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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Enteral nutrition in the ICU: How we should be feeding our critically ill patients.

Link to Article

Link to PDF

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

These are the ASPEN guidelines that were published in 2016. They were created to assist us in providing patients with appropriate nutrition while they recover from critical illness. This paper is free and although the 53 pages seem intimidating, the last 11 pages are the references. Also, the font is large and the format is easy to digest as it is laid out in a question/answer type format. I honestly look forward to the updated guidelines but these have a bunch of goodies that I do not feel the vast majority of my colleagues are aware of. I must admit, the majority of the recommendations are based on consensus rather than solid data. If that's what we have, though, we must make do while asking healthy questions.

Fun facts I've picked up on re-reading these guidelines that I had missed out on previous reads and that I may or may not have known:
- clear liquid diet is not necessary after post-op. Patients can be provided with solid food.
- patients should be getting 1.2-2.0g/kg of body weight of protein/ day. Some standard tube feeds may not reach this target in certain patients.
- I knew this but it begs reminding: DO NOT CHECK RESIDUALS!
- fancy formulas may be more confusing that practical for a standard patient in the MICU at the time of this publication.
- they made no recommendations for probiotics but I have found data stating otherwise.
- don't bother with high-fat low carb formulations for reps failure
- check phosphorus levels regularly in respiratory failure patients. That was you can replace the K with K/Phos instead of compartmentalizing the electrolytes.
A 🎩 tip to the many contributors to this guideline.

That's enough for today
-EJ