Delirmanagement, Analgesie, Sedierung - Die neue S3-Leitlinie

Mit dem Update der S3-Leitlinie zur Sedierung, Analgesie und Delirmanagement vom Oktober 2015 wurde die 2. Version dieser bedeutenden Leitlinie veröffentlicht, die bis 2020 gültig ist [1]. Zählt man die 2005 erschienene S2-Leitlinie ebenfalls hinzu, betreibt man in Deutschland bereits seit über einem Jahrzehnt leitliniengestützte Analgesie und Sedierung auf der Intensivstation [2], [3].

Kernaussagen

• Der intensivmedizinisch behandelte Patient soll wach, aufmerksam, schmerz-, angst- und delirfrei sein, um an seiner Behandlung und Genesung aktiv teilnehmen zu können.

• Ziel und derzeitiger Grad von Delir, Sedierung, Analgesie und Angst sollten mindestens einmal pro Schicht erhoben und dokumentiert werden.

• Sedierung ist einer der wesentlichen Risikofaktoren für die Entwicklung eines Delirs.

• Ein nicht pharmakologischer Präventions- und Therapieansatz für ein Delir mit Frühmobilisierung, Reorientierung und kognitiver Stimulierung wird empfohlen.

• Ein Delir sollte umgehend symptomatisch behandelt werden. Zur Therapie wird eine kontinuierliche Gabe von Alpha2-Agonisten empfohlen

• Unruhige Patienten sollte man auf Schmerzen untersuchen. Noch vor einer Sedierung muss eine ausreichende Analgesie erreicht werden.

• Angestrebt wird ein Sedierungsniveau mit einem RASS von 0 bis -1, eine tiefere Sedierung ist speziellen Indikationen vorbehalten (z. B. Schädel-Hirn-Trauma).

• Ein täglicher Aufwachversuch wird nur bei Patienten mit einem RASS < -2 empfohlen, sofern keine Kontraindikationen bestehen.

• Literatur

• 1 Taskforce DAS, Baron R, Binder A et al Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version Ger Med Sci. 2015 13. Doc19
• 2 Martin J, Bäsell K, Bürkle H et al Analgesie und Sedierung in der Intensivmedizin – Kurzversion. S2-Leitlinien der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Anästh Intensivmed 2005; 46: S1–20
• 3 Martin J, Heymann A, Basell K et al Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care – short version. Ger Med Sci. 2010 8. Doc02
• 4 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. Critical care medicine 2013; 41: 263-306
• 5 Ely EW, Shintani A, Truman B et al Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Jama 2004; 291: 1753-1762
• 6 Pandharipande PP, Girard TD, Jackson JC et al Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369: 1306-1316
• 7 Schiemann A, Hadzidiakos D, Spies C. Managing ICU delirium. Curr Opin Crit Care 2011; 17: 131-140
• 8 van Meenen LC, van Meenen DM. de Rooij SE et al Risk prediction models for postoperative delirium: a systematic review and meta-analysis. J Am Geriatr Soc 2014; 62: 2383-2390
• 9 Pandharipande P, Cotton BA, Shintani A et al Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma 2008; 65: 34-41
• 10 Mehta S, Cook D, Devlin JW et al Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults. Crit Care Med 2015; 43: 557-566
• 11 Ely EW, Girard TD, Shintani AK et al Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients. Crit Care Med 2007; 35: 112-117
• 12 Vasilevskis EE, Morandi A, Boehm L et al Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. J Am Geriatr Soc 2011; 59 (Suppl. 02) S249-255
• 13 Gaudreau JD, Gagnon P, Harel F et al Fast, systematic, and continuous delirium assessment in hospitalized patients: the nursing delirium screening scale. J Pain Symptom Manage 2005; 29: 368-375
• 14 Shehabi Y, Bellomo R, Reade MC et al Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012; 186: 724-731
• 15 Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010; 375: 475-480
• 16 Tanaka LM, Azevedo LC, Park M et al Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18: R156
• 17 Arroliga AC, Thompson BT, Ancukiewicz M et al Use of sedatives, opioids, and neuromuscular blocking agents in patients with acute lung injury and acute respiratory distress syndrome. Crit Care Med 2008; 36: 1083-1088
• 18 Colombo R, Corona A, Praga F et al A reorientation strategy for reducing delirium in the critically ill. Results of an interventional study. Minerva Anestesiol 2012; 78: 1026-1033
• 19 Pisani MA, Friese RS, Gehlbach BK et al Sleep in the intensive care unit. Am J Respir Crit Care Med 2015; 191: 731-738
• 20 Schweickert WD, Pohlman MC, Pohlman AS et al Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373: 1874-1882
• 21 Hatta K, Kishi Y, Wada K. Ramelteon for Delirium in Hospitalized Patients. JAMA 2015; 314: 1071-1072
• 22 Martin J, Franck M, Sigel S et al Changes in sedation management in German intensive care units between 2002 and 2006: a national follow-up survey. Crit Care 2007; 11: R124
• 23 Chanques G, Viel E, Constantin JM et al The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain 2010; 151: 711-721
• 24 Payen JF, Bru O, Bosson JL et al Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001; 29: 2258-2263
• 25 Mullins ME, Empey M, Jaramillo D et al A prospective randomized study to evaluate the antipyretic effect of the combination of acetaminophen and ibuprofen in neurological ICU patients. Neurocrit Care 2011; 15: 375-378
• 26 Chanques G, Jaber S, Barbotte E et al Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006; 34: 1691-1699
• 27 Girard TD, Kress JP, Fuchs BD et al Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371: 126-134
• 28 Blenkharn A. Faughnan S Morgan A Developing a pain assessment tool for use by nurses in an adult intensive care unit. Intensive Crit Care Nurs 2002; 18: 332-341
• 29 Kong R, Payen D. Controlling sedation rather than sedation controlling you. Clin Intensive Care 1994; 5: 5-7
• 30 Tonner PH, Weiler N, Paris A et al Sedation and analgesia in the intensive care unit. Curr Opin Anaesthesiol 2003; 16: 113-121
• 31 Mehta S, Burry L, Cook D et al Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012; 308: 1985-1992
• 32 Burry L, Rose L, McCullagh IJ et al Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014 7. CD009176
• 33 Ely EW, Truman B, Shintani A et al Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). Jama 2003; 289: 2983-2991
• 34 Tonner PH, Wei C, Bein B et al Comparison of two bispectral index algorithms in monitoring sedation in postoperative intensive care patients. Crit Care Med 2005; 33: 580-584
• 35 Swisher CB, Shah D, Sinha SR et al Baseline EEG pattern on continuous ICU EEG monitoring and incidence of seizures. J Clin Neurophysiol 2015; 32: 147-151
• 36 Sricharoenchai T, Parker AM, Zanni JM et al Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014; 29: 395-400
• 37 Davydow DS, Gifford JM, Desai SV et al Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008; 30: 421-434
• 38 Girard TD, Shintani AK, Jackson JC et al Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Crit Care 2007; 11: R28
• 39 Shehabi Y, Riker RR, Bokesch PM et al Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010; 38: 2311-2318
• 40 Chahraoui K, Laurent A, Bioy A et al Psychological experience of patients 3 months after a stay in the intensive care unit: A descriptive and qualitative study. J Crit Care 2015; 30: 599-605
• 41 Tipping CJ, Young PJ, Romero L et al A systematic review of measurements of physical function in critically ill adults. Crit Care Resusc 2012; 14: 302-311
• 42 Perpina-Galvan J, Richart-Martinez M. Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: a review. Am J Crit Care 2009; 18: 571-580
• 43 Figueroa-Ramos MI, Arroyo-Novoa CM, Lee KA et al Sleep and delirium in ICU patients: a review of mechanisms and manifestations. Intensive Care Med 2009; 35: 781-795
• 44 Watson PL. Measuring sleep in critically ill patients: beware the pitfalls. Crit Care 2007; 11: 159
• 45 Reinke L, van der Hoeven JH, van Putten MJ et al Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated. Crit Care 2014; 18: R66
• 46 Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care 2008; 12 (Suppl. 03) S3