ICU pain, agitation, delirium, immobility, and sleep: SCCM updates guidelines

  • Devlin JW & al.
  • Crit Care Med
  • 1 Sep 2018

  • curated by Jenny Blair, MD
  • Clinical Essentials
Access to the full content of this site is available only to registered healthcare professionals. Access to the full content of this site is available only to registered healthcare professionals.


  • For ICU patients, Society of Critical Care Medicine (SCCM) recommends multicomponent interventions to treat delirium, promote sleep.


  • 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guideline updates 2013 Pain, Agitation, and Delirium edition. 
  • Panel includes patients.
  • Endorsed by American College of Chest Physicians, Society of Critical Care Anesthesiologists, additional organizations. 

Key details

  • Treat pain before sedation.
  • Optional opioid adjuncts: acetaminophen (Tylenol), postoperative ketamine (conditional recommendation [CR]; very-low-quality evidence [VLQ]).
  • Use neuropathic pain medication with opioids for neuropathic pain (strong recommendation [SR]; moderate-quality evidence [MQ]) or in postcardiovascular surgery patients (CR; low-quality evidence [LQ]).
  • NSAIDs, except topical gel, for procedures (CR/LQ).
  • For pain, panel suggests massage, music therapy, cold therapy (CR/LQ), relaxation therapy (CR/VLQ).
  • Panel discourages:
    • Routine lidocaine, cyclooxygenase-1 selective NSAIDs as opioid adjuncts (CR/LQ);
    • Procedural inhaled volatile anesthetics (SR/VLQ);
    • Cybertherapy (CR/VLQ).
  • Light, not deep sedation preferred during mechanical ventilation (MV) (CR/LQ).
  • Propofol, dexmedetomidine preferred during MV vs benzodiazepines (CR/LQ).
  • For delirium, modifiable risk factors are benzodiazepines, blood transfusions (strong evidence).
  • Delirium strongly associated with later cognitive impairment but not posttraumatic stress disorder, length of stay, and mortality.
  • For delirium, panel recommends multicomponent, nonpharmacologic intervention that prevents risk factors, improves cognition, and optimizes sleep, mobility, hearing, and vision (CR/LQ).
  • Panel discourages:
    • Prevention with haloperidol, atypical antipsychotic, dexmedetomidine, statins, ketamine (CR/LQ/VLQ);
    • Treatment with haloperidol, atypical antipsychotic, statin (CR/LQ), or bright light (CR/MQ).
  • Panel recommends rehabilitation or mobilization (CR/LQ), which are seldom associated with harm.
    • Safe initiation depends on stable cardiovascular, respiratory, neurologic status;
    • Vasoactive infusions or MV are not contraindications.
  • Associations between sleep quality and hard outcomes like mortality are unclear.
  • For sleep, panel suggests:
    • Multicomponent sleep-promoting protocol (CR/VLQ);
    • Noise, light reduction (CR/LQ);
    • During MV, nocturnal assist-control ventilation (CR/LQ).
  • Panel discourages:
    • Aromatherapy, acupressure (CR/LQ), music (CR/VLQ);
    • Propofol (CR/LQ).
  • For sleep, no recommendation about melatonin or dexmedetomidine (VLQ).

Please confirm your acceptance

To gain full access to GPnotebook please confirm:

By submitting here you confirm that you have accepted Terms of Use and Privacy Policy of GPnotebook.