Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit

doi:10.5847/wjem.j.1920-8642.2018.02.004

Abstract

Abstract:

BACKGROUND: Agitation occurs frequently among critically ill patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU.
METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status.
RESULTS: A total of 102 intubated patients were enrolled; of which 46 (45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95% CI=1.35-18.27), subarachnoid hemorrhage (OR=5.11; 95% CI=1.38-18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95% CI=1.16-15.35) were independent predictors for agitation (P<0.01).
CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.

Key words: Trauma, Intensive care unit, Agitation, Head injury, Propofol, Outcome

Saeed Mahmood, Omaima Mahmood, Ayman El-Menyar, Mohammad Asim, Hassan Al-Thani. Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit[J]. World Journal of Emergency Medicine, 2018, 9(2): 105-112.

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References 40

1	Lombard LA, Zafonte RD. Agitation after traumatic brain injury: considerations and treatment options. Am J Phys Med Rehabil. 2005;84(10):797-812. doi: 10.1097/01.phm.0000179438.22235.08 pmid: 16205436
2	Sabzghabaee AM, Yaraghi A, Khalilidehkordi E, Mirhosseini SM, Beheshtian E, Eizadi-Mood N. The outcome of agitation in poisoned patients in an Iranian tertiary care university hospital. Neurol Res Int. 2014;2014:275064. doi: 10.1155/2014/275064 pmid: 25548668
3	Crippen D. Agitation in the ICU: part one Anatomical and physiologic basis for the agitated state. Crit Care. 1999;3(3):R35-R46. doi: 10.1186/cc348 pmid: 11094481
4	Chevrolet JC, Jolliet P. Clinical review: agitation and delirium in the critically ill--significance and management. Crit Care. 2007;11(3):214. doi: 10.1186/cc5787 pmid: 17521456
5	Treggiari MM, Romand JA, Yanez ND, Deem SA, Goldberg J, Hudson L, et al. Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med. 2009;37(9):2527-34. doi: 10.1097/CCM.0b013e3181a5689f pmid: 19602975
6	Rubio-Valera M, Luciano JV, Ortiz JM, Salvador-Carulla L, Gracia A, Serrano-Blanco A. Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence. BMC Psychiatry. 2015;15:35. doi: 10.1186/s12888-015-0417-x pmid: 25881240
7	Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119-41. doi: 10.1097/00003246-200201000-00020 pmid: 11902253
8	Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post-publication perspective. Ann Intensive Care. 2013;3(1):9. doi: 10.1186/2110-5820-3-9 pmid: 23547921
9	Sessler CN, Grap MJ, Ramsay MA. Evaluating and monitoring analgesia and sedation in the intensive care unit. Crit Care. 2008;12(Suppl 3):S2.
10	Bordini AL, Luiz TF, Fernandes M, Arruda WO, Teive HA. Coma scales: a historical review. Arq Neuropsiquiatr. 2010;68(6):930-7. doi: 10.1590/s0004-282x2010000600019 pmid: 21243255
11	Nogueira Lde S, Domingues Cde A, Campos Mde A, Sousa RM. Ten years of new injury severity score (NISS): is it a possible change. Rev Lat Am Enfermagem. 2008;16(2):314-9. doi: 10.1590/s0104-11692008000200022 pmid: 18506353
12	Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10. doi: 10.1001/jama.2016.0287 pmid: 26903338
13	Chalmers JD, Singanayagam A, Akram AR, Mandal P, Short PM, Choudhury G, et al. Severity assessment tools for predicting mortality in hospitalised patients with community-acquired pneumonia. Systematic review and meta-analysis. Thorax. 2010;65(10):878-83. doi: 10.1136/thx.2009.133280 pmid: 20729231
14	O'Connor H, Al-Qadheeb NS, White AC, Thaker V, Devlin JW. Agitation during prolonged mechanical ventilation at a long-term acute care hospital: risk factors, treatments, and outcomes. J Intensive Care Med. 2014;29(4):218-24. doi: 10.1177/0885066613486738
15	Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, 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. doi: 10.1097/CCM.0b013e3182783b72 pmid: 23269131
16	Robinson BR, Berube M, Barr J, Riker R, Gélinas C. Psychometric analysis of subjective sedation scales in critically ill adults. Crit Care Med. 2013;41(9 Suppl 1):S16-29. doi: 10.1097/CCM.0b013e3182a16879 pmid: 23989092
17	de Wit M, Epstein SK. Administration of sedatives and level of sedation: comparative evaluation via the Sedation-Agitation Scale and the Bispectral Index. Am J Crit Care. 2003;12(4):343-8. pmid: 12882065
18	Kadyan V, Mysiw WJ, Bogner JA, Corrigan JD, Fugate LP, Clinchot DM. Gender differences in agitation after traumatic brain injury. Am J Phys Med Rehabil. 2004;83(10):747-52. doi: 10.1097/01.phm.0000140790.30468.f4 pmid: 15385782
19	Jaber S, Chanques G, Altairac C, Sebbane M, Vergne C, Perrigault PF, et al. A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes. Chest. 2005;128(4):2749-57. doi: 10.1378/chest.128.4.2749 pmid: 16236951
20	Burk RS, Grap MJ, Munro CL, Schubert CM, Sessler CN. Predictors of agitation in critically ill adults. Am J Crit Care. 2014;23(5):414-23. doi: 10.4037/ajcc2014714
21	Woods JC, Mion LC, Connor JT, Viray F, Jahan L, Huber C, et al. Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes. Intensive Care Med. 2004;30(6):1066-72. doi: 10.1007/s00134-004-2193-9 pmid: 14966671
22	Fraser GL, Prato BS, Riker RR, Berthiaume D, Wilkins ML. Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU. Pharmacotherapy. 2000;20(1):75-82. doi: 10.1592/phco.20.1.75.34663 pmid: 10641977
23	Saoût V, Gambart G, Leguay D, Ferrapie AL, Launay C, Richard I. Aggressive behavior after traumatic brain injury. Ann Phys Rehabil Med. 2011;54(4):259-69. doi: 10.1016/j.rehab.2011.04.003
24	Brooke MM, Questad KA, Patterson DR, Bashak KJ. Agitation and restlessness after closed head injury: a prospective study of 100 consecutive admissions. Arch Phys Med Rehabil. 1992;73(4):320-3. doi: 10.1016/0003-9993(92)90003-f pmid: 1554303
25	Singh R, Venkateshwara G, Nair KP, Khan M, Saad R. Agitation after traumatic brain injury and predictors of outcome. Brain Inj. 2014;28(3):336-40. doi: 10.3109/02699052.2013.873142 pmid: 24377492
26	Mahmood S, Al-Thani H, El-Menyar A, Alani M, Al-Hassani A, Mathrdikkal S, et al. Tramadol in traumatic brain injury: Should we continue to use it? J Anaesthesiol Clin Pharmacol. 2015;31(3):344-48 doi: 10.4103/0970-9185.161670 pmid: 26330713
27	Robert DJ, Hall RI, Kramer AH, Robertson HL, Gallagher CN, Zygun DA. Sedation for critically ill adults with severe traumatic brain injury: a systematic review of randomized controlled trials. Crit Care Med. 2011;39(12):2743-51. doi: 10.1097/CCM.0b013e318228236f pmid: 22094498
28	Oddo M, Crippa IA, Mehta S, Menon D, Payen JF, Taccone FS, et al. Optimizing sedation in patients with acute brain injury. Crit Care. 2016;20(1):128. doi: 10.1186/s13054-016-1294-5 pmid: 27145814
29	Gholami B, Haddad WM, Tannenbaum AR. Agitation and pain assessment using digital imaging. Conf Proc IEEE Eng Med Biol Soc. 2009;2009:2176-2179.
30	Lakie AS, Bolhasani M, Nobahar M, Movahedi AF, Mahmoudi H. The effect of touch on the arterial blood oxygen saturation in agitated patients undergoing mechanical ventilation. Iran J Crit Care Nurs. 2012;5:125-32.
31	Bogner JA, Corrigan JD, Fugate L, Mysiw WJ, Clinchot D. Role of agitation in prediction of outcomes after traumatic brain injury. Am J Phys Med Rehabil. 2001;80(9):636-44. doi: 10.1097/00002060-200109000-00002 pmid: 11523965
32	McNett M, Sarver W, Wilczewski P. The prevalence, treatment and outcomes of agitation among patients with brain injury admitted to acute care units. Brain Inj. 2012;26(9):1155-62. doi: 10.3109/02699052.2012.667587 pmid: 22642404
33	Wood C, Boucher BA. Management of acute traumatic brain injury. Neurol Psych PSAP-VII; 139-56. Retrieved from https://www.accp.com/docs/bookstore/psap/p7b10sample03.pdf accessed on August 03, 2016.
34	Williamson DR, Frenette AJ, Burry L, Perreault MM, Charbonney E, Lamontagne F, et al. Pharmacological interventions for agitation in patients with traumatic brain injury: protocol for a systematic review and meta-analysis. Syst Rev. 2016;5(1):193. doi: 10.1186/s13643-016-0374-6 pmid: 27855720
35	Flower O, Hellings S. Sedation in traumatic brain injury. Emerg Med Int. 2012;2012:637171. doi: 10.1155/2012/637171 pmid: 23050154
36	Reznik ME, Schmidt JM, Mahta A, Agarwal S, Roh DJ, Park S, et al. Agitation After subarachnoid hemorrhage: a frequent omen of hospital complications associated with worse outcomes. Neurocrit Care. 2017;26(3):428-35. doi: 10.1007/s12028-016-0331-1 pmid: 28008563
37	Patel MB, McKenna JW, Alvarez JM, Sugiura A, Jenkins JM, Guillamondegui OD, et al. Decreasing adrenergic or sympathetic hyperactivity after severe traumatic brain injury using propranolol and clonidine (DASH After TBI Study): study protocol for a randomized controlled trial. Trials. 2012;13:177. doi: 10.1186/1745-6215-13-177 pmid: 23013802
38	Reade MC, O'Sullivan K, Bates S, Goldsmith D, Ainslie WR, Bellomo R. Dexmedetomidine vs. haloperidol in delirious, agitated, intubated patients: a randomised open-label trial. Crit Care. 2009;13(3):R75. doi: 10.1186/cc7890 pmid: 19454032
39	Luauté J, Plantier D, Wiart L, Tell L, SOFMER group. Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations. Ann Phys Rehabil Med. 2016;59(1):58-67. doi: 10.1016/j.rehab.2015.11.001 pmid: 26700025
40	Trivedi V, Iyer VN. Utility of the Richmond Agitation-Sedation Scale in evaluation of acute neurologic dysfunction in the intensive care unit. J Thorac Dis. 2016;8(5):E292-294. doi: 10.21037/jtd.2016.03.71 pmid: 27162685

Variables	Overall (n=102)	Patients without agitation (n=56)	Patients with agitation (n=46)	P value
Age (mean±SD)	34.3±13.9	37.2±14.8	30.2±11.7	0.01
Males	91 (89.2%)	47 (83.9%)	44 (95.7%)	0.05
Mechanism of injury
Motor vehicle crashes	60 (58.8%)	33 (58.9%)	27 (58.7%)	0.91 for all
Fall from height	21 (20.6%)	13 (23.2%)	8 (17.4%)
Fall of heavy object	2 (2.0%)	1 (1.8%)	1 (2.2%)
All-terrain vehicle	3 (2.9%)	1 (1.8%)	2 (4.3%)
Assault	5 (4.9%)	2 (3.6%)	3 (6.5%)
Others	11 (10.8%)	6 (10.7%)	5 (10.9%)
GCS Scene	9.6±4.4	10.5±4.4	8.5±4.1	0.03
GCS at trauma room	7.4±5.3	8.5±5.6	6.1±4.5	0.02
GCS 1-hour post-admission	5.7±4.9	6.5±5.4	4.8±4.2	0.07
Associated injuries
Head	71 (69.6%)	32 (57.1%)	39 (84.8%)	0.003
Chest	48 (47.1%)	27 (48.2%)	21 (45.7%)	0.79
Spine	31 (30.4%)	23 (41.1%)	8 (17.4%)	0.01
Upper extremity	25 (24.5%)	15 (26.8%)	10 (21.7%)	0.55
Lower extremity	26 (25.5%)	13 (23.2%)	13 (28.3%)	0.56
Abdomen	23 (22.5%)	15 (26.8%)	8 (17.4%)	0.25
Pelvis	19 (18.6%)	12 (21.4%)	7 (15.2%)	0.42
Face	9 (8.8%)	3 (5.4%)	6 (13.0%)	0.17
Injury Severity Score	21.6±11.1	20.6±12.0	22.9±9.7	0.30
Head AIS	3.8±0.9	3.9±0.9	3.7±0.8	0.53
Severe Head Injury (GCS<8) 54 (77%) 22 (71.0%) 32 (82.1%) 0.27

Variables	Overall (n=102)	Patients without agitation (n=56)	Patients with agitation (n=46)	P value
Oxygen saturation in trauma room	99.6±0.8	99.6±0.6	99.5±0.9	0.62
Lactate (mmol/L)	0.5 (0.1-3.2)	0.5 (0.1-2.8)	0.55 (0.1-3.2)	0.49
Sodium (mmol/L)	139.3±13.7	138.0±18.3	140.8±2.9	0.32
Potassium (mmol/L)	4.0±0.3	4.1±0.3	4.0±0.2	0.13
Magnesium (mmol/L)	0.67±0.05	0.7±0.05	0.6±0.05	0.02
Tramadol	13 (12.7%)	8 (14.3%)	5 (10.9%)	0.60
Analgesics
Fentanyl	56 (70.9%)	25 (71.4%)	31 (70.5%)	0.92 for all
Remifentanil	23 (29.1%)	10 (28.6%)	13 (29.5%)	0.92 for all
Sedatives
Midazolom alone	30 (30.0%)	23 (42.6%)	7 (15.2%)	0.001 for all
Propofol alone	26 (26.0%)	8 (14.8%)	18 (39.1%)
Midazolom + Propofol	37 (37.0%)	17 (31.5%)	20 (43.5%)
Dihydrocodeine	7 (7.0%)	6 (11.1%)	1 (2.2%)
Head intervention
Craniectomy	10 (9.8%)	1 (1.8%)	9 (19.6%)	0.003
Craniotomy	15 (14.7%)	6 (10.7%)	9 (19.6%)	0.21
ICP catheter insertion	38 (37.3%)	10 (17.9%)	28 (60.9%)	0.001
ICP (median, range)	19 (11-28)	19.5 (12-22)	19 (11-28)	0.38
Ventilator days	8 (2-25)	7 (2-13)	9 (2-25)	0.001
Hospital length of stay (days)	25.5 (2-147)	21 (2-88)	29 (2-147)	0.34
ICU length of stay (days)	13 (1-96)	11.5 (1-78)	17 (1-96)	0.15
Sepsis	5 (4.9%)	1 (1.8%)	4 (8.7%)	0.10
Pneumonia	10 (9.8%)	2 (3.6%)	8 (17.4%)	0.04

Variables	OR	95% CI	P value
Age	0.95	0.91-1.00	0.05
Males	8.55	0.98-74.66	0.05
Initial GCS at trauma room	1.005	0.89-1.12	0.92
ICP catheter insertion	4.23	1.16-15.35	0.03
Injury Severity Score	1.001	0.95-1.05	0.98
Subarachnoid hemorrhage	5.11	1.38-18.91	0.01
Propofol alone	4.97	1.35-18.27	0.01

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