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Critical Care Medicine:
doi: 10.1097/CCM.0b013e3182783b72
Special Article

Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Barr, Juliana MD, FCCM1; Fraser, Gilles L. PharmD, FCCM2; Puntillo, Kathleen RN, PhD, FAAN, FCCM3; Ely, E. Wesley MD, MPH, FACP, FCCM4; Gélinas, Céline RN, PhD5; Dasta, Joseph F. MSc, FCCM, FCCP6; Davidson, Judy E. DNP, RN7; Devlin, John W. PharmD, FCCM, FCCP8; Kress, John P. MD9; Joffe, Aaron M. DO10; Coursin, Douglas B. MD11; Herr, Daniel L. MD, MS, FCCM12; Tung, Avery MD13; Robinson, Bryce R. H. MD, FACS14; Fontaine, Dorrie K. PhD, RN, FAAN15; Ramsay, Michael A. MD16; Riker, Richard R. MD, FCCM17; Sessler, Curtis N. MD, FCCP, FCCM18; Pun, Brenda MSN, RN, ACNP19; Skrobik, Yoanna MD, FRCP20; Jaeschke, Roman MD21

Supplemental Author Material
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Objective: To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.

Methods: The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method ( to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks® database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey ( All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (–) an intervention. A strong recommendation (either for or against) indicated that the intervention’s desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase “We recommend …” is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase “We suggest …” is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

Conclusion: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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