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7/26/12

Introduction

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Juliana Barr, MD, FCCMActing Medical Director, Critical Care

VA Palo Alto Health Care System

Juliana Barr, MD, FCCM

Chair, ACCM PAD Guideline Task ForceAssociate Professor of Anesthesia,

Stanford University School of MedicineAssociate ICU Medical Director,VA Palo Alto Health Care System

COI DisclosuresCOI Disclosures

No Commercial Affiliations....

Learning ObjectivesLearning Objectives

• What’s new in the ACCM ‘s 2012 Pain, Agitation, and Delirium Clinical Practice Guidelines for Adult ICU Patients.

• Use of validated scales for assessing pain, sedation, and delirium in the management of critically ill patients.

• Integrating the management of pain, agitation, and delirium in adult ICU patients.

• Applying these principles in your ICU.

Clinical Practice Guidelines for the Management Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patientsof Pain, Agitation, and Delirium in Adult Patients

in the Intensive Care Unitin the Intensive Care Unit

 Authors: Juliana Barr, MD, FCCM; Gilles L. Fraser, PharmD, FCCM; Kathleen Puntillo, RN, DNSc, FAAN; E. Wesley Ely, MD, MPH, FACP, FCCM; Céline

Gélinas, RN, PhD; Joseph F. Dasta, MSc; Judy E. Davidson, DNP, RN; John W. Devlin, PharmD, FCCM; John P. Kress, MD; Aaron M. Joffe, DO; Douglas B.

Coursin, MD; Daniel L. Herr, MD, MS, FCCM; Avery Tung, MD; Bryce RH Robinson, MD, FACS; Dorrie K. Fontaine, PhD, RN, FAAN; Michael A. Ramsay, MD; Richard R. Riker, MD, FCCM; Curtis N. Sessler, MD, FCCP, FCCM; Brenda Pun, RN, MSN, ACNP; Yoanna Skrobik, MD, FRCP; Roman Jaeschke, MD, MSc

Critical Care Medicine. 2012 (In press)

What’s Different about this Version of What’s Different about this Version of the PAD Guidelines?-the PAD Guidelines?-MethodsMethods

• Professional librarian:– Charlie Kishman, MSLS, Univ. of Cincinnati– Developed MeSH terms, conducted standardized searches,

managed Refworks ™ database.

• Electronic Database:– Web-based database (Refworks™ software)- >19,000 refs!– Accessible on-line to all Task Force members.

What’s Different about this Version of What’s Different about this Version of the PAD Guidelines?-the PAD Guidelines?-Methods (cont.)Methods (cont.)

• GRADE Methodology: (www.gradeworkinggroup.org) – More rigorous , transparent process – minimizes COI.– Strength of recommendations = strength of evidence + relative

risks, benefits of interventions – more practical, applicable.– Expert opinion not used as a substitute for making

recommendations without evidence – more robust.

• Voting Process:– Anonymous on-line voting (E-survey™) by all Task Force

members.– Polling managed by SCCM staff.– Standardized voting thresholds used to achieve consensus for all

statements and recommendations.

What’s Different about this Version What’s Different about this Version of the PAD Guidelines? − of the PAD Guidelines? − ContentContent

• Psychometric assessments comparing pain, sedation, delirium monitoring tools (defines the most valid, reliable, and feasible tools to use in ICU patients).

• More patient-centered, integrated, and interdisciplinary approach to managing pain, agitation, and delirium (less emphasis on drug recipes).

• Greater emphasis on the pathophysiology, risks, and management of delirium.

What’s Different About this Version What’s Different About this Version of the PAD Guidelines? − of the PAD Guidelines? − ScopeScope

• Way bigger than the last version!– Total of 53 statements and recommendations! – vs. 28 recommendations in the 2002 SAG Guidelines.– vs. 36 statements, recommendations in the 2008 Sepsis

Guidelines.

• Not meant to be comprehensive:– Attempts to answer the most important questions related to

pain, agitation, and delirium in ICU patients.– Some questions have no answers due to a lack of evidence.– Identifies area for future research.

2012 Pain, Agitation, and Delirium 2012 Pain, Agitation, and Delirium Clinical Practice GuidelinesClinical Practice Guidelines

Why are they significant?

Early Mobility of ICU PatientsEarly Mobility of ICU Patients

Integrated PAD ManagementIntegrated PAD Management

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

SBT protocol¯ MV1.5d

(Ely, et al,NEJM)

SAT-DSI protocol̄ MV>2d, ICU LOS3.5d(Kress, et al,NEJM)

CAM-ICUvalidated,delirium

incidence = 87%(Ely et al,CCM)

ACCM SAG revision(Jacobi, et al,CCM)

ICU Delirium­ mortality risk

10%/d ofdelirium (Ely et

al,JAMA)

SAT-Target SS¯ MV2.2d

(Breen et al,CCM)

Analgesia+Sedation protocoltitr to BPS,RASS

¯ pain 21%,̄agitation 17%,¯ MV2.2d, ¯ infect. rates 50%

(Chanques et al,CCM)

Feasibility, safety ofEM in MV ICU pts(Bailey et al,CCM)

SAT +SBT = ABC¯ MV 3d, ICU, hospital LOS4d,¯ risk of death by 32%

(Girard, et al, Lancet)

ABC+EM¯ ICU LOS1.4d,Hosp LOS3.3d,(Morris et al,CCM)

SAT + EM/PT̄delirium2d, ¯ MV2d, ­ post d/c indep FS (OR=2.7)

(Schweickert, et al, Lancet)

ABCDE protocolproposed (Vasilevskis et

al,CCM)

Duration of ICUdelirium predicts LT

cognitivedysf.(Girard et al,CCM)

Revised PADGuidelinepublished?

(Barr, et al,CCM)

The Path to The Path to PAD Integration…PAD Integration…

ABCDE Bundle*

*Awakening and Breathing Coordination, Delirium Management, and Early Mobility and Exercise

PAD Interdisciplinary TeamPAD Interdisciplinary Team

PAD Guideline ImplementationPAD Guideline ImplementationPAD

 Implem

entation (%)Interdisciplinary PAD

Stakeholder Team

MD Champion!MD Champion!

Expected Benefits of Implementing Expected Benefits of Implementing the PAD Guidelinesthe PAD Guidelines

• Shortened duration of MV• Reduced ICU, hospital LOS• Increased ICU patient throughput, bed availability • Decreased costs per patient• Improved long-term cognitive function, mobility• Increased number of patients discharged to home!• Lives saved!

ICU PAD Care BundleICU PAD Care BundlePAIN

AGITATION

DELIRIUM

Assess pain ≥ 4x/shift & prnPreferred pain assessment tools:•Patient able to self-report NRS (0-10)•Unable to self-report BPS (3-12) or CPOT (0-8)Patient is in significant pain if NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3

Treat pain within 30” then reassess:•Non-pharmacologic treatment– relaxation therapy•Pharmacologic treatment:•Non-neuropathic pain IV opioids +/- non-opioid analgesics•Neuropathic pain gabapentin or carbamazepine, + IV opioids•S/p AAA repair, rib fractures thoracic epidural

• Administer pre-procedural analgesia and/or non-pharmacologic interventions (eg, relaxation therapy)

• Treat pain first, then sedate

Assess agitation, sedation ≥ 4x/shift & prn

Preferred sedation assessment tools:•RASS (-5 to +4) or SAS (1 to 7) •NMB suggest using brain function monitoring

Depth of agitation, sedation defined as:•agitated if RASS = +1 to +4, or SAS = 5 to 7•awake and calm if RASS = 0, or SAS = 4•lightly sedated if RASS = -1 to -2, or SAS = 3•deeply sedated if RASS = -3 to -5, or SAS = 1 to 2

Assess delirium Q shift & prnPreferred delirium assessment tools:•CAM-ICU (+ or -)•ICDSC (0 to 8) Delirium present if:•CAM-ICU is positive•ICDSC ≥ 4

Targeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 – 0, SAS = 3 - 4•If under sedated (RASS >0, SAS >4) assess/treat pain treat w/sedatives prn (non-benzodiazepines preferred, unless ETOH or benzodiazepine withdrawal suspected)•If over sedated (RASS <-2, SAS <3) hold sedatives until @ target, then restart @ 50% of previous dose

• Consider daily SBT, early mobility and exercise when patients are at goal sedation level, unless contraindicated

• EEG monitoring if:– at risk for seizures– burst suppression therapy is

indicated for ­ICP

• Identify delirium risk factors: dementia, HTN, ETOH abuse, high severity of illness, coma, benzodiazepine administration

• Avoid benzodiazepine use in those at ­ risk for delirium

• Mobilize and exercise patients early• Promote sleep (control light, noise; cluster

patient care activities; decrease nocturnal stimuli)

• Restart baseline psychiatric meds, if indicated

• Treat pain as needed• Reorient patients; familiarize

surroundings; use patient’s eyeglasses, hearing aids if needed

• Pharmacologic treatment of delirium:• Avoid benzodiazepines unless ETOH or

benzodiazepine withdrawal suspected• Avoid rivastigmine• Avoid antipsychotics if ­ risk of Torsades

de pointes

Implementing the ICU PAD Care BundleImplementing the ICU PAD Care BundlePAIN

AGITATION

DELIRIUM

Treat pain within 30” then reassess:•Non-pharmacologic treatment– relaxation therapy•Pharmacologic treatment:•Non-neuropathic pain IV opioids +/- non-opioid analgesics•Neuropathic pain gabapentin or carbamazepine, + IV opioids•S/p AAA repair, rib fractures thoracic epidural

• Administer pre-procedural analgesia and/or non-pharmacologic interventions (eg, relaxation therapy)

• Treat pain first, then sedate

Targeted sedation or DSI (Goal: patient purposely follows commands without agitation): RASS = -2 – 0, SAS = 3 - 4•If under sedated (RASS >0, SAS >4) assess/treat pain treat w/sedatives prn (non-benzodiazepines preferred, unless ETOH or benzodiazepine withdrawal suspected)•If over sedated (RASS <-2, SAS <3) hold sedatives until @ target, then restart @ 50% of previous dose

• Consider daily SBT, early mobility and exercise when patients are at goal sedation level, unless contraindicated

• EEG monitoring if:– at risk for seizures– burst suppression therapy is

indicated for ­ICP

• Identify delirium risk factors: dementia, HTN, ETOH abuse, high severity of illness, coma, benzodiazepine administration

• Avoid benzodiazepine use in those at ­ risk for delirium

• Mobilize and exercise patients early• Promote sleep (control light, noise; cluster

patient care activities; decrease nocturnal stimuli)

• Restart baseline psychiatric meds, if indicated

• Treat pain as needed• Reorient patients; familiarize

surroundings; use patient’s eyeglasses, hearing aids if needed

• Pharmacologic treatment of delirium:• Avoid benzodiazepines unless ETOH or

benzodiazepine withdrawal suspected• Avoid rivastigmine• Avoid antipsychotics if ­ risk of Torsades

de pointes

Assess pain ≥ 4x/shift & prnPreferred pain assessment tools:•Patient able to self-report NRS (0-10)•Unable to self-report BPS (3-12) or CPOT (0-8)Patient is in significant pain if NRS ≥ 4, BPS ≥ 6, or CPOT ≥ 3

Assess agitation, sedation ≥ 4x/shift & prn

Preferred sedation assessment tools:•RASS (-5 to +4) or SAS (1 to 7) •NMB suggest using brain function monitoring

Depth of agitation, sedation defined as:•agitated if RASS = +1 to +4, or SAS = 5 to 7•awake and calm if RASS = 0, or SAS = 4•lightly sedated if RASS = -1 to -2, or SAS = 3•deeply sedated if RASS = -3 to -5, or SAS = 1 to 2

Assess delirium Q shift & prnPreferred delirium assessment tools:•CAM-ICU (+ or -)•ICDSC (0 to 8) Delirium present if:•CAM-ICU is positive•ICDSC ≥ 4

Time for a Quick Poll!

Please answer the following poll questions as they relate to your facility.

The ICU PAD Care BundleThe ICU PAD Care Bundle

Notes will

be on our website…

www.cynosurehealth.org

ICU Pain, Agitation & Delirium Care Bundle Metrics: Measurement for Improvement

Join us for a FREE Webinar

Thursday,  August 30, 201211:00 AM - 12:00 PM

The soon-to-be published Pain, Agitation and Delirium (PAD) Guidelines from the American College of Critical Care Medicine (ACCM) outline, in great detail,

recommendations for the assessment, treatment and prevention of pain, agitation and delirium in ICU patients. But how do you assess your hospital's performance in

these areas?

Please join us for a free webinar where Juliana Barr, MD, FCCM and Chair of ACCM's Task Force to revise these clinical practice guidelines, will discuss the metrics used

to assess performance with ICU PAD Care Bundle.

This will be an interactive program with the opportunity to submit/ask questions.

Thanks for joining us today!