Comparison of clinical practice guidelines for the management of pain, agitation, and delirium in critically ill adult patients

Abstract

Guideline‐based management approaches for pain, agitation, and delirium (PAD) in critically ill adult patients are widely believed to result in good outcomes. However, there are some differences in the recommendations and evidence levels among the management guidelines established for PAD. To identify and compare the current management guidelines, we used the PubMed database. The PAD guidelines and Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva (FEPIMCTI) guidelines were identified from our search. We compared the main aspects of these two guidelines as well as the Japanese guidelines for the management of PAD (J‐PAD guidelines). The PAD, FEPIMCTI, and J‐PAD guidelines contained a total of 4, 12, and 5 sections, having 32, 138, and 37 recommendations, respectively, pertaining to routine monitoring of pain in adult patients in the intensive care unit. Intravenous opioids were recommended as the first‐line drug of choice for treating pain. Sedative titrated to maintain a light, rather than deep, level of sedation can be given unless clinically contraindicated. Although neither the PAD nor J‐PAD guidelines recommend use of a pharmacologic delirium prevention protocol or treatment with any pharmacological agent to reduce the duration of delirium, the FEPIMCTI guidelines provide such recommendations. The FEPIMCTI guidelines provide suggestions on which analgesics to use for several different cases and present algorithms for sedation and analgesia. The outlines of the three guidelines are similar, and all reinforce the management of PAD to improve patient outcomes.

Influence of early elective tracheostomy on the incidence of postoperative complications in patients undergoing head and neck surgery

“…In our institution as it is in most units caring for critical ill patients prevention of (postoperative) delirium is seen as a very important part of intensive care therapy. We implemented delirium prevention as a standard operation procedure (SOP) using a multimodal approach in management of pain, agitation and delirium (PAD) [15, 16]. Aims are a pain level of NRS < = 3, sedation on a level of − 1 to 0 on RASS and ICDSC > = 4.…”

Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses

“…Despite the importance of this issue and efforts made in the last 30 years in the field of pain management and existing standards ( 7 ) and valid guidelines ( 8 - 11 ) such as Pain, Agitation, Delirium (PAD), Japanese guidelines for the management of PAD (J-PAD), Federacion Panamericana e Iberica de Sociedades de Medicina Critica y Terapia Intensiva (FEPIMCTI) ( 12 ), various training courses, applied strategies, and multidisciplinary pain teams, there are still deficiencies in the field of pain management ( 13 ) and patients’ pain control remains a major challenge in patients hospitalized in intensive care units ( 14 ). Most nurses and physicians are unable to properly monitor and relieve the pain of critical patients ( 7 ) because proper pain management is a difficult task for many reasons such as patients’ inability to describe their pain ( 3 ), using sedatives, mechanical ventilation, and unstable physiological status ( 15 , 16 ).…”

Variations in the care of agitated patients in Australia and New Zealand ambulance services

“…The GCS is not a validated tool to assess agitation, but the Mental Health Triage Tool assigns treatment acuity codes (from 1 to 5) based on a description of the level of agitation, and forms part of the pre‐hospital guidelines on the management of acute agitation published by the New South Wales Department of Health and Human Services . In a recent review of international guidelines on the management of agitation and sedation in critical care, the Richmond Area Sedation Scale and the Sedation‐Agitation Scale were indicated as best practice in measuring sedation of agitated patients in ED and hospital settings . However, the suitability of these tools for agitated patients in the pre‐hospital environment is unclear.…”

“…There is limited evidence regarding the optimum dose for ketamine, reflected in the wide dose range in the CPGs. Although only one CPG indicated analgesia‐first sedation, which was also recommended in the review of international guidelines, ketamine was a commonly administered analgesic in the pre‐hospital setting. This may increase its effectiveness in the management of agitated patients.…”