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

Publication Date: September 1, 2018
Last Updated: March 14, 2022

Recommendations

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.
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Assessment

Self-Report Scales

A patient’s self-report of pain is the reference standard for pain assessment in patients who can communicate reliably.
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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.
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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.
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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).
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Pharmacologic Adjuvants to Opioid Therapy

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)
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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)
(Nefopam is not available in United States and Canada.)
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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)
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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)
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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)
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Lidocaine

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

Opioid Use and Dose

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

We recommend not using inhaled volatile anesthetics for procedural pain management in critically ill adults. (Strong, Very Low)
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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)
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We suggest not using an NSAID topical gel for procedural pain management in critically ill adults. (Conditional, Low)
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Nonpharmacologic Interventions to Reduce Pain

Cybertherapy/Hypnosis

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

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

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

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

We suggest offering relaxation techniques for procedural pain management in critically ill adults. (Conditional, Very Low)
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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. (, )
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We suggest using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults. (Conditional, Moderate)
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AGITATION/SEDATION

Light Sedation

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

We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery. (Conditional, Low)
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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)
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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. (, )
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Sedation that is monitored with BIS compared with subjective scales may improve sedative titration when a sedative scale cannot be used. (, )
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Physical Restraints

Physical restraints are frequently used for critically ill adults although prevalence rates vary greatly by country. (, )
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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). (, )
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DELIRIUM

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. (, )
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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. (, )
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Assessment

Critically ill adults should be regularly assessed for delirium using a valid tool. (, )
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Level of Arousal and Assessment

Level of arousal may influence delirium assessments with a validated screening tool. (, )
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Outcomes

Delirium

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. (, )
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Delirium in critically ill adults has consistently been shown NOT to be associated with PTSD or post-ICU distress. (, )
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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. (, )
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Rapidly Reversible Delirium
Rapidly reversible delirium is associated with outcomes that are similar to patients who never experience delirium. (, )
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Pharmacologic Prevention and Treatment

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)
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Subsyndromal Delirium Treatment
We suggest not using haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults. (Conditional)
(Very Low/Low)
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Delirium Treatment
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)
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Dexmedetomidine
We suggest using dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation. (Conditional, Low)
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Nonpharmacologic Prevention and Treatment

Single Component
We suggest not using bright light therapy to reduce delirium in critically ill adults. (Conditional, Moderate)
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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)
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IMMOBILITY (REHABILITATION/MOBILIZATION)

Efficacy and Benefit

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

Serious safety events or harms do not occur commonly during physical rehabilitation or mobilization. (, )
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Indicators for Initiation

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

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

Characterization

Critically Ill Versus Healthy
Total sleep time (TST) and sleep efficiency are often normal. (, )
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Sleep fragmentation, the proportion of time spent in light sleep (stages N1 + N2), and time spent sleeping during the day (vs night) are higher. (, )
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The proportion of time spent in deep sleep (stage N3 sleep and REM) is lower. (, )
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Subjective sleep quality is reduced. (, )
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Delirium Versus No Delirium
The presence of delirium may not affect TST, sleep efficiency, or sleep fragmentation. (, )
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The influence of delirium on the proportion of time spent in light (N1 + N2) versus deeper (N3) sleep is unknown. (, )
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REM sleep is lower if delirium is present. (, )
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Delirium is associated with greater circadian sleep-cycle disruption and increased daytime sleep. (, )
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Whether delirium affects reported subjective sleep quality remains unclear. (, )
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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. (, )
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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. (, )
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Prevalence of Unusual/Dissociated Sleep
The prevalence of unusual or dissociated sleep patterns is highly variable and depends on patient characteristics. (, )
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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. (, )
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During ICU Admission
Pain, environmental stimuli, healthcare-related interruptions, psychologic factors, respiratory factors, and medications each affect sleep quality in the ICU.
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Outcomes

Although an association between sleep quality and delirium occurrence exists in critically ill adults, a cause-effect relationship has not been established.

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An association between sleep quality and duration of mechanical ventilation, length of ICU stay, and ICU mortality in critically ill adults remains unclear. (, )
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The effects of sleep quality and circadian rhythm alterations on outcomes in critically ill patients after ICU discharge are unknown.

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Monitoring
We suggest not routinely using physiologic sleep monitoring clinically in critically ill adults. (Conditional, Very Low)
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Nonpharmacologic Interventions to Improve Sleep

Ventilator Mode
We suggest using assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults. (Conditional, Low)
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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)
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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)
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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)
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[music] (Conditional, Very Low)
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Noise and Light Reduction
We suggest using noise and light reduction strategies to improve sleep in critically ill adults. (Conditional, Low)
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Pharmacologic Interventions to Improve Sleep

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

We make no recommendation regarding the use of dexmedetomidine at night to improve sleep.

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

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

Overview

Title

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

Authoring Organization

Publication Month/Year

September 1, 2018

Last Updated Month/Year

January 23, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

Target Patient Population

Patients in ICU

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D059408 - Pain Management, D003422 - Critical Care, D016638 - Critical Illness, D007362 - Intensive Care Units, D011595 - Psychomotor Agitation, D003693 - Delirium, D000071257 - Emergence Delirium

Keywords

delirium, critical care, Agitation, critical illness, intensive care unit

Source Citation

Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299. PMID: 30113379.