Pain, anxiety and delirium are frequent symptoms of our ICU patients and are known to be related to adverse outcomes. Early management of these symptoms results in improved recovery and outcome, but this is easier said than done. Ensuring that critically ill patients are free from these devastating symptoms can conflict at times with other clinical management goals and increase the workload. Therefore, practical oriented and solid up-to-date evidence based guidelines are of paramount importance in order to optimise the care of the ICU patient.
Such a guideline concerning the management of delirium, analgesia and sedation is now available (1). Recently, a conglomerate of 17 participating German societies has updated and extended their guideline (called the DAS-guideline) concerning this topic, using the highest standards of development. They have included the vast body of new evidence (including the recommendations of the ACCM (2), SCCM and ASHP) and extended their scope to include new aspects of treatment, such as sleep and anxiety management. This resulted in an extensive, practice oriented guideline with emphasis on implementing non-pharmacological interventions aimed at prevention, extensive monitoring of these symptoms using validated instruments and early goal directed therapy. Furthermore, they included several useful algorithms to facilitate the implementation of these guidelines in clinical practice. The guideline also elaborates on specific patient populations, such as children, elderly and severe burn injured patients among others.
These are several of their key messages for the adult ICU patient (for more information, one is strongly advised to read the guidelines):
- Patient-centered strategies for analgesia and sedation are recommended.
- The treatment target and current degree of analgesia, sedation, and anxiety should be documented at least once per shift with the use of validated scales.
- Risk factors should be evaluated at regular times.
- Sedation should be avoided.
- Non-pharmacological preventive strategies, such as early mobilisation, cognitive stimulation and reorientation, are recommended.
- A prompt initialisation of a symptomatic therapy of delirium is recommended.
- A continuous application of alpha-2-agonists for delirium therapy is recommended.
- Non-pharmacological measures can be considered in order to reduce pain and anxiety, such as use of muscular resources and cognitive stimulation.
- The use of opioid-based analgesia is suggested.
- The use of epidural catheters is advised where applicable.
- A target RASS of 0/-1 for all ICU patients is recommended and sedation must be reserved only for patients with specific indications (e.g. increased intracranial pressure).
- Daily spontaneous awakening trials and spontaneous breathing trials are only recommended in patients with a RASS ≤-2, if there are no contraindications.
Remarkably, the guideline specifically emphasises that the ultimate goal is to assure that the critically ill patient should be awake and alert, without pain, anxiety or delirium, so they can participate in their treatment and recovery. Envisioning the ICU patient as an alert companion of the ICU physician in their treatment is truly a “paradigm-shift”.
This article review was prepared and submitted by Steven Thiessen on behalf of the NEXT Committee.
(1) 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; Ger Med Sci. 2015; 13.
(2) Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Barr et al. ACCM; Crit Care Med. 2013; 41(1): 263-306.