Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients
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1 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit January 2013 Volume 41 Number 1 Society of Critical Care Medicine 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權
2 Juliana Barr, MD, FCCM1; Gilles L. Fraser, PharmD, FCCM2; Kathleen Puntillo, RN, PhD, FAAN, FCCM3; E. Wesley Ely, MD, MPH, FACP, FCCM4; Céline Gélinas, RN, PhD5; Joseph F. Dasta, MSc, FCCM, FCCP6; Judy E. Davidson, DNP, RN7; John W. Devlin, PharmD, FCCM, FCCP8; John P. Kress, MD9; Aaron M. Joffe, DO10; Douglas B. Coursin, MD11; Daniel L. Herr, MD, MS, FCCM12; Avery Tung, MD13; Bryce R. H. Robinson, MD, FACS14; DorrieK. Fontaine, PhD, RN, FAAN15; Michael A. Ramsay, MD16; Richard R. Riker, MD, FCCM17; Curtis N. Sessler, MD, FCCP, FCCM18; Brenda Pun, MSN, RN, ACNP19; YoannaSkrobik, MD, FRCP20; Roman Jaeschke, MD21
3 Objective To revise the Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult published in Critical Care Medicine in 2002.
4 Methods The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multiinstitutional task force Expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients.
5 Methods Divided into four subcommittees Grading of Recommendations Assessment, Development and Evaluation method 1. PubMed 2. MEDLINE 3. Cochrane Database of Systematic Reviews 4. Cochrane Central Register of Controlled Trials 5. CINAHL 6. Scopus 7. ISI Web of Science 8. the International Pharmaceutical Abstracts.
6 Methods The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against ( ) an intervention.
7
8 Methods We recommend => strong recommendation We suggest => weak recommendation
9 Conclusion These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients. (Crit Care Med 2013; 41: )
10 1. Pain and Analgesia 2. Agitation and Sedation 3. Delirium 4. Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes
11 1. Pain and Analgesia a. Incidence of pain ii. Pain in adult cardiac surgery patients is common and poorly treated; women experience more pain than men after cardiac surgery (B).
12 b. Pain assessment i. Routinely pain monitoring (+1B) ii. The Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT) are the most valid and reliable behavioral pain scales for monitoring pain (except for brain injury) iii. Vital sign (+2C)
13
14
15 CPOT
16 c. Treatment of pain iii. intravenous (IV) opioidsbe considered as the first-line drug class of choice to treat non-neuropathic pain in critically ill patients (+1C) iv. Opioids are equally effective (C)
17 vi. We recommend that either enterally administered gabapentin or carbamazepine, in addition to IV opioids, be considered for treatment of neuropathic pain (+1A)
18 x. We suggest that thoracic epidural analgesia be considered for patients with traumatic rib fractures (+2B).
19 2. Agitation and Sedation a. Depth of sedation vs. clinical outcomes i. Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (B).
20 ii. Maintaining light levels of sedation increases the physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B).
21 b. Monitoring depth of sedation and brain function i. The Richmond Agitation-Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) are the most valid and reliable sedation assessment tools for measuring quality and depth of sedation in adult ICU patients (B).
22
23 c. Choice of sedative i. We suggest that sedation strategies using non-bzd sedatives (either propofolor dexmedetomidine) may be preferred over sedation with BZD (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B).
24 3. Delirium a. Outcomes associated with delirium i. Increased mortality (A). ii. Prolonged ICU and hospital LOS (A). iii. Development of post-icu cognitive impairment (B).
25 b. Detecting and monitoring delirium i. Recommend routine monitoring of delirium (+1B). ii. The Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most valid and reliable delirium monitoring tools (A). iii. Routine monitoring of delirium is feasible (B).
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27
28 c. Delirium risk factors i. Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU: preexisting dementia, history of hypertension and/or alcoholism, and a high severity of illness at admission (B).
29 iii. Conflicting data surround the relationship between opioid use and the development of delirium in adult ICU patients (B). iv. Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients (B).
30 vi. In mechanically ventilated adult ICU patients at risk of developing delirium, dexmedetomidine infusions administered for sedation may be associated with a lower prevalence of delirium compared to benzodiazepine infusions (B)
31 d. Delirium prevention i. We recommend performing early mobilizationof adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B).
32
33 v. We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adult ICU patients ( 2C).
34 e. Delirium treatment i. There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (No Evidence).
35 e. Delirium treatment i. There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (No Evidence).
36 v. We suggest that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidinerather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients (+2B)
37 4. Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes a. We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients (+1B).
38 b. We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B).
39 c. We recommend promoting sleep in adult ICU patients by optimizing patients environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patients sleep cycles (+1C).
40 Thank you very much!!
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