Earlier this year, the Society of Critical Care Medicine (SCCM) updated its clinical practice guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. The 2025 version updates the 2018 version based on the best available evidence available to frame its recommendations.
The SCCM created a task force of physicians, nurses, physiotherapists, psychologists, pharmacists, and ICU survivors. The task force’s efforts resulted in five statements regarding managing anxiety, agitation/sedation, delirium, immobility, and sleep disruption among adults admitted to the ICU. Additionally, the task force produced conditional recommendations for particular topics. No recommendations were issued regarding administering benzodiazepines for anxiety, nor for the use of antipsychotics for delirium.
Today, we’re comparing the updated 2025 version of the SCCM clinical practice guidelines to the previous 2018 version.
Guidelines Referenced:
- Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
- Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
SCCM Guidelines Comparison (2018–2025)
| Item | 2018 | 2025 |
|---|---|---|
| Benzodiazepine Use for Anxiety | No recommendation previously existed. | There is insufficient evidence to make a recommendation on the use of benzodiazepines to treat anxiety in adult patients admitted to the ICU (No recommendation; no evidence available). |
| Sedation in Mechanically Ventilated Patients | We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults (Conditional recommendation, low quality of evidence). | We suggest using dexmedetomidine over propofol for sedation in mechanically ventilated adult patients admitted to the ICU where light sedation and/or a reduction in delirium are of highest priorities (Conditional recommendation; for intervention; moderate certainty). |
| Antipsychotics for Delirium | We suggest not routinely using haloperidol or an atypical antipsychotic, to treat delirium (Conditional recommendation, low quality of evidence). | We are unable to issue a recommendation for or against the use of antipsychotics over usual care for the treatment of delirium in adult patients admitted to the ICU (Conditional recommendation; for intervention or comparison; low certainty). |
| Mobilization/Rehabilitation | We suggest performing rehabilitation or mobilization in critically ill adults (Conditional recommendation, low quality evidence). | We suggest providing enhanced mobilization/rehabilitation over usual care mobilization/rehabilitation to adult patients admitted to the ICU (Conditional recommendation; for intervention; moderate certainty). |
| Melatonin for Sleep | We make no recommendation regarding the use of melatonin to improve sleep in critically ill adults (No recommendation, very low quality of evidence). | We suggest administering melatonin over no melatonin in adult patients admitted to the ICU (Conditional recommendation; for intervention; low certainty). |
Key Takeaways on Updated Recommendations
- Recommendation 1: There is insufficient evidence to make a recommendation on the use of benzodiazepines to treat anxiety in adult patients admitted to the ICU.
- Takeaway: The assembled task force was unable to make a recommendation due to limited available evidence.
- Recommendation 2: We suggest using dexmedetomidine over propofol for sedation in mechanically ventilated adult patients admitted to the ICU where light sedation and/or a reduction in delirium are of highest priorities (conditional recommendation; for intervention; moderate certainty of evidence).
- Takeaway: The desirable effects of dexmedetomidine outweighed the possibility of bradycardia, additional the cost of dexmedetomidine is lower than what it was previously, but that cost and the ability to obtain dexmedetomidine may be prohibitive in some areas, hence the "conditional" recommendation.
- Recommendation 3: We are unable to issue a recommendation for or against the use of antipsychotics over usual care for the treatment of delirium in adult patients admitted to the ICU (conditional recommendation; for intervention or comparison; low certainty of evidence).
- Takeaway: The task force was unable to issue a recommendation due to the low certainty of evidence based on indeterminable benefits. An example provided was that a delirium-free outcome can mean a patient who has a normal mental status and a patient who is comatose.
- Recommendation 4: We suggest providing enhanced mobilization/rehabilitation over usual care mobilization/rehabilitation to adult patients admitted to the ICU (conditional recommendation; for intervention; moderate certainty of evidence).
- Takeaway: The conditional recommendation was made based on the understanding that resource limitations can be an implementation barrier. Evidence did suggest that enhanced mobilization / rehabilitation include benefits that outweigh the risk of an adverse event occurring.
- Recommendation 5: We suggest administering melatonin over no melatonin in adult patients admitted to the ICU (conditional recommendation; for intervention; low certainty of evidence).
- Takeaway: The low risk of adverse events should be weighed against the reduction of delirium prevalence and the perceived improvement of sleep quality, hence the conditional recommendation. Limited data dulled the recommendation's strength.
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