1Center of Excellence in Critical and Complex Care, College of Nursing, The Ohio State University, Columbus, OH.2The Ohio State University Wexner Medical Center, Columbus, OH.3Harvard Medical School, Boston, MA.4Division of Pulmonary and Critical Care, Brigham and Women’s Hospital, Boston, MA.5Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia.6Department of Anesthesia and Intensive Care, Montpellier University Saint Eloi Hospital, PhyMedExp, University of Montpellier, Montpellier, France.7Department of Medicine, McMaster University, Hamilton, ON, Canada.8Department of Philosophy, University of Toronto, Toronto, ON, Canada.9Faculty of Medicine, McGill University, Montreal, QC, Canada.10School of Pharmacy, Northeastern University, Boston, MA.11Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA.12School of Medicine, Tufts University, Boston, MA.13Department of Critical Care, Maine Medical Center, Portland, ME.
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The 2018 Clinical Practice Guideline for the Prevention and Management of Pain, Agitation (Sedation), Delirium, Immobility, and Sleep (Disruption) (PADIS) in adult patients in the ICU addresses new management challenges related to pain, agitation, and delirium and offers guidance on two additional topics—rehabilitation/mobility and sleep (1, 2). The PADIS guidelines build on the 2013 Society of Critical Care Medicine (SCCM) PAD guidelines (3) and incorporate a number of methodological innovations, including critical illness survivor input from start to finish (4–6). The PADIS methods, with an emphasis on those approaches that are novel, are outlined in a separate methods article (7).If guideline recommendations and statements are to improve ICU clinical practice, effective knowledge translation and implementation science efforts are critical. Although our goal was to provide specific recommendations for each question, we suspect some guideline readers may be discouraged by the conditional nature of many recommendations and daunted by the breadth of topics discussed. The goals of this accompanying article are to stimulate clinician dialogue, guide the interpretation of the PADIS 2018 recommendations and statements, facilitate implementation and quality improvement (QI) efforts, share strategies for effective bedside application, and provide patient scenarios where application of PADIS recommendations and statements may pose challenges.HOW TO READ THE GUIDELINEThe PADIS guideline represents a wasted effort unless its recommendations can be easily interpreted, understood, and implemented by practicing ICU clinicians. Although the use of GRADE methodology ensures a systematic and transparent approach (8), the basis for determining the strength and quality of evidence inserts uncertainty since the language used is not typically included in our critical care lexicon. Furthermore, critics justifiably express concerns about involving professionals whose very expertise potentially introduces bias, including intellectual conflicts of interest, in the guideline development effort (9).So, where does a GRADE-naive ICU clinician begin? The recommendations themselves (see PADIS executive summary) (2) are a good starting point. Each actionable question uses a PICO format (i.e., addresses which patients, intervention, comparator, and outcome are being assessed) and is then answered by a recommendation. These recommendations are intentionally brief and direct. (e.g., “We suggest using propofol as compared to benzodiazepines in mechanically ventilated cardiovascular surgery patients.”) They are meant for clinicians looking simply for bottom-line guidance. Although a strong recommendation is more valuable to clinicians than a condition recommendation, practice guidelines, including PADIS, generally contain far more conditional than strong recommendations. The characteristics of conditional and strong recommendations are compared in Table 1 (10).After reading the recommendations, clinicians may have many important questions. For example, what factors did the panelists consider when generating the specific recommendation? Why was a conditional recommendation issued rather than a strong one? Why does the recommendation only address a specific population? The answer to some of these questions may be found in the “rationale” section which immediately follows each actionable recommendation (1). Relevant factors are described including a brief review of the evidence and strength, the balance of desirable and undesirable outcomes, and any relevant decision-making factors such as costs/resources, feasibility, subgroup considerations, etc. For most clinicians, the recommendation and rationale, taken together, should provide adequate insight and clarity to allow clinical application. The evidence gap sections describe why a question could not be answered unequivocally (i.e., uncertainty remains) and may be especially helpful for those interested in conducting future research. Finally, supplemental materials (1) (e.g., forest plots, evidence summaries, evidence-to-decision frameworks, and voting results) provide all the data that were considered by the guideline writing committee during its deliberations.