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

2. Barr J et al, CCM 2013;41:

3. Key Management Points:
Establish an overarching protocolized approach to daily ICU patient management using 2013 PAD Guidelines
Assess & treat pain first (may be sufficient)
If patient remains agitated after adequately treating pain, use prn/bolus sedation initially, if frequent boluses (>3/hr) use continuous sedation
Avoid benzodiazepines in most patients
Turn off sedation daily and restart only if needed at lowest dose to maintain chosen target level of consciousness
Deep sedation (RASS -4/-5) appears harmful; target awake/alert
Screen for delirium (CAM-ICU or ICDSC); If delirious, first seek reversible causes and attempt non-pharmacologic management
Use the ABCDEs to improve outcomes for your patients
Slide from E. Wesley Ely, MD, MPH

4. 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

5. 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

6. Prescriber Responsibilities
Order
goals for pain and sedation
medication dosages and frequencies
daily ECG

7. 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

8. Agitation Treatment Delirium 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

9. Agitation Treatment Delirium Positive and RASS target = 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
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

10. Agitation Treatment Delirium 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

11. Questions?