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

Abstract

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.

Delirium: one size does not fit all

“…Indeed, the modern approach to sedation in intubated patients is to maintain the patient as awake as possible, applying specific prophylaxis and treatment for pain and delirium rather than masking these with sedation . The evidence guiding delirium management in critical care is comprehensively summarised in the 2018 Guidelines from the Society of Critical Care Medicine . Like the ACSQH recommendations, these recommend a multicomponent approach to non‐pharmacological prophylaxis and treatment, but the only intervention supported by both before‐after studies and a randomised controlled trial is sedation interruption and early mobilisation.…”

“…Curiously, given their near‐ubiquitous use in many parts of the world, no randomised trial has ever evaluated the use of physical restraints. The current SCCM guidelines simply note this lack of evidence alongside the extensive published rationale for their continued use, including patient safety, prevention of self‐extubation, tube dislodgement, and/or medical device removal, protection of staff from combative patients and to prevent falls …”

“…Choice of sedative appears important: a lower incidence of delirium (or more days free of coma or delirium) was seen when intubated patients were randomised to dexmedetomidine rather than benzodiazepines . While attempts at pharmacological prophylaxis have been generally disappointing, three large studies of postoperative patients found benefit: one randomised trial of low‐dose prophylactic haloperidol (457 patients), and two randomised trials of dexmedetomidine (700 patients and 100 patients). Haloperidol has repeatedly been found ineffective for established ICU delirium, but two placebo‐controlled trials have shown effectiveness of other medications.…”

“…While attempts at pharmacological prophylaxis have been generally disappointing, three large studies of postoperative patients found benefit: one randomised trial of low‐dose prophylactic haloperidol (457 patients), and two randomised trials of dexmedetomidine (700 patients and 100 patients). Haloperidol has repeatedly been found ineffective for established ICU delirium, but two placebo‐controlled trials have shown effectiveness of other medications. The first of these randomised 36 patients with delirium (approx.…”

Targeting light versus deep sedation for patients receiving mechanical ventilation

“…The current recommendations by the Society of Critical Care Medicine are to maintain light sedation in all patients receiving mechanical ventilation, recognizing that this is a conditional recommendation given the low quality of available evidence (13). Much of this lack of evidence stems from inconsistency in how light sedation is defined.…”