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.

Neuromuscular blockade in the intensive care unit.

Neuromuscular blocking agents (NMBA) are frequently utilized in the ICU, primarily to facilitate mechanical ventilation. An ideal NMBA is nondepolarizing, has no propensity to accumulate, is easily titrated, has a rapid onset and offset, does not rely on organ function for metabolism, and has no toxic or active metabolites. Current NMBAs are classified as aminosteroids or benzylisoquinoliniums and have different features, but none are ideal. Selection of the best NMBA is determined by individual patient characteristics. Proper use of these agents includes a comprehensive plan to manage all aspects of care affected by NMBA, as well as monitoring of clinical effect and degree of neuromuscular blockade via periodic peripheral nerve stimulation. There are well-recognized complications of NMBA, including prolonged drug effect and acute quadriplegic myopathy. The latter condition can result in prolonged rehabilitation. The use of an NMBA can be essential for the successful outcome from critical illness; however, cautious use of these agents with a structured approach to minimize complications is urged.

Multidisciplinary management of sedation and analgesia in critical care.

Management of sedation and analgesia in critical care medicine is a multidisciplinary process that involves physicians, nurses, pharmacists, and other healthcare providers. Optimal management of these common issues includes recognition of the importance of predisposing and causative conditions that contribute to the sensations of pain and discomfort, anxiety, and delirium. Treatment includes pharmacological intervention, correction of predisposing factors, and use of other preventative and nonpharmacological measures. It is increasingly clear that, although necessary for patient comfort, sedative and analgesic medications can have adverse consequences, including side-effects as well as prolonged mechanical ventilation and ICU length of stay. Optimal use of sedative and analgesic medications involves matching unique properties of specific medications with individual patient characteristics. Guidelines that minimize unnecessary variability in practice, prevent excessive medication, and emphasize management based on individual patient characteristics improve the effective utilization of these medications.

Continuous measurement of backrest elevation in critical care: a research strategy.

OBJECTIVE: To develop and test a procedure for continuous measurement of backrest elevation in critical care for enhancing the precision of this measurement for research purposes. DESIGN: Descriptive, correlational. SETTING AND MEASUREMENTS: Backrest elevation, defined as the height of the head of the bed in degrees of elevation above horizontal, can be continuously monitored by using two transducers, one attached to the bed frame just distal to the head of the bed gatch and another attached to the bed frame at the top of the bed. By monitoring the differential head pressure between the two pressure channels, the height of the head of the bed can be calculated. A total of 30 random measurements of backrest elevation, from 0 degrees to 60 degrees, were taken by using the backrest elevation measurement on the bed frame, a handheld protractor, and the pressure differential between two transducers attached to the bed frame. Data collectors recorded one measurement independent of the other measurements. All measurements were conducted on the same bed. RESULTS: When the transduced method was compared with measurements by using a protractor, the Bland-Altman analysis technique yielded upper and lower limits of agreement of 8.93 degrees and -5.91 degrees, respectively. The bias was 1.51 degrees, and the precision was 3.71 degreees. CONCLUSIONS: The measurement technique described here was developed for research purposes to add precision to research studies examining the appropriate height of the backrest. However, the procedure could be used in a continuous quality improvement process to enhance compliance with patient care procedures involving backrest elevation or to confirm actual nursing practice and its correlation with patient outcome. In light of the risks associated with the use of supine positioning in critically ill and mechanically ventilated patients, the information gained from continuous measurement of backrest position could be an extremely valuable research tool.

Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic.

CONTEXT: Under routine hospital conditions handwashing compliance of health care workers including nurses, physicians, and others (eg, physical therapists and radiologic technicians) is unacceptably low. OBJECTIVES: To investigate the efficacy of an education/ feedback intervention and patient awareness program (cognitive approach) on handwashing compliance of health care workers; and to compare the acceptance of a new and increasingly accessible alcohol-based waterless hand disinfectant (technical approach) with the standard sink/soap combination. DESIGN: A 6-month, prospective, observational study. SETTING: One medical intensive care unit (ICU), 1 cardiac surgery ICU, and 1 general medical ward located in a 728-bed, tertiary care, teaching facility. PARTICIPANTS: Medical caregivers in each of the above settings. INTERVENTIONS: Implementation of an education/ feedback intervention program (6 in-service sessions per each ICU) and patient awareness program, followed by a new, increasingly accessible, alcohol-based, waterless hand antiseptic agent, initially available at a ratio of 1 dispenser for every 4 patients and subsequently 1 for each patient. MAIN OUTCOME MEASURE: Direct observation of hand-washing for 1575 potential opportunities monitored over 120 hours randomized for both time of day and bed locations. RESULTS: Baseline handwashing compliance before and after defined events was 9% and 22% for health care workers in the medical ICU and 3% and 13% for health care workers in the cardiac surgery ICU, respectively. After the education/feedback intervention program, handwashing compliance changed little (medical ICU, 14% [before] and 25% [after]; cardiac surgery ICU, 6% [before] and 13% [after]). Observations after introduction of the new, increasingly accessible, alcohol-based, waterless hand antiseptic revealed significantly higher handwashing rates (P<.05), and handwashing compliance improved as accessibility was enhanced-before 19% and after 41% with 1 dispenser per 4 beds; and before 23% and after 48% with 1 dispenser for each bed. CONCLUSIONS: Education/feedback intervention and patient awareness programs failed to improve handwashing compliance. However, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.

Endotracheal tube narrowing after closed-system suctioning: prevalence and risk factors.

BACKGROUND: Few data exist about buildup of secretions within endotracheal tubes of patients treated with closed-system suctioning in the intensive care unit. OBJECTIVES: To describe the extent, prevalence, and distribution of narrowing of endotracheal tubes related to buildup of secretions and to determine contributing factors. METHODS: Forty endotracheal tubes were examined within 4 hours of extubation, after at least 72 hours of use. Data on patients' daily weight and fluid balance, ventilator humidification temperatures, and nurses' descriptions of secretions during the 3 days preceding extubation were recorded. Any secretion debris in the endotracheal tubes was weighed. At 1-cm intervals along the tube, the debris was described and the depth of the debris was measured to the nearest 0.5 mm. RESULTS: Mean duration of intubation was 6.6 days. Two tubes had no debris. Mean overall depth of debris was 0.64 mm, mean greatest depth was 2.0 mm (range, 0-5 mm), and mean weight was 1.16 g. The entire tube was affected, with the greatest depth of debris at the 6- to 9-cm and 13- to 14-cm markings. Duration of intubation correlated with mean greatest depth of debris (r = 0.37, P = .02), mean overall depth of debris (r = 0.48, P = .002), and mean weight of debris (r = 0.38, P = .02). CONCLUSIONS: Endotracheal tubes are markedly narrowed by the buildup of secretions after closed-system suctioning. Duration of intubation, but not endotracheal tube size or amount of secretions, was associated with the degree of narrowing.

Mechanical ventilation of patients with acute lung injury.

Ventilatory management of patients with acute lung injury (ALI), particularly its most severe subset, acute respiratory distress syndrome (ARDS), is complex. Newer lung protective strategies emphasize measures to enhance alveolar recruitment and avoid alveolar overdistention, thus minimizing the risk of ventilator-induced lung injury (VILI). Key components of such strategies include the use of smaller-than-conventional tidal volumes which maintain peak transpulmonary pressure below the pressure associated with overdistention, and titration of positive end-expiratory pressure to promote maximal alveolar recruitment. Novel techniques, including prone positioning, inverse ratio ventilation, tracheal gas insufflation, and high frequency ventilation, are considerations in severe ARDS. No single approach is best for all patients; adjustment of ventilatory parameters to individual characteristics, such as lung mechanics and gas exchange, is required.

Abbreviated cognitive test for delirium.

The cognitive test for delirium (CTD) was recently developed to identify delirium in an intensive care unit (ICU) setting. Stepwise discriminant analyses using the original validation sample indicated that a total score formed by summing only two of the nine content scores (visual attention span and recognition memory for pictures) maintained good reliability (coefficient alpha = 0.79) and the ability to discriminate delirium from dementia, schizophrenia, and depression (p < 0.0001) and delirium from moderate to severe dementia (p < 0.0002). This abbreviated version of the CTD is more practical for use by ICU clinicians.

Soluble E-selectin levels in sepsis and critical illness. Correlation with infection and hemodynamic dysfunction.

E-selectin, an early mediator of leukocyte-endothelial adhesion, is expressed on activated endothelium. Soluble E-selectin is present in the supernatant of cytokine-activated endothelial cells and elevated serum levels are found in a variety of inflammatory conditions. We documented elevated E-selectin serum levels in 119 critically ill medical ICU patients (log transformed mean E-selectin level, measured by ELISA, was 5.28 ng/ml) compared to normal volunteers (1 ng/ml). Forty-three patients with culture-positive sepsis had higher (p < 0.05) E-selectin levels (15.39 ng/ml) than 24 patients with culture-negative sepsis (4.87 ng/ml), 44 with noninfectious SIRS (2.33 ng/ml), and eight without SIRS (1.97 ng/ml). E-selectin levels related strongly to the degree of hemodynamic compromise (p < 0.0001). Further analysis demonstrated microbiological status and hemodynamic status to be independent variables related to E-selectin level. Day 1 E-selectin levels correlated positively with peak organ failure score over the course of ICU hospitalization (r = 0.30, p = 0.001) and were higher (p < 0.05) for nonsurvivor (10.61 ng/ml, n = 26) than survivors (4.35 ng/ml, n = 93). We conclude that soluble E-selectin levels are higher in serum of patients with microbiologically documented sepsis than in other critically ill medical ICU patients. Day 1 E-selectin levels correlate highly with hemodynamic compromise and modestly with subsequent organ dysfunction and survival.

Validation of a cognitive test for delirium in medical ICU patients.

Patients with delirium, dementia, depression, and schizophrenia were administered a newly developed test designed to identify delirium in an intensive care unit (ICU) setting. Two alternate forms of the Cognitive Test for Delirium (CTD) were highly correlated. The delirium patients performed least well, and an optimal cutoff score derived from relative-operating characteristic analysis resulted in a sensitivity of 100% and a specificity of 95%. In a follow-up study, the Mini-Mental State Exam could not be administered to 42% of the ICU patients who completed the CTD. Early identification of delirium with the CTD may lead to timely treatment of specific etiologic conditions and a reduction in mortality and morbidity.

Current concepts of sepsis and acute lung injury.

Acute respiratory distress syndrome continues to be a vexing clinical problem with no specific therapy. Epidemiologic and basic sciences have advanced our understanding of the clinical syndrome and have brought us to the brink of effective intervention strategies. This article carefully examines the current state of knowledge, with reference to acute lung injury and current efforts, to arrive at effective pharmacologic approaches.

Circulating ICAM-1 is increased in septic shock.

Adhesion molecules play a critical role in the interaction of circulating neutrophils with vascular endothelium during inflammation. Increased quantities of soluble, circulating intercellular adhesion molecule-1 (cICAM-1) are present in various inflammatory conditions. The purpose of this investigation was to measure cICAM-1 levels in septic adults, as well as to examine the relationship between this potential marker of endothelial-cell activation and the consequences of sepsis (i.e., multiple organ failure and death). Using a sandwich-type enzyme-linked immunosorbent assay (ELISA), we measured cICAM-1 in blood samples obtained within 12 h of admission to an intensive care unit (ICU) for sepsis and other conditions. We found cICAM-1 levels to be increased in 25 septic patients (1,259 +/- 159 ng/ml, mean +/- SEM) as compared with 12 healthy volunteers (355 +/- 41 ng/ml, p < 0.0001) and four ICU patients without systemic inflammatory response syndrome (SIRS) (585 +/- 76 ng/ml, p < 0.001). Twenty-five patients with SIRS but no evidence of causative infection also had elevated levels of cICAM-1 (937 +/- 144 ng/ml, p = 0.12 versus sepsis). Serial measurements over the first week of sepsis demonstrated persistent elevation in most patients. Day 1 cICAM-1 levels were higher (p = 0.017, ANOVA) in 16 patients with septic shock than in seven with severe sepsis and two with sepsis but without hypotension or hypoperfusion. There was a positive correlation (r = 0.50, p = 0.009) between Day-1 cICAM-1 measurements and severity of shock as determined by the presence of hypotension and vasopressor use.(ABSTRACT TRUNCATED AT 250 WORDS)

Central venous catheter infections: concepts and controversies.

Central venous catheters (CVCs) are widely used in critically ill patients in intensive care units. However, infectious complications are common and may limit their utility. We critically review the literature to determine the impact of CVC design and composition, insertion site selection, insertion procedures, care and removal of temporary CVCs on infectious complications. Relevant articles were identified and selected for review using a database search (Medline and manual of the English language literature) based upon study design and sample size with an emphasis on prospective randomized trials. To minimize infectious complications and maintain a reasonable cost-benefit ratio, we recommend: i) use a single lumen catheter unless clear indications for a multi-lumen catheter exist; ii) insert the catheter via the subclavian vein if no relative contraindication exists (bleeding diathesis, positive pressure ventilation); iii) disinfect the insertion site employing sterile technique; iv) apply a dry, sterile dressing and change the dressing every other day; v) inspect the insertion site for signs of infection and remove the catheter if pus is present; vi) if a catheter-related infection is suspected, change the catheter over a guidewire and culture the distal segment. The replacement catheter should be removed if an original catheter segment culture is positive.

Unplanned extubation. Clinical predictors for reintubation.

STUDY OBJECTIVE: To examine the incidence, clinical impact, and predictors of reintubation following unplanned extubation (UE) in ICU patients. DESIGN: Retrospective data collection of prospectively identified consecutive cases of UE. SETTING: The adult Medical, Coronary, Surgical, Cardiac Surgery, and Neuroscience ICUs of a University Medical Center. PATIENTS: Eighty-one episodes of UE in 72 adolescent or adult (53 +/- 19 years) ICU patients. MEASUREMENTS AND RESULTS: In 39 (48 percent) of 81 cases, reintubation was performed within 24 h of UE, 33 (85 percent) within the first hour, and 31 (79 percent) as a result of respiratory distress. There were five documented complications of UE and/or reintubation but no deaths. Clinical predictors for reintubation were sought from routinely available demographic, clinical, laboratory, and respiratory factors which had been documented in the medical records for the 24 h period prior to UE. Using univariate analysis followed by stepwise logistic regression in the first 56 cases (model set), the following factors were identified as being associated with reintubation: (1) volume controlled ventilation (synchronous intermittent mandatory ventilation or assist-control ventilation) with rate more than 6/min; (2) most recent arterial pH level prior to UE being 7.45 or more; (3) most recent ratio of PaO2 to fraction of inspired oxygen prior to UE less than 250 mm Hg; (4) highest heart rate in the 24 h prior to UE greater than 120 beats per minute; (5) presence of 3 or more coexisting medical disorders (of 7 possible); (6) mental status other than alert; and (7) indication for intubation other than "preoperative." In the model set, the presence of 4 or more of these 7 factors correctly predicted reintubation in 23 of 25 (92 percent positive predictive value) and presence of 3 or fewer factors correctly predicted no reintubation in 26 of 31 cases (83 percent negative predictive value), with outcome of 88 percent of cases being correctly predicted. The model was tested in the next 24 cases (validation set) in which 18 (75 percent) were correctly predicted. CONCLUSION: Unplanned extubation can result in serious complications; however, about half the patients who have UE can be safely observed without immediate reintubation. Selected clinical factors, which are readily available from standard ICU records for the 24-h period prior to UE, may be useful to predict the likelihood of reintubation.

In situ pulmonary vascular perfusion for improved recovery of pulmonary intravascular macrophages.

The microcirculation contains mononuclear phagocytes, with features characteristic of macrophages, adhered to luminal capillary surfaces by intercellular adhesion plaques. These pulmonary intravascular macrophages may play an important role in regulating lung vascular tone and capillary permeability, and may modulate capillary endothelial cell growth and replication by the secretion of soluble mediators (i.e., arachidonate metabolites, cytokines). This study describes a technique which utilizes in situ lung perfusion to remove intravascular macrophages in large numbers from the microcirculation of porcine lung (n = 26). This technique yielded 3.8 +/- 0.5 x 10(8) (mean +/- SEM) mononuclear cells which were highly phagocytic toward particulate carbon (phagocytic index, 80 +/- 6%). Harvested mononuclear phagocytes reestablished intercellular adhesion plaques when placed on small vessel porcine pulmonary artery endothelial cell monolayers and exhibited histochemical characteristics typical of monocyte/macrophage lineage cells. Mononuclear cells obtained from lung microcirculation displayed size heterogeneity varying from 10.4 to 16.5 microns in diameter. Both large and small cell populations phagocytosed particulate carbon. Morphometric studies performed on collagenase-treated lung demonstrated that in situ perfusion removed significant numbers of intravascular macrophages in lung capillaries. The technique described permits the rapid removal of anchored mononuclear phagocytes from lung capillaries with minimal postmortem delay.