Abstract
The recently published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit differ from earlier guidelines in the following ways: literature searches were performed in eight databases by a professional librarian; psychometric validation of assessment scales was considered in their recommendation; discrepancies in recommendation votes by guideline panel members are available in online supplements; and all recommendations were made exclusively on the basis of evidence available until December of 2010. Pain recognition and management remains challenging in the critically ill. Patient outcomes improve with routine pain assessment, use of co-analgesics and administration as well as dose adjustment of opiates to patient needs. Thoracic epidurals help ease patients undergoing abdominal aortic surgery. Little data exists to guide clinicians as to the type or dose of co-analgesics; no opiate choice is associated with better patient outcomes. Lighter or no sedation is beneficial, and interruption is desirable in patients who require deep sedation for specific pathologic states. Delirium screening is probably useful; no treatment modality can be unequivocally recommended, and the benefit of prophylaxis is established only for early mobilization. The details of these recommendations, as well as more recent publications that complement the guidelines, are provided in this commentary.
Highlights
The Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit was recently published [1]
One pediatric and one war-trauma study suggest more frequent use of morphine might reduce the risk of subsequent development of Posttraumatic stress disorder (PTSD)-related symptoms after injury [16,17], these findings have not been documented in an adult critical care population
We provide no recommendation for the use of thoracic epidural analgesia in patients undergoing either intrathoracic or nonvascular abdominal surgical procedures, because of insufficient and conflicting evidence for this mode of analgesic delivery in these patients (0, B)
Summary
The Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit was recently published [1]. One pediatric and one war-trauma study suggest more frequent use of morphine might reduce the risk of subsequent development of PTSD-related symptoms after injury [16,17], these findings have not been documented in an adult critical care population As these guidelines point out, improved pain management is clearly associated with better patient outcome in the ICU [8,18,19]. (actionable),” the guidelines provide the following answer: “We recommend that performing early mobilization of adult ICU patients be performed whenever feasible to reduce the incidence and duration of delirium (+1B).” This recommendation is based on the first multicenter, randomized, controlled trial of early mobility [11] and a subsequent implementation study, where investigators noted striking reductions in the incidence of delirium in mobilized patients. Delirium in association to alcohol withdrawal was not covered in these guidelines because of space considerations; this topic is reviewed in a separate publication [95]
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