Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (9)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jaber, S.
Right arrow Articles by Eledjam, J.-J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jaber, S.
Right arrow Articles by Eledjam, J.-J.
(Chest. 2005;128:2749-2757.)
© 2005 American College of Chest Physicians

A Prospective Study of Agitation in a Medical-Surgical ICU*

Incidence, Risk Factors, and Outcomes

Samir Jaber, MD, PhD; Gérald Chanques, MD; Claire Altairac, PharmD; Mustapha Sebbane, MD; Christine Vergne, MD; Pierre-François Perrigault, MD and Jean-Jacques Eledjam, MD, PhD

* From the Intensive Care Unit and Transplantation (Drs. Jaber, Chanques, Altairac, Sebbane, Perrigault, and Eledjam), Department of Anesthesiology, DAR B, Hospital Saint Eloi, University of Montpellier; and Department of Biostatistics (Dr. Vergne), Hospital Arnaud de Villeneuve, University of Montpellier, Montpellier, France.

Correspondence to: Samir Jaber, MD, PhD, Département d’Anesthésie-Réanimation "B," University Hospital, Chu de Montpellier Hopital Saint Eloi, 80, Avenue Augustin Fliche, 34295 Montpellier Cedex 5, France; e-mail: s-jaber{at}chu-montpellier.fr


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 
Study objectives: Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU.

Design: Prospective observational study.

Interventions: None.

Method: All consecutive ICU admissions over an 8-month period were analyzed.

Measurements and results: Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 ± 5.6 days (± SD) after admission to the ICU and lasted 3.9 ± 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 ± 16 vs 33 ± 13, p < 0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 ± 19 days vs 6 ± 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p < 0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation).

Conclusions: Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.

Key Words: confusion • delirium • ICU • mechanical ventilation • psychomotor agitation • sedation


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 
Although agitation is thought to be common in the ICU, only two studies12 have evaluated its incidence and risk factors. Fraser et al1 investigated the effect of age on the incidence of agitation, and Woods et al2 reported incidence, risk factors, and outcomes of agitation in medical ICU patients receiving mechanical ventilation. There are no studies that describe the incidence, risk factors, and outcomes in a mixed medical-surgical population of critically ill patients receiving and not receiving mechanical ventilation.

Most of the trials345 that have studied neuropsychiatric disorders in ICU have not focused on agitation but have evaluated delirium or ICU syndrome using different definitions and diagnostic criteria. However, delirium differs from agitation because delirium may be either hypoactive (not agitated), hyperactive, or mixed.3 However, agitation without delirium may develop because the patient has pain, other discomfort, or anxiety. This difference between agitation and delirium in the ICU was recently well reported in the 2002 Agitation Roundtable Meeting.6 The authors6 stated that despite a number of well-designed studies that aggregate patients for the purpose of assessing differing sedative regimens, there is still a paucity of comprehensive studies evaluating the outcomes of agitated ICU patients.

The purpose of this study was to describe the incidence, risk factors, characteristics, and outcomes of agitation in a mixed medical-surgical population of critically ill patients receiving and not receiving mechanical ventilation. Our hypothesis was that agitation in ICU patients has an impact on outcomes such as self-extubation, removal of arterial and venous catheters, nosocomial infections, and ICU length of stay.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 Appendix
 References
 
During an 8-month period (November 1999 to June 2000), we screened all consecutive admissions to the medical-surgical ICU (12 beds) of the St. Eloi Hospital, a 660-bed teaching and referral facility of the University of Montpellier in France. The protocol was approved by our institutional review board for human subjects. The requirement for obtaining written informed consent was waived, as this noninterventional study posed no added risk to patients. Patients were excluded from the analysis if they died before awakening or if they had dementia before ICU admission.

Definition and Documentation of Agitation
We defined agitation as frequent movements of head, arms, or legs, and/or bucking the ventilator that persisted despite attempts of staff to calm the patient. During the patient’s stay in the ICU, agitation was documented each morning by a clinical pharmacist (C.A.), who used the modified Ramsay score (Appendix 1) for each patient. Agitation was defined by a modified Ramsay score of 1. The same investigator also screened for agitation by reading the nurses’ notes (Appendix 2) for each patient for the previous 24 h. Finally, agitation was determined and confirmed for each patient on each day at a daily meeting of ICU physicians and nurses. Weekly quality checks were conducted by one of two investigators (S.J., G.C.) to ensure interrater reliability. Chart audits were performed for all suspicious or missing data.

Data Collection
On ICU admission, the following data were collected for each patient: demographic data, reason for ICU admission, Simplified Acute Physiology Score (SAPS) II,7 and previous history of psychoactive drug use or ethanol abuse (> 14 U/wk and/or periods of time with > 4 U/d).8 We collected the following characteristics of agitation: day of onset, duration, use of sedation (benzodiazepines, opioids, neuroleptics) or restraints during the previous 48 h, and presence and duration of mechanical ventilation. We also evaluated if we could identify (yes or no) an obvious cause or causes of agitation (pain, anxiety, sepsis, shock, alcoholic withdrawal, pruritus, discomfort, or use of medication). We described the consequences of agitation: requirement for sedation or restraints, and complications such as self-extubation and self-removal of central venous or bladder catheters. We also documented serum concentrations of urea, creatinine, sodium, potassium, calcium, phosphorus, magnesium, and the highest body temperature for the 48 h before onset of agitation or the most abnormal value during the ICU stay for patients in whom agitation did not develop. Sepsis was defined according to the criteria of Bone.9 Rupture of anastomotic sutures after abdominal surgery was also documented. At time of discharge, we collected data related to nosocomial infections, expressed as the ratio of nosocomial infections to the number days exposed to the risk, and to the number of patients having a nosocomial infection (ventilator-acquired pneumonia: at least one organism isolated by BAL at a concentration ≥ 104 cfu/mL; colonization of central venous catheters: at least one organism at a concentration ≥ 103 cfu/mL identified by a culture of the catheter tip via the Brun-Buisson technique10; urinary catheter-related infection: the association of a leukocyturia at a concentration of ≥ 104 mL with the presence of a organism at a concentration of 105 cfu/mL; bacteremia: a positive hemoculture with the isolation of a organism or at least two positive hemoculture results for a coagulase-negative staphylococcus); workload evaluated by the Omega activity index11; duration of ICU stay; and ICU mortality. The Omega score is composed of therapeutic items that are assigned 1 to 10 points and is divided into three categories: category 1, items entered only at the time of their first application; category 2, items entered at each application; and category 3, items entered every day of application. The total score, which covers the entire length of stay, is calculated by adding the points obtained in the three categories (Table 1 ).


View this table:
[in this window]
[in a new window]

  		Table 1. Omega Scoring System

 
Data Analysis
Data are expressed as the mean ± SD for normally distributed data, and median with interquartile range (25th to 75th percentile) for nonnormally distributed data for continuous variables or as number of events for counts. For every patient, only the first admission to the ICU was included for the analysis, and only the first episode of agitation during this ICU admission was studied. Univariate analyses ({chi}2, Mann-Whitney U test) between the two populations studied (group 1, agitation; group 2, nonagitation) were used for preliminary selection of model variables, based on a 0.05 {alpha} level. Continuous variables were categorized using optimal cutoffs derived from receiver-operating characteristic curves. Stepwise block logistic regression was then applied to model the risk of agitation using significant univariate predictors. Odds ratios and their 95% confidence intervals (CIs) were used to assess the independent contribution of significant factors. The Hosmer and Lemeshow test was used to determine appropriateness of the model; p < 0.05 was considered significant. Statistical analysis was done using statistical software (SAS version 6.12; SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 Appendix
 References
 
Population Studied and Incidence of Agitation
Two hundred eleven patients were admitted a total of 216 times to the ICU during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness: 3 patients had neurologic degenerative pathology, and 26 patients died prior to full assessment (12 patients in a coma at the time of ICU admission, and 14 patients who died prior to stopping sedation). Five patients were admitted twice. In all, 182 patients were included for analysis. The mean age was 60 ± 15 years, and 65% were men. Severity of illness as measured by SAPS II was 37 ± 15 at the time of ICU admission. Thirty percent had a history of alcohol abuse, and 21% used psychoactive drugs before hospitalization. The reason for ICU admission was surgical in 75% of patients and medical in 25% of patients. At least one episode of agitation occurred in 52% (95 of 182 patients) during their stay in the ICU.

Risk Factors
Univariate analysis showed that there were no significant differences in age or gender between the patients with had agitation and patients without agitation (Table 2 ). However, the groups differed in SAPS II, alcohol abuse, psychoactive drug use, reason for ICU admission, mechanical ventilation, sepsis, fever, and use of sedatives (Table 2). In addition, among the seven laboratory tests evaluated, there were differences between the two groups in highest and lowest sodium concentration, lowest potassium concentration, and highest level of magnesium (Table 3 ). Among all of the medical patients, the incidence of agitation was greater than that among the surgical patients (38 of 46 patients, 83%; vs 57 of 136 patients, 42%; p < 0.001). Moreover, the frequency of sepsis was greater in the medical patients than in the surgical patients (35 of 46 patients, 76%; vs 68 of 136 patients, 50%; p = 0.003). Duration of mechanical ventilation before agitation in the agitation group and total duration of ventilation in the nonagitation group were not significantly different (4.4 ± 5.8 days vs 3.4 ± 5.2 days; p = 0.15).


View this table:
[in this window]
[in a new window]

  		Table 2. Patient Characteristics of the Two Groups*

 

View this table:
[in this window]
[in a new window]

  		Table 3. Laboratory Findings*

 
Multivariate analysis showed that sepsis, alcohol abuse, use of sedatives, fever, dysnatremias, and use of psychoactive drugs were independent predictors of the development of agitation (Table 4 ). The multivariate model used had a 90.1% concordance between the association of predicted probabilities and observed responses. The Hosmer and Lemeshow test verified the validity of the model (p = 0.53).


View this table:
[in this window]
[in a new window]

  		Table 4. Independent Risk Factors for the Agitation

 
Characteristics and Outcomes of Agitation
Agitation occurred 4.4 ± 5.6 days after admission to the ICU, and its duration was 3.9 ± 4.1 days (Table 5 ). Individual distributions of onset and duration of agitation are shown in Figures 1234 . Most of the patients became agitated early (ie, < 3 to 5 days) during their stay in the ICU (Fig 1). Agitation occurred day and night for 77% of the agitated patients. In a third of the cases of agitation, we did not find of obvious cause (Table 5). Agitation did not occur exclusively during the intubation period in 85% of the agitated patients (Table 5). The duration of ICU stay after an agitation episode was 11.7 ± 11.5 days.


View this table:
[in this window]
[in a new window]

  		Table 5. Characteristics of Agitation*

 


View larger version (13K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. Cumulative distribution of onset of agitation from the day of admission to the ICU.

 


View larger version (11K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. Cumulative distribution of duration of agitation.

 


View larger version (16K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3. Correlation between duration of agitation and onset of agitation from the day of ICU admission.

 


View larger version (15K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 4. Correlation between duration of stay in the ICU and duration of agitation.

 
Agitation was associated with a prolonged ICU stay (16 ± 19 days vs 6 ± 6 days, p = 0.0001), greater frequency of nosocomial infections (34% vs 7%, p < 0.0001), higher unplanned extubations (17% vs 2%, p = 0.003), and central venous catheter removal rate (16% vs 1%, p = 0.001) [Table 6 ]. There was also a higher frequency of surgical reintervention because of rupture of anastomotic sutures in the agitation group (29%, vs 3% in the nonagitation group; p < 0.001).


View this table:
[in this window]
[in a new window]

  		Table 6. Consequences and Outcomes*

 
There was increased utilization of resources in the agitation group as evaluated by the Omega activity index (252 ± 259 vs 123 ± 141, p = 0.0001). However, there was no significant difference in mortality (12% in the agitation group vs 8% in the nonagitation group).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 Appendix
 References
 
The main finding of our study is that agitation is common in a population of medical-surgical ICU patients (50%) receiving and not receiving mechanical ventilation. We also found that agitation is associated with a higher rate of self-extubation and self-removal of catheters, a higher rate of nosocomial infections, a longer duration of stay, and requires extra resources as measured by the Omega activity index. Moreover, we identified seven independent risk factors for the development of agitation in the ICU (Table 4). To our knowledge, this is the largest study to describe the incidence, risk factors, characteristics, and outcomes of agitation in a mixed medical-surgical population of critically ill patients receiving and not receiving mechanical ventilation.

Incidence
Agitation developed in 95 of 182 patients (52%) in the present study. This high frequency of agitation is consistent with results of Fraser et al,1 who observed agitation (sedation agitation scale score > 4) in 71% and severe agitation (sedation agitation scale score > 5) in 46% of 130 medico-surgical ICU patients. However, Woods et al,2 using a different definition, observed an incidence of severe agitation in 16% of 143 medical ICU patients receiving mechanical ventilation. Possible explanations for these discrepancies include differences in inclusion criteria (ventilation or no ventilation, medical or surgical patients), severity and definition of agitation, and the use of a clinical protocol for management of sedation and analgesia.

Risk Factors
Seven independent risk factors for agitation in the ICU are identified in our study (Table 4), four of which are amenable to change (abuse of sedation, neglected hyperthermia > 38°C, untreated hyponatremia and hypernatremia). Similar to the study of Fraser et al,1 we found that age is not related to the incidence of agitation. However, Woods et al2 found that severely agitated patients were younger (50 ± 19 years vs 62 ± 16 years, p < 0.01). In the study by Woods et al,2 younger age was a factor associated with severe agitation in multivariate analysis (hazard ratio, 1.32; 95 CI, 1.01 to 1.72; p = 0.04). However, the limitations of multivariate analysis should be considered, as the number of agitated patients was relatively small (n = 23).

A history of alcoholism or psychiatric disorders as indicated by the regular use of antipsychotics medications are also important risk factors. In our study, alcoholism increased the risk of becoming agitated threefold, and regular use of psychoactive drugs increased the risk fivefold. Woods et al2 found that marijuana use was associated with agitation in univariate analysis only and ethanol dependency was not. It is possible that this difference is explained by the difference between our study populations. Our ICU is part of the Institute of Liver and Gastroenterology Disease of the University Hospital Center of Montpellier, which treats many alcoholic patients.8 In fact, the results of this study were obtained in a single institution with limited generalizability. Moreover, French patients are also frequent users of psychoactive drugs. Before admission in the ICU, these patients are often anxious, and anxiety may present as agitation in the ICU environment. However, based on our results, the use of sedatives and/or analgesics in the 48 h preceding the onset of agitation is more frequent in agitated patients than in patients who are not agitated (72% vs 36%, p = 0.001; Table 2). The use of sedatives and/or analgesics increases the risk of agitation by approximately fourfold (Table 4). Sedation is widely used in intensive care.34 The aim of sedation is to ensure the physical and mental comfort of the patient, to assist in adapting the patient to mechanical ventilation, and to calm the patient to reduce the danger he may pose to himself or those around him.3 However, many sedative drugs can induce agitation. In our logistic regression model, we found no increase in the agitation state based on the different classes of drugs used alone: benzodiazepines, opioids, neuroleptics, and others (propofol, clonidine), even those that have been implicated in causing delirium.

Severe metabolic disorders due to variations in the plasma concentrations of sodium, potassium, magnesium, calcium, and phosphorus may lead to neuropsychiatric disorders.12 Univariate analysis showed that agitated patients had lower concentrations of serum potassium and higher serum concentrations of magnesium (Table 3). In multivariate analysis, only disorders of plasma sodium were significant risk factors in our model (Table 4). In total, serum sodium concentrations < 134 mmol/L or > 143 mmol/L expose the patient to a fourfold or fivefold increase in agitation. Although profound electrolyte abnormalities can cause mental status changes, less important abnormalities can also induce cerebral dysfunction if development is rapid.1213 Although agitation was not directly studied, similar findings were reported in the study by Aldemir et al14 and studies in other populations such as delirious elderly patients (abnormal sodium levels)15 and postoperative delirious patients (abnormal preoperative sodium levels).16 Electrolyte imbalance may be responsible for the decrease in acetylcholine activity in the brain,17 which, according to several hypotheses, is the major neurotransmitter involved in agitation delirium.1819 One component of neuropsychiatric disorders linked to hospitalization is that they appear most often at night.3 In our unit, agitation manifested itself equally during the day as well as at night and may be explained by the absence of variation of light as well as medical and paramedical activity between day and night (Table 5). Physical restraint is a precipitating factor for delirium in hospitalized elderly people.20 However, we cannot confirm that physically restraining a patient in ICU is a risk factor for agitation. Physical restraint was present in 50% of episodes of agitation.

Encephalopathy is a common complication of sepsis.2122 Indeed, sepsis is associated with an approximately twofold increase in agitation and raises an alarm in intensive care, as demonstrated by Sprung et al.23 In this study,23 23% of septic patients presented with encephalopathy. In our present study, the incidence of agitation in the patients with sepsis was 68% (70 of 103 patients).

Manifestations of agitation occurred 3 to 5 days after abdominal surgery and were often early signs of a rupture of sutures. Among the 127 surgical patients, 17 needed surgical reintervention because of rupture of anastomotic sutures (Table 6). Moreover, delirium in elderly people is often reported after diverticulis or other intra-abdominal infections24 or fever.15 Cytokines and/or bacterial toxins and cerebral metabolic changes may be causes of the mental changes associated with infection.21222325 In other words, agitation alone can be considered as an early sign of the onset of sepsis before development of the usual symptoms (eg, fever, shiver, arterial hypotension) in some patients.22 However, sepsis or fever could be associated with agitation because of concurrent development of pain or discomfort due to myalgia and back pain.2226

Although medical patients became agitated more frequently than surgical patients (38 of 46 patients, 83%; vs 57 of 136 patients, 42%; p < 0.001), in the multivariate analysis this variable was not significant (Table 4). This may be explained by the fact that the medical patients had significantly higher sepsis rates than the surgical patients (35 of 46 patients, 76%; vs 68 of 136 patients, 50%; p = 0.003), making it a confounding factor in our analysis.

Another interesting result is that in one third of the cases of agitation, we did not find an obvious cause (Table 5). Identification of the etiology or etiologies of agitation may be particularly difficult in a critically ill patient. The multifactorial nature of agitation (pain, anxiety, sepsis, shock, withdrawal, pruritus, discomfort, and medication) makes its primary causes complex and often enigmatic and/or speculative. Interestingly, it was more frequent not to find an obvious cause of agitation in surgical patients (30 of 57 patients, 53%) than in medical patients (3 of 38 patients, 8%). Among the 30 surgical patients without an obvious cause, agitation occurred in the early postoperative period (1 to 2 days), suggesting that drugs administered during anesthesia could be involved in agitation development.

Outcome
Agitation is associated with an increased risk of complications. We found a higher risk of self-extubation in the agitated group, as did Woods et al.2 The rate of catheter removal was also more frequent in the agitated group in our study. Coppolo and May27 found a 54% frequency of agitation in a prospective study of self-extubations over the course of a year. The frequency of agitation in patients who did not self-extubate was not determined in that study. Self-extubations are associated with an increased morbidity and mortality and a longer length of stay.2829 Fraser et al30 studied the frequency with which patients remove medical devices on their own in the ICU and the costs associated with this problem. They found that 28% of the 36 studied patients removed 42 devices. Significant agitation was documented within 2 h before 74% of the events. The estimated annual cost of these events in their ICU was > $250,000. Although agitation was not specifically evaluated, Milbrandt et al31 also reported that delirium was associated with significantly higher ICU and hospital costs.

Our findings showed that agitation was associated with a longer length of stay in ICU, as did Woods et al.2 It is difficult to determine if the duration of stay was longer because of occurrence of agitation or if agitation appeared because of a longer stay. However, agitation occurred early (ie, < 3 to 5 days); therefore, it is unlikely to be a consequence of a long stay. As far as mortality is concerned, we excluded patients who died before they were able to be evaluated; that is to say death either occurred rapidly or before sedation was able to be decreased. In our study, agitation in the ICU does not seem to be a factor associated with an elevated mortality, also observed by Woods et al.2

Limits of the Study and Perspectives
It is difficult to evaluate agitated ICU patients because of the complexity of their health status, heterogeneity, and frequent inability to communicate. It is noteworthy that although it is one of the most common issues facing critical care practitioners, agitation in the ICU has no clear and concise definition. It would be interesting to separately analyze outcomes associated with light, moderate, or very severely agitated patients; agitation within a state of confusion (delirium); or agitation secondary to discomfort, pain or anxiety. To our knowledge, when our study started (November 1999), no tool permitting a quantification of agitation and an easy recognition of delirium in all ICU patients had been published. New validated scales have been developed to evaluate sedation and agitation in ICU.3233343536 The new Richmond Agitation-Sedation Scale3437 containing several levels of agitation is the first tool validated in the sedated and nonsedated, ventilated and nonventilated ICU adult patient, in contrast to other widely used sedation scales.3839 Practice tools to determine pain, anxiety, delirium, or other acute mental status changes are necessary to improve the understanding of the determinants of agitation.36 However, to our knowledge, there are only two studies12 specifically addressing agitation in ICU, and the main findings of our study are the high incidence of agitation in ICU and its association with a worse outcome. Agitation ranges from mild to severe,338 and further studies should determine incidence and outcomes for each type of agitation with the objective of targeting the more clinically important features.40 Risk factors are numerous, and we could not observe all of these at the same time. Moreover, ICU populations and practices differ among countries and localities. For example, French ICU nurses are not able to prescribe any change in sedative or analgesic medications, and sedation algorithms are unusual. Another limitation is that we did not record the doses and drugs administered perioperatively for the surgical patients; thus, we cannot evaluated the influence of the anesthetic drugs in this population.

Effective prevention of agitation is predicated on recognizing the previously identified predisposing risk/precipitating factors and mitigating their impact. Since the results of the present study that identified seven independent risk factors for agitation, we established a multidisciplinary standard of care for assessing, monitoring, and treating agitation in our unit. Moreover, we changed our clinical practice to treat early the four risk factors that may be better controlled (abuse of sedation, neglected hyperthermia > 38°C, untreated hyponatremia and hypernatremia). It should be noted that management strategies for agitation include both prevention and treatment.

Finally, our population has a high frequency of ethanol (30%) use prior to hospitalization. The generalization of our results to a more general population of critically ill patients should be treated with caution.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
Appendix
 References
 
In conclusion, agitation in a medical-surgical ICU occurs frequently, affects one of every two patients, and is associated with increased morbidity. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation. Other studies are needed to demonstrate that reducing risk factors will decrease the incidence of agitation in intensive care, its consequences, and its costs.314041


   Appendix
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
References
 
The Modified Ramsay Scale
The modified Ramsay scale is adapted from Ramsay et al39:

1 = Patient agitated or fidgeting or bucking ventilator despite attempts of the staff to calm the patient

2 = Patient cooperative, oriented, and tranquil

3 = Patient responds to commands only

4 = A brisk response to a light glabelar tap

5 = A sluggish response to a light glabelar tap

6 = No response to a light glabelar tap

Documented Descriptors of Patient Behaviors
Fidgeting

Constant motion

Agitation

Combative

Kicking

Repeated attempts to sit

Repeated attempts to get out of bed

Bucking the ventilator

Pulling tubes

Pulling restraints


   Acknowledgements
 
The authors thank Dr. Peter Dodek for his comments and Dr. Joel Butler for reviewing the manuscript.


   Footnotes
 
Abbreviations: CI = confidence interval; SAPS = Simplified Acute Physiology Score

Received for publication January 1, 2005. Accepted for publication April 3, 2005.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix
 References
 

  1. Fraser, G, Prato, B, Riker, R, et al (2000) Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU. Pharmacotherapy 20,75-82[CrossRef][ISI][Medline]
  2. Woods, J, Mion, L, Connor, J, et al Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes. Intensive Care Med 2004;30,1066-1072[Medline]
  3. Jacobi, J, Fraser, G, Coursin, G, et al Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30,119-141[CrossRef][ISI][Medline]
  4. Trzepacz, P, Breitbart, W, Frankiln, J American Psychiatric Association guidelines: practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999;156,1-19[Free Full Text]
  5. Wise, M, Terrell, M Neuropsychiatric disorders: delirium, psychotic disorders, and anxiety. Hall, JB eds. Principles of critical care 2nd ed. 1998,965-978 McGraw-Hill Publishing. Columbus, OH:
  6. Management of the agitated intensive care unit patient Crit Care Med 2002;30,S97-S125[CrossRef][ISI][Medline]
  7. Le Gall, J-R, Lemeshow, S, Saulnier, F New Simplified Acute Physiology Score (SAPS II) based on a European/North American Multicenter Study. JAMA 1993;270,2957-2963[Abstract]
  8. Pageaux, G, Bismuth, M, Perney, P, et al Alcohol relapse after liver transplantation for alcoholic liver disease: does it matter? J Hepatol 2003;38,629-634[CrossRef][ISI][Medline]
  9. Bone, R The pathogenesis of sepsis. Ann Intern Med 1991;115,457-469[ISI][Medline]
  10. Brun-Buisson, C, Abrouk, F, Legrand, P, et al Diagnosis of central venous catheter-related sepsis: critical level of quantitative tip cultures. Arch Intern Med 1987;147,873-877[Abstract]
  11. Girou, E, Stephan, F, Novara, A, et al Risk factors and outcome of nosocomial infections: results of a matched case-control study of ICU patients. Am J Respir Crit Care Med 1998;157,1151-1158[Abstract/Free Full Text]
  12. Kumar, S, Berl, T Sodium. Lancet 1998;352,220-228[CrossRef][ISI][Medline]
  13. Varavithya, W, Hellerstein, S Acute symptomatic hyponatremia. J Pediatr 1967;71,269-283[CrossRef][ISI][Medline]
  14. Aldemir, M, Özen, S, Kara, I, et al Predisposing factors for delirium in the surgical intensive care unit. Crit Care 2001;5,265-270[CrossRef][ISI][Medline]
  15. Francis, J, Martin, D, Kapoor, W A prospective study of delirium in hospitalized elderly. JAMA 1990;263,1097-1101[Abstract]
  16. Marcantonio, ER, Juarez, G, Goldman, L, et al The relationship of postoperative delirium with psychoactive medications. JAMA 1994;272,1518-1522[Abstract]
  17. Haj-Dahmane, S, Andrade, R Muscarinic activation of a voltage-dependent cation nonselective current in rat association cortex. J Neurosci 1996;16,3848-3861[Abstract/Free Full Text]
  18. Golinger, R, Peet, T, Tune, L Association of elevated plasma anticholinergic activity with delirium in surgical patients. Am J Psychiatry 1987;144,1218-1220[Abstract/Free Full Text]
  19. Owen, J, Campbell, D A comparison of plasma electrolyte and urea values in healthy persons and in hospital patients. Clin Chim Acta 1968;22,611-618[Medline]
  20. Inouye, S, Bogardus, SJ, Baker, D, et al The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients; Hospital Elder Life Program. J Am Geriatr Soc 2000;48,1697-1706[ISI][Medline]
  21. Zauner, C, Gendo, A, Kramer, L, et al Metabolic encephalopathy in critically ill patients suffering from septic or nonseptic multiple organ failure. Crit Care Med 2000;28,1310-1315[Medline]
  22. Papadopoulos, M, Davies, D, Moss, R, et al Pathophysiology of septic encephalopathy: a review. Crit Care Med 2000;28,3019-3024[CrossRef][ISI][Medline]
  23. Sprung, C, Cerra, F, Freund, H, et al Amino acid alterations and encephalopathy in the sepsis syndrome. Crit Care Med 1991;19,753-757[Medline]
  24. Normal, D, Yoshikawa, T Intra-abdominal infections in the elderly. J Am Geriatr Soc 1983;31,677-684[Medline]
  25. Freund, H, Muggia-Sullam, M, LaFrance, R, et al Regional brain amino acid and neurotransmitter derangements during abdominal sepsis and septic encephalopathy in the rat. Arch Surg 1986;121,209-216[Abstract]
  26. Boivin, G, Hardy, I, Tellier, G, et al Predicting influenza infections during epidemics with use of a clinical case definition. Clin Infect Dis 2000;31,1166-1169[CrossRef][ISI][Medline]
  27. Coppolo, D, May, J Self-extubations: a 12-month experience. Chest 1990;98,165-169[Abstract/Free Full Text]
  28. Chevron, V, Menard, J, Richard, J, et al Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med 1998;26,1049-1053[CrossRef][ISI][Medline]
  29. de Lassence, A, Alberti, C, Azoulay, E, et al Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit: a prospective multicenter study. Anesthesiology 2002;98,148-156
  30. Fraser, G, Riker, R, Prato, B, et al The frequency and cost of patient-initiated device removal in the ICU. Pharmacotherapy 2001;21,1-6[CrossRef][ISI][Medline]
  31. Milbrandt, E, Deppen, S, Harrison, P, et al Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004;32,955-962[CrossRef][ISI][Medline]
  32. 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;29,1370-1379[CrossRef][ISI][Medline]
  33. Bergeron, N, Dubois, MJ, Dumont, M, et al Intensive care unit screening checklist: evaluation of a new screening tool. Intensive Care Med 2001;27,859-864[CrossRef][ISI][Medline]
  34. Sessler, CN, Gosnell, MS, Grap, MJ, et al The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166,1338-1344[Abstract/Free Full Text]
  35. Weinert, C, McFarland, L The state of intubated ICU patients: development of a two-dimensional sedation rating scale for critically ill adults. Chest 2004;126,1883-1890[Abstract/Free Full Text]
  36. Sessler, C Sedation scales in the ICU. Chest 2004;126,1728-1730
  37. Ely, EW, Truman, B, Shintani, A, et al Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289,2983-2991[Abstract/Free Full Text]
  38. Riker, R, Picard, J, Fraser, G Prospective evaluation of the sedation-agitation scale for adult critically ill patients. Crit Care Med 1999;27,1325-1329[CrossRef][ISI][Medline]
  39. Ramsay, M, Savege, T, Simpson, B Controlled sedation with alphaxalone/alphadolone. BMJ 1974;2,656-659[ISI][Medline]
  40. Tanios, M, Epstein, S, Teres, D Are we ready to monitor for delirium in the intensive care unit? Crit Care Med 2004;32,295-296[Medline]
  41. Ely, E, Stephens, R, Jackson, J, et al Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med 2004;32,106-112[CrossRef][ISI][Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (9)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jaber, S.
Right arrow Articles by Eledjam, J.-J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jaber, S.
Right arrow Articles by Eledjam, J.-J.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS