PADIS Guidelines

Background

The SCCM discusses Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption (PADIS), targets for optimal critical care management of patients not primarily related to their illness. The ICU Liberation Bundle (A to F) discusses implementation strategies to apply PADIS recommendations to all ICU patients. This section discusses PADIS and how to address them in evidence-based bundled care.

Element	Bundle
A	Assess, Prevent, and Manage Pain
B	Both SAT and SBTs
C	Choice of analgesia and sedation
D	Delirium: assess, prevent, manage
E	Early mobility and exercise
F	Family engagement and empowerment

Pain

Critically ill patients experience moderate to severe pain at rest and during standard care procedures. Severe pain negatively affects patient status (vitals, immunosuppression), and standardized pain management protocols improve ICU outomes. - self-reported pain is the reference statndard - in patients unable to report pain, and in whom behaviours are observable, the Behavioural Pain Scale in intubated (BPS) and nonintubated (BPS-NI) patients and the Critical-Care Pain Observation Tool (CPOT) demonstrate the greatest validity and reliability for monitoring pain - involve family as well for pain assessment - physiologic measures of pain - vital signs are NOT valid indicators; use as cues to initiate further assessment using validated tools

Pharmacologic adjuvants to opioid therapy

• acetaminophen - use as adjuvant. IV acetaminophen may cause hypotension
• nefopam - use as adjunct or opioid replacement (not avail in USA/Canada)
• ketamine - use low-dose ketamine (push and infusion) as adjunct to opioids particularly in postsurgical adults
• neuropathic pain meds (gabapentin, pregabalin, CBZ) should be used for neuropathic pain management
• lidocaine - do not routinely use IV lidocaine
• COX-1 inhibitors - do not routinely use COX-1 NSAIDs as adjunct for pain, mainly due to risk of adverse effects

Pharmacologic interventions to reduce procedural pain (regular activities, discrete procedures)

• assess and treat pain before the procedure (i.e. pre-emptive)
• use an opioid at the lowest effective dose (fentanyl, hydromorphone, morphine, remifentanil, etc)
• suggest not using either local analgesia or nitrous oxide for pain management (disagree...)
• do not use inhaled volatile anesthetic for procedural pain management
• suggest using NSAID as alternative to opioid for procedural pain management (orall, IV, rectally, not topically)

Nonpharm methods

• consider massage, music therapy, cold therapy, relaxation techniques

Agitation and Sedation

2013 guidelines suggest (1) targeting light levels of sedation or daily awakening trials (2) minimizing benzos.

• Light sedation recommended over deep sedation (shortened time to extubation, reduced ICU LOS)
  • light sedation was defined in 2013 PAD guidelines as RASS >= -2 and eye opening of at least 10 minutes. This is probably deeper than required to management of vented patients in the ICU
  • no universal definition of light sedation
• daily sedative interruptions and nurse-protocolized sedation can achieve and maintain light sedation
• choice of sedative
  • 2013 PAD guidelines: non-benzo sedatives (propofol, dexmedetomidine) preferred to benzos (midazolam, lorazepam) due to better LOS, mech vent, delirium outcomes.
  • cardiac surgery patients
    • propofol recommended over benzos
  • non-cardiac surgery patients
    • propofol or dexmedetomidine preferred over benzos
    • dex possibly better than propofol (PRODEX study)
• physical restraints
  • commonly used, little evidence
  • may paradoxically increase risk of unplanned extubations, reintubations, device removal, agitation, benzo dose

See Sedation for mechanical ventilation for more detailed notes.

Delirium

Background

• risk factors for delirium in the ICU
  • modifiable
    • benzo use
    • blood transfusion
  • non-modifiable
    • age, dementia
    • proir coma
    • pre-ICU emergency surgery or trauma
    • sickness (ASA, APACHE scores)
• screen for delirium using CAM-ICU or ICDSC
  • level of arousal influences delirium assessment particularly below RASS -3
• Delirium is associated with cognitive impairment long term, longer hospital LOS. It is NOT associated with PTSD or depression, post-ICU distress, ICU LOS

Interventions

• pharmacologic prevention
  • Do NOT suggest routine use of haloperidol, atypical antipsychotic, dexmedetomidine, statin, or ketamine to prevent delirium. These medications decrease delirium, but not other clinically relevant outcomes.
• pharmacologic treatment of ICU-delirium
  • Consider haloperidol (not per guidelines). Due to MIND-USA and AID-ICU trials (showed the safety of haloperidol in this setting). However, not routinely.
  • suggest using dexmedetomidine for delirium in vented patients where agitation is precluding weaning/extubation
• nonpharm prevention and treatment
  • suggest to not use bright light therapy
  • suggest using multicomponent, nonpharm intervention (sleep, mobility, hearing, vision, orientation) such as the ABCDE(F) bundle

Immobility

Background

• survivors of critical illness often develop ICU-acquired muscle weakness (ICUAW), as much as 25-50% of critically ill patients.
• major risk factor for ICUAW is bed rest

Recommendations

• perform rehab/mobilization in critically ill patients. this reduces duration of mechanical ventilation, improves muscle strength, but no change on hospital mortality
• rehab/mobilization is not associated with strong risk of serious safety events or harms. The majority of these are respiratory related (desaturations, unplanned extubations)
• indicators for safe initiation of rehabilitation/mobilization:
  • CV stability (vasoactive infusions NOT barrier)
  • respiratory stability (mechanical ventilation NOT barrier)
  • neurologic stability
• indicators for stopping rehab/mobilization: development of new CV, resp, neurologic instability

Sleep Disruption

Background

• common, and can be characterized by sleep fragmentation, abnormal circadian rhythms, increased light sleep, decreased slow-wave and REM sleep. Total sleep time and sleep efficiency are often normal.
• may contribute to ICU delirium, prolonger mech vent, immunosuppression, neurocognitive dysfunction
• ICU delirium leads to less REM sleep, and greater derangements in circadian rhythm
• mech vent has no clear consistent effect on sleep architecture (may improve sleep with respiratory distress and worsen otherwise)

Monitoring

• not recommended to routinely monitor using physiologic sleep monitoring

Interventions

Non-pharmacologic

• assist-control ventilation over PSV at night for improving sleep
• not recommended to use aromatherapy, acupressure, or music at night
• reduce noise and light
• sleep-promoting protocol: earplugs, eyeshades, relaxing music, etc

Pharmacologic

• melatonin - no recommendation. Evidence generally shows no difference in sleep qty or quality. However, it is cheap and inexpensive. Ramelteon, melatonin receptor agonist, does reduces delirium.
• dexmedetomidine - no recommendation. Likely no effect on REM sleep, and side effects and high cost are barriers
• propofol - suggest against using

References

1. ICU Liberation Bundle (A-F) | SCCM | SCCM
2. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Critical Care Medicine. 2018;46(9):e825. doi:10.1097/CCM.0000000000003299