Feasibility and acceptability of hand massage therapy for pain management of postoperative cardiac surgery patients in the intensive care unit

The Effect of Hand Reflexology Massage on Pain and Anxiety After Coronary Artery Bypass Graft Surgery: A Double-Blind, Randomized, Placebo-Controlled Trial

BACKGROUND

Pain and anxiety are common postoperative problems that impair recovery and quality of life in patients undergoing coronary artery bypass graft (CABG) surgery. Reflexology is a nonpharmacologic method used to control pain and anxiety.

OBJECTIVE

The aim of this study was to examine the effects of reflexology hand massage and stroking massage on pain and anxiety in patients in the immediate postoperative period after CABG.

METHODS

In this double-blind, randomized, placebo-controlled study, we compared the effects of a 20-minute hand-reflexology massage to placebo stroking massage on pain and anxiety in newly extubated patients in the intensive care unit who had undergone CABG surgery. Pain was measured by visual analog scale and anxiety by the State-Trait Anxiety Inventory before and at 5, 30, and 60 minutes post intervention.

RESULTS

A total of 48 patients were enrolled: 24 in the intervention group and 24 in the placebo. Mean pain scores were significantly reduced in the group who received reflexology compared with the placebo group (F = 36.569, P = .000). Mean anxiety scores were significantly reduced at 60 minutes for the reflexology group compared with the control group (P = .000).

CONCLUSIONS

We found that hand reflexology massage was effective in reducing pain and anxiety in patients during the immediate postoperative period after CABG.

The effect of massage therapy on pain after surgery: A comprehensive meta-analysis

BACKGROUND

Findings on the usefulness of massage therapy (MT) in postoperative pain management are often inconsistent among studies.

OBJECTIVES

This study's aim is to conduct a meta-analysis of randomized controlled trials (RCT) to clarify the effects of massage therapy in the treatment of postoperative pain.

METHODS

Three databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were searched for RCTs published from database inception through January 26, 2021. The primary outcome was pain relief. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. The random-effect model was used to calculate the effect sizes and standardized mean difference (SMD) with 95 % confidential intervals (CIs) as a summary effect. The heterogeneity test was conducted through I². Subgroup and sensitivity analyses were used to explore the source of heterogeneity. Possible publication bias was assessed using visual inspection of funnel plot asymmetry.

RESULTS

The analysis included 33 RCTs and showed that MT is effective in reducing postoperative pain (SMD, -1.32; 95 % CI, -2.01 to -0.63; p = 0.0002; I² = 98.67 %). A similar significant effect was found for both short (immediate assessment) and long terms (assessment performed 4-6 weeks after the MT). Remarkably, we found neither the duration per session nor the dose had an impact on the effect of MT and there seemed to be no difference in the effects of different MT types. In addition, MT seemed to be more effective for adults. Furthermore, MT had better analgesic effects on cesarean section and heart surgery than orthopedic surgery.

LIMITATIONS

Publication bias is possible due to the inclusion of studies in English only. Additionally, the included studies were extremely heterogeneous. Double-blind research on MT is difficult to implement, and none of the included studies is double-blind. There was some heterogeneity and publication bias in the included studies. In addition, there is no uniform evaluation standard for the operation level of massage practitioners, which may lead to research implementation bias.

CONCLUSIONS

MT is effective in reducing postoperative pain in both short and long terms.

Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit

Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.

Effect of Hand Massage on Pain, Anxiety, and Vital Signs in Patients Before Venipuncture Procedure: A Randomized Controlled Trial

BACKGROUND

Massage is one of the relaxation techniques commonly used in recent years to control pain, stress, and anxiety.

AIMS

This study was conducted to evaluate the effect of hand massage application on pain, anxiety, and vital signs before venipuncture procedure.

METHODS

The sample of the study consisted of 97 individuals (48 experimental and 49 controls) who were admitted to a training and research hospital in Turkey between December 2018 and May 2019. Individuals assigned to the experimental group received hand massage. The data were obtained with an individual information form, a visual analog scale (VAS), and the State-Trait Anxiety Inventory (STAI).

RESULTS

The mean age of the participants was 49.52 ± 12.48 years. There was no significant difference between the pain levels of the experimental and control groups (p > .05), but the anxiety level of the experimental group was significantly less than that of the control group (p < .05). There was also a significant difference between the experimental and control groups in terms of systolic and diastolic blood pressure and heart rate. The blood pressure and heart rate of the experimental group decreased significantly (p < .05).

CONCLUSION

Hand massage was found to be a simple, non-pharmacologic, inexpensive, and independent nursing practice that could be used to reduce anxiety and positively affect vital signs in patients before venipuncture procedure.

Efficacy of Precise Foot Massage Therapy on Pain and Anxiety Following Cardiac Surgery: Pilot Study

BACKGROUND

Pain is the most pervasive distressing symptom following cardiac surgery. Forty percent of postoperative cardiac patients report inadequate pain management. Undertreated acute pain results in increased anxiety, delayed wound healing, and increased chance of persistent chronic pain. Foot massage is a safe, visible complementary approach to manage acute pain following surgery.

AIM

The aim of this study is to evaluate the efficacy of integrating foot massage therapy for managing postcardiac pain.

METHOD

A randomized placebo controlled single blinded trial comparing foot massage to placebo was conducted at a large hospital in Saudi Arabia. Thirty-one patients who had undergone cardiac surgery (16 in experimental and 15 in placebo group) participated in the study. Ten-minute foot massage was delivered to the experimental group by a nurse researcher, twice during one day, within 30 minutes after receiving an opioid pain medication.

RESULTS

The findings of this study indicate that foot massage significantly (p < .05) decreases pain intensity and anxiety in patients who have undergone cardiac surgery compared with a placebo control group.

CONCLUSION

Providing non-pharmacologic interventions for pain is the responsibility of the nursing staff. Foot massage is within the scope of nursing practice and is a safe and effective manner of improving patient care. Foot massage in conjunction with pharmacological interventions is effective in improving pain and anxiety. Future studies should consider focusing on frequency, dose, feasibility, acceptability, and participants' satisfaction.

Characteristics of Nonpharmacological Interventions for Pain Management in the ICU: A Scoping Review

Pain relief in the intensive care unit (ICU) is of particular concern since patients are exposed to multiple painful stimuli associated with care procedures. Considering the adverse effects of pharmacological approaches, particularly in vulnerable populations such as the elderly, the use of non-pharmacological interventions has recently been recommended in the context of critical care. The main goal of this scoping review was to systematically map the research done on non-pharmacological interventions for pain management in ICU adults and describe the characteristics of these interventions. A wide variety of non-pharmacological interventions have been tested, with music and massage therapies being the most frequently used. An interesting new trend is the use of combined or bundle interventions. Lastly, it was observed that these interventions have not been studied in specific subgroups, such as the elderly, women, and patients unable to self-report.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial

Objective

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill.

Design

A three-arm randomized controlled trial.

Setting

This study was conducted in a medical-surgical intensive care unit in Canada.

Subjects

Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible.

Methods

Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention.

Results

From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups.

Conclusions

Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Interpersonal touch interventions for patients in intensive care: A design-oriented realist review

AIM

To develop a theoretical framework to inform the design of interpersonal touch interventions intended to reduce stress in adult intensive care unit patients.

DESIGN

Realist review with an intervention design-oriented approach.

METHODS

We searched CINAHL, MEDLINE, EMBASE, CENTRAL, Web of Science and grey literature sources without date restrictions. Subject experts suggested additional articles. Evidence synthesis drew on diverse sources of literature and was conducted iteratively with theory testing. We consulted stakeholders to focus the review. We performed systematic searches to corroborate our developing theoretical framework.

RESULTS

We present a theoretical framework based around six intervention construction principles. Theory testing provided some evidence in favour of treatment repetition, dynamic over static touch and lightening sedation. A lack of empirical evidence was identified for construction principles relating to intensity and positive/negative evaluation of emotional experience, moderate pressure touch for sedated patients and intervention delivery by relatives versus healthcare practitioners.

Effects of massage on outcomes of adult intensive care unit patients: a systematic review

BACKGROUND

The critical care experience is particularly stressful for patients, which can result in a number of physiological and psychological consequences, including haemodynamic instability, increased pain, agitation and delirium, leading to prolonged mechanical ventilation, length of stay and subsequent complications. Massage therapy encompasses different techniques to promote relaxation and to counter stress, therefore potentially affecting several patients' outcomes.

AIMS

To systematically review evidence on the effects of massage on outcomes of adult critically ill patients. The outcome measures included pain, vital signs (VS), haemodynamic measurements, level of consciousness, sleep quality, muscle tension, anxiety, feelings of calm and relaxation, coping, arterial blood gases and serum biomarkers.

METHOD

This was a systematic review based on focused literature searches (PubMed, CINAHL, Scopus, EMBASE-Ovid databases, Google Scholar). The Cochrane Collaboration's tool was used to assess the risk of bias. Eligibility criteria included published experimental and quasi-experimental studies reporting on the physiological and psychological outcomes of critically ill patients.

RESULTS

Based on the selection criteria, 12 studies were included in the review. The main findings are as follows: 8 of 12 studies used randomized control designs with high internal validity, and there was a high level of evidence of favourable effects with respect to improvements in VS and a reduction in pain and anxiety. Outcomes that need to be more rigorously pursued include quality of sleep, analgesic and sedative dosages and level of consciousness.

CONCLUSION

The results suggest that massage interventions can have positive effects on critically ill patients' outcomes. However, there are several gaps in the literature, along with methodological limitations, that require further consideration in critical care settings.

RELEVANCE TO CLINICAL PRACTICE

The results of this systematic review can inform implementation of massage interventions in critical care, which can be challenging as a result of several barriers.

The Effect of Foot Massage on Pain Intensity and Anxiety in Patients Having Undergone a Tibial Shaft Fracture Surgery: A Randomized Clinical Trial

OBJECTIVE

To determine the effect of massage therapy on pain intensity and anxiety in patients who have undergone tibial shaft fracture surgery.

DESIGN

This study was a randomized clinical trial with a pre-post design. As the study included 2 treatment groups, it was a parallel study.

SETTING

Khatam-Al-Anbia Hospital in Zahedan, Iran, between July and August 2017.

PATIENTS

In all, 66 patients who underwent a tibial shaft fracture surgery were enrolled and randomly assigned to intervention and control groups (33 patients each).

INTERVENTION

The intervention included a 10-minute foot massage (5 minutes per leg) using sweet almond oil, the most common lubricant used in massage therapy.

MAIN OUTCOME MEASUREMENTS

Data were collected using pain numeric rating scale and Spielberger State-Trait Anxiety Inventory before and after intervention.

RESULTS

After intervention, the mean scores for pain intensity, and anxiety in the intervention and control groups were 4.72 (0.97) and 5.72 (0.91), and 42.84 (6.50) and 58.36 (10.37), respectively. A significant difference was noted between the intervention and control groups concerning pain intensity and anxiety.

CONCLUSIONS

The results indicated that massage therapy reduced pain intensity and anxiety in patients who underwent tibial shaft fracture surgery. Therefore, using massage as a noninvasive and acceptable intervention is suggested in orthopaedic surgery, especially after tibial shaft fracture surgeries.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

HF app to support self-care among community dwelling adults with HF: A feasibility study

BACKGROUND

The prevalence of Heart Failure (HF) is expected to increase by 46% from 2012 to 2030, which will result in over 8 million adults with HF. The development and testing of interventions that can support HF self-care behaviors is critical.

AIM

Determine the: 1) feasibility of using the HF App in middle to older adult community dwelling patients with HF; and 2) acceptability of using the HF App mobile health application.

METHODS

A convenience sample of community dwelling HF participants daily used the HF App to enter physiologic data, answer questions about symptoms, reviewed HF education within the application and received reminders over a two-week period. Feasibility and acceptability measures were assessed using data extracted from the principal investigator's qualitative diary. In addition, two acceptability questionnaires were utilized.

RESULTS

All participants enrolled (N = 10) completed the two-week period. Participant mean age was 64.5 years. The mean scores on the acceptability of the HF App 19 (SD 2.87) indicated increased perceived benefit of using the app while the mean scores of acceptability of the education offered in the app 12.4 (SD 2.84) indicated that participants positively benefited from viewing the education. Qualitative results indicated that participants were more aware of their symptoms and the need to self-monitor.

CONCLUSIONS

This feasibility study points to the incorporation of mobile applications to support self-care as promising research that can be useful to aid middle to older individuals in performing effective HF self-care but further studies with a larger randomized sample is needed.

Effect of physiotherapy on quality of life after coronary artery bypass graft surgery: A randomized study

Background:

This study aims to assess the impact that physiotherapy (PT) has on the quality of life (QoL) of patients who have undergone coronary artery bypass grafting (CABG) surgery. The objective of this study was to assess the effect of PT on physical and mental aspects of patients’ QoL.

Materials and Methods:

The study population consisted of 50 patients who aged between 60 and 70 years and who had previously undergone CABG surgery. The patients were randomly allocated to two groups: a PT group (n = 25) and a control group (n = 25). The physical characteristics of the participants were recorded at the outset of the study. The patients who were allocated to the PT group completed 16 sessions of classic PT. QoL assessments of all participants were performed before and after the program in the form of a short form-36 health survey. An independent sample t-test and an ANCOVA were performed for the purpose of statistical analyses.

Results:

The QoL scores of the patients (mean age = 62.08 years) who underwent PT significantly improved after the intervention (P < 0.001). A significant difference between groups was observed (P < 0.001) in both the mental component summary and physical component summary variables.

Conclusion:

PT can help relieve pain, reduce depression, help patients more effectively perform the tasks of everyday living, and help ease the symptoms of other disabilities associated with cardiac surgery. In the current study, the implementation of a PT program improved the patient's mental health and increased their QoL.

The Effects of Massage Therapy on Pain and Anxiety after Surgery: A Systematic Review and Meta-Analysis

Pain management is critical for patients after surgery, but current pain management methods are not always adequate. Massage therapy may be a therapeutic complementary therapy for pain. Many researchers have investigated the effects of massage therapy on post-operative pain, but there have been no systematic reviews and meta-analysis of its efficacy for post-operative patients. Our objective was to assess the effects of massage therapy on pain management among post-operative patients by conducting a systematic review and meta-analysis. The databases searched included MEDLINE, CINAHL, and the Cochrane Library's CENTRAL. To assess the effects of massage therapy on post-operative pain and anxiety, we performed a meta-analysis and calculated standardized mean difference with 95% CIs (Confidential Intervals) as a summary effect. Ten randomized controlled trials were selected (total sample size = 1,157). Meta-analysis was conducted using subgroup analysis. The effect of single dosage massage therapy on post-operative pain showed significant improvement (-0.49; 95% confidence intervals -0.64, -0.34; p < .00001) and low heterogeneity (p = .39, I² = 4%), sternal incisions showed significant improvement in pain (-0.68; -0.91, -0.46; p< .00001) and low heterogeneity (p = .76, I² = 0%). The anxiety subgroups showed substantial heterogeneity. The findings of this study revealed that massage therapy may alleviate post-operative pain, although there are limits on generalization of these findings due to low methodological quality in the reviewed studies.

Hand Massage for Cancer Patients Undergoing Chemotherapy as Outpatients: A Pilot Study

CONTEXT

There are no studies on the effect of volunteer-provided hand massage in a busy chemotherapy outpatient practice.

OBJECTIVE

To assess the feasibility of introducing hand massage therapy into an outpatient chemotherapy unit and to evaluate the effect of the therapy on various symptoms experienced by cancer patients.

DESIGN

A pilot, quasi-experimental, pretest-posttest study.

SETTING

Chemotherapy outpatient clinic of a large tertiary care academic medical center.

PATIENTS/PARTICIPANTS

Forty chemotherapy outpatients.

INTERVENTION

After being approached by a trained volunteer from a hand massage team, patients consented to receive a 20-minute hand massage before chemotherapy that was individualized according to patient preference and expressed needs.

MAIN OUTCOME MEASURES

The visual analog scale (VAS) was used to measure pain, fatigue, anxiety, muscular discomfort, nervousness, stress, happiness, energy, relaxation, calmness, and emotional well-being (on a scale from 0-10) before and after the intervention; a satisfaction survey was administered after the therapy. Patients' demographic data were summarized with descriptive statistics, and VAS total scores were compared between groups at each time point with the two-group t test. Feasibility was evaluated from the number of patients who were approached, received a hand massage, and completed the study surveys.

RESULTS

Of the 40 participants, 19 were men (mean age, 59.5 years). Significant improvement after hand massage was indicated by VAS scores for fatigue, anxiety, muscular discomfort, nervousness, stress, happiness, energy, relaxation, calmness, and emotional well-being (P < .05). Pain scores also improved, but the difference was not statistically significant (P = .06). All patients indicated that they would recommend hand massage to other patients, and 37 were interested in receiving it during their next chemotherapy treatment.

The Effect of Massage on Acute Postoperative Pain in Critically and Acutely Ill Adults Post-thoracic Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials

Critical care practice guidelines identify a lack of clear evidence on the effectiveness of massage for pain control. To assess the effect of massage on acute pain in critically and acutely ill adults post-thoracic surgery. Medline, Embase, CINAHL, PsychInfo, Web of Science, Scopus and Cochrane Library databases were searched. Eligible studies were randomized controlled trials (RCTs) evaluating the effect of massage compared to attention control/sham massage or standard care alone on acute pain intensity post-thoracic surgery. Twelve RCTs were included. Of these, nine evaluated massage in addition to standard analgesia, including 2 that compared massage to attention control/sham massage in the intensive care unit (ICU), 6 that compared massage to standard analgesia alone early post-ICU discharge, and 1 that compared massage to both attention control and standard care in the ICU. Patients receiving massage with analgesia reported less pain (0-10 scale) compared to attention control/sham massage (3 RCTs; N = 462; mean difference -0.80, 95% confidence interval [CI] -1.25 to -0.35; p < 0.001; I² = 13%) and standard care (7 RCTs; N = 1087; mean difference -0.85, 95% CI -1.28 to -0.42; p < 0.001; I² = 70%). Massage, in addition to pharmacological analgesia, reduces acute post-cardiac surgery pain intensity.

Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial

Although many intensive care unit patients experience significant pain, very few studies explored massage to maximize their pain relief. This study aimed to evaluate the preliminary effects of hand massage on pain after cardiac surgery in the adult intensive care unit. A pilot randomized controlled trial was used for this study. The study was conducted in a Canadian medical-surgical intensive care unit. Forty adults who were admitted to the intensive care unit after undergoing elective cardiac surgery in the previous 24 hours participated in the study. They were randomly assigned to the experimental (n = 21) or control (n = 19) group. The experimental group received a 15-minute hand massage, and the control group received a 15-minute hand-holding without massage. In both groups the intervention was followed by a 30-minute rest period. The interventions were offered on 2-3 occasions within 24 hours after surgery. Pain, muscle tension, and vital signs were assessed. Pain intensity and behavioral scores were decreased for the experimental group. Although hand massage decreased muscle tension, fluctuations in vital signs were not significant. This study supports potential benefits of hand massage for intensive care unit postoperative pain management. Although larger randomized controlled trials are necessary, this low-cost nonpharmacologic intervention can be safely administered.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol

Background

Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown.

Objective

The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery.

Methods

A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016.

Results

Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done.

Conclusions

This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population.

ClinicalTrial

ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS)

Characteristics of Qualitative Descriptive Studies: A Systematic Review

Qualitative description (QD) is a term that is widely used to describe qualitative studies of health care and nursing-related phenomena. However, limited discussions regarding QD are found in the existing literature. In this systematic review, we identified characteristics of methods and findings reported in research articles published in 2014 whose authors identified the work as QD. After searching and screening, data were extracted from the sample of 55 QD articles and examined to characterize research objectives, design justification, theoretical/philosophical frameworks, sampling and sample size, data collection and sources, data analysis, and presentation of findings. In this review, three primary findings were identified. First, although there were some inconsistencies, most articles included characteristics consistent with the limited available QD definitions and descriptions. Next, flexibility or variability of methods was common and effective for obtaining rich data and achieving understanding of a phenomenon. Finally, justification for how a QD approach was chosen and why it would be an appropriate fit for a particular study was limited in the sample and, therefore, in need of increased attention. Based on these findings, recommendations include encouragement to researchers to provide as many details as possible regarding the methods of their QD studies so that readers can determine whether the methods used were reasonable and effective in producing useful findings. © 2016 Wiley Periodicals, Inc.

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.