Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Decreasing the use of benzodiazepines and anticholinergics in patients at risk of delirium; use the

lowest effective doses of any sedating medication (e.g., opiates, antipsychotics).

REDUCE was a randomized, double-blind, placebo-controlled study of 1789 critically ill patients

randomized to prophylactic haloperidol 1 mg, haloperidol 2 mg, or placebo. The 1-mg haloperidol group

median days that patients survived in 28 days in the 2-mg haloperidol group compared with 28 days in

the placebo group (95% CI, 0-0; p=0.93) with a hazard ratio of 1.003 (95% CI, 0.78–1.30; p=0.82). None

of the 15 secondary outcomes were statistically different between the three groups. These outcomes

included delirium incidence (mean difference 1.5%; 95% CI, −3.6% to 6.7%), delirium- and coma-free

days (mean difference 0 days; 95% CI, 0–0 days), and duration of mechanical ventilation, ICU, and

hospital length of stay (mean difference 0 days; 95% CI, 0–0 days for all three measures). Adverse

events did not differ between groups.

illness, to maintain normal metabolic and hormonal balance, and to help decrease delirium and/or agitation.

Disturbances in the ICU such as multiple alarms and frequent physical interruptions (e.g., examination,

turning, laboratory tests, medication administration) make it challenging for patients to maintain the slow-

wave sleep cycle needed for optimal immune function. Sleep research in the ICU is ongoing, and more

information will be forthcoming regarding its effects in the critically ill patient. The PADIS guidelines

suggest not routinely using physiologic sleep monitoring clinically in critically ill adults. In addition, the

PADIS guidelines suggest not using aromatherapy, acupressure, or music at night to improve sleep in

critically ill adults. However the PADIS guidelines do suggest using noise and light reduction strategies

to improve sleep in critically ill adults. The PADIS guidelines make no recommendation regarding the

use of melatonin to improve sleep or regarding the use of dexmedetomidine at night to improve sleep. The

PADIS guidelines suggest not using propofol to improve sleep in critically ill adults. In addition, the PADIS

guidelines suggest using a sleep-promoting, multicomponent protocol in critically ill adults.

To avoid waking patients at night, pharmacists should ensure that medications are scheduled during

the daytime and evening hours, if possible—particularly orally or subcutaneously administered

medications.

laboratory checks, sedation assessments) around nighttime sleeping hours unless clinically indicated in

a specific patient population.

A two-center, double-blind randomized trial randomized 100 critically ill adults without delirium to

stay, nocturnal dexmedetomidine was associated with a greater proportion of patients who remained

delirium free (dexmedetomidine (40 of 50 patients [80%]) than with placebo (27 of 50 patients [54%];

relative risk 0.44; 95% CI, 0.23–0.82; p=0.006). Adverse events did not differ between the two groups.