Guidelines for Pain, Agitation/Sedation, Delirium in the ICU

I am currently working on a lecture where I discuss reducing the utilization of opioids in the ICU for our critically ill patients. The sources of pain are plentiful, unfortunately. Truth is, opioids are the best option for our patients at the time of this writing but we also need to work hard to try to minimize the exposure to this family of medications via alternatives. Which alternatives might you ask? In particular, I have taken deep dives into the utilization of ketamine, magnesium, gabapentin/pregabalin, NSAIDS, nefopam, acetaminophen, dexmedetomidine, as well as regional blocks performed by our anesthesia colleagues. 

The PADIS (pain, agitation/sedation, delirium, immobility, and sleep disruption) guidelines linked here, and are completely FREE to download, provide some direction as to how to better take care of our patients. When I write these lectures, and this may seem counterintuitive to some, I leave the guidelines for last and attempt to read everything under the sun on the topic so that it does not cloud my interpretation. I had read these guidelines in 2018 when they initially came out but now I have even more respect for the section on pain management bc the quality of the studies just aren't as good as we want them to be. Hence the "very low quality of evidence" tied to many of the recommendations made. I surprised that they even made a dosing recommendation for ketamine as the dosing behind most of the articles are pretty scattered.  

These guidelines are a monumental undertaking and I send a definite hat tip to the authors.

Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825–e873.

-EJ

Link to FULL FREE Article



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Delirium in Mechanically Ventilated Patients: Let the Natural Light in!

I have great disdain for delirium. Natural light brings me great joy. Today, for example, the sun isn't shining bright. The day is cloudy and gloomy. I am, in turn, a little grouchy. Daylight savings is coming and I'm already upset about it. I can turn on the light but it won't be the same. This study was published today. How's that for so fresh and so clean?

Preventing and treating delirium is something we haven't quite figured out just yet. But studies like this one help us chip away at that giant piece of rock to eventually present a great sculpture. Bad analogy? Yep! In this study, the authors were curious to see whether patients having natural light would affect the incidence of delirium in patients who are on the ventilator (primary outcome). The secondary outcomes included the "duration of delirium, duration of coma, use of antipsychotics to treat agitation, the incidence of hallucinations, the incidence of self-extubation, duration of mechanical ventilation, ICU and hospital length of stay, ICU and hospital mortality."

This was a single centered trial with 195 patients. Out of their measured outcomes, they noted that the patients exposed to natural light had a reduced incidence of severe agitation (p=0.04). In addition, the patients exposed to natural light also had fewer hallucinations (p=0.04). Fortunately, this study is free and you can download it and read it yourself. I like natural light. It's free. It may not ameliorate delirium, but it is another tool in our tool belt to make these patients better.
-EJ

Link to Abstract

Link to full free PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Benzodiazepine use should be minimized for sedation in the ICU

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

Team, I'll get to making this whole post prettier in the AM when I have some rest under my belt. I saw everyone chiming in on bedsideroundz’ page how they provide versed/midazolam for sedation in their critically ill patients and I had no choice but to put off my bedtime for a few hours and work on this post instead. A 🎩 tip to bedsideroundz for shining some indirect light to this conversation. Here are the official 2018 guideline statements regarding utilizing benzodiazepines such as midazolam/versed.
"The 2013 guidelines suggested targeting light levels of sedation or using daily awakening trials, and minimizing benzodiazepines to improve short-term outcomes (e.g., duration of mechanical ventilation and ICU LOS)."
"...sedation with benzodiazepines, which are no longer recommended for sedation in critically ill patients"
"The 2013 PAD guidelines suggest (in a conditional recommendation) that nonbenzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults because of improved short-term outcomes such as ICU LOS, duration of mechanical ventilation, and delirium"
"We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery"
"...shorter time to extubation with propofol versus a benzodiazepine"
"Overall, the panel judged that the desirable consequences of using propofol probably outweigh the undesirable consequences, and thus issued a conditional recommendation favoring propofol over a benzodiazepine."
"We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults"
"the study by Xu et al also showed reduced delirium with dexmedetomidine use"
"the Dexmedetomidine Versus Midazolam for Continuous Sedation in the ICU (MIDEX) study demonstrated a shorter duration of mechanical ventilation with dexmedetomidine over a benzodiazepine infusion"

I'll post some more later. Please read the article for yourself. Don’t trust what I post.

-EJ.




Link to abstract

Link to PDF

Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, Agitation/Sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.Crit Care Med 2018;46:e825–73.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

The effect of melatonin on delirium in hospitalised patients: A systematic review and meta-analyses with trial sequential analysis

Link to Abstract

Link to PDF

We are all trying to combat delirium by all possible means. Getting pts their glasses and hearing aides. Keeping the lights on during the day. Having family around to speak to them. We’ve also had recent trials which have been quite disappointing using medications. Could there be a good cheap medication to prevent #delirium? This paper on using #melatonin is a strong meta analysis that looks into this and could potentially change my practice... but not for the reasons on the surface. I’ve even recently heard of using melatonin for sepsis, but that’s a discussion for another day and something else I’m going to dig into. Either way, a 🎩 tip to the authors.

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.