9. P-A-D guidelines 2013
• Routine assessment of pain in all adult ICU
patients by self reporting NRS (0-10)
• Behavioral Pain Scale (BPS) and the Critical-Care
Pain Observation Tool (CPOT) are the most valid
and reliable behavioral pain assessment tools
• Vital signs (or observational pain scales that
include vital signs) be used alone for pain
assessment in adult ICU patients, but as a cue to
further assess pain.
13. P-A-D guidelines 2013
• IV opioids as first-line drug to treat
nonneuropathic pain.
• All IV opioids, when titrated to similar pain
intensity endpoints, are equally effective.
• Enteral gabapentin or carbamazepine in addition
to IV opioid for neuropathic pain are
RECOMMENDED
• Non-opioid analgesics may reduce dose or need
for IV opioids
14. P-A-D guidelines 2013
• Sedation using non-benzodiazepine sedatives
(propofol or dexmedetomidine) over
benzodiazepines (midazolam/lorazepam) to
improve clinical outcomes in mechanically
ventilated ICU patients
15. Compared with traditional sedatives, long-term sedation using
dexmedetomidine in critically ill adults reduced the duration of
mechanical ventilation and ICU length of stay.
16. Dexmedetomidine might be associated with lower ICU
stay when compared with traditional sedative agents.
The included studies showed that dexmedetomidine
was associated with a shorter period of mechanical
ventilation than the compared groups.
Dexmedetomidine was associated with decrease in the
risk of delirium.
Bradycardia was reported in higher rates in
dexmedetomidine groups than comparators
17. Monitoring sedation
• The RASS and SAS are the most valid and
reliable sedation assessment tools for
measuring quality and depth of sedation in
adult ICU patients
• PAD guidelines do not recommend objective
measures of brain function (AEP, BIS,
Narcotrend, PSI, or state entropy) be used as
the primary method to monitor depth of
sedation in non-comatose, non-paralyzed
critically ill adult patients.
20. “RASS demonstrated excellent interrater reliability and criterion,
construct, and face validity. This is the first sedation scale to be
validated for its ability to detect changes in sedation status over
consecutive days of ICU care, against constructs of level of
consciousness and delirium, and correlated with the
administered dose of sedative and analgesic medications”
21. • Analgesia-first sedation be used in adult ICU
patients who are mechanically ventilated
• Light levels of sedation is associated with
improved clinical outcomes
22. Protocol vs non-protocol sedation
• protocol-directed sedation can reduce the
duration of mechanical ventilation, ICU stay
and hospital lengths of stay, and the need for
tracheostomy among critically ill patients with
acute respiratory failure.
24. A recent Cochrane review
There is currently insufficient evidence to evaluate the effectiveness of protocol-
directed sedation. Results from the two RCTs were conflicting, resulting in the quality
of the body of evidence as a whole being assessed as low. Further studies, taking into
account contextual and clinician characteristics in different ICU environments, are
necessary to inform future practice. Methodological strategies to reduce the risk of
bias need to be considered in future studies.
25. Daily sedation interruption?
We have not found strong evidence that DSI alters the duration of mechanical
ventilation, mortality, length of ICU or hospital stay, adverse event rates, drug
consumption, or quality of life for critically ill adults receiving mechanical
ventilation compared to sedation strategies that do not include DSI.
26. PAD guidelines 2013: Delirium
• Delirium is associated with:
increased mortality in adult ICU
prolonged ICU and hospital lengths of stay in
development of post-ICU cognitive
impairment in adult ICU patients
27. • Routine monitoring for delirium with the
CAM-ICU or the Intensive Care Delirium
Screening Checklist (ICDSC) - the most valid
and reliable delirium monitoring tools in adult
ICU patients is recommended.
30. Delirium prevention
• PAD guidelines provide no recommendation
for:
the use of dexmedetomidine to prevent
delirium.
pharmacological or non-pharmacological
delirium prevention.
31. • PAD guidelines do not suggest that
haloperidol or atypical antipsychotics be
administered to prevent delirium in ICU
patients.
• Recommend that early mobilization be
performed to reduce the incidence and
duration of delirium
33. Quitapine?
• Quetiapine added to as-needed haloperidol results in faster
delirium resolution, less agitation, and a greater rate of
transfer to home or rehabilitation.
35. Dexmedetomidine vs Midazolam
At comparable sedation levels, dexmedetomidine-treated
patients spent less time on the ventilator, experienced less
delirium, and developed less tachycardia and hypertension.
The most notable adverse effect of dexmedetomidine was
bradycardia.
38. Paralysis in ICU: When to do?
• Facilitate mechanical ventilation if patients
can’t tolerate even with appropriate sedation
• non-conventional ventilatory strategies such
as permissive hypercapnia, prone positioning,
use of high levels of PEEP, and high frequency
oscillatory ventilation.
41. Which NMBA?
• At present, there are limited data to support
the use of one NMBA over another in critically
ill patients.- Crit Care Med 2004;32(11 Suppl):S554-S561
• Pancuronium/ vecuronium- prolonged in
hepatic/ renal dysfunction
• Atracurium- histamine release & seizure due
to laudonosine after prolonged infusion
42. • Steroidal NMBA- concern of myopathy when
used along with corticosteroids-
• Cautious use is recommended in asthmatics
43. Paralysis: What to monitor
• Depth of paralysis: TOF-
• Usefulness is controversial
Notes de l'éditeur
Rivastigmine did not decrease duration of delirium and might have increased mortality so we do not recommend use of rivastigmine to treat delirium in critically ill patients.
In patients with severe ARDS, early administration of a neuromuscular blocking agent improved the adjusted 90-day survival and increased the time off the ventilator without increasing muscle weakness.
