Critical Care Medicine:
Creating and Implementing the 2013 ICU Pain, Agitation, and Delirium Guidelines for Adult Icu Patients
Implementation of the Pain, Agitation, and Delirium Clinical Practice Guidelines and Promoting Patient Mobility to Prevent Post-Intensive Care Syndrome
Davidson, Judy E. DNP, RN, FCCM1; Harvey, Maurene A. RN, MPH, MCCM2; Bemis-Dougherty, Anita PT, DPT, MAS3; Smith, James M. PT, DPT4; Hopkins, Ramona O. PhD5,6
1Evidence-based Practice and Research Liaison, UCSD Medical Center, San Diego, CA.
2Critical Care Educator and Consultant, Glenbrook, NV.
3Clinical Practice, American Physical Therapy Association, Alexandria, VA.
4Department of Physical Therapy, Utica College, Utica, NY.
5Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, UT.
6Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT.
Dr. Davidson has received speaking honoraria and travel support from Hospira and the France Foundation. Ms. Harvey has received travel support from the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflicts of interest.
For information regarding this article, E-mail: firstname.lastname@example.org
Surviving critical illness is associated with persistent and severe physical, cognitive, and psychological morbidities. The Society of Critical Care Medicine has developed pain, agitation, and delirium guidelines and promoted mobility to improve care of critically ill patients. A task force has developed tools to facilitate and rapidly implement the translation of guideline care recommendations into practice. The Society of Critical Care Medicine has also assembled a task force to assess the long-term consequences of critical illness. This article will explore relationships between the pain, agitation, and delirium guidelines, mobility recommendations, and post-intensive care syndrome initiative. Implementation of the pain, agitation, and delirium guidelines taking into account current data regarding post-intensive care syndrome outcomes and potential interventions are an important first step toward improving outcomes for patients and their families. Research is needed to reduce the impact of long-term negative consequences of critical illness and to fully understand the best within- and post-ICU interventions, along with the optimal timing and dose of such interventions to produce the best long-term outcomes.
Implementation of the practice guidelines for the management of pain, agitation, and delirium (PAD) in the ICU (1) presents both challenges and opportunities for the critical care team. The PAD guidelines provide important evidence-based strategies regarding management of PAD to improve patient care. Following the publication of the PAD guidelines, the Society of Critical Care Medicine (SCCM) developed a PAD and immobility in ICU patients task force to develop work tools to facilitate and rapidly implement guideline care recommendations into practice. The goals of this initiative are to optimize management of PAD and to improve both short- and long-term outcomes of critically ill patients. Because there are adverse long-term outcomes associated with critical illness, the patient’s response to treatment and attainment of functional goals requires attention throughout the continuum of care. Previously, critical care providers’ responsibility was understood predominately as ensuring high-quality care during the ICU stay. Today, it is recognized that ICU providers have the expertise and opportunity to partner with clinical providers who care for critically ill patients after they leave the ICU and even following hospital discharge.
Surviving critical illness along with its attendant physical, cognitive, and psychological morbidities is a growing clinical and research challenge (2) and is a burgeoning public health concern. As a recent editorial emphasized, “discharge from the ICU no longer marks the endpoint of critical illness” (3). In response to the growing concern regarding the long-term morbidities of critical illness, SCCM established a separate task force to assess long-term consequences of critical illness, and in 2010, the task force convened a stakeholder’s conference. National representatives from a number of organizations and professions who care for survivors of intensive care and their families during and after ICU admission gathered to review current scientific data regarding post-ICU physical, cognitive, and mental health (i.e., depression, anxiety, and posttraumatic stress disorder [PTSD]) outcomes. Based on these data, three major themes regarding ICU outcome were identified: awareness and education, barriers to practice and research gaps, and needed resources (4). Post-intensive care syndrome (PICS) was recommended by the task force and supported by SCCM, as the term to describe “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.” PICS affects both the patient and family (4). Figure 1 depicts a model of outcomes for PICS and post-intensive care syndrome-family (PICS-F). Review articles have been published that describe and raise awareness regarding the adverse patient (5) and family (6) outcomes that occur following critical illness.
In 2012, the SCCM PICS task force held a second conference with returning and new stakeholders, with the goal of creating an action agenda aimed at increasing education and awareness, furthering research efforts, and overcoming barriers to improving the quality of care for PICS, entitled the PICS initiative. This article will explore important relationships between the PAD guidelines, mobility, and the PICS initiative.
THE RELATIONSHIP BETWEEN PAD ELEMENTS AND PICS: COGNITIVE IMPAIRMENT OUTCOMES
The manifestations of PICS include physical impairments, cognitive impairments (e.g., impaired executive function, memory, attention, and mental processing speed), and mental health morbidities that include acute stress disorder, anxiety, depression, and PTSD. Cognitive impairments occur in up to 100% of survivors at hospital discharge and up to 56% of survivors several years after ICU discharge (7). Cognitive impairments occur in multiple cognitive domains, including impaired memory, executive function, language, attention, and visual-spatial abilities. The new or worsening impairments in cognitive or mental health persist months to years (7) after hospital discharge and are associated with poor daily functioning and reduced quality of life.
A number of mechanisms (e.g., inflammation, hypoxia, and glucose dysregulation) and risk factors for cognitive impairments and mental health problems have been identified; however, research in this area is in its infancy. Several important risk factors for long-term cognitive impairments include delirium (acute cognitive dysfunction) and sedative use (8, 9). Although data are limited regarding the effects of delirium and sedative use on cognitive function after critical illness, existing data indicate that delirium and sedative use may not be harmless as previously thought. A study in critically ill patients with delirium reported more cognitive problems compared with critically ill patients without delirium after adjusting for covariates (10). Longer duration of delirium was associated with greater memory deficits such as remembering names. In a second study by Girard et al (11) that assessed the relationship between delirium duration and cognitive functioning, longer delirium duration was associated with severe cognitive impairments at 3 and 12 months after adjusting for age, education, preexisting cognitive functioning, illness severity, and sepsis. A meta-analysis in hospitalized elderly patients found delirium during hospitalization increased the risk of developing dementia, even after adjusting for age, sex, comorbid illness or illness severity, and baseline dementia (12). These data suggest that if delirium is reduced, there may be a concomitant improvement in cognitive outcomes.
Although data are limited regarding the effects of sedatives on long-term cognitive and mental health outcomes, several studies indicate sedatives are risk factors for adverse mental health outcomes. Critically ill patients who experienced sedative-induced delusional memories were more likely to develop PTSD after hospital discharge (13). In addition, higher doses of benzodiazepines during ICU treatment are associated with a higher rate of PTSD 6 months after hospital discharge in survivors of critical illness (14). Thus, a strategy to reduce sedative use was associated with decreased prevalence of PTSD. The adverse mental health effects of sedatives persist months after hospital discharge. Only recently have the effects of sedatives on long-term outcomes been studied. In a study that assessed the relationship between sedatives and long-term cognitive outcome, subjects in the intervention arm in whom sedation was stopped each day for spontaneous awakening trials and spontaneous breathing trials had better neurocognitive functioning at 3-month follow-up, although this effect was not present at 12-month follow-up (8). Although reducing sedative drug exposure appeared to improve cognitive function in the first few months after hospital discharge, there was no long-term benefit on cognitive outcomes. In addition, delirium duration adversely impacts cognitive function for months after ICU discharge. These findings suggest that reducing the prevalence or duration of delirium may translate to improved long-term mental health outcomes. The data are less clear regarding the relationship between reduced sedative exposure and long-term cognitive impairments. Additional research is needed to determine if reducing sedatives will improve long-term cognitive and mental health outcomes.
THE RELATIONSHIP BETWEEN PAD ELEMENTS AND PICS: IMMOBILITY OUTCOMES
The manifestations of PICS, as noted above, include physical impairments, such as reduced neuromuscular, pulmonary, and physical functioning (4). New or worsening impairments in physical function and immobility accompanying critical illness are worrisome, as such impairments often persist long beyond the acute care hospitalization and adversely affect mobility, self-care, and daily functioning. Over 50% of patients with acute respiratory distress syndrome require care at home for the first year after discharge (5). Data from within ICU interventions, such as early mobility, suggest that there is a direct relationship between activity in the ICU and functional ability. Mobilization and exercise have been shown to be safe and feasible in the ICU. Patients in the ICU who receive interventions for early mobilization and exercise are more likely to preserve physical abilities (e.g., strength) and functioning (e.g., ability to walk), while reducing ICU-acquired weakness that develops during critical illness (15–19).
Even though the literature supports early mobilization and physical therapy as a safe and effective intervention that can positively impact functional outcomes, clinical implementation in practice across ICUs is inconsistent. Typically, physical therapy interventions for long-term patients in the ICU consisted of passive, active assisted, or active exercise (20). Patients who are intubated and ventilated are rarely mobilized (20). Hanekom et al (21) reviewed the literature and found a lack of information to guide clinical decision making on a practical level for therapists, which may be a barrier to the early mobilization of patients in the ICU. There are a number of protocols and strategies for implementing early mobilization in the ICU, which vary widely in their recommendations (22). Variations in practice and research may further create challenges in translating and implementing evidence regarding early mobilization or physical therapy into clinical practice. Additionally, there is little evidence regarding the dose of exercise or type of activities that may best benefit patients in the ICU (23). For example, Winkelman et al (24) found that one 20-minute episode of exercise daily for two or more days reduced ICU length of stay. To prevent PICS physical morbidities, physical rehabilitation and mobilization should challenge the cardiopulmonary, musculoskeletal, and neuromuscular systems rather than promoting inactivity and rest (23).
THE RELATIONSHIP BETWEEN MOBILITY, DELIRIUM, AND LONG-TERM COGNITIVE FUNCTION
As noted above, research regarding early mobility to improve long-term physical, cognitive, and mental health outcomes is increasing. Early mobility is promoted within the guideline as a tested intervention to minimize the development of delirium, an acute cognitive dysfunction associated with critical illness. Benefits of early mobilization include reduced ICU and hospital length of stays, as well as decreased prevalence of delirium and shorter delirium duration. A randomized controlled trial in the patients who received daily early physical therapy and occupational therapy along with interruption of sedation demonstrated improved physical function and, importantly, decreased presence and duration of ICU-related delirium compared with a control group who received “usual care” (15). Since sedative use was similar in the two groups (intervention vs “usual care”), the decrease in delirium was most likely directly related to physical and occupational therapy. Barr et al (1) recommended “performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium”. The taskforce concurs with the statement that “These studies suggest that early and aggressive mobilization is unlikely to harm ICU patients, but may reduce the incidence and duration of delirium, shorten ICU and hospital length of stay, and lower hospital costs” (1). Research is needed to determine whether in-ICU interventions, such as reducing ICU delirium duration or early mobility or early physical therapy, can improve long-term physical, cognitive, and mental health outcomes. Although little information is available in critically ill populations, a recent review discussed the effects of physical activity on improving cognitive and mental health outcomes in non-ICU populations and their potential implications for critically ill populations (25).
SHIFTING THE CULTURE OF IMMOBILITY TO REDUCE PICS
Hospitalized patients are adversely impacted by a culture of immobility (26, 27) and traditionally this has been most prominent among critically ill patients as they were considered too sick to tolerate activity/mobility. Consistent with evidence that patients in the ICU may benefit from early mobilization (15, 18, 19, 28–31), the PAD clinical practice guidelines recommend the mobilization of patients in the ICU when feasible to reduce the prevalence and duration of delirium and to improve functional outcomes. Achieving within-ICU mobilization requires collaboration among many members of the healthcare team (32, 33) and acceptance of a culture of mobility among the team of providers (29, 31, 34–36). Creating a new culture of mobility in an ICU requires a deliberate and comprehensive effort to engage the stakeholders-physicians, nurses, respiratory therapists, physical therapists, and others (29) and benefits from reliance on a protocol to guide patient management (31). An important step in early physical rehabilitation and mobilization is determination of which patients may safely engage in a program of exercise and mobilization. A decision-making algorithm for assessing patient readiness for mobilization and physical therapy interventions is depicted in Figure 2 (23).
PROTOCOLS FOR PROMOTING MOBILITY TO IMPROVE PICS
Once the determination has been made that a patient is physiologically appropriate for activity, there are a number of protocols that are valuable resources for the team engaging in early mobilization in the ICU. One protocol designed to minimize sedation, reduce delirium, and prevent immobilization is the awakening and breathing coordination, delirium monitoring, and exercise/early mobility (ABCDE) bundle, “a multicomponent process that is intentionally interdependent and designed to 1) improve collaboration among clinical team members, 2) standardize care processes, and 3) break the cycle of over-sedation and prolonged ventilation” (37). Refer to Figure 3 for a representation of strategies for implementing the ABCDE bundle.
There are a number of mobility protocols that have been used, all of which require requisite level of cognitive function (i.e., able to follow commands) to determine patient readiness for mobilization. For example, a mobility protocol by Morris et al (31) provides strategies for patient mobilization and decision making for advancing the physical challenge provided to the patient. This protocol recommends four levels of activity: passive range of motion, active-assisted range of motion, exercises with the patient sitting on the edge of the bed, and mobilization. Although this progression of levels of activity was designed and applied as part of a research protocol, the sequence of activities provides a reasonable framework for initiating a program of mobilization activities. Alternative strategies for implementing and progressing the physical challenges provided to patients who are critically ill have been described (30, 33, 38) and could be considered so that the unique needs of organizations and patients are met.
Along with ICU physical rehabilitation and mobilization, there is also a need for post-ICU interventions that ameliorate physical, cognitive, and mental health morbidities. This burden is compounded by healthcare workers inability to identify the patients who may benefit from rehabilitation following hospital discharge (39). Several small studies have assessed the effects of physical rehabilitation on long-term cognitive function in patients with prolonged mechanical ventilation (> 14 d) and found improved cognitive function in the intervention group (18, 40). A prospective study that combined a 12-week program of physical and cognitive rehabilitation found improved cognitive and functional outcomes at 3-month follow-up (41). These data are promising, but larger studies are needed to confirm benefit of post-ICU physical rehabilitation on PICS.
Efforts are also needed to create a hospital discharge and patient management process for strategic ongoing monitoring and identification of patients with physical impairments who would benefit from referral to rehabilitation with the goal of shortening or reducing the severity of long-term physical disability. Such patient management processes will require focused educational activities for healthcare providers and education to increase awareness of PICS for providers so that treatment strategies can be developed and implemented. Patients and their caregivers should receive education about the signs and symptoms of each of the outcome domains within PICS (physical, cognitive, and mental health) to validate any symptoms that are experienced, provide information regarding diagnostic and supportive resources, and help educate and plan for accommodations as needed.
RELATIONSHIP BETWEEN PAD AND PICS-F: THE FAMILY
Long-term consequences of critical illness affect not only the patient but also the family members and are termed PICS-F (6). Family members may develop severe mental health disorders, including depression, anxiety, and PTSD, which can negatively impact quality of life as a long-term consequence of exposure to critical illness. The relationships between PAD guidelines and PICS-F are theoretical because most have yet to be formally studied or are understudied.
The PAD guideline proposes two new recommendations:
- Maintain a light enough level of sedation to allow the patient to participate in care activities
- Promote early mobility to prevent physical deterioration and lower the risk of delirium.
Although these two recommendations increase patient/family interaction, they create challenges and raise questions for clinical staff. Some questions for clinical staff are as follows: What can be done to keep a lightly sedated patient occupied? How will more frequent passive or guided active range of motion and early mobility activities be included as part of patient care? It has been proposed in adults (42, 43) and tested in neonates (44–46) that, when preferred by the family, participation in providing care may reduce the prevalence or severity of stress disorders in the family. Melnyk and Feinstein (45) found that providing families with structured guidance regarding how to engage in bedside activities decreased hospital length of stay. Maintaining light sedation and promoting early mobility provide opportunities for family engagement with the patient. For example, family involvement in passive and active range of motion will help to achieve mobility goals.
Several studies support the use of ICU diaries to help protect the mental health of patients and their family members (47–50). If patients have a lighter level of sedation, they may be alert and able to actively participate in chronicling their journey through critical illness. Myths and distortions uncovered through the journaling process could be handled iteratively and proactively to prevent locking delusions or mistruths into memory as facts. The act of journaling events and progress, even verbally using the family as a scribe, is another way to keep the lightly sedated patient occupied. Journaling promotes cognitive activity, which may protect the brain and reduce mental health morbidities for both patients and their families (28).
The PAD guidelines recommend the use of the patient self-report for pain and less reliance on vital signs to guide pain management. When coupled with light sedation, the patient may be able to self-report pain more effectively. The family can also observe symptoms of pain, agitation, sedation, and delirium when adequately educated. Inclusion in the patient’s plan of care, with appropriate preparation, could decrease stress by providing the family with meaningful duties, when desired, to participate as part of the healthcare team.
Linking principles of family-centered care may help to promote successful implementation of PAD guideline strategies while minimizing long-term consequences in the family members of critically ill patients. Table 1 lists the relationship between principles of family-centered care recommended by the American College of Critical Care/SCCM (51) along with an implementation plan for the PAD guideline.
FAMILY INFORMATION AFTER THE ICU
The best efforts to provide care according to the PAD recommendations may result in reduction or amelioration of PICS; however, it is unclear if the guideline implementation will prevent PICS. Communication about possible outcomes should be provided to the patient and the family, not only because most patients have cognitive impairments at ICU discharge and may not remember or understand the information, but also because of the family involvement and caregiving of their loved one. Providing family members with the signs and symptoms of PICS that may occur in the family or the patient, as well as referrals to medical providers, can improve post-ICU communication and may help in identification of PICS and PIC-F. This information may help validate the ICU experience and prepare the family with information which they can share with their post-ICU clinicians in the event that physical, cognitive, or mental morbidities occur.
FUTURE DIRECTIONS: RESEARCH NEEDS
The last decade has seen rapid growth in research regarding the benefits of early mobilization and exercise for survivors of critical illness. Additional evidence is needed to inform patient and family management strategies to achieve optimal outcomes following critical illness. Recommendations for future research to prevent or reduce PICS and PICS-F are found in Appendix 1.
By focusing on appropriate PAD care in the ICU, these interventions may reduce or prevent the development of PICS and PICS-F (e.g., physical, mental health, cognitive, and quality of life domains). Implementation of the PAD guidelines and data regarding PICS outcomes and interventions are the first steps to improve outcomes for patients and their families. Although we are beginning to understand that being awake and mobile helps to reduce the impact of long-term negative consequences of critical illness, research is needed to fully understand the best approaches, provided by the best skill set of providers, at the best time to produce beneficial long-term outcomes. These new guidelines of care will provide researchers with novel opportunities to determine if maintaining light sedation, avoiding deliriogenic medications, and providing early mobility, or a combination thereof, within a model of family-centered care can prevent or improve adverse long-term outcomes in critically ill patients and their families.
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APPENDIX 1. Pain, Agitation, and Delirium to Prevent Post-intensive care syndrome: Assessment, Recommendations, and Research Questions (Note: Questions Sorted by Recommendations Extracted Verbatim From Pain, Agitation, and Delirium Guidelines)
1. Pain and Analgesia
- b. Pain assessment
- i. We recommend that pain be routinely monitored in all adult ICU patients (+1B).
- ii. The Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool are the most valid and reliable BPSs for monitoring pain in medical, postoperative, or trauma (except for brain injury) adult ICU patients who are unable to self-report and in whom motor function is intact and behaviors are observable. Using these scales in other ICU patient populations and translating them into foreign languages other than French or English require further validation testing (B).
1. What is the prevalence of chronic pain long term associated with critical illness?
2. Does better pain assessment decrease the risk of chronic pain long term?
- c. Treatment of pain
- i. We recommend that preemptive analgesia and/or nonpharmacologic interventions (e.g., relaxation) be administered to alleviate pain in adult ICU patients prior to chest tube removal (+1C).
- ii. We suggest that for other types of invasive and potentially painful procedures in adult ICU patients, preemptive analgesic therapy and/or nonpharmacologic interventions may also be administered to alleviate pain (+2C).
1. Does preemptive analgesia decrease the risk of chronic pain?
2. Does preemptive analgesia decrease the risk of posttraumatic stress disorder (PTSD)/anxiety/depression?
- iii. We recommend that IV opioids be considered the first-line drug class of choice to treat nonneuropathic pain in critically ill patients (+1C).
- v. We suggest that nonopioid analgesics be considered to decrease the amount of opioids administered (or to eliminate the need for IV opioids altogether) and to decrease opioid-related side effects (+2C).
- xi. We provide no recommendation for neuraxial/regional analgesia over systemic analgesia in medical ICU patients, due to lack of evidence in this patient population (0, no evidence).
1. Does use of nonopioids help to decrease the burden of post-intensive care syndrome (PICS)?
2. What is the prevalence of opioid dependence after critical illness?
3. Does the use of nonopioid analgesics and/or neuraxial and regional anesthesia in certain patient populations decrease the likelihood of chronic pain or psychiatric problems after critical illness?
2. Agitation and Sedation
- a. Depth of sedation versus clinical outcomes
- i. Maintaining light levels of sedation in adult ICU patients is associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay [LOS]) (B).
- ii. Maintaining light levels of sedation increases the physiologic stress response but is not associated with an increased prevalence of myocardial ischemia (B).
- iii. The association between depth of sedation and psychological stress in these patients remains unclear (C).
- iv. We recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation in adult ICU patients, unless clinically contraindicated (+1B).
1. Does maintenance of light versus heavy sedation decrease the risk of cognitive dysfunction after critical illness?
2. Does choice of sedative matter for long-term cognitive dysfunction?
3. What is the relationship between reducing sedative use and mental health outcomes?
4. Does light sedation provide an opportunity for increased cognitive activities such as direct patient participation in the creation of an ICU diary?
5. If so, does patient involvement in the creation of a diary affect long-term psychological outcomes?
6. After transitioning to a light sedation protocol, does the ability to directly communicate with the patient change the prevalence of long-term psychological outcomes in the patient and/or family?
- b. Monitoring depth of sedation and brain function
- ii. We do not recommend that objective measures of brain function (e.g., auditory evoked potentials [AEPs], bispectral index [BIS], Narcotrend Index [NI], Patient State Index [PSI], or state entropy [SE]) be used as the primary method to monitor depth of sedation in noncomatose, nonparalyzed critically ill adult patients, as these monitors are inadequate substitutes for subjective sedation scoring systems (–1B).
- iii. We suggest that objective measures of brain function (e.g., AEPs, BIS, NI, PSI, or SE) be used as an adjunct to subjective sedation assessments in adult ICU patients who are receiving neuromuscular blocking agents, as subjective sedation assessments may be unobtainable in these patients (+2B).
1. Does objective measurement of brain function to guide sedation help to decrease risk of cognitive dysfunction or other psychiatric sequelae long term?
- c. Choice of sedative
- i. We suggest that sedation strategies using nonbenzodiazepine sedatives (either propofol or dexmedetomidine) may be preferred over sedation with benzodiazepines (either midazolam or lorazepam) to improve clinical outcomes in mechanically ventilated adult ICU patients (+2B).
1. What is the best sedative regimen to minimize the risk of PTSD and anxiety long term?
- a. Outcomes associated with delirium
- i. Delirium is associated with increased mortality in adult ICU patients (A).
- ii. Delirium is associated with prolonged ICU and hospital LOS in adult ICU patients (A).
- iii. Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B).
1. Is delirium a marker of severe critical illness and/or a risk factor itself for development of post-ICU cognitive impairment?
2. What is the burden of cognitive impairment for different critically ill populations?
3. How many people who develop cognitive impairment progress to dementia?
- b. Detecting and monitoring delirium
- i. We recommend routine monitoring of delirium in adult ICU patients (+1B).
- ii. The Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist are the most valid and reliable delirium monitoring tools in adult ICU patients (A).
- c. Delirium risk factors
- i. Four baseline risk factors are positively and significantly associated with the development of delirium in the ICU: preexisting dementia, history of hypertension and/or alcoholism, and a high severity of illness at admission (B).
- ii. Coma is an independent risk factor for the development of delirium in ICU patients (B).
- iii. Conflicting data surround the relationship between opioid use and the development of delirium in adult ICU patients (B).
- iv. Benzodiazepine use may be a risk factor for the development of delirium in adult ICU patients (B).
- v. There are insufficient data to determine the relationship between propofol use and the development of delirium in adult ICU patients (C).
- vi. In mechanically ventilated adult ICU patients at risk of developing delirium, dexmedetomidine infusions administered for sedation may be associated with a lower prevalence of delirium compared with benzodiazepine infusions (B).
1. Does a reduction in modifiable risk factors for development of delirium prevent or ameliorate post-ICU cognitive impairment?
2. Does choice of sedatives and potential reduction in delirium prevent or ameliorate post-ICU cognitive impairment?
- d. Delirium prevention
- i. We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the prevalence and duration of delirium (+1B).
- ii. We provide no recommendation for using a pharmacologic delirium prevention protocol in adult ICU patients, as no compelling data demonstrate that this reduces the prevalence or duration of delirium in these patients (0, C).
- iii. We provide no recommendation for using a combined nonpharmacologic and pharmacologic delirium prevention protocol in adult ICU patients, as this has not been shown to reduce the prevalence of delirium in these patients (0, C).
- iv. We do not suggest that either haloperidol or atypical antipsychotics be administered to prevent delirium in adult ICU patients (–2C).
- v. We provide no recommendation for the use of dexmedetomidine to prevent delirium in adult ICU patients, as there is no compelling evidence regarding its effectiveness in these patients (0, C).
1. Can prevention of delirium decrease the risk of post-ICU cognitive impairment?
2. Can prevention of delirium decrease the risk of PTSD in patients or family members/caregivers?
3. Is it the early physical therapy, being alert, or the prolonged interaction with caregivers that may impact cognitive dysfunction?
4. Which patient characteristics predict benefit from interventions with mobilization and exercise?
5. What is the optimal dose (frequency, duration, and intensity) of mobility and exercise for the patient in the ICU?
6. What is the optimal construction or sequencing for interventions (e.g., begin with the most difficult or the easiest tasks) to achieve positive outcomes at discharge and long term?
7. Which criteria inform response to mobilization or exercise (e.g., patient tolerance and benefit from the load of increased activity)?
8. What is the relationship between provision of mobilization/exercise and ICU, hospital, LOS, and discharge disposition (home vs extended care)?
9. What is the long-term relationship between provision of mobilization/exercise with physical disability, cognitive impairments, mental health issues, and quality of life?
10. What is the feasibility of mobilization/exercise in unique patient populations (e.g., obese patients, patients on extracorporeal membrane oxygenation)?
11. Which strategy(s) for promotion of a culture of early mobility within the ICU produces the best outcomes?
12. Does electrophysiological testing in the ICU differentiate patients who have true ICU-acquired weakness from those who have simple deconditioning?
13. What is the optimal dose (frequency, duration, and intensity) of mobility and exercise for the patient in the ICU?
14. What are the optimal modes for interventions, including contributions from technologies, for exercise and mobilization for the patient in the ICU?
15. What is the relationship between reducing delirium and long-term cognitive and mental health outcomes?
16. What post-ICU cognitive and/or physical rehabilitation interventions will improve cognitive and mental health outcomes?
17. What is the long-term relationship between provision of mobilization/exercise with physical disability, cognitive impairments, mental health issues, and quality of life?
18. What is the feasibility of mobilization/exercise in unique patient populations (e.g., obese patients, patients on extracorporeal membrane oxygenation)?
19. What levels of clinical expertise or competencies among physical therapists, speech and language pathologists, rehabilitation specialists, psychologists, etc., are needed in treating patients in the ICU?
20. What other within- and post-ICU interventions prevent or ameliorate PICS morbidities?
21. Does family involvement in care result in earlier patient mobility?
22. Does family involvement in promotion of early mobility affect functional physical outcomes for critically ill patients?
23. Does family involvement in promotion of early mobility affect functional cognitive outcomes and mental health outcomes for critically ill patients?
24. Does family involvement in early patient mobility affect long-term mental health outcomes in the family?
- e. Delirium treatment
- i. There is no published evidence that treatment with haloperidol reduces the duration of delirium in adult ICU patients (no evidence).
- ii. Atypical antipsychotics may reduce the duration of delirium in adult ICU patients (C).
- iii. We do not recommend administering rivastigmine to reduce the duration of delirium in ICU patients (–1B).
- iv. We do not suggest using antipsychotics in patients at significant risk for torsades de pointes (i.e., patients with baseline prolongation of corrected QT interval (QTc) interval, patients receiving concomitant medications known to prolong the QTc interval, or patients with a history of this arrhythmia) (–2C).
- v. We suggest that in adult ICU patients with delirium unrelated to alcohol or benzodiazepine withdrawal, continuous IV infusions of dexmedetomidine rather than benzodiazepine infusions be administered for sedation to reduce the duration of delirium in these patients (+2B).
1. Does faster resolution of delirium decrease the risk of post-ICU cognitive dysfunction and/or other mental health morbidities (depression, anxiety, and PTSD)?
4. Strategies for Managing Pain, Agitation, and Delirium to Improve ICU Outcomes
- a. We recommend either daily sedation interruption or a light target level of sedation be routinely used in mechanically ventilated adult ICU patients (+1B).
- b. We suggest that analgesia-first sedation be used in mechanically ventilated adult ICU patients (+2B).
- c. We recommend promoting sleep in adult ICU patients by optimizing patients’ environments, using strategies to control light and noise, clustering patient care activities, and decreasing stimuli at night to protect patients’ sleep cycles (+1C).
- e. We recommend using an interdisciplinary ICU team approach that includes provider education, preprinted and/or computerized protocols and order forms, and quality ICU rounds checklists to facilitate the use of pain, agitation, and delirium management guidelines or protocols in adult ICUs (+1B).
1. What is the role of disrupted sleep in development of long-term cognitive dysfunction, PTSD, and other psychiatric sequelae?
2. Does use of brochures for family members regarding sedation, sleep, and pain management help to mitigate long-term psychiatric distress in family members?
3. Can interventions to improve sleep improve long-term cognitive function?
4. Can integration of family members on rounds decrease mental health outcomes for families long-term?
5. Does light sedation provide an opportunity for increased cognitive activities such as direct patient participation in the creation of an ICU diary?
6. If so, does patient involvement in the creation of a diary affect long-term psychological outcomes?
7. After transitioning to a light sedation protocol, does the ability to directly communicate with the patient change the prevalence of long-term mental health outcomes in the patient and/or family?
cognitive impairments; critical care illness; delirium; immobility; ICU; pain; physical rehabilitation
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