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  • image The primary goal of pain, agitation, and delirium (PAD) management is to provide patient comfort and safety with secondary goals to prevent immediate and long-term adverse physical and psychological outcomes.

  • image PAD are interrelated and can confound efforts to provide intensive care including mobility, sleep, participation in care and in shared patient/caregiver decisions about appropriate levels of care.

  • image It is important to systematically evaluate PAD with validated tools for timely identification and correction of inciting clinical issues.

  • image Preventative measures and nonpharmacologic strategies for PAD management should be initiated as early as possible.

  • image A multifaceted, multidisciplinary approach to PAD management impacts care and clinical outcomes.

  • image Pain is an important cause of agitation in the intensive care unit (ICU) and should be assessed and treated before administration of sedatives.

  • image No proven pharmacologic strategies limit the severity and duration of ICU delirium.

  • image Sedative choice (dexmedetomidine or propofol) and depth of sedation may have an important impact on patient assessments and outcomes.


Patient Care Process for the Management of Critically Ill Adults with Pain, Agitation, and Delirium



  • Patient-specific characteristics, comorbidities, allergies, and intolerance to medications

  • Psychosocial history (eg, chronic pain, substance abuse, psychiatric diagnoses)

  • Symptom-specific history (eg, onset, location, duration, chronicity, severity, consequences, and inciting/remediating factors)

  • Documented response to interventions for PAD management (efficacy and intolerance)

  • Current and past medication use with attention to those associated with agitation or delirium (see Table e26-2)

  • Objective data including vital signs, pertinent labs, physical and neurologic evaluations, pertinent imaging studies, short- and long-term goals of care including the need for palliative care


  • Presence of PAD symptoms (see Table e26-1)

  • Presence of risk factors for PAD (see Table e26-3)

  • Symptom resolution using validated PAD assessment tools per SCCM guidelines (see Table e26-4)

  • Presence of co-occurring psychological conditions that may confound treatment plan

  • Adverse drug reactions or intolerance associated with the use of medications for the management of PAD (see Table e26-6)

Plan (collaborate with patient, family, and healthcare professionals)

  • Before using medications for symptom relief, ensure that preemptive/preventative strategies are in place, that inciting/precipitating factor(s) are identified and reversed if possible, and employ nonpharmacologic management strategies (see Table e26-1)

  • If necessary, offer pharmacologic management options with identification of treatment goals and a plan to safely terminate therapy when the clinical issue resolves (see Tables e26-1 and e26-5)

  • Contingencies should be identified if the initial plan is not successful or not tolerated


  • Educate patient/family and treating team about all elements of the therapeutic plan

  • Identify proper starting and incremental dose adjustments along with reasonable assessment durations when using tiratable medications

Follow-up: Monitor and Evaluate

  • Resolution of PAD

  • Presence of adverse drug reactions

  • Monitor withdrawal and resurgence of clinical issues upon discontinuance of medications for PAD management; implement a dose-tapering strategy if appropriate

  • Evaluate the continued need for medications initiated in the ICU for PAD management upon discharge ...

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