Evidence-Based ICU Sedation Guidelines in 2012: Are We There?

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PAIN

Agitation

Delirium

PAIN

• Incidence of Pain in ICU Patients

• Pain Assessment in ICU Patients

• Treatment of Pain in ICU Patients

• Treatment of Pain vs. Agitation in ICU Patients

Incidence of Pain in ICU Patients

i. Adult medical, surgical, and trauma ICU patients routinely experience pain, both at rest and with routine ICU care (B).

ii. Procedural pain is common in adult ICU patients (B).

iii. Pain in adult cardiac surgery patients is common and poorly treated; women experience more pain than men after cardiac surgery (B).

Pain Assessment in ICU Patients

i. We recommend that pain be routinely monitored in all adult ICU patients (+1B).

ii. The Behavioral Pain Scale (BPS) and the Critical‐Care Pain Observation Tool (CPOT) (unable to self-report, and in whom motor function is intact)

Pain Assessment in ICU Patients

iii. We do not suggest that vital signs (or observational pain scales that include vital signs) be used alone for pain assessment in adult ICU patients (‐2C).

iv. We suggest that vital signs may be used as a clue to begin further assessment of pain (+2C).

Treatment of Pain in ICU Patients

i. Pre‐emptive analgesia and/or non‐pharmacologic interventions prior to chest tube removal (+1C).

ii. Pre‐emptive analgesic therapy and/or nonpharmacologic interventions other types of invasive and potentially painful procedures (+2C).

iii. IV opioids the first‐line drug to treat non-neuropathic pain in critically ill patients (+1C).

iv. All available IV opioids, when titrated to similar pain intensity endpoints, are equally effective (C).

v. Non‐opioid analgesics decrease the amount of opioids and opioid‐related side effects (+2C).

vi. Enteral gabapentin or carbamazepine, in addition to intravenous opioids, should be considered for treatment of neuropathic pain (+1A).

Treatment of Pain vs. Agitation in ICU Patients

i. We suggest that analgesia‐first sedation be used in adult ICU patients who are mechanically ventilated (+2B).

SEDATION & AGITATION

• Depth of Sedation in ICU Patients

• Sedation Monitoring in ICU Patients

– Sedation Scales

– Brain Function Monitors

• Choice of Sedatives in ICU Patients

Depth of Sedation in ICU Patients

i. Light levels of sedation in adult ICU patients is associated with improved clinical outcomes (B).

ii. Light levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B).

iii. The association between depth of sedation and psychological stress in these patients remains unclear (C).

Depth of Sedation in ICU Patients

iv. Light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated (+1B).

v. Either daily sedation interruption or targeting a light level of sedation in mechanically ventilated adult ICU patients (+1B).

Sedation Monitoring in ICU Patients

• Sedation scales

– The Richmond Agitation‐Sedation Scale (RASS)

– Sedation‐Agitation Scale (SAS)

• Brain Function Monitors

– an adjunct in patients who are receiving neuromuscular blocking agents (+2B)

– EEG monitoring : non‐convulsive seizure activity with either known or suspected seizures, or to titrate medication (+1A).

Choice of Sedatives in ICU Patients

i. Non-benzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B).

DELIRIUM

• Outcomes Associated with Delirium in ICU Patients

• Delirium Risk Factors in ICU Patients

• Delirium Monitoring in ICU Patients

• Delirium Prevention in ICU Patients

• Delirium Treatment in ICU Patients

Outcomes Associated with Delirium in ICU Patients

i. Delirium is associated with increased mortality in adult ICU patients (A).

ii. Delirium is associated with prolonged ICU and hospital lengths of stay in adult ICU patients (A).

iii. Delirium is associated with the development of post‐ICU cognitive impairment in adult ICU patients (B).

Those with delirium had greater cognitive drop and slower recovery over the 1 year period

N Engl J Med 2012;367:1

Delirium Risk Factors in ICU Patients

i. Four baseline risk factors (B)

– Preexisting dementia

– history of hypertension

– history of alcoholism

– high severity of illness on admission

ii. Independent risk factor : Coma (B).

Delirium Risk Factors in ICU Patients

iii. Opioid and delirium Conflicting data (B).

iv. Benzodiazepines may be a risk factor (B).

v. Propofol and delirium insufficient data (C).

vi. Dexmedetomidine may be associated with a lower prevalence of delirium compared to benzodiazepine, mechanically ventilated (B).

Delirium Monitoring in ICU Patients

i. We recommend routine monitoring for delirium in adult ICU patients (+1B).

ii. Routine monitoring of delirium in adult ICU patients is feasible in clinical practice (B).

iii. The Confusion Assessment Method for the ICU (CAMICU) and the Intensive Care Delirium Screening Checklist (ICDSC) (A).

Delirium Prevention in ICU Patients

i. Early mobilization whenever feasible to reduce the incidence and duration of delirium (+1B).

ii. Promoting sleep by optimizing patients' environments to protect patients' sleep cycles) (+1C).

iii. Modes of mechanical ventilation to promote sleep no recommendation (0, No Evidence).

Delirium Prevention in ICU Patients

iv. pharmacological delirium prevention protocol no recommendation (0,C).

v. non‐pharmacological and pharmacological delirium prevention protocol no recommendation (0,C).

vi. Either haloperidol or atypical antipsychotics to prevent delirium not suggest (‐2C).

vii. dexmedetomidine to prevent delirium no recommendation (0,C).

Delirium Treatment in ICU Patients

i. Treatment with haloperidol reduces the duration of delirium No Evidence

ii. Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C).

iii. Rivastigmine to reduce the duration of delirium Not recommend (‐1B).

Delirium Treatment in ICU Patients

iv. Using antipsychotics in patients at risk for torsades de pointes Not suggest (‐2C).

v. Dexmedetomidine reduce the duration of delirium in patients with delirium unrelated to alcohol or benzodiazepine withdrawal (+2B).