In January 2013, The Society of Critical Care Medicine (SCCM) published the Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. This website is one of the tools offered to clinicians worldwide to achieve an aim of enhanced knowledge transfer of interventions to the bedside with special focus on the recent guidelines as well as assessment tools.
The use of valid and reliable bedside assessment tools to measure Pain, Agitation, and Delirium (PAD) in ICU patients leads to better recognition and management of these important issues. Yet the use of these assessment tools is still limited in clinical practice. Our expanded knowledge of the clinical pharmacology of medications commonly administered for PAD has enabled us to better understand the short- and long-term consequences of prolonged exposure to these agents. The methods of administering and titrating pain and sedative medications affect patient outcomes as much as drug choice. For most ICU patients, a safe and effective strategy ensuring patient comfort while maintaining a light level of sedation has been proven to lead to improved clinical outcomes. However, like with many other evidence-based improvements in care, the use of a light sedation strategy has not been reliably incorporated into ICU care.
Over the past decade, we have gained greater insight into the epidemiology of delirium in critically ill patients. We now know 60% to 80% of mechanically ventilated adult ICU patients experience delirium. Those patients have a subsequent increased risk of death. Even for those patients who survive, ICU delirium is a serious problem leading to an increased risk of long-term cognitive dysfunction. Many studies have shown that ICU delirium cannot be accurately diagnosed unless a valid and reliable delirium assessment tool is used.
Neuromuscular weakness can occur in 25% to 50% of ICU patients and last for years after hospital discharge. Early mobilization therapy is the evidence-based intervention recommended to prevent or ameliorate ICU–acquired weakness. Early and progressive rehabilitation is safe for ICU patients, can reduce the incidence and duration of delirium, can shorten ICU and hospital length of stay (LOS) and can lower hospital costs. As such, early mobility is a key tool in combatting the problems of pain, agitation, and delirium.
As noted above, a number of studies have shown that ICU ventilator weaning protocols, maintaining light levels of sedation in ICU patients, and early mobility protocols can all individually improve patient outcomes. However, the greatest benefit has been shown when these interventions are combined together. For example, the Awakening and Breathing Coordination (ABC) trial that combined spontaneous awakening trials (SAT) with spontaneous breathing trials (SBT) reduced the duration of mechanical ventilation (MV) by 3 days, ICU and hospital LOS by 4 days, and decreased risk of death by 32%. Linking an ABC trial with an early mobility (EM) protocol further reduces ICU LOS by 1.4 days and hospital LOS by 3.3 days. Linking an EM protocol to SATs significantly reduces the incidence of delirium, and results in a 3-fold increase in the likelihood that patients will achieve an independent functional status at hospital discharge.
Although there has yet to be good evidence of the added benefit of combining all of the interventions in the PAD guidelines, it is clear that the effect will be large and revolutionary in its impact on ICU patients and their families.