Pain is one of the most distressful symptoms among critically ill patients, along with shortness of breath and delirium. Pain is reported by 38 to 51% of patients at risk of dying. Delirium is highly prevalent among patients who are critically ill and is associated with worse short-term and long-term outcomes, including in-hospital mortality, longer duration of mechanical ventilation, longer stay in the hospital and the ICU and cognitive impairment.


Sedatives and analgesics are commonly prescribed in the ICU, with nearly 90% of critically ill patients receiving these drugs at some point during their stay. While these drugs are often needed to control pain and anxiety, they are also associated with a high risk of adverse events such as delirium, hospital-acquired infections and increased mortality.


The 2018 Clinical Practice Guidelines for the Prevention of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the ICU (PADIS) recommend the use of sedatives, analgesics and psychoactive drugs for the management of these symptoms. Before these guidelines were published, the ABCDEF bundle was used to guide practices for sedation and analgesia.


While the 2018 guidelines are used in critically ill patients, there has been no evaluation or assessment of these recommendations in an international context. The Practices in Sedation, analgesia, mobilisation, delirium and sleep deprivation in adults in intensive care units (SAMDS-ICU) survey was conducted to investigate these recommendations and evaluate whether the COVID-19 pandemic has changed them.


Researchers analysed 1768 questionnaires. They observed that before the pandemic, the Visual Analog Scale, the Behavioural Pain Scale, the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit were the most frequently used tools for assessing pain sedation level and delirium. Midazolam and fentanyl were the most frequently used drugs for sedation and analgesia, and haloperidol and atypical antipsychotics were the most prescribed drugs for delirium.


During the pandemic, most sedation, analgesia, and delirium practices were comparable to the pre-pandemic period. The rate of mechanical ventilation was higher, and patients received sedation more often. Morphine, instead of fentanyl, was the most commonly used drug for analgesia and sedatives such as midazolam, propofol, ketamine and quetiapine were used more frequently.


Overall, the survey showed that sedation, analgesia and delirium practices were comparable before and during the pandemic. Most of the strategies used in the ICU were in accordance with evidence-based recommendations. Still, there is always room for improvement, in particular practices related to pain assessment in patients unable to communicate, delirium assessment, use of pharmacists during daily ICU rounds, use of sedative drugs to promote sleep and the use of opioids for pain management.


Source: Annals of Intensive Care

Image Credit: iStock



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delirium, sedation, sleep deprivation, Analgesia, mobilisation, COVID-19 Findings from the SAMDS-ICU Survey