Journal of Critical Care, Год журнала: 2018, Номер 48, С. 372 - 384
Опубликована: Сен. 29, 2018
Язык: Английский
Critical Care Medicine, Год журнала: 2018, Номер 46(9), С. e825 - e873
Опубликована: Авг. 16, 2018
To update and expand the 2013 Clinical Practice Guidelines for Management of Pain, Agitation, Delirium in Adult Patients ICU.Thirty-two international experts, four methodologists, critical illness survivors met virtually at least monthly. All section groups gathered face-to-face annual Society Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict interest policy was developed a priori enforced throughout process. Teleconferences electronic discussions among subgroups whole panel were part guidelines' development. general content review completed by all members January 2017.Content ICU represented each five sections guidelines: Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), Sleep (disruption). Each created Population, Intervention, Comparison, Outcome, nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, patients prioritized importance. For Outcome question, searched best available evidence, determined its quality, formulated recommendations as "strong," "conditional," or "good" practice statements Grading Recommendations Assessment, Development Evaluation principles. In addition, evidence gaps caveats explicitly identified.The Agitation/Sedation, (disruption) issued 37 (three strong 34 conditional), two good statements, 32 ungraded, nonactionable statements. Three from patient-centered question list remained without recommendation.We found substantial agreement large, interdisciplinary cohort experts regarding supporting recommendations, remaining literature assessment, prevention, treatment critically ill adults. Highlighting this research needs will improve management provide foundation improved outcomes science vulnerable population.
Язык: Английский
Процитировано
2892
Intensive Care Medicine, Год журнала: 2016, Номер 42(6), С. 962 - 971
Опубликована: Апрель 13, 2016
Язык: Английский
Процитировано
360
DOAJ (DOAJ: Directory of Open Access Journals), Год журнала: 2015, Номер 13, С. Doc19 - Doc19
Опубликована: Янв. 1, 2015
In 2010, under the guidance of DGAI (German Society Anaesthesiology and Intensive Care Medicine) DIVI Interdisciplinary Association for Emergency Medicine), twelve German medical societies published "Evidence- Consensus-based Guidelines on Management Analgesia, Sedation Delirium in Care". Since then, several new studies publications have considerably increased body evidence, including recommendations from American College Critical Medicine (ACCM) conjunction with (SCCM) Health-System Pharmacists (ASHP) 2013. For this update, a major restructuring extension guidelines were needed order to cover aspects treatment, such as sleep anxiety management. The literature was systematically searched evaluated using criteria Oxford Center Evidence Based Medicine. evidence used formulate these reviewed approved by representatives 17 national societies. Three grades recommendation follows: Grade "A" (strong recommendation), "B" (recommendation) "0" (open recommendation). result is comprehensive, interdisciplinary, consensus-based set level 3 guidelines. This publication designed all ICU professionals, takes into account critically ill patient populations. It represents guide symptom-oriented prevention, diagnosis, treatment delirium, anxiety, stress, protocol-based analgesia, sedation, sleep-management intensive care medicine. Die vorherige Version der S3-Leitlinie „Analgesie, Sedierung und Delirmanagement Intensivmedizin“ wurde 2010 unter Federführung Deutschen Gesellschaft für Anästhesiologie Intensivmedizin (DGAI) Interdisziplinären Vereinigung Intensiv- Notfallmedizin (DIVI) publiziert. Neue Evidenz aus Studien ebenso wie neue Leitlinien, u.a. die 2013 erschienene Leitlinie U.S.-amerikanischen (SCCM), des (ASHP), gaben nicht nur Anlass zu einem Update deutschen Empfehlungen von 2010. Für Fortschreibung wurden eine Neuformulierung klinisch relevanten Schlüsselfragen signifikante Erweiterung um Facetten Behandlung, zum Beispiel das Schlafmanagement, notwendig. Dazu systematisch gesuchte Literatur nach Kriterien Centre bewertet. Der enorme Evidenzkörper bildete Grundlage Empfehlungen, Mandatsträgern Fachgesellschaften konsentiert wurden. den „A“ (starke Empfehlung), „B“ (Empfehlung) „0“ (offene Empfehlung) gewählt. Als Ergebnis dieses Prozesses liegt nun weltweit umfassendste, interdisziplinär erarbeitete evidenz- konsensbasierte Stufe vor. richtet sich an alle auf Intensivstation tätigen Berufsgruppen, berücksichtigen intensivmedizinisch-behandelten Patientengruppen. Sie stellt einen Leitfaden zur symptomorientierten Prävention, Diagnostik Therapie Delir, Angst, Stress protokollbasierten Analgesie, dem Schlafmanagement Erwachsene Kinder dar.
Язык: Английский
Процитировано
312
Critical Care Clinics, Год журнала: 2017, Номер 33(3), С. 461 - 519
Опубликована: Июнь 8, 2017
Язык: Английский
Процитировано
262
Critical Care Medicine, Год журнала: 2018, Номер 46(9), С. 1532 - 1548
Опубликована: Авг. 16, 2018
Clinical practice guidelines are published and promoted, often by professional societies, because they provide a current transparently analyzed review of relevant research written with the aim to guide clinical practice. The 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), Sleep (disruption) (PADIS) (1) first 1) builds on this mission updating 2013 PAD (2); 2) adding two inextricably related care topics (immobility sleep); 3) including patients as collaborators coauthors; 4) inviting panelists from high-income countries an early step toward incorporating more diverse practices expertise global critical community. Readers will find rationales for 37 recommendations (derived actionable Patient Intervention Comparison Outcome questions), good statements, 32 statements nonactionable, descriptive questions which Grading Recommendations Assessment, Development Evaluation methodology was not used) across five guideline sections. Only strong; most conditional. Compared strong recommendation (most desirable clinicians), conditional apply most, but all critically ill adults, made when evidence is conflicting, low quality, insufficient and/or applicable just one patient subgroup, potential benefits require weighing almost equal risks. supplemental digital figures tables linked full background how were established, profiles evidence, “evidence decision” used develop recommendations, voting results. We also describe gaps that prevented us fully addressing priority questions. sections interrelated, thus, should be considered in its entirety rather than discrete or distinct recommendations. A separate PADIS implementation integration article (3) detailed description methodologic innovations characterize these (4) have been separately. This executive summary highlights 18 section leaders chair/vice-chair felt would greatest interest ICU clinicians. All (including those highlighted summary) found Table 1. ungraded 2.TABLE 1.: Summary Actionable Questions RecommendationsTABLE 2.: Descriptive Ungraded StatementsRECOMMENDATIONS Pain management complex has many origins. consistent approach pain assessment paramount, particularly given unique features inherent adults. In population, whose reference standard measure patient’s self-report, inability communicate clearly does negate experience need appropriate (5). Severe negatively affects adults (6) beyond unpleasant dimension. Implementation assessment-driven standardized protocols improves outcomes (5,6). Carefully titrated analgesic dosing important balancing versus risks opioid exposure (7–10). Protocol-Based Assessment Management Question. Should we use protocol-based (analgesia/analgosedation) programs adult compared usual care? Good statement. guided routine treated before sedative agent considered. Recommendation. suggest using assessment-driven, protocol-based, stepwise sedation (conditional recommendation, moderate quality evidence). Remarks. For analgosedation defined either analgesia-first (i.e., [usually opioid] reach goal) analgesia-based instead goal). infers institutions protocol mandates regular validated tools, provides clear guidance medication choice dosing, makes treating over providing sedatives. Our pooled analysis suggests therapy reduce requirements, duration mechanical ventilation, length stay (LOS), intensity (5,11–31). Panel members issued observed outcomes. Pharmacologic Adjuvants Opioid Therapy. Opioids remain mainstay settings; however, their side effects preoccupy clinicians safety concerns, such sedation, delirium, respiratory depression, ileus, immunosuppression, may increase LOS worsen post-ICU outcome. panel generally supports multimodal pharmacotherapy component spare/minimize optimize analgesia rehabilitation (32), described below. Acetaminophen acetaminophen adjunct (vs alone) adults? decrease consumption very When placebo perioperative period, IV 1 g every 6 hours associated reduced 24 after surgery (33,34). risk acetaminophen-associated hypotension preclude some (35). Given findings, (IV, oral, rectal) patients, at higher opioid-associated concerns. Nefopam nefopam replacement (if feasible) concerns nonopioid analgesic; 20-mg dose effect comparable mg morphine (36). advantages opioids other analgesics (e.g., cyclooxygenase selective nonsteroidal anti-inflammatory drugs) it no detrimental hemostasis, gastric mucosal integrity, renal function, vigilance, ventilatory drive, intestinal motility. However, can tachycardia, glaucoma, seizure, delirium. Although available United States Canada, low-cost drug nearly 30 countries. cardiac nefopam’s resembles fentanyl delivered patient-controlled analgesia, less nausea (37). Ketamine ketamine low-dose (1–2 µg/kg/hr) seeking postsurgical admitted ketamine, although shown requirements among abdominal ICU, improve patients’ self-reported (38). Reduced only surrogate better patient-centered frequency nausea, hallucinations, hypoventilation, pruritus, sedation) similar between control groups. indirect randomized controlled trials (RCTs) non-ICU role adjuvant therapy, evaluating indication currently remains limited. Neuropathic medications neuropathic gabapentin, carbamazepine, pregabalin) Recommendations. recommend (strong cardiovascular evaluated Guillain-Barré syndrome who recently undergone (39–42). Across both populations, significantly within initiation. Among did affect time extubation (41,42). estimated agents had negligible costs widely possible cognitive could patients. These drugs ability swallow enteral access. Agitation/Sedation Sedatives frequently administered relieve anxiety prevent agitation-related harm (2). predispose increased morbidity (43–46). addition healthcare provider determining specific use, subsequent status continuously assessed valid reliable scales (47–49). (2) suggested targeting light levels daily awakening (44,50–52), minimizing benzodiazepines (53), short-term ventilation LOS). addition, delivery paradigms 90-day mortality, physical functioning, neurocognitive psychologic Light Sedation Does deep sedation), regardless agent(s) used, mechanically ventilated ill, guidelines’ statement maintaining level shortened previous Richmond Agitation-Sedation Scale (RASS) scale score greater –2 eye opening least 10 seconds (50), probably deeper required ICU. No universally accepted definition exists. studies scales, RASS (48), +1 (or equivalent scales) panel. differ consideration discharge measurements. shorter (51,54,55) tracheostomy rate (50). reduction mortality (44,50,53), delirium prevalence (44,54), posttraumatic stress disorder incidence (31,50), self-extubation (44,50,53,55). RCTs impact functioning. Choice Sedative. indication, goal, pharmacology, acquisition cost determinants choosing agent. (conditionally) nonbenzodiazepine sedatives (either propofol dexmedetomidine) preferable benzodiazepine midazolam lorazepam) improved outcomes, LOS, (1), short- long-term our evaluation. Questions. propofol, benzodiazepine, dexmedetomidine, dexmedetomidine three analyses deemed critical. studies, continuous infusions intermittent boluses. combined lorazepam. 4 8–12 (one nursing shift) clinically significant. seven (56–62) nine (56,57,61, 67). RCT difference (61). data self-extubation, CI outcome wide unclear if resulted reintubation). Dexmedetomidine, infusion study boluses), (53,67–70) (53,68,71). Delirium four (53,68,69,71); Midazolam Dexmedetomidine (MIDEX) (69) trial once, 48 discontinuation. significant remaining bid throughout (53, 68, 71). Safety Efficacy With (53) Maximizing Targeted Reducing Neurological Dysfunction (MENDS) (68) demonstrated bradycardia group; neither intervention bradycardia. comparing propofol; none any (67, 69, 72). single RCT, Propofol (PRODEX) study, showed decreased point cessation (69). Patients effectively sedated differences reported Economic considerations surrounding now lower initially studied. Incorporating into likely acceptable feasible, whereas recognizing preferred (with without neuromuscular blockade) required. judged undesirable consequences balanced; therefore, common diagnosis; detect presence screening tools Confusion Method (CAM-ICU) Intensive Care Screening Checklist (73,74). disturbing affected relatives worse outcome, hospital (75). Multicomponent Nonpharmacologic Prevention Treatment multicomponent, nonpharmacologic strategy strategy) focused (but limited to) reducing modifiable factors improving cognition, optimizing sleep, mobility, hearing, vision multicomponent interventions include strategies shorten reorientation, stimulation, clocks), sleep noise), wakefulness immobility rehabilitation/mobilization), hearing visual impairment enable devices aids glasses). randomized, bundle interventions. Overall, (76, 80). Further, developed (79), (76), (77). Another multiple approach, Awakening Breathing Coordination, monitoring/management, Early exercise/mobility (ABCDE) bundle, before-after (81). revised expanded ABCDEF (which included focus “A,” treatment pain, “F,” family engagement) larger, multicenter, before-after, cohort where CAM-ICU, adjusted improvements compliance days coma (82). Adverse studies. pharmacologic agent) “treat” delirium? Antipsychotic/Statin routinely haloperidol, atypical antipsychotic, 3-hydroxy-3-methylglutaryl coenzyme reductase inhibitor statin) treat total six RCTs, haloperidol (n = (83,84), antipsychotics (quetiapine [n 1] [83], ziprasidone [81], olanzapine [84]), statin (rosuvastatin) (87), informed question. typical mortality. discourages “routine” antipsychotic warranted, despite lack distress secondary symptoms hallucination delusion-associated fearfulness delirious agitation physically harmful themselves others (88). discontinued immediately following resolution distressful symptoms. precluding weaning/extubation dexmedetomidine’s ventilator liberation (89). It screened 21,500 intubated 15 ICUs enroll 71 terminated allocated funding (from manufacturer) expended placebo) small, statistically significant, ventilator-free 7 randomization, disposition location discharge. (Rehabilitation Mobility) Survivors illness sequelae, ICU-acquired muscle weakness (ICUAW). ICUAW occur 25–50% (90) impairments survival, life (91–93). One factor bed rest (91,94). safety, feasibility, mobilization setting means mitigate impaired As (2), rehabilitation/mobilization beneficial strategy. Furthermore, associations exist practices, whether participate (95). (performed in-bed out-of-bed) patient, family, health system care, different intervention, placebo, sham intervention? performing Rehabilitation “set designed functioning disability individuals condition.” Mobilization type facilitates movement expends energy goal duration, frequency, later onset. influenced feasibility-related issues, variability availability staffing resources perform ICUs. identified 16 (96–111) met eligibility criteria Rehabilitation/mobilization strength (99–101,103,105,111) (96–100,102,104, 107). moderate, improvement health-related measured short form 36 instrument 2 months (103,107–109). (96,98–109,112) measures (96,102,105,107,110). adverse events based eight observational Three additional (cognitive mental health, timing return work economic outcomes) due data. key stakeholders, cost-effective preliminary (112), along discussion representative), value (113). small benefit overall agreed outweigh consequences. Disruption Poor complaint source (114,115). disruption severe characterized fragmentation, abnormal circadian rhythms, (stage N1), slow-wave N3) rapid (REM) (116). interplay medications, illness, cerebral perfusion, complex, increasing research. emotional distress, deprivation hypothesized contribute (117), prolonged (116), deranged immune function (118), dysfunction. Interventions sleep-promoting melatonin, propofol) medication) Melatonin make regarding melatonin (no placebo-controlled, 60) night-time administration reviewed (119–121). Two (120,121) determined warrant recommendation. manufacture Food Drug Administration regulated; consistency product hospitals formulary. is, relatively few mild headache) inexpensive. night 74) (122) nonmechanically requiring (123). stage studies; fragmentation REM sleep. third, trial, analysis, corroborated findings regard architecture noted preserved day-night cycling overnight (124). If indicated hemodynamically stable overnight, reasonable option architecture. (125,126), (127). demonstrable occurred placebo. suppression, hemodynamic effects, sometimes necessitating ventilation. against sole purpose intend address procedural sedation. Sleep-Promoting Protocol sleep-promoting, eligible inclusion varied components: offering earplugs eyeshades (128–131) relaxing music (128,130). compromising combination (128,131), specified discouraged sedating known alter precipitate introduced stages 5-month period (128). applied target subset poor quality. open-heart earplugs, eyeshades, (129). Of before-and-after mixed population (131), Pooled protocol. Which interventions, combinations effective cannot discerned above SUMMARY Under auspices Society Critical Medicine, aims meaningful novel aspects, section, clinicians, decision makers consider rationales, fueled rigorous evaluation, debate, discussion, circled back bedside experience—and perspective what best patient—held involved producing guidelines. believe foster excellent agitation/sedation, immobility, stimulate completion pragmatic, each domains.
Язык: Английский
Процитировано
262
Pediatric Critical Care Medicine, Год журнала: 2022, Номер 23(2), С. e74 - e110
Опубликована: Фев. 1, 2022
A guideline that both evaluates current practice and provides recommendations to address sedation, pain, delirium management with regard for neuromuscular blockade withdrawal is not currently available.To develop comprehensive clinical guidelines critically ill infants children, specific attention seven domains of care including sedation/agitation, iatrogenic withdrawal, blockade, delirium, PICU environment, early mobility.The Society Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, Delirium in pediatric patients consideration the Environment Early Mobility Guideline Taskforce was comprised 29 national experts who collaborated from 2009 2021 via teleconference and/or e-mail at least monthly planning, literature review, development, revision, approval. The full taskforce gathered annually in-person during Congress progress reports further strategizing final face-to-face meeting occurring February 2020. Throughout this process, standard operating procedures Manual Guidelines development adhered to.Taskforce content separated into subgroups addressing pain/analgesia, tolerance/iatrogenic environment (family presence sleep hygiene), mobility. Subgroups created descriptive actionable Population, Intervention, Comparison, Outcome questions. An experienced medical information specialist developed search strategies identify relevant between January 1990 reviewed literature, determined quality evidence, formulated classified as "strong" "we recommend" or "conditional" suggest." Good statements were used when indirect evidence supported benefit no minimal risk. Evidence gaps noted. Initial by each subgroup revised deemed necessary prior being disseminated voting taskforce. Individuals had an overt potential conflict interest abstained votes. Expert opinion alone substitution a lack evidence.The issued 44 (14 strong 30 conditional) five good statements.The represent list practical assessment, prevention, key aspects critical children. Main areas focus included 1) need routine monitoring agitation, using validated tools, 2) enhanced use protocolized sedation analgesia, 3) recognition importance nonpharmacologic interventions enhancing patient comfort provision.
Язык: Английский
Процитировано
113
Intensive Care Medicine, Год журнала: 2015, Номер 41(6), С. 1048 - 1056
Опубликована: Апрель 17, 2015
Delirium incidence in intensive care unit (ICU) patients is high and associated with poor outcome. Identification of high-risk may facilitate its prevention.To develop validate a model based on data available at ICU admission to predict delirium development during patient's complete stay determine the predictive value this relation time development.Prospective cohort study 13 ICUs from seven countries. Multiple logistic regression analysis was used early prediction (E-PRE-DELIRIC) first two-thirds validated last one-third every participating ICU.In total, 2914 were included. 23.6%. The E-PRE-DELIRIC consists nine predictors assessed admission: age, history cognitive impairment, alcohol abuse, blood urea nitrogen, category, urgent admission, mean arterial pressure, use corticosteroids, respiratory failure. area under receiver operating characteristic curve (AUROC) 0.76 [95% confidence interval (CI) 0.73-0.77] dataset 0.75 (95% CI 0.71-0.79) validation dataset. well calibrated. AUROC increased 0.70 0.67-0.74), for that developed <2 days, 0.81 0.78-0.84), >6 days.Patients' risk length can be predicted using model, allowing preventive interventions aimed reduce severity delirium.
Язык: Английский
Процитировано
172
Critical Care Medicine, Год журнала: 2016, Номер 44(5), С. 992 - 999
Опубликована: Янв. 7, 2016
A systematic review and meta-analysis to assess the efficacy of earplugs as an ICU strategy for reducing delirium.MEDLINE, EMBASE, Cochrane Central Register controlled trials were searched using terms "intensive care," "critical "earplugs," "sleep," "sleep disorders," "delirium."Intervention studies (randomized or nonrandomized) assessing a sleep hygiene in patients admitted critical care environment included. Studies excluded if they included only healthy volunteers, did not report any outcomes interest, contain intervention group crossover studies, published abstract form.Nine between 2009 2015, including 1,455 participants, fulfilled eligibility criteria review. isolated (n = 3), part bundle with eye shades 2), earplugs, shades, additional noise abatement strategies 4). The risk bias was high all studies.Five comprising 832 participants reported incident delirium. Earplug placement associated relative delirium 0.59 (95% CI, 0.44-0.78) no significant heterogeneity (I, 39%; p 0.16). Hospital mortality four 481) 0.77 0.54-1.11; I, 0%; < 0.001). Compliance six 681). mean per-patient noncompliance 13.1% 7.8-25.4) those assigned receive earplugs.Placement ICU, either isolation improvement, is reduction potential effect cointerventions optimal improving on patient-centered remains uncertain.
Язык: Английский
Процитировано
145
Scientific Reports, Год журнала: 2019, Номер 9(1)
Опубликована: Май 29, 2019
Currently, many critical care indices are not captured automatically at a granular level, rather repetitively assessed by overburdened nurses. In this pilot study, we examined the feasibility of using pervasive sensing technology and artificial intelligence for autonomous monitoring in Intensive Care Unit (ICU). As an exemplary prevalent condition, characterized delirious patients their environment. We used wearable sensors, light sound camera to collect data on analyzed collected detect recognize patient's face, postures, facial action units expressions, head pose variation, extremity movements, pressure levels, intensity visitation frequency. found that functional status entailing movement environmental factors including frequency, levels night were significantly different between non-delirious patients. Our results showed critically ill environment is feasible noninvasive system, demonstrated its potential characterizing factors.
Язык: Английский
Процитировано
122
American Journal of Psychiatry, Год журнала: 2019, Номер 176(10), С. 785 - 793
Опубликована: Окт. 1, 2019
Процитировано
105