Determining any potentially treatable cause of agitation is paramount in optimal delivery of care to critically ill patients. The author presents a case report that illustrates the use of BIS monitoring in a patient initially treated with sedation/analgesia and neuromuscular blockade to manage dangerous agitation and dyssynchrony with controlled ventilation.

Pain, anxiety, agitation, and ventilator dyssynchrony all may be consequences of critical illness, traumatic injury, or intubation and controlled ventilation.1,2 Controlled ventilation, airway manipulation, and suctioning can cause pain and an arousal response. Excessive intrathoracic pressure may also compromise hemodynamic stability and venous return and increase pulmonary vascular resistance3 and the risk for barotrauma and pneumothorax.3,4 

Pain, anxiety, and agitation also mobilize the stress response, a complex, neurohormonal response to physiological stress, including stress caused by critical illness. Consequences include elevation in circulating catecholamines, which may increase heart rate, blood pressure, and metabolic...

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