Seminars in respiratory and critical care medicine
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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
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
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.
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Semin Respir Crit Care Med · Apr 2013
Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies.
Although pharmacotherapy remains the mainstay for the prevention and treatment of pain, anxiety, and delirium (PAD) in the intensive care unit (ICU), many of the PAD-related medications currently used may lead to unintended consequences, particularly when these agents are administered at excessive doses for prolonged periods. The method by which these medications are administered and titrated is increasingly being recognized as potentially affecting patient outcomes as much as the drug itself. ⋯ The recently published American College of Critical Care Medicine (ACCM) Pain, Agitation, and Delirium Clinical Practice Guidelines provide 12 medication-related recommendations surrounding the prevention and treatment of PAD. This paper (1) provides the ICU bedside clinician with more background on the most important, and in some cases most contentious and challenging areas, of sedation and delirium pharmacotherapy in the critical care setting; (2) provides an update on the most recent evidence surrounding the prevention and treatment of agitation and delirium in ICU; and (3) highlights areas that require further investigation and provide practical strategies by which to apply current evidence in this area to daily ICU practice.
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Semin Respir Crit Care Med · Apr 2013
Cognitive impairment after critical illness: etiologies, risk factors, and future directions.
Mortality rates have declined substantially among critically ill populations in recent years, resulting in increasing numbers of individuals with significant physical, cognitive, and psychiatric morbidities due to the effects of their illness. A consensus has begun to develop regarding the nature of the difficulties experienced by intensive care unit (ICU) survivors, including physical, cognitive, and psychiatric decrements. This article focuses primarily on wide-ranging aspects of cognition and discusses potential mechanisms, risk factors, and recovery and rehabilitation of post-ICU cognitive impairment.