Agitation, Confusion, and Neuromuscular Blockade in Critically Ill Patients

ByCherisse Berry, MD, New York University School of Medicine
Reviewed/Revised Dec 2022
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Intensive care unit (ICU) patients are often agitated, confused, and uncomfortable. They can become delirious (ICU delirium). These symptoms are unpleasant for patients and often interfere with care and safety. At worst, they may be life threatening (eg, patients dislodge the endotracheal tube or IV lines).

Etiology of Agitation and Confusion

In a critically ill patient, agitation, confusion, or both can result from the original medical condition, from medical complications, or from treatment or the ICU environment (see table Some Causes of Agitation or Confusion in Critical Care Patients). It is important to remember that neuromuscular blockade merely masks pain and agitation, it does not prevent it; paralyzed patients may be suffering significantly.


Evaluation of Agitation and Confusion

The chart should be reviewed and the patient examined before sedatives are ordered for “agitation.”


The presenting injury or illness is a prime causative suspect. Nursing notes and discussion with personnel may identify downward trends in blood pressure and urine output (suggesting hypoperfusion of the central nervous system [CNS]) and dysfunctional sleep patterns. Drug administration records are reviewed to identify inadequate or excessive analgesia and sedation.

Past medical history is reviewed for potential causes. Underlying liver disease suggests possible portosystemic encephalopathy (hepatic encephalopathy). Known substance dependency or abuse suggests a withdrawal syndrome.

Awake, coherent patients are asked what is troubling them and are questioned specifically about pain, dyspnea, and previously unreported substance dependency.

Physical examination

Oxygen saturation < 90% suggests a hypoxic etiology. Low blood pressure and urine output suggest CNS hypoperfusion. Fever and tachycardia suggest sepsis, drug withdrawal, or delirium tremens. Neck stiffness suggests meningitis, although this finding may be difficult to demonstrate in an agitated patient. Focal findings on neurologic examination suggest stroke, hemorrhage, or increased intracranial pressure (ICP).

Continuously assessing the degree of agitation and the need for sedation are key to preventing increased morbidity. The two most common sedation scales are the Richmond Agitation-Sedation Scale (RASS) and the Riker Sedation-Agitation Scale (SAS) (see table Riker Sedation-Agitation Scale). The Ramsay Sedation Scale is also sometimes used. Use of such scales allows better consistency between observers and the identification of trends. Patients who are under neuromuscular blockade are difficult to evaluate because they may be highly agitated and uncomfortable despite appearing motionless. It is typically necessary to allow paralysis to wear off periodically (eg, daily) so that the patient can be assessed.

The Confusion Assessment Method (see table Confusion Assessment Method for Diagnosing Delirium) can be used to screen for delirium as a cause of agitation.



Identified abnormalities (eg, hypoxia, hypotension, fever) should be clarified further with appropriate testing. Head CT need not routinely be done unless focal neurologic findings are present or no other etiology is found. A bispectral index (BIS) monitor placed on the head to capture cerebral cortex electrical activity may be helpful in determining the level of sedation/agitation of patients under neuromuscular blockade.

Treatment of Agitation and Confusion

Underlying conditions (eg, hypoxia, shock, sepsis, drugs, progression of traumatic brain injury) should be addressed. The environment should be optimized (eg, darkness, quiet, and minimal sleep interruption at night) as much as is compatible with medical care. Clocks, calendars, outside windows, and TV or radio programs also help connect the patient with the world, lessening confusion. Family presence and consistent nursing personnel may be calming.

Drug treatment is dictated by the most vexing symptoms. Pain is treated with analgesics; anxiety and insomnia are treated with sedatives; and psychosis and delirium are treated with small doses of an antipsychotic drug. Intubation may be needed when sedative and analgesic requirements are high enough to jeopardize the airway or respiratory drive. Many drugs are available; generally, short-acting drugs are preferred for patients who need frequent neurologic examination or who are being weaned to extubation.



> >400 mg/dL) may herald PRIS (1

< 48 hours).

Neuromuscular blockade

For intubated patients, neuromuscular blockade is not

Prolonged neuromuscular blockade should be avoided unless patients have severe lung injury and cannot do the work of breathing safely. Use for >

Treatment reference

  1. 1. Diaz JH,  Prabhakar A, Urman RD, et alCrit Care Res Pract 2014;2014:346968, 2014. doi: 10.1155/2014/346968

Key Points

  • Agitation, confusion, or both can result from the original medical condition, from complications of the acute illness, from treatment, or from the ICU environment.

  • History and physical examination often suggest a cause and direct subsequent testing.

  • Neuromuscular blockade merely masks pain and agitation; paralyzed patients may be suffering significantly.

Drugs Mentioned In This Article
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