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


Crit Care Med. 2018;46(9):1532-1548. 

In This Article

Abstract and Introduction


Clinical practice guidelines are published and promoted, often by professional societies, because they provide a current and transparently analyzed review of relevant research and are written with the aim to guide clinical practice. The 2018 Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) (PADIS) guidelines[1] first 1) builds on this mission by updating the 2013 PAD guidelines;[2] 2) by adding two inextricably related clinical care topics (immobility and sleep); 3) by including patients as collaborators and coauthors; and 4) by inviting panelists from high-income countries as an early step toward incorporating more diverse practices and expertise from the global critical care community.

Readers will find rationales for 37 recommendations (derived from actionable Patient Intervention Comparison Outcome questions), two good practice statements, and 32 statements (derived from nonactionable, descriptive questions for which the Grading of Recommendations Assessment, Development and Evaluation methodology was not used) across the five guideline sections. Only two of the 37 recommendations are strong; most are conditional. Compared with a strong recommendation (most desirable to clinicians), conditional recommendations apply to most, but not all critically ill adults, and are made when evidence is conflicting, low quality, insufficient and/or applicable to just one patient subgroup, and/or when potential benefits require weighing almost equal risks. The supplemental digital figures and tables linked to the full guideline provide background on how the questions were established, profiles of the evidence, the "evidence to decision" tables used to develop recommendations, and voting results. We also describe the evidence gaps that prevented us from fully addressing all clinical priority questions.

The five sections of this guideline are interrelated, and thus, the guideline should be considered in its entirety rather than as discrete or distinct recommendations. A separate PADIS guideline implementation and integration article[3] and a detailed description of the methodologic innovations that characterize these guidelines[4] have been published separately. This executive summary highlights the 18 recommendations the section leaders and guideline chair/vice-chair felt would be of greatest interest to ICU clinicians. All PADIS recommendations (including those highlighted in this executive summary) are found in Table 1. All descriptive questions and ungraded statements are found in Table 2.