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

Devlin, John W.; Skrobik, Yoanna; Gélinas, Céline; Needham, Dale M.; Slooter, Arjen J. C.; Pandharipande, Pratik P.; Watson, Paula L.; Weinhouse, Gerald L.; Nunnally, Mark; Rochwerg, Bram; Balas, Michele C.; Boogaard, Mark van den; Bosma, Karen J.; Brummel, Nathan E.; Chanques, Gérald; Denehy, Linda; Drouot, Xavier; Fraser, Gilles L.; Harris, Jocelyn E.; Joffe, Aaron M.; Kho, Michelle E.; Kress, John P.; Lanphere, Julie; McKinley, Sharon; Neufeld, Karin J.; Pisani, Margaret A.; Payen, Jean François; Pun, Brenda T.; Puntillo, Kathleen; Riker, Richard R.; Robinson, Bryce R. H.; Shehabi, Yahya; Szumita, Paul M.; Winkelman, Chris; Centofanti, John; Price, Carrie; Nikayin, Sina; Misak, Cheryl; Flood, Pamela; Kiedrowski, Ken; Alhazzani, Waleed

doi:10.1097/ccm.0000000000003259

Cited by 214 publications

(92 citation statements)

References 128 publications

(92 reference statements)

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“…4 10 The relationship between subjective sleep quality and delirium remains poorly explored; multiple investigative challenges exist in critically ill adults. [3][4][5] Any study addressing whether a link between subjective sleep quality and delirium exists should pair delirium and sleep assessments in individual patients, and consider them over short time periods given the natural fluctuation of both of these outcomes over the course of the ICU stay.…”

Section: Key Messagesmentioning

confidence: 99%

“…3 While several non-pharmacological sleep promotion efforts have been shown to reduce delirium, they have generally not been found to improve sleep, regardless of whether it is evaluated by objective or subjective means. 4 Although clinicians assume poor sleep provokes delirium and delirium provokes poor sleep, whether delirium and sleep quality are associated in a complex ICU environment remains unclear. 4 5 One 2018 systematic review of 12 studies evaluating patients admitted to the ICU after major surgery found a strong association between sleep disturbances and postoperative delirium occurrence.…”

Section: Introductionmentioning

confidence: 99%

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Is there an association between subjective sleep quality and daily delirium occurrence in critically ill adults? A post hoc analysis of a randomised controlled trial

2020

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ObjectivesWhether and how delirium and sleep quality in the intensive care unit (ICU) are linked remains unclear. A recent randomised trial reported nocturnal low-dose dexmedetomidine (DEX) significantly reduces incident ICU delirium. Leeds Sleep Evaluation Questionnaire (LSEQ) scores were similar between intervention (DEX; n=50) and control (placebo (PLA); n=50) groups. We measured the association between morning LSEQ and delirium occurrence in the prior 24 hours (retrospective analysis) and the association between morning LSEQ and delirium occurrence in the following 24 hours (predictive analysis).DesignPost hoc analysis of randomised controlled trial data.ParticipantsAdult ICU patients (n=100) underwent delirium screening twice a day using the Intensive Care Delirium Screening Checklist (ICDSC) if Richmond Agitation Sedation Scale (RASS) was ≥−3 and patient-reported sleep quality evaluations at 09:00 daily with the LSEQ if RASS was ≥−1.OutcomesThe analysis included all 24-hour study periods with LSEQ documentation and matched delirium screening in coma-free patients. Separate logistic regression models controlling for age, baseline Acute Physiology and Chronic Health Evaluation II score and DEX/PLA allocation evaluated the association between morning LSEQ and delirium occurrence for both retrospective and predictive analyses.ResultsThe 100 patients spent 1115 24-hour periods in the ICU. Coma, delirium and no delirium occurred in 130 (11.7%), 114 (10.2%) and 871 (78.1%), respectively. In the retrospective analysis, when an LSEQ result was preceded by an ICDSC result (439/985 (44.6%) 24-hour periods), delirium occurred during 41/439 (9.3%) periods. On regression analysis, the LSEQ score had no relationship to prior delirium occurrence (OR (per every 1 point average LSEQ change) 0.97, 95% CI 0.72 to 1.31). For the predictive analysis, among the 387/985 (39.1%) 24-hour periods where an LSEQ result was followed by an ICDSC result, delirium occurred during 56/387 (14.5%) periods. On regression analysis, the LSEQ score did not predict subsequent delirium occurrence (OR (per 1 point LSEQ change) 1.02, 95% CI 0.99 to 1.05).ConclusionsThe sleep quality ICU patients perceive neither affects nor predicts delirium occurrence.Trial registration numberNCT01791296

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Section: Key Messagesmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Is there an association between subjective sleep quality and daily delirium occurrence in critically ill adults? A post hoc analysis of a randomised controlled trial

2020

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“…So, NMBAs have been recommended as clinical practice guideline for the management of severe ARDS and mechanical ventilation patients under certain circumstances [12,13]. However, despite these encouraging results, the use of NMBAs did not be suggested as a clinical practice guideline for mechanical ventilation in adult patients with ARDS [14], and early neuromuscular blockade was also not widely adopted and strongly recommended in current guidelines [4,[15][16][17]. Resource constraints and limited data about the effects of NMBAs on neuromuscular function and other long-term outcomes may be the main potential concerns.…”

Section: Introductionmentioning

confidence: 99%

Neuromuscular blockers in the acute respiratory distress syndrome: A meta-analysis

Hua

et al. 2020

PLoS ONE

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Background The effects of neuromuscular blocking agents (NMBAs) on adult patients with acute respiratory distress syndrome (ARDS) remain unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate its effect on mortality. Methods We searched the Cochrane (Central) database, Medline, Embase, the Chinese Biomedical Literature Database (SinoMed), WanFang data and ClinicalTrials from inception to June 2019, with language restriction to English and Chinese. We included published RCTs and eligible clinical trials from ClinicalTrials.gov that compared NMBAs with placebo or usual treatment in adults with ARDS. We pooled data using random-effects models. The primary outcome was mortality. The secondary outcomes were the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO 2 /FIO 2), total positive end expiratory pressure (PEEP), plateau pressure (Pplat), days free of ventilator at day 28, barotrauma and ICU-acquired weakness. Results We included 6 RCTs (n = 1557). Compared with placebo or usual treatment, NMBAs were associated with lower 21 to 28-day mortality (RR 0.72, 95% CI 0.53-0.97, I2 = 59%). NMBAs significantly improved oxygenation (Pao2:Fio2 ratios) at 48 hours (MD 27.26 mm Hg, 95% CI 1.67, 52.84, I2 = 92%) and reduced the incidence of barotrauma (RR 0.55, 95% CI 0.35, 0.85, I2 = 0). However, NMBAs had no effect on oxygenation (Pao2:Fio2 ratios) (MD 18.41 mm Hg, 95% CI-0.33, 37.14, I2 = 72%) at 24 hours. We also found NMBAs did not affect total PEEP, plateau pressure, days free of ventilation at day 28 and ICU-acquired weakness.

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“…Finally, with the inflow of patients exceeding traditional ICU bed capacity, many intubated patients needed to be cared for outside of a traditional ICU setting by clinicians without primary critical care specialization. A critical step to ensure patient safety was implementing sedation guidelines to aid clinicians with treating ventilated patients in these nontraditional areas ( 23 ). This task proved extremely challenging due to looming medication shortages.…”

mentioning

confidence: 99%

“…Opioid analgesics and benzodiazepines were chosen as the backbone of analgesia and sedation ensuring physician familiarity and relative low risk of hemodynamic compromise. The first line of those were fentanyl and midazolam, considering safety and ease of use, however, overuse would invariably lead to severe shortage ( 23 ). Pharmacists led education regarding bolus use and the addition of enteral agents to preserve IV agents for more acute situations.…”

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confidence: 99%

Clinical Pharmacists: An Invaluable Part of the Coronavirus Disease 2019 Frontline Response

Ferguson¹,

Quinn²,

Khalique³

et al. 2020

Critical Care Explorations

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Although coronavirus disease 2019 was first identified in December 2019, it rapidly spread and became a global pandemic. The number of patients infected with the novel coronavirus (severe acute respiratory syndrome coronavirus 2) rose rapidly in New York State, placing great stress on healthcare systems. The traditional roles and practices of healthcare providers were dramatically redefined to meet the demand to care for the large number of ill patients. While literature reports on the experiences of many frontline staff, there is a scarcity of reports on the role of clinical pharmacists during this crisis. We report the role of critical care clinical pharmacists at a large academic medical center in New York City during this pandemic. Effective crisis management required clinical pharmacists to employ a wide array of skills and knowledge. Areas included clinical expertise, education, data analysis, health informatics infrastructure, and inventory management in times of surging medication use and manufacturer shortages. Clinical pharmacists fulfilled an essential service during the coronavirus pandemic by working to ensure the best possible outcomes for the patients they served on the frontline.

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

Cited by 214 publications

References 128 publications

Is there an association between subjective sleep quality and daily delirium occurrence in critically ill adults? A post hoc analysis of a randomised controlled trial

Is there an association between subjective sleep quality and daily delirium occurrence in critically ill adults? A post hoc analysis of a randomised controlled trial

Neuromuscular blockers in the acute respiratory distress syndrome: A meta-analysis

Clinical Pharmacists: An Invaluable Part of the Coronavirus Disease 2019 Frontline Response

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