Clinical Practice Flowcharts for Pain, Agitation, and Delirium Management
Recognition that heavy sedation may increase mortality and morbidity has led to a new approach that maximizes the comfort of the patients while they remain awake, interactive, and oriented. This new approach relies on strategies such as daily interruptions of sedation, analgesia-based sedation, enteral sedation, avoidance of paralytic agents, early mobilization, and use of validated tools for sedation assessment [1]. In recent years, many guidelines have been proposed [4-6], representing a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep management. They comprehensively describe all attentions to be paid to perform the best neurological treatment. Nevertheless, even in guidelines with a high-quality rating, numerous recommendations have moderate or low levels of evidence [65].
Overall, the principal recommendation regarding analgesia is to evaluate pain and maintain its level < 4/10, by beginning early than late the treatment of pain, and by using opioid drugs first, together with non-opioid and multimodal analgesia techniques. A simple and practical flowchart at the bedside is presented in Fig. 18.4.
Regarding sedation, a target RASS of 0/-1 is recommended for all ICU patients, with the use of deep sedation reserved only for patients with specific indications (e.g., early ARDS patients, requiring neuromuscular blocking or prone positioning). In particular, intensivists should consider the specific indication and individual goal of sedation and the pharmacokinetics/pharmacodynamics of each drug used. Nonbenzodiazepine drugs, such as propofol or dexmedetomidine, have to be preferred. The need for sedation varies widely among different patients and with the illness course, and it has to be defined among “deep sedation”, “cooperative/awake sedation,” and “no sedation,” always preferring superficial levels of sedation and promoting early mobilization. The use of containment measures in episodes of severe agitation has to be performed in this order: first verbal, then pharmacological, and finally physical, considering that neuroactive drugs should not be administered in excess as a form of “chemical immobilization.” In the sedation flowchart (Fig. 18.5), it is clear that defining a target and evaluating the actual level of sedation or agitation with validated tools are absolute priorities. The choice of the specific sedative drug, albeit important, comes only after a clinical reasoning focused on managing the organic/metabolic causes and the problems that may be caused by adjustable invasive devices.
Recommendations about delirium are prescribed first to identify modifiable risk factors (Fig. 18.6) and to detect regularly the appearance of delirium by using the CAM-ICU. In case of delirium appearance, it is indicated to use a nonpharmacological protocol first, along with the suspension or decreasing of
Fig. 18.4 This flowchart can be used at the bedside, to adequately manage pain in critically ill patients
Fig. 18.5 This flowchart can be used at the bedside, to adequately manage agitation symptoms and to titrate sedative therapy for critically ill patients
Fig. 18.6 This flowchart can be used at the bedside, to timely manage delirium in ICU
deliriogenic therapies, and then to select the most appropriate drug (haloperidol, atypical antipsychotics, or dexmedetomidine; avoid the use of benzodiazepines) and titer its dose to the lowest effective dose.
