Guidelines Pharmacology Quality and Patient Safety

A Focused Update to the Clinical Practice Guideline for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

J. Matthew Aldrich MD, FCCM Michele C. Balas RN, PhD, CCRN, FAAN, FCCM Kimberley Lewis MD, MSc, FRCPC

PUBLISHED: 02/20/2025

A Focused Update to the Clinical Practice Guideline for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Citation: Lewis K, Balas MC, Stollings JL, et al. A focused update to the clinical practice guideline for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2025 Mar 1;53(3):e711-e727.

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Critically ill adults are at risk for a variety of consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes. These SCCM guidelines update and expand on SCCM’s 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

The task force issued five statements related to the management of anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption in adults the ICU. The task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

Guideline Type: Clinical

Related Resources:

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

Read Full Guideline

There is insufficient evidence to make a recommendation on the use of benzodiazepines to treat anxiety in adult patients admitted to the ICU.

Anxiety Benzodiazepines

We suggest using dexmedetomidine over propofol for sedation in mechanically ventilated adult patients admitted to the ICU where light sedation and/or a reduction in delirium are of highest priorities.
Quality of evidence: Moderate

Sedation Conditional Dexmedetomidine

We are unable to issue a recommendation for or against the use of antipsychotics over usual care for the treatment of delirium in adult patients admitted to the ICU.
Quality of evidence: Low

Delirium Conditional Antipsychotics

We suggest providing enhanced mobilization/rehabilitation over usual care mobilization/rehabilitation to adult patients admitted to the ICU.
Quality of evidence: Moderate

Immobility Conditional Mobilization

We suggest administering melatonin over no melatonin in adult patients admitted to the ICU.
Quality of evidence: Low

Outcomes Conditional Melatonin

Author

J. Matthew Aldrich MD, FCCM

J. Matthew Aldrich MD, FCCM, is the executive medical director for critical care medicine and clinical professor of anesthesia at University of California San Francisco (UCSF). His clinical practice includes anesthesia and critical care. Within these fields, he has a particular interest in resuscitation training and practice and advanced respiratory failure. His academic interests are focused on quality improvement and harm reduction in critically ill patients. He was a member of the UCSF Critical Care Innovations Group, an interprofessional group of providers, staff, and patient/family advisors that worked to reduce preventable harms and improve patient/family experience in the ICU. He also served as the campus PI for the UC-Wide Implementation of the Advanced Resuscitation Training Program.

Author

Michele C. Balas RN, PhD, CCRN, FAAN, FCCM

Michele C. Balas RN, PhD, CCRN, FAAN, FCCM, is the associate dean of research and Dorothy Hodges Olson Distinguished Professor of Nursing at the University of Nebraska Medical Center College of Nursing. Dr. Balas is an implementation scientist and registered nurse with extensive training and experience in the conduct of clinical trials and mixed-methods research in the ICU and hospital setting.

Author

Kimberley Lewis MD, MSc, FRCPC

Kimberley Lewis MD, MSc, FRCPC, is an assistant professor in the Division of Critical Care at McMaster University. Dr. Lewis has received numerous awards including the David Sackett Award, St. Joseph's Studentship Award, Dr. Paul O'Byrne Internal Medicine Research Grant, and Clinician Investigator Program Ministry of Health Funding.