Literature Review

SCCM 2018 PADIS Guideline Recommendations

In 2018, the Society of Critical Care Medicine published Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in critically ill adult patients. This chapter summarizes the key recommendations from these guidelines relating to sedation, analgesia, and delirium management.

Analgesia Recommendations

• Self-report using a 0-10 numeric rating scale is the gold standard for pain assessment when possible. Behavioral pain scales like CPOT and BPS are preferred for non-verbal patients.
• Vital signs alone are not accurate indicators of pain.
• An opioid is suggested for procedural pain management using lowest effective doses. NSAIDs may be an alternative for infrequent procedures.
• Analgesia-first approach focusing on optimizing pain control before considering sedative medications.

Sedation Recommendations

• Light sedation is preferred over deep sedation for most mechanically ventilated patients
• Propofol or dexmedetomidine are suggested over benzodiazepines for sedation
• Propofol is specifically suggested over benzodiazepines for post-cardiac surgery patients
• Sedation scales like RASS should be used to monitor sedation depth
• Daily sedation interruption protocols can achieve light sedation targets

Delirium Recommendations

• All critically ill patients should be regularly monitored for delirium using CAM-ICU or ICDSC
• Medications like haloperidol, atypical antipsychotics, and dexmedetomidine are not recommended for delirium prevention
• Dexmedetomidine may be considered for delirium treatment if agitation is preventing extubation
• Multicomponent non-pharmacological interventions focusing on delirium risk factor reduction are suggested

The PADIS guidelines provide a robust, evidence-based framework to guide sedation, pain, and delirium management in ICU patients. Key themes include maintaining light sedation, managing pain first, avoiding benzodiazepines, and taking a multimodal approach to delirium.

Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-e873. doi: 10.1097/CCM.0000000000003299. PMID: 30113379.