Clinical practice guidelines for the sustained use of ...

1 Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult Judith Jacobi, PharmD, FCCM, BCPS; Gilles L. Fraser, PharmD, FCCM; Douglas B. Coursin, MD;. Richard R. Riker, MD; Dorrie Fontaine, RN, DNSc, FAAN; Eric T. Wittbrodt, PharmD;. Donald B. Chalfin, MD, MS, FCCM; Michael F. Masica, MD, MPH; H. Scott Bjerke, MD;. William M. Coplin, MD; David W. Crippen, MD, FCCM; Barry D. Fuchs, MD; Ruth M. Kelleher, RN;. Paul E. Marik, MDBCh, FCCM; Stanley A. Nasraway, Jr, MD, FCCM; Michael J. Murray, MD, PhD, FCCM;. William T. Peruzzi, MD, FCCM; Philip D. Lumb, MB, BS, FCCM. Developed through the Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), in collaboration with the American Society of Health-System Pharmacists (ASHP), and in alliance with the American College of Chest Physicians; and approved by the Board of Regents of ACCM and the Council of SCCM and the ASHP Board of Directors M aintaining an optimal level tion for a description of the methodology bined use of analgesics and sedatives may of comfort and safety for used to develop these guidelines (2).

2 Ameliorate the stress response in critically critically ill patients is a This document is limited to a discus- ill patients (7, 8). Pain may also contribute universal goal for critical sion of prolonged sedation and analgesia. to pulmonary dysfunction through local- care practitioners. The American College Consistent with the previous practice ized guarding of muscles around the area of of Critical Care Medicine (ACCM) of the guidelines , this document pertains to pa- pain and a generalized muscle rigidity or Society of Critical Care Medicine's tients older than 12 years. The majority spasm that restricts movement of the chest (SCCM's) practice parameters for the op- of the discussion focuses on the care of wall and diaphragm (9). Effective analgesia timal use of sedatives and analgesics was patients during mechanical ventilation.

3 A may diminish pulmonary complications in published in 1995 and recommended a discussion of regional techniques is not postoperative patients (10). tiered approach to the use of sedatives included. Appendix A summarizes the Some patients recall unrelieved pain and analgesics, largely on the basis of ex- recommendations made herein. when interviewed about their ICU stays (3, pert opinion (1). These Clinical practice 11, 12). The perception of pain can be in- guidelines replace the previously published ANALGESIA fluenced by several factors, such as the ex- parameters and include an evaluation of pectation of pain, prior pain experiences, a the literature published since 1994 com- In these guidelines , analgesia is de- patient's emotional state, and the cognitive paring the use of these agents.

4 The reader fined as the blunting or absence of sensa- processes of the patient (11). Patients should refer to the accompanying introduc- tion of pain or noxious stimuli. Intensive should be educated about the potential for care unit (ICU) patients commonly have pain and instructed to communicate their pain and physical discomfort from obvious needs in an appropriate manner (such as The American College of Critical Care Medicine factors, such as preexisting diseases, inva- using an assessment tool or other commu- (ACCM), which honors individuals for their achieve- nication techniques). The goals of therapy sive procedures, or trauma. Patient pain ments and contributions to multidisciplinary critical care medicine, is the consultative body of the Society and discomfort can also be caused by mon- should also be communicated to the pa- of Critical Care Medicine (SCCM) that possesses rec- itoring and therapeutic devices (such as tient and family.)

5 In many cases, pain will be ognized expertise in the practice of critical care. The catheters, drains, noninvasive ventilating managed but not completely eliminated. College has developed administrative guidelines and devices, and endotracheal tubes), routine Fear of potent analgesics and misconcep- Clinical practice parameters for the critical care prac- titioner. New guidelines and practice parameters are nursing care (such as airway suctioning, tions about pain and analgesics should be continually developed, and current ones are system- physical therapy, dressing changes, and pa- addressed. Similarly, practitioner bias atically reviewed and revised. tient mobilization), and prolonged immo- against the adequate use of opioids or mis- Special thanks to E.

6 Wesley Ely, MD, for his con- bility (3, 4). Unrelieved pain may contribute placed fears of adverse effects or addiction tribution to the section on delirium. may produce inadequate prescribing or ad- to inadequate sleep, possibly causing ex- Address correspondence to Society of Critical Care Medicine, 701 Lee Street, Suite 200, Des Plaines, IL haustion and disorientation. Agitation in an ministration (13, 14). Educating practitio- 60016. Available at ICU patient may result from inadequate ners and assessing the quality of a pain Key Words: analgesia; sedation; evidence-based pain relief. Unrelieved pain evokes a stress management program may improve anal- medicine; fentanyl; hydromorphone; morphine; loraz- response characterized by tachycardia, in- gesia therapy, but such programs have not epam; midazolam; propofol; haloperidol; guidelines Copyright 2002 by the Society of Critical Care creased myocardial oxygen consumption, been universally successful (4, 15).

7 The im- Medicine and the American Society of Health-System hypercoagulability, immunosuppression, portance of appropriate pain management Pharmacists, Inc. and persistent catabolism (5, 6). The com- programs has been reinforced by the Joint Crit Care Med 2002 Vol. 30, No. 1 119. Commission on Accreditation of Health- ports, critically ill patients are often un- Sedation and Analgesia care Organizations's (JCAHO's) establish- able to communicate their level of pain if Task Force ment of standards on pain assessment and sedated, anesthetized, or receiving neu- Chair, Sedation and Analgesia Task Force Judith Jacobi, , FCCM, BCPS management. romuscular blockade. Neither the VAS. Task Force Chair Critical Care Pharmacy Specialist nor the NRS will resolve this problem as Methodist Hospital, Clarian Health Partners Recommendation: All critically ill pa- they rely on the patient's ability to com- Indianapolis, IN tients have the right to adequate an- Stanley A.

8 Nasraway, Jr, MD, FCCM municate with the care provider. Behav- Executive Director of Task Force algesia and management of their pain. ioral-physiological scales may be useful Director, SICU (Grade of recommendation C). Associate Professor of Surgery, Medicine, and Anesthesia in assessing pain in these patients. Mod- Tufts New England Medical Center Boston, MA erate agreement was found between the Pain Assessment Members H. Scott Bjerke, MD. VAS and the observer-reported Faces Medical Director of Trauma There is a limited amount of literature scale for all observations, but less agree- Methodist Hospital Indianapolis, IN that directly addresses pain assessment in ment was noted as the pain intensity in- Donald B. Chalfin, MD, MS, FCCM the critical care unit.

9 The articles re- creased (19). The verbal descriptive scale Director, Division of Research and Attending Intensivist Department of Emergency Medicine viewed in this report include descriptions (VDS) used in another trial showed mod- Maimonides Medical Center Associate Professor of Clinical Epidemiology and of pain assessment tools used for criti- erate correlation (r ) with a behav- Social Medicine cally ill patients, even if these tools were ioral pain scale in assessing pain in post- Albert Einstein College of Medicine Brooklyn, NY not validated in this population. Studies anesthesia patients (23). A behavioral- William M. Coplin, MD of pain in the critically ill indicate the physiological scale was compared with an Associate Professor, Departments of Neurology &.

10 Neurological Surgery importance of systematic and consistent NRS and a moderate-to-strong correla- Wayne State University Chief, Neurology; Medical Director Neurotrauma and assessment and documentation (16). The tion was observed between the scales Critical Care Detroit Receiving Hospital most reliable and valid indicator of pain is (24). The behavioral-physiological scale Detroit, MI the patient's self-report (17). The loca- also assessed pain-related behaviors Douglas B. Coursin, MD. Professor of Anesthesiology and Internal Medicine tion, characteristics, aggravating and al- (movement, facial expression, and pos- Associate Director of the Trauma and Life Support Center leviating factors, and intensity of pain turing) and physiological indicators University of Wisconsin Madison, WI should be evaluated.