Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: Executive summary

Barr, Juliana; Fraser, Gilles L.; Puntillo, Kathleen; Ely, E. Wesley; Gélinas, Céline; Dasta, Joseph F.; Davidson, Judy E.; Devlin, John W.; Kress, John P.; Joffe, Aaron M.; Coursin, Douglas B.; Herr, Daniel; Tung, Avery; Robinson, Bryce R. H.; Fontaine, Dorrie K.; Ramsay, Michael A. E.; Riker, Richard R.; Sessler, Curtis N.; Pun, Brenda T.; Skrobik, Yoanna; Jaeschke, Roman

doi:10.1093/ajhp/70.1.53

Cited by 167 publications

(144 citation statements)

References 33 publications

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“…A reduction in benzodiazepine requirements may be a clinically important marker of dexmedetomidine efficacy due to the association of benzodiazepines with oversedation, respiratory depression, and delirium. 6 However, whether the avoidance of benzodiazepine therapy leads to lower rates of intubation or delirium or increases the risk of seizure in patients with alcohol withdrawal is not well studied. In the only randomized, placebo-controlled trial to date evaluating the use of dexmedetomidine in AWS, 11 of 24 patients included were intubated at the time of study entry and no patients required intubation or experienced a seizure during the study period; however, the study was not powered to detect differences in this endpoint.…”

Section: Discussionmentioning

confidence: 99%

“…Despite the advantages of benzodiazepine use in AWS, these drugs may be associated with oversedation, respiratory depression, and a transition to intensive care unit (ICU) delirium. 5,6 Adjunctive agents in the management of AWS are attractive in an effort to control symptoms and prevent the development of complications from benzodiazepine use.…”

Section: Introductionmentioning

confidence: 99%

“…[9][10][11] The most common adverse effects of dexmedetomidine that may limit its use are bradycardia and hypotension; however it may also cause loss of oropharyngeal tone leading to airway obstruction in nonintubated patients. 6 The objective of this review is to provide an update on the available evidence evaluating dexmedetomidine in AWS while identifying gaps in evidence for the use of dexmedetomidine in this setting.…”

Section: Introductionmentioning

confidence: 99%

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Dexmedetomidine for Alcohol Withdrawal Syndrome

Linn

Loeser

2015

Ann Pharmacother

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Dexmedetomidine for Alcohol Withdrawal Syndrome

Linn

Loeser

2015

Ann Pharmacother

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“…2 As acknowledged in the new Society of Critical Care Medicine's Pain, Agitation, and Delirium Guidelines 3 , both conditions contribute to detrimental patient outcomes and are commonly precipitated and/or prevented by modifiable processes of care. These processes include sedative and opioid medication administration, mechanical ventilation, and immobility.…”

Section: Introductionmentioning

confidence: 99%

Implementing the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle into Everyday Care

Balas¹,

Burke

Gannon

et al. 2013

Critical Care Medicine

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209

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Objective The Awakening and Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle is an evidence-based, interprofessional, multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation and managing intensive care unit (ICU) acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to ABCDE bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design Prospective, before-after, mixed-methods study. Setting Five adult ICUs, 1 step-down unit, and a special care unit located in a 624 bed, academic medical center Subjects Interprofessional ICU team members at participating institution. Interventions and Measurements In collaboration with the participating institution, we developed, implemented, and refined an ABCDE bundle policy. Over the course of an 18 month period, all ICU team members were offered the opportunity to participate in numerous, multimodal educational efforts. Three focus group sessions, 3 online surveys, and 1 educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. Main Results Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds, 2) engagement of key implementation leaders, 3) sustained and diverse educational efforts, and 4) the bundle's quality and strength. Barriers identified included: 1) intervention related issues (e.g. timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions In this study of the implementation of the ABCDE bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU Pain, Agitation and Delirium (PAD) Guidelines, which has many similarities but also some important differences as compared to the ABCDE bundle

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“…Both the American College of Critical Care Medicine11 and the UK Intensive Care Society12 have published practice guidance that included the detection, prevention and management of delirium and agitation. Although approaches for managing ‘ dangerous motor activity ’ in the form of pharmacological interventions were outlined, there remains a lack of guidance for managing the acute event of a mobile, agitated patient who is a risk to themselves, visitors and staff.…”

Section: Key Messages From the Twitter Chat (#Ebnjc)mentioning

confidence: 99%