Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Risk Factors

• Pain at rest is influenced by both psychologic (e.g., anxiety and depression) and demographic (e.g., young age, one or more comorbidities, and history of surgery) factors. (Ungraded)

Self-Report Scales

• A patient’s self-report of pain is the reference standard for pain assessment in patients who can communicate reliably. (Ungraded)

Behavioral Assessment Tools

• Among critically ill adults unable to self-report pain and in whom behaviors are observable, the Behavioral Pain Scale in intubated (BPS) and nonintubated (BPS-NI) patients and the Critical-Care Pain Observation Tool (CPOT) demonstrate the greatest validity and reliability for monitoring pain. (Ungraded)

Proxy Reporters

• When appropriate, and when the patient is unable to self-report, family can be involved in their loved one’s pain assessment process. (Ungraded)

Physiologic Measures

• Vital signs (VS) (i.e., heart rate [HR], BP, respiratory rate [RR], oxygen saturation [Spo2], and end-tidal CO2) are not valid indicators for pain in critically ill adults and should only be used as cues to initiate further assessment using appropriate and validated methods such as the patient’s self-report of pain (whenever possible) or a behavioral scale (i.e., BPS, BPS-NI, CPOT). (Ungraded)

Acetaminophen

• We suggest using acetaminophen as an adjunct to an opioid to decrease pain intensity and opioid consumption for pain management in critically ill adults. (Conditional, Very Low)

Nefopam

• We suggest using nefopam (if feasible) either as an adjunct or replacement for an opioid to reduce opioid use and their safety concerns for pain management in critically ill adults. (Conditional, Very Low)

Ketamine

• We suggest using 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. (Conditional, Very Low)

Neuropathic Pain Medications

• We recommend using a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) with opioids for neuropathic pain management in critically ill adults. (Strong, Moderate), We suggest using a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) with opioids for pain management in ICU adults after cardiovascular surgery. (Conditional, Low)

Lidocaine

• We suggest not routinely using IV lidocaine as an adjunct to opioid therapy for pain management in critically ill adults. (Conditional, Low)

NSAIDs

• We suggest not routinely using a COX-1–selective NSAID as an adjunct to opioid therapy for pain management in critically ill adults. (Conditional, Low)

Opioid Use and Dose

• We suggest using an opioid, at the lowest effective dose, for procedural pain management in critically ill adults. (Conditional, Moderate)

Local Analgesia/Nitrous Oxide

• We suggest not using either local analgesia or nitrous oxide for pain management during CTR in critically ill adults. (Conditional, Low)

Volatile Anesthetics

• We recommend not using inhaled volatile anesthetics for procedural pain management in critically ill adults. (Strong, Very Low)

NSAIDs

• We suggest using an NSAID administered IV, orally, or rectally as an alternative to opioids for pain management during discrete and infrequent procedures in critically ill adults. (Conditional, Low)
• We suggest not using an NSAID topical gel for procedural pain management in critically ill adults. (Conditional, Low)

Cybertherapy/Hypnosis

• We suggest not offering cybertherapy (VR) or hypnosis for pain management in critically ill adults. (Conditional, Very Low)

Massage

• We suggest offering massage for pain management in critically ill adults. (Conditional, Low)

Music

• We suggest offering music therapy to relieve both nonprocedural and procedural pain in critically ill adults. (Conditional, Low)

Cold Therapy

• We suggest offering cold therapy for procedural pain management in critically ill adults. (Conditional, Low)

Relaxation Techniques

• We suggest offering relaxation techniques for procedural pain management in critically ill adults. (Conditional, Very Low)

Protocol-Based Pain Assessment and Management

• 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. (Good Practice Statement)
• We suggest using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults. (Conditional, Moderate)

Light Sedation

• We suggest using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults. (Conditional, Low)

Daily Sedative Interruption/Nurse-Protocolized Sedation

• In critically ill, intubated adults, DSI protocols and NP-targeted sedation can achieve and maintain a light level of sedation. (Ungraded)

Cardiac Surgery

• We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery. (Conditional, Low)

Medical and Surgical Patients Not Undergoing Cardiac Surgery

• We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults. (Conditional, Low)

Objective Sedation Monitoring

• Bispectral index (BIS) monitoring appears best suited for sedative titration during deep sedation or neuromuscular blockade, though observational data suggest potential benefit with lighter sedation as well. (Ungraded)
• Sedation that is monitored with BIS compared with subjective scales may improve sedative titration when a sedative scale cannot be used. (Ungraded)

Physical Restraints

• Physical restraints are frequently used for critically ill adults although prevalence rates vary greatly by country. (Ungraded)
• Critical care providers report using restraints to prevent self-extubation and medical device removal, avoid falls, and to protect staff from combative patients despite a lack of studies demonstrating efficacy and the safety concerns associated with physical restraints (e.g., unplanned extubations and greater agitation). (Ungraded)

Risk Factors

• For the following risk factors, strong evidence indicates that these are associated with delirium in critically ill adults: “modifiable”—benzodiazepine use and blood transfusions, and “nonmodifiable”—greater age, dementia, prior coma, pre-ICU emergency surgery or trauma, and increasing Acute Physiology and Chronic Health Evaluation (APACHE) and ASA scores. (Ungraded)

Prediction

• Predictive models that include delirium risk factors at both the time of ICU admission and in the first 24 hours of ICU admission have been validated and shown to be capable of predicting delirium in critically ill adults. (Ungraded)

Assessment

1. Critically ill adults should be regularly assessed for delirium using a valid tool. (Good Practice Statement)

Level of Arousal and Assessment

• Level of arousal may influence delirium assessments with a validated screening tool. (Ungraded)

Delirium Outcomes

• Positive delirium screening in critically ill adults is strongly associated with cognitive impairment at 3 and 12 months after ICU discharge and may be associated with a longer hospital stay. (Ungraded)
• Delirium in critically ill adults has consistently been shown NOT to be associated with PTSD or post-ICU distress. (Ungraded)
• Delirium in critically ill adults has NOT been consistently shown to be associated with ICU LOS, discharge disposition to a place other than home, depression, functionality/dependence, or mortality. (Ungraded)

Rapidly Reversible Delirium Outcomes

• Rapidly reversible delirium is associated with outcomes that are similar to patients who never experience delirium. (Ungraded)

Prevention

• We suggest not using haloperidol, an atypical antipsychotic, dexmedetomidine, a β-Hydroxy β-methylglutaryl-Coenzyme A (HMG-CoA) reductase inhibitor (i.e., statin), or ketamine to prevent delirium in all critically ill adults. (Conditional) (Very Low/Low)

Subsyndromal Delirium Treatment

• We suggest not using haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults. (Conditional) (Very Low/Low)

Antipsychotic/statin

• We suggest not routinely using haloperidol, an atypical antipsychotic, or a HMG-CoA reductase inhibitor (i.e., a statin) to treat delirium. (Conditional, Low)

Dexmedetomidine

• We suggest using dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation. (Conditional, Low)

Single Component

• We suggest not using bright light therapy to reduce delirium in critically ill adults. (Conditional, Moderate)

Multicomponent

• We suggest using 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. (Conditional, Low)

Efficacy and Benefit

• We suggest performing rehabilitation or mobilization in critically ill adults. (Conditional, Low)

Safety and Risk

• Serious safety events or harms do not occur commonly during physical rehabilitation or mobilization.
• (Ungraded)

Indicators for Initiation

• Major indicators for safely initiating rehabilitation/mobilization include stability in cardiovascular, respiratory, and neurologic status. (Ungraded)
• Vasoactive infusions or mechanical ventilation are not barriers to initiating rehabilitation/mobilization, assuming patients are otherwise stable with the use of these therapies. (Ungraded)

Indicators for Stopping

• Major indicators for stopping rehabilitation/mobilization include development of new cardiovascular, respiratory, or neurologic instability.(Ungraded)
• Other events, such as a fall or medical device removal/malfunction, and patient distress are also indications for stopping. (Ungraded)

Characterization

• Critically Ill Versus Healthy Total sleep time (TST) and sleep efficiency are often normal. (Ungraded)
• Sleep fragmentation, the proportion of time spent in light sleep (stages N1 + N2), and time spent sleeping during the day (vs night) are higher. (Ungraded)
• The proportion of time spent in deep sleep (stage N3 sleep and REM) is lower. (Ungraded)
• Subjective sleep quality is reduced. (Ungraded)

Delirium Versus No Delirium

• The presence of delirium may not affect TST, sleep efficiency, or sleep fragmentation. (Ungraded)
• The influence of delirium on the proportion of time spent in light (N1 + N2) versus deeper (N3) sleep is unknown. (Ungraded)
• REM sleep is lower if delirium is present. (Ungraded)
• Delirium is associated with greater circadian sleep-cycle disruption and increased daytime sleep. (Ungraded)
• Whether delirium affects reported subjective sleep quality remains unclear. (Ungraded)

Mechanical Ventilation Versus No Mechanical Ventilation

• The use of mechanical ventilation in critically ill adults may worsen sleep fragmentation, architecture, and circadian rhythm (daytime sleep) compared with normal sleep, but these effects are often variable and have not yet been fully investigated. (Ungraded)
• The use of mechanical ventilation (vs periods without mechanical ventilation) in patients with respiratory failure may improve sleep efficiency and reduce fragmentation, but data are limited. (Ungraded)

Prevalence of Unusual/Dissociated Sleep

• The prevalence of unusual or dissociated sleep patterns is highly variable and depends on patient characteristics. (Ungraded)

Risk Factors Before ICU Admission

• Patients who report poor-quality sleep and/or use of a pharmacologic sleep aid at home are more likely to report poor-quality sleep in the ICU. (Ungraded)

Risk Factors During ICU Admission

• Pain, environmental stimuli, healthcare-related interruptions, psychologic factors, respiratory factors, and medications each affect sleep quality in the ICU. (Ungraded)

Outcomes

• Although an association between sleep quality and delirium occurrence exists in critically ill adults, a cause-effect relationship has not been established. (Ungraded)
• An association between sleep quality and duration of mechanical ventilation, length of ICU stay, and ICU mortality in critically ill adults remains unclear. (Ungraded)
• The effects of sleep quality and circadian rhythm alterations on outcomes in critically ill patients after ICU discharge are unknown. (Ungraded)

Monitoring

• We suggest not routinely using physiologic sleep monitoring clinically in critically ill adults. (Conditional, Very Low)

Ventilator Mode

• We suggest using assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults. (Conditional, Low)
• We make no recommendation regarding the use of an adaptive mode of ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults. (Very Low)

NIV-Dedicated Ventilator

• We suggest using either an NIV-dedicated ventilator or a standard ICU ventilator for critically ill adults requiring NIV to improve sleep. (Conditional, Very Low)

Aromatherapy/Acupressure/Music

• We suggest not using aromatherapy, acupressure, or music at night to improve sleep in critically ill adults. [aromatherapy and acupressure] (Conditional, Low) [music] (Conditional, Very Low)

Noise and Light Reduction

• We suggest using noise and light reduction strategies to improve sleep in critically ill adults. (Conditional, Low)

Pharmacologic Interventions to Improve Sleep

• We make no recommendation regarding the use of melatonin to improve sleep in critically ill adults. (Very Low)

Dexmedetomidine

• We make no recommendation regarding the use of dexmedetomidine at night to improve sleep. (Low)

Propofol
We suggest not using propofol to improve sleep in critically ill adults. (Conditional, Low)

Sleep-Promoting Protocol
We suggest using a sleep-promoting, multicomponent protocol in critically ill adults. (Conditional, Very Low)