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

Abstract

Objective: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. Design: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines’ development. A general content review was completed face-to-face by all panel members in January 2017. Methods: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as “strong,” “conditional,” or “good” practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. Results: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. Conclusions: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Keywords

Affiliated Institutions

• Brigham and Women's Hospital US
• London Health Sciences Centre CA
• Western University CA
• Harvard University US
• Impact CA
• The University of Melbourne AU
• Johns Hopkins Medicine US
• Université de Poitiers FR
• Yale University US
• Tufts Medical Center US
• Johns Hopkins Hospital US
• Deakin University AU
• Monash University AU
• Case Western Reserve University US
• Intermountain Healthcare US
• Northeastern University US
• Centre Hospitalier Universitaire de Montpellier FR
• Melbourne Health AU
• Université de Montpellier FR
• Centre National de la Recherche Scientifique FR
• Tufts University US
• Université Grenoble Alpes FR
• University of Chicago US
• Utrecht University NL
• Inserm FR
• Stanford University US
• The Ohio State University Wexner Medical Center US
• New York Medical College US
• NYU Langone Health US
• The Ohio State University US
• McGill University CA
• University Medical Center Utrecht NL
• Johns Hopkins University US
• McMaster University CA
• University of Washington US
• Radboud University Medical Center NL
• Harborview Medical Center US
• University of California, San Francisco US
• Vanderbilt University Medical Center US
• Centre Hospitalier Universitaire de Poitiers FR
• Radboud University Nijmegen NL
• Maine Medical Center US

Related Publications