Guidelines

In an attempt to standardise and improve patient outcomes in the ICU, a variety of guidelines have been produced. Some of the latest guidelines can be found in this section.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit (Barr et al., 2013).

  • A central principle of the 2013 guidelines is the importance of managing pain, agitation/sedation and delirium (PAD) in critically ill patients in an integrated and interdisciplinary fashion.
  • These guidelines highlight that the first step in the management of an ICU patient is to control pain, then to control agitation and delirium.
  • Compared with previous versions of these guidelines, the 2013 PAD guidelines are more evidence-based and patient-centred.
  • This guideline has been widely accepted.

Key points

  • The guidelines advocate an 'assess, treat, prevent' approach to PAD management.
  • It is suggested that analgesia-first sedation be used in mechanically ventilated adult ICU patients..
  • PAD guidelines recommend that pain, agitation and delirium should be routinely monitored.
  • They also suggest that sedatives should be titrated to promote a light level of sedation rather than deep sedation.
  • Early mobilisation should be performed whenever feasible to reduce the incidence and duration of delirium

Evidence and consensus based guideline for the management of delirium, analgesia and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version (DAS-Taskforce, 2015).

  • This German guideline is the only country-specific comprehensive PAD management guidance to date.
  • Evidence used to formulate the guideline recommendations was reviewed and approved by representatives of 17 German national societies.
  • This guideline is intended for all ICU professionals, and encompasses all critically ill patient populations.

Key points

  • Recommends the use of light sedation for all suitable patients with a target RASS level of 0/-1.
  • Proposes a new nomenclature for sedation as a RASS score ≤-2 with RASS scores of 0/-1 no longer classified as sedation although they may be achieved using sedatives.
  • Suggests the routine use of nonpharmacological delirium prevention strategies for all ICU patients.
  • The routine monitoring of pain, sedation and delirium is recommended.

Comfort and patient-centred care without excessive sedation: the eCASH concept (Vincent et al., 2016).

  • eCASH stands for early comfort using analgesia, minimal sedatives and maximal humane care.
  • A proposed concept that provides an integrated and adaptable approach to improving patient care in the ICU
  • The protocol suggests the use of effective analgesia and light sedation as a priority early in critical care.
  • It represents an evolution of the PAD guidelines with a strong focus on the promotion of sleep, early mobilisation and improved communication between patients, staff and relatives.

The ABCDEF bundle

(Available at http://icudelirium.org/medicalprofessionals.html)

  • An approach to align and coordinate care in the ICU based on the PAD management guidelines.
  • It was developed by the Institute for Healthcare Improvement in the USA.
  • Provides a suggested method to implement best practice at the ICU ward level.
  • ABCDEF is a mnemonic that stands for:

Assess, prevent and manage pain
Both spontaneous awakening trials and spontaneous breathing trials
Choice of analgesia and sedation
Delirium: Assess, prevent and manage
Early mobility and exercise
Family engagement and empowerment