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

John W. Devlin, Yoanna Skrobik, Céline Gélinas, Dale Needham, Arjen J.C. Slooter, Pratik P. Pandharipande, Paula L. Watson, Gerald L. Weinhouse, Mark E. Nunnally, Bram Rochwerg, Michele C. Balas, Mark van den Boogaard, Karen J. Bosma, Nathaniel E. Brummel, Gerald Chanques, Linda Denehy, Xavier Drouot, Gilles L. Fraser, Jocelyn E. Harris, Aaron M. Joffe & 21 others Michelle E. Kho, John P. Kress, Julie A. Lanphere, Sharon McKinley, Karin Jane Neufeld, Margaret A. Pisani, Jean Francois Payen, Brenda T. Pun, Kathleen A. Puntillo, Richard R. Riker, Bryce R.H. Robinson, Yahya Shehabi, Paul M. Szumita, Chris Winkelman, John E. Centofanti, Carrie Price, Sina Nikayin, Cheryl J. Misak, Pamela D. Flood, Ken Kiedrowski, Waleed Alhazzani

Research output: Contribution to journalArticle

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.

Original languageEnglish (US)
Pages (from-to)e825-e873
JournalCritical care medicine
Volume46
Issue number9
DOIs
StatePublished - Sep 1 2018

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Delirium
Practice Management
Practice Guidelines
Sleep
Pain
Rehabilitation
Guidelines
Critical Illness
Survivors
Telecommunications
Conflict of Interest
Vulnerable Populations
Population
Research

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. / Devlin, John W.; Skrobik, Yoanna; Gélinas, Céline; Needham, Dale; Slooter, Arjen J.C.; Pandharipande, Pratik P.; Watson, Paula L.; Weinhouse, Gerald L.; Nunnally, Mark E.; Rochwerg, Bram; Balas, Michele C.; van den Boogaard, Mark; Bosma, Karen J.; Brummel, Nathaniel E.; Chanques, Gerald; Denehy, Linda; Drouot, Xavier; Fraser, Gilles L.; Harris, Jocelyn E.; Joffe, Aaron M.; Kho, Michelle E.; Kress, John P.; Lanphere, Julie A.; McKinley, Sharon; Neufeld, Karin Jane; Pisani, Margaret A.; Payen, Jean Francois; Pun, Brenda T.; Puntillo, Kathleen A.; Riker, Richard R.; Robinson, Bryce R.H.; Shehabi, Yahya; Szumita, Paul M.; Winkelman, Chris; Centofanti, John E.; Price, Carrie; Nikayin, Sina; Misak, Cheryl J.; Flood, Pamela D.; Kiedrowski, Ken; Alhazzani, Waleed.

In: Critical care medicine, Vol. 46, No. 9, 01.09.2018, p. e825-e873.

Research output: Contribution to journalArticle

Devlin, JW, Skrobik, Y, Gélinas, C, Needham, D, Slooter, AJC, Pandharipande, PP, Watson, PL, Weinhouse, GL, Nunnally, ME, Rochwerg, B, Balas, MC, van den Boogaard, M, Bosma, KJ, Brummel, NE, Chanques, G, Denehy, L, Drouot, X, Fraser, GL, Harris, JE, Joffe, AM, Kho, ME, Kress, JP, Lanphere, JA, McKinley, S, Neufeld, KJ, Pisani, MA, Payen, JF, Pun, BT, Puntillo, KA, Riker, RR, Robinson, BRH, Shehabi, Y, Szumita, PM, Winkelman, C, Centofanti, JE, Price, C, Nikayin, S, Misak, CJ, Flood, PD, Kiedrowski, K & Alhazzani, W 2018, 'Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU', Critical care medicine, vol. 46, no. 9, pp. e825-e873. https://doi.org/10.1097/CCM.0000000000003299
Devlin, John W. ; Skrobik, Yoanna ; Gélinas, Céline ; Needham, Dale ; Slooter, Arjen J.C. ; Pandharipande, Pratik P. ; Watson, Paula L. ; Weinhouse, Gerald L. ; Nunnally, Mark E. ; Rochwerg, Bram ; Balas, Michele C. ; van den Boogaard, Mark ; Bosma, Karen J. ; Brummel, Nathaniel E. ; Chanques, Gerald ; Denehy, Linda ; Drouot, Xavier ; Fraser, Gilles L. ; Harris, Jocelyn E. ; Joffe, Aaron M. ; Kho, Michelle E. ; Kress, John P. ; Lanphere, Julie A. ; McKinley, Sharon ; Neufeld, Karin Jane ; Pisani, Margaret A. ; Payen, Jean Francois ; Pun, Brenda T. ; Puntillo, Kathleen A. ; Riker, Richard R. ; Robinson, Bryce R.H. ; Shehabi, Yahya ; Szumita, Paul M. ; Winkelman, Chris ; Centofanti, John E. ; Price, Carrie ; Nikayin, Sina ; Misak, Cheryl J. ; Flood, Pamela D. ; Kiedrowski, Ken ; Alhazzani, Waleed. / Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. In: Critical care medicine. 2018 ; Vol. 46, No. 9. pp. e825-e873.
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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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TY - JOUR

T1 - Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

AU - Devlin, John W.

AU - Skrobik, Yoanna

AU - Gélinas, Céline

AU - Needham, Dale

AU - Slooter, Arjen J.C.

AU - Pandharipande, Pratik P.

AU - Watson, Paula L.

AU - Weinhouse, Gerald L.

AU - Nunnally, Mark E.

AU - Rochwerg, Bram

AU - Balas, Michele C.

AU - van den Boogaard, Mark

AU - Bosma, Karen J.

AU - Brummel, Nathaniel E.

AU - Chanques, Gerald

AU - Denehy, Linda

AU - Drouot, Xavier

AU - Fraser, Gilles L.

AU - Harris, Jocelyn E.

AU - Joffe, Aaron M.

AU - Kho, Michelle E.

AU - Kress, John P.

AU - Lanphere, Julie A.

AU - McKinley, Sharon

AU - Neufeld, Karin Jane

AU - Pisani, Margaret A.

AU - Payen, Jean Francois

AU - Pun, Brenda T.

AU - Puntillo, Kathleen A.

AU - Riker, Richard R.

AU - Robinson, Bryce R.H.

AU - Shehabi, Yahya

AU - Szumita, Paul M.

AU - Winkelman, Chris

AU - Centofanti, John E.

AU - Price, Carrie

AU - Nikayin, Sina

AU - Misak, Cheryl J.

AU - Flood, Pamela D.

AU - Kiedrowski, Ken

AU - Alhazzani, Waleed

PY - 2018/9/1

Y1 - 2018/9/1

N2 - 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.

AB - 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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