Management of conscious critically ill

Most recent guidelines about the administration of sedatives and analgesics in ICU recommended a drastic reduction in drug use.This highlight the necessity of starting specific competences in order to “keep awake” high risk patients even during the critical illness phases. Before thinking to keep critical patients “awake and quiet” it is necessary to adjust, as much as possible, all the organic/metabolic dysfunctions that determine a severe alteration of vital balance (shock, hypoxia/hypercapnia, hypoglycemia, dyselectrolytemias, etc).
The verbal reassurance is the first step to an adequate management of conscious critical patients. It includes the continuous explanation of what is happening and the use of all the possible orientation strategies that are usable in that specific context (calling by name, use of glasses or hearing aid where necessary, availability of personal items of the patient, coherence of intervention by medical and nursing staff, use of television or music during the day, presence of relatives for the most of time when possible).
Secondly, a systemically check of all the correctable causes of discomfort (such as: necessity of bronchoaspiration, mechanical ventilation modality, sense of thirst and dry throat, placement of the body on the bed or on the armchair, early removal of invasive tools – as soon as the clinical conditions permit to do that) is essential.

After the “non-pharmacological” efforts, it is crucial to control the pain measuring its extent, administering an adequate analgesic therapy and ,finally, verifying its efficacy through validated tools for neurological monitoring (i.e. the Verbal Numerical Rating scale (VNR) or the Behavioural Pain Scale (BPS)) available for both intubated and non-intubated patients.
Once pain is adequately controlled, it is convenient to use the minimal efficacious dose of sedatives to reach the level of a patient “awake and quiet”, namely RASS=0.
If the patient has no pain and reached the desired RASS level but delirium is still present, it is necessary to look into all the correctable organic/metabolic causes and,, start the most convenient antipsychotic therapy if necessary.
Obviously, it is not always possible to follow this program… but, independently from the troubles that surely will come in, it is important not to “stop trying”, keeping on searching for the best compromise between the patient comfort and the hoped reduction of analgesic/sedative/antipsychotic therapy.
Among all the possible organization strategies, we have to consider the employment of available staff  when an increase of workload can occur due to uncontrollable agitation of the patients. Finally it might be convenient to use physical means of restraint with the aim to avoid the removal of invasive tools necessary in a context where the “pharmacological restraint” could expose the patient to unacceptable risks.

AJCC 2009 Galvan - Scales for evaluating anxiety level in ICU patients

CCM 2001 Marik - Early enteral nutrition review

CCM 2003 Maccioli - Guidelines for use of restreining therapies in ICU

CCM 2006 Iapichino - Scoring system for high-risk critically ill patients

CCM 2010 Vasilevskis - Saving injured brain

CCM 2011 Desai - Long term complications of critical care

CHEST 2010 Vasilevskis - Reducing iatrogenic risk for delirium and weakness

ICM 2004 Woods - Severe agitation among ventilated ICU patients

ICM 2010 Mirski - ANIST Cognitive improvement in awake and responsive ICU·patients·

LANCET 2009 Schweickert - early physical therapy in ICU

Metabolic Care 2008 Kreymann - Early nutrition european perspective