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1 EBM Strategies for Improving 2013 ICU PAD Guidelines ICU PAD - PDF document

Oct 21, 2023 •354 likes •455 views

Faculty Disclosures SCCMs New ICU Pain, Agitation, and Delirium Clinical Practice Guidelines Speaking honoraria received from: Juliana Barr, MD, FCCM SCCM, ACCP, Cynosure, Sutter Health, University of Hawaii, France Foundation Chair, ACCM

  1. Faculty Disclosures SCCM’s New ICU Pain, Agitation, and Delirium Clinical Practice Guidelines Speaking honoraria received from: Juliana Barr, MD, FCCM SCCM, ACCP, Cynosure, Sutter Health, University of Hawaii, France Foundation Chair, ACCM PAD Guideline Task Force Associate Professor of Anesthesia Stanford University School of Medicine VA Palo Alto Health Care System Palo Alto, CA Learning Objectives 2002 SAG Guidelines • Understand the key concepts of the 2013 SCCM PAD Guidelines. • Understand the synergistic benefits of implementing the PAD Guidelines in an integrated fashion. • Understand how to apply the ICU PAD Care Bundle in your ICU. Crit Care Med 2002 30(1):119-141 1

  2. EBM Strategies for Improving 2013 ICU PAD Guidelines ICU PAD Management Crit Care Med 2013 41(1):263-306 T he ICU PAD Care Bundle What’s Different About DELIRIUM the 2013 ICU PAD Guidelines? PAIN AGITATION Assess agitation, sedation ≥ 4x/shift & prn Assess delirium Q shift & prn • Methods: Assess pain ≥ 4x/shift & prn Preferred sedation assessment tools: Preferred delirium assessment • RASS (-5 to +4) or SAS (1 to 7) Preferred pain assessment tools: tools: – GRADE Method - strength of evidence, risks, benefits • Patient able to self-report  NRS (0- • NMB  suggest using brain function monitoring • CAM-ICU (+ or -) ASSESS Depth of agitation, sedation defined as: • ICDSC (0 to 8) 10) – Professional Librarian - database management • Unable to self-report  BPS (3-12) or • agitated if RASS = +1 to +4, or SAS = 5 to 7 Delirium present if: – Electronic Refworks™ Database - >19,000 refs • awake and calm if RASS = 0, or SAS = 4 • CAM-ICU is positive CPOT (0-8) • lightly sedated if RASS = -1 to -2, or SAS = 3 • ICDSC ≥ 4 Patient is in significant pain if NRS ≥ 4, – Anonymous Voting - all statements, recommendations • deeply sedated if RASS = -3 to -5, or SAS = 1 to 2 BPS ≥ 6, or CPOT ≥ 3 • Treat pain as needed • Content: • Reorient patients; familiarize Targeted sedation or DSI ( Goal : patient Treat pain within 30” then reassess: purposely follows commands without surroundings; use patient’s – Psychometric Analyses – pain, sedation, delirium monitoring • Non-pharmacologic treatment – eyeglasses, hearing aids if needed agitation ): RASS = -2 – 0, SAS = 3 - 4 relaxation therapy • If under sedated (RASS >0, SAS >4) • Pharmacologic treatment of delirium: – Patient-centered > Drug-centered • Pharmacologic treatment: assess/treat pain  treat w/sedatives • Avoid benzodiazepines unless ETOH TREAT • Non-neuropathic pain  IV opioids – Integrated, Interdisciplinary prn (non-benzodiazepines preferred, or benzodiazepine withdrawal +/- non-opioid analgesics unless ETOH or benzodiazepine suspected – ↑ delirium emphasis • Neuropathic pain  gabapentin or • Avoid rivastigmine withdrawal suspected) carbamazepine, + IV opioids • Avoid antipsychotics if  risk of • If over sedated (RASS <-2, SAS <3) hold • S/p AAA repair, rib fractures  sedatives until @ target, then restart @ Torsades de pointes • Scope: thoracic epidural 50% of previous dose • Identify delirium risk factors: dementia, – Bigger! – 2x ‘02 PAD CPG, >‘13 Sepsis CPG HTN, ETOH abuse, high severity of illness, • Consider daily SBT, early mobility – Evidence-based – literature gaps, identifies future research areas coma, benzodiazepine administration • Administer pre-procedural analgesia and exercise when patients are at • Avoid benzodiazepine use in those at  risk – ICU PAD Care Bundle -integrates PAD management, links PAD to SBT, and/or non-pharmacologic goal sedation level, unless for delirium PREVENT interventions (eg, relaxation contraindicated • Mobilize and exercise patients early Early Mobility, sleep hygiene programs • EEG monitoring if: therapy) • Promote sleep (control light, noise; cluster – at risk for seizures • Treat pain first, then sedate patient care activities; decrease nocturnal – burst suppression therapy is stimuli) indicated for  ICP • Restart baseline psychiatric meds, if indicated 2

  3. Pain Assessment Step 1: Implement Pain, Agitation, and Numerical Rating Scale* (NRS) Delirium Assessment Tools in the ICU Anxiety Delirium Pain *NRS > 4 is significant *NRS > 4 is significant Pain Assessment Pain Assessment Critical Care Pain Observation Tool* (CPOT) Behavioral Pain Scale* (BPS) *BPS Range = 3-12, BPS > 6 is significant *CPOT range = 0 – 8, CPOT > 3 is significant 3

  4. Sedation Assessment Sedation Assessment Sedation Agitation Scale* (SAS) Richmond Agitation Sedation Scale* (RASS) *RASS range = -5 to +4, target RASS = 0 to -2 *SAS range = 1 to 7, target SAS = 3 to 4 Delirium Assessment Delirium Assessment Intensive Care Delirium Screening Checklist* CAM-ICU (ICDSC) *Delirium present if ICDSC > 4 ICUdelirium.org 4

  5. Step 3: Apply ICU Specific Pain, Agitation, Step 2: Incorporate PAD Assessments and Delirium Management Protocols Into Daily ICU Care Plan • Pain: – Assess and treat pain first, then sedate (analgo-sedation) – Treat significant pain: NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3 • What is the patient’s pain score and their current – Use appropriate pain management strategies (patient-specific) – Administer pre-procedural analgesia analgesia regimen? • Agitation/Sedation: – Minimize sedative use, avoid over- sedation (DSI or TSS→SAT) – Choose sedatives that minimize side effects (patient-specific) • What is the patient’s current and target sedation – Sedation goals: patient is responsive, aware, and able to purposely follow commands* (RASS = 0 to -2, SAS = 3 to 4) scores, and their current sedation regimen? – *Light Sedation: Performs 3 out of 5 commands - opens eyes , maintains eye contact , squeezes hand , sticks out tongue , wiggles toes. • Delirium: • What is the patient’s delirium score and what are – Optimize pain management – Reorient patient their delirium risk factors? – D/C deliriogenic drugs – Treat with antipsychotics (patient-specific) Barriers to Implementing Step 4: Link PAD to Other Strategies the ICU PAD Care Bundle to Improve Clinical Outcomes • Performing PAD assessments consistently, reliably • Link spontaneous awakening trials (SAT) to spontaneous breathing trials (SBT)-- facilitate • Making PAD management less medication, MD weaning from MV dependent. • Light sedation – GOOD! Deep sedation – BAD! • Link SAT to early mobility and exercise (EM) protocols-- reduce delirium, improve strength • Coordinating PAD management with SATs, SBT, and PT/OT activities. • Implement environmental controls to protect • Getting ventilated ICU patients out of bed will not patients’ sleep -wake cycles-- reduce delirium necessarily kill them! (D), improve sleep 5

  6. PAD Implementation Strategies PAD Interdisciplinary Team Top Ten List* 1. Integrated PAD management – PAD Care Bundle Physical Pharmacy Interdisciplinary, team based approach – ICU clinician champion 2. Therapy Champion Champion Perform gap analysis – current practice vs. PAD Guidelines 3. RT Hospital ICU Staff education – increase buy-in, support for change 4. Champion Administrators Start with PAD assessments – (i.e., NRS, CPOT or BPS, RASS or 5. SAS, CAM-ICU or ICDSC) Create institutional PAD protocols – adapted to formulary, ICU culture, 6. RN Champion Family individualize drugs to pts., allow for practice variation 7. Primary goals: optimal pain management; light sedation; delirium prevention/treatment 8. Link PAD protocols with SATs, SBTs, Early Mobility protocols Integrated MD Approach Patient Take PAD to the bedside – ICU rounds discussions, goal sheets, 9. Champion to PAD checklists 10. Measure performance – identify process, outcome measures; share data with stakeholders frequently *Pun, Balas, Davidson, SRCCM April 2013 (in press) Challenges to Implementing PAD Guideline Implementation the ICU PAD Care Bundle Assessment PAD Implementation (%) ICU Champion! Interdisciplinary PAD Stakeholder Team ICU PAD Compliance Care Treatment Bundle Prevention 6

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