The Society of Critical Care Medicine’s (SCCM) American College of Critical Care Medicine (ACCM) has published a revised version of its pain, agitation and delirium (PAD) clinical practice guidelines for adult intensive care unit (ICU) patients.(1) In the decade since these guidelines were last published, we have gained a greater understanding of how to better provide physical and psychological comfort for critically ill patients.(2) The development of valid and reliable bedside assessment tools to measure pain, sedation, agitation, and delirium separately has allowed clinicians to better evaluate and manage ICU patients.(3,4) Further, our increased understanding of the clinical pharmacology of medications commonly administered to treat PAD has given us greater insight to both the short- and long-term consequences of prolonged exposure to these agents.(5-7) How we administer these medications can affect patient outcomes as much as drug choice.(8-12) Maintaining a light level of sedation while also ensuring patient comfort is associated with improved ICU clinical outcomes in most patients.(13-15) Our understanding of the risk factors and long-term consequences of delirium has also expanded.(16-18)
The 2013 Guidelines
Ensuring that critically ill patients are free from pain, agitation and delirium may directly conflict with other ICU management goals, such as maintaining cardiopulmonary stability while preserving adequate end-organ perfusion and function.(19, 20) Tremendous variability exists among ICUs in terms of cultural, philosophical and clinical practice norms, as well as the availability of manpower and resources, making widespread implementation of the PAD guidelines challenging.(21-23) The overarching goal of the 2013 PAD guidelines is to recommend evidence-based, best practices for managing PAD in order to improve clinical outcomes in adult ICU patients. Given the ubiquitous nature of these derangements, we believe that these guidelines will have a transformative impact on ICU care; however, the full impact will only be realized if the guidelines are widely adopted and implemented in an interdisciplinary and integrated fashion. The PAD guidelines are not meant to be overly proscriptive or applied to the care of critically ill patients in absolute terms; rather, clinicians should adapt them to individual patients and the available resources of their local healthcare system.
The 2013 PAD guidelines differ significantly from previous versions in terms of the methods used, their content and scope. All statements and recommendations were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method (www.gradeworkinggroup.org
), which allows for guideline recommendations to be based upon not only the strength of the evidence, but the risks and benefits of each intervention as well.(24-26) This process allows for strong recommendations to be made based upon weak evidence, and vice versa. In the absence of sufficient evidence, or if the evidence is conflicting, then no recommendation is made. GRADE does not allow for expert opinion to be used in the absence of evidence, which enables us to make more robust statements and recommendations. By contrast, the 2002 version of the guidelines was developed using the Cochrane method, which grades guideline recommendations strictly on the strength of clinical evidence and allows for the substitution of expert consensus opinion in the absence of evidence.(27, 28)
Creating New Recommendations
The 2013 PAD guidelines were created with the help of a professional medical librarian, who was responsible for conducting all literature searches and maintaining the electronic database used to create the document. PAD Task Force members constructed clinical questions and a list of key words. The librarian developed corresponding medical subject heading (MeSH) terms, systematically searching relevant clinical databases, and creating and maintaining an electronic, Web-based database using Refworks® software (Bethesda, MD). The resulting database included more than 19,000 references related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The use of a single online electronic database enabled all task force members to have direct, simultaneous access to all references, which helped to streamline the literature review process. The use of a professional medical librarian significantly increased the relevant search yield and maintained the integrity of the Refworks® database used to develop these guidelines.
Another unique aspect of the 2013 guideline methodology was the use of anonymous, online voting, with predefined voting threshold, to achieve group consensus for all statements and recommendations.(28) The use of anonymous polling for achieving group consensus in guideline recommendations has been proposed by the GRADE Working Group, and it was previously adopted, in part, by the 2008 Surviving Sepsis Campaign Guidelines Committee to ensure fairness, transparency and anonymity in the creation of guideline recommendations.(29,30) The use of an anonymous voting scheme significantly improved inter-rater reliability and helped to achieve a high degree of concordance in developing PAD guideline statements and recommendations.(31)
The Use of Bedside Tools to Improve Outcomes
The updated PAD guidelines place a greater emphasis on the use of valid and reliable bedside tools for assessing pain, agitation/sedation and delirium in ICU patients. Rigorous psychometric analyses were performed to determine which assessment tools were most valid and reliable in critically ill patients. The use of robust assessment tools enables clinicians to better assess and treat pain, agitation and delirium as separate entities, and helps to avoid a random poly-pharmaceutical approach to treating agitation of unclear etiology, which frequently leads to oversedation in these patients. In contrast to the earlier version, the 2013 guidelines place less emphasis on recommending specific drugs for given clinical circumstances, focusing more on evidence-based strategies for optimally managing critically ill patients. The guidelines also emphasize the importance of achieving pain management first, then sedating as needed (i.e., analgosedation), and of using both pharmacologic and nonpharmacologic patient management strategies. This approach helps to avoid oversedation of ICU patients and allows them to more actively participate in spontaneous breathing trials, early mobility programs, and pain and delirium assessments. It also minimizes the potential complications of deep sedation. Compared to the earlier version, the guidelines place a greater emphasis on preventing, diagnosing and treating delirium, reflecting our growing understanding of this disease process in critically ill patients. Finally, the 2013 guidelines emphasize a patient-centered, integrated and interdisciplinary approach to managing PAD in critically ill patients.
The 54 statements and recommendations included in the 2013 PAD guidelines (more than twice as many as in the previous version) cover both short- and long-term management of pain, agitation/sedation, and delirium in intubated and non-intubated adult medical, surgical, and trauma ICU patients. Similarly, the ACCM is developing a separate guideline document for the management of pain, agitation/sedation and delirium in pediatric patients.
Applying the ICU PAD Care Bundle
The 2013 PAD guidelines have been incorporated into the ICU PAD Care Bundle, with corresponding metrics developed to facilitate implementation (see Figures 1
). The bundle emphasizes an integrated approach to assessing, treating and preventing significant pain, overor undersedation, and delirium in critically ill patients. It also links PAD management strategies with spontaneous awakening and breathing trials, early mobility protocols and environmental management strategies to preserve patients’ sleep-wake cycles, in order to achieve synergistic improvements in ICU patient outcomes. Over the past two decades, a growing body of evidence has demonstrated that ventilator weaning protocols, sedation protocols that minimize depth of sedation (using either sedation titration protocols or daily sedation holidays), and early mobility protocols can improve ICU patient outcomes.(32-36) Individually, these interventions have been shown to reduce the duration of mechanical ventilation, shorten ICU length of stay, and/or reduce the incidence of delirium in critically ill patients. One study has shown that by linking sedation strategies that allow for light levels of sedation (i.e., daily spontaneous awakening trials or targeted sedation strategies) with spontaneous breathing trials and early mobility protocols, additional synergistic benefits can be achieved in improving patient outcomes.(37)
Benefits of Guideline Implementation
If widely adopted, the 2013 PAD guidelines have the potential to broadly transform the care of critically ill patients, which could translate to significant improvements in outcomes, such as improved pain management, a shortened duration of mechanical ventilation, a reduced incidence of delirium, and a reduced incidence of significant long-term physical and cognitive dysfunction in ICU survivors. Such benefits in turn may reduce lengths of stay and patient mortality rates, improve ICU and hospital patient flow, and improve ICU patients’ functionality at hospital discharge – meaning more ICU patients are likely to survive hospitalization, go home sooner, and return to their previous level of functioning. However, these potential benefits can only be achieved if the guidelines are widely adopted and implemented in an integrated and interdisciplinary fashion. Over the past 10 years, widespread adoption of the Surviving Sepsis Campaign guidelines has led to significant improvements in clinical outcomes for septic ICU patients.38 Let this be the decade of the ICU PAD guidelines.
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