Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU
Authors: Devlin John W. , Skrobik Yoanna , Gélinas Céline , Needham Dale M. , Slooter Arjen J. C. , Pandharipande Pratik P. , Watson Paula L. , Weinhouse Gerald L. , Nunnally Mark E. , Rochwerg Bram , Balas Michele C. , van den Boogaard Mark , Bosma Karen J. , Brummel Nathaniel E. , Chanques Gerald , Denehy Linda , Drouot Xavier , Fraser Gilles L. , Harris Jocelyn E. , Joffe Aaron M. , Kho Michelle E. , Kress John P. , Lanphere Julie A. , McKinley Sharon , Neufeld Karin J. , Pisani Margaret A. , Payen Jean-Francois , Pun Brenda T. , Puntillo Kathleen A. , Riker Richard R. , Robinson Bryce R. H. , Shehabi Yahya , Szumita Paul M. , Winkelman Chris , Centofanti John E. , Price Carrie , Nikayin Sina , Misak Cheryl J. , Flood Pamela D. , Kiedrowski Ken , Alhazzani Waleed 
Published: August 2018

Objective:
To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

Design:
Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines’ development. A general content review was completed face-to-face by all panel members in January 2017.

Methods:
Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as “strong,” “conditional,” or “good” practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

Results:
The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

Conclusions:
We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.