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

Abstract in English, German

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.

Die vorherige Version der S3-Leitlinie „Analgesie, Sedierung und Delirmanagement in der Intensivmedizin“ wurde 2010 unter der Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) publiziert. Neue Evidenz aus Studien ebenso wie neue Leitlinien, u.a. die 2013 erschienene Leitlinie der U.S.-amerikanischen Society of Critical Care Medicine (SCCM), des American College of Critical Care Medicine (ACCM) und der American Society of Health-System Pharmacists (ASHP), gaben nicht nur Anlass zu einem Update der deutschen Empfehlungen von 2010. Für die Fortschreibung der S3-Leitlinie wurden eine Neuformulierung von klinisch relevanten Schlüsselfragen und die signifikante Erweiterung der Leitlinie um neue Facetten der Behandlung, wie zum Beispiel das Schlafmanagement, notwendig. Dazu wurde die systematisch gesuchte Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Der enorme Evidenzkörper bildete die Grundlage für die Empfehlungen, die von Mandatsträgern aus 17 Fachgesellschaften konsentiert wurden. In den Empfehlungen wurden die Grade „A“ (starke Empfehlung), „B“ (Empfehlung) und „0“ (offene Empfehlung) gewählt. Als Ergebnis dieses Prozesses liegt nun die weltweit umfassendste, interdisziplinär erarbeitete evidenz- und konsensbasierte Stufe 3 Leitlinie vor. Die Leitlinie richtet sich an alle auf der Intensivstation tätigen Berufsgruppen, die Empfehlungen berücksichtigen alle intensivmedizinisch-behandelten Patientengruppen. Sie stellt einen Leitfaden zur symptomorientierten Prävention, Diagnostik und Therapie von Delir, Angst, Stress und der protokollbasierten Analgesie, Sedierung und dem Schlafmanagement in der Intensivmedizin für Erwachsene und Kinder dar.

Keywords: Germany; analgesia; anxiety; critical care; delirium; evidence; guideline; intensive care; monitoring; sedation; sleep; stress; treatment.

Figures

Table 1. Risk factors for ICU-delirium

Table 2. Prevention and risk reduction

Table 3. Long-term consequences

Table 4. Monitoring – general aspects

Table 5. Monitoring of analgesia

Table 6. Monitoring of sedation

Table 7. Monitoring of delirium

Table 8. Monitoring of anxiety

Table 9. Monitoring of sleep

Table 10. Treatment concepts – non-pharmacological concepts

Table 11. Analgesia and regional analgesia

Table 12. Sedation

Table 13. Moderate/deep sedation

Table 14. Symptom oriented sedative therapy (target RASS 0/–1)

Table 15. Therapy of delirium

Table 16. Weaning from mechanical ventilation

Table 17. Treatment with neuromuscular blocking agents (NMBA)

Table 18. Intra- and inter-hospital transports

Table 19. Pregnant and breastfeeding patients in the ICU

Table 20. End-of-life care

Table 21. Patients with severe burn injuries

Table 22. Burn-injured children

Table 23. Multiple trauma patients

Table 24. Patients with intracranial hypertension

Table 25. Cardiac surgery

Table 26. Patients on extracorporeal life support systems (ECLS)

Table 27. Monitoring of analgesia in children

Table 28. Monitoring of sedation in children

Table 29. Monitoring of delirium in children

Table 30. Analgesia in children

Table 31. Non-pharmacological procedures in children

Table 32. Sedation in children

Table 33. Therapy of delirium in children

Table 34. Monitoring in the elderly

Table 35. Treatment strategies in the elderly

Table 36. Economy, quality assurance, and implementation of the guideline

Figure 1. Algorithm for monitoring of sedation, delirium, and pain in adult patients

RASS: Richmond Agitation, Sedation Scale; CAM-ICU: Confusion Assessment Method for the Intensive Care Unit; ICDSC: Intensive Care Delirium Screening Checklist; BPS: Behavioral Pain Scale; BPS-NI: Behavioral Pain Scale, not intubated; CPOT: Critical Care Pain Observation Tool; FPS-R: Faces Pain Scale, revised

Figure 2. Symptom-based therapy and reduction of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine

Algorithm that focuses on a possible holistic management for adult critically ill patients. RASS: Richmond Agitation-Sedation Scale. Other scores (delirium, analgesia: observational/self-assessment), please, s.f. addendum at http://www.awmf.org/leitlinien/detail/ll/001-012.html.