Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2013
ReviewEvaluation and treatment of pain in critically ill adults.
Pain is experienced by the overwhelming majority of patients during their intensive care unit stay, but it remains an underappreciated problem. To effectively treat pain, it must be detected and quantified using a validated assessment tool. ⋯ This review covers practices and techniques specific to addressing and treating pain in the adult intensive care environment. Traditional pharmacological approaches including opiate and nonopiate medications are reviewed, as are regional anesthetic techniques and nonpharmacological approaches used for controlling pain.
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Semin Respir Crit Care Med · Apr 2013
Delirium monitoring in the ICU: strategies for initiating and sustaining screening efforts.
Delirium in the intensive care unit (ICU) is associated with many negative outcomes, including increased length of stay in both the ICU and the hospital, increased duration of mechanical ventilation, increased mortality, worse long-term cognitive impairment, and increased costs. The 2013 American College of Critical Care Medicine (ACCM)/Society of Critical Care Medicine (SCCM) clinical practice guidelines for pain, agitation, and delirium (PAD), based on available evidence, strongly recommend that critically ill patients be routinely monitored for delirium in the ICU using a validated tool. ⋯ Strategies needed to implement and sustain delirium screening efforts in different critically ill populations are introduced and discussed. Accurate detection is the first step in managing ICU patients who develop delirium in an attempt to reduce the negative sequelae of delirium in this population.
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Semin Respir Crit Care Med · Apr 2013
Evaluating and monitoring sedation, arousal, and agitation in the ICU.
Optimal management of patient comfort and sedative drug therapy for intensive care unit (ICU) patients includes establishing a goal of therapy-often defined by a desired level of consciousness, with titration of medications to achieve this target. An assessment of the level of consciousness is best performed using a simple tool, such as a sedation scale that relies on observation of the patient to assign a level of conscious that ranges from alert to unarousable. Many sedation scales incorporate observation of the patient's response to stimulation, which typically escalates from simply calling the patient's name to physical stimulation. ⋯ Implementation of sedation scales has been associated with improved outcomes, and the frequent assessment of level of consciousness using a sedation scale is strongly recommended in clinical practice guidelines. Further, selection of a sedation scale that has been demonstrated to be valid and reliable in your patient population is endorsed. Objective measures of consciousness, such as devices that use processed electroencephalography, are less well established for routine ICU management and are recommended only for selected situations.
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Semin Respir Crit Care Med · Apr 2013
Pain, sedation, and delirium management in the neurocritically ill: lessons learned from recent research.
Critically ill patients with a primary neurological injury or illness pose unique challenges for pain, agitation, and delirium management in intensive care units (ICUs). Detection and monitoring can be limited by contextual level of consciousness (LOC) alterations, cognition, expression, or language deficits. Recent data suggest that existing pain assessment tools may not be applicable to all neurocritically ill patients, especially in those with LOC alterations and atypical pain-associated behaviors. ⋯ However, delirium symptoms may herald life-threatening primary insult progression or result from a new secondary neurological injury and should be monitored. Patients with neurological injury or illness are often excluded from ICU studies addressing pain, sedation, and delirium, but this need not be the case. We review what is understood in this area based on current evidence.
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Semin Respir Crit Care Med · Apr 2013
Implementing the 2013 PAD guidelines: top ten points to consider.
It has been 10 years since the last publication of the clinical practice guidelines for pain, agitation/sedation, and delirium (PAD). The results of new studies have directed significant changes in critical care practice. Using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, the guidelines were revised, resulting in 32 recommendations and 22 summary statements. ⋯ A gap analysis grid is provided. The release of any guideline should prompt reevaluation of current institutional practice standards. This manuscript uses the PAD guidelines as an example of how to approach the interprofessional work of guideline implementation.