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

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;41:263-3062

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Key Management Points:

1) Establish an overarching protocolized approach to daily ICU patient management using 2013 PAD Guidelines

2) Assess & treat pain first (may be sufficient)

3) If patient remains agitated after adequately treating pain, use prn/bolus sedation initially, if frequent boluses (>3/hr) use continuous sedation

4) Avoid benzodiazepines in most patients

5) Turn off sedation daily and restart only if needed at lowest dose to maintain chosen target level of consciousness

6) Deep sedation (RASS -4/-5) appears harmful; target awake/alert

7) Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible causes and attempt non-pharmacologic management

8) 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 TreatmentDelirium 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 TreatmentDelirium Positive and RASS target = 0

• RASS > 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 – Discontinue existing lorazepam infusion – 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 TreatmentDelirium 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?