Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f

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Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

The ABCDEF Bundle in Critical Care

Objective:To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool.Design:Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared

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Cornell Assessment of Pediatric Delirium: A Valid, Rapid, Observational Tool for Screening Delirium in the PICU*

Importance Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown Objective To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care Design, Setting, and Participants Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs) A total of 2449 children (mean age, 47 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge Intervention Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care Main Outcomes and Measures The primary outcome was duration of mechanical ventilation Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal Results Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 65 [IQR, 41-112] days; control: median, 65 [IQR, 37-121] days) Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups Intervention patients experienced more postextubation stridor (7% vs 4%; P  = 03) and fewer stage 2 or worse immobility-related pressure ulcers ( P  = 001) In exploratory analyses, intervention patients had fewer days of opioid administration (median, 9 [IQR, 5-15] days vs 10 [IQR, 4-21] days; P  = 01), were exposed to fewer sedative classes (median, 2 [IQR, 2-3] classes vs 3 [IQR, 2-4] classes; P P  = 004) than control patients, respectively; however, intervention patients had more days with any report of a pain score ≥4 (median, 50% [IQR, 27%-67%] of days vs 23% [IQR, 0%-46%] of days; P P  = 003), respectively Conclusions and Relevance Among children undergoing mechanical ventilation for acute respiratory failure, the use of a sedation protocol compared with usual care did not reduce the duration of mechanical ventilation Exploratory analyses of secondary outcomes suggest a complex relationship among wakefulness, pain, and agitation Trial Registration clinicaltrialsgov Identifier:NCT00814099

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Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure: A Randomized Clinical Trial

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the "Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care". Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade "A" (strong recommendation), Grade "B" (recommendation) and Grade "0" (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version

Objective:To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements.Design and Setting:A prospective observational cohort study investigating the Pediatric Confusion Asses

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Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

To the Editor: Smith et al recently developed the Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), which is a highly reliable and valid bedside tool conducted by the caregiver that assesses four cardinal features of the diagnosis of delirium in critically ill children 5 yrs of age. The characteristics of the pCAM-ICU, including the pocket card, worksheet, and daily guide, are amply explained in a report published in Critical Care Medicine (1). Given the absence of this kind of instrument in the Spanish language, we translated and adapted the original tool to the pCAM-ICU–Spanish (pCAM-ICU-S). Principles of good practice for translation and cultural adaptation were followed (2). The ten steps of the translation and adaptation process are described subsequently. 1) Preparation: We formed an international interdisciplinary team of native Spanish speakers from Colombia and Spain (JGF, CR, JFM, JdeP) and members of the original instrument development group (PB, EWE, HABS). The team members’ expertise included pediatric consultation–liaison psychiatry, pediatric neuropsychology, pediatric critical care, and delirium research; 2) forward translation: three independent forward-translated versions were developed (JGF, CR, JFM); 3) reconciliation: divergences in the interpretation of concepts in the three versions were resolved by consensus of the three translators, and a merged Spanish version was obtained; 4) back translation: an independent, highly qualified, native English-speaking medical translator back translated the merged Spanish version into English to provide quality control; 5) back translation review: the back-translated version was reviewed against the English source language (PB, EWE, HABS) to ensure its conceptual equivalence. Comments from this review were returned to the forward translators; 6) harmonization: the merged Spanish version was modified, taking into account the comments from the back translation reviewers; 7) cognitive debriefing: one expert on delirium from Spain (JdeP) evaluated the merged and modified, Spanish version to highlight and correct potentially confusing issues. All team members were informed of any changes; 8) approval and finalization: the Spanish tool was approved by all international team members; 9) proofreading: an independent, Spanish-speaking proofreader checked the Spanish tool for remaining spelling errors; and 10) publication: the pCAM-ICU-S was published on the Web site (http://www.icudelirium.org). The most relevant potentially confusing aspects that were resolved in steps 3 through 8 were related to the use of the word “delirium.” Although some clinicians in Spain use the word delirio when referring to the brain dysfunction evaluated by the pCAM-ICU-S, the word “delirium” was preferred for this tool, which was developed for use in Spain and Latin America. The Spanish word delirio also means “delusion” and is a source of interdisciplinary communication difficulties. The acute brain dysfunction evaluated by the pCAM-ICU-S is called “delirium” in the Spanish version of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised. It is recommended that the term “delirium” be used across languages and medical disciplines (3, 4). Another cultural adaptation issue that deserves mention is that a backslash (/) was used in a few cases to include different words when cultural differences could hinder comprehension of the items (for example, “alligator” was translated as “caimán/cocodrilo/lagarto”). Validity and reliability studies of the pCAM-ICU-S in diverse clinical settings are needed. Dr. Ely is supported by the National Institutes of Health (AG001023), Modifying the Impact of ICU-associated Neurological Dysfunction-USA (MIND-USA) Study (1R01AG035117-01A1), and the Veterans Affairs Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC). Dr. Ely also consulted for Cumberland, Masimo, received honoraria/speaking fees form Hospira, and received grant support from Lilly. The remaining authors have not disclosed any potential conflicts of interest. José G. Franco, MD, MSci, PhD, Hospital Universitari Psiquiàtric Institut Pere Mata, IISPV, Universitat Rovira I Virgili, Tarragona, Spain; and Faculty of Medicine, Universidad Pontificia Bolivariana, Medellín, Colombia; Carmenza Ricardo, MD, Faculty of Medicine, Universidad Pontificia Bolivariana, Medellín, Colombia; Juan F. Muñoz, MD, Instituto Neurológico de Antioquia, Medellín, Colombia; Joan de Pablo, MD, PhD, Hospital Universitari Psiquiàtric Institut Pere Mata, IISPV, Universitat Rovira I Virgili, Tarragona, Spain; Pamela Berry, RN, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; and Department of Pediatrics, Division of Pediatric Critical Care, Monroe Carrell Jr Children’s Hospital at Vanderbilt, Nashville, NC; E. Wesley Ely, MD, MPH, Department of Internal Medicine, Center for Health Services Research and Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN; and Tennessee Valley VA Geriatric Research, Education and Clinical Center, Nashville, TN, Heidi A. B. Smith, MD, MSci, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN

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Diagnosing delirium in critically ill children: Spanish translation and cultural adaptation of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

(acute physiology score), predicted ICU length of stay (PIS) and predicted hospital length of stay (PHS), predicted mortality, actual ICU stay(AIS) and actual hospital stay (AHS), and actual mortality in context of BMI. World Health Organization classification of BMI for obesity was used for the study. Data was extracted through the APACHEIV scoring system. We used analysis of variance and logistic regression analysis with SPSS version 22 (SPSS, Chicago, IL). Results: Increase in APS was found with increase in BMI but surprisingly the correlation was not found to be statistically significant. Mean ICU stay was 4.85, 5.21, 5.34, 6.20, 6.96 days for normal BMI, overweight, obesity class I, II, and III respectively. Both PIS and AIS correlated with increase in BMI in linear fashion (P < 0.01). Similarly, both PHS and AHS correlated with increase in BMI in linear fashion (P < 0.01). Surprisingly, no significant correlation was found between BMI and predicted ICU mortality or actual ICU mortality. Likewise, no significant correlation was found between age and gender of patients with ICU and hospital length of stay. Conclusions: BMI is related linearly with the ICU and hospital length of stay which could be explained by various comorbid conditions associated with obesity. However, absence of statistically significant correlation between increasing BMI with APS and ICU mortality was surprising, but supports the findings of previously published studies. Various theories have been proposed for this obesity paradox; for instance high level of antiinflammatory cytokines, better nutritional reserve, and effective adrenal steroid synthesis in the critically ill obese population. It would seem, however, that obesity is an independent predictor of the ICU duration, and that should be factored into current reimbursement equations in our evolving health care environment.

Pamela Berry

Papers

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

Diagnosing delirium in critically ill children: Spanish translation and cultural adaptation of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

653: Executive Dysfunction and Post-traumatic Stress Disorders after Critical Illness in Children