Sedation, analgesia, and neuromuscular blockade of the critically ill adult: Revised clinical practice guidelines for 2002

Abstract

The critically ill and injured patient is invariably anxious, confused, uncomfortable, and in pain from immobility, wounds, and indwelling tubes and is generally distressed by the adverse environs of the intensive care unit. The restlessness associated with critical illness must nearly always, by necessity, be quelled with sedation and analgesia. Clinicians must sometimes use neuromuscular blockade as a last resort. The knowledge and practice of using sedatives, analgesics, and neuromuscular receptor blocking agents originated in and migrated out of the operating theater and postanesthesia recovery units. However, critical care clinicians have discovered that the sustained use of these agents in intensive care units has consequences that are different from those seen in the immediate perioperative period. The Society of Critical Care Medicine (SCCM) and the American College of Critical Care Medicine (ACCM) systematically reviewed, developed, and, in 1995, published clinical practice guidelines (CPGs) for sedation, analgesia, and neuromuscular blockade in the critically ill patient (1, 2). These CPGs are the most popular and requested of the SCCM and ACCM documents because of the complexities involved in achieving appropriate levels of sedation and analgesia without inducing complications. Recommendations stemming from the 1995 CPGs, although evidence based, were limited because of the lack of prospective randomized trials comparing agents. Since that time, new evidence has emerged and ACCM believes that the CPGs require updating. ACCM and SCCM have joined forces with the American Society of Health-System Pharmacists (ASHP) to develop new CPGs on the sustained use of sedatives, analgesics, and neuromuscular blocking agents in the critically ill adult (3, 4). The quality of care can be improved by implementing the best known and tested standards, measuring the consequences of what we do, and reducing variability found in practice through the use of protocols. CPGs, in tandem with protocol development, can serve as educational tools, improve outcomes, and reduce costs (5, 6). Evidence suggests that, in real practice, recommendations such as these are often not followed (7). “Clinical practice guidelines” are defined by the Institute of Medicine as “systematically developed statements to assist the practitioner and patient in decisions about appropriate health care for specific clinical circumstances” (8). Clinicians need to differentiate CPGs from a summary or review article (9–11). CPGs are vitally different from review articles and greatly valued for several reasons. Ideally, CPGs are created by a multidisciplinary task force of clinicians, including physicians, nurses, and pharmacists, as well as other health care professionals, under the auspices of the recommendations developed by critical evaluation of the graded scientific literature. CPGs are typically more comprehensive and far-reaching in scope than review articles and serve as virtual guiding lights by providing a useful construct of available evidence and expert decision-making against which individual decisions by clinicians and programs can be evaluated (12). A comprehensive literature search was performed to develop the CPGs. Published studies identified through a MEDLINE search (Sedation and Analgesia 1994 –2001; Neuromuscular blocking agents 1994–2001) were reviewed, as were the reference lists of the retrieved documents and abstracts from meetings of professional associations. The literature was critically evaluated for research design, patient selection, medication dose, administration route, combination treatment, test measures, statistics, and results. The medical literature ranged in quality from prospective randomized trials and retrospective observations to expert opinions (Table 1). Pertinent references were assigned a score to account for variance in quality. The recommendations of SCCM, ACCM, and ASHP (Joint Task Force) were graded according to the strength and quality of the scientific evidence (Table 2). A substantial effort was made by the Joint Task Force to adhere to the methodology for developing scientifically sound CPGs as prescribed by the American Medical Association, the Institute of Medicine, and the Canadian Medical Association (13–17). The 2002 clinical practice guidelines state the rationale, benefits, and harms of the recommendations, describe the expected health outcomes, and cite and rank the evidence. These CPGs will be reviewed and updated in three to five years. There are major additions, besides the updating of the science, to the 2001 CPGs being issued by the Joint Task Force (3, 4), compared with the 1995 guidelines. These guidelines are the most comprehensive documents in the fields of sedation, analgesia, and neuromuscular Address correspondence to Dr. Nasraway, Jr. at Tufts University School of Medicine, Department of Surgery, Tufts-New England Medical Center, 750 Washington Street, Box 4630, Boston, MA 02111 (snasraway@lifespan.org). Copyright © 2002 by the Society of Critical Care Medicine and the American Society of Health-System Pharmacists, Inc.