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Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299.

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

Author information

1
School of Pharmacy, Northeastern University, Boston, MA.
2
Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA.
3
Faculty of Medicine, McGill University, Montreal, QC, Canada.
4
Regroupement de Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Montreal, QC, Canada.
5
Ingram School of Nursing, McGill University, Montreal, QC, Canada.
6
Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.
7
Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center, Utrecht University, Utrecht, The Netherlands.
8
Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
9
Division of Sleep Medicine, Vanderbilt University Medical Center, Nashville, TN.
10
Division of Pulmonary and Critical Care, Brigham and Women's Hospital and School of Medicine, Harvard University, Boston, MA.
11
Division of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY.
12
Division of Medicine, New York University Langone Health, New York, NY.
13
Division of Neurology, New York University Langone Health, New York, NY.
14
Division of Surgery, New York University Langone Health, New York, NY.
15
Department of Medicine (Critical Care), McMaster University, Hamilton, ON, Canada.
16
Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada.
17
The Ohio State University, College of Nursing, Center of Excellence in Critical and Complex Care, Columbus, OH.
18
The Ohio State University Wexner Medical Center, Columbus, OH.
19
Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
20
Division of Critical Care, London Health Sciences Centre, London, ON, Canada.
21
Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
22
Center for Quality Aging, Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.
23
Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
24
Department of Anesthesia and Intensive Care, Montpellier University Saint Eloi Hospital, Montpellier, France.
25
PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France.
26
Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
27
Faculte de Medecine Pharmacie, University of Poitiers, Poitiers, France.
28
Service de Neurophysiologie, CHU de Poitiers, Poitiers, France.
29
Department of Critical Care, Maine Medical Center and School of Medicine, Tufts University, Portland, ME.
30
School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
31
Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
32
Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
33
Department of Physical Medicine and Rehabilitation, Intermountain Healthcare, Salt Lake City, UT.
34
School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.
35
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
36
Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, Yale University, New Haven, CT.
37
Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France.
38
School of Nursing, University of California San Francisco, San Francisco, CA.
39
Department of Surgery, University of Washington, Seattle, WA.
40
Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
41
Department of Pharmacy, Brigham and Women's Hospital, Boston, MA.
42
Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
43
Department of Anesthesia and Critical Care, McMaster University, Hamilton, ON, Canada.
44
Welch Medical Library, Johns Hopkins University, Baltimore, MD.
45
Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, NY.
46
Department of Philosophy, University of Toronto, Toronto, CA.
47
Division of Anesthesiology, Stanford University Hospital, Palo Alto, CA.
48
Patient and Family Advisory Committee, Johns Hopkins Hospital, Baltimore, MD.
49
Department of Medicine (Critical Care and Gastroenterology), McMaster University, Hamilton, ON, Canada.

Abstract

OBJECTIVE:

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN:

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS:

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS:

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS:

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

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