Episode 324: 2018 Updated Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Guidelines

In this episode, I’ll discuss the updated pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) guidelines.

The SCCM Guidelines for sedative use in the ICU have been updated for 2018 and now cover pain, agitation, delirium, immobility, and sleep disruption. The following are my top 7 takeaways from the new guidelines:

1. Use an opioid prior to a sedative to reach the sedation goal. This is referred to as analgosedation or analgesic-first sedation. The guideline authors emphasize treating pain as a priority over providing sedatives. This approach should reduce the duration of mechanical ventilation, ICU length of stay (LOS), and pain intensity.

2. Almost all recommendations regarding pharmacologic adjuvants to opioid therapy are conditional and based on a very low quality of evidence. This includes recommendations on the use of acetaminophen, ketamine, and nefopam (which is not available in the US). The one exception is the use of neuropathic pain medications (gabapentin, carbamazepine, and pregabalin) which are based on moderate quality evidence. Unfortunately, none of the adjunctive medications have been shown to affect clinically meaningful outcomes such as opioid-related side effects, ICU length of stay, or mortality.

3. Target light sedation over deep sedation. The definition of light sedation used by the guideline authors is a Richmond Agitation Sedation Scale from -2 to +1. A shorter time to extubation and reduced rate of patients needing tracheostomy can be expected with the use of light sedation.

4. The guideline authors do not make a graded statement on whether there is a difference between daily sedative interruption (DSI) protocols and nursing-protocolized (NP)-targeted sedation. Previous studies have evaluated these types of interventions in the context of benzodiazepine use. Since benzodiazepines are not recommended first line for sedation, evidence regarding DSI and NP sedation protocols is no longer relevant. The authors emphasize that it is light sedation that is associated with better outcomes and it should be the strategy used for the majority of patients the majority of the time.

5. Use propofol or dexmedetomidine before using benzodiazepines for sedation in critically ill patients. Compared to benzodiazepines, propofol is associated with shorter time to light sedation and shorter time to extubation. Compared to benzodiazepines, dexmedetomidine is associated with shorter duration of mechanical ventilation, shorter ICU stay, and reduced incidence of delirium. When comparing propofol with dexmedetomidine, the guideline authors judged that the desirable and undesirable consequences of propofol vs dexmedetomidine were balanced; therefore, they issued a conditional recommendation to use either agent for sedation of critically ill adults.

6. No pharmacologic treatment is recommended for patients who develop ICU delirium unless there is a clinically relevant symptom of the delirium. For patients that are distressed, agitated, or harmful to themselves or others antipsychotics may be used. For patients who are unable to wean from the ventilator due to agitated delirium, dexmedetomidine may be used.

7. Use an analgesic prior to a procedure that may cause pain. The dose should be the lowest effective dose possible, and administration should be timed so that peak effect coincides with the procedure. The guideline authors suggest using opioids for procedural related pain and also state that NSAIDs may be used instead if their are no contraindications.

You can get a detailed pdf on the different uses for ketamine in critical care in my free download section at pharmacyjoe.com/free (it’s download #13).

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