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Cited by 372Intensive Care Unit Cognitive DisordersClinical practice guidelines implementationFamily and Patient Care in Intensive Care Units

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

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Devlin, John W., Skrobik, Yoanna, Gélinas, Céline, Needham, Dale M., Slooter, Arjen J. C., Pandharipande, Pratik P., Watson, Paula L., Weinhouse, Gerald L. +33 more·2018·Critical Care Medicine
DOI 10.1097/ccm.0000000000003259
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Abstract

Clinical practice guidelines are published and promoted, often by professional societies, because they provide a current and transparently analyzed review of relevant research and are written with the aim to guide clinical practice. The 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) (PADIS) guidelines (1) first 1) builds on this mission by updating the 2013 PAD guidelines (2); 2) by adding two inextricably related clinical care topics (immobility and sleep); 3) by including patients as collaborators and coauthors; and 4) by inviting panelists from high-income countries as an early step toward incorporating more diverse practices and expertise from the global critical care community. Readers will find rationales for 37 recommendations (derived from actionable Patient Intervention Comparison Outcome questions), two good practice statements, and 32 statements (derived from nonactionable, descriptive questions for which the Grading of Recommendations Assessment, Development and Evaluation methodology was not used) across the five guideline sections. Only two of the 37 recommendations are strong; most are conditional. Compared with a strong recommendation (most desirable to clinicians), conditional recommendations apply to most, but not all critically ill adults, and are made when evidence is conflicting, low quality, insufficient and/or applicable to just one patient subgroup, and/or when potential benefits require weighing almost equal risks. The supplemental digital figures and tables linked to the full guideline provide background on how the questions were established, profiles of the evidence, the “evidence to decision” tables used to develop recommendations, and voting results. We also describe the evidence gaps that prevented us from fully addressing all clinical priority questions. The five sections of this guideline are interrelated, and thus, the guideline should be considered in its entirety rather than as discrete or distinct recommendations. A separate PADIS guideline implementation and integration article (3) and a detailed description of the methodologic innovations that characterize these guidelines (4) have been published separately. This executive summary highlights the 18 recommendations the section leaders and guideline chair/vice-chair felt would be of greatest interest to ICU clinicians. All PADIS recommendations (including those highlighted in this executive summary) are found in Table 1. All descriptive questions and ungraded statements are found in Table 2.TABLE 1.: Summary of Actionable Patient Intervention Comparison Outcome Questions and RecommendationsTABLE 2.: Summary of Descriptive Questions and Ungraded StatementsRECOMMENDATIONS Pain Pain management is complex and has many origins. A consistent approach to pain assessment and management is paramount, particularly given the unique features inherent to critically ill adults. In this population, whose reference standard measure of pain is the patient’s self-report, the inability to communicate clearly does not negate a patient’s pain experience or the need for appropriate pain management (5). Severe pain negatively affects critically ill adults (6) beyond its unpleasant experience dimension. Implementation of assessment-driven and standardized pain management protocols improves ICU outcomes and clinical practice (5,6). Carefully titrated analgesic dosing is important in balancing the benefits versus risks of opioid exposure (7–10). Protocol-Based Pain Assessment and Management Question. Should we use a protocol-based (analgesia/analgosedation) pain assessment and management programs in the care of adult ICU patients when compared with usual care? Good practice statement. Management of pain for adult ICU patients should be guided by routine pain assessment and pain should be treated before a sedative agent is considered. Recommendation. We suggest using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults (conditional recommendation, moderate quality of evidence). Remarks. For this recommendation, analgosedation is defined as either analgesia-first sedation (i.e., an analgesic [usually an opioid] is used before a sedative to reach the sedative goal) or analgesia-based sedation (i.e., an analgesic [usually an opioid] is used instead of a sedative to reach the sedative goal). The implementation of this recommendation infers that institutions should have an assessment-driven protocol that mandates regular pain and sedation assessment using validated tools, provides clear guidance on medication choice and dosing, and makes treating pain a priority over providing sedatives. Our pooled analysis suggests that protocol-based (analgesia/analgosedation) pain and sedation assessment and management programs compared with usual therapy reduce sedative requirements, duration of mechanical ventilation, ICU length of stay (LOS), and

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  • More recent guidelines have recommended against the use of antipsychotics in the management of delirium in adults, reserving them to selected cases.

    “In fact, more recent guidelines have recommended against the use of antipsychotics in the management of delirium in adults, reserving them to selected cases [80].”

    From Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness (2022) · cites this paper as [80]

    The Delirium Treatment section conditionally recommends against routine antipsychotic use and allows short-term use for selected patients with distressing symptoms or dangerous agitation. The guideline applies to critically ill adults in the ICU, whereas the citing sentence does not state that limitation. (LLM, conf=0.86)

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Authors
Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., Joffe, A. M., Kho, M. E., Kress, J. P., Lanphere, J. A., McKinley, S., Neufeld, K. J., Pisani, M. A., Payen, J.-F., Pun, B. T., Puntillo, K. A., Riker, R. R., Robinson, B. R. H., Shehabi, Y., Szumita, P. M., Winkelman, C., Centofanti, J. E., Price, C., Nikayin, S., Misak, C. J., Flood, P. D., Kiedrowski, K., & Alhazzani, W.
Affiliations
  • Tufts Medical Center (US)
  • McGill University (CA)
  • Johns Hopkins University (US)
  • Utrecht University (NL)
  • Vanderbilt University Medical Center (US)
  • Brigham and Women's Hospital (US)
  • NYU Langone Health (US)
  • McMaster University (CA)
  • The Ohio State University Wexner Medical Center (US)
  • Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
  • Western University (CA)
  • Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Center for Quality Aging, and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
  • Department of Anesthesia and Intensive Care, Montpellier University Saint Eloi Hospital, Montpellier, France.
  • The University of Melbourne (AU)
  • Université de Poitiers (FR)
  • Tufts University (US)
  • University of Washington (US)
  • University of Chicago (US)
  • Intermountain Healthcare (US)
  • Deakin University (AU)
  • Yale University (US)
  • Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France.
  • University of California, San Francisco (US)
  • Monash University (AU)
  • Case Western Reserve University (US)
  • New York Medical College (US)
  • University of Toronto (CA)
  • Stanford Medicine (US)
ORCID
Venue
Critical Care Medicine
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2018-09
Volume
46
Issue
9
Pages
1532-1548
ISSN
0090-3493 (ISSN-L)
DOI
10.1097/ccm.0000000000003259
OpenAlex
W2886033986
Cited by
372
References
136
Citations by year
2026: 56 · 2025: 59 · 2024: 51 · 2023: 47 · 2022: 38 · 2021: 53 · 2020: 40 · 2019: 24 · 2018: 4
FWCI
25.15
Type
journal article
Language
en
Open access
Licence
other-oa
Locations
  • Critical Care Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • HAL (submittedVersion, other-oa)
  • eScholarship (California Digital Library) (submittedVersion)
  • Utrecht University Repository (Utrecht University) (submittedVersion, other-oa)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Utrecht University Repository (Utrecht University) (submittedVersion)
Funders
  • Society of Critical Care Anesthesiologists
  • National Institutes of Health
  • Baxter Healthcare Corporation
  • Canadian Institutes of Health Research
  • National Institute on Aging (K76AG054864, L30 AG048581)
  • National Heart, Lung, and Blood Institute
Topics
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Health Professions › Radiological and Ultrasound Technology › Family and Patient Care in Intensive Care Units
Keywords
delirium, immobility, sleep disruption, intensive care unit, critically ill adults, evidence gaps, patient-centered care, shared decision-making, patient-centered outcomes
MeSH terms
Adult, Critical Care, Delirium, Humans, Intensive Care Units, Pain, Psychomotor Agitation, Restraint, Physical, Sleep Wake Disorders, Procedural Sedation, Deep Sedation, Pain Management

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