The above algorithm is developed based on the society of critical care medicine PADIS guidelines with overall objectives to:
Address pain first and use "analgosedation".
Minimize the use of opioids through a multimodal approach to pain management
Minimize the use of sedatives through the use of light sedation and daily awakening trials
Minimize the use of benzodiazepines and use dexmedetomidine or propofol for light sedation and propofol for deep sedation.
Prevent ICU delirium through a multimodal approach
Implement early mobilization and rehabilitation programs.
Promote sleep and improve sleep quality.
PAIN
In order to reduce sedative requirements, duration of mechanical ventilation, ICU length of stay (LOS), and pain intensity in critically ill adults, the society of critical care medicine suggests that a protocol-based approach be implemented. This suggestion infers that hospitals should have an assessment-driven protocol encompassing regular pain and sedation assessments via validated tools, and clear guidance on medication selection and dosage levels, with the priority being given to treating pain over administering sedatives. Protocol-based (analgesia/analgosedation) pain and sedation assessment and management programs have been shown to reduce the need for sedatives, duration of mechanical ventilation, ICU length of stay (LOS), and pain intensity compared with usual therapy.
Opioids are commonly used for pain management in ICU settings, but their side effects (such as sedation, delirium, respiratory depression, ileus, and immunosuppression) may lead to an increased length of stay in the ICU or worsen post-ICU patient outcomes. It is suggested that multimodal pharmacotherapy be used as part of an analgesia-first approach so opioid use can be spared or minimized.
Acetaminophen in combination with an opioid, or nefopam as a replacement for opioids can help lower pain intensity and the amount of opioids used for pain management with critically ill adults. In postsurgical adults who are admitted to the ICU, low-dose ketamine (1–2 µg/kg/hr) can be used in addition to opioids as a way of seeking reduced opioid consumption. For neuropathic pain, combining opioids with neuropathic pain medication (e.g., gabapentin, carbamazepine, or pregabalin) can be more effective in adults who are critically ill.
Sedation
Sedative agents may have an impact on short-term outcomes (length of stay in ICU or duration of mechanical ventilation ), and can have important effects on post-ICU outcomes including 90-day mortality, physical functioning, neurocognitive function, and psychological states. The SCCM guideline suggests targeting a light level of sedation or using daily awakening trials and minimizing the use of benzodiazepine to improve short-term and long-term outcomes.
Multiple studies have found that patients who were lightly sedated (with a RASS score of –2 to +1) had a shorter time to extubation and lower rate of tracheostomies. Light sedation did not lead to a reduced 90-day mortality rate, delirium prevalence, posttraumatic stress disorder incidence, or self-extubations. However, no RCTs have been conducted yet to compare the impact of light versus deep sedation on cognitive or physical functioning.
Propofol use resulted in a shorter time to light sedation and extubation when compared with benzodiazepine. Dexmedetomidine was associated with a shorter duration of mechanical ventilation and ICU stay than benzodiazepine infusion. Additionally, there was a significant reduction in delirium amongst dexmedetomidine users throughout their ICU stay according to the three RCTs that evaluated this outcome. Both propofol and dexmedetomidine can be feasibly used in practice, however dexmedetomidine may not be the best sedative when deep sedation is needed.
Delirium
Delirium is a common condition in critically ill adults, characterized by a disturbed mental state and confused thinking. Delirium can be worrying for patients and relatives and is linked with worse cognitive outcomes, increased length of stay in ICU and hospital, as well as greater costs.
To decrease the rate of delirium, it is recommend to usie multicomponent interventions. A few examples are: providing clocks and calendars to help with orientation and cognition; reducing exposure to light and noise during nighttime hours to improve sleep; lessening sedation levels to increase wakefulness; utilizing rehabilitation/mobilization therapy to reduce immobility; lastly, if someone suffers from impairments in hearing or vision, enabling the use of devices such as hearing aids or glasses.
The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle (ABCDE) was significantly associated with less delirium in a before-after study that used a multiple intervention approach. A study evaluating the before-after effects of a revised and expanded ABCDEF bundle--which places an emphasis on "A," or assessment and treatment of pain, as well as "F," for family engagement--found that these improvements were significantly linked to reduced mortality rates and more ICU days without coma or delirium. The analysis also showed that there were no adverse effects associated with the nonpharmacologic interventions studied.
Immobility (Rehabilitation and Mobility)
ICUAW (ICU-acquired muscle weakness) affects 25-50% of patients who were critically ill at some point during their hospital stay and may cause long-term consequences like physical impairment and decreased quality of life. Bed rest is one key factor that contributes to this condition. Rehabilitation/mobilization may be beneficial as a delirium management strategy and may decrease the rate of ICUAW. Furthermore, important associations exist between patients' use of analgesics and sedatives, their pain and sedation levels, and whether they participate in rehabilitation/mobilization activities in the ICU.
Rehabilitation is a process that helps people with conditions improve their functioning and reduce disability. Mobilization is one type of intervention within rehabilitation that helps patients move and spend energy to achieve better patient outcomes. Five critical outcomes were evaluated in a total of 16 RCTs of rehabilitation and mobilization of critically ill patients. Results showed improved muscle strength at ICU discharge and significantly reduced duration of mechanical ventilation. There was no effect on hospital mortality or short-term physical functioning measures with a very low incidence of adverse events for patients.
Sleep Disruption
Sleep disruption is a common and distressing complaint for many critically ill patients in the ICU. This can include severe sleep fragmentation, abnormal circadian rhythms, increased light sleep (stage N1), and decreased slow-wave (stage N3) and rapid eye movement (REM) sleep. The interactions between medications, critical illness, delirium, cerebral perfusion, and sleep is intricate. Beyond emotional stress, it has been theorized that sleep deprivation leads to ICU delirium, prolonged duration of mechanical ventilation usage, impaired immune function
It is suggested to use a sleep-promoting, multicomponent protocol in critically ill adults. This protocol would include interventions such as reducing noise and light exposure during nighttime hours, lessening sedation levels to increase wakefulness, and utilizing rehabilitation/mobilization therapy to reduce immobility.
Although there is a lack of data regarding the use of melatonin in promoting night sleep, it is relatively inexpensive and has few side effects. Dexmedetomidne has shown to improve sleep quality and architecture in clinical studies. If a sedative is necessary, then dexmedetomidine may be the best option with the added benefit of improving sleep quality.
Pain, immobility, and sleep disruption are common complaints among critically ill patients. These issues can lead to delirium, ICU-acquired muscle weakness, and impaired immune function. A multicomponent protocol that includes interventions such as reducing noise and light exposure during nighttime hours, lessening sedation levels to increase wakefulness, and utilizing rehabilitation/mobilization therapy may help reduce these problems. Melatonin and dexmedetomidine may also be helpful in promoting sleep and reducing delirium.
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Reference
Devlin, John W. PharmD, FCCM (Chair)1,2; Skrobik, Yoanna MD, FRCP(c), MSc, FCCM (Vice-Chair)3,4; Gélinas, Céline RN, PhD5; Needham, Dale M. MD, PhD6; Slooter, Arjen J. C. MD, PhD7; Pandharipande, Pratik P. MD, MSCI, FCCM8; Watson, Paula L. MD9; Weinhouse, Gerald L. MD10; Nunnally, Mark E. MD, FCCM11,12,13,14; Rochwerg, Bram MD, MSc15,16; Balas, Michele C. RN, PhD, FCCM, FAAN17,18; van den Boogaard, Mark RN, PhD19; Bosma, Karen J. MD20,21; Brummel, Nathaniel E. MD, MSCI22,23; Chanques, Gerald MD, PhD24,25; Denehy, Linda PT, PhD26; Drouot, Xavier MD, PhD27,28; Fraser, Gilles L. PharmD, MCCM29; Harris, Jocelyn E. OT, PhD30; Joffe, Aaron M. DO, FCCM31; Kho, Michelle E. PT, PhD30; Kress, John P. MD32; Lanphere, Julie A. DO33; McKinley, Sharon RN, PhD34; Neufeld, Karin J. MD, MPH35; Pisani, Margaret A. MD, MPH36; Payen, Jean-Francois MD, PhD37; Pun, Brenda T. RN, DNP23; Puntillo, Kathleen A. RN, PhD, FCCM38; Riker, Richard R. MD, FCCM29; Robinson, Bryce R. H. MD, MS, FACS, FCCM39; Shehabi, Yahya MD, PhD, FCICM40; Szumita, Paul M. PharmD, FCCM41; Winkelman, Chris RN, PhD, FCCM42; Centofanti, John E. MD, MSc43; Price, Carrie MLS44; Nikayin, Sina MD45; Misak, Cheryl J. PhD46; Flood, Pamela D. MD47; Kiedrowski, Ken MA48; Alhazzani, Waleed MD, MSc (Methodology Chair)16,49. 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: September 2018 - Volume 46 - Issue 9 - p e825-e873
doi: 10.1097/CCM.0000000000003299