The Johns Hopkins Hospital Pain, Anxiety, and Delirium (PAD) Management Protocol: An Interdisciplinary Clinical Practice Algorithm Sean Berenholtz MD, MHS, FCCM

Barr J et al, CCM 2013;41:263-306

Key Management Points: Establish an overarching protocolized approach to daily ICU patient management using 2013 PAD Guidelines Assess & treat pain first (may be sufficient) If patient remains agitated after adequately treating pain, use prn/bolus sedation initially, if frequent boluses (>3/hr) use continuous sedation Avoid benzodiazepines in most patients Turn off sedation daily and restart only if needed at lowest dose to maintain chosen target level of consciousness Deep sedation (RASS -4/-5) appears harmful; target awake/alert Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible causes and attempt non-pharmacologic management Use the ABCDEs to improve outcomes for your patients Slide from E. Wesley Ely, MD, MPH

The Johns Hopkins Hospital PAD Protocol Interdisciplinary management of pain, anxiety, and delirium For ICU patients expect to require mechanical ventilation for greater than 24 hours Discontinue as soon as appropriate

Nurse Responsibilities Document at baseline, as needed, and every two hours for pain score every four hours for RASS (sedation) score every twelve hours for CAM-ICU (delirium) score every day ECG (QTc) Notify prescriber if goals are missed or QTc is prolonged

Prescriber Responsibilities Order goals for pain and sedation medication dosages and frequencies daily ECG

Pain Treatment First treat pain above target Start intermittent fentanyl If pain persists, start fentanyl infusion If already on fentanyl infusion, start breakthrough dosing and increase infusion rate If no increase in fentanyl infusion for 2 hours, decrease infusion If low dose infusion, dc infusion and start intermittent dosing

Agitation Treatment Delirium Negative Only when pain target met, treat agitation If CAM-ICU (delirium) negative and RASS > goal Start intermitterent lorazepam If persists, start lorazepam or propofol infusion Titrate infusion up to achieve target RASS If CAM-ICU (delirium) negative and RASS < goal Titrate infusion down to achieve target RASS or infusion is off

Agitation Treatment Delirium Positive and RASS target = 0 Discontinue existing lorazepam infusion If QTc < 500 msec, start intermittent haldol and quetiapine; if persists, start dexmedetomidine If QTc > 500 msec, start dexmedetomidine RASS < 0 Hold quetiapine Titrate down dexmedetomidate or propofol to target RASS or infusion is off; Hold daily for SAT and resume at half of previous dose

Agitation Treatment Delirium Positive and RASS target < -2 RASS > goal Titrate up propofol or dexmedetomidine infusion RASS < goal Titrate down dexmedetomidate or propofol to target RASS or infusion is off Hold dexmedetomidate or propofol daily for SAT and resume at half of previous dose

Questions?