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 M.
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 J.
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
N1 - Funding Information:
Dr. Devlin has received research funding from the National Institute of Aging, National Heart, Lung and Blood Institute, and AstraZeneca Pharmaceuticals, he is on the editorial board of Critical Care Medicine, and he is the president of the American Delirium Society. Dr. Skrobik participates in the ATS and the American College of Chest Physicians (ACCP), and she is on the editorial board for Intensive Care Medicine and Chest. Dr. Needham is a principal investigator on a National Institutes of Health (NIH)-funded, multicentered randomized trial (R01HL132887) evaluating nutrition and exercise in acute respiratory failure and, related to this trial, is currently in receipt of an unrestricted research grant and donated amino acid product from Baxter Healthcare and an equipment loan from Reck Medical Devices to two of the participating study sites, external to his institution. Dr. Slooter has disclosed that he is involved in the development of an electroencephalogram-based delirium monitor, where any (future) profits from electroencephalogram-based delirium monitoring will be used for future scientific research only. Dr. Pandharipande’s institution received funding from Hospira (research grant to purchase study drug [dexmedetomidine] in collaboration with a NIH-funded RO1 study) and disclosed that he is the past president of the American Delirium Society. Dr. Nunnally participates in the Society of Critical Care Anesthesiologists, International Anesthesia Research Society, and American Society of Anesthesiology (ASA). Dr. Rochwerg participates as a guideline methodologist for other organizations (i.e., American Thoracic Society [ATS] and Canadian Blood Service) in addition to the Society of Critical Care Medicine. Dr. Balas received funding from Select Medical (primary investigator on research study exploring Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials and Spontaneous Breathing Trials, Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment bundle adoption). Dr. Bosma received funding from the Canadian Institutes of Health Research (CIHR) where she is the primary investigator of an industry partnered research grant with Covidien as the industry partner of the CIHR for a study investigating proportional assist ventilation versus pressure support ventilation for weaning from mechanical ventilation. Dr. Brummel participates in the ATS (Aging and Geriatrics Working Group CoChair) and ArjoHuntleigh (advisory board activities). Dr. Chanques participates in other healthcare professional organization activities. Dr. Denehy participates in the Australian Physiotherapy Association. Dr. Drouot participates in the French Sleep Society and the French Institute for Sleep and Vigilance. Mr. Joffe participates on committees for ASA. Dr. Kho received funding from Restorative Therapies (Baltimore, MD) (loaned two supine cycle ergometers for ongoing research). Dr. Kress received funding from a dexmedetomidine speaker program, he participates in the ATS and ACCP, and he has served as an expert witness in medical malpractice. Dr. McKinley participates in the American Association of Critical-Care Nurses (AACN) (editorial board of American Journal of Critical Care) and the American Heart Association (editorial board of Journal of Cardiovascular Nursing). Dr. Neufeld participates in the American Delirium Society (board member). Dr. Pisani participates in the ACCP (Chair Scientific Programming Committee and Steering Committee Women’s Health Network). Dr. Payen received funding from Baxter SA (distributor of dexmedetomidine in France), and he has received honorariums from Baxter SA (oral presentations of dexmedetomidine). Ms. Pun participates as an AACN speaker at the National Conference. Dr. Puntillo participates in other healthcare professional organizations (e.g., AACN). Dr. Robinson participates in the Easter Association for the Surgery of Trauma, American College of Surgeons, and American Association for the Surgery of Trauma. Dr. Shehabi received funding from an unrestricted research grant (drug supply) from Pfizer (Hospira) and Orion Pharma to an ongoing multinational multicenter study. Mr. Szumita participates in several committees for the American Society of Health-System Pharmacists. Ms. Price has disclosed that she is a medical librarian working at Johns Hopkins University, and she consults as an information specialist to the Cochrane Urology Review Group. Dr. Flood participates on the Society of Obstetric Anesthesia and Perinatology research committee and the ASA Chronic Pain Committee. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Publisher Copyright:
Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
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.
KW - Delirium
KW - guidelines
KW - immobility
KW - intensive care
KW - mobilization
KW - pain
KW - sedation
KW - sleep
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U2 - 10.1097/CCM.0000000000003299
DO - 10.1097/CCM.0000000000003299
M3 - Article
C2 - 30113379
AN - SCOPUS:85060764483
SN - 0090-3493
VL - 46
SP - E825-E873
JO - Critical care medicine
JF - Critical care medicine
IS - 9
ER -