Protocol-driven ventilator weaning: reviewing the evidence

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

[Weaning from invasive ventilation : Challenges in the clinical routine]

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Development of a Questionnaire for the Reflective Practice of Nursing Involving Invasive Mechanical Ventilation: Assessment of validity and reliability

AIM

To develop the Questionnaire for Reflective Practice of Nursing Involving Invasive Mechanical Ventilation (Q-RPN-IMV), a Japanese self-evaluation instrument for ward nurses' IMV practices.

DESIGN

Cross-sectional survey.

METHODS

Participants were 305 ward nurses from five hospitals in Japan with nursing involving invasive mechanical ventilation. Items concerning the process of nursing practice, including the thought process related to ventilator care, were collected from the literature and observation and interviews with five IMV specialists. Construct validity, concurrent validity, internal consistency and test-retest reliability were tested.

RESULTS

Initially, 141 items were collected and classified into three domains (i.e., observation, assessment and practice). Examination of exploratory factor analysis yielded five factors in the observation domain, six factors in the assessment domain and six factors in the practice domain. The data exhibited internal consistency, stability and concurrent validity. Items of practical content, including thoughts on ventilator care, are useful for preparing educational programmes.

Experts' guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF) : In collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR)

BACKGROUND

Intubation and extubation of ventilated patients are not risk-free procedures in the intensive care unit (ICU) and can be associated with morbidity and mortality. Intubation in the ICU is frequently required in emergency situations for patients with an unstable cardiovascular or respiratory system. Under these circumstances, it is a high-risk procedure with life-threatening complications (20-50%). Moreover, technical problems can also give rise to complications and several new techniques, such as videolaryngoscopy, have been developed recently. Another risk period is extubation, which fails in approximately 10% of cases and is associated with a poor prognosis. A better understanding of the cause of failure is essential to improve success procedure.

RESULTS AND CONCLUSION

In constructing these guidelines, the SFAR/SRLF experts have made use of new data on intubation and extubation in the ICU from the last decade to update existing procedures, incorporate more recent advances and propose algorithms.

Clinical characteristics, prevalence, and factors related to delirium in children of 5 to 14 years of age admitted to intensive care

OBJECTIVE

To evaluate the clinical characteristics, prevalence and factors associated with delirium in critical patients from 5 to 14 years of age.

DESIGN

An analytical, cross-sectional observational study was made. Delirium was assessed with the Pediatric-Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU) and motor classification was established with the Delirium Rating Scale Revised-98.

SETTING

A pediatric Intensive Care Unit.

PATIENTS

All those admitted over a one-year period were assessed during the first 24-72h, or when possible in deeply sedated patients.

EXCLUSION CRITERIA

Patients in stupor or coma, with severe communication difficulty, subjected to deep sedation throughout admission, and those with denied consent.

RESULTS

Twenty-nine of the 156 assessed patients suffered delirium (18.6%) and 55.2% were hypoactive. The neurocognitive alterations evaluated by the pCAM-ICU were similar in the three motor groups. Intellectual disability (OR=17.54; 95%CI: 3.23-95.19), mechanical ventilation (OR=18.80; 95%CI: 4.29-82.28), liver failure (OR=54.88; 95%CI: 4.27-705.33), neurological disease (OR=4.41; 95%CI: 1.23-15.83), anticholinergic drug use (OR=3.23; 95%CI: 1.02-10.26), different psychotropic agents (OR=4.88; 95%CI: 1.42-16.73) and tachycardia (OR=4.74; 95%CI: 1.21-18.51) were associated to delirium according to the logistic regression analysis.

CONCLUSION

The frequency of delirium and hypoactivity was high. It is therefore necessary to routinely evaluate patients with standardized instruments. All patients presented with important neurocognitive alterations. Several factors related with the physiopathology of delirium were associated to the diagnosis; some of them are modifiable through the rationalization of medical care.

Studying the Power of the Integrative Weaning Index in Predicting the Success Rate of the Spontaneous Breathing Trial in Patients under Mechanical Ventilation

BACKGROUND AND AIMS

The use of weaning predictive indicators can avoid early extubation and wrongful prolonged mechanical ventilation. This study aimed to determine the power of the integrative weaning index (IWI) in predicting the success rate of the spontaneous breathing trial (SBT) in patients under mechanical ventilation.

MATERIALS AND METHODS

In this prospective study, 105 patients undergoing mechanical ventilation for over 48 h were enrolled. Before weaning initiation, the IWI was calculated and based on the defined cutoff point (≥25), the success rate of the SBT was predicted. In case of weaning from the device, 2-h SBT was performed and the physiologic and respiratory indices were continuously studied while being intubated. If they were in the normal range besides the patient's tolerance, the test was considered as a success. The result was then compared with the IWI and further analyzed.

RESULTS

The SBT was successful in 90 (85.7%) and unsuccessful in 15 (14.3%) cases. The difference between the true patient outcome after SBT, and the IWI prediction was 0.143 according to the Kappa agreement coefficient (P < 0.001). Moreover, regarding the predictive power, IWI had high sensitivity (95.6%), specificity (40%), positive and negative predictive values (90.5% and 60), positive and negative likelihood ratios (1.59 and 0.11), and accuracy (86.7%).

CONCLUSION

The IWI as a more objective indicator has acceptable accuracy and power for predicting the 2-h SBT result. Therefore, in addition to the reliable prediction of the final weaning outcome, it has favorable power to predict if the patient is ready to breathe spontaneously as the first step to weaning.

Management of Respiratory Failure

The management of acute respiratory failure varies according to the etiology. A clear understanding of physiology of respiration and pathophysiological mechanisms of respiratory failure is mandatory for managing these patients. The extent of abnormality in arterial blood gas values is a result of the balance between the severity of disease and the degree of compensation by cardiopulmonary system. Normal blood gases do not mean that there is an absence of disease because the homeostatic system can compensate. However, an abnormal arterial blood gas value reflects uncompensated disease that might be life threatening.

Understanding nurses' decision-making when managing weaning from mechanical ventilation: a study of novice and experienced critical care nurses in Scotland and Greece

AIM AND OBJECTIVES

To examine how nurses collect and use cues from respiratory assessment to inform their decisions as they wean patients from ventilatory support.

BACKGROUND

Prompt and accurate identification of the patient's ability to sustain reduction of ventilatory support has the potential to increase the likelihood of successful weaning. Nurses' information processing during the weaning from mechanical ventilation has not been well-described.

DESIGN

A descriptive ethnographic study exploring critical care nurses' decision-making processes when weaning mechanically ventilated patients from ventilatory support in the real setting.

METHODS

Novice and expert Scottish and Greek nurses from two tertiary intensive care units were observed in real practice of weaning mechanical ventilation and were invited to participate in reflective interviews near the end of their shift. Data were analysed thematically using concept maps based on information processing theory. Ethics approval and informed consent were obtained.

RESULTS

Scottish and Greek critical care nurses acquired patient-centred objective physiological and subjective information from respiratory assessment and previous knowledge of the patient, which they clustered around seven concepts descriptive of the patient's ability to wean. Less experienced nurses required more encounters of cues to attain the concepts with certainty. Subjective criteria were intuitively derived from previous knowledge of patients' responses to changes of ventilatory support. All nurses used focusing decision-making strategies to select and group cues in order to categorise information with certainty and reduce the mental strain of the decision task.

CONCLUSIONS

Nurses used patient-centred information to make a judgment about the patients' ability to wean. Decision-making strategies that involve categorisation of patient-centred information can be taught in bespoke educational programmes for mechanical ventilation and weaning.

RELEVANCE TO CLINICAL PRACTICE

Advanced clinical reasoning skills and accurate detection of cues in respiratory assessment by critical care nurses will ensure optimum patient management in weaning mechanical ventilation.

Mechanical Ventilator Discontinuation Process

The goal of this article is to discuss approaches to discontinuing invasive mechanical ventilation in a general intensive care unit (ICU) population. It considers approaches in which the clinician expects patient survival, as well as those that do not. Additionally, approaches to acute and chronic critical illness are included.

Establishing the Content Validity of an Early Extubation Protocol: A Quality Improvement Project for Improving Early Extubation of Coronary Artery Bypass Graft Patients

Introduction: Patients undergoing coronary artery bypass graft surgery will require intubation and the use of mechanical ventilation during and after surgery. It is well accepted that early extubation is associated with not only positive patient outcomes but also organizational outcomes as well. Patients who are not extubated early are at risk for complications associated with prolonged intubation. The literature supports the use of protocol aid with early extubation. The goal and expected outcome of this project is to establish the usability of an early extubation protocol by assessing its appropriateness for use in the postoperative cardiac surgical adult patient. Methods: For the purpose of establishing content validity of an early extubation protocol, 2 protocols were chosen from the literature. Fifteen cardiac surgery experts were invited to select the protocol they felt was most appropriate for use in this patient population. These reviewers were then asked to further analyze the protocol based on a 5-question survey. Their response was used to calculate a scale-content validity index (S-CVI) and an item-content validity index (I-CVI). Results: Twelve of 15 experts participated in the project. The content validity was estimated using (a) interrater agreement for relevance for each item (I-CVI) and (b) S-CVI. The means were established for each item. Content validity was estimated using (a) interrater agreement for relevance for each item (I-CVI: 0.75-1.00); and the S-CVI/average = 0.92. Cronbach's alpha was estimated to establish reliability (0.972). Conclusion: Selecting an appropriate protocol to be used in this patient population is the first step in implementing an effective early extubation process. The results highly suggest that the content of this protocol is quite relevant in this patient population. It is hoped that this will set the stage for early extubation in postoperative cardiac surgery patients.

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

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.

NICU bedside caregivers sustain process improvement and decrease incidence of bronchopulmonary dysplasia in infants < 30 weeks gestation

BACKGROUND

The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation.

METHODS

A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1-T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010.

RESULTS

A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03-0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11-2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07-0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period.

CONCLUSIONS

In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.

Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in critically ill paediatric patients

BACKGROUND

Mechanical ventilation is a critical component of paediatric intensive care therapy. It is indicated when the patient's spontaneous ventilation is inadequate to sustain life. Weaning is the gradual reduction of ventilatory support and the transfer of respiratory control back to the patient. Weaning may represent a large proportion of the ventilatory period. Prolonged ventilation is associated with significant morbidity, hospital cost, psychosocial and physical risks to the child and even death. Timely and effective weaning may reduce the duration of mechanical ventilation and may reduce the morbidity and mortality associated with prolonged ventilation. However, no consensus has been reached on criteria that can be used to identify when patients are ready to wean or the best way to achieve it.

OBJECTIVES

To assess the effects of weaning by protocol on invasively ventilated critically ill children. To compare the total duration of invasive mechanical ventilation of critically ill children who are weaned using protocols versus those weaned through usual (non-protocolized) practice. To ascertain any differences between protocolized weaning and usual care in terms of mortality, adverse events, intensive care unit length of stay and quality of life.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 10, 2012), MEDLINE (1966 to October 2012), EMBASE (1988 to October 2012), CINAHL (1982 to October 2012), ISI Web of Science and LILACS. We identified unpublished data in the Web of Science (1990 to October 2012), ISI Conference Proceedings (1990 to October 2012) and Cambridge Scientific Abstracts (earliest to October 2012). We contacted first authors of studies included in the review to obtain further information on unpublished studies or work in progress. We searched reference lists of all identified studies and review papers for further relevant studies. We applied no language or publication restrictions.

SELECTION CRITERIA

We included randomized controlled trials comparing protocolized weaning (professional-led or computer-driven) versus non-protocolized weaning practice conducted in children older than 28 days and younger than 18 years.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned titles and abstracts identified by electronic searching. Three review authors retrieved and evaluated full-text versions of potentially relevant studies, independently extracted data and assessed risk of bias.

MAIN RESULTS

We included three trials at low risk of bias with 321 children in the analysis. Protocolized weaning significantly reduced total ventilation time in the largest trial (260 children) by a mean of 32 hours (95% confidence interval (CI) 8 to 56; P = 0.01). Two other trials (30 and 31 children, respectively) reported non-significant reductions with a mean difference of -88 hours (95% CI -228 to 52; P = 0.2) and -24 hours (95% CI -10 to 58; P = 0.06). Protocolized weaning significantly reduced weaning time in these two smaller trials for a mean reduction of 106 hours (95% CI 28 to 184; P = 0.007) and 21 hours (95% CI 9 to 32; P < 0.001). These studies reported no significant effects for duration of mechanical ventilation before weaning, paediatric intensive care unit (PICU) and hospital length of stay, PICU mortality or adverse events.

AUTHORS' CONCLUSIONS

Limited evidence suggests that weaning protocols reduce the duration of mechanical ventilation, but evidence is inadequate to show whether the achievement of shorter ventilation by protocolized weaning causes children benefit or harm.

Outcomes of the patients in the respiratory care center are not associated with the seniority of the caring resident

Although many studies show that the experience level of physicians is significantly associated with the outcomes of their patients, little evidence exists to show whether junior residents provide worse care than senior residents. This study was conducted to analyze whether the experience level of residents may affect the outcomes of patients cared for in a well-organized setting. We conducted a 7-year retrospective study utilizing statistical data from a respiratory care center (RCC) in a medical center between October 2004 and September 2011. In addition to the two medical residents who had been trained in the intensive care unit (ICU), the RCC team also included attending physicians in charge, a nurse practitioner, a case manager, a dietitian, a pharmacist, a social worker, registered respiratory therapists, and nursing staff. Weaning from mechanical ventilation was done according to an established weaning protocol. The 84 months analyzed were classified into five groups according to the levels of the two residents working in the RCC: R2 + R1, R2 + R2, R3 + R1, R3 + R2, and R3 + R3. The monthly weaning rate and mortality rate were the major outcomes, while the mean ventilator days, rate of return to the ICU, and nosocomial infection incidence rate were the minor outcomes. The groups did not differ significantly in the monthly weaning rate, mortality rate, mean ventilator days, rate of return to the ICU, or nosocomial infection incidence rate (p > 0.1). Further analysis showed no significant difference in the monthly weaning rate and mortality rate between months with a first-year resident (R1) and those with two senior residents (p > 0.2). Although the weaning rate in the RCC gradually improved over time (p < 0.001), there was no significant difference in the monthly weaning rate between the groups after adjusting for time and disease severity (p > 0.7). Thus, we concluded that in a well-organized setting, the levels (experiences) of residents did not significantly affect patient outcomes. This result may be attributed to the well-developed weaning protocol and teamwork processes in place, which avoid a large effect from any single factor and provide stable and high-quality care to the patients.

Working with capacity limitations: operations management in critical care

As your hospital's ICU director, you are approached by the hospital's administration to help solve ongoing problems with ICU bed availability. The ICU seems to be constantly full, and trauma patients in the emergency department sometimes wait up to 24 hours before receiving a bed. Additionally, the cardiac surgeons were forced to cancel several elective coronary-artery bypass graft cases because there was not a bed available for postoperative recovery. The hospital administrators ask whether you can decrease your ICU length of stay, and wonder whether they should expand the ICU to include more beds For help in understanding and optimizing your ICU's throughput, you seek out the operations management researchers at your university.

Mechanical Ventilation

Mechanical ventilation is a common therapeutic modality required for the management of patients unable to maintain adequate intrinsic ventilation and oxygenation. Mechanical ventilators can be found within various hospital and nonhospital environments (ie, nursing homes, skilled nursing facilities, and patient’s home residence), but these devices generally require the skill of a multidisciplinary health care team to optimize therapeutic outcomes. Unfortunately, pharmacists have been excluded in the discussion of mechanical ventilation since this therapeutic modality may be perceived as irrelevant to drug utilization and the usual scope of practice of a hospital pharmacist. However, the pharmacist provides a crucial role as a member of the multidisciplinary team in the management of the mechanically ventilated patient by verifying accuracy of prescribed medications, providing recommendations of alternative drug selections, monitoring for drug and disease interactions, assisting in the development of institutional weaning protocols, and providing quality assessment of drug utilization. Pharmacists may be intimidated by the introduction of advanced ventilator microprocessor technology, but understanding and integrating ventilator management with the pharmacotherapeutic needs of the patient will ultimately help the pharmacist be a better qualified and respected practitioner. The goal of this article is to assist the pharmacy practitioner with a better understanding of mechanical ventilation and to apply this information to improve delivery of pharmaceutical care.

Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version

Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.