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
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Takeaway

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

Description

  • 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).

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