1. Mechanical Ventilation in Agitated Patients

Mechanical ventilation may be required when severe agitation compromises airway protection, oxygenation, or ventilator synchrony. The primary goals are to ensure patient safety and gas exchange while minimizing sedation-related harms. An analgesia-first strategy is paramount.

Key Indications for Intubation

• Loss of Airway Reflexes: Inability to protect the airway, indicated by a diminished cough or gag reflex, increases aspiration risk.
• Refractory Hypoxemia: Failure to maintain adequate oxygenation despite high-flow nasal cannula or noninvasive positive pressure ventilation.
• Severe Ventilator Dyssynchrony: Patient-ventilator asynchrony that is unresponsive to sedation adjustments and compromises ventilation.

Sedation and Weaning Strategies

The goal is to use the minimum effective sedation to achieve safety and comfort, facilitating rapid liberation from the ventilator.

• Sedation Targets: Aim for light sedation (Richmond Agitation-Sedation Scale [RASS] –2 to 0), where the patient is arousable to voice. Avoid deep sedation (RASS ≤ –4), which is linked to prolonged ventilation, increased delirium, and long-term cognitive impairment.
• Weaning Considerations: Pair daily spontaneous breathing trials (SBTs) with sedation interruption. Before declaring an SBT failure, systematically address and treat pain and delirium. Dexmedetomidine is often preferred for agitated patients during weaning due to its minimal respiratory depression.

2. Prevention of ICU-Related Complications

Sedated and immobilized ICU patients are at high risk for venous thromboembolism (VTE), stress-related mucosal bleeding, and device-associated infections. Prophylaxis using bundled, evidence-based interventions is critical to reducing morbidity.

3. Environmental and Nonpharmacologic Interventions

Optimizing the ICU environment and promoting patient engagement are powerful, low-risk strategies to mitigate delirium, reduce anxiety, and support functional recovery. These interventions form the foundation of the ABCDEF bundle.

Sleep Hygiene

• Noise and Light Control: Systematically reduce ambient noise and light, especially at night. Provide patients with earplugs and eye masks to promote restorative sleep.
• Cluster Care: Group nursing tasks, medication administration, and lab draws to create protected blocks of time for uninterrupted sleep.

Early Mobilization and Cognitive Reorientation

• Early Mobility: Initiate passive or active range-of-motion exercises within 48 hours of ICU admission, as soon as the patient is hemodynamically stable. Progress systematically to sitting, standing, and ambulation.
• Cognitive Reorientation: Encourage family presence to provide familiar social interaction. Use clocks, calendars, and personal photographs to orient the patient. Nurses should frequently reorient the patient to person, place, and time.

4. Management of Iatrogenic Complications

Pharmacotherapies used to manage agitation and delirium carry significant risks. Vigilant monitoring and proactive management are essential to prevent harm from cardiac effects, neurologic syndromes, oversedation, and withdrawal.

5. Sedation and Analgesia Protocols

A structured, protocolized approach to sedation and analgesia is proven to improve outcomes. Key principles include prioritizing pain control (analgesia-first), maintaining light sedation, and performing daily awakenings to assess neurologic function and readiness for liberation.

6. Multidisciplinary Goals of Care Conversations

In the context of critical illness, it is vital to involve patients (when able), families, and the entire care team in ongoing discussions. These conversations help align intensive medical treatments with the patient’s values, preferences, and overall prognosis.

Ethical Considerations and Palliative Care

• Burdens vs. Benefits: Regularly re-evaluate the goals of invasive support. Is the current treatment plan achieving the desired outcome, or is it merely prolonging suffering?
• Palliative Care Integration: Engage palliative care specialists early, especially for patients with refractory symptoms, a high burden of therapy, or a poor prognosis. Their expertise is invaluable for managing complex symptoms and facilitating difficult conversations.

Communication Tools

Structured communication frameworks can help guide these sensitive discussions:

• SPIKES Protocol:
  • Setting: Ensure a private, comfortable setting.
  • Perception: Ask what the family understands about the situation.
  • Invitation: Ask for permission to share information.
  • Knowledge: Give information in clear, simple terms.
  • Empathy: Acknowledge and validate emotions.
  • Summary: Summarize the plan and check for understanding.
• Documentation: Clearly document advance directives, code status, and patient/family preferences in the medical record to ensure all team members are aware of the established goals.