Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.
Devlin, John W. PharmD, FCCM (Chair) 1,2; Skrobik, Yoanna MD, FRCP(c), MSc, FCCM (Vice-Chair) 3,4; Gelinas, Celine RN, PhD 5; Needham, Dale M. MD, PhD 6; Slooter, Arjen J. C. MD, PhD 7; Pandharipande, Pratik P. MD, MSCI, FCCM 8; Watson, Paula L. MD 9; Weinhouse, Gerald L. MD 10; Nunnally, Mark E. MD, FCCM 11,12,13,14; Rochwerg, Bram MD, MSc 15,16; Balas, Michele C. RN, PhD, FCCM, FAAN 17,18; van den Boogaard, Mark RN, PhD 19; Bosma, Karen J. MD 20,21; Brummel, Nathaniel E. MD, MSCI 22,23; Chanques, Gerald MD, PhD 24,25; Denehy, Linda PT, PhD 26; Drouot, Xavier MD, PhD 27,28; Fraser, Gilles L. PharmD, MCCM 29; Harris, Jocelyn E. OT, PhD 30; Joffe, Aaron M. DO, FCCM 31; Kho, Michelle E. PT, PhD 30; Kress, John P. MD 32; Lanphere, Julie A. DO 33; McKinley, Sharon RN, PhD 34; Neufeld, Karin J. MD, MPH 35; Pisani, Margaret A. MD, MPH 36; Payen, Jean-Francois MD, PhD 37; Pun, Brenda T. RN, DNP 23; Puntillo, Kathleen A. RN, PhD, FCCM 38; Riker, Richard R. MD, FCCM 29; Robinson, Bryce R. H. MD, MS, FACS, FCCM 39; Shehabi, Yahya MD, PhD, FCICM 40; Szumita, Paul M. PharmD, FCCM 41; Winkelman, Chris RN, PhD, FCCM 42; Centofanti, John E. MD, MSc 43; Price, Carrie MLS 44; Nikayin, Sina MD 45; Misak, Cheryl J. PhD 46; Flood, Pamela D. MD 47; Kiedrowski, Ken MA 48; Alhazzani, Waleed MD, MSc (Methodology Chair) 16,49
Critical Care Medicine.
46(9):e825-e873, September 2018.
(Format: HTML, PDF)
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.
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