ICU patients are often agitated, leading confused and difficult. They can also be delirious (transitional syndrome). These clinical signs are uncomfortable for the patient and also often also complicate treatment and safety. At worst, they may even (z. B. when patients remove an endotracheal tube or intravenous catheter arbitrarily) are vital threatening. Etiology For a seriously ill patient can restlessness and / or due confusion to the original disease, to medical complications, the treatment or the environmental situation of the intensive care unit (see Table: Some causes of restlessness or confusion in ICU patients). It is important to remember that a neuromuscular blockade pain and restlessness merely masked, but not prevented. Paralyzed patients can suffer greatly. Some causes of restlessness or confusion in ICU patients mechanism Examples underlying disease head injury shock toxin uptake pain and discomfort (eg., Caused by injury, surgery, intubation, IV access, blood or NGT) complications hypoxia (desaturation) hypotension sepsis organ failure (eg . B. hepatic encephalopathy) pulmonary embolism Drug therapy Beruhigun gsmittel and other CNS-active drugs, especially opioids, benzodiazepines, H2 blockers and antihistamines alcohol and / or drug withdrawal environmental situation in intensive care * Sleep deprivation (eg. As noise, bright light, or medical interventions around the clock) dread fear of unpleasant medical procedures * Especially a problem for the elderly. Clarification Before administration of sedatives because of “agitation” should the disease be carefully gone through and a careful examination of the patient to be done. History The current injury or illness must first be accepted as the most likely cause. Records and observations of the nursing staff can (suggestive of CNS hypoperfusion) identify and dysfunctional sleep patterns, a decline in blood pressure and urine output. The documentation of medication is checked to detect insufficient or excessive analgesia and sedation. The history is checked for possible causes. Pre-existing liver disease makes hepatic encephalopathy conceivable. Known addictions or abuse disorders lead to withdrawal symptoms. Guard-oriented patients are even questioned about what they worried. In particular, they are about pain, shortness of breath and not previously reported addictions to befragen.Körperliche investigation O2 saturations <90% suggest a hypoxic aetiology. Low blood pressure and low urine production make CNS perfusion likely. Fever and tachycardia are found in sepsis or delirium. With stiff neck must be thought of meningitis. However, this clinical signs in restless patients is difficult to differentiate. Fokalbefunde as part of the neurological examination provide information on stroke, intracranial hemorrhage, or increase in intracranial pressure The degree of agitation can with the aid of a classification as "Riker Sedation-Agitation Scale" (see table:. Riker-SAS (Riker Sedation-Agitation Scale are classified)) or the "Ramsay sedation Scale". The "Confusion Assessment Method" (see table: Confusion Assessment Method (CAM) for the diagnosis of delirium *) can be used to check whether delirium is the cause of agitation. Such scaling systems allow a better comparison of observations of different investigators and then to better recognize trends. Muskelrelaxierte patients can be judged only with difficulty. In these patients, a high degree of anxiety and discomfort may be present, without this being recognized from the outside. So it is necessary to interrupt the intermittent relaxation (z. B. for one day) to assess the patients. Riker-SAS (Riker Sedation-Agitation Scale) classification description notes 7 to eliminate dangerous unrest Tries monitors and medical equipment, or climbs out of bed, throws himself back and forth strikes after staff 6 Very agitated remains unsettled despite frequent attempts verabalen reassurance, biting endotracheal tube requires fixing 5 Agitation Anxious or restless urge to move, reassured by popularity 4 Quiet and cooperative Quiet, easily be awakened, can follow instructions 3 Sedated heavy be awakened, responds to verbal commands or gently shaking, but dawns again two strong sedated No communication possible, while responding to physical stimuli, but verbal instructions can not follow, still mostly spontaneous movements 1 Not arousable No communication possible with little or no response to pain stimuli Confusion Assessment Method (CAM) for the diagnosis of delirium * feature judging Required features Acute onset and fluctuating course Indicated by positive answers to the following questions: "Has the mental state of patients ve rglichen changed abruptly with the current situation? " "Fluctuates the abnormal behavior throughout the day (d. E., It tends to occur and disappear, or at the severity and decrease)?" Inattention Indicated by positive answers to the following questions: "If the patient has difficulty in his attention (.. That is, he was easily distracted or he had this trouble following what has been said)?" is one of the features necessary thought disorders Indicated by positive answers to the following questions: "Was thinking of the patient disorganized or incoherent (. eg rambling or irrelevant conversation, unclear or illogical thought processes, or unpredictable jumping between topics)" Changes in consciousness Indicated by any response other than "vigilant" to the following questions: "How would you assess the overall state of consciousness of the patient?" Normal = vigilant attention About = vigilant income, easily excitable = lethargic heavy excite = stupor Not excitable = coma * The diagnosis of delirium requires the presence of the first two features plus a second two features. The information is usually inquired by a family member or a nurse. Tests Identified standard deviations (z. B. hypoxia, hypotension, fever) should be further clarified and investigated accordingly. A CT scan of the skull is not routinely required but may be useful in eye-catching focal findings or persistently uncertain etiology. The Bispectral Index (BIS Index) can help you determine the level of sedation or agitation in patients with neuromuscular blockade. Therapy Underlying causes (hypoxia, shock events, the influence of drugs) need to be addressed. The environmental conditions should, as far as permitted by the overall treatment plan optimized (lighting, sound volume, smallest possible nightly sleep interruptions). Clocks, calendars, windows looking out, television or radio broadcasts can help the patient to maintain the connection with the outside world, and thus limit the degree of confusion. The presence of family and regularity in the nursing care can be reassuring. Drug therapy is geared to the priority irritating symptom. Pain requiring analgesics, anxiety and insomnia are treated with sedatives, psychosis and delirium with smaller doses psychotropic drugs. Intubation may be necessary when the need for sedatives and analgesics is so high that the safety of the airways or respiratory drive in danger device (Restoring and Backing up the airways: Endotracheal intubation). There are here numerous substances available. Basically, however, short-acting preparations should be preferred. This is especially true for those patients who require frequent neurological evaluation, or those that are to be weaned in the near future from the respirator and extubated. Analgesia pain must be treated with adequate dosage of intravenous opioids. With awareness clear patients with painful disorders (fractures, surgery), but can communicate not suitable, must be in doubt, and believed to be properly addressed with analgesics pain as a cause of unrest. Mechanical ventilation is an unpleasant for the patient measure. Therefore ventilated patients should receive a combination of opioids and sedatives amnesic effective. Fentanyl is due to its potency, short duration of action and minimal cardiovascular side effects the opioid of choice for short-term treatment. A common treatment regimen may consist of fentanyl 30-100 micrograms / h. Individual needs can thereby greatly sein.Sedierung Despite adequate analgesia remains in many patients a restlessness that makes then the additional use of sedatives required. Sedatives may be helpful even at lower doses as analgesics for the patient. Benzodiazepines (eg. As lorazepam, midazolam) are most commonly used, but can also Propofol, a sedative-hypnotic agent, used for short-term sedation. Usually, i.v. for sedation 1-2 mg Lorazepam used in each case 1 to 2-hourly or as a continuous infusion with 1-2 mg / h, if the patient is intubated. The use of these substances carries the risk of respiratory depression, hypotension, delirium and prolonged duration of action in some patients. Long-acting benzodiazepines such as diazepam, flurazepam and chlordiazepoxide should be avoided in elderly patients. Psychotropic drugs with low anticholinergic effect as haloperidol (1-3 mg i.v.) work best when combined with benzodiazepines. Dexmedetomidine is a newer drug that anxiolytic, sedative and some analgesic properties and has no effect on the respiratory drive. The risk of delirium is less than with benzodiazepines. Due to this lower risk dexmedetomidine is increasingly used as an alternative to benzodiazepines in patients who require mechanical ventilation. The character and the depth of sedation caused by dexmedetomidine may allow artificially ventilated ventilated patients to interact or to be easily aroused without an uncomfortable situation for them is generated. The most common side effects include hypotension and bradycardia. The typical dosage is 0,2-0,7?g / kg / h, but some patients may require doses up to 1,5?g / kg / h. Because dexmedetomidine is expensive, it is usually only for short periods (eg. As <48h) eingesetzt.Neuromuskuläre blockade Neuromuscular block should not be misunderstood as a substitute of sedation for intubated patients, as this is only the visible manifestations of the problem removed (agitation), without causing an actual correction of the fault. Nevertheless, for certain studies (CT, MRI) or certain procedures need to be assured (eg. As construction of a central venous catheter) that the patient does not move reliably. Here is occasionally neuromuscular blockade required. This also applies to patients who can not be ventilated despite adequate analgesia and sedation. Unless newer sedatives are used (including dexmedetomidine), a neuromuscular blockade is rarely necessary. A longer-term neuromuscular blockade should be avoided. Exceptions are patients with severe lung injury that can safely do any work of breathing. The application of more than 1-2 days of time can lead to longer-term weakness. Particularly with concomitant use of corticosteroids. Typically, vecuronium is given (as demand continuous infusion). Summary unrest and / or confusion may be due to the original disease, complications of acute illness, to treatment, or to the situation in intensive care. History and physical examination often can suggests a cause and direct the following technical examination. treating the cause (incl. the administration of analgesics to relieve pain and to optimize the environment to minimize confusion), the remaining restlessness is treated with a sedative such as lorazepam or propofol. The neuromuscular blockade masked only pain and restlessness; paralyzed patients can suffer greatly.