Patient agitation and its management in adult critical care: A integrative review and narrative synthesis

Aims and objective: To critically review the evidence relating to the management
of agitation within the Adult Critical Care Unit environment and identify any risks
and benefits of current management strategies.
Background: Admission to an Adult Critical Care Unit can be traumatic and potentially
life altering for the patient. Patient agitation is common in Adult Critical Care
Units and is associated with the potential for harm. Despite inherent safety risks,
there is a paucity of evidence-based guidance underpinning the care of agitation in
patients with critical illness.
Study Design: Integrative review and narrative synthesis.
Methods: A systematic procedure for searching and selecting the literature was followed
and applied to databases including CINAHL, British Nursing Index, Cochrane
Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts
were analysed using a structured narrative review approach.
Results: A total of 208 papers were identified and following a systematic deselection
process 24 original articles were included in the review. It was identified that
agitation in the setting of Adult Critical Care Unit is associated with high-risk events
such as unplanned removal of life-supporting devices. There were consistent links
to sepsis, previous high alcohol intake and certain medications, which may increase
the development of agitation. Prompt assessment and early liberation from mechanical
ventilation was a major contributing factor in the reduction in agitation. Administration
of antideliriogenic mediation may reduce the need for physical restraint.
There was repeated uncertainty about the role of physical restraint in developing
agitation and its effective management.
Conclusions: Our review has shown that there is a dearth of research focusing on
care of agitated patients in the Adult Critical Care Unit, despite this being a highrisk
group. There are dilemmas for clinical teams about the effectiveness of applying
physical and/or pharmacological restraint. The review has highlighted that the risk
of self-extubation increases with the presence of agitation, reinforcing the need for
constant clinical observation and vigilance.
Relevance to clinical practice: The importance of ensuring patients are re-orientated
regularly and signs of agitation assessed and acted upon promptly is reiterated.
Early identification of specific patient profiles such as those with previous high
alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the from ventilation and encouragement of family or loved ones involvement in care
need to be considered.