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Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

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Published: 8/22/2018

Crit Care Med. 2018 Sep;46(9):e825-e873.

Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Citation: Crit Care Med. 2018 Sep;46(9):e825-e873.

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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

The Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS guidelines) are an update to the 2013 Pain, Agitation, Delirium Guidelines.

The PADIS guidelines:

  • Add two inextricably related clinical care topics (immobility and sleep)
  • Include patients as collaborators and coauthors


Abstract

Objective: 
To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

Design: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines’ development. A general content review was completed face-to-face by all panel members in January 2017.

Methods: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as “strong,” “conditional,” or “good” practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

Results: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

Conclusions: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep(disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Guideline Type: Clinical

Related Resources:

PADIS Guidelines Teaching Slides Translations

Category: Quality and Patient Safety,

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Pain at rest is influenced by both psychologic (e.g., anxiety and depression) and demographic (e.g., young age, one or more comorbidities, and history of surgery) factors. Pain during a procedure is influenced by preprocedural pain intensity, the type of procedure, underlying surgical or trauma diagnoses, and demographic factors (younger age, female sex, and non-white ethnicity).

A patient’s self-report of pain is the reference standard for pain assessment in patients who can communicate reliably. Among critically ill adults who are able to self-report pain, the 0–10 Numeric Rating Scale (NRS) administered either verbally or visually is a valid and feasible pain scale.

Among critically ill adults unable to self-report pain and in whom behaviors are observable, the Behavioral Pain Scale in intubated (BPS) and nonintubated (BPS-NI) patients and the Critical-Care Pain Observation Tool (CPOT) demonstrate the greatest validity and reliability for monitoring pain.

When appropriate, and when the patient is unable to self-report, family can be involved in their loved one’s pain assessment process.

Vital signs (VS) (i.e., heart rate [HR], BP, respiratory rate [RR], oxygen saturation [Spo2], and endtidal CO2) are not valid indicators for pain in critically ill adults and should only be used as cues to initiate further assessment using appropriate and validated methods such as the patient’s self-report of pain (whenever possible) or a behavioral scale (i.e., BPS, BPS-NI, CPOT).

Should acetaminophen be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?
Quality of Evidence: Very low

We suggest using nefopam (if feasible) either as an adjunct or replacement for an opioid to reduce opioid use and their safety concerns for pain management in critically ill adults.
Quality of Evidence: Very low

Should ketamine be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?
Quality of Evidence: Very low

Should a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?
Quality of Evidence: Moderate

Should IV lidocaine be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?
Quality of Evidence: Low

We suggest not routinely using a COX1–selective non-steroidal anti-inflammatory drug as an adjunct to opioid therapy for pain management in critically ill adults.
Quality of Evidence: Low

We suggest not offering cybertherapy (virtual reality) or hypnosis for pain management in critically ill adults.
Quality of Evidence: Very low

We suggest offering massage for pain management in critically ill adults.
Quality of Evidence: Low

Massage interventions varied in session time (10–30 min), frequency (once or bid), duration (for 1–7 d), andbody area (back, feet and hands, or only hands).

We suggest offering music therapy to relieve both nonprocedural and procedural pain in critically ill adults.
Quality of Evidence: Low

Management of pain for adult ICU patients should be guided by routine pain assessment and pain should be treated before a sedative agent is considered.

We suggest using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults.
Quality of Evidence: Moderate

For this recommendation, analgosedation is defined as either analgesia-first sedation (i.e., an analgesic [usually an opioid] is used before a sedative to reach the sedative goal) or analgesia-based sedation (i.e., an analgesic [usually an opioid] is used instead of a sedative to reach the sedative goal). The implementation of this recommendation infers that institutions should have an assessment-driven protocol that mandates regular pain and sedation assessment using validated tools, provides clear guidance on medication choice and dosing, and makes treating pain a priority over providing sedatives.

We suggest using an opioid, at the lowest effective dose, for procedural pain management in critically ill adults.
Quality of Evidence: Moderate

The same opioids (i.e., fentanyl, hydromorphone, morphine, and remifentanil) that are recommended in the 2013 guidelines to manage pain should also be considered when an opioid is deemed to be the most appropriate pharmacologic intervention to reduce procedural pain.

We suggest not using either local analgesia or nitrous oxide for pain management during CTR in critically ill adults.
Quality of Evidence: Low

We recommend not using inhaled volatile anesthetics for procedural pain management in critically ill adults.
Quality of Evidence: Very low

We suggest using an non-steroidal anti-inflammatory drugs  administered IV, orally, or rectally as an alternative to opioids for pain management during discrete and infrequent procedures in critically ill adults.
Quality of Evidence: Low

We suggest not using an non-steroidal anti-inflammatory drug topical gel for procedural pain management in critically ill adults.
Quality of Evidence: Low

We suggest offering relaxation techniques for procedural pain management in critically ill adults. Studies vary in in technique used for this recommendation related to breathing.
Quality of Evidence: Very low

We suggest offering cold therapy for procedural pain management in critically ill adults. Cold ice packs  applied for 10 minutes, and wrapped in dressing gauze, on the area around the chest tube before its removal.
Quality of Evidence: Low

We suggest offering music therapy to relieve both nonprocedural and procedural pain in critically ill adults.
Quality of Evidence: Low

We suggest using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults.
Quality of Evidence: Low

In critically ill, intubated adults, DSI protocols and NP-targeted sedation can achieve and maintain a light level of sedation.

A DSI or a SAT is defined as a period of time, each day, during which a patient’s sedative medication is discontinued and patients can wake up and achieve arousal and/or alertness, defined by objective actions such as opening eyes in response to a voice, following simple commands, and/or having a Sedation-Agitation Scale (SAS) score of 4–7 or a RASS score of –1 to +1. NP-targeted sedation is defined as an established sedation protocol implemented by nurses at the bedside to determine sedative choices and to titrate these medications to achieve prescription-targeted sedation scores.

We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery.
Quality of Evidence: Low

We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults.
Quality of Evidence: Low

Bispectral index (BIS) monitoring appears best suited for sedative titration during deep sedation or neuromuscular blockade, though observational data suggest potential benefit with lighter sedation as well. Sedation that is monitored with BIS compared with subjective scales may improve sedative titration when a sedative scale cannot be used.

Physical restraints are frequently used for critically ill adults although prevalence rates vary greatly by country. Critical care providers report using restraints to prevent self-extubation and medical device removal, avoid falls, and to protect staff from combative patients despite a lack of studies demonstrating efficacy and the safety concerns associated with physical restraints (e.g., unplanned extubations and greater agitation).

For the following risk factors, strong evidence indicates that these are associated with delirium in critically ill adults: “modifiable”—benzodiazepine use and blood transfusions, and “nonmodifiable”—greater age, dementia, prior coma, pre-ICU emergency surgery or trauma, and increasing Acute Physiology and Chronic Health Evaluation (APACHE) and ASA scores.

Predictive models that include delirium risk factors at both the time of ICU admission and in the first 24 hours of ICU admission have been validated and shown to be capable of predicting delirium in critically ill adults.

Critically ill adults should be regularly assessed for delirium using a valid tool.

The previous guidelines provided psychometric appraisals of pain, sedation, and delirium screening tools. A reevaluation of the psychometrics for available delirium screening tools was not conducted as part of these guidelines. This question’s focus is the effect of using any delirium assessment tool (vs no assessment tool) in clinical practice.

Level of arousal may influence delirium assessments with a validated screening tool.

Rapidly reversible delirium is associated with outcomes that are similar to patients who never experience delirium.

Positive delirium screening in critically ill adults is strongly associated with cognitive impairment at 3 and 12 months after ICU discharge and may be associated with a longer hospital stay.

Delirium in critically ill adults has consistently been shown NOT to be associated with PTSD or post-ICU distress.

Delirium in critically ill adults has NOT been consistently shown to be associated with ICU LOS discharge disposition to a place other than home, depression, functionality/dependence, or mortality.

We suggest not using haloperidol, an atypical antipsychotic, dexmedetomidine, a β-Hydroxy β-methylglutaryl-Coenzyme A (HMG-CoA) reductase inhibitor (i.e., statin), or ketamine to prevent delirium in all critically ill adults.
Quality of Evidence: Very low to low

We suggest not using haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults.
Quality of Evidence: Very low to low

We suggest using dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation.
Quality of Evidence: Low

We suggest not using bright light therapy to reduce delirium in critically ill adults.
Quality of Evidence: Moderate

We suggest using a multicomponent, nonpharmacologic intervention that is focused on (but not limited to) reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision in critically ill adults.
Quality of Evidence: Low

We suggest performing rehabilitation or mobilization in critically ill adults.
Quality of Evidence: Low

Serious safety events or harms do not occur commonly during physical rehabilitation or mobilization.

Major indicators for safely initiating rehabilitation/mobilization include stability in cardiovascular, respiratory, and neurologic status.

Major indicators for stopping rehabilitation/mobilization include development of new cardiovascular, respiratory, or neurologic instability. Other events, such as a fall or medical device removal/malfunction, and patient distress are also indications for stopping.

Total sleep time (TST) and sleep efficiency are often normal.

Sleep fragmentation, the proportion of time spent in light sleep stages (N1 + N2), and time spent sleeping during the day (vs night) are higher.

The proportion of time spent in deep sleep (stage N3 sleep and REM) is lower.

Subjective sleep quality is reduced.

The presence of delirium may not affect total sleep time, sleep efficiency, or sleep fragmentation. The influence of delirium on the proportion of time spent in light (N1 + N2) versus deeper (N3) sleep is unknown. REM sleep is lower if delirium is present. Delirium is associated with greater circadian sleep-cycle disruption and increased daytime sleep. Whether delirium affects reported subjective sleep quality remains unclear.

The use of mechanical ventilation in critically ill adults may worsen sleep fragmentation, architecture, and circadian rhythm (daytime sleep) compared with normal sleep, but these effects are often variable and have not yet been fully investigated. The use of mechanical ventilation (vs periods without mechanical ventilation) in patients with respiratory failure may improve sleep efficiency and reduce fragmentation, but data are limited.

The prevalence of unusual or dissociated sleep patterns is highly variable and depends on patient characteristics.

Patients who report poor-quality sleep and/or use of a pharmacologic sleep aid at home are more likely to report poor-quality sleep in the ICU.

Pain, environmental stimuli, health care-related interruptions, psychologic factors, respiratory factors, and medications each affect sleep quality in the ICU.

Although an association between sleep quality and delirium occurrence exists in critically ill adults, a cause-effect relationship has not been established. An association between sleep quality and duration of mechanical ventilation, length of ICU stay, and ICU mortality in critically ill adults remains unclear.

We suggest not routinely using physiologic sleep monitoring clinically in critically ill adults.
Quality of Evidence: Very low

We suggest using assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.
Quality of Evidence: Low

We make no recommendation regarding the use of an adaptive mode of ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.
Quality of Evidence: Very low

We suggest using either an NIV-dedicated ventilator or a standard ICU ventilator for critically ill adults requiring NIV to improve sleep.
Quality of Evidence: Very low

We suggest not using aromatherapy, acupressure, or music at night to improve sleep in critically ill adults.
Quality of Evidence: Low

We suggest using noise and light reduction strategies to improve sleep in critically ill adults.
Quality of Evidence: Low

We make no recommendation regarding the use of melatonin to improve sleep in critically ill adults.
Quality of Evidence: Very low

We make no recommendation regarding the use of dexmedetomidine at night to improve sleep.

We suggest not using propofol to improve sleep in critically ill adults.
Quality of Evidence: Low

We suggest using a sleep-promoting, multicomponent protocol in critically ill adults.
Quality of Evidence: Very low

A complete list of the guidelines authors and contributors is available within the published manuscript.