Updated Guidelines Target Pain, Anxiety, Sleep Management
SCCM guidelines include recommending dexmedetomidine over propofol for sedation.
For adult patients in the ICU, revised and expanded guidelines from the Society of Critical Care Medicine (SCCM) recommend dexmedetomidine over propofol for sedation, enhanced mobilization/rehabilitation over standard practices, and melatonin to address sleep disruption.
“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,“ in Critical Care Medicine, also addresses gaps in recommendations, citing insufficient evidence to support benzodiazepines for anxiety management or antipsychotics for delirium treatment. “These recommendations are intended for consideration along with the patient’s clinical status,” the report adds.
A 24-member task force, including nurses, physicians, pharmacists, physiotherapists, psychologists and ICU survivors, used the GRADE approach to identify evidence and conduct systematic reviews to update the 2018 guidelines. Their work led to recommendations in five areas: anxiety, agitation/sedation, delirium, immobility and sleep disruption.
A related article in PulmCCM highlights the recommendation for enhanced mobilization, meaning rehabilitation beyond standard physical therapy. It could involve helping patients stand, walk or use in-bed cycling while on mechanical ventilation.
Based on evidence from over 50 studies conducted across Australasia, the U.S., Europe and Canada, the recommendation is largely symbolic because physical therapy is used sparingly, if at all, for mechanically ventilated patients, the article adds. However, this update may encourage healthcare systems to prioritize enhanced rehabilitation and early mobilization efforts.
A separate article in PulmCCM focuses on the evolving view on melatonin, noting that in 2018, the society declined to recommend it due to poor evidence. Since then, an analysis of 30 international studies informed the 2025 update, which suggests melatonin is a low risk and could potentially improve delirium, enhance sleep quality and reduce ICU stays.
An AACN webinar, “Awake and Walking ICU: Mastery of the ABCDEF Bundle,“ provides an in-depth understanding of sedation, delirium and immobility in the ICU. Access the webinar for insights that empower nurses to implement evidence-based early mobility practices.
Insights From ICU Caregivers Show Variations in Spiritual Support From Clinicians
Spiritual assessment and care may need to be standardized in some ICUs.
A qualitative study of religion and spirituality’s role as a coping mechanism for family caregivers of ICU patients found some commonalities but also racial differences in how clinicians offer support.
“A Descriptive Qualitative Study of Religion and Spirituality’s Role in Critical Illness Decision-Making Among Black and White Family Caregivers,” in Chest Critical Care, notes that despite caregivers requesting support from clinicians on spiritual issues, hospital staff discussed the subject less often with Black caregivers. “Instituting structural processes to provide standardized and culturally competent spiritual care to patients and caregivers for whom this is important may improve their experience of critical care,” the study adds.
The study included 21 family caregivers (nine Black, 12 White) for ICU patients at a single U.S. hospital. The caregivers participated in extended interviews. Common themes for both groups were trust in God’s plan for their ill family member, a desire for a spiritual space in the ICU and a preference for clinicians to open conversations proactively regarding religion and spirituality.
The two racially distinct issues that emerged from the interviews were that clinicians engaged less often with Black caregivers, and Black caregivers were more comfortable discussing spiritual matters in their community. Our “results may suggest that religion and spirituality serve similar supportive roles for Black and White caregivers dealing with serious illness; however, the way that these beliefs and needs are shared with and appraised by agents of the health care system is different for Black and White caregivers.”
The study suggests that clinicians could use a standard spirituality assessment tool early in the process, to avoid suggesting that involving chaplains implies imminent death for patients and also to begin the conversation in a safe way. “Given the high burden of psychological distress among ICU [family] caregivers, standardizing spiritual assessment and care in ICUs may improve the psychological health of [these] caregivers.”
CGM Could Reduce ICU Admissions for Hospitalized Patients With DKA
The study involved 20 adult ED patients with DKA and paired measurements using CGM and POCBG checks.
Continuous glucose monitoring (CGM) could provide opportunities for earlier intervention for patients with diabetic ketoacidosis (DKA), making it a potentially better approach than hourly measurements of blood glucose.
“Analytical Accuracy of a Continuous Glucose Monitor in Adult Diabetic Ketoacidosis,” in Chest Critical Care, notes the accuracy of real-time monitors in a hospital setting could provide safe observation in an emergency department (ED), lower costs and reduce the necessity of ICU admissions. “Safe strategies to prevent the need for ICU admission are needed to help mitigate ED boarding of critically ill patients and to improve patient and resource use outcomes,” adds the prospective, observational study.
The study involved 20 adult ED patients, mean age 42 years, 60% female with DKA and paired measurements using CGM and capillary point-of-care blood glucose (POCBG) checks. Diagnostic accuracy of the pairings placed 97% within targeted zones, and CGM first detected glucose levels dropping below defined thresholds as much as 13.8 minutes earlier than POCBG did.
CGM-guided DKA management can potentially:
- Improve patient comfort by avoiding repeated fingersticks and sleep interruptions
- Reduce nursing burden by replacing hourly collection of POCBG samples
- Improve patient outcomes by reducing the risk of severe hypoglycemia with earlier detection
- Reduce ICU admissions based on decreasing the need for monitoring
“In this study, CGM provided accurate measurements of blood glucose and identified missed opportunities for earlier intervention in adults with DKA. Future interventional trials can assess the impact of CGM-guided DKA management on patient outcomes, patient experience, and resource use.”
AACN resources for blood glucose management include a CE article in Critical Care Nurse that reviews insulin infusion protocols with 21 approaches.
Vasopressors Might Not Exclude ECMO Candidacy
Patients receiving larger norepinephrine equivalent dosages at ECMO onset had slightly higher survival rates.
Vasopressor requirements might not exclude a patient in respiratory failure from receiving venovenous extracorporeal membrane oxygenation (VV ECMO), and the procedure could lower patients’ dosage requirements.
“Improvements in Vasopressor Requirements With Venovenous Extracorporeal Membrane Oxygenation,” a retrospective study in Chest Critical Care, notes that patients receiving larger norepinephrine equivalent dosages at the onset of ECMO had slightly higher survival rates than patients receiving low dosages, and the cohort required a significantly decreased dosage within 24 hours.
“Overall, we believe that the cause of shock requiring vasopressors should be considered or elucidated to ensure appropriate venovenous ECMO candidacy,” the study adds.
Reviewing the cases of 205 patients with VV ECMO at a single center, the study included 108 who had already received vasopressors before starting the procedure. The majority received ECMO due to pneumonia (27.8%) or COVID-19 (40.7%), and 54.6% survived to discharge.
At 24 hours past ECMO cannulation, the mean norepinephrine dose dropped by 39% (from 0.23 to 0.14), and total vasopressors dropped by 24% from 1.69 to 1.29. “We hypothesized that the decrease in vasopressor dosing 24 hours after ECMO initiation could be the result of improvement in pH, a decrease in mean airway pressure (including PEEP), improvement in oxygenation, or a combination thereof.”
One study limitation is that patients who were considered but not selected for ECMO are not included, possibly indicating selection bias based on criteria that was not reviewable. “Other patients declined for ECMO may have had similar vasopressor requirements as those accepted, but were declined based on clinical judgment that included other patient factors and shock causes.”
AACN offers many resources on its ECMO webpage, including clinical research, an online course, a micro-credential and stories from clinicians experienced in the process. The page also includes educational content ranging from journal articles and blogs to webinars and books.
Review Examines Asthma, COPD Best Practices in ICU
The review offers five key takeaways for diagnosis and treatment.
When managing asthma and COPD in patients who require intensive care, clinicians should consider a severity assessment before proceeding with care strategies.
“Management of Asthma and COPD Exacerbations in Adults in the ICU,” a review of best practices in Chest Critical Care, indicates that both conditions can be life-threatening, require clinical diagnosis since disease-specific laboratory or radiographic testing is not available, and have similarities in initial evaluations.
“A stepwise treatment approach will aim to reduce airway inflammation, to reverse bronchospasm, and if needed, to support patients with mechanical ventilation or advanced therapies until clinical improvement is achieved,” the review adds.
After confirming a diagnosis, clinicians should determine the severity of the asthma or COPD exacerbation by using objective criteria such as changes in vital signs or peak expiratory flow. The review offers five key takeaways for diagnosis and treatment:
- Use prednisone 40 to 50 mg/d (or equivalent) for five to seven days for asthma and five days for COPD (consider higher doses on a case-by-case basis)
- Use noninvasive ventilation (NIV) initially for COPD, and consider it cautiously for severe asthma
- Monitor plateau airway pressure and intrinsic positive end-expiratory pressure during invasive mechanical ventilation (IMV)
- Use NIV or high-flow nasal therapy immediately after extubation to reduce the risk of reintubation for COPD, but evidence is lacking for patients with asthma
- Do not reduce arterial carbon dioxide tension (PaCO2) by > 20 mm Hg or 50% of the PaCO2 before treatment (whichever is less) within the first day to avoid neurologic complications after venovenous extracorporeal membrane oxygenation.
The review also includes a breakdown of pharmacological interventions with indications and regimens based on asthma and COPD diagnoses. Additional assessments of clinical evidence include discussions on inhaled gases, supplemental oxygen, high-flow nasal therapy, NIV, IMV, advanced therapies and extubation.
No Fasting, No Problem: Redefining Cardiac Care
Patients who did not fast reported significantly higher satisfaction scores.
Skipping fasting before percutaneous cardiovascular procedures significantly improves patient satisfaction with no observed increases in adverse safety events, according to an analysis of eight randomized trials involving 3,131 patients through 2024.
“Fasting vs No Fasting Prior to Percutaneous Cardiac Procedures: A Meta-Analysis of Randomized Controlled Trials,” in JACC Cardiovascular Interventions, compares outcomes for 1,576 patients who fasted and 1,555 patients who did not fast. Participants, mostly male (67.9%) with a mean age of 68, experienced significantly different fasting durations, averaging 3.11 hours in the no-fasting group versus 11.9 hours in the fasting group.
While no differences were found in outcomes such as nausea, aspiration pneumonia or hypoglycemia, patients who did not fast reported significantly higher satisfaction scores, with a mean difference of 1.11 points on a scale of 1 to 5.
A related article in TCTMD notes that the study suggests no fasting is a reasonable option for most patients undergoing percutaneous cardiovascular procedures. However, caution should be used for patients with gastroenteritis, gastroparesis and other conditions that increase the risks for nausea, vomiting or aspiration.
Lead author Sripal Bangalore, NYU Langone Health, suggests that it’s “time to get rid of the age-old practice” of fasting before cath lab procedures, adding that there’s no disadvantage to allowing patients to eat. He explains that after eliminating the NPO (nothing by mouth) protocol at his center months ago, both patient satisfaction and care team morale improved significantly.
“It was a source of frustration, so we now feel that patients and physicians alike are much happier,” Bangalore adds in the article.
The no-fasting approach does not apply to patients who require general anesthesia, the article adds. The authors also explain that the study is limited by small-scale trials conducted in specific regions, which may affect generalizability, and by variability in satisfaction scores.
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