Society for Critical Care Medicine has released it’s 2018 Guidelines on Care of Adult Patients in the ICU. The aim is to update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. A lot of effort has gone into the development of guidelines with the participation of Content experts, methodologists, and ICU survivors who represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). The guidelines have appeared in the Journal of Critical Care Medicine.
a) Pain Management in ICU
- Management of pain for adult ICU patients should be guided by routine pain assessment and pain should be treated before a sedative agent is considered.
- An assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults is recommended.
- Use acetaminophen as an adjunct to an opioid to decrease pain intensity and opioid consumption for pain management in critically ill adults.
- Use nefopam either as an adjunct or replacement for an opioid to reduce opioid use and their safety concerns for pain management in critically ill adults.
- Use low-dose ketamine (0.5 mg/kg IVP x 1 followed by 1-2 μg/kg/min infusion) as an adjunct to opioid therapy when seeking to reduce opioid consumption in postsurgical adults admitted to the ICU.
- Use a neuropathic pain medication (eg, gabapentin, carbamazepine, and pregabalin) with opioids for neuropathic pain management in critically ill adults.
- IV lidocaine should not be routinely used as an adjunct to opioid therapy for pain management in critically ill adults.
- Use an opioid (eg, fentanyl, hydromorphone, morphine, and remifentanil) at the lowest effective dose, for procedural pain management in critically ill adults.
- Use an NSAID administered IV, orally, or rectally as an alternative to opioids for pain management during discrete and infrequent procedures in critically ill adults.
- Do not use inhaled volatile anaesthetics for procedural pain management in critically ill adults.
- Do not use either local analgesia or nitrous oxide for pain management during chest tube removal (CTR) in critically ill adults.
b) Agitation/Sedation Management in ICU
- Light sedation (vs deep sedation) should be used in critically ill, mechanically ventilated adults.
- Using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults is recommended.
c) Delirium Management in ICU
- Critically ill adults should be regularly assessed for delirium using a valid tool.
- Use dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation.
- Use a multicomponent, nonpharmacologic intervention that is focused on (but not limited to) reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision in critically ill adults.
- Do not use haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults.
- Do not routinely use haloperidol, an atypical antipsychotic, or a statin to treat delirium.
- Do not use bright-light therapy to reduce delirium in critically ill adults.
c) Immobility Management in ICU
- Perform rehabilitation or mobilization in critically ill adults.
d) Sleep Disruption Management in ICU
- Use a sleep-promoting protocol in critically ill adults.
- Use assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.
- Use either an NIV (noninvasive ventilation)-dedicated ventilator or a standard ICU ventilator for critically ill adults requiring NIV to improve sleep.
- Do not use propofol to improve sleep in critically ill adults.
- Do not routinely use physiologic sleep monitoring clinically in critically ill adults.
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Dr. Kamal Kant Kohli
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