Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

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 (http://www.gradeworkinggroup.org) 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 (http://www.esurvey.com). 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.

Pain experiences of traumatically injured patients in a critical care setting.

BACKGROUND: Little is known about the acute pain experiences of traumatically injured critically ill patients. OBJECTIVES: To describe pain experiences of traumatically injured adults during the first 72 hours of hospitalization. METHODS: Thirty multiply injured adults at a level I trauma center participated in the study. Pain was measured by using the McGill Pain Questionnaire and a visual analog scale. Subjects completed pain measures while at rest in a supine recumbent position and after a turn onto the side. RESULTS: The typical subject was 37 years old, had 4 major blunt trauma injuries, and had received the equivalent of 55.9 mg of morphine during the 24 hours before data collection. Mean at-rest scores were 26.5 on the pain-rating index, 2 on the present pain intensity index, and 34.6 on the visual analog scale. Immediately after the turn, mean scores on the visual analog scale increased from 25 to 48.1 (P = .002). Other pain scores after the turn did not differ significantly from at-rest values. Subjects who turned had lower scores on the visual analog scale at rest (P = .02) and less anxiety (P = .02) than did those who refused to turn. Ninety-six percent reported pain in the injured areas, and 36% reported pain related to biomedical devices. No relationship was found among reported pain and demographic, treatment, or clinical variables. CONCLUSIONS: Additional research is needed on pain at rest and during commonly performed procedures and on improved methods for pain relief in traumatically injured critically ill patients.

Beyond the essentials. Teaching critical care to undergraduate and graduate students in nursing.

With more new graduates entering the critical care setting and with the evolving role of the advanced practice nurse, teaching critical care content to students in nursing is a challenge for faculty. The burden to educate undergraduate novices and advanced practice nurses to care for the complex critically ill patient is costly for health care agencies. To help prepare the generalist to enter a world of specialty, precepted critical care experiences, faculty/critical care nurse collaboration, critical care simulation experiences, a computerized entry-level critical care examination, and a National Fellowship critical care registry are suggested. Teaching strategies for the advanced practice nurse beyond the American Association of Colleges of Nursing's "essentials" document include consideration of expanded science education, simulation for psychomotor skills and diagnostic reasoning cases, and interdisciplinary education for bioethics and business courses. Although such controversies as preparing the generalist for a specialty and the availability of preceptors continue to be debated, the future of critical care education is exciting and challenging. As technology continues to evolve, and the consumer in a market-driven society becomes more involved and inquisitive, the need for caring remains. That is the joy of teaching critical care nursing.

Designing humanistic critical care environments.

The critical care environment can be designed to become more humanistic. Consideration of the environmental challenges of noise, lights, color, views, temperature, and comfort is essential. This article identifies the issues and concerns in the design of more humanistic healing in critical care units. Strategies to improve the environment include improving the physical and emotional tone of the unit through creative design, family and pet visitation, sleep promotion, and aromatherapy among others. In a life-threatening illness, attention paid to these concerns may significantly improve quality of life for patients and family.

Therapeutic considerations in the management of agitated or delirious critically ill patients.

Agitation and delirium in the critical care unit are common problems that at times are difficult to treat. The difficulty stems from few placebo-controlled or even blinded trials evaluating various therapies. In addition, the literature in these areas is scattered through various journals in a variety of disciplines. Pharmacologic and nonpharmacologic techniques may achieve the therapeutic objective for these patients. Since no one drug will achieve the goals in every patient, therapy must be tailored to the characteristics and needs of each individual.

Lessons from a mentor: a dance for two.

The powerful relationship between a teacher and student of nursing is described through stories that illustrate three lessons: (1) Caring gets results, (2) family comes first, and (3) passionate commitment is contagious. These are the lessons I learned from my mentor, Dr Cathie Guzzetta. Textbooks can tell part of a story, but the "dance for two" between a special teacher and a student can change perspectives and lives forever.

Sleep in the pediatric ICU: an empirical investigation.

BACKGROUND: Although sleep is important for physical and psychological health, no research has assessed the sleep of children in a pediatric ICU and the factors that affect sleep. OBJECTIVES: To observe the sleep of children in a pediatric ICU and to determine the relationship of noise, light, contact with caregivers, parental presence, and severity of illness to the sleep obtained by children in a pediatric ICU during a 10-hour night. METHODS: At 5-minute intervals from 8 PM until 6 AM, a convenience sample of nine patients was observed. Sleep state, noise and light levels, contact with caregivers, and parental presence were recorded. Severity of illness was measured on admission and within 26 hours of data collection. RESULTS: Subjects slept for a mean total of 4.7 hours (SD = 0.49) during the 10-hour night, interrupted by a mean of 9.8 awakenings (SD = 2.48). The mean length of a sleep episode was only 27.6 minutes (SD = 25.85). Mean noise level was 55.1 dB(A) (SD = 6.82), with sudden, sharp elevations of up to 90 dB(A). Probit analysis indicated that noise, light, and contact with caregivers were significant predictors of sleep. Parental presence and severity of illness were not. CONCLUSIONS: Patients in the pediatric ICU sleep significantly less than is normal for children of the same ages, and their patterns of sleep are seriously disturbed. Because noise, light, and contact with caregivers are significant predictors of sleep state, health professionals can use these findings to structure the environment and the care they give to promote the sleep of critically ill children.

Nonpharmacologic management of patient distress during mechanical ventilation.

Patients on mechanical ventilators experience distress related to the endotracheal tube, the critical care environment, and the critical illness. The strategies suggested here to limit distress--therapeutic relationship building and communication, cognitive-behavioral therapies, and contracted family visiting--all can be implemented by critical care providers. A growing research base documents the success of these interventions in intubated patients.

Measurement of nocturnal sleep patterns in trauma patients.

Sleep pattern disturbance is a common occurrence in critical care units. Nurses are often unaware of the magnitude of the sleep disturbance because of a lack of reliable, valid and feasible measures to assess sleep patterns. The purpose of this study was to determine the reliability and validity of a sleep perception tool and a sleep observation instrument for the trauma patient in a critical care setting. The research investigated the relationships among the measures of observed sleep, patient perception of sleep, and polysomnograph sleep data on the sleep traits: sleep latency, midsleep awakening, and wake after sleep onset. A purposive sample of 20 patients with multisystem trauma participated in this descriptive correlational study. Instruments used to measure sleep for one night were the Dynograph R-511A, the Patient's Sleep Behavior Observational Tool, and the Verran/Snyder Halpern Sleep Scale. Results of the multitrait-multimethod analysis revealed that observed wake after sleep onset met all the criteria for convergent and discriminant validity, with perceived awakenings demonstrating convergent validity alone with polysomnographic awakenings lasting longer than 4 minutes. All sleep variables were reliable. It is concluded that nursing observation of trauma patients' wakefulness can be used to test sleep-promoting interventions.

Positioning as a nursing therapy in trauma care.

The therapy of patient positioning is an independent nursing intervention with profound implications for improving the outcomes of trauma patients. With knowledge of disease pathophysiology and the effects of position variations, the nurse can use available assessment parameters to guide positioning choices to optimize the patient's condition. Undoubtedly, further nursing research exploring the effects of positioning on pulmonary and cerebrovascular status is necessary to enhance the scientific basis for this nursing therapy.

Physical, personal, and cognitive responses to trauma.

This article has presented an overview of important physical, personal, and cognitive responses to trauma that are necessary to provide enlightened critical care for the multiple trauma patient. The nurse who understands the full range of responses to trauma is better able to harness the patient's natural healing ability and promote optimal recovery. The unique pattern of responses that characterize the critically ill trauma patient provides a special challenge for the critical care nurse.