Pain and Delirium Guidelines 2013

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.

Assessment of pain

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 in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report and in whom motor function is intact and behaviors are observable.

Vital signs alone should not be used to assess a patients pain level but should only be used as a cue to further assessment.

Treatment of pain

We suggest that for other types of invasive and potentially painful procedures in adult ICU patients, preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered to alleviate pain.

We recommend that intravenous (IV) opioids be considered as the first-line drug class of choice to treat non-neuropathic pain in critically ill patients.

It is also suggested that non opioid analgesics be considered to reduce the doses of opioids.

We provide no recommendation for using a lumbar epidural over parenteral opioids for postoperative analgesia in patients undergoing abdominal aortic aneurysm surgery, due to a lack of benefit of epidural over parenteral opioids in this patient population.

We provide no recommendation for the use of thoracic epidural analgesia in patients undergoing either intrathoracic or nonvascular abdominal sur- gical procedures, due to insufficient and conflicting evidence for this mode of analgesic delivery in these patients.

Agitation and sedation

We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated.

There is acknowledgement that light levels of sedation can increase physiologic stress, but this is countered by the fact that light levels of sedation improves outcomes.

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.

There is no recommendation for the use of objective measurements such as auditory evoked potentials. There is also a preference for non benzodiazepines.

Delirium

Delirium is associated with increased mortality in adult ICU patients.
Delirium is associated with prolonged ICU and hospital LOS in adult ICU patients.
Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients.

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 in adult ICU patients.

Benzodiazepines maybe a risk factor for delirium, but there seems to be little data between the use of propofol and delirium.

Treatment of delirium

We recommend performing early mobilisation of adult ICU patients whenever feasible to reduce the incidence and duration of delirium.
We provide no recommendation for using a pharmacologic delirium prevention protocol in adult ICU patients, as no compelling data demonstrate that this reduces the incidence or duration of delirium in these patients.

Do not suggest use of atypical antipsychotics or haloperidol for the treatment of delirium.

We suggest that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients.

Strategies for managing Pain, Agitation and Delirium to improve ICU outcomes.

We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients.
We recommend promoting sleep in adult ICU patients by optimising patients’ environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patients’ sleep cycles.