Primary Recommendations for Patient Management in an ICU Setting
In the ICU setting, implementing an interdisciplinary team approach with protocolized pain, agitation, and delirium (PAD) management is strongly recommended to improve patient outcomes including mortality, length of stay, and quality of life. 1
Pain Management
Assessment
- Use validated pain assessment tools:
- For communicative patients: Numerical Rating Scale (NRS, 0-10)
- For non-communicative patients: Behavioral Pain Scale (BPS, 3-12) or Critical-Care Pain Observation Tool (CPOT, 0-8)
- Consider pain significant if NRS ≥4, BPS >5, or CPOT ≥3
- Assess pain at least 4 times per shift and as needed
Treatment
- Implement analgesia-first sedation (analgosedation) approach 1
- For non-neuropathic pain:
- First-line: IV opioids (short-acting and easily titratable)
- Add non-opioid analgesics to reduce opioid side effects
- For neuropathic pain: Add gabapentin or carbamazepine to IV opioids
- Preemptively treat procedural pain, especially for chest tube removal
- Consider thoracic epidural analgesia for traumatic rib fractures
Sedation Management
Assessment
- Use validated sedation scales:
- Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS)
- Target light sedation levels when possible 1
Treatment
- Avoid benzodiazepines when possible, especially in patients at risk for delirium 1
- Prefer non-benzodiazepine sedatives:
- Dexmedetomidine for patients with delirium not related to alcohol or benzodiazepine withdrawal
- Propofol for short-term sedation needs
- Implement daily sedation interruption paired with spontaneous breathing trials 1
- Use EEG monitoring for patients at risk for seizures or those requiring burst suppression for elevated intracranial pressure
Delirium Management
Assessment
- Screen for delirium routinely using validated tools:
- Confusion Assessment Method for ICU (CAM-ICU)
- ICU Delirium Screening Checklist (ICDSC)
Prevention
- Implement early mobility protocols 1
- Optimize patients' environment to promote sleep:
- Control light and noise
- Cluster patient care activities
- Establish protected sleep periods (particularly between 12-5 AM) 1
- Avoid medications that increase delirium risk when possible
Treatment
- For patients requiring sedation who develop delirium, use dexmedetomidine rather than benzodiazepines 1
- Avoid routine use of haloperidol or atypical antipsychotics for delirium prevention
- Withhold antipsychotics in patients with baseline QT prolongation, history of Torsades de Pointes, or those on other QT-prolonging medications
Organizational Approach
- Implement an integrated PAD protocol using an interdisciplinary team approach 1
- Include provider education, computerized protocols, and quality rounds checklists
- Use daily multidisciplinary rounds to coordinate care
- Promote family presence and engagement in care when appropriate 1
- Ensure appropriate nurse-to-patient ratios based on level of care:
- Level III (highest acuity): 1:1 nurse-to-patient ratio
- Level II: 1:1.6 nurse-to-patient ratio
- Level I: 1:3 nurse-to-patient ratio 1
Common Pitfalls to Avoid
Deep sedation practices - These are more harmful than beneficial, leading to prolonged mechanical ventilation, delirium, and increased mortality 1
Inadequate pain assessment and management - Despite decades of emphasis on pain management, 40% of ICU patients still report moderate to severe pain 1
Overreliance on benzodiazepines - These increase delirium risk and may worsen outcomes compared to non-benzodiazepine alternatives 1
Failure to implement protocolized care - Only 60% of ICUs have implemented PAD protocols, and adherence is often low 1
Neglecting sleep promotion - Sleep deprivation contributes to delirium development and impairs healing responses 1
By implementing these evidence-based recommendations, ICU teams can significantly improve patient outcomes including reduced mortality, shorter ICU stays, decreased duration of mechanical ventilation, and improved quality of life for survivors.