The most appropriate management of this patient's pain and related anxiety is to use an opioid such as fentanyl as an interrupted infusion. Untreated pain increases the risk of posttraumatic stress disorder in patients in the ICU. Although pain assessment is difficult in critically ill patients, it should be monitored with a validated pain scale and not just with vital signs alone; physiologic indicators such as hypertension and tachycardia correlate poorly with valid measures of pain. The 2013 Society of Critical Care Medicine clinical practice guidelines for pain, agitation, and delirium recommend preemptive analgesia and/or nonpharmacologic interventions to alleviate pain. Opioids are considered the drug class of choice for treatment of non–neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU. Therefore, for this patient, an opioid analgesic such as fentanyl should be given as an interrupted infusion. Daily interruption of analgesia and sedation and spontaneous breathing trials should be used as a standard of care for appropriate patients in ICUs. Their use will shorten the need for mechanical ventilation by an average of 1.5 days, dramatically decrease the number of patients who require mechanical ventilation for more than 3 weeks, decrease ICU length of stay, and lower 1-year mortality.

Benzodiazepines, such as lorazepam, given either intermittently or continuously, should generally be avoided or used sparingly because benzodiazepines are a risk factor for delirium in patients in the ICU.

Neuromuscular blocking agents are sometimes used in patients with acute respiratory distress syndrome or in other critical care scenarios where control of carbon dioxide or patients' movements to allow mechanical ventilation are needed. This patient does not have an indication for neuromuscular blockade. Additionally, if needed, neuromuscular blockade should never be used as a single agent. It should only be used when adequate pain control and sedation of the patient are assured prior to its administration.