Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015)

000223 10.3205/000223 urn:nbn:de:0183-0002238 Guideline Leitlinie Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) – short version S3-Leitlinie Analgesie, Sedierung und Delirmanagement in der Intensivmedizin. Revision 2015 (DAS-Leitlinie 2015) – Kurzversion DAS-Taskforce 2015 DAS-Taskforce 2015 author Baron Baron Ralf R

German Society of Neurology (DGN)

Deutsche Gesellschaft für Neurologie (DGN)

author Binder Binder Andreas A

German Society of Neurology (DGN)

Deutsche Gesellschaft für Neurologie (DGN)

author Biniek Biniek Rolf R

German Society of Neurology (DGN)

Deutsche Gesellschaft für Neurologie (DGN)

author Braune Braune Stephan S

German Society of Internal Medicine Intensive Care (DGIIN)

Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN)

author Buerkle Buerkle Hartmut H

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Dall Dall Peter P

German Society of Gynecology & Obstetrics (DGGG)

Deutsche Gesellschaft für Gynäkologie & Geburtshilfe (DGGG)

author Demirakca Demirakca Sueha S

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Eckardt Eckardt Rahel R

German Society of Geriatrics (DGG)

Deutsche Gesellschaft für Geriatrie (DGG)

author Eggers Eggers Verena V

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Eichler Eichler Ingolf I

German Society for Thoracic and Cardiovascular Surgery (DGTHG)

Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG)

author Fietze Fietze Ingo I

German Sleep Society (DGSM)

Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)

author Freys Freys Stephan S

German Society of Surgery (DGCH)

Deutsche Gesellschaft für Chirurgie (DGCH)

author Fründ Fründ Andreas A

German Association for Physiotherapy (ZVK)

Deutscher Verband für Physiotherapie (ZVK)

author Garten Garten Lars L

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Gohrbandt Gohrbandt Bernhard B

German Society for Thoracic and Cardiovascular Surgery (DGTHG)

Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG)

author Harth Harth Irene I

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Hartl Hartl Wolfgang W

German Society of Surgery (DGCH)

Deutsche Gesellschaft für Chirurgie (DGCH)

author Heppner Heppner Hans-Jürgen HJ

German Society of Geriatrics (DGG)

Deutsche Gesellschaft für Geriatrie (DGG)

author Horter Horter Johannes J

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Huth Huth Ralf R

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Janssens Janssens Uwe U

German Society of Internal Medicine Intensive Care (DGIIN)

Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN)

author Jungk Jungk Christine C

German Society of Neurosurgery (DGNC)

Deutsche Gesellschaft für Neurochirurgie (DGNC)

author Kaeuper Kaeuper Kristin Maria KM

German Society of Midwifery Science (DGHWi)

Deutsche Gesellschaft für Hebammenwissenschaft (DGHWi)

author Kessler Kessler Paul P

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Kleinschmidt Kleinschmidt Stefan S

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Kochanek Kochanek Matthias M

German Society of Haematology and Oncology (DGHO)

Deutsche Gesellschaft für Hämatologie und Medizinische Onkologie (DGHO)

author Kumpf Kumpf Matthias M

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Meiser Meiser Andreas A

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Mueller Mueller Anika A

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Orth Orth Maritta M

German Sleep Society (DGSM)

Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)

author Putensen Putensen Christian C

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Roth Roth Bernd B

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Schaefer Schaefer Michael M

German Pain Society (DGSS)

Deutsche Schmerzgesellschaft (DGSS)

author Schaefers Schaefers Rainhild R

German Society of Midwifery Science (DGHWi)

Deutsche Gesellschaft für Hebammenwissenschaft (DGHWi)

author Schellongowski Schellongowski Peter P

German Society of Haematology and Oncology (DGHO)

Deutsche Gesellschaft für Hämatologie und Medizinische Onkologie (DGHO)

author Schindler Schindler Monika M

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author Schmitt Schmitt Reinhard R

German Society for Specialised Nursing and Allied Health Professions (DGF)

Deutsche Gesellschaft für Fachkrankenpflege (DGF)

author Scholz Scholz Jens J

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Schroeder Schroeder Stefan S

German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)

Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN)

author Schwarzmann Schwarzmann Gerhard G

German Society for Specialised Nursing and Allied Health Professions (DGF)

Deutsche Gesellschaft für Fachkrankenpflege (DGF)

author Spies Spies Claudia C Univ.-Prof. Dr.

Department for Anesthesiology and Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Charité Campus Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany, Phone: 0049 (0)30 450551002, Fax: 0049 (0)30 450551909German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin der Charité – Universitätsmedizin Berlin, Campus Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Deutschland, Tel.: 0049 (0)30 450551002, Fax: 0049 (0)30 450551909Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

claudia.spies@charite.de author Stingele Stingele Robert R

German Society of Neurology (DGN)

Deutsche Gesellschaft für Neurologie (DGN)

author Tonner Tonner Peter P

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Trieschmann Trieschmann Uwe U

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Tryba Tryba Michael M

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Wappler Wappler Frank F

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Waydhas Waydhas Christian C

German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)

Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)

author Weiss Weiss Bjoern B

German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)

author Weisshaar Weisshaar Guido G

German Society of Neonatology and Pediatric Intensive Care (GNPI)

Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)

author German Medical Science GMS Publishing House

Düsseldorf

610 guideline evidence analgesia sedation delirium anxiety stress sleep monitoring treatment intensive care critical care Germany Leitlinie Analgesie Sedierung Delir Angst Stress Schlaf Monitoring Therapie Intensivmedizin Intensive Care Medicine Intensivmedizin 20150925 2015111220151116 engl germ This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 1612-3174 13 GMS German Medical Science GMS Ger Med Sci 19 20151116In the initial publication the author Irene Harth was erroneously omitted in the html version. 20151116Bei der ersten Veröffentlichung fehlte irrtümlicherweise die Autorin Irene Harth in der HTML-Version. Die vorherige Version der S3-Leitlinie „Analgesie, Sedierung und Delirmanagement in der Intensivmedizin“ wurde 2010 unter der Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) publiziert. Neue Evidenz aus Studien ebenso wie neue Leitlinien, u.a. die 2013 erschienene Leitlinie der U.S.-amerikanischen Society of Critical Care Medicine (SCCM), des American College of Critical Care Medicine (ACCM) und der American Society of Health</PlainText></TextGroup>-System Pharmacists (ASHP), gaben nicht nur Anlass zu einem Update der deutschen Empfehlungen von 2010. Für die Fortschreibung der S3-Leitlinie wurden eine Neuformulierung von klinisch relevanten Schlüsselfragen und die signifikante Erweiterung der Leitlinie um neue Facetten der Behandlung, wie zum Beispiel das Schlafmanagement, notwendig. Dazu wurde die systematisch gesuchte Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Der enorme Evidenzkörper bildete die Grundlage für die Empfehlungen, die von Mandatsträgern aus 17 Fachgesellschaften konsentiert wurden. In den Empfehlungen wurden die Grade „A“ (starke Empfehlung), „B“ (Empfehlung) und „0“ (offene Empfehlung) gewählt. Als Ergebnis dieses Prozesses liegt nun die weltweit umfassendste, interdisziplinär erarbeitete evidenz- und konsensbasierte Stufe 3 Leitlinie vor. Die Leitlinie richtet sich an alle auf der Intensivstation tätigen Berufsgruppen, die Empfehlungen berücksichtigen alle intensivmedizinisch-behandelten Patientengruppen. Sie stellt einen Leitfaden zur symptomorientierten Prävention, Diagnostik und Therapie von Delir, Angst, Stress und der protokollbasierten Analgesie, Sedierung und dem Schlafmanagement in der Intensivmedizin für Erwachsene und Kinder dar.</Pgraph></Abstract> <Abstract language="en" linked="yes"><Pgraph>In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.</Pgraph></Abstract> <TextBlock language="en" linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>In 2010, twelve German medical societies published the <Mark2>Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium</Mark2>. Since this publication, the body of evidence in the field has increased considerably. Several new studies and publications, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) in 2013, make a substantial actualization of the German guidelines necessary. This update not only accounts for new evidence, but also contains a major restructuring and extension of the guidelines to cover new aspects of treatment, such as sleep and anxiety management.</Pgraph><Pgraph>This new version aims to provide practical guidance for the symptom-based prevention, diagnostics and therapy of delirium, anxiety, and agitation, as well as for the protocol-based analgesia, sedation, and sleep management during critical illness. Under the guidance of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) and German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), this is one of the most comprehensive guidelines worldwide, being developed and approved by 17 national societies.</Pgraph><Pgraph>These guidelines were developed for all professions working in the intensive care unit (ICU), and its recommendations encompass critically ill patients of all age groups and severity of illness, regardless of comorbidities.</Pgraph><Pgraph>Delirium and coma are the most common manifestations of acute brain dysfunction during critical illness. Pain, stress, and a disruption of the sleep-wake-cycle are typical symptoms observed during ICU treatment, all of which can lead to delirium and impair outcome. An early management of these symptoms improves recovery and long-term outcome, while reducing post-intensive-care-unit-syndrome (PICS) and mortality. The basic principle follows an “early goal directed therapy” (EGDT) with immediate and evidence-based targets for treatment, the assessment of the clinical situation with validated instruments, and the goal-directed pharmacological therapy. These measures are to be accompanied by non-pharmacological interventions aimed at prevention and treatment.</Pgraph><Pgraph><Mark1>The critically ill patient should be awake and alert, without pain, anxiety, or delirium. Ultimately, this allows the patient to actively participate in their treatment and recovery.</Mark1></Pgraph><Pgraph>The term “sedation” was left in the title intentionally: the indication and conduction of sedation require special attention in order not to harm the patient through oversedation, as this has been proven to negatively affect patient outcome. In the interest of the patients, the use of sedatives and analgesics must therefore be very carefully considered. The patient must be allowed to be as alert and oriented as possible, so that they may partake in the therapy and convalescence process, as evidence shows is feasible, practical, and safe.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Einleitung"> <MainHeadline>Einleitung</MainHeadline><Pgraph>Die 2010 publizierte S3-Leitlinie „Analgesie, Sedierung und Delirmanagement in der Intensivmedizin“ wurde interdisziplinär von Mandatsträgern aus 12 Fachgesellschaften konsentiert. Seit der Publikation der letzten Leitlinie ist der Evidenzkörper erheblich gewachsen. Neue Evidenz aus Studien ebenso wie neue Leitlinien (u.a. die 2013 erschienene Leitlinie der U.S.-amerikanischen <Mark2>Society of Critical Care Medicine (SCCM), des American College of Critical Care Medicine (ACCM) und der American Society of Health-System Pharmacists (ASHP))</Mark2> gaben nicht nur Anlass zu einem Update der deutschen Empfehlungen von 2010, sondern machten auch eine Neuformulierung von klinisch relevanten Schlüsselfragen und die signifikante Erweiterung der Leitlinie um neue Facetten der Behandlung, wie zum Beispiel dem Schlafmanagement, notwendig.</Pgraph><Pgraph>Die neu bearbeitete S3-Leitlinie hat zum Ziel als Leitfaden zur symptomorientierten Prävention, Diagnostik und Therapie von Delir, Angst, Stress und der protokollbasierten Analgesie, Sedierung und dem Schlafmanagement in der Intensivmedizin für Erwachsene und Kinder zu dienen. Für dieses Thema ist sie weltweit die umfassendste Evidenz- und Konsensus-basierte Leitlinie und ist im nationalen Konsens aus nunmehr 17 Fachgesellschaften unter Federführung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) entstanden. Damit sind Zielgruppe der Leitlinie alle auf der Intensivstation tätigen Berufsgruppen. Die Empfehlungen gelten für alle intensivpflichtigen Patientinnen und Patienten, jeden Alters, jeden Schweregrades der Erkrankung und sind unabhängig von Komorbiditäten.</Pgraph><Pgraph>Delir und Koma sind die häufigsten syndromatischen Formen der zerebralen Dysfunktion im Rahmen einer kritischen Erkrankung. Schmerzen, Stress und Schlaflosigkeit sind typische Symptome, die im Rahmen der Behandlung auftreten können, Delirien verursachen und das Behandlungsergebnis verschlechtern. Ein frühes Management kann den Heilverlauf und das Behandlungsergebnis nachhaltig verbessern, indem es insbesondere die Sterblichkeit reduziert und das funktionelle Langzeitergebnis positiv beeinflusst. Das Grundprinzip folgt den Vorgaben der <Mark2>„Early Goal Directed Therapy“</Mark2> (EGDT) mit frühen, evidenzbasierten Zielvorgaben, dem Messen von klinischen Parametern und der zielgesteuerten pharmakologischen Therapie. Flankiert wird sie von einem nicht-pharmakologischen Präventions- und Therapieansatz. <Mark1>Der intensivmedizinisch behandelte Patient soll wach, aufmerksam, schmerz-, angst- und delirfrei sein, um an seiner Behandlung und Genesung aktiv teilnehmen zu können.</Mark1></Pgraph><Pgraph>Sedierung wurde mit Absicht im Titel der Leitlinie belassen. Indikationsstellung und Durchführung einer Sedierung bedürfen der besonderen Aufmerksamkeit, um Patienten nicht akzidentell durch Übersedierung zu schaden. Im Sinne unserer Patientinnen und Patienten ist der zurückhaltende und umsichtige Umgang mit Sedativa und Analgetika unter der höchsten Prämisse des wachen und kooperativen Patienten klinisch umsetzbar, sicher und einzufordern.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Methods"> <MainHeadline>Methods</MainHeadline><Pgraph>This guideline has the highest development credentials, S3, indicating that it is both evidence- and consensus based. The guideline task-force consisted of 49 voting members nominated by 17 participating national societies. These members formed work groups that identified main clinical issues and framed key-questions to be addressed. Should previous versions of the guideline not /no longer provide satisfactory resolutions to the selected topics, search strategies were developed to address the subject. The resulting recommendations were then collected in an early version and further discussed within the groups. The members interacted with each other via consensus-conferences, email, fax, or mail. Communication was managed by a coordinating group consisting of 4 members, as well as the chairing societies. A systematic literature search was performed by a special team under the supervision of an epidemiologist. Finally, the evaluation process was done by the individual working groups, which also set the level-of-evidence (LoE). All searches were performed between April and May of 2014. When necessary, new evidence was integrated manually. The LoE was determined, as in the previous version of the guideline, using the Oxford System <TextLink reference="1"></TextLink>. The overview tables allow to identification the evidence for each individual manuscript. Literature was accessible for all task-force members. The specific search strategies, searched terms, inclusion and exclusion criteria, as well as exact time frames, are all detailed in the methodological report.</Pgraph><Pgraph>Sources were electronic databases (Medline<Superscript>®</Superscript>), guideline networks, and (manually) abstracts and congress-publications. In order to identify “grey literature”, all task-force members were asked to search for publications outside Medline and Embase and include relevant entries to the literature-data-base. Systematic guideline searches were conducted within the AWMF-registry (<Hyperlink href="http://www.awmf.org/leitlinien.html">http://www.awmf.org/leitlinien.html</Hyperlink>) and the Guidelines International Network (G-I-N) (<Hyperlink href="http://www.g-i-n.net">http://www.g-i-n.net</Hyperlink>). In line with the AWMF-guideline developer manual, a consensus-based decision was used to assess whether recommendations from other guidelines could be adapted. Cultural adaptions were adopted in accordance with recommendations from the <Mark2>ADAPTE-Collaboration</Mark2> <TextLink reference="2"></TextLink>.</Pgraph><Pgraph>Voting only took place following a full disclosure of potential conflicts of interest by the task-force members. The conflict of interest forms were stored centrally, and all task-force members declaring a conflict of interest were required to abstain from voting in the corresponding issues. This was consented in the task-force before the voting process. The voting-process itself was conducted during consensus-conferences, under the supervision of an independent observer from the AWMF. Alternatively, members could vote using an online DELPHI, as published and recommended in the AWMF-guideline developer manual. The used grades of recommendation (GoR) were A = strong recommendation (we recommend/one shall), B = recommendation (we suggest/one should), and O = open recommendation (one might consider) for or against any specific intervention. Significant deviations between LoE and GoR were generally possible if a member of the group requested upgrading or downgrading of a recommendation (e.g. due to ethical relevance or lack of research-possibilities). Expert opinions and consensus-based decisions were only allowed when the resolutions were highly relevant for clinical routine and there was lack of available evidence.</Pgraph><Pgraph>The guideline was reviewed and approved by 17 scientific societies. Reviewers were all independent peers.</Pgraph><Pgraph>All procedures are in adherence to the actualization protocol. The next regular update of the guideline is scheduled for 2018, although earlier modifications are permitted should significant new evidence arise.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Methoden"> <MainHeadline>Methoden</MainHeadline><Pgraph>Bei vorliegender Leitlinie handelt es sich um eine Leitlinie der Entwicklungsstufe S3 (evidenz- und konsensusbasierte Leitlinie). Die Leitliniengruppe hat 49 Mitglieder, die sich aus Delegierten der verschiedenen Fachgesellschaften zusammensetzen. Leitliniengruppenmitglieder wurden von den jeweiligen Fachgesellschaften bestimmt und haben Arbeitsgruppen formiert, die Schlüsselfragen formuliert und dazu Suchstrategien entwickelt haben. Die Ergebnisse wurden in einer Vorversion zusammengefasst und schließlich der Gruppe zur Diskussion gestellt. Die Gruppenkommunikation fand auf Konsensuskonferenzen und fernmündlich per Mail koordiniert über die DGAI statt. Die systematische Literaturrecherche wurde von einem Rechercheteam durchgeführt und dann dezentral von den Arbeitsgruppen bewertet. Zeitpunkt der Primärrecherche war 04-05/2014. Aktuelle Evidenz wurde im Bedarfsfall manuell ergänzt. Der Evidenzgrad (Level of Evidence – LoE) wurde für jede Studie einzeln nach dem Oxford System bestimmt <TextLink reference="1"></TextLink>. Die Literaturübersicht in den Statements lässt für jede Studie den Evidenzgrad erkennen. Alle Leitliniengruppenmitglieder hatten Zugang zur Literatur. Die Suchstrategie für die Identifizierung von Evidenz, ebenso die Ein- und Ausschlusskriterien für Literatur, sind detailliert im separaten Methodenreport hinterlegt. Dieser beinhaltet eine Auflistung der verwendeten Suchbegriffe und Quellen sowie die Publikationszeitspanne für die berücksichtigte Literatur. Als Quellen wurden elektronische Datenbanken, Leitliniendatenbanken und manuell Kongressbeiträge gesucht. Zur Identifikation von „grauer Literatur“ wurden Leitlinienmitglieder angehalten Artikel in die Diskussion miteinzubringen. Zur systematischen Leitliniensuche wurden das Register der AWMF (<Hyperlink href="http://www.awmf.org/leitlinien.html">http://www.awmf.org/leitlinien.html</Hyperlink>) sowie das Guidelines International Network (G I N) (<Hyperlink href="http://www.g-i-n.net/">http://www.g-i-n.net/</Hyperlink>) herangezogen. Im Konsensusverfahren wurde entsprechend dem Regelwerk der AWMF bei einzelnen Empfehlungen überprüft, ob diese daraus übernommen bzw. adaptiert werden können. Kulturelle Adaptationen wurde nach Empfehlungen der <Mark2>ADAPTE-Collaboration</Mark2> vorgenommen <TextLink reference="2"></TextLink>. Vor Abstimmung und Mitarbeit hat jedes Mitglied der Leitliniengruppe Angabe zu einem möglichen Interessenkonflikt abgegeben. Interessenkonflikte werden regelmäßig aktualisiert, wenn notwendig. Zum Abstimmungszeitpunkt bestehende Interessenkonflikte sind zentral hinterlegt. Gruppenmitglieder, die einen COI (conflict of interest) zu einem bestimmten Thema angegeben haben, wurden zur Enthaltung verpflichtet (Umgang mit Interessenkonflikten der LL-Gruppe). Abstimmungsverfahren wurden unter Aufsicht eines AWMF-Mitarbeiters während der Konsensuskonferenzen oder fernmündlich mittels Online-DELPHI-Verfahrens der AWMF durchgeführt. Als Empfehlungsgrad (Grade of Recommendation, GoR) wurden 0 = offene Empfehlung (kann), B = Empfehlung (sollte), A = starke Empfehlung (soll) für oder gegen eine Intervention/Maßnahme angegeben. Signifikante Abweichungen von Evidenzgrad und Empfehlungsgrad kamen zustande, wenn ein Hochstufen (<Mark2>up-grading</Mark2>) oder Herunterstufen (<Mark2>down-grading</Mark2>) beantragt wurde (z.B. wegen ethischer Relevanz oder fehlender Möglichkeit Studien durchzuführen). Expertenmeinungen und konsensusbasierte Entscheidungen wurden nur für klinisch relevante Schlüsselfragen zugelassen, wenn keine Evidenz vorlag. Vor Publikation ist die Leitlinie von den Präsidien der Fachgesellschaften begutachtet und freigegeben worden. Das Aktualisierungsprotokoll wurde eingehalten. Die nächste reguläre Wiederaufnahme der Leitlinientätigkeit ist für 2018 geplant, im Bedarfsfall kann die Leitlinie vorher modifiziert werden (z.B. bei grundlegender Änderung des Evidenzkörpers).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Management of delirium, analgesia, and sedation in adult intensive care"> <MainHeadline>Management of delirium, analgesia, and sedation in adult intensive care</MainHeadline><SubHeadline>Risk and prevention of ICU related delirium</SubHeadline><Pgraph>Pain, stress, anxiety, and a disrupted sleep-wake cycle are common symptoms that occur in critically ill patients that increase the risk for ICU related delirium <TextLink reference="3"></TextLink>. Delirium is one of the most common manifestations of cerebral dysfunction in critically ill patients, which affects not only short-term recovery (in terms of prolonged ventilation and length of stay, as well as increased mortality) <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, but also leads to cognitive long-term impairment, posttraumatic stress disorders (PTSD), and reduced quality of life <TextLink reference="7"></TextLink>. These entities are part of the Post Intensive Care Unit Syndrome (PICS) that has been recently described in ICU survivors.</Pgraph><Pgraph>Aside from managing the risk factors, several effective pharmacological and non-pharmacological prevention strategies can be used to prevent or treat ICU delirium. In addition to baseline factors, the risk for delirium also comprises treatment associated factors, as well as psychological, social, and iatrogenic aspects <TextLink reference="8"></TextLink>.</Pgraph><Pgraph>The presence or development of risk factors for delirium shall be closely evaluated in order to ensure the prompt introduction of preventive measures. The non-pharmacological measures were shown to be particularly effective in the prevention of delirium, and shall therefore be implemented for all critically ill patients.</Pgraph><Pgraph>The excessive use of sedation shall be avoided, since a deep sedation were shown to deteriorate the clinical outcome <TextLink reference="9"></TextLink>. A pharmacological prevention is to be reserved only for patients at high risk for delirium, and is not generally recommended (Table 1 <ImgLink imgNo="1" imgType="table"/>, Table 2 <ImgLink imgNo="2" imgType="table"/>, Table 3 <ImgLink imgNo="3" imgType="table"/>).</Pgraph><SubHeadline>Monitoring of analgesia, sedation, delirium, anxiety, stress, and sleep</SubHeadline><Pgraph>A basic concept of patient-oriented therapy in intensive-care is the definition of a patient-specific treatment goal, and the frequent assessment of the current status in order to promptly introduce or adjust interventions (Goal Directed Therapy). The definition and monitoring of treatment goals must be symptom-oriented, using validated scores and instruments. The use of such validated methods has a major impact on treatment: the systematic evaluation of pain, sedation, and delirium can significantly improve treatment of pain, reduce nosocomial infections, decrease duration of mechanical ventilation and hospitalization, as well as reduce mortality <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>.</Pgraph><Pgraph>Therefore, it should be a standard in all ICUs to define goals, measure, and document the current state of analgesia, sedation, and delirium once per shift (usually every 8 hours) with a validated clinical scores and instruments (Figure 1 <ImgLink imgNo="1" imgType="figure"/>).</Pgraph><Pgraph>The evaluation of anxiety with a validated scale is desirable, since anxiety is often not properly estimated, and thus not properly treated. There are short versions of standard psychological measurement instruments available (State-Trait Anxiety Inventory, state subscale <TextGroup><PlainText>[STAI-s]</PlainText></TextGroup>, Brief Symptom Inventory Anxiety, subscale [BSI-A]) that allow a valid and reliable assessment of anxiety. From pain assessment, we know that one-dimensional self-assessment scales have proven to be especially practical to measure therapeutic needs and therapeutic response. From pain assessment studies, it is clear that the use one-dimensional self-assessment scales are particularly useful in evaluating the therapeutic needs and therapeutic response. Studies on anxiety show that similar scales (for example linear Visual Analogue Scale and the Faces Anxiety Scale) are also suitable to measure anxiety with good diagnostic validity <TextLink reference="12"></TextLink>. Further studies are needed to clarify whether the controllability of anxiolysis can also be monitored with these scales.</Pgraph><Pgraph>Stress and disturbances of the sleep-wake cycle are further syndromes in ICU-patients that not only negatively affect recovery, but also constitute risk factors for serious complications. Nevertheless, there are currently no validated routine instrument for measuring stress and sleep, and the sole subjective assessment of vital signs by the ICU personnel is not suitable to monitor stress in critically ill patients <TextLink reference="13"></TextLink>. Regarding the sleep-wake cycle of ICU patients, not only is there a lack of suitable monitoring procedures that can be routinely used, but also no valid evaluation of sleep stages in critically ill subjects <TextLink reference="14"></TextLink> (Table 4 <ImgLink imgNo="4" imgType="table"/>, Table 5 <ImgLink imgNo="5" imgType="table"/>, Table 6 <ImgLink imgNo="6" imgType="table"/>, Table 7 <ImgLink imgNo="7" imgType="table"/>, Table 8 <ImgLink imgNo="8" imgType="table"/>, Table 9 <ImgLink imgNo="9" imgType="table"/>).</Pgraph><SubHeadline>Treatment concepts</SubHeadline><Pgraph>See Figure 2 <ImgLink imgNo="2" imgType="figure"/>.</Pgraph><SubHeadline2>Non-pharmacological concepts</SubHeadline2><Pgraph>See Table 10 <ImgLink imgNo="10" imgType="table"/>.</Pgraph><SubHeadline2>Analgesia</SubHeadline2><Pgraph>ICU-patients require an individualized pain management. Pain exerts considerable negative effects on recovery and is one of the most commonly reported stressors for ICU-patients. Therefore, a sufficient analgesia in all ICU patients – regardless of indication of sedation – should be ensured, and potentially painful procedures should be met with a preventive analgesic approach. In the ICU, the analgesia regimen is usually opioid based <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, as the risk-benefit profile of non-opioid analgesics is still a matter of scientific discussion (low analgesic potential, but considerable side effects).</Pgraph><Pgraph>A combination with regional analgesia can be used <TextLink reference="19"></TextLink>, and a patient-controlled analgesia is recommended as soon as the patient is sufficiently awake (RASS 0/-1 and no delirium) <TextLink reference="20"></TextLink> (Table 11 <ImgLink imgNo="11" imgType="table"/>).</Pgraph><SubHeadline2>Sedation</SubHeadline2><Pgraph>The current evidence reveals that a measurable sedation should always be avoided, as long as there is no mandatory clinical indication for sedation <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. A deep sedation, also within the first 48 hours, is associated with increased mortality, prolonged mechanical ventilation, prolonged ICU-LOS, and hospitalization <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. Aside from specific indications (e.g. surgical indications, signs of increased intracranial pressure with impending herniation, or reduction of oxygen consumption in case of imminent hypoxia), the treatment goal should be an alert, cooperative patient who can tolerate the required interventions (RASS 0/–1). It is fundamental to achieve an adequate analgesia, which is accompanied by a specific treatment of possible symptoms, such as hallucinations, stress, and anxiety <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>. A recent systematic review revealed a decreased importance of daily sedation interruptions (DSIs), which is no longer considered superior to protocol-driven management of sedation <TextLink reference="30"></TextLink>. The goal for light sedation should be set as early as possible, as the first 48 hours of sedation predict long-term outcome. Sedation should follow the principles of an “early goal directed therapy” with target-RASS 0/–1 (Table 12 <ImgLink imgNo="12" imgType="table"/>).</Pgraph><SubHeadline2>Moderate or deep sedation</SubHeadline2><Pgraph>If the indication for a deep sedation is provided, the target RASS and the time of the next re-evaluation must be defined. Sedation should be performed with a combination of hypnotic and analgesic agents, whereas the choice of hypnotic agent should be appropriate to level of sedation and controllability desired. Aside from propofol and benzodiazepines, volatile anesthetics are also feasible options. In the absence of contraindications, DSI protocol (e.g., Spontaneous Awakening Trial, SAT) and Spontaneous Breathing Trials (SBT) should be carried out daily in patients with RASS ≤–2 <TextLink reference="31"></TextLink> (Table 13 <ImgLink imgNo="13" imgType="table"/>).</Pgraph><SubHeadline2>Symptom oriented sedative therapy</SubHeadline2><Pgraph>Aside from pain, the most common symptoms of critically ill patients are stress, anxiety, agitation, psychotic symptoms, and sleep disturbances, all of which require a targeted, symptom-oriented therapy. In addition to non-pharmacological strategies and a causal treatment, a pharmacological therapy may be necessary to control the symptoms. Alpha-2-agonists are available for stress-reduction and treatment of vegetative symptoms, and benzodiazepines can be used for anxiolysis (Table 14 <ImgLink imgNo="14" imgType="table"/>).</Pgraph><SubHeadline2>Pharmacological therapy of delirium</SubHeadline2><Pgraph>Preventive measures for delirium are both safe and effective <TextLink reference="32"></TextLink>. If delirium does occur, it should be treated promptly and symptomatically. The treatment of psychotic symptoms (with or without delirium) may include low-dose neuroleptics <TextLink reference="33"></TextLink>. In addition, the use of <TextGroup><PlainText>alpha-2</PlainText></TextGroup> agonists is also suitable for a symptom-orientated therapy of delirium <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. A special situation is the alcohol withdrawal delirium in the ICU, for which long-acting benzodiazepines should be considered <TextLink reference="36"></TextLink> (Table 15 <ImgLink imgNo="15" imgType="table"/>).</Pgraph><SubHeadline2>Weaning from mechanical ventilation</SubHeadline2><Pgraph>The new German S2k-Guidelines on “Prolonged Weaning” AWMF (020/015) provides recommendations regarding weaning from mechanical ventilation <TextLink reference="37"></TextLink>. The management of analgesia, sedation, and delirium influence the weaning process significantly <TextLink reference="38"></TextLink>. In order to start weaning as early as possible, it is useful to combine sedation and weaning protocols (Table 16 <ImgLink imgNo="16" imgType="table"/>).</Pgraph><SubHeadline2>Treatment with neuromuscular blocking agents (NMBA)</SubHeadline2><Pgraph>There is no indication for a general use of a neuromuscular blockade during intensive care treatment. During neuromuscular blockade, patients cannot be awake, actively participate in their recovery, nor benefit from physiotherapy. When there is a specific indication for NMBAs, adequate analgesia and sedation should be provided <TextLink reference="39"></TextLink>. Furthermore, the depth of blockade should be monitored <TextLink reference="40"></TextLink>, and the duration should be kept as short as possible (Table 17 <ImgLink imgNo="17" imgType="table"/>).</Pgraph><SubHeadline2>Intra- and inter- hospital transports</SubHeadline2><Pgraph>Especially during intra- and inter-hospital transports, movements or changes in the position of the patient are potentially painful events. Therefore, a symptomatic therapy should be continued and possibly adjusted during a transport <TextLink reference="41"></TextLink>. An inadequate sedation (over- and under-sedation) should be avoided at all times, as this can lead to an acute deterioration of neurological and cardiovascular parameters (Table 18 <ImgLink imgNo="18" imgType="table"/>).</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Analgesie, Sedierung und Delirmanagement bei Erwachsenen"> <MainHeadline>Analgesie, Sedierung und Delirmanagement bei Erwachsenen</MainHeadline><SubHeadline>Risiko und Prävention des intensivmedizinischen Delirs</SubHeadline><Pgraph>Schmerzen, Stress, Angst und ein gestörter Schlaf-Wach-Rhythmus sind häufige Symptome, die im Rahmen einer intensivstationären Behandlung auftreten und das Auftreten vom intensivmedizinischen Delir begünstigen <TextLink reference="3"></TextLink>. Das Delir ist die häufigste Form einer zerebralen Dysfunktion bei intensivmedizinisch-behandelten Patienten. Dies beeinträchtigt nicht nur kurzfristig die Genesung (im Sinne einer verlängerten Beatmungs-, und Verweildauer sowie einer erhöhten Mortalität) <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, sondern führt zu kognitiven Langzeitstörungen, posttraumatische Belastungsstörungen und Einschränkungen der Lebensqualität <TextLink reference="7"></TextLink>. Für das intensivmedizinische Delir sind neben relevanten Risikofaktoren diverse effektive pharmakologische und nicht-pharmakologische Präventionsstrategien etabliert. Die Risikofaktoren für ein Delir umfassen neben Basisfaktoren auch behandlungsassoziierte Faktoren, und zusätzlich psychologische, soziale und iatrogene Faktoren <TextLink reference="8"></TextLink>. Auf das Vorliegen von Risikofaktoren soll während der intensivmedizinischen Behandlung geachtet werden, um frühzeitig präventive Maßnahme einsetzen zu können. Nicht-pharmakologische Maßnahmen erwiesen sich besonders effektiv zur Prävention eines Delirs und sollen daher bei allen intensivmedizinisch-behandelten Patienten durchgeführt werden. Dringend empfohlen wird, eine Sedierung zu vermeiden, da eine Übersedierung den Behandlungserfolg erheblich verschlechtert <TextLink reference="9"></TextLink>. Eine pharmakologische Delirprävention ist lediglich Patienten mit einem hohen Risiko für ein Delir vorbehalten. Diese Leitlinie richtet sich auf Grund der Vielfalt der präventiven und therapeutischen Maßnahmen an alle auf der Intensivstation tätigen Berufsgruppen, an die Patienten und Angehörigen (Tabelle 1 <ImgLink imgNo="1" imgType="table"/>, Tabelle 2 <ImgLink imgNo="2" imgType="table"/>, Tabelle 3 <ImgLink imgNo="3" imgType="table"/>).</Pgraph><SubHeadline>Monitoring von Analgesie, Sedierung, Delir, Angst, Stress und Schlaf</SubHeadline><Pgraph>Grundlegender Bestandteil patientenorientierter Therapiekonzepte in der Intensivmedizin ist ein regelmäßiges Festlegen von individuellen, patientenspezifischen Behandlungszielen und dem Überprüfen, in wie weit diese Ziele erreicht werden (<Mark2>Goal Directed Therapy</Mark2>). Sowohl zur Formulierung dieser Behandlungsziele als auch zum adäquaten Monitoring werden symptombezogene, validierte Messinstrumente eingesetzt. Das Monitoring mit validierten klinischen Messinstrumenten beeinflusst das Behandlungsergebnis nachhaltig: die systematische Bewertung von Schmerzen, Sedierungsgrad und Delir selbst geht einher mit einer besseren Therapie von Schmerzen, einer Senkung der Inzidenz nosokomialer Infektionen, einer Verkürzung der Beatmungs- und Intensivbehandlungsdauer und einer Reduktion der Letalität <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>.</Pgraph><Pgraph>Daher soll der Standard für alle Intensivstationen sein, dass das Behandlungsziel und der aktuelle Grad von Analgesie, Sedierung und Delir mindestens einmal pro Schicht (in der Regel alle 8 h) mit validierten klinischen Messinstrumenten durchgeführt und dokumentiert werden (Abbildung 1 <ImgLink imgNo="1" imgType="figure"/>).</Pgraph><Pgraph>Die Evaluation von Angst anhand einer validierten Skala ist wünschenswert, da Angst häufig nicht richtig eingeschätzt und somit nicht richtig therapiert wird. Es stehen Kurzversionen von psychologischen Standardmessinstrumenten zur Verfügung (<Mark2>State-Trait Anxiety Inventory</Mark2>, <Mark2>state subscale</Mark2> (<Mark2>STAI-s</Mark2>) oder der <Mark2>Brief Symptom Inventory</Mark2>, <Mark2>anxiety subscale (BSI-a)</Mark2>), die eine Einschätzung von Angst valide und reliabel ermöglichen. Aus der Schmerzeinschätzung wissen wir, dass sich eindimensionaler Selbsteinschätzungsskalen als besonders praktikabel erwiesen haben um Therapiebedarf und Therapieerfolg zu messen. Untersuchungen aus dem Bereich der Angsterfassung zeigen, dass solche Skalen (z.B. <Mark2>Linear Visual Analogue Scale</Mark2> und die <Mark2>Faces Anxiety Scale</Mark2>) auch geeignet sind, Angst mit guter diagnostischer Validität zu erfassen <TextLink reference="12"></TextLink>. Diesbezüglich besteht, insbesondere in Hinblick auf die Steuerbarkeit der Anxiolyse, weiter Forschungsbedarf.</Pgraph><Pgraph>Stress und Störungen des Tag-Nacht-Rhythmus sind weitere Symptome von intensivmedizinisch-behandelten Patienten, die den Heilverlauf nicht nur direkt negativ beeinflussen, sondern auch Risikofaktoren für schwerwiegende Komplikationen darstellen. Um Stress und Schlaf während des intensivstationären Aufenthaltes vergleichbar zu Analgesie, Sedierung, Delir und Angst zu bestimmen, fehlen derzeit einsetzbare Messinstrumente. Sicher ist, dass eine alleinige subjektive Beurteilung der Vitalparameter durch das behandelnde Personal nicht geeignet ist, um valide ein Monitoring von Stress an intensivmedizinisch-behandelten Patienten durchzuführen <TextLink reference="13"></TextLink>. Zum Monitoring von Schlaf fehlt es an einer validen Beurteilung von Schlafstadien bei intensivmedizinischen Patienten, zum anderen an praktisch durchführbaren Monitoringverfahren, die sich in die Routine eingliedern lassen <TextLink reference="14"></TextLink> (Tabelle 4 <ImgLink imgNo="4" imgType="table"/>, Tabelle 5 <ImgLink imgNo="5" imgType="table"/>, Tabelle 6 <ImgLink imgNo="6" imgType="table"/>, Tabelle 7 <ImgLink imgNo="7" imgType="table"/>, Tabelle 8 <ImgLink imgNo="8" imgType="table"/>, Tabelle 9 <ImgLink imgNo="9" imgType="table"/>).</Pgraph><SubHeadline>Therapeutische Konzepte</SubHeadline><Pgraph>Siehe Abbildung 2 <ImgLink imgNo="2" imgType="figure"/>.</Pgraph><SubHeadline2>Nicht-pharmakologische Konzepte</SubHeadline2><Pgraph>Siehe Tabelle 10 <ImgLink imgNo="10" imgType="table"/>.</Pgraph><SubHeadline2>Analgesie</SubHeadline2><Pgraph>Intensivmedizinisch-behandelte Patienten bedürfen einer individuell angepassten Schmerztherapie. Schmerzen haben deutlich negative Auswirkungen auf den Genesungsprozess und sind die häufigsten subjektiv empfundenen Stressoren bei Intensivpatienten. Daher muss eine suffiziente Analgesie bei allen Intensivpatienten – unabhängig von der Indikation einer Sedierung- durchgeführt werden. Dabei erfolgen potentiell schmerzhafte Maßnahmen unter präventiver analgetischer Abschirmung. Die Analgesie wird auf der Intensivstation vorwiegend Opioid-basiert durchgeführt <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>. Die Rolle von Nicht-Opioid-Analgetika wird neu diskutiert, weil beispielsweise NSAID ein vergleichsweise geringes analgetisches Potential bei einem gleichzeitig für Intensivpatienten ungünstigen Nebenwirkungsprofil aufweisen. Eine patientenkontrollierten Analgesie wird empfohlen, sobald der Zustand des Patienten dies ermöglicht (RASS 0/–1 und kein Delir) <TextLink reference="20"></TextLink>. Auch eine Kombination mit Regionalverfahren ist möglich <TextLink reference="19"></TextLink> (Tabelle 11 <ImgLink imgNo="11" imgType="table"/>).</Pgraph><SubHeadline2>Sedierung</SubHeadline2><Pgraph>Die aktuelle Evidenz belegt, dass eine messbare Sedierung immer vermieden werden soll, solange keine zwingende Indikation für eine solche vorliegt <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. Eine tiefe Sedierung auch innerhalb der ersten 48 h geht mit einer erhöhten Mortalität, einer prolongierten Beatmungsdauer und einer verlängerten Intensiv- und Krankenhausverweildauer einher <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. Außerhalb spezieller Indikationen (z.B. chirurgische Indikationen, Hirndrucksymptomatik mit drohender Einklemmung oder zur Reduktion des Sauerstoffverbrauchs bei drohender Hypoxie), soll das Ziel ein wacher, kooperativer Patient, der die intensivmedizinisch erforderlichen Maßnahmen gut toleriert (RASS 0/–1) sein. Grundlage ist die suffiziente Analgesie, die von einer möglichst spezifischen Therapie von Symptomen, wie Halluzinationen, Stress und Angst begleitet wird <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>. Patienten bedürfen keiner Aufwachversuche, wenn keine Sedierung durchgeführt wird. Der Stellenwert von täglichen Sedierungsunterbrechungen (<Mark2>daily sedation interruption</Mark2> (DSI)) zeigt sich in einem aktuellen systematischen Review nicht mehr der protokollbasierten Sedierung überlegen <TextLink reference="30"></TextLink>. Der Ziel-RASS 0/–1 soll so früh wie möglich etabliert werden, da die ersten 48 h der Intensivbehandlung entscheidend für das Behandlungsergebnis sehen. Daher sollte ein Sedierungsprotokoll dem Prinzip der „early goal directed therapy“ folgen (Tabelle 12 <ImgLink imgNo="12" imgType="table"/>). </Pgraph><SubHeadline2>Moderate oder tiefe Sedierung</SubHeadline2><Pgraph>Wenn die medizinische Indikation für eine tiefe Sedierung gestellt wird, müssen der Ziel-RASS und die Dauer bis zur Reevaluation festgelegt werden. Eine tiefe Sedierung wird mit einem Hypnotikum in Kombination mit einem Analgetikum durchgeführt. Die Wahl des Hypnotikums erfolgt unter Berücksichtigung der angestrebten Sedierungstiefe und einer guten Steuerbarkeit, wobei neben Propofol und Benzodiazepinen auch die inhalative Sedierung zur Auswahl stehen, sofern eine Übersedierung in jedem Fall vermieden werden soll. Wenn keine Kontraindikation vorliegt, soll bei Patienten mit Ist-RASS ≤–2 ein täglicher Aufwach- und Spontanatmungsversuch erfolgen <TextLink reference="31"></TextLink> (Tabelle 13 <ImgLink imgNo="13" imgType="table"/>).</Pgraph><SubHeadline2>Symptomorientierte Therapie mit Sedativa</SubHeadline2><Pgraph>Neben Schmerzen sind Stress, Angst, Agitation, psychotische Symptome und Schlafstörungen sind die häufigsten Symptome intensivmedizinisch-behandelter Patienten. Sie bedürfen einer gezielten, symptomorientierten Therapie. Neben nicht-pharmakologischen Maßnahmen und dem Beheben der Ursachen dieser Symptome kann eine pharmakologische Therapie notwendig sein. Zur Stressreduzierung und vegetativen Dämpfung stehen Alpha-2-Agonisten und zur Anxiolyse Benzodiazepine zur Verfügung (Tabelle 14 <ImgLink imgNo="14" imgType="table"/>).</Pgraph><SubHeadline2>Pharmakologische Therapie des Delirs</SubHeadline2><Pgraph>Präventive Maßnahmen zur Vermeidung eines Delirs sind effektiv und sicher durchführbar <TextLink reference="32"></TextLink>. Falls ein Delir dennoch auftritt, muss es zeitnah symptomorientiert behandelt werden. Die Behandlung von produktiv-psychotischen Symptomen (im Rahmen eines Delirs oder auch ohne Delir) kann mit niedrig-dosierten Neuroleptika erfolgen <TextLink reference="33"></TextLink>. Ebenfalls ist der Einsatz von Alpha-2-Agonisten zur Delirtherapie geeignet <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>. Eine Besonderheit stellt das Alkoholentzugsdelir auf Intensivstationen dar, bei dem langwirksame Benzodiazepine indiziert sind <TextLink reference="36"></TextLink> (Tabelle 15 <ImgLink imgNo="15" imgType="table"/>).</Pgraph><SubHeadline2>Entwöhnung von der Beatmung</SubHeadline2><Pgraph>Das Prozedere der Beatmungsentwöhnung wird in der neuen S2k-Leitlinie „Prolongiertes Weaning“ über die AWMF-Leitlinie (020/015) dargestellt <TextLink reference="37"></TextLink>. Das Management von Analgesie, Sedierung und Delirmanagement beeinflusst den Weaning-Prozess maßgeblich <TextLink reference="38"></TextLink>. Um das Weaning zu einem frühestmöglichen Zeitpunkt beginnen zu können, empfiehlt sich ein Weaningsprotokoll mit einem Sedierungsprotokoll zu kombinieren (Tabelle 16 <ImgLink imgNo="16" imgType="table"/>).</Pgraph><SubHeadline2>Neuromuskuläre Blockade (NMB)</SubHeadline2><Pgraph>Der generelle Einsatz einer neuromuskulären Blockade in der Intensivmedizin ist nicht mehr indiziert. Unter neuromuskulärer Blockade kann der Patient weder wach und aktiv an seiner Genesung teilnehmen, noch von Physiotherapie profitieren. Ist eine spezielle Indikation zu NMB gegeben, soll diese unter adäquater Analgesie und Sedierung <TextLink reference="39"></TextLink> und unter Monitoring der Blockade-Tiefe <TextLink reference="40"></TextLink> erfolgen und die Dauer auf die kürzest nötige Zeit begrenzt sein (Tabelle 17 <ImgLink imgNo="17" imgType="table"/>).</Pgraph><SubHeadline2>Intra- und Interhospitaltransporte</SubHeadline2><Pgraph>Besonders während Intra- und Interhospitaltransporten sind Bewegungen und oder Positionsänderungen des Patienten potentiell schmerzhafte Ereignisse. Daher ist eine symptomorientierte Therapie auch während eines Transportes fortzuführen und ggf. anzupassen <TextLink reference="41"></TextLink>. Besonders bei Inter- und Intrahospitaltransporten soll eine inadäquate Sedierung (Über- und Untersedierung) vermieden werden, weil dies zu einer akuten Verschlechterung neurologischer und kardiovaskulärer Parameter führen kann (Tabelle 18 <ImgLink imgNo="18" imgType="table"/>).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Analgesia, sedation, and delirium management in special patients"> <MainHeadline>Analgesia, sedation, and delirium management in special patients</MainHeadline><SubHeadline>Pregnant and breastfeeding women in the ICU</SubHeadline><Pgraph>The pharmacotherapy of pregnant and breastfeeding patients in the ICU is particularly challenging, as it must account for the effects of the drugs on the unborn or breast-fed child. Due to the lack of randomized-controlled trials, there is little evidence for pharmacotherapy of pregnant or breastfeeding women. Should there be an indication for opioids or sedatives during these periods, an adequate monitoring of the child is obligatory (Table 19 <ImgLink imgNo="19" imgType="table"/>).</Pgraph><SubHeadline>End-of-life care</SubHeadline><Pgraph>Impending death is a period that can be severely influenced by anxiety, stress, and pain. Dying patients require the same patient-centred care as other ICU patients. Frequent monitoring and sufficient pharmacotherapy should ensure the patient is free of discomfort, even if this leads to a acceleration of the dying process <TextLink reference="42"></TextLink>. This guideline should be used and evaluated in the light and in-line with the “guideline of limitations to intensive care treatment” <TextLink reference="43"></TextLink> and the “basic principles for medical palliative care”, published by the German Medical Association <TextLink reference="44"></TextLink> (Table 20 <ImgLink imgNo="20" imgType="table"/>).</Pgraph><SubHeadline>Patients with severe burn injury</SubHeadline><Pgraph>Severe burn injuries lead to strong pain, possible hyperalgesia, as well as a prolonged hospitalization. Aside from an adequate basic level of analgesia, additional analgesics (local and systemic) and/or procedural sedation may be necessary when performing various procedures (e.g. dressing changes). There are multimodal concepts for the use of analgesics, adjuvants, and non-pharmacological strategies regarding pain management in patients with severe burns <TextLink reference="45"></TextLink>. Especially for analgesia and sedation of burn-injured children, the use of standardized protocols and training programs should be used <TextLink reference="46"></TextLink> (Table 21 <ImgLink imgNo="21" imgType="table"/>, Table 22 <ImgLink imgNo="22" imgType="table"/>).</Pgraph><SubHeadline>Multiple trauma patients</SubHeadline><Pgraph>The German AWMF-guideline registered under 012/019 provides recommendations regarding patients with multiple trauma <TextLink reference="47"></TextLink>. There is no evidence for a clear superiority of a particular drug for analgesia in severely injured patients. Opioids (morphine, fentanyl, sufentanil, alfentanil, remifentanil), ketamine <TextLink reference="48"></TextLink> (s-enantiomer, racemate), and adjuvant alpha-2-agonists (clonidine) are used routinely in the clinic. Due to an increased risk for adrenal insufficiency and numerous alternatives, etomidate should no longer be used for procedural sedation, and is no longer recommended in trauma patients. <TextGroup><PlainText>Nevertheless</PlainText></TextGroup>, there is no evidence that the administration of etomidate has long-term effects on outcome <TextLink reference="47"></TextLink>, <TextLink reference="49"></TextLink> (Table 23 <ImgLink imgNo="23" imgType="table"/>).</Pgraph><SubHeadline>Patients with intracranial hypertension</SubHeadline><Pgraph>A main focus of the intensive care management of patients with severe traumatic brain injury is the reduction of secondary damage. Although there is little evidence that sedation directly lowers intra-cranial-pressure (ICP), the acute treatment of patients with elevated ICP starts with a deep sedation (RASS-5). There are no validated monitoring systems for this patient subgroup, so the general scores and monitoring instruments are used <TextLink reference="50"></TextLink>. A frequent neurological examination is obligatory. The choice of sedatives should be in-line with recommendations made in the general part. An ideal analgesic/sedative for patients with elevated intracranial pressure should decrease ICP while sustaining an adequate cerebral perfusion pressure, as well as maintain cerebral hemodynamics, including cerebral autoregulation. Additionally, it should reduce the cerebral metabolic rate for oxygen (CMRO2), have anticonvulsive and neuroprotective properties, and should allow short wake-up times for the assessment of patients after a brief infusion interruption <TextLink reference="51"></TextLink> (Table 24 <ImgLink imgNo="24" imgType="table"/>).</Pgraph><SubHeadline>Cardiac surgery</SubHeadline><Pgraph>Fast-track concepts include a 2-hour sedation phase after uncomplicated cardiac surgery. In this setting, numerous analgesia and sedation protocols have proven to be advantageous <TextLink reference="52"></TextLink>, and fast-track strategies seem to reduce the incidence of postoperative delirium <TextLink reference="53"></TextLink>.</Pgraph><Pgraph>Delirium in cardiac surgical patients is associated with a higher mortality <TextLink reference="54"></TextLink>, so that a delirium screening with a validated tool – as generally recommended – is especially important <TextLink reference="55"></TextLink>, <TextLink reference="56"></TextLink> (Table 25 <ImgLink imgNo="25" imgType="table"/>).</Pgraph><SubHeadline>Patients on extracorporeal life support systems (ECLS)</SubHeadline><Pgraph>There is a grey area regarding the level of sedation for patients on ECLS, where safety-aspects and the ability to positively influence recovery must be balanced. Patients on ECLS have numerous delirium risk-factors. Hyperactive delirium or agitation can be life-threatening for these patients, so that a consequent monitoring and a symptomatic therapy of stress, anxiety, delirium, pain, and insomnia is essential to safely achieve a target RASS of 0 <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink>, <TextLink reference="61"></TextLink> (Table 26 <ImgLink imgNo="26" imgType="table"/>).</Pgraph><SubHeadline>Special positioning of patients</SubHeadline><Pgraph>Positioning therapy is used for prophylaxis and treatment of respiratory dysfunctions <TextLink reference="62"></TextLink>, and requires an individual sedation target. Changes of the position frequently represent a challenge for the symptomatic treatment of anxiety, stress, and pain. Therefore, a symptom-orientated therapy should be adapted for changing demands during positioning therapy. Though a deep sedation may be indicated for patient repositioning, <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>, an excessive sedation should be avoided.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Analgesie, Sedierung und Delirmanagement bei speziellen Patientengruppen"> <MainHeadline>Analgesie, Sedierung und Delirmanagement bei speziellen Patientengruppen</MainHeadline><SubHeadline>Schwangere und Stillende in der Intensivmedizin</SubHeadline><Pgraph>Die besondere Herausforderung bei der intensivmedizinischen Pharmakotherapie von schwangeren und stillenden Patientinnen ist die Wirkungen auf das ungeborene Kind/Muttermilch-ernährte Kind zu berücksichtigen. Generell ist die Evidenzlage zur Pharmakotherapie von Schwangeren auf Grund fehlender randomisiert-kontrollierter Studien lückenhaft. Bei gegebener Indikation für Opioide und Sedativa in Schwangerschaft und Stillzeit ist eine adäquate Überwachung des Kindes obligat (Tabelle 19 <ImgLink imgNo="19" imgType="table"/>).</Pgraph><SubHeadline>Moribunde und Sterbende</SubHeadline><Pgraph>Sterben ist ein Prozess, der von Angst, Stress und Schmerzen stark beeinflusst werden kann. Sterbende Patienten sollen daher den gleichen Anspruch auf eine patientenorientierte ärztliche und pflegerische Behandlung und Betreuung wie alle Intensivpatienten haben. Durch ein regelmäßiges Monitoring und eine hinreichende Pharmakotherapie bei sterbenden Patienten soll die klinische Beschwerdefreiheit überprüft und sichergestellt werden, auch wenn dies zu einer Beschleunigung des Sterbeprozesses führt <TextLink reference="42"></TextLink>. Die hier formulierten Leitlinien müssen im Zusammenhang mit der Leitlinie zu Grenzen der intensivmedizinischen Behandlungspflicht <TextLink reference="43"></TextLink> und den von der Bundesärztekammer veröffentlichten Grundsätzen zur ärztlichen Sterbebegleitung <TextLink reference="44"></TextLink> betrachtet werden (Tabelle 20 <ImgLink imgNo="20" imgType="table"/>).</Pgraph><SubHeadline>Brandverletzte Patienten</SubHeadline><Pgraph>Schwere Brandverletzungen gehen mit starken Schmerzen, dem Problem einer möglichen Hyperalgesie und langen Verläufen einher. Neben einer adäquaten Basisanalgesie kann bei der Durchführung von verschiedenen Prozeduren (zum Beispiel Verbandswechsel) eine zusätzliche Analgesie (lokal und systemisch) und/oder prozedurale Sedierung notwendig sein. Zur Schmerztherapie von Verbrennungspatienten stehen multimodale Konzepte zum Einsatz von Analgetika, Adjuvantien und non-pharmakologischen Maßnahmen zur Verfügung <TextLink reference="45"></TextLink>. Besonders zur Analgesie und Sedierung brandverletzter Kinder sollen standardisierte Protokolle und Trainingsprogramme eingesetzt werden <TextLink reference="46"></TextLink> (Tabelle 21 <ImgLink imgNo="21" imgType="table"/>, Tabelle 22 <ImgLink imgNo="22" imgType="table"/>).</Pgraph><SubHeadline>Polytraumatisierte Patienten</SubHeadline><Pgraph>Zur Behandlung des Polytrauma wird auf die AWMF-Leitlinie zur Polytrauma/Schwerverletzten-Behandlung verwiesen (AWMF-Register Nummer 012/019) <TextLink reference="47"></TextLink>. In der Literatur wird keine eindeutige Überlegenheit einer bestimmten Substanz zur Analgesie bei Schwerverletzten herausgestellt. Sowohl Opioide (Morphin, Fentanyl, Sufentanil, Alfentanil, Remifentanil) als auch Ketamin <TextLink reference="48"></TextLink> (<TextGroup><PlainText>S-Enantiomer</PlainText></TextGroup>, Razemat) und adjunktiv Clonidin werden klinisch eingesetzt. Auf Grund der Nebennierensuppression und zahlreicher Alternativen sollte Etomidate nicht mehr für eine prozedurale Sedierung bei polytraumatisierten Patienten verwendet werden, obwohl in der Literatur bisher keine dauerhaften Auswirkungen auf den Heilverlauf beschrieben wurden (Tabelle 23 <ImgLink imgNo="23" imgType="table"/>).</Pgraph><SubHeadline>Patienten mit erhöhtem intrakraniellen Druck</SubHeadline><Pgraph>Im Mittelpunkt der intensivmedizinischen Behandlung von Patienten mit einem schweren Schädel-Hirn-Trauma steht die Reduktion des Sekundärschadens. Auch wenn bisher nur geringe Evidenz dafür vorliegt, dass eine Analgosedierung direkt den intrakraniellen Druck (ICP) senkt, beginnt die Therapie von Patienten mit erhöhtem ICP mit einer tiefen Analgosedierung (RASS-5). Es existieren keine für dieses Patientenkollektiv validierte Monitoring-Systeme, so dass die allgemeinen Scores und apparativen Monitoring-Instrumente Anwendung finden <TextLink reference="50"></TextLink>. Eine regelmäßige neurologische Untersuchung ist obligat. Zur Pharmakotherapie stehen bei der Auswahl der Medikation die in den allgemeinen Empfehlungen geforderten Anforderungen im Vordergrund. Darüber hinaus sollte das ideale Sedativum/Analgetikum in der Neurointensivmedizin den ICP senken unter Aufrechterhaltung eines adäquaten zerebralen Perfusionsdrucks (CPP), die zerebrale Hämodynamik einschließlich der Autoregulation erhalten, den zerebralen Stoffwechselgrundumsatz für Sauerstoff (CMRO2) reduzieren, antikonvulsive und neuroprotektive Eigenschaften besitzen und eine rasche neurologische Beurteilung des Patienten nach Pausieren der Substanz ermöglichen <TextLink reference="51"></TextLink> (Tabelle 24 <ImgLink imgNo="24" imgType="table"/>).</Pgraph><SubHeadline>Kardiochirurgische Patienten</SubHeadline><Pgraph>Fast-track-Konzepte nach unkomplizierten kardiochirurgischen Verläufen beinhalten eine postoperative Kurzzeitsedierung in den ersten zwei Stunden nach der Operation. In diesem Setting haben sich zahlreiche Analgesie- und Sedierungsprotokolle als vorteilhaft erwiesen <TextLink reference="52"></TextLink>. Fast-track-Konzepte scheinen somit die Inzidenz für ein postoperatives Delir zu reduzieren <TextLink reference="53"></TextLink>.</Pgraph><Pgraph>Gerade bei kardiochirurgischen Patienten wurde eine durch ein Delir erhöhte Mortalität nachgewiesen <TextLink reference="54"></TextLink>. Daher ist ein Delirscreening mit validem Instrument – wie im allgemeinen Teil empfohlen – besonders wichtig <TextLink reference="55"></TextLink>, <TextLink reference="56"></TextLink> (Tabelle 25 <ImgLink imgNo="25" imgType="table"/>).</Pgraph><SubHeadline>Patienten mit extrakorporalen Herz- und Lungenersatzverfahren</SubHeadline><Pgraph>Patienten mit extrakorporalen Herz- und Lungenersatzverfahren befinden sich bezüglich des Grades an zu erzielender Wachheit in einem Spannungsfeld zwischen Sicherheitsaspekten und der Möglichkeit wach aktiv den eigenen Heilverlauf zu beeinflussen.</Pgraph><Pgraph>Patienten an extrakorporalen Herz- und Lungenersatzverfahren weisen etliche Risikofaktoren für das Auftreten eines Delirs auf. Agitation und ein hyperaktives Delir stellen ein vital bedrohliches Sicherheitsrisiko dar. Daher ist ein engmaschiges Monitoring und eine symptomorientierte Therapie von Stress, Angst, Delir, Schmerzen und Schlaflosigkeit essentiell, um einen Ziel-RASS = 0 bei Patienten an extrakorporalen Herz- und Lungenersatzverfahren sicher durchzuführen <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink>, <TextLink reference="61"></TextLink> (Tabelle 26 <ImgLink imgNo="26" imgType="table"/>).</Pgraph><SubHeadline>Patienten mit spezieller Lagerungstherapie</SubHeadline><Pgraph>Lagerungstherapien dienen der Prophylaxe und Behandlung von pulmonalen Funktionsstörungen <TextLink reference="62"></TextLink> und bedürfen eines individuellen Sedierungsziels. Positionsänderungen stellen häufig eine Herausforderung für die symptomorientierte Therapie von Angst, Stress und Schmerzen dar. Ihre symptomorientierte Therapie muss daher während einer Lagerungstherapie angepasst werden. Zur Umlagerung im Rahmen der Lagerungstherapie kann eine tiefe Sedierung indiziert sein <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>. Auch dabei muss eine Übersedierung vermieden werden.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Analgesia, sedation, and delirium management in children"> <MainHeadline>Analgesia, sedation, and delirium management in children</MainHeadline><SubHeadline>Monitoring</SubHeadline><Pgraph>For the monitoring of analgesia, sedation, and delirium in children, there are validated monitoring scales are that take developmental stage into account <TextLink reference="65"></TextLink>. Also in the pediatric intensive care, adequate monitoring and individual therapy goals are essential for successful patient-oriented care (Table 27 <ImgLink imgNo="27" imgType="table"/>, Table 28 <ImgLink imgNo="28" imgType="table"/>, Table 29 <ImgLink imgNo="29" imgType="table"/>).</Pgraph><Pgraph>Generally, children aged ≥3 years are able to evaluate pain-levels. Even in children, a self-assessment of pain is superior to observational scales <TextLink reference="66"></TextLink>, and the <Mark2>Faces Pain Scale-revised</Mark2> has been well-established as a valid monitoring tool <TextLink reference="67"></TextLink>. If children are unable to assess their pain, there are several age-appropriate observational pain assessment scales. However, both in very premature infants as well as in children and adolescents with neurocognitive impairment, those instruments have a limited value and tend to systematically underestimate pain <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>, <TextLink reference="70"></TextLink>.</Pgraph><Pgraph>Combined pain and distress sedation scales have been validated for the monitoring of sedation in children. For premature and full-term neonates, the <Mark2>Neonatal Pain, Agitation and Sedation Scale</Mark2> (N-PASS) is available. For infants and toddlers, the <Mark2>COMFORTneo Scale</Mark2> and the <Mark2>Comfort-B Scale</Mark2> are available. Additionally, there are special scales for assessing opioid or sedative withdrawal following a continuous therapy.</Pgraph><Pgraph>Children can also suffer from delirium, and their symptoms are often misinterpreted. The pediatric critical care community has a need for a systematic delirium screening with validated tools <TextLink reference="71"></TextLink>, <TextLink reference="72"></TextLink>, <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>.</Pgraph><SubHeadline>Treatment strategies in children</SubHeadline><Pgraph>Critically ill children – like adults – require an individual pain therapy adapted to their current situation. This includes multimodal therapy strategies for opioids, non-opioids, and regional analgesia, as well as for local anesthetics, co-analgesics and non-pharmacological procedures (Table 30 <ImgLink imgNo="30" imgType="table"/>, Table 31 <ImgLink imgNo="31" imgType="table"/>, Table 32 <ImgLink imgNo="32" imgType="table"/>, Table 33 <ImgLink imgNo="33" imgType="table"/>). When regarding analgesia in children, it is important to consider that pharmacokinetics and pharmacodynamics differ with age. Additional and supportive procedures for analgesia are also recommended for children. There are different non-pharmacological procedures available that can be used for co-analgesia, per example the administration of oral glucose, non-nutritive suction for neonates, or virtual reality for pediatric burn patients.</Pgraph><Pgraph>Children require sedation, sometimes continuously, in order to undergo certain diagnostic and therapeutic procedures. For sedation in children, special personnel and structural prerequisites are required. Oversedation should be avoided as always, and careful titration is required to keep dosages as low as possible.</Pgraph><Pgraph>There is still a high demand for research regarding pediatric delirium. In principle, it is essential to detect delirious symptoms as early as possible and identify and neutralize potential causes. Current evidence revealed a combination of psychological, social (presence of family, toys, pictures of home, normal day-night rhythm, etc.), and pharmacological interventions to be effective <TextLink reference="75"></TextLink>.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Analgesie, Sedierung und Delirmanagement bei Kindern"> <MainHeadline>Analgesie, Sedierung und Delirmanagement bei Kindern</MainHeadline><SubHeadline>Monitoring von Analgesie, Sedierung und Delir bei Kindern</SubHeadline><Pgraph>Bei Kindern stehen zum Monitoring von Analgesie, Sedierung und Delir validierte Messinstrumente unter Berücksichtigung des Entwicklungsalters der Patienten zur Verfügung <TextLink reference="65"></TextLink>. Auch in der pädiatrischen Intensivmedizin sind ein adäquates Monitoring und eine individuelle Festlegung von patientenspezifischen Therapiezielen Grundlage für patientenorientierte Therapiekonzepte (Tabelle 27 <ImgLink imgNo="27" imgType="table"/>, Tabelle 28 <ImgLink imgNo="28" imgType="table"/>, Tabelle 29 <ImgLink imgNo="29" imgType="table"/>).</Pgraph><Pgraph>Kindern sind etwa ab dem 4. Lebensjahr in der Lage ihre Schmerzen selbst zu beurteilen. Auch bei Kindern ist eine Selbsteinschätzung ihrer Schmerzen überlegen <TextLink reference="66"></TextLink>. Als validiertes klinisches Messinstrument hat sich dabei die <Mark2>Faces Pain Scale – revised</Mark2> etabliert <TextLink reference="67"></TextLink>. Sind Kindern nicht in der Lage ihre Schmerzen zu beurteilen, gibt es verschiedene altersgemäße Fremdeinschätzungsinstrumente. Sowohl bei sehr unreifen Frühgeborenen als auch bei neurologisch-kognitiv beeinträchtigten Kindern und Jugendlichen stoßen auch die klinischen Fremdeinschätzungsmessinstrumente an ihre Grenzen. In beiden Gruppen besteht die Gefahr Schmerzen systematisch zu unterschätzen <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>, <TextLink reference="70"></TextLink>.</Pgraph><Pgraph>Zum Monitoring der Sedierung bei Kindern wurden kombinierte Schmerz-Distress-Sedierungskalen validiert. Für Früh- und Reifgeborene stehen die <Mark2>Neonatal Pain</Mark2>, <Mark2>Agitation and Sedation Scale</Mark2> (N-PASS) oder <Mark2>COMFORTneo Scale</Mark2> und für Säuglinge und Kinder die <Mark2>Comfort-B Scale</Mark2> zur Verfügung.</Pgraph><Pgraph>Als Besonderheit zum Monitoring von Analgesie und Sedierung bei Kindern wurden validierte klinische Messinstrumente zur Beurteilung eines Opioid- oder Sedativaentzuges nach kontinuierlicher Therapie entwickelt.</Pgraph><Pgraph>Auch Kinder können ein Delir erleiden, dessen Symptome ebenfalls häufig missinterpretiert werden. International wird mittlerweile auch für pädiatrische Intensivpatienten ein systematisches Delirscreening gefordert <TextLink reference="71"></TextLink>, das mittels validierter, pädiatrischer Messinstrumente durchgeführt wird <TextLink reference="72"></TextLink>, <TextLink reference="73"></TextLink>, <TextLink reference="74"></TextLink>.</Pgraph><SubHeadline>Therapeutische Konzepte bei Kindern</SubHeadline><Pgraph>Intensivmedizinisch-behandelte Kinder bedürfen genau wie Erwachsene einer an die individuelle Situation angepasste Schmerztherapie. Es handelt sich um multimodale Therapiekonzepte, die neben Opioid-, Nicht-Opioid-Analgetika und regionalen Analgesieverfahren, Lokalanästhetika, Koanalgetika und nicht-pharmakologische Maßnahmen umfassen (Tabelle 30 <ImgLink imgNo="30" imgType="table"/>, Tabelle 31 <ImgLink imgNo="31" imgType="table"/>, Tabelle 32 <ImgLink imgNo="32" imgType="table"/>, Tabelle 33 <ImgLink imgNo="33" imgType="table"/>). Bei der pharmakologischen Analgesie von Kindern ist zu beachten, dass sich Pharmakokinetik und Pharmakodynamik mit dem Alter verändern. Auch bei Kindern werden zusätzlich zur pharmakologischen Analgesie supportive Maßnahmen empfohlen. Bei Kindern gibt es verschiedene nicht-pharmakologische Maßnahmen, die adjuvant zur Schmerztherapie eingesetzt werden. Dies kann zum Beispiel für Neugeborene aus einer Gabe von oralen Zuckerstoffen oder nicht-nutritivem Saugen oder beispielsweise für brandverletzte Kinder aus dem Einsatz von virtueller Realität bestehen.</Pgraph><Pgraph>Zur Durchführung einiger diagnostischer und therapeutischer Verfahren, in einigen Fällen sogar dauerhaft, benötigen Kinder eine Sedierung. Für eine Sedierung beim Kind sind besondere personelle und strukturelle Voraussetzungen erforderlich. Auch bei Kindern soll eine Übersedierung in jedem Fall vermieden werden. Dies sollte durch eine sorgfältige Titration zum Erreichen einer möglichst niedrigen Dosierung erfolgen.</Pgraph><Pgraph>Zur sicheren und effektiven Therapie des Delirs bei Kindern besteht aktuell noch großer Forschungsbedarf. Prinzipiell gilt es delirante Symptome möglichst früh zu erkennen, eine Ursache zu suchen und diese zeitnah zu beheben. Zur Therapie eines Delirs im Kindesalter kann bei der aktuellen Datenlage derzeit lediglich empfohlen werden, eine Kombination aus pyschosozialen (Anwesenheit der Familie, Lieblings-Spielzeug, Fotos von zu Hause, normaler Tag-Nacht-Rhythmus, u.a.) und pharmakologischen Intervention im Kindesalter einzusetzen <TextLink reference="75"></TextLink>.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Analgesia, sedation, and delirium management in elderly patients"> <MainHeadline>Analgesia, sedation, and delirium management in elderly patients</MainHeadline><Pgraph>The “clinical age” is determined by the biological age, frailty, comorbidities, long-term medication, and external influences. The ageing of the cardiovascular, respiratory, renal, and nervous-systems lead to changes in pharmacodynamics and kinetics. The inherent age cannot be based on a chronological age alone (Table 34 <ImgLink imgNo="34" imgType="table"/>, Table 35 <ImgLink imgNo="35" imgType="table"/>).</Pgraph><Pgraph>Elderly patients lack the resources to compensate for delirium-associated complications, thus a frequent and active screening for delirium is paramount. In principle, all monitoring instruments used for the adult patients may be used for elderly patients. To evaluate pain in patients with cognitive impairment or dementia, tools such as Faces Pain Scale, PAINAD-scale as well as the BESD-scale (German scale) are available.</Pgraph><Pgraph>Preventive measures such as reorientation, visual and hearing aids are especially indicated for elderly patients <TextLink reference="76"></TextLink>. Regarding the treatment of delirium, a symptomatic treatment should consider the delirogenic effects of long-acting benzodiazepines <TextLink reference="77"></TextLink>, the cardiac side effects of neuroleptics, and the use of appropriately cautious dosages <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, <TextLink reference="80"></TextLink>. For the treatment of delirium, melatonin or melatonin-analogues should be considered at night to reduce the incidence and duration of delirium <TextLink reference="81"></TextLink>.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Analgesie, Sedierung und Delirmanagement bei älteren Patienten"> <MainHeadline>Analgesie, Sedierung und Delirmanagement bei älteren Patienten</MainHeadline><Pgraph>Das klinische Alter setzt sich neben dem biologischen Alter aus Begleiterkrankungen, Dauermedikation und externen Einflüssen zusammen. Die Alterung im kardiovaskulären, pulmonalen, renalen und nervalen System führt zu einer veränderten Pharmakodynamik und -kinetik der medikamentösen Therapie. Eine Definition einer Altersgrenze nach chronologischem Alter ist daher nicht möglich. Besonders bei älteren Patienten ist ein engmaschiges und aktives Screening für ein Delir wichtig, weil delirassoziierte Komplikationen im Alter weniger gut kompensiert werden können. Prinzipiell können zum Monitoring älterer Patienten alle klinischen Messinstrumente verwendet werden, die auch im allgemeinen Teil für erwachsene Patienten beschrieben sind. Zur Beurteilung von Schmerzen von kognitiv eingeschränkten oder dementen Patienten eignen sich besonders die Faces Pain Scale und die deutsche Version der PAINAD-Scale, die BESD-Skala.</Pgraph><Pgraph>Präventive Maßnahmen wie Seh-und Hörhilfen und Reorientierungsmaßnahmen sind vor allem bei älteren Patienten indiziert <TextLink reference="76"></TextLink>. In der Delirtherapie sollten v.a. die delirogene Potenz von langwirksamen Benzodiazepinen <TextLink reference="77"></TextLink> sowie die kardialen Nebenwirkungen der Neuroleptika beachtet und eine entsprechend vorsichtige Dosierung angewandt werden <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, <TextLink reference="80"></TextLink>. Zur Behandlung des Delirs sollte Melatonin bzw. deren Analoga zur Nacht erwogen werden, um die Inzidenz und die Dauer des Delirs zu reduzieren <TextLink reference="81"></TextLink> (Tabelle 34 <ImgLink imgNo="34" imgType="table"/>, Tabelle 35 <ImgLink imgNo="35" imgType="table"/>).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Economy, quality assurance and implementation of the guideline"> <MainHeadline>Economy, quality assurance and implementation of the guideline</MainHeadline><Pgraph>In terms of quality assurance, management of analgesia, sedation and delirium in the ICU should be conducted according to guidelines and subject to a continuous quality verification <TextLink reference="82"></TextLink>.</Pgraph><Pgraph>This includes the regular training of personnel in the implementation of the guidelines <TextLink reference="83"></TextLink>. Special consideration for regional characteristics and internal Standard Operating Procedures improved the integration of guideline recommendations <TextLink reference="83"></TextLink>. As a follow-up to the surveys of 2002 and 2006, a current survey on the current implementation of the S3-guideline in clinical routine is being carried out and will be published. Before the next guideline update process, an additional survey will assess the level of implementation (Table 36 <ImgLink imgNo="36" imgType="table"/>).</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Ökonomie, Qualitätssicherung und Implementierung der Leitlinie"> <MainHeadline>Ökonomie, Qualitätssicherung und Implementierung der Leitlinie</MainHeadline><Pgraph>Unter dem Aspekt der Qualitätssicherung sollen Analgesie, Sedierung und Delirmanagement auf der Intensivstation Leitlinien konform erfolgen und einer kontinuierlichen Qualitätsüberprüfung unterliegen <TextLink reference="82"></TextLink>.</Pgraph><Pgraph>Dazu gehört, dass eine regelmäßige Schulung des Personals in der Anwendung der Leitlinienempfehlungen erfolgt <TextLink reference="83"></TextLink>. Die Eingliederung der Leitlinienempfehlungen unter Berücksichtigung der regionalen Besonderheiten in die klinikinternen <Mark2>Standard</Mark2> <Mark2>Operating Procedures</Mark2> erhöht die Implementierungsrate <TextLink reference="83"></TextLink>. Als <Mark2>Follow-up</Mark2> zu den Umfragen von 2002 und 2006 wird aktuell eine Ist-Stand-Umfrage zur S3-Leitlinie durchgeführt und publiziert. Vor dem nächsten Aktualisierungsprozess wird eine erneute Umfrage den Implementierungsgrad abbilden (Tabelle 36 <ImgLink imgNo="36" imgType="table"/>).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Extended version of the guideline</SubHeadline><Pgraph>The German extended version, patient version, and methodology report are available under <Hyperlink href="http://www.awmf.org/leitlinien/detail/ll/001-012.html">http://www.awmf.org/leitlinien/detail/ll/001-012.html</Hyperlink>.</Pgraph><SubHeadline>Authorship</SubHeadline><Pgraph>DAS Taskforce 2015: The task-force members (authors) are listed in alphabetical order.</Pgraph><Pgraph>Chairing medical societies: German Society of Anaesthesiology and Intensive Care Medicine (DGAI) and German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) with 15 participating medical societies<Superscript>$</Superscript>. All societies or their executive boards consented on the final version of the guidelines. </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">German Society of Anaesthesiology and Intensive Care Medicine (DGAI)</ListItem><ListItem level="1" levelPosition="2" numString="2.">German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)</ListItem><ListItem level="1" levelPosition="3" numString="3.">German Society of Surgery (DGCH)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="4" numString="4.">German Society for Specialised Nursing and Allied Health Professions (DGF)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="5" numString="5.">German Society of Geriatrics (DGG)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="6" numString="6.">German Society for Gynecology & Obstetrics (DGGG)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="7" numString="7.">German Society of Haematology and Oncology (DGHO)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="8" numString="8.">German Society of Midwifery Science (DGHWi)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="9" numString="9.">German Society of Internal Medicine Intensive Care (DGIIN)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="10" numString="10.">German Society of Neurosurgery (DGNC)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="11" numString="11.">German Society of Neurology (DGN)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="12" numString="12.">German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="13" numString="13.">German Sleep Society (DGSM)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="14" numString="14.">German Society for Thoracic and Cardiovascular Surgery (DGTHG)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="15" numString="15.">German Pain Society (DGSS)$</ListItem><ListItem level="1" levelPosition="16" numString="16.">German Association for Physiotherapy (ZVK)<Superscript>$</Superscript></ListItem><ListItem level="1" levelPosition="17" numString="17.">German Society of Neonatology and Pediatric Intensive Care (GNPI)<Superscript>$</Superscript></ListItem></OrderedList></Pgraph><SubHeadline>Conflicts of interest</SubHeadline><Pgraph>The declarations of conflict of interest from all participants can be viewed upon request and are published on the AWMF homepage. </Pgraph><SubHeadline>Funding</SubHeadline><Pgraph>This guideline has been funded independently of interest groups by the DGAI. </Pgraph><SubHeadline>Acknowledgements</SubHeadline><Pgraph>We thank all participating societies for their work, their outstanding commitment and the sound review of the guideline before publication. Our special thanks to Rudolf Mörgeli for the thorough correction of the English version of the guideline.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Anmerkungen"> <MainHeadline>Anmerkungen</MainHeadline><SubHeadline>Langfassung der Leitlinie </SubHeadline><Pgraph>Die Langfassung der Leitlinie in deutscher Sprache ist verfügbar unter <Hyperlink href="http://www.awmf.org/leitlinien/detail/ll/001-012.html">http://www.awmf.org/leitlinien/detail/ll/001-012.html</Hyperlink>.</Pgraph><SubHeadline>Autorenschaft</SubHeadline><Pgraph>Federführende Fachgesellschaften:</Pgraph><Pgraph><UnorderedList><ListItem level="1">Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI)</ListItem><ListItem level="1">Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)</ListItem></UnorderedList></Pgraph><Pgraph>Beteiligte Fachgesellschaften: </Pgraph><Pgraph><UnorderedList><ListItem level="1">Deutsche Gesellschaft für Chirurgie (DGCH)</ListItem><ListItem level="1">Deutsche Gesellschaft für Fachkrankenpflege (DGF)</ListItem><ListItem level="1">Deutsche Gesellschaft für Geriatrie (DGG)</ListItem><ListItem level="1">Deutsche Gesellschaft für Gynäkologie & Geburtshilfe (DGGG)</ListItem><ListItem level="1">Deutsche Gesellschaft für Hämatologie und Medizinische Onkologie (DGHO)</ListItem><ListItem level="1">Deutsche Gesellschaft für Hebammenwissenschaft (DGHWi)</ListItem><ListItem level="1">Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN)</ListItem><ListItem level="1">Deutsche Gesellschaft für Neurochirurgie (DGNC)</ListItem><ListItem level="1">Deutsche Gesellschaft für Neurologie (DGN)</ListItem><ListItem level="1">Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde (DGPPN) </ListItem><ListItem level="1">Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)</ListItem><ListItem level="1">Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG)</ListItem><ListItem level="1">Deutsche Schmerzgesellschaft (DGSS)</ListItem><ListItem level="1">Deutscher Verband für Physiotherapie (ZVK)</ListItem><ListItem level="1">Gesellschaft für Neonatologie und pädiatrische Intensivmedizin (GNPI)</ListItem></UnorderedList></Pgraph><Pgraph>Alle Fachgesellschaften oder ihre Vorstände haben sich mit der finalen Version der Leitlinie einverstanden erklärt. Die Mandatsträger der beteiligten Fachgesellschaften sind in alphabetischer Reihenfolge aufgeführt.</Pgraph><SubHeadline>Interessenkonflikte </SubHeadline><Pgraph>Die Erklärungen zu Interessenkonflikten aller Teilnehmer der Arbeitsgruppe können auf Wunsch eingesehen werden und sind auf der AWMF-Homepage veröffentlicht. </Pgraph><SubHeadline>Finanzierung der Leitlinien </SubHeadline><Pgraph>Diese Leitlinie wurde von der DGAI unabhängig von Interessengruppen finanziert.</Pgraph><SubHeadline>Danksagung</SubHeadline><Pgraph>Wir danken allen beteiligten Fachgesellschaften für ihre Arbeit, ihr außergewöhnliches Engagement und das gründliche Review der Leitlinie.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>OCEBM Levels of Evidence Working Group</RefAuthor> <RefTitle></RefTitle> <RefYear></RefYear> <RefBookTitle>The Oxford 2011 Levels of Evidence</RefBookTitle> <RefPage></RefPage> <RefTotal>OCEBM Levels of Evidence Working Group. 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DOI: 10.1055/s-2001-13832</RefTotal> <RefLink>http://dx.doi.org/10.1055/s-2001-13832</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID language="en">1en</MediaID> <MediaID language="de">1de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 1: Risk factors for ICU-delirium</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 1: Risikofaktoren für ein Delir in der Intensivmedizin</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID language="en">2en</MediaID> <MediaID language="de">2de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 2: Prevention and risk reduction</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 2: Prävention und Risikoreduktion</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>3</MediaNo> <MediaID language="en">3en</MediaID> <MediaID language="de">3de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 3: Long-term consequences</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 3: Spätfolgen</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>4</MediaNo> <MediaID language="en">4en</MediaID> <MediaID language="de">4de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 4: Monitoring – general aspects</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 4: Monitoring – Allgemeines</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>5</MediaNo> <MediaID language="en">5en</MediaID> <MediaID language="de">5de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 5: Monitoring of analgesia</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 5: Monitoring von Analgesie</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>6</MediaNo> <MediaID language="en">6en</MediaID> <MediaID language="de">6de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 6: Monitoring of sedation</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 6: Monitoring von Sedierung</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>7</MediaNo> <MediaID language="en">7en</MediaID> <MediaID language="de">7de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 7: Monitoring of delirium</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 7: Monitoring von Delir</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>8</MediaNo> <MediaID language="en">8en</MediaID> <MediaID language="de">8de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 8: Monitoring of anxiety</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 8: Monitoring von Angst</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>9</MediaNo> <MediaID language="en">9en</MediaID> <MediaID language="de">9de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 9: Monitoring of sleep</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 9: Monitoring von Schlaf</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>10</MediaNo> <MediaID language="en">10en</MediaID> <MediaID language="de">10de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 10: Treatment concepts – non-pharmacological concepts</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 10: Therapeutische Konzepte – Nicht-pharmakologische Konzepte</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>11</MediaNo> <MediaID language="en">11en</MediaID> <MediaID language="de">11de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 11: Analgesia and regional analgesia</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 11: Analgesie und Regionanalgesie</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>12</MediaNo> <MediaID language="en">12en</MediaID> <MediaID language="de">12de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 12: Sedation </Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 12: Sedierung</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>13</MediaNo> <MediaID language="en">13en</MediaID> <MediaID language="de">13de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 13: Moderate/deep sedation</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 13: Moderate oder tiefe Sedierung</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>14</MediaNo> <MediaID language="en">14en</MediaID> <MediaID language="de">14de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 14: Symptom oriented sedative therapy (target RASS 0/–1)</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 14: Symptomorientierte Therapie mit Sedativa (Ziel-RASS 0/–1)</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>15</MediaNo> <MediaID language="en">15en</MediaID> <MediaID language="de">15de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 15: Therapy of delirium</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 15: Pharmakologische Therapie des Delirs</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>16</MediaNo> <MediaID language="en">16en</MediaID> <MediaID language="de">16de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 16: Weaning from mechanical ventilation</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 16: Entwöhnung von der Beatmung</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>17</MediaNo> <MediaID language="en">17en</MediaID> <MediaID language="de">17de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 17: Treatment with neuromuscular blocking agents (NMBA)</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 17: Neuromuskuläre Blockade</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>18</MediaNo> <MediaID language="en">18en</MediaID> <MediaID language="de">18de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 18: Intra- and inter-hospital transports</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 18: Intra- und Interhospitaltransporte</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>19</MediaNo> <MediaID language="en">19en</MediaID> <MediaID language="de">19de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 19: Pregnant and breastfeeding patients in the ICU</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 19: Schwangere und Stillende in der Intensivmedizin</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>20</MediaNo> <MediaID language="en">20en</MediaID> <MediaID language="de">20de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 20: End-of-life care</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 20: Morbibunde und Sterbende Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>21</MediaNo> <MediaID language="en">21en</MediaID> <MediaID language="de">21de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 21: Patients with severe burn injuries</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 21: Brandverletzte Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>22</MediaNo> <MediaID language="en">22en</MediaID> <MediaID language="de">22de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 22: Burn-injured children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 22: Das brandverletze Kind</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>23</MediaNo> <MediaID language="en">23en</MediaID> <MediaID language="de">23de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 23: Multiple trauma patients</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 23: Polytraumatisierte Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>24</MediaNo> <MediaID language="en">24en</MediaID> <MediaID language="de">24de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 24: Patients with intracranial hypertension</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 24: Patienten mit erhöhtem intrakraniellen Druck</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>25</MediaNo> <MediaID language="en">25en</MediaID> <MediaID language="de">25de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 25: Cardiac surgery</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 25: Kardiochirurgische Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>26</MediaNo> <MediaID language="en">26en</MediaID> <MediaID language="de">26de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 26: Patients on extracorporeal life support systems (ECLS)</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 26: Patienten mit extrakorporalen Herz- und Lungenersatzverfahren</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>27</MediaNo> <MediaID language="en">27en</MediaID> <MediaID language="de">27de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 27: Monitoring of analgesia in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 27: Monitoring von Analgesie bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>28</MediaNo> <MediaID language="en">28en</MediaID> <MediaID language="de">28de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 28: Monitoring of sedation in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 28: Monitoring von Sedierung bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>29</MediaNo> <MediaID language="en">29en</MediaID> <MediaID language="de">29de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 29: Monitoring of delirium in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 29: Monitoring des Delirs bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>30</MediaNo> <MediaID language="en">30en</MediaID> <MediaID language="de">30de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 30: Analgesia in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 30: Analgesie bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>31</MediaNo> <MediaID language="en">31en</MediaID> <MediaID language="de">31de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 31: Non-pharmacological procedures in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 31: Nicht-pharmakologische Maßnahmen bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>32</MediaNo> <MediaID language="en">32en</MediaID> <MediaID language="de">32de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 32: Sedation in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle</Mark1><Mark1> 32: Sedierung bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>33</MediaNo> <MediaID language="en">33en</MediaID> <MediaID language="de">33de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 33: Therapy of delirium in children</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 33: Delirtherapie bei Kindern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>34</MediaNo> <MediaID language="en">34en</MediaID> <MediaID language="de">34de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 34: Monitoring in the elderly</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 34: Monitoring bei älteren Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>35</MediaNo> <MediaID language="en">35en</MediaID> <MediaID language="de">35de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 35: Treatment strategies in the elderly</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 35: Therapeutische Konzepte bei älteren Patienten</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>36</MediaNo> <MediaID language="en">36en</MediaID> <MediaID language="de">36de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 36: Economy, quality assurance, and implementation of the guideline</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 36: Ökonomie, Qualitätssicherung und Implementierung der Leitlinie</Mark1></Pgraph></Caption> </Table> <NoOfTables>36</NoOfTables> </Tables> <Figures> <Figure format="png" height="897" width="1266"> <MediaNo>1</MediaNo> <MediaID language="en">1en</MediaID> <MediaID language="de">1de</MediaID> <Caption language="en"><Pgraph><Mark1>Figure 1: Algorithm for monitoring of sedation, delirium, and pain in adult patients </Mark1></Pgraph><Pgraph>RASS: Richmond Agitation, Sedation Scale; CAM-ICU: Confusion Assessment Method for the Intensive Care Unit; ICDSC: Intensive Care Delirium Screening Checklist; BPS: Behavioral Pain Scale; BPS-NI: Behavioral Pain Scale, not intubated; CPOT: Critical Care Pain Observation Tool; FPS-R: Faces Pain Scale, revised</Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Abbildung 1: Monitoring von Sedierung, Delir und Schmerz</Mark1> </Pgraph><Pgraph>RASS: Richmond Agitation, Sedation Scale; CAM-ICU: Confusion Assessment Method for the Intensive Care Unit; ICDSC: Intensive Care Delirium Screening Checklist; BPS: Behavioral Pain Scale; BPS-NI: Behavioral Pain Scale, not intubated; CPOT: Critical Care Pain Observation Tool; FPS-R: Faces Pain Scale, revised</Pgraph></Caption> </Figure> <Figure format="png" height="772" width="1084"> <MediaNo>2</MediaNo> <MediaID language="en">2en</MediaID> <MediaID language="de">2de</MediaID> <Caption language="en"><Pgraph><Mark1>Figure 2: Symptom-based therapy and reduction of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine</Mark1></Pgraph><Pgraph>Algorithm that focuses on a possible holistic management for adult critically ill patients. RASS: Richmond Agitation-Sedation Scale. Other scores (delirium, analgesia: observational/self-assessment), please, s.f. addendum at http://www.awmf.org/leitlinien/detail/ll/001-012.html.</Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Abbildung 2: Symptomorientierte Therapie und Reduktion von Delir, Angst, Stress und protokollbasierte Analgesie, Sedierung und Schlafmanagement in der Intensivmedizin</Mark1></Pgraph><Pgraph>Der Algorithmus stellt einen möglichen, leitliniengerechten Ablauf für erwachsene Patienten dar. RASS: Richmond Agitation-Sedation Scale. Andere validierte Instrumente (Delir, Analgesie: Selbst und Fremdeinschätzung), vgl. bitte Addendum auf http://www.awmf.org/leitlinien/detail/ll/001-012.html.</Pgraph></Caption> </Figure> <NoOfPictures>2</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <NoOfAttachments>0</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>