Executive Summary

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

John W. Devlin, PharmD, FCCM; Yoanna Skrobik, MD, FRCP(c), MSc, FCCM; Céline Gélinas, RN, PhD; Dale M. Needham, MD, PhD; Arjen J. C. Slooter, MD, PhD; Pratik P. Pandharipande, MD, MSCI, FCCM; Paula L. Watson, MD; Gerald L. Weinhouse, MD; Mark E. Nunnally, MD, FCCM; Bram Rochwerg, MD, MSc; Michele C. Balas, RN, PhD, FCCM, FAAN; Mark van den Boogaard, RN, PhD; Karen J. Bosma, MD; Nathaniel E. Brummel, MD, MSCI; Gerald Chanques, MD, PhD; Linda Denehy, PT, PhD; Xavier Drouot, MD, PhD; Gilles L. Fraser, PharmD, MCCM; Jocelyn E. Harris, OT, PhD; Aaron M. Joffe, DO, FCCM; Michelle E. Kho, PT, PhD; John P. Kress, MD; Julie A. Lanphere, DO; Sharon McKinley, RN, PhD; Karin J. Neufeld, MD, MPH; Margaret A. Pisani, MD, MPH; Jean-Francois Payen, MD, PhD; Brenda T. Pun, RN, DNP; Kathleen A. Puntillo, RN, PhD, FCCM; Richard R. Riker, MD, FCCM; Bryce R. H. Robinson, MD, MS, FACS, FCCM; Yahya Shehabi, MD, PhD, FCICM; Paul M. Szumita, PharmD, FCCM; Chris Winkelman, RN, PhD, FCCM; John E. Centofanti, MD, MSc; Carrie Price, MLS; Sina Nikayin, MD; Cheryl J. Misak, PhD; Pamela D. Flood, MD; Ken Kiedrowski, MA; Waleed Alhazzani, MD, MSc

Disclosures

Crit Care Med. 2018;46(9):1532-1548.

Summary

Under the auspices of the Society of Critical Care Medicine, this executive summary aims to provide the most clinically meaningful and novel aspects, by section, of the PADIS guidelines that clinicians, stakeholders, and decision makers should consider using when improving care for critically ill adults. The recommendation rationales, fueled by rigorous data evaluation, debate, and discussion, circled back to the bedside experience—and the perspective of what was best for patient—held by the panelists and patients involved in producing the guidelines. We believe that the 2018 PADIS guideline^[1] will foster the delivery of excellent care regarding pain, agitation/sedation, delirium, immobility, and sleep disruption and stimulate the completion of pragmatic, patient-centered research across each of these important critical care domains.

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The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

Table 1. Summary of Actionable Patient Intervention Comparison Outcome Questions and Recommendations
Question	Recommendation	Strength	Quality of Evidence
Pain
Should a protocol-based (analgesia/analgosedation) pain assessment and management program be used in the care of critically ill adults when compared with usual care?	Management of pain for adult ICU patients should be guided by routine pain assessment and pain should be treated before a sedative agent is considered (Good Practice Statement).	N/A	N/A
	We suggest using an assessment-driven, protocol-based, stepwise approach for pain and sedation management in critically ill adults.	Conditional	Moderate
	Remarks: For this recommendation, analog sedation is defined as either analgesia-first sedation (i.e., an analgesic [usually an opioid] is used before a sedative to reach the sedative goal) or analgesia-based sedation (i.e., an analgesic [usually an opioid] is used instead of a sedative to reach the sedative goal). The implementation of this recommendation infers that institutions should have an assessment-driven protocol that mandates regular pain and sedation assessment using validated tools, provides clear guidance on medication choice and dosing, and makes treating pain a priority over providing sedatives.
Should acetaminophen be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?	We suggest using acetaminophen as an adjunct to an opioid to decrease pain intensity and opioid consumption for pain management in critically ill adults.	Conditional	VL
Should nefopam be used either as an adjunct or a replacement for an opioid (vs an opioid alone) for pain management in critically ill adults?	We suggest using nefopam (if feasible) either as an adjunct or replacement for an opioid to reduce opioid use and their safety concerns for pain management in critically ill adults.	Conditional	VL
Should ketamine be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?	We suggest using low-dose ketamine (1–2 μg/kg/hr) as an adjunct to opioid therapy when seeking to reduce opioid consumption in postsurgical adults admitted to the ICU.	Conditional	Low
Should a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?	We recommend using a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) with opioids for neuropathic pain management in critically ill adults.	Strong	Moderate
	We suggest using a neuropathic pain medication (e.g., gabapentin, carbamazepine, and pregabalin) with opioids for pain management in ICU adults after cardiovascular surgery.	Conditional	Low
Should IV lidocaine be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?	We suggest not routinely using IV lidocaine as an adjunct to opioid therapy for pain management in critically ill adults.	Conditional	Low
Should a COX-1 selective NSAID be used as an adjunct to an opioid (vs an opioid alone) for pain management in critically ill adults?	We suggest not routinely using a COX-1 selective NSAID as an adjunct to opioid therapy for pain management in critically ill adults.	Conditional	Low
Should an opioid (vs no opioid) be used for critically ill adults undergoing a procedure? Should a high-dose opioid (vs a low-dose opioid) be used for critically ill adults undergoing a procedure?	We suggest using an opioid, at the lowest effective dose, for procedural pain management in critically ill adults. Remarks: The same opioids (i.e., fentanyl, hydromorphone, morphine, and remifentanil) that are recommended in the 2013 guidelines to manage pain should also be considered when an opioid is deemed to be the most appropriate pharmacologic intervention to reduce procedural pain (2).	Conditional	Moderate
Should local analgesia (vs an opioid) be used for critically ill adults undergoing a procedure?	We suggest not using either local analgesia or nitrous oxide for pain management during chest tube removal in critically ill adults.	Conditional	Low
Should nitrous oxide (vs an opioid) be used for critically ill adults undergoing a procedure?
Should an inhaled volatile anesthetic (vs no use of this agent) be used for critically ill adults undergoing a procedure?	We recommend not using inhaled volatile anesthetics for procedural pain management in critically ill adults.	Strong	VL
Should an NSAID administered IV, orally, or rectally (vs an opioid) be used for critically ill adults undergoing a procedure?	We suggest using an NSAID administered IV, orally, or rectally as an alternative to opioids for pain management during discrete and infrequent procedures in critically ill adults.	Conditional	Low
Should an NSAID topical gel (vs no use of NSAID gel) be used for critically ill adults undergoing a procedure?	We suggest not using an NSAID topical gel for procedural pain management in critically ill adults	Conditional	Low
Should cybertherapy (i.e., virtual reality) (vs no use of cybertherapy) be used for pain management in critically ill adults?	We suggest not offering cybertherapy (virtual reality) or hypnosis for pain management in critically ill adults	Conditional	VL
Should hypnosis (vs no use of hypnosis) be used for pain management in critically ill adults?
Should massage (vs no massage) be used for pain management in critically ill adults?	We suggest offering massage for pain management in critically ill adults. Remarks: Massage interventions varied in session time (10–30 min), frequency (once or bid), duration (for 1–7 d), and body area (back, feet and hands, or only hands).	Conditional	Low
Should music therapy (vs no music therapy) be used for pain management in critically ill adults to relieve both procedural and nonprocedural pain?	We suggest offering music therapy to relieve both non-procedural and procedural pain in critically ill adults.	Conditional	Low
Should cold therapy (vs no use of cold therapy) be used for critically ill adults undergoing a procedure?	We suggest offering cold therapy for procedural pain management in critically ill adults. Remarks: Cold ice packs were applied for 10 min, and wrapped in dressing gauze, on the area around the chest tube before its removal.	Conditional	Low
Should relaxation techniques (vs no use of relaxation techniques) be used for critically ill adults undergoing a procedure?	We suggest offering relaxation techniques for procedural pain management in critically ill adults. Remarks: The relaxation technique used in each study differed.	Conditional	VL
Agitation/sedation
Does light sedation (vs deep sedation), regardless of the sedative agent(s) used, significantly affect outcomes in critically ill, mechanically ventilated adults?	We suggest using light sedation (vs deep sedation) in critically ill, mechanically ventilated adults.	Conditional	Low
Should propofol, when compared with a benzodiazepine, be used for sedation in mechanically ventilated adults after cardiac surgery?	We suggest using propofol over a benzodiazepine for sedation in mechanically ventilated adults after cardiac surgery.	Conditional	Low
Should propofol, when compared with a benzodiazepine, be used for sedation in critically ill, mechanically ventilated adults?	We suggest using either propofol or dexmedetomidine over benzodiazepines for sedation in critically ill, mechanically ventilated adults.	Conditional	Low
Should dexmedetomidine, when compared with a benzodiazepine, be used for sedation in critically ill, mechanically ventilated adults? Should dexmedetomidine, when compared with propofol, be used for sedation in critically ill, mechanically ventilated adults?
Delirium
Should we assess for delirium using a valid tool (compared with not performing this assessment with a valid tool) in critically ill adults?	Critically ill adults should be regularly assessed for delirium using a valid tool (Good Practice Statement). Remarks: The 2013 guideline provided psychometric appraisals of pain, sedation, and delirium screening tools. A reevaluation of the psychometrics for available delirium screening psychometrics was not conducted as part of these guidelines. The focus of this question is the effect of using any delirium assessment tool (vs no assessment tool) in clinical practice.	N/A	N/A
Should a pharmacologic agent (vs no use of this agent) be used to "prevent" delirium in critically ill adults?	We suggest not using haloperidol, an atypical antipsychotic, dexmedetomidine, a HMG-CoA reductase inhibitor (i.e., statin), or ketamine to prevent delirium in all critically ill adults.	Conditional	VL to Low
Should a pharmacologic agent (vs no use of this agent) be used to "treat subsyndromal delirium" in all critically ill adults with subsyndromal delirium?	We suggest not using haloperidol or an atypical antipsychotic to treat subsyndromal delirium in critically ill adults.	Conditional	VL to Low
Should a pharmacologic agent (vs no use of this agent) be used to treat delirium in all critically ill adults with delirium?	We suggest not routinely using haloperidol, an atypical antipsychotic, or a HMG-CoA reductase inhibitor (i.e., a statin) to treat delirium. We suggest using dexmedetomidine for delirium in mechanically ventilated adults where agitation is precluding weaning/extubation.	Conditional Conditional	Low Low
Should a single-component, nonpharmacologic strategy not solely focused on sleep improvement or early mobilization (vs no such strategy) be used to reduce delirium in critically ill adults?	We suggest not using bright light therapy to reduce delirium in critically ill adults.	Conditional	Moderate
Should a multicomponent, nonpharmacologic strategy (vs no such strategy) be used to reduce delirium in critically ill adults?	We suggest using a multicomponent, nonpharmacologic intervention that is focused on (but not limited to) reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision in critically ill adults. Remarks: These multicomponent interventions include (but are not limited to) strategies to reduce or shorten delirium (e.g., reorientation, cognitive stimulation, use of clocks), improve sleep (e.g., minimizing light and noise), improve wakefulness (i.e., reduced sedation), reduce immobility (e.g., early rehabilitation/mobilization), and reduce hearing and/or visual impairment (e.g., enable use of devices such as hearing aids or eye glasses).	Conditional	Low
Immobility (rehabilitation/mobilization)
For critically ill adults, is rehabilitation or mobilization (performed either in-bed or out-of-bed) beneficial in improving patient, family, or health system outcomes compared with usual care, a different rehabilitation/mobilization intervention, placebo, or sham intervention?	We suggest performing rehabilitation or mobilization in critically ill adults (conditional recommendation, low quality of evidence). Remarks: Rehabilitation is a "set of interventions designed to optimize functioning and reduce disability in individuals with a health condition." Mobilization is a type of intervention within rehabilitation that facilitates the movement of patients and expends energy with a goal of improving patient outcomes. This recommendation supports performing rehabilitation/mobilization interventions over usual care or similar interventions with a reduced duration, reduced frequency, or later onset. The implementation of this recommendation will be influenced by feasibility-related issues, particularly related to variability in the availability of appropriate staffing and resources to perform rehabilitation/mobilization interventions across ICUs.	Conditional	Low
Sleep
Should physiologic monitoring be routinely used clinically to evaluate sleep in critically ill adults?	We suggest not routinely using physiologic sleep monitoring clinically in critically ill adults. Remarks: Physiologic monitoring refers to the use of actigraphy, bispectral analysis, electroencephalography, and polysomnography to determine if a patient is asleep or awake. It specifically does "not" include monitoring of patients' perceived sleep by either validated assessment (e.g., the Richards Campbell Sleep Questionnaire) or informal subjective bedside assessment.	Conditional	VL
Should assist-control ventilation be used at night (vs pressure support ventilation) to improve sleep in critically ill adults?	We suggest using assist-control ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.	Conditional	Low
Should an adaptive mode of ventilation be used at night (vs pressure support ventilation) to improve sleep in critically ill adults?	We make no recommendation regarding the use of an adaptive mode of ventilation at night (vs pressure support ventilation) for improving sleep in critically ill adults.	None	VL
Among critically ill adults requiring NIV, should an NIV-dedicated ventilator (vs a standard ICU ventilator with NIV capacity) be used to improve sleep?	We suggest using either an NIV-dedicated ventilator or a standard ICU ventilator for critically ill adults requiring NIV to improve sleep.	Conditional	VL
Should aromatherapy, acupressure, or music be used at night (vs not using it) to improve sleep in critically ill adults?	We suggest not using aromatherapy, acupressure, or music at night to improve sleep in critically ill adults	Conditional	Low, VL
Should noise and light reduction strategies (vs not using these strategies) be used at night to improve sleep in critically ill adults?	We suggest using noise and light reduction strategies to improve sleep in critically ill adults.	Conditional	Low
Should a sleep-promoting medication (i.e., melatonin, dexmedetomidine, or propofol) (vs no use of medication) be used to improve sleep in critically ill adults?	We make no recommendation regarding the use of melatonin to improve sleep in critically ill adults.	None	VL
	We make no recommendation regarding the use of dexmedetomidine at night to improve sleep.	None	Low
	We suggest not using propofol to improve sleep in critically ill adults.	Conditional	Low
Should a sleep-promoting protocol be used to improve sleep in critically ill adults?	We suggest using a sleep-promoting, multicomponent protocol in critically ill adults.	Conditional	VL

COX-1 = cyclooxygenase 1, HMG-CoA =3-hydroxy-3-methylglutaryl coenzyme A reductase, N/A = not applicable, NIV = noninvasive ventilation, NSAID = nonsteroidal anti-inflammatory drug, VL, very low.

Table 2. Summary of Descriptive Questions and Ungraded Statements
Descriptive Question	Ungraded Statement
Pain
What factors influence pain in critically ill adults during both rest and during procedures?	Pain at rest is influenced by both psychologic (e.g., anxiety, depression) and demographic (e.g., young age, one or more comorbidities, history of surgery) factors. Pain during a procedure is influenced by preprocedural pain intensity, the type of procedure, underlying surgical or trauma diagnoses, and demographic factors (younger age, female sex, and non-white ethnicity).
What are the most reliable and valid pain assessment methods to use in critically ill adults?	Self-report scales: A patient's self-report of pain is the reference standard for pain assessment in patients who can communicate reliably. Among critically ill adults who are able to self-report pain, the 0–10 numeric rating scale administered either verbally or visually is a valid and feasible pain scale. Behavioral pain assessment tools: Among critically ill adults unable to self-report pain and in whom behaviors are observable, the BPS and BPS-NI patients and the CPOT demonstrate the greatest validity and reliability for monitoring pain. Proxy reporters: When appropriate, and when the patient is unable to self-report, family can be involved in their loved one's pain assessment process. Physiologic measures: Vital signs (i.e., heart rate, blood pressure, respiratory rate, oxygen saturation, and end-tidal CO₂) are not valid indicators for pain in critically ill adults and should only be used as cues to initiate further assessment using appropriate and validated methods such as the patient's self-report of pain (whenever possible) or a behavioral scale (i.e., BPS, BPS-NI, CPOT).
Agitation/sedation
In critically ill intubated adults, is there a difference between DSIs vs NP-targeted sedation in the ability to achieve and maintain a light level of sedation?	In critically ill intubated adults, DSIs and NP-targeted sedation can achieve and maintain a light level of sedation. Remarks: A DSI or a spontaneous awakening trial is defined as a period of time, each day, during which a patient's sedative medication is discontinued and patients can wake up and achieve arousal and/or alertness, defined by objective actions such as opening eyes in response to a voice, following simple commands, and/or having a Sedation-Agitation Scale score of 4–7 or a Richmond Agitation-Sedation Scale score –1 to +1. NP-targeted sedation is defined as an established sedation protocol implemented by nurses at the bedside to determine sedative choices and to titrate these medications to achieve prescription-targeted sedation scores.
Are objective sedation monitoring tools (electroencephalogram-based tools or tools such as heart rate variability, actigraphy, and evoked potentials) useful in managing sedation in adult critically ill intubated adults?	BIS monitoring appears best suited for sedative titration during deep sedation or neuromuscular blockade, although observational data suggest potential benefit with lighter sedation as well. Sedation that is monitored with BIS compared with subjective scales may improve sedative titration when a sedative scale cannot be used.
What are the prevalence rates, rationale, and outcomes (harm and benefit) associated with physical restraint use in intubated or nonintubated critically ill adults?	Physical restraints are frequently used for critically ill adults although prevalence rates vary greatly by country. Critical care providers report using restraints to prevent self-extubation and medical device removal, avoid falls, and to protect staff from combative patients despite a lack of studies demonstrating efficacy and the safety concerns associated with physical restraints (e.g., unplanned extubations, greater agitation).
Delirium
Which predisposing and precipitating risk factors are associated with delirium occurrence (i.e., incidence, prevalence, or daily transition), delirium duration, or severity in critically ill adults?	For the following risk factors, strong evidence indicates that these are associated with delirium in critically ill adults: 1) Modifiable: benzodiazepine use and blood transfusions b) Nonmodifiable: greater age, dementia, prior coma, pre-ICU emergency surgery or trauma, and increasing Acute Physiology and Chronic Health Evaluation and American Society of Anesthesiology scores
Can delirium be predicted in critically ill adults?	Predictive models that include delirium risk factors at both the time of ICU admission and in the first 24 hr of ICU admission have been validated and shown to be capable of predicting delirium in critically ill adults.
Does the level of arousal influence delirium assessments with a validated screening tool?	Level of arousal may influence delirium assessments with a validated screening tool.
What are the short- and long-term outcomes of delirium in critically ill adults and are these causally related?	Positive delirium screening in critically ill adults is strongly associated with cognitive impairment at 3 and 12 mo after ICU discharge and may be associated with a longer hospital stay. Delirium in critically ill adults has consistently been shown not to be associated with posttraumatic stress disorder or post-ICU distress. Delirium in critically ill adults has not been consistently shown to be associated with ICU length of stay, discharge disposition to a place other than home, depression, functionality/dependence, or mortality.
What are the short- and long-term outcomes of rapidly reversible delirium?	Rapidly reversible delirium is associated with outcomes that are similar to patients who never experience delirium.
Immobility (rehabilitation and mobility)
For critically ill adults, is receiving rehabilitation/mobilization (performed either in-bed or out-of-bed) commonly associated with patient-related safety events or harm?	Serious safety events or harms do not occur commonly during physical rehabilitation or mobilization.
For critically ill adults, what aspects of patient clinical status are indicators for the safe initiation of rehabilitation/mobilization (performed either in-bed or out-of-bed)?	Major indicators for safely initiating rehabilitation/mobilization include stability in cardiovascular, respiratory, and neurologic status. Vasoactive infusions or mechanical ventilation are not barriers to initiating rehabilitation/mobilization, assuming patients are otherwise stable with the use of these therapies.
For adult critically ill patients, what aspects of patient clinical status are indicators that rehabilitation/mobilization (performed either in-bed or out-of-bed) should be stopped?	Major indicators for stopping rehabilitation/mobilization include development of new cardiovascular, respiratory, or neurologic instability. Other events, such as a fall or medical device removal/malfunction, and patient distress are also indications for stopping.
Sleep (disruption)
How does sleep in critically ill adults differ from normal sleep in healthy adults?	Total sleep time and sleep efficiency are often normal. Sleep fragmentation, the proportion of time spent in light sleep (stages N1 + N2), and time spent sleeping during the day (vs night) are higher. The proportion of time spent in deep sleep (stage N3 sleep and REM) is lower. Subjective sleep quality is reduced.
Is sleep different in critically ill adults if delirium (vs no delirium) is present?	The presence of delirium may not affect total sleep time, sleep efficiency, or sleep fragmentation. The influence of delirium on the proportion of time spent in light (N1 + N2) vs deeper (N3) sleep is unknown. REM sleep is lower if delirium is present. Delirium is associated with greater circadian sleep-cycle disruption and increased daytime sleep. Whether delirium affects reported subjective sleep quality remains unclear.
Is sleep different in critically ill adults who are mechanically ventilated (vs not mechanically ventilated)?	The use of mechanical ventilation in critically ill adults may worsen sleep fragmentation, architecture, and circadian rhythm (daytime sleep) compared with normal sleep, but these effects are often variable and have not yet been fully investigated. The use of mechanical ventilation (vs periods without mechanical ventilation) in patients with respiratory failure may improve sleep efficiency and reduce fragmentation, but data are limited.
What is the prevalence of unusual or dissociative sleep patterns in critically ill adults?	The prevalence of unusual or dissociated sleep patterns is highly variable and depends on patient characteristics.
What risk factors that exist prior to the onset of critical illness affect sleep quality in critically ill adults in the ICU?	Patients who report poor-quality sleep and/or use of a pharmacologic sleep aid at home are more likely to report poor-quality sleep in the ICU.
Which ICU-acquired risk factors affect sleep quality in critically ill adults?	Pain, environmental stimuli, healthcare-related interruptions, psychologic factors, respiratory factors, and medications each affect sleep quality in the ICU.
Do sleep and circadian rhythm alterations "during" an ICU admission affect outcomes during and/or after the ICU stay in critically ill adults?	Although an association between sleep quality and delirium occurrence exists in critically ill adults, a cause-effect relationship has not been established. An association among sleep quality and duration of mechanical ventilation, length of ICU stay, and ICU mortality in critically ill adults remains unclear. The effects of sleep quality and circadian rhythm alterations on outcomes in critically ill patients after ICU discharge are unknown.

BIS = bispectral analysis, BPS = Behavioral Pain Scale in intubated, BPS-NI = Behavioral Pain Scale in nonintubated, CPOT = Critical Care Pain Observation Tool, DSI = daily sedative interruption, NP = nursing protocolized, REM = rapid eye movement.

Authors and Disclosures

John W. Devlin, PharmD, FCCM^1,2, Yoanna Skrobik, MD, FRCP(c), MSc, FCCM^3,4, Céline Gélinas, RN, PhD⁵, Dale M. Needham, MD, PhD⁶, Arjen J. C. Slooter, MD, PhD⁷, Pratik P. Pandharipande, MD, MSCI, FCCM⁸, Paula L. Watson, MD⁹, Gerald L. Weinhouse, MD¹⁰, Mark E. Nunnally, MD, FCCM^11,12,13,14, Bram Rochwerg, MD, MSc^15,16, Michele C. Balas, RN, PhD, FCCM, FAAN¹⁷, Mark van den Boogaard, RN, PhD¹⁸, Karen J. Bosma, MD¹⁹, Nathaniel E. Brummel, MD, MSCI²⁰, Gerald Chanques, MD, PhD^21,22, Linda Denehy, PT, PhD²³, Xavier Drouot, MD, PhD^24,25, Gilles L. Fraser, PharmD, MCCM²⁶, Jocelyn E. Harris, OT, PhD²⁷, Aaron M. Joffe, DO, FCCM²⁸, Michelle E. Kho, PT, PhD²⁷, John P. Kress, MD²⁹, Julie A. Lanphere, DO³⁰, Sharon McKinley, RN, PhD³¹, Karin J. Neufeld, MD, MPH³², Margaret A. Pisani, MD, MPH³³, Jean-Francois Payen, MD, PhD³⁴, Brenda T. Pun, RN, DNP³⁵, Kathleen A. Puntillo, RN, PhD, FCCM³⁶, Richard R. Riker, MD, FCCM²⁶, Bryce R. H. Robinson, MD, MS, FACS, FCCM³⁷, Yahya Shehabi, MD, PhD, FCICM³⁸, Paul M. Szumita, PharmD, FCCM³⁹, Chris Winkelman, RN, PhD, FCCM⁴⁰, John E. Centofanti, MD, MSc⁴¹, Carrie Price, MLS⁴², Sina Nikayin, MD⁴³, Cheryl J. Misak, PhD⁴⁴, Pamela D. Flood, MD⁴⁵, Ken Kiedrowski, MA⁴⁶ and Waleed Alhazzani, MD, MSc^16,47

¹School of Pharmacy, Northeastern University, Boston, MA.
²Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA.
³Faculty of Medicine, McGill University, Montreal, PQ, Canada.
⁴Regroupement de Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Montreal, PQ, Canada.
⁵Ingram School of Nursing, McGill University, Montreal, PQ, Canada.
⁶Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD.
⁷Department of Intensive Care Medicine, Brain Center Rudolf Magnus, University Medical Center, Utrecht University, Utrecht, The Netherlands.
⁸Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.
⁹Division of Sleep Medicine, Vanderbilt University Medical Center, Nashville, TN.
¹⁰Division of Pulmonary and Critical Care, Brigham and Women's Hospital and School of Medicine, Harvard University, Boston, MA.
¹¹Division of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY.
¹²Division of Medicine, New York University Langone Health, New York, NY.
¹³Division of Neurology, New York University Langone Health, New York, NY.
¹⁴Division of Surgery, New York University Langone Health, New York, NY.
¹⁵Department of Medicine (Critical Care), McMaster University, Hamilton, ON, Canada.
¹⁶Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada.
¹⁷The Ohio State University College of Nursing, Center of Excellence in Critical and Complex Care, The Ohio State University Wexner Medical Center, Columbus, OH.
¹⁸Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
¹⁹Division of Critical Care, London Health Sciences Centre and Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.
²⁰Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Center for Quality Aging, and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
²¹Department of Anesthesia and Intensive Care, Montpellier University Saint Eloi Hospital, Montpellier, France.
²²PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France.
²³Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.
²⁴Faculte de Medecine Pharmacie, University of Poitiers, Poitiers, France.
²⁵Service de Neurophysiologie, CHU de Poitiers, Poitiers, France.
²⁶Department of Critical Care, Maine Medical Center and School of Medicine, Tufts University, Portland, ME.
²⁷School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.
²⁸Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
²⁹Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
³⁰Department of Physical Medicine and Rehabilitation, Intermountain Health, Salt Lake City, UT.
³¹School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia.
³²Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
³³Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, Yale University, New Haven, CT.
³⁴Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France.
³⁵Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN.
³⁶School of Nursing, University of California San Francisco, San Francisco, CA.
³⁷Department of Surgery, University of Washington, Seattle, WA.
³⁸Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
³⁹Department of Pharmacy, Brigham and Women's Hospital, Boston, MA.
⁴⁰Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
⁴¹Department of Anesthesia and Critical Care, McMaster University, Hamilton, ON, Canada.
⁴²Welch Medical Library, Johns Hopkins University, Baltimore, MD.
⁴³Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, NY.
⁴⁴Department of Philosophy, University of Toronto, Toronto, CA.
⁴⁵Division of Anesthesiology, Stanford University Hospital, Palo Alto, CA.
⁴⁶Patient and Family Advisory Committee, Johns Hopkins Hospital, Baltimore, MD.
⁴⁷Department of Medicine (Critical Care and Gastroenterology), McMaster University, Hamilton, ON, Canada.

Dr. Devlin has received research funding from the NIA, NHLBI, and Astra-Zeneca Pharmaceuticals, is on the editorial board of Critical Care Medicine, and he is the president of the American Delirium Society. Dr. Skrobik participates in the ATS and the American College of Chest Physicians (ACCP), and she is on the Editorial Board for Intensive Care Medicine and Chest. Dr. Needham is a principal investigator on a National Institutes of Health (NIH)-funded, multi-centered randomized trial (R01HL132887) evaluating nutrition and exercise in acute respiratory factor, and related to this trial, is currently in receipt of an unrestricted research grant and donated amino acid product from Baxter Healthcare Corporation and an equipment loan from Reck Medical Devices to two of the participating study sites, external to his institution. Dr. Slooter has disclosed that he is involved in the development of an electroencephalogram-based delirium monitor, where any (future) profits from electroencephalogram-based delirium monitoring will be used for future scientific research only. Dr. Pandharipande institution received funding from Hospira (research grant to purchase study drug [dexmedetomidine] in collaboration with an NIH-funded RO1 study) and disclosed that he is the past president of the American Delirium Society. Dr. Nunnally participates in the SOCCA, IARS, and American Society of Anesthesiology (ASA). Dr. Rochwerg participates as a guideline methodologist for other organizations (i.e., ATS and CBS) in addition to Society of Critical Care Medicine. Dr. Balas received funding from Select Medical (primary investigator on research study exploring ABCDEF bundle adoption). Dr. Bosma received funding from the Canadian Institutes of Health Research (CIHR) where she is the primary investigator of an industry partnered research grant with Covidien as the industry partner of the CIHR for a study investigating PAV versus PSV for weaning from mechanical ventilation. Dr. Brummel participates in the ATS (Aging and Geriatrics Working Group Co-Chair) and ArjoHuntleigh (advisory board activities). Dr. Chanques participates in other healthcare professional organization activities. Dr. Denehy participates in the Australian Physiotherapy Association. Dr. Drouot participates in the French Sleep Society and the French Institute for Sleep and Vigilance. Dr. Joffe participates on committees for ASA. Dr. Kho received funding from Restorative Therapies (Baltimore, MD) (loaned two supine cycle ergometers for ongoing research). Dr. Kress received funding from a dexmedetomidine speaker program; he participates in the ATS and ACCP; and he has served as an expert witness in medical malpractice. Dr. McKinley participates in the American Association of Critical Care Nurses (Editorial Board of American Journal of Critical Care) and the American Heart Association (Editorial Board of Journal of Cardiovascular Nursing). Dr. Neufeld participates in the American Delirium Society (Board Member). Dr. Pisani participates in the ACCP (Chair Scientific Programming Committee and Steering Committee Womens Health Network). Dr. Payen received funding from Baxter SA (distributor of dexmedetomidine in France), and he has received honorariums from Baxter SA (oral presentations of dexmedetomidine). Dr. Pun participates as an AACN Speaker at the National Conference. Dr. Puntillo participates in other healthcare professional organizations (e.g., AACN). Dr. Robinson participates in EAST, ACS, and AAST. Dr. Shehabi received funding from an unrestricted research grant (drug supply) from Pfizer (Hospira) and Orion Pharma to an ongoing multinational multi-center study. Dr. Szumita participates in several committees for the American Society of Health-System Pharmacists. Ms. Price has disclosed that she is a medical librarian working at Johns Hopkins University, and she consults as an information specialist to the Cochrane Urology Review Group. Dr. Flood participates on the SOAP research committee and the ASA Chronic Pain Committee. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

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