The 2013 guideline for managing pain, agitation and delirium (PAD) has recently been published.1 Guideline development, using a patient-centered approach, started in 2006 and included 20 critical care practitioners with expertise in intensive care unit (ICU) PAD. The GRADE method was used to rank recommendations based on the quality of evidence [A=randomized controlled trials (RCT), B=RCTs of low quality or observational studies, C= lower quality observational studies or uncontrolled case series] and the risk or benefit to patients [0=no recommendations given, 1= benefits outweigh the risks (strong), 2=risks outweigh the benefits (weak)]. The final recommendation would either suggest using an intervention (+) or suggest avoiding it (-).2 This feature will highlight just a few of the 54 recommendations from the PAD taskforce.
In terms of recommendations regarding the management of PAIN in the ICU, the recommendations include: 1) pain to be routinely monitored in all adult ICU patients (+1B), 2) The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) is to be used for patients in the ICU unable to self-report (B). Managing pain should be by using intravenous (IV) opioids to treat non-neuropathic pain in critically ill patients (+1C).
In terms of AGITATION assessment and management, the Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are considered valid and reliable assessment tools for measuring quality and depth of sedation in adult ICU patients (B). However, the use of objective measures of brain function such as Bispectral Index and patient State Index is only recommended for patients receiving neuromuscular blockade (+2B). Analgesia-first sedation is suggested be used in adult ICU patients (+2B). This approach seems to shorten time on mechanical ventilation and improves time in sedation target. The guidelines also recommend either daily sedation interruption or a light target level of sedation be routinely used in adult ICU patients (+1B). When compared with titrating drugs to a lighter level, use of daily sedation interruption was associated with similar clinical outcomes but patients required higher doses of fentanyl and midazolam.3 Finally, due to the fact that benzodiazepines are associated with increased duration of mechanical ventilation and ICU length of stay and maybe associated with a greater incidence of delirium when compared with propofol or dexmedetomidine, the guidelines recommend using the later rather than benzodiazepines to improve clinical outcomes (+2B).
Assessment of DELIRIUM using the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) is recommended (A). Risk factors for delirium include coma, benzodiazepine and opioid use (B). Propofol use has insufficient data to determine the relationship with delirium development (C). Dexmedetomidine may be associated with a lower prevalence of delirium compared with benzodiazepine infusions (B). Early mobilization is recommended to reduce the incidence and duration of delirium (+1B). Dexmedetomidine is suggested rather than benzodiazepine infusions to be administered to reduce the duration of delirium (+2B). There is no published evidence that treatment with haloperidol reduces the ...