The New 2018 SCCM PADIS Guidelines: Quick Hits of ...

Introduction 4 2018 Pain, Agitation/sedation, Delirium, Immobility, and Sleep disruption (PADIS) guideline • Updating 2013 PAD guidelines ... SlideShareusescookiestoimprovefunctionalityandperformance,andtoprovideyouwithrelevantadvertising.Ifyoucontinuebrowsingthesite,youagreetotheuseofcookiesonthiswebsite.SeeourUserAgreementandPrivacyPolicy. SlideShareusescookiestoimprovefunctionalityandperformance,andtoprovideyouwithrelevantadvertising.Ifyoucontinuebrowsingthesite,youagreetotheuseofcookiesonthiswebsite.SeeourPrivacyPolicyandUserAgreementfordetails. Home Explore Login Signup Successfullyreportedthisslideshow. WeuseyourLinkedInprofileandactivitydatatopersonalizeadsandtoshowyoumorerelevantads.Youcanchangeyouradpreferencesanytime. TheNew2018SCCMPADISGuidelines:QuickHitsofRecommendationsforSedation,DeliriumandMobility-DaleNeedham UpcomingSlideShare Loadingin…5 × 1 1of26 Likethispresentation?Whynotshare! 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Dr.NeedhamreceivedhisMDdegreefromMcMasterUniversityinHamilton,Canada,andcompletedbothhisresidencyininternalmedicineandhisfellowshipincriticalcaremedicineattheUniversityofToronto.HeobtainedhisPhDinClinicalInvestigationfromtheBloombergSchoolofPublicHealthatJohnsHopkinsUniversity.Notably,priortohismedicaltraining,hecompletedBachelorandMasterdegreesinAccountingandpracticedinalargeinternationalaccountingfirm,withafocusinthehealthcarefield. Dr.NeedhamisPrincipalInvestigatoronanumberofNIHresearchgrantsandhasauthoredmorethan250publications.HisresearchinterestsincludeevaluatingandimprovingICUpatients’long-termphysical,cognitiveandmentalhealthoutcomes,includingresearchintheareasofsedation,delirium,earlyphysicalrehabilitation,andknowledgetranslationandqualityimprovement. Readmore IntensiveCareSociety Follow MakingBritainGreatAgain-BrianCuthbertson IntensiveCareSociety ObstetricEarlyWarningscores–the4P’sstudy-PeterWatkinson IntensiveCareSociety EnhancedMaternalCare–TheYorkshire&Humberexperience-SarahWinfield IntensiveCareSociety CareoftheCriticallyIllWomaninChildbirth-AudreyQuinn IntensiveCareSociety MothersinCriticalCare:learningfrompatients’experiences&challengesto... IntensiveCareSociety Howdowegetitrightfirsttime?-AnnaBatchelor IntensiveCareSociety Defenceofphysiologicalfunctionduringhighriskairwaymanagement-Paul... IntensiveCareSociety INTEREST:EfficacyandSafetyofFP-1201-lyo(InterferonBeta-1a)inPatients... IntensiveCareSociety POPPI:ProvisionOfPsychologicalsupporttoPeopleinIntensivecare-Kathy... 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FinancialDisclosure/ConflictofInterest •ReckMedicalDevices&BaxterHealthcareagreedtolend bedsidecycleergometersandprovideaminoacid product/grantfunding,respectively,foraNIH-fundedRCT ofearlyexercise&nutritionintheICU •IwasamemberofSCCMPADISGuidelinecommittee,and ChairoftheMobility/RehabsectionofPADIS Disclosure 3. Introduction 4 2018Pain,Agitation/sedation,Delirium,Immobility,and Sleepdisruption(PADIS)guideline •Updating2013PADguidelinesby: –Adding2newtopics:rehab/mobilization&sleepdisruption –Includingpatientsascollaboratorsandco-authors –AddingexpertsfromEurope&Australia •37recommendations&2ungradedgoodpracticestatements •2of37recommendations,ratedas“strong” •32ungradedstatements(non-actionabledescriptivequestions) 4. Agitation/Sedation 30 2013Guidelines •Focusonimprovingpatientshort-termoutcomes 2018Guidelines •Focusonimprovingpost-ICUoutcomes,investigating: –Sedationdeliveryparadigm&specificsedativemedications •3actionable(PICO)question+3descriptivequestions 5. Lightvs.DeepSedation 32 Evidence:8RCTs,3observationalstudy 6. Lightvs.DeepSedation(?Harms) 36 •90daysmortality(2RCTs,324pts) –Notsignificant,RR1.01(95%CI,0.80to1.27;lowquality) •Self-extubation(4RCT,546pts) –Notsignificant,RR1.29(95%CI,0.58to2.88;lowquality) •LightsedationwasNOTassociatedwith: –PTSD(2RCTs,62pts),RR0.67(95%CI,0.12to3.79) –Depression(2RCTs,128pt),RR0.76(95%CI,0.10to5.58) –Delirium(2RCTs,140pts),RR0.96(95%CI,0.80to1.16) 7. Lightvs.DeepSedation 37 •Tracheostomyrate(1RCT&1observational,452pts) –Reduced,RR0.57(95%CI,0.41to0.80) •Timetoextubation(3RCTs,453pts;lowquality) –Associatedw/shortertime,MD-0.77days(95%CI,-2.04to0.50) •Timetoextubation(3observational,1524pts;lowquality) –Associatedw/shortertime,MD-3.46days(95%CI,-5.70to-1.23) 8. Recommendation… 43 Recommendation: Wesuggestusinglightvs.deepsedationincriticallyill,mech- ventilatedadults(conditionalrecommendation,lowqualityofevidence). 9. ChoiceofSedative: Medical&Surgicalpts(Noncardiacsurgery) 47 Question:Forsedationincriticallyill,mechventilatedadults… ShouldPropofol,ascomparedtoaBenzodiazepine,beused? ShouldDexmed,ascomparedtoaBenzodiazepine,beused? ShouldDexmed,ascomparedtoPropofol,beused? 10. ChoiceofSedative: Medical&Surgicalpts(Noncardiacsurgery) 49 Propofolvs.Benzodiazepine: •Timetoextubation(10RCTs,423pts) –Reducedby11.6hr(95%CI,-15.6to-7.6;lowquality) •Timetolightsedation(10RCTs,357pts) –Reducedby7.2hr(95%CI,-8.9to-5.5;lowquality) Dexmedvs.Benzodiazepine(BZD): •Nosignificantbenefit*ofDexmedoverBZDinfusionfor: –Durationofmechanicalventilation(5RCT,1052pts) –ICUlengthofstay(3RCTs,969pts) –Riskofdelirium(4RCTs,1007pts) *SEDCOMRCThadlowestROB&significantdecreaseextubationtime(1.9d) anddelirium(RR0.71)–influencedgradingofrecommendation Dexmedvs.Propofol: •Nosignificantdifferenceintimetoextubation(3RCTs,850pts) 11. Recommendation… 51 Recommendation: Wesuggestusingeitherpropofolordexmedetomidineover benzodiazepineforsedationincriticallyill,mechanically ventilatedadults(conditionalrecommendation,lowqualityof evidence). NOTEintheexistingstudiesforthisrecommendation: −Benzodiazepinesmostlygivenasinfusionratherthanbolus 12. Delirium 60 •~50%frequencyinICUpatients •6actionable(PICO)question+5descriptivequestions 13. DeliriumpharmacologicalPrevention 68 Question: Shouldapharmacologicagent(versusnouseofthisagent)be usedtopreventdeliriumincriticallyilladults? Rationale:3RCTs,1283pts Significantreductionindeliriumincidencefavoringthepharmacologicagent: •Haloperidol*(457pts),RR0.66;95%CI,0.45to0.97;lowquality −*Update:REDUCERCT(1789pts):Noeffectondeliriumorsurvival •Risperidone(126pts),RR0.35;95%CI,0.16to0.77;lowquality •Dexmed**(700pts),OR0.35;95%CI,0.22to0.54;lowquality **SuetalDexmedforpreventionofdeliriuminelderlypatientsafternon-cardiacsurgery.Lancet2016 lowseverityofillness;onlysurgicalpts,assessingshort-termoutcomes;cost&sideeffects 14. DeliriumpharmacologicalPrevention 69 Recommendation: WesuggestNOTusinghaloperidol,anatypical antipsychotic,dexmedetomidine,statin,orketamineto preventdeliriuminallcriticallyilladults(Conditional recommendation,verylowtolowqualityofevidence) 15. Haloperidolvs.NoMedication(Treatment) 71 •DurationofDelirium(3RCTs,265pts) –NOTsignificant,Increasedby0.29days(95%CI,-1.49to2.07) •DurationofMechanicalVentilation(2RCT,124pts) –Notsignificant,Reducedby1.12days(95%CI,-4.85to2.61) •ICUMortality(3RCTs,265pts) –NOTsignificant,RR1.00(95%CI,0.62to1.61) 16. AtypicalAntipsychoticvs.None(Treatment) 72 •DurationofDelirium(2RCTs,102pts) –NOTsignificant,Reducedby0.87days(95%CI,-6.70to4.97) •DurationofMechanicalVentilation(2RCTs,95pts) –NOTsignificant,Reducedby0.34days(95%CI,-6.54to5.86) •LengthofICUStay(2RCTs,102pts) –NOTsignificant,Increasedby1.93days(95%CI,-1.17to5.68) •ICUMortality(2RCT,102pts) –NOTsignificant,RR0.75(95%CI,0.29to1.96) 17. 73 Rationale,includes: •Unnecessarycontinuationcausessignificantmorbidity&cost Recommendation: WesuggestNOTroutinelyusinghaloperidolandatypical antipsychotictotreatdelirium(conditionalrecommendation,lowquality ofevidence). Antipsychotic/statinvs.None(Treatment) 18. 75 Rationale:1RCT(71pts) •Significantincreaseinventilator-freehours –MeanDifference17hrs(95%CI,4to33hrs);verylowquality •NOeffectonICU/HospLOSorhospitaldischargelocation Recommendation: Wesuggestusingdexmedetomidinefordeliriuminmechanically ventilatedadultswhereagitationisprecludingweaning/extubation (conditionalrecommendation,lowqualityofevidence). Dexmedetomidinevs.Placebo(Treatment) 19. 82 Rationale:5studies(1RCT*,4Before-after),1318pts •Useofthesestrategieswasassociatedwith: –Reduceddeliriumsignificantly,OR=0.59(95%CI,0.39to0.88) –DecreasedICUdurationofdelirium,ICULOS&Hospitalmortality Recommendation: Wesuggestusingamulticomponent,non-pharmacologic interventionthatisfocusedon(butnotlimitedto)reducing modifiableriskfactorsfordelirium,improvingcognition,and optimizingsleep,mobility,hearing,andvisionincriticallyilladults (conditionalrecommendation,lowqualityofevidence) Non-PharmacologicalTreatment Multi-component *IntJNursStud2015;52:1423–1432(N=123patientsinKorea–noeffectondelirium&LOS 20. Whyadd“Immobility”toPAD (Rehabilitation/Mobilization) 84 •ICU-AcquiredmuscleWeakness(ICUAW) –Presentin25-50%ofcriticallyillpatients –Associatedw/long-termsurvival,physicalfunction&qualityoflife –Immobility/bedrestisanimportantriskfactor •Mobility/rehabalsomaybebeneficialfordelirium •Assoc.ofpain&sedationstatus/practicesw/ICURehab •1actionable(PICO)question+3descriptivequestions 21. EfficacyandBenefit 96 1.MusclestrengthatICUdischarge(6RCTs,304pt) –Improvedby6.2points(95%CI,1.7to10.8;scaleis0to60) –lowquality(statisticalheterogeneity,CIincludesMCID) 2.Durationofmech.ventilation(11RCTs,1128pt) –Reducedby1.3days(95%CI,2.4to0.2days) –lowquality(2largeRCThighROB,competingrisk,heterogeneity) 3.Qualityoflife(SF-36Physicalfunction)w/in2mo.(4RCTs,303pt) –ImprovedbySMDof0.64(95%CI,-0.05to1.34–notsignificant) 4.Hospitalmortality(13RCTs,1421pt) –Noeffect,RR=0.93(95%CI,0.74to1.18)–moderatequality(CIincludesharm) 5.Physicalfunc:smallNd/theterogeneityinmeasures;NOTsignificant –TimedUp&Gotest,meandif2.22(95%CI,-4.99to9.43;3RCT,172pt) –PhysFunc.inICU(PFIT)test,meandif-0.19(95%CI,-0.69to0.31;3RCT,209pt) 22. Recommendation… 99 FormalRecommendation: Wesuggestperformingrehabilitationormobilizationincritically illadults(conditionalrecommendation,lowqualityevidence). •Implementationinfluencedbyfeasibility,staffing& resourcesacrossICUs 23. SafetyandRisk 102 Question: …isreceivingrehab/mobilization(performedeitherin-bedorout-of-bed) commonlyassociatedwithpatient-relatedsafetyeventsorharm? UngradedStatement: Serioussafetyeventsorharmsdonotoccurcommonlyduring physicalrehabilitationormobilization. •Rationale:10observational&9RCTs –Serioussafetyevents/harmswererare(15during>12,200sessions) –Majoritywererespiratory-related(4desaturation&3unplannedextubation) 24. Table1.Safetycriteriaforstart/stoprehab/mobilization(in-bedorout-of-bed) 105 SafetycriteriaStartingaRehab/MobilitysessionStoppingaRehab/Mobilitysession SystemStartwhenALLofthefollowingarepresent:StopwhenANYofthefollowingarepresent: Cardiovascular●Heartratebetween60-130bpm ●SystolicB/Pbetween90-180mmHg,or ●Meanarterialpressurebetween60-100 ●Heartratedecreases<60orincreases>130 ●Systolicdecreases<90orincreases>180 ●MAPdecreases<60orincreases>100 Respiratory●Respiratoryratebetween5-40bpm ●SpO2>=88% ●FiO2<0.6&PEEP<10cmH2O ●Airway(ETTortrach)adequatelysecured ●Resp.ratedecreases<5orincreases>40 ●SpO2decreases<88% ●Concernsre:securementofETTortrach Neurologic●Abletoopeneyestovoice●ChangeinLOC OtherThefollowingshouldbeabsent: ●Neworsymptomaticarrhythmia ●Chestpainwithconcernforischemia ●Unstablespinalinjuryorlesion ●Unstablefracture ●ActiveoruncontrolledGIbleed Mobilitymaybeperformedwith ●FemoralVAD,exceptsheath,inwhichhip mobilizationisgenerallyavoided ●Continuousrenalreplacementtherapy ●Vasoactivemedicationinfusion Iffollowingdevelop&clinicallyrelevant: ●New/symptomaticarrhythmia ●Chestpainwithconcernforischemia ●Ventilatorasynchrony ●Fall ●Bleeding ●Medicaldeviceremovalormalfunction ●Distressreportedbypatientorclinician “…notbeasubstituteforclinicaljudgment” “Allthresholdsshouldbeinterpretedormodified, asneeded,inthecontextofindividualpatients’ clinicalsymptoms,expectedvalues,recenttrends,and anyclinician-prescribedgoalsortargets.” 25. Publicationsrelatedtothe2018SCCMPADISguidelines: •PADISGuidelines •ExecutiveSummary •Interpreting&Implementing2018PADISGuideline •MethodologicInnovationin2018PADISGuideline Freeaccesstopublications&PADISpresentation: http://www.sccm.org/ICULiberation/Guidelines 2018SCCM 26. 1JohnDevlin,PharmD(ChairforOverallCPG) 2YoannaSkrobik,MD,MSc(Vice-Chair) 3CélineGélinas,RN,PhD(Chair,Pain) 4AaronJoffe,DO 5KathleenPuntilloRN,PhD 6GeraldChanques,MD,PhD 7Jean-FrancoisPayen,MD,PhD 8PaulSzumita,PharmD 9PratikPandharipande,MD,MSCI(Chair,Sedation) 10RichardRiker,MD 11MicheleBalas,RN,PhD 12YahyaShehabi,MD,PhD 13JohnKress,MD 14BryceRobinsonMD,MS 15ArjenSlooter,MD,PhD(Chair,Delirium) 16BrendaPun,RN,DNP 17GillesFraser,PharmD,MCCM 18MargaretPisani,MD,MPH 19KarinNeufeld,MD,MPH 20MarkvandenBoogaard,RN,PhD 21DaleNeedham,MD,PhD(Chair,Immobility) 22LindaDenehy,PT,PhD 23MichelleKho,PT,PhD 24ChrisWinkelman,RN,PhD 25NathanielBrummel,MD,MSCI 26JocelynHarris,OT,PhD 27JulieLanphere,DO 28SinaNikayin,MD(researchstaff) 29PaulaWatson,MD,MPH(Chair,Sleep) 30XavierDrouot,MD,PhD 31GeraldWeinhouse,MD 32KarenBosma,MD 33SharonMcKinley,RN,PhD 34WaleedAlhazzani,MD,MSc(Chair,Methods) 35MarkNunnally,MD 36BramRochwerg,MD,MSc 37JohnCentofani,MD,MSc 38CarriePrice,MLS(medicallibrarian) 39CherylMisak,PhD(patientrep) 40KenKiedrowski,MA(patientrep)108 Co-authorsforentireGuideline MakingBritainGreatAgain-BrianCuthbertson IntensiveCareSociety ObstetricEarlyWarningscores–the4P’sstudy-PeterWatkinson IntensiveCareSociety EnhancedMaternalCare–TheYorkshire&Humberexperience-SarahWinfield IntensiveCareSociety CareoftheCriticallyIllWomaninChildbirth-AudreyQuinn IntensiveCareSociety MothersinCriticalCare:learningfrompatients’experiences&challengesto... IntensiveCareSociety Howdowegetitrightfirsttime?-AnnaBatchelor IntensiveCareSociety Defenceofphysiologicalfunctionduringhighriskairwaymanagement-Paul... IntensiveCareSociety INTEREST:EfficacyandSafetyofFP-1201-lyo(InterferonBeta-1a)inPatients... IntensiveCareSociety POPPI:ProvisionOfPsychologicalsupporttoPeopleinIntensivecare-Kathy... IntensiveCareSociety Optin,Optout:stirrednotshaken-DaleGardiner IntensiveCareSociety Dr.NeedhamisProfessorofPulmonaryandCriticalCareMedicine,andofPhysicalMedicineandRehabilitationattheJohnsHopkinsUniversityinBaltimore,USA.HeisDirectorofthe“OutcomesAfterCriticalIllnessandSurgery”(OACIS)ResearchGroupandcorefacultywiththeArmstrongInstituteforPatientSafetyandQuality,bothatJohnsHopkins.Fromaclinicalperspective,heisanattendingphysicianinthemedicalintensivecareunitatJohnsHopkinsHospitalandMedicalDirectoroftheJohnsHopkinsCriticalCarePhysicalMedicineandRehabilitationprogram. Dr.NeedhamreceivedhisMDdegreefromMcMasterUniversityinHamilton,Canada,andcompletedbothhisresidencyininternalmedicineandhisfellowshipincriticalcaremedicineattheUniversityofToronto.HeobtainedhisPhDinClinicalInvestigationfromtheBloombergSchoolofPublicHealthatJohnsHopkinsUniversity.Notably,priortohismedicaltraining,hecompletedBachelorandMasterdegreesinAccountingandpracticedinalargeinternationalaccountingfirm,withafocusinthehealthcarefield. Dr.NeedhamisPrincipalInvestigatoronanumberofNIHresearchgrantsandhasauthoredmorethan250publications.HisresearchinterestsincludeevaluatingandimprovingICUpatients’long-termphysical,cognitiveandmentalhealthoutcomes,includingresearchintheareasofsedation,delirium,earlyphysicalrehabilitation,andknowledgetranslationandqualityimprovement. 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