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Pain, agitation, delirium, and coma are not uncommon in the intensive care unit (ICU). They are secondary to the patient’s underlying disease or to the multiple interventions, such as medications, procedures, mechanical ventilation, wound care, and bed rest. They can also be a marker of critical illness, which is associated with catabolism, immune dysregulation, hypercoagulable states, increased myocardial workload, impaired wound healing, and ischemia.
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An ideal individualized approach should be identification of pain, agitation, and alertness, followed by the use of nonpharmacologic and pharmacologic treatment. Nonpharmacological strategies to improve patient’s comfort include lighting adjustment, music therapy, massage, verbal reassurance, optimized sleep hygiene, and involvement of family members in the care of the patient. Often, critically ill patients are unable to report pain, and the behavioral pain scale and critical care observation tool have been shown to have inter-rater reliability and best internal consistency.1,2 Clinical scales have been used to evaluate the agitation or alertness and degree of sedation of critically ill patients regardless of their requirements for mechanical ventilation. These scales include Adaptation to the Intensive Care Environment (ATICE), the Minnesota Sedation Assessment Tool (MSAT), the Motor Activity Assessment Scale, and the Vancouver Interactive and Calmness Scale (VICS). The most commonly used are the Ramsey Sedation Scale, the Richmond Agitation Sedation Scale1,2 (RASS; Table 14-1), and the Sedation Agitation Scale (SAS; Table 14-2).3,4 All the scales have been validated, through correlations with other sedation scales, bispectral index (BIS), electrocardiography (EEG), actigraphy, and different investigators. According to the guidelines of the Society of Critical Care Medicine (SCCM), RASS and SAS are the most validated tools (Level of Evidence [LOE] B).5–7
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