossRefGoogle Scholar
  73. 73.
    Davydow DS, Gifford JM, Desai SV, Needham DM, Bienvenu J. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry. 2008;30:421–34.CrossRefGoogle Scholar
  74. 74.
    Elliott D, Davidson EJ, Harvey AM, et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014;42(12):2518–36.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Surgical Critical CareHospital of the University of PennsylvaniaPhiladelphiaUSA

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