Table 2 Treatment choices for anxiety in the intensive care unit

Benzodiazapines

Central nervous system depressants with anterograde amnestic musculoskeletal relaxation and anxiolytic action.

Blunts the patient's perception of distress. No analgesic activity.

     Lorezapam

Mild anxiolytic, slow acting, long acting, not titratable. Accumulates quickly when used in continuous infusion. Low

performance-high safety factor.

     Midazolam

Potent, titratable for 48 h can be titrated to siut the sedation requirements of the individual. Moderate

performance-moderate safety.

     Propofol

Very potent, very titratable (up to 1 week). Facilitates control of life threatening agitation. High performance, low

safety.

Neuroleptics

Not sedatives. Treatment for true delerium, not anxiety or discomfort. Reorganizes brain chemistry at level of

dopamine.

     Haloperidol

Always used intravenously. Step up dosing required. Continuous infusion useful in selected patients.

     Droperidol

Similar to haloperidol except associated with frightening dreams that may require benzodiazepines for relief (thus

limiting its action).

Analgesics

Stops pain reflex and offers comfort and mild anxiolysis.

     Morphine sulfate

Gold standard of analgesia/sedation. Multiple routes of delivery. Reversible. May cause hemodynamic respiratory

supression in patients with little reserve.

     Fentanyl

As effective as morphine but titratable in real time for 48 h. No histamine release. Effectively titrates analgesia for

unstable patients.

     Meperidine

Not titratable. Causes hypotension, tachycardia, seizures and mental status changes in critically ill patients.

     Ketorolac

Pure analgesia without sedation. Effective in stopping pain reflex for hemodynamically unstable patients.

Combination therapy

Effective real time titration of both analgesia and sedation at the same time in the same patient.

     Midazolam and fentanyl

When separation of theraputic effect is desired, start with one and then add the other. The doses of both must be

reduced.

Speciality sedation agents

Usually used as adjuncts to treatment for complicated patients.

     Clonidine

Offers analgesia, decreases adrenergic response. Side effects of bradycardia and dry mouth. Intravenous

formulation if possible.

     Dexmetomidine

In trial. A purer α2 action. More beneficial effects, fewer side effects. Will be useful in treating substance

withdrawal.

Reversal agents

Titrating the effect of sedation or analgesia at the level of brain receptors.

     Naloxone

Rapid reversal of narcotics. Short acting. Should be used in continuous infusion to avoid complications of sudden

awakening.

     Flumazenil

Rapid reversal of benzodiazepines. Short acting. Should be used in continuous infusion to avoid complications of

sudden awakening.