Pain/Agitation/Delirium

Pain, agitation, and delirium commonly occur in critically ill patients. Over the past decade, clinicians have gained a greater understanding of how to better assess and manage pain and sedation, and how to recognize and prevent delirium in these patients. Valid and reliable pain, sedation, and delirium assessment tools are becoming more widely adopted in intensive care units (ICUs). We have more insight into the clinical pharmacology of sedative and pain medications in critically ill patients, and the short- and long-term clinical consequences of patients' exposure to these agents. In contrast to previously held conventional wisdom, maintaining a light level of sedation while also ensuring patient comfort is associated with better clinical outcomes than deep sedation in most ICU patients. Finally, we have a better understanding of some of the risk factors for ICU patients developing delirium, the short- and long-term clinical consequences of ICU delirium, and effective delirium prevention strategies in these patients. The recently published“Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit”[1] (PAD Guidelines) incorporate these principles and advocate for clinicians taking a more integrated and holistic approach to managing pain, sedation, and delirium in critically ill patients, to achieve synergistic improvements in their ICU outcomes.

In this issue of Seminars in Respiratory and Critical Care Medicine, authors with expertise in ICU pain, sedation, and delirium offer greater insight into each of these domains through a combination of original research and state-of-the-art reviews that enable ICU clinicians to translate basic knowledge of PAD Guideline principles into their clinical practice. The article by Gélinas et al includes an updated comparative analysis of the psychometric properties of behavioral pain scales for use in ICU patients who are otherwise unable to self-report pain. Sessler et al take an in-depth and historical look at the development, structure, and use of subjective sedation scales for assessing agitation and depth of sedation in critically ill patients. Pun and Devlin discuss the importance and feasibility of delirium screening in ICU patients.They compare and contrast the most valid and reliable ICU delirium assessment tools: the Confusion Assessment Method for the ICU (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC). Joffe and colleagues provide a state-of-the-art summary of strategies for diagnosing and treating pain in ICU patients, including both pharmacological and nonpharmacological approaches to pain management. Devlin and colleagues summarize the most recent evidence surrounding the prevention and treatment of agitation and delirium in ICU patients, highlighting important and, in some cases, controversial issues surrounding the management of sedation and delirium in ICU patients, as well as practical strategies for applying these principles to daily ICU practice. Jackson and Ely provide an in-depth analysis of the epidemiology and pathophysiology of long-term cognitive impairment in patients who recover from their critical illness. Pun et al offer strategies and tools for successful implementation of the 2013 PAD Guidelines in the ICU, emphasizing the use of an interdisciplinary approach to implement the key elements of the ICU PAD Care Bundle to successfully assess, treat, and prevent pain, agitation, and delirium in ICU patients. Gélinas and colleagues highlight the unique challenges for applying the 2013 PAD Guidelines in neurocritically ill patients. Smith and colleagues compare and contrast the application of the PAD Guidelines for adult ICU patients to that for pediatric ICU patients. Finally, Davidson et al discuss the use of a professional librarian and the GRADE[2] method in creating the 2013 PAD Guidelines, and assess the impact of using GRADE on interrater reliability in developing guideline statements and recommendations.

Pain, agitation, and delirium are ubiquitous in critically ill patients, and the 2013 PAD Guidelines have the potential to improve dramatically the care of critically ill patients and their clinical outcomes depending on the implementation and translation of the guidelines into bedside practice modifications amid the changing culture of ICU care. The articles included in this issue of Seminars in Respiratory and Critical Care Medicine highlight the strengths and weaknesses of these guidelines and will help to guide clinicians in the appropriate application of the PAD Guidelines to their ICU patient populations. We would like to thank all of the authors who have thoughtfully contributed to this important issue.

• References

• 1 Barr J, Fraser GL, Puntillo K , et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41 (1) 278-280
• 2 GRADE Working Group. Software program. www.gradeworkinggroup.org