A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Summary

This SCCM focused update uses GRADE-based systematic reviews to issue conditional recommendations in adult ICUs: prefer dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation, and administer melatonin for sleep. The panel could not recommend benzodiazepines for anxiety or antipsychotics for delirium.

Key Findings

• Conditional recommendation to use dexmedetomidine over propofol for ICU sedation in adults
• Conditional recommendation to provide enhanced mobilization/rehabilitation over usual care
• Conditional recommendation to administer melatonin for sleep disruption
• No recommendation on benzodiazepines for treating anxiety
• No recommendation on antipsychotics for treating delirium

Clinical Implications

Consider dexmedetomidine as first-line sedative over propofol when appropriate, implement enhanced mobilization/rehabilitation protocols, and consider melatonin for sleep; avoid routine benzodiazepines for anxiety and antipsychotics for delirium absent clear indications.

Limitations

• Predominantly conditional recommendations reflecting heterogeneous evidence
• Evidence gaps precluded recommendations for anxiety benzodiazepines and delirium antipsychotics

Future Directions

High-quality RCTs are needed to evaluate benzodiazepines for anxiety and antipsychotics for delirium, define optimal melatonin dosing, and refine mobilization strategies in diverse ICU populations including ARDS.