Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients.

INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. METHODOLOGY: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. CONCLUSIONS: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.

Evidence-based clinical practice guidelines for the management of sedoanalgesia and delirium in critically ill adult patients. / Guías de práctica clínica basadas en la evidencia para el manejo de la sedoanalgesia y delirium en el paciente adulto críticamente enfermo.

Given the importance of the management of sedation, analgesia and delirium in Intensive Care Units, and in order to update the previously published guidelines, a new clinical practice guide is presented, addressing the most relevant management and intervention aspects based on the recent literature. A group of 24 intensivists from 9 countries of the Pan-American and Iberian Federation of Societies of Critical Medicine and Intensive Therapy met to develop the guidelines. Assessment of evidence quality and recommendations was made according to the Grading of Recommendations Assessment, Development and Evaluation Working Group. A systematic search of the literature was carried out using MEDLINE, Cochrane Library databases such as the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL), the Database of Abstracts of Reviews of Effects, the National Health Service Economic Evaluation Database and the database of Latin American and Caribbean Literature in Health Sciences (LILACS). A total of 438 references were selected. After consensus, 47 strong recommendations with high and moderate quality evidence, 14 conditional recommendations with moderate quality evidence, and 65 conditional recommendations with low quality evidence were established. Finally, the importance of initial and multimodal pain management was underscored. Emphasis was placed on decreasing sedation levels and the use of deep sedation only in specific cases. The evidence and recommendations for the use of drugs such as dexmedetomidine, remifentanil, ketamine and others were incremented.

[Transcultural adaptation to the Spanish language of the Balance Evaluation Systems Test (BESTest) in older adults]. / Adaptacion transcultural al castellano del sistema de evaluacion del equilibrio (BESTest) en adultos mayores.

INTRODUCTION: The risk of falls in older adults increases because of the decrease in strength, flexibility, balance and sensory changes affecting functionality and quality of life. For this reason, an integral system of evaluation of equilibrium is necessary, for preventive purposes or for early therapeutic interventions. AIM: To present the results of the transcultural translation and adaptation process of the Balance Evaluation Systems Test (BESTest) to Spanish language. SUBJECTS AND METHODS: The original version of the BESTest was translated into Spanish, following the process of retro-traduction and cultural adaptation considering the semantic, idiomatic, conceptual and experiential equivalences. Subsequently the version was reviewed by a panel of experts qualifying clarity, coherence, relevance and sufficiency. The pilot test included 32 adults between 50 and 80 years old. RESULTS: It was possible to carry out the complete translation of the instrument, the instructions for the subject and for the evaluator. Most items of the test reached the maximum score of 4.0 (100%), nine items achieved an average score of 3.9 (99%), one item got an average score of 3.8 (95%) and two items achieved an average score of 3.7 (92.5%). CONCLUSIONS: With this study the Spanish speakers community has a pertinent sufficient, coherent and clear instrument in order to identify the control postural system altered to focus treatment and to get better functional outcomes from balance evaluation in older adults.

TITLE: Adaptacion transcultural al castellano del sistema de evaluacion del equilibrio (BESTest) en adultos mayores.Introduccion. El riesgo de caidas en adultos mayores se incrementa a consecuencia de la disminucion de la fuerza, la flexibilidad, el equilibrio y los cambios sensoriales, que afectan a la funcionalidad y la calidad de vida. Por tal razon se hace necesario un sistema integral de evaluacion del equilibrio con fines preventivos o para intervenciones terapeuticas tempranas. Objetivo. Presentar los resultados del proceso de traduccion y adaptacion transcultural del sistema de evaluacion del equilibrio (BESTest) al castellano. Sujetos y metodos. Se tradujo al castellano la version original del BESTest, siguiendo el proceso de retrotraduccion y adaptacion cultural y teniendo en cuenta las equivalencias semanticas, idiomaticas, conceptual y experiencial. Posteriormente, la version fue revisada por un panel de expertos que califico la claridad, la coherencia, la pertinencia y la suficiencia. En la prueba piloto participaron 32 adultos de 50-80 años. Resultados. Se realizo la traduccion completa del instrumento y de las instrucciones para el sujeto y para el evaluador. La mayoria de items de la prueba alcanzaron la puntuacion maxima de 4 (100%), nueve items lograron una calificacion media de 3,9 (99%); un item, una calificacion media de 3,8 (95%), y dos items, una calificacion media de 3,7 (92,5%). Conclusiones. Con este estudio, la comunidad de habla hispana cuenta con un instrumento pertinente, suficiente, coherente y claro para identificar el sistema del equilibrio afectado, enfocar el tratamiento y obtener mejores resultados funcionales a partir de la evaluacion del equilibrio en adultos mayores.