Expert consensus on late stage of critical care management.

Bo Tang; Wen Jin Chen; Li Dan Jiang; Shi Hong Zhu; Bin Song; Yan Gong Chao; Tian Jiao Song; Wei HE; Yang Liu; Hong Min Zhang; Wen Zhao Chai; Man Hong Yin; Ran Zhu; Li Xia Liu; Jun WU; Xin Ding; Xiu Ling Shang; Jun Duan; Qiang Hong XU; Heng Zhang; Xiao Meng Wang; Qi Bing Huang; Rui Chen Gong; Zun Zhu LI; Mei Shan LU; Xiao Ting Wang

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Expert consensus on late stage of critical care management.

Author: Bo TANG ¹ ; Wen Jin CHEN ² ; Li Dan JIANG ² ; Shi Hong ZHU ³ ; Bin SONG ³ ; Yan Gong CHAO ⁴ ; Tian Jiao SONG ⁴ ; Wei HE ⁵ ; Yang LIU ⁵ ; Hong Min ZHANG ¹ ; Wen Zhao CHAI ¹ ; Man hong YIN ⁶ ; Ran ZHU ⁷ ; Li Xia LIU ⁸ ; Jun WU ⁹ ; Xin DING ¹ ; Xiu Ling SHANG ¹⁰ ; Jun DUAN ¹¹ ; Qiang Hong XU ¹² ; Heng ZHANG ¹³ ; Xiao Meng WANG ¹⁴ ; Qi Bing HUANG ¹⁵ ; Rui Chen GONG ¹⁶ ; Zun Zhu LI ¹ ; Mei Shan LU ¹⁷ ; Xiao Ting WANG ¹
Author Information

1. Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China.
2. Department of Neurosurgery ICU, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
3. Department of Critical Care Medicine, the Seventh Medical Center of PLA General Hospital, Beijing 100700, China.
4. Department of Critical Care Medicine, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China.
5. Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.
6. Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China.
7. Department of Critical Care Medicine, the First Hospital of China Medical Uinversity, Shenyang 110001, China.
8. Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China.
9. Department of Critical Care Medicine, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200025, China.
10. Department of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou 350001, China.
11. Department of Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China.
12. Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou 310013, China.
13. Department of Neurosurgery, the First Hospital of China Medical University, Shenyang 110001, China.
14. Department of Critical Care Medicine, Xuzhou Central Hospital, Xuzhou 221009, China.
15. Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan 250012, China.
16. Department of Critical Care Medicine, Affiliated Hospital of Taiwan Kaohsiung University, China.
17. Department of Health Care and Medical, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences,Beijing 100730, China.
Publication Type:Journal Article
MeSH: Humans; Consensus; Critical Care/methods*; Intensive Care Units; Pain/drug therapy*; Analgesics/therapeutic use*; Delirium/therapy*; Critical Illness
From: Chinese Journal of Internal Medicine 2023;62(5):480-493
CountryChina
Language:Chinese
Abstract: We wished to establish an expert consensus on late stage of critical care (CC) management. The panel comprised 13 experts in CC medicine. Each statement was assessed based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) principle. Then, the Delphi method was adopted by 17 experts to reassess the following 28 statements. (1) ESCAPE has evolved from a strategy of delirium management to a strategy of late stage of CC management. (2) The new version of ESCAPE is a strategy for optimizing treatment and comprehensive care of critically ill patients (CIPs) after the rescue period, including early mobilization, early rehabilitation, nutritional support, sleep management, mental assessment, cognitive-function training, emotional support, and optimizing sedation and analgesia. (3) Disease assessment to determine the starting point of early mobilization, early rehabilitation, and early enteral nutrition. (4) Early mobilization has synergistic effects upon the recovery of organ function. (5) Early functional exercise and rehabilitation are important means to promote CIP recovery, and gives them a sense of future prospects. (6) Timely start of enteral nutrition is conducive to early mobilization and early rehabilitation. (7) The spontaneous breathing test should be started as soon as possible, and a weaning plan should be selected step-by-step. (8) The waking process of CIPs should be realized in a planned and purposeful way. (9) Establishment of a sleep-wake rhythm is the key to sleep management in post-CC management. (10) The spontaneous awakening trial, spontaneous breathing trial, and sleep management should be carried out together. (11) The depth of sedation should be adjusted dynamically in the late stage of CC period. (12) Standardized sedation assessment is the premise of rational sedation. (13) Appropriate sedative drugs should be selected according to the objectives of sedation and drug characteristics. (14) A goal-directed minimization strategy for sedation should be implemented. (15) The principle of analgesia must be mastered first. (16) Subjective assessment is preferred for analgesia assessment. (17) Opioid-based analgesic strategies should be selected step-by-step according to the characteristics of different drugs. (18) There must be rational use of non-opioid analgesics and non-drug-based analgesic measures. (19) Pay attention to evaluation of the psychological status of CIPs. (20) Cognitive function in CIPs cannot be ignored. (21) Delirium management should be based on non-drug-based measures and rational use of drugs. (22) Reset treatment can be considered for severe delirium. (23) Psychological assessment should be conducted as early as possible to screen-out high-risk groups with post-traumatic stress disorder. (24) Emotional support, flexible visiting, and environment management are important components of humanistic management in the intensive care unit (ICU). (25) Emotional support from medical teams and families should be promoted through"ICU diaries"and other forms. (26) Environmental management should be carried out by enriching environmental content, limiting environmental interference, and optimizing the environmental atmosphere. (27) Reasonable promotion of flexible visitation should be done on the basis of prevention of nosocomial infection. (28) ESCAPE is an excellent project for late stage of CC management.