000091 10.3205/000091 urn:nbn:de:0183-0000916 Review Article Übersichtsarbeit S3-Leitlinie zu Analgesie, Sedierung und Delirmanagement in der Intensivmedizin – Kurzversion Martin Martin Jörg J Prof.

Department of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Eichertstr. 3, 73035 Göppingen, GermanyDepartment of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Göppingen, Germany

Anästhesiologie und operative Intensivmedizin, Klinik am Eichert, Eichertstr. 3, 73035 Göppingen, DeutschlandAnästhesiologie und operative Intensivmedizin, Klinik am Eichert, Göppingen, Deutschland

Joerg.Martin@email.de author Heymann Heymann Anja A Dr.

Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, GermanyDepartment of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany

Klinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, DeutschlandKlinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Virchow, Berlin, Deutschland

Anja.Heymann@charite.de author Bäsell Bäsell Katrin K Dr.

DRK Kliniken Berlin Köpenick, Salvador Allende 2-8, 12559 Berlin, GermanyDRK Kliniken Berlin Köpenick, Berlin, Germany

DRK Kliniken Berlin Köpenick, Salvador Allende Strasse 2-8, 12559 Berlin, DeutschlandDRK Kliniken Berlin Köpenick, Berlin, Deutschland

drkatrinbaesell@hotmail.com author Baron Baron Ralf R Prof.

Department of Neurology, Christian-Albrechts University, Kiel, Schittenhelmstr. 10, 24105 Kiel, GermanyDepartment of Neurology, Christian-Albrechts University, Kiel, Germany

Klinik für Neurologie, Christian-Albrechts Universität zu Kiel, Schittenhelmstr. 10, 24105 Kiel, DeutschlandKlinik für Neurologie, Christian-Albrechts Universität zu Kiel, Deutschland

r.baron@neurologie.uni-kiel.de author Biniek Biniek Rolf R Prof.

LVR-Klinik Bonn, Department of Neurology, Kaiser-Karl-Ring 20, 53111 Bonn, GermanyDepartment of Neurology, LVR-Klinik Bonn, Germany

LVR-Klinik Bonn, Abteilung Neurologie, Kaiser-Karl-Ring 20, 53111 Bonn, DeutschlandAbteilung Neurologie, LVR-Klinik Bonn, Deutschland

Rolf.biniek@lvr.de author Bürkle Bürkle Hartmut H Prof.

Clinic for Anaesthesiology and Operative Intensive Care and Pain Clinic of Memmingen, Bismarckstr. 3, 87700 Memmingen, GermanyClinic for Anaesthesiology and Operative Intensive Care and Pain Clinic of Memmingen, Germany

Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie des Klinikums Memmingen, Bismarckstr. 3, 87700 Memmingen, DeutschlandKlinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie des Klinikums Memmingen, Deutschland

anaesthesie@klinikum-memmingen.de author Dall Dall Peter P Prof.

Municipal Hospital of Lüneburg, Bögelstraße 1, 21339 Lüneburg, GermanyMunicipal Hospital of Lüneburg, Germany

Städtisches Klinikum Lüneburg, Bögelstraße 1, 21339 Lüneburg, DeutschlandStädtisches Klinikum Lüneburg, Deutschland

Peter.Dall@klinikum-lueneburg.de author Dictus Dictus Christine C Dr.

Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, GermanyDepartment of Neurosurgery, University of Heidelberg, Germany

Klinik für Neurochirurgie, Universität Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, DeutschlandKlinik für Neurochirurgie, Universität Heidelberg, Deutschland

Christine.dictus@med.uni-heidelberg.de author Eggers Eggers Verena V Dr.

Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Augustenburger Platz 1, 13353 Berlin, GermanyDepartment of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany

Klinik für Anästhesiologie und op. Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Augustenburger Platz 1, 13353 Berlin, DeutschlandKlinik für Anästhesiologie und op. Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland

eggers@web.de author Eichler Eichler Ingolf I Dr.

Department of Cardiac and Vascular Surgery, Klinikum Dortmund GgmbH, Beurhausstr. 40, 44137 Dortmund, GermanyDepartment of Cardiac and Vascular Surgery, Klinikum Dortmund GgmbH, Germany

Klinik für Herz- und Gefäßchirurgie, Klinikum Dortmund GgmbH, Beurhausstr. 40, 44137 Dortmund, DeutschlandKlinik für Herz- und Gefäßchirurgie, Klinikum Dortmund GgmbH, Deutschland

Ingolf.Eichler@klinikumdo.de author Engelmann Engelmann Lothar L Prof.

Department of Internal Medicine and Intensive Care Medicine, University of Leipzig, Liebigstr. 20, 04103 Leipzig, GermanyDepartment of Internal Medicine and Intensive Care Medicine, University of Leipzig, Germany

Department für Innere Medizin, Fachbereich Intensivmedizin, Universität Leipzig, Liebigstr. 20, 04103 Leipzig, DeutschlandDepartment für Innere Medizin, Fachbereich Intensivmedizin, Universität Leipzig, Deutschland

lothar.engelmann@medizin.uni-leipzig.de author Garten Garten Lars L Dr.

Department of Neonatology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, GermanyDepartment of Neonatology, Charité University Medicine Berlin, Germany

Klinik für Neonatologie, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, DeutschlandKlinik für Neonatologie, Charité Universitätsmedizin Berlin, Deutschland

lars.garten@charite.de author Hartl Hartl Wolfgang W Prof.

Department of Surgery Grosshadern, University of Munich, 81377 Munich, GermanyDepartment of Surgery Grosshadern, University of Munich, Germany

Chirurgische Klinik und Poliklinik Großhadern, Universität München, 81377 München, DeutschlandChirurgische Klinik und Poliklinik Großhadern, Universität München, Deutschland

whartl@med.uni-muenchen.de author Haase Haase Ulrike U Dr.

Department of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, Schumannstr.20-21, 10117 Berlin, GermanyDepartment of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, Berlin, Germany

Klinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Mitte, Schumannstr.20-21, 10117 Berlin, DeutschlandKlinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Mitte, Berlin, Deutschland

ulrike.haase@charite.de author Huth Huth Ralf R Dr.

University Children's Hospital of Mainz, Langenbeckstraße 1, 55101 Mainz, GermanyUniversity Children's Hospital of Mainz, Germany

Universitätskinderklinik Mainz, Langenbeckstraße 1, 55101 Mainz, DeutschlandUniversitätskinderklinik Mainz, Deutschland

Huth@kinder.klinik.uni-mainz.de author Kessler Kessler Paul P Prof.

Department of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Marienburgstr. 2, 60528 Frankfurt, GermanyDepartment of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Frankfurt, Germany

Anästhesiologie und Intensivmedizin, Orthopädische Universitäts-Klinik, Marienburgstr. 2, 60528 Frankfurt, DeutschlandAnästhesiologie und Intensivmedizin, Orthopädische Universitäts-Klinik, Frankfurt, Deutschland

p.kessler@friedrichsheim.de author Kleinschmidt Kleinschmidt Stefan S Prof.

Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, GermanyDepartment of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany

Abteilung Anästhesie, Intensivmedizin, Schmerztherapie, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 7071 Ludwigshafen, DeutschlandAbteilung Anästhesie, Intensivmedizin, Schmerztherapie, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Deutschland

skleinschmidt@bgu-ludwigshafen.de author Koppert Koppert Wolfgang W Prof.

Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover, GermanyDepartment of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Germany

Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str.1, 30625 Hannover, DeutschlandKlinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Deutschland

Koppert.Wolfgang@mh-hannover.de author Kretz Kretz Franz-Josef FJ Prof.

Olgahospital, Department of Anesthesiology and Operative Intensive Care, Bismarckstraße 8, 70176 Stuttgart, GermanyOlgahospital, Department of Anesthesiology and Operative Intensive Care, Stuttgart, Germany

Olgahospital, Klinik für Anästhesie und operative Intensivmedizin, Bismarckstraße 8, 70176 Stuttgart, DeutschlandOlgahospital, Klinik für Anästhesie und operative Intensivmedizin, Stuttgart, Deutschland

kretz.anaesthesie@olgahospital.de author Laubenthal Laubenthal Heinz H Prof.

Heckertstr. 50, 44807 Bochum, GermanyBochum, Germany

Heckertstr. 50, 44807 Bochum, DeutschlandBochum, Deutschland

heinz.laubenthal@rub.de author Marggraf Marggraf Guenter G Dr.

West German Heart Center Essen, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Hufelandstr. 55, 5122 Essen, GermanyWest German Heart Center Essen, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Germany

Westdeutsches Herzzentrum Essen, Klinik für Thorax- und Kardiovaskuläre Chirurgie, Universitätsklinikum Essen, Hufelandstr. 55, 45122 Essen, DeutschlandWestdeutsches Herzzentrum Essen, Klinik für Thorax- und Kardiovaskuläre Chirurgie, Universitätsklinikum Essen, Deutschland

Guenter.marggraf@uni-essen.de author Meiser Meiser Andreas A Dr.

Department of Anesthesiology, Intensive Care and Pain, Saarland University Hospital, 66421 Homburg, GermanyDepartment of Anesthesiology, Intensive Care and Pain, Saarland University Hospital, Homburg, Germany

Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, 66421 Homburg, DeutschlandKlinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg, Deutschland

andreas.meiser@uks.eu author Neugebauer Neugebauer Edmund E Prof.

IFOM - Institute for Research in Operative Medicine, Institute for Surgical Research, Private University of Witten/Herdecke GmbH, Ostmerheimer Street 200, house 38, 51109 Cologne, GermanyIFOM - Institute for Research in Operative Medicine, Institute for Surgical Research, Private University of Witten/ Herdecke GmbH, Köln, Germany

IFOM - Institut für Forschung in der Operativen Medizin, Lehrstuhl für Chirurgische Forschung, Private Universität Witten/Herdecke GmbH, Ostmerheimer Straße 200, Haus 38, 51109 Köln, DeutschlandIFOM - Institut für Forschung in der Operativen Medizin, Lehrstuhl für Chirurgische Forschung, Private Universität Witten/Herdecke GmbH, Köln, Deutschland

ifom-neugebauer-sek@uni-wh.de author Neuhaus Neuhaus Ulrike U

Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, GermanyDepartment of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany

Klinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Virchow, Augustenburger Platz 1, 13353 Berlin, DeutschlandKlinik für Anästhesiologie und op. Intensivmedizin, Charité Campus Virchow, Berlin, Deutschland

ulrike.neuhaus@charite.de author Putensen Putensen Christian C Prof.

Anesthesiology and Operative Intensive Care, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, GermanyAnesthesiology and Operative Intensive Care, University of Bonn, Germany

Anästhesiologie und operative Intensivmedizin, Universität Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, DeutschlandAnästhesiologie und operative Intensivmedizin, Universität Bonn, Deutschland

putensen@uni-bonn.de author Quintel Quintel Michael M Prof.

Surgical Intensive Care, University of Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, GermanySurgical Intensive Care, University of Göttingen, Germany

Operative Intensivmedizin, Universität Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, DeutschlandOperative Intensivmedizin, Universität Göttingen, Deutschland

mquintel@zari.de author Reske Reske Alexander A Dr.

Universitätsklinikum Carl Gustav Carus Dresden, Department of Anesthesiology and Intensive Care, Fetscherstraße 74, 01307 Dresden, GermanyDepartment of Anesthesiology and Intensive Care, Universitätsklinikum Carl Gustav Carus, Dresden, Germany

Universitätsklinikum Dresden Carl Gustav Carus, Klinik für Anästhesiologie und Intensivmedizin, Fetscherstraße 74, 01307 Dresden, DeutschlandKlinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland

Alexander.Reske@uniklinikum-dresden.de author Roth Roth Bernard B Prof.

Department of General Pediatrics, Josef-Stelzmann-Str. 9, 50924 Cologne, GermanyDepartment of General Pediatrics, Cologne, Germany

Klinik und Poliklinik für Allgemeine Kinderheilkunde, Josef-Stelzmann-Str. 9, 50924 Köln, DeutschlandKlinik und Poliklinik für Allgemeine Kinderheilkunde, Köln, Deutschland

Bernhard.Roth@uk-koeln.de author Scholz Scholz Jens J Prof.

Department of Anesthesiology and Surgical Intensive Care, University Hospital of Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, GermanyDepartment of Anesthesiology and Surgical Intensive Care, University Hospital of Schleswig-Holstein, Kiel, Germany

Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, DeutschlandKlinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland

scholz@anaesthesie.uni-kiel.de author Schröder Schröder Stefan S PD

Department of Psychiatry and Psychotherapy, CMM Hospital Guestrow, Friedrich Trendelenburg-Allee 1, 18273 Guestrow, GermanyDepartment of Psychiatry and Psychotherapy, CMM Hospital Guestrow, Germany

AG Gerontopsychiatrie der EMAU Greifswald, Klinik für Psychiatrie und Psychotherapie (mit Geriatrie), KMG Klinikum Güstrow, Friedrich-Trendelenburg-Allee 1, 18273 Güstrow, DeutschlandAG Gerontopsychiatrie der EMAU Greifswald, Klinik für Psychiatrie und Psychotherapie (mit Geriatrie), KMG Klinikum Güstrow, Deutschland

s.schroeder@kmg.ag author Schreiter Schreiter Dierk D Dr.

Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Fetscherstraße 74, 01307 Dresden, GermanyDepartment of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany

Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307 Dresden, DeutschlandKlinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland

dierk.schreiter@uniklinikum-dresden.de author Schüttler Schüttler Jürgen J Prof.

Anaesthesiology Clinic University Hospital of Erlangen, Krankenhausstr. 12, 91054 Erlangen, GermanyAnaesthesiology Clinic University Hospital of Erlangen, Germany

Anästhesiologische Klinik Universitätsklinikum Erlangen, Krankenhausstr. 12, 91054 Erlangen, DeutschlandAnästhesiologische Klinik Universitätsklinikum Erlangen, Deutschland

Juergen.Schuettler@kfa.imed.uni-erlangen.de author Schwarzmann Schwarzmann Gerhard G

Anaesthesiology, Surgical Intensive Care Unit, Theodor Stern Kai 7, 60590 Frankfurt, GermanyAnaesthesiology, Surgical Intensive Care Unit, Frankfurt, Germany

Anästhesiologisch-Operative Intensivstation, Theodor-Stern Kai 7, 60590 Frankfurt, DeutschlandAnästhesiologisch-Operative Intensivstation, Frankfurt, Deutschland

Gerhard.Schwarzmann@t-online.de author Stingele Stingele Robert R PD

Department of Neurology, University Hospital of Schleswig-Holstein, Schittenhelmstr. 10, 24105 Kiel, GermanyDepartment of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany

Neurologie Kiel, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 10, 24105 Kiel, DeutschlandNeurologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland

r.stingele@neurologie.uni-kiel.de author Tonner Tonner Peter P Prof.

Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Senator-Wessling-Str. 1, 28277 Bremen, GermanyDepartment of Anesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany

Klinik für Anästhesie, op. und allg. Intensivmedizin, Notfallmedizin, Klinikum Links der Weser GmbH, Senator-Weßling-Str. 1, 28277 Bremen, DeutschlandKlinik für Anästhesie, op. und allg. Intensivmedizin, Notfallmedizin, Klinikum Links der Weser GmbH, Bremen, Deutschland

Peter.Tonner@Klinikum-Bremen-Ldw.de author Tränkle Tränkle Philip P

Department of Internal Medicine, Division III, ICU 3IS, Otfried-MüllerStr.10, 72076 Tübingen, GermanyDepartment of Internal Medicine, Division III, ICU 3IS, Tübingen, Germany

Medizinische Klinik, Abteilung III, Intensivstation 3IS, Otfried-MüllerStr.10, 72076 Tübingen, DeutschlandMedizinische Klinik, Abteilung III, Intensivstation 3IS, Tübingen, Deutschland

philipp.traenkle@med.uni-tuebingen.de author Treede Treede Rolf Detlef RD Prof.

Department of Neurophysiology, Center for Biomedicine and Medical Technology Mannheim (CBTM), Ludolf-Krehl-Str.13-17, 68167 Mannheim, GermanyDepartment of Neurophysiology, Center for Biomedicine and Medical Technology Mannheim (CBTM), Germany

Abteilung für Neurophysiologie, Center für Biomedizin und medizinische Technologie Mannheim (CBTM), Ludolf-Krehl-Str.13-17, 68167 Mannheim, DeutschlandAbteilung für Neurophysiologie, Center für Biomedizin und medizinische Technologie Mannheim (CBTM), Deutschland

Rolf-Detlef.Treede@medma.uni-heidelberg.de author Trupkovic Trupkovic Tomislav T Dr.

Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, GermanyDepartment of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany

Abteilung Anästhesie, Intensivmedizin, Schmerztherapie, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, DeutschlandAbteilung Anästhesie, Intensivmedizin, Schmerztherapie, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Deutschland

ttrupkovic@bgu-ludwigshafen.de author Tryba Tryba Michael M Prof.

Anesthesiology and Operative Intensive Care, Klinikum Kassel, Mönchebergstr. 41-43, 34125 Kassel, GermanyAnesthesiology and Operative Intensive Care, Klinikum Kassel, Germany

Anästhesiologie und operative Intensivmedizin, Klinikum Kassel, Mönchebergstr. 41-43, 34125 Kassel, DeutschlandAnästhesiologie und operative Intensivmedizin, Klinikum Kassel, Deutschland

michael.tryba@klinikum-kassel.de author Wappler Wappler Frank F Prof.

Department of Anesthesiology and Operative Intensive Care, Hospital Cologne-Merheim, University of Witten/Herdecke, Ostmerheimer Str. 200, Cologne 51189, GermanyDepartment of Anesthesiology and Operative Intensive Care, Hospital Cologne-Merheim, University of Witten/ Herdecke, Cologne, Germany

Klinik für Anästhesiologie und operative Intensivmedizin, Krankenhaus Köln-Merheim, Universität Witten/Herdecke, Ostmerheimer Str 200, 51189 Köln, DeutschlandKlinik für Anästhesiologie und operative Intensivmedizin, Krankenhaus Köln-Merheim, Universität Witten/Herdecke, Köln, Deutschland

wapplerf@kliniken-koeln.de author Waydhas Waydhas Christian C Prof.

Department of Trauma Surgery, University Hospital Essen, Hufelandstr. 55, 45147 Essen, GermanyDepartment of Trauma Surgery, University Hospital Essen, Germany

Klinik für Unfallchirurgie, Universitätsklinikum Essen, Hufelandstr. 55, 45147 Essen, DeutschlandKlinik für Unfallchirurgie, Universitätsklinikum Essen, Deutschland

christian.waydhas@uni-due.de author Spies Spies Claudia C Prof. Dr.

Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité – University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany, Phone: +49 30 450 5510 02; Fax: +49 30 450 5519 09Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany

Klinik für Anästhesiologie und op. Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Deutschland, Tel.: +49 30 450 5510 02; Fax: +49 30 450 5519 09Klinik für Anästhesiologie und op. Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Berlin, Deutschland

claudia.spies@charite.de author German Medical Science GMS Publishing House

Düsseldorf

610 guideline evidence analgesia sedation delirium monitoring treatment intensive care Leitlinie Analgesie Sedierung Delir Monitoring Therapie Intensivmedizin 20091204 20100210 engl germ 1612-3174 8 GMS German Medical Science GMS Ger Med Sci 02 Ein gezieltes Monitoring von Analgesie, Sedierung und Delir sowie das adäquate therapeutische Management bei kritisch kranken Patienten auf Intensivstationen ist eine Basismaßnahme jeder intensivmedizinischen Behandlung. Aus den unumstrittenen Vorteilen einer leitlinienorientierten Therapie ergab sich die Notwendigkeit der Entwicklung von eigenen Leitlinien zur Analgesie und Sedierung in der Intensivmedizin für Deutschland, die als S2 Leitlinie 2005 veröffentlicht wurde. Durch die Verbreitung dieser Leitlinie wurde 2006 eine Verbesserung des Monitorings von 8 auf 51% und eine Steigerung von protokollbasiertem Vorgehen von 21 auf 46% festgestellt werden.Von 2006–2009 wurde die bestehende S2 Leitlinie von der DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) und der DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) unter Bündelung aller verfügbaren Kräfte zur Sicherung und Verbesserung der Qualität der Analgesie und Sedierung sowie zur Delirbehandlung auf der Intensivstation auf eine S3-LL erweitert. In Zusammenarbeit mit weiteren 10 Fachgesellschaften wurde die Literatur nach Kriterien des Oxford Centre of Evidence Based Medicine bewertet. Unter Berücksichtigung von 671 Literaturstellen wurden Volltext, Schemata und Empfehlungen erstellt. In den Empfehlungen wurden die Grade „A“ (sehr starke Empfehlung), „B“ (starke Empfehlung) und „0“ (offene Empfehlung) gewählt.Als Ergebnis dieses Prozesses liegt nun eine interdisziplinär erarbeitete evidenz- und konsensbasierte Stufe 3 Leitlinie vor, die alle kritisch kranken Patientengruppen berücksichtigt.Der Nutzen von Protokollen in der Analgosedierung und bei der Delirbehandlung wurde vielfach gezeigt. Diese Leitlinie bietet eine Handlungsempfehlung für das intensivmedizinische Team. Für die Umsetzung ist die Implementierung von Scores und Protokollen in den klinischen Alltag in der Intensivmedizin erforderlich. 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 2nd 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 3rd 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 3rd 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. IntroductionAnalgesia, sedation and delirium management are relevant to ICU course and outcome , , . In these new guidelines, the current recommendations concerning these topics are integrated. They also address the specific features of many different groups of patients: children or the elderly, pregnant and lactating patients or patients with serious injuries. The fact that so many special requirements could be taken into account is thanks to intensive cooperation between medical and nursing experts from 12 different professional societies. EinleitungAnalgesie, Sedierung und Delir-Management sind relevant für den intensivmedizinischen Verlauf und das Überleben der Patienten , , . In der neuen Leitlinie sind die aktuellen Empfehlungen dazu integriert. Ferner wurde auf die Besonderheiten vieler verschiedener Patientengruppen eingegangen: Die Versorgung von Kindern oder alten Menschen, schwangeren und stillenden Patientinnen oder Patienten mit schweren Verletzungen. Die Tatsache, dass so viele spezielle Anforderungen berücksichtigt werden konnten, ist der intensiven Zusammenarbeit von einem ärztlichen und pflegerischen Expertenteam aus 12 verschiedenen Fachgesellschaften zu verdanken. MethodsCreation process The methodological approach was in accordance with the DELBI (German Instrument for the Methodological Assessment of Guidelines) criteria (http://www.versorgungsleitlinien.de/methodik/delbi/pdf/delbi05.pdf). The complete guidelines development process was supported and monitored by the Association of Scientific Medical Societies (AWMF) of Germany. Initially, the objectives of the guidelines as well as management for the various key topics and patient groups were defined and formed by groups of experts from 12 disciplines. The following areas have been identified as priority areas: Need for guidelines Monitoring of analgesia, sedation and delirium in adults Treatment and weaning – analgesia, sedation and delirium in adults Regional anesthesia Neuromuscular blockade – monitoring, treatment Economy, quality assurance and implementation Special populations: a. Burn patients b. Multiply injured patients c. Neurotrauma patients d. Pregnant and lactating patientse. Patients ≥ 65 years f. Moribund/dying patients Monitoring and treatment of analgesia, sedation and delirium in neonates and troddlers .Selection and evaluation of literature A systematic literature search was conducted using pre-defined search terms for the priority areas and pre-selecte</PlainText></TextGroup>d databases. </Pgraph><Pgraph>For the Cochrane database and PubMed&#47;MEDLINE, using the above-mentioned subjects, in the research period from 1995 to 2007, a total of 2418 papers were identified. After reviewing the literature and taking into account the exclusion criteria (language other than English&#47;German, animal experiments, purely pharmacological model, only abstract, editorial or commentary) 671 publications were included. </Pgraph><Pgraph>The existing publications were classified in terms of their evidence level. We used the sign-50 criteria of the Oxford Center of Evidence Based Medicine (<Hyperlink href="http:&#47;&#47;www.cebm.net&#47;index.aspx&#63;o&#61;1025">http:&#47;&#47;www.cebm.net&#47;index.aspx&#63;o&#61;1025</Hyperlink>). Clinical studies were classified according to their scientific validity and value into different levels of evidence level (1&#8211;5), and an additional assessment of their clinical relevance (a&#8211;c) was also performed. Highest priority was given to meta-analyses of randomized, controlled clinical trials. The recommendations and the text were developed from a first draft.</Pgraph><Pgraph>The recommendations were reached via consensus procedures that were moderated by the AWMF. In reaching consensus particular emphasis was placed on the level of evidence, ethical aspects, patient preferences, clinical relevance, risk&#47;benefit ratios and degree of applicability. </Pgraph><Pgraph>In the recommendations, grade &#8220;A&#8221; is a very strong recommendation that is represented using the phrase &#8220;should be&#8221;, Grade &#8220;B&#8221; is a strong recommendation (&#8220;should be&#8221;), and level &#8220;0&#8221; is an open recommendation (&#8220;can be&#8221;). The recommendation levels are derived from the requirements of the Council of Europe 2001 <TextLink reference="4"></TextLink>. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Methodik"> <MainHeadline>Methodik</MainHeadline><SubHeadline>Erstellungsprozess</SubHeadline><Pgraph>Das methodische Vorgehen hat sich an den DELBI (Deutsches Instrument zur Methodischen Leitlinienbewertung) Kriterien orientiert (<Hyperlink href="http:&#47;&#47;www.versorgungsleitlinien.de&#47;methodik&#47;delbi&#47;pdf&#47;delbi05.pdf">http:&#47;&#47;www.versorgungsleitlinien.de&#47;methodik&#47;delbi&#47;pdf&#47;delbi05.pdf</Hyperlink>). Der gesamte Leitlinienentwicklungsprozess wurde durch die Arbeitsgemeinschaft Wissenschaftlich Medizinischer Fachgesellschaften (AWMF) unterst&#252;tzt und begleitet.</Pgraph><Pgraph>Zun&#228;chst wurden die Ziele der Leitlinie definiert und Expertengruppen aus 12 Fachgebieten sowie der Pflege f&#252;r die einzelnen Themenschwerpunkte und Patientengruppen gebildet. Folgende Bereiche wurden als Schwerpunkt eingestuft:</Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">Notwendigkeit der Leitlinien</ListItem><ListItem level="1" levelPosition="2" numString="2.">Monitoring von Analgesie, Sedierung und Delir bei Erwachsenen</ListItem><ListItem level="1" levelPosition="3" numString="3.">Therapie und Weaning &#8211; Analgesie, Sedierung und Delir bei Erwachsenen</ListItem><ListItem level="1" levelPosition="4" numString="4.">Regionalan&#228;sthesie</ListItem><ListItem level="1" levelPosition="5" numString="5.">Neuromuskul&#228;re Blockade &#8211; Monitoring, Behandlung</ListItem><ListItem level="1" levelPosition="6" numString="6.">&#214;konomie, Qualit&#228;tssicherung und Implementierung</ListItem><ListItem level="1" levelPosition="7" numString="7.">Spezielle Patientengruppen: <LineBreak></LineBreak>a. Verbrennungspatienten<LineBreak></LineBreak>b. Polytraumatisierte Patienten<LineBreak></LineBreak>c. Sch&#228;del-Hirn-traumatisierte Patienten<LineBreak></LineBreak>d. Schwangere und stillende Patientinnen<LineBreak></LineBreak>e. &#228;ltere Patienten &#8805; 65 Jahre<LineBreak></LineBreak>f. moribunde&#47;sterbende Patienten</ListItem><ListItem level="1" levelPosition="8" numString="8.">Monitoring und Therapie der Analgesie, Sedierung und des Delirs bei Neugeborenen sowie im Kindesalter.</ListItem></OrderedList></Pgraph><SubHeadline>Auswahl und Bewertung der Literatur</SubHeadline><Pgraph>Nach Definition der Suchbegriffe zu den Themenschwerpunkten und Festlegung der relevanten Datenbanken wurde eine systematische Literaturrecherche durchgef&#252;hrt. </Pgraph><Pgraph>In den Datenbanken Cochrane und PubMed&#47;MEDLINE wurden f&#252;r die oben genannten Themen in dem Recherchezeitraum 1995 bis 2007 insgesamt 2418 Arbeiten identifiziert. Nach Sichtung der Literatur unter Ber&#252;cksichtigung der Ausschlusskriterien (Sprache nicht englisch&#47;deutsch; tierexperimentell; rein pharmakologisches Modell; nur Abstract, Editorial oder Kommentar) konnten 671 Publikationen ber&#252;cksichtigt werden.</Pgraph><Pgraph>Die vorhandenen Publikationen wurden hinsichtlich ihres Evidenzlevel nach den Sign-50 Kriterien des Oxford Centre of Evidence Based Medicine klassifiziert (<Hyperlink href="http:&#47;&#47;www.cebm.net&#47;index.aspx&#63;o&#61;1025">http:&#47;&#47;www.cebm.net&#47;index.aspx&#63;o&#61;1025</Hyperlink>). Klinische Studien wurden entsprechend ihrer wissenschaftlichen Validit&#228;t und Wertigkeit in verschiedene Evidenzlevel (1&#8211;5) eingeteilt, zus&#228;tzlich erfolgte eine Beurteilung der klinischen Relevanz&#47;des Evidenzniveaus (a&#8211;c). Dabei nahmen Metaanalysen aus randomisierten, kontrollierten, klin<TextGroup><PlainText>ische</PlainText></TextGroup>n Studien den h&#246;chsten Stellenwert ein. Aus dem Rohentwurf der Leitlinienempfehlungen wurden die Empfehlungen und der Volltext formuliert.</Pgraph><Pgraph>Im Konsensusverfahren wurden unter Moderation der AWMF anhand des Evidenzlevels und unter Ber&#252;cksichtigung ethischer Aspekte, Patientenpr&#228;ferenzen, der klin<TextGroup><PlainText>ische</PlainText></TextGroup>n Relevanz, Abw&#228;gung des Nutzen&#47;Risiko Verh&#228;ltnisses und der Anwendbarkeit Empfehlungsgrade f&#252;r die Empfehlungen erarbeitet. </Pgraph><Pgraph>In den Empfehlungen wurde der Grad &#8222;A&#8220; als sehr starke Empfehlung mit der Formulierung &#8222;soll&#8220; dargestellt; Grad &#8222;B&#8220; wurde als eine starke Empfehlung (&#8222;sollte&#8220;), und Grad &#8222;0&#8220; als eine offene Empfehlung (&#8222;kann&#8220;) formuliert. Der Empfehlungsgrad leitete sich aus einer methodischen Vorgabe des Europarates 2001 ab <TextLink reference="4"></TextLink>.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Monitoring"> <MainHeadline>Monitoring</MainHeadline><Pgraph>The systematic monitoring of pain, sedation and delirium, targeted protocols for the management of sedation, analgesia and delirium are associated with a lower incidence of nosocomial infections, a reduction in the duration of ventilation and length of ICU stay (LOS), lower mortality and lower resource consumption <TextLink reference="5"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>. The monitoring should be performed regularly (8-hourly) and be documented. A goal for sedation and analgesia should be set for each individual patient and delirium should be treated immediately. The level achieved should be monitored regularly, documented and the treatment should be adapted appropriately. </Pgraph><SubHeadline>Monitoring of analgesia </SubHeadline><Pgraph>Approximately 75&#37; of ICU patients report severe pain during their treatment however over 80&#37; of their care givers consider the analgesia provided by them to be adequate <TextLink reference="10"></TextLink>. The best existing standard for assessment of pain is individual assessment by the patients themselves (Numeric Rating Scale NRS, Visual Analogue Scale VAS, Verbal Rating Scale VRS). For patients who are unable or unreliably able to communicate, subjective criteria such as movement, facial expression, physiological parameters such as blood pressure, heart rate, respiratory rate, lacrimation, sweating and changes in all these parameters after analgesic therapy as well as specific assessment tools (e.g. Behavioral Pain Scale BPS) should be considered. Adequate monitoring of analgesia is relevant to the outcome of critically ill patients <TextLink reference="2"></TextLink>. </Pgraph><SubHeadline>Monitoring of sedation </SubHeadline><Pgraph>Over-sedation is associated with prolonged ventilation times, higher incidence of pneumonia, hypotension, gastroparesis, delirium, longer stays, higher costs and a higher mortality <TextLink reference="1"></TextLink>. After their stay in the ICU, these patients often have difficulty sleeping and more post-traumatic stress disorders <TextLink reference="11"></TextLink>. A validated sedation scale like the Richmond Agitation and Sedation Scale (RASS) should routinely be used. </Pgraph><SubHeadline>Monitoring of delirium </SubHeadline><Pgraph>Thirty to eighty percent of ICU patients suffer delirium. Delirium is associated with 6 month mortality three times greater than background <TextLink reference="12"></TextLink>, higher costs <TextLink reference="13"></TextLink>, and a significant permanent cognitive deterioration <TextLink reference="14"></TextLink>. A validated scale should be also be used for delirium monitoring. The Confusion Assessment Method for the ICU (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) are the most widely used scales <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Monitoring"> <MainHeadline>Monitoring</MainHeadline><Pgraph>Die systematische Evaluation von Schmerz, Sedierungsgrad und Delir selbst sowie zielgerichtete Protokolle zur Anpassung des Sedierungsgrades und zur Behandlung von Schmerz und Delir sind mit einer geringeren Inzidenz nosokomialer Infektionen, einer Verk&#252;rzung der Beatmungs- und Intensivbehandlungsdauer, einer geringeren Letalit&#228;t sowie einem geringeren Ressourcenverbrauch assoziiert <TextLink reference="5"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>. Das Monitoring sollte regelm&#228;&#223;ig (z.B. 8-st&#252;ndlich) erfolgen und dokumentiert werden. Dabei ist immer ein Sedierungs- und Analgesieziel f&#252;r jeden Patienten individuell festzulegen sowie ein auftretendes Delir unmittelbar zu behandeln, den Erreichungsgrad &#252;ber ein regelm&#228;&#223;iges Monitoring zu &#252;berpr&#252;fen und zu dokumentieren und ggf. an neue Bedingungen zu adaptieren.</Pgraph><SubHeadline>Monitoring der Analgesie</SubHeadline><Pgraph>Etwa 75&#37; der intensivpflichtigen Patienten berichten &#252;ber starke bis st&#228;rkste Schmerzen w&#228;hrend ihrer Behandlung; dagegen halten &#252;ber 80&#37; der Behandelnden die Schmerztherapie f&#252;r ad&#228;quat <TextLink reference="10"></TextLink>. Optimaler Standard f&#252;r ein Analgesieziel w&#228;re die individuelle Einsch&#228;tzung durch den Patienten selbst (Numerische &#34;Rating&#34; Skala NRS, Visuelle Analog Skala VAS, Verbale Rating Skala VRS). Bei Patienten, die nicht oder nur unzureichend zur Kommunikation in der Lage sind, m&#252;ssen zur Beurteilung des Analgesiegrades durch &#196;rzte und Pflegepersonal subjektive Kriterien wie Bewegungen, Mimik und physiologische Parameter wie Blutdruck, Herzfrequenz, Atemfrequenz, Tr&#228;nenfluss und Schwei&#223;sekretion sowie die Ver&#228;nderung dieser Faktoren unter analgetischer Therapie zus&#228;tzlich zu einem Fremdbeurteilungsscore (z.B. Behavioral Pain Scale BPS) herangezogen werden. Analgesiemonitoring ist relevant f&#252;r das Outcome kritisch kranker Patienten <TextLink reference="2"></TextLink>.</Pgraph><SubHeadline>Monitoring der Sedierung</SubHeadline><Pgraph>&#220;bersedierung ist mit l&#228;ngerer Beatmungsdauer, h&#246;here Pneumonieinzidenz, Hypotension, Gastroparese, h&#246;herer Delirinzidenz, l&#228;ngerem Aufenthalt, h&#246;heren Kosten und einer h&#246;here Mortalit&#228;t assoziiert <TextLink reference="1"></TextLink>. Nach ihrer Intensivbehandlung haben diese Patienten h&#228;ufiger Schlafst&#246;rungen und mehr posttraumatischen Stress <TextLink reference="11"></TextLink>. Ein validierter Sedierungsscore, wie der Richmond Agitation and Sedation Scale (RASS), sollte routinem&#228;&#223;ig zum Einsatz kommen.</Pgraph><SubHeadline>Monitoring des Delirs</SubHeadline><Pgraph>30&#8211;80&#37; der intensivmedizinischen Patienten erleiden ein Delir <TextLink reference="12"></TextLink>. (Das Delir ist ein Pr&#228;diktor f&#252;r eine dreifach erh&#246;hte Mortalit&#228;t &#252;ber 6 Monate <TextLink reference="12"></TextLink>, h&#246;here Kosten <TextLink reference="13"></TextLink>, und eine signifikante anhaltende kognitive Verschlechterung <TextLink reference="14"></TextLink>. Zum Delirmonitoring sollten ebenfalls eine validierte Skala verwendet werden, dabei sind der Confusion Assessment Method for the ICU (CAM-ICU) und die Intensive Care Delirium Screening Checklist (ICDSC) am weitesten verbreitet <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Therapy"> <MainHeadline>Therapy</MainHeadline><Pgraph>In the management of analgesia, sedation and delirium, patient-centered concepts with individual treatment goals are essential. </Pgraph><SubHeadline>Analgesia </SubHeadline><Pgraph>ICU patients should receive analgesia tailored to their individual requirements <TextLink reference="17"></TextLink>. Patient-controlled administration is preferable if the patient is able for it <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>. Non-opioid analgesics and adjuvant substances may be used when needed <TextLink reference="20"></TextLink>. </Pgraph><SubHeadline2>Regional analgesia </SubHeadline2><Pgraph>Prior to the use of regional analgesia, a careful and critical risk-benefit assessment should be performed for each individual patient. The risk-benefit analysis should be reassessed daily. Epidural catheter techniques can positively influence outcome <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. The decisive factor is <TextGroup><PlainText>atra</PlainText></TextGroup>umatic catheter placement and continuous monitoring of any neurological complications that require immediate intervention. </Pgraph><SubHeadline>Sedation </SubHeadline><Pgraph>A sedation-as-needed approach requires sufficient analgesia and optimized ventilation settings in advance <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>. Sedation goals should be formulated in advance. Regular monitoring and appropriate adjustment of the medication is required to avoid both over- and under-sedation <TextLink reference="1"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. Because of the known negative consequences, deep sedation should be reserved for only a few specific indications (e.g. increased intracranial pressure). In cases of expected short duration of sedation, propofol and inhalative sedation or midazolam boli could all be used <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>. In prolonged therapy, bolus lorazepam sedation is another option <TextLink reference="29"></TextLink>. </Pgraph><SubHeadline>Weaning </SubHeadline><Pgraph>In addition to a sedation protocol, a weaning protocol is strongly recommended, as this is also associated with improved survival <TextLink reference="9"></TextLink>. During weaning, analgesics and sedatives with short context-sensitive half lives are preferable. </Pgraph><SubHeadline>Delirium treatment </SubHeadline><Pgraph>There is some evidence for the use of neuroleptics for both treatment and prophylaxis <TextLink reference="30"></TextLink>. Additive alpha-2 agonists and benzodiazepines (which will mainly be used in cases of substance withdrawal) can be used <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink>. The prophylactic maintenance of day-night rhythm, re-orientation methods, cognitive stimulation and early mobilization are important elements <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>. High priority should also be given to tapering of analgesics and sedatives in order to minimize risk of withdrawal <TextLink reference="35"></TextLink>.</Pgraph><SubHeadline>Neuromuscular blockade </SubHeadline><Pgraph>Both new ventilation modes and the advent of modern drugs for analgesia and sedation have allowed for adjustment of sedation to suit almost any clinical situation. ICU patients only rarely require profound sedation with additional muscle relaxation. Muscle relaxants should only be a method of last resort. Muscle relaxants are not an alternative to analgesia and sedation. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Therapie"> <MainHeadline>Therapie</MainHeadline><Pgraph>Hinsichtlich des Managements von Analgesie, Sedierung und Delir sind patientenorientierte Konzepte mit individueller Festlegung von Therapiezielen eine wichtige Voraussetzung. </Pgraph><SubHeadline>Analgesie</SubHeadline><Pgraph>Patienten auf Intensivstationen sollen eine an die individuelle Situation angepasste Schmerztherapie erhalten <TextLink reference="17"></TextLink>. Eine patientenkontrollierte Applikation ist zu bevorzugen, sofern der Patient dazu in der Lage ist <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>. Nicht-Opioid-Analgetika und adjuvante Substanzen k&#246;nnen bei Bedarf eingesetzt werden <TextLink reference="20"></TextLink>.</Pgraph><SubHeadline2>Regionalverfahren</SubHeadline2><Pgraph>Vor der Anwendung regionaler Analgesieverfahren sollte f&#252;r jeden einzelnen Patienten eine kritische und individuelle Risiko-Nutzen-Abw&#228;gung erfolgen, die t&#228;glich zu &#252;berpr&#252;fen ist. Epidurale Katheterverfahren k&#246;nnen das Outcome positiv beeinflussen <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. Entscheidend ist dabei die atraumatische Katheteranlage und die l&#252;ckenlose &#220;berwachung eventueller neurologischer Komplikationen, die die M&#246;glichkeit zum raschen Eing<TextGroup><PlainText>reife</PlainText></TextGroup>n voraussetzen. </Pgraph><SubHeadline>Sedierung</SubHeadline><Pgraph>Eine bedarfsadaptierte Sedierung setzt eine suffiziente Analgesie und optimierte Beatmungseinstellung voraus <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>. Bei Indikation zur Sedierung soll zun&#228;chst ein Sedierungsziel formuliert werden. Eine regelm&#228;&#223;ige Kontrolle des Ist-Zustandes und ggf. Anpassung der Medikation soll sowohl &#220;ber- als auch Untersedierung vermeiden <TextLink reference="1"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>. Aufgrund der bekannten negativen Folgen sollte die tiefe Sedierung nur wenigen speziellen Indikationen (z.B. erh&#246;hter intrakranieller Druck) vorbehalten sein. Bei voraussichtlich kurzer Sedierungsdauer kann neben Propofol und Midazolamboli auch die inhalative Sedierung eingesetzt werden <TextLink reference="27"></TextLink>, <TextLink reference="28"></TextLink>. In der l&#228;nger andauernden Therapie ist auch die Lorazepam Bolus Sedierung eine Option <TextLink reference="29"></TextLink>. </Pgraph><SubHeadline>Weaning</SubHeadline><Pgraph>Neben einem Sedierungsprotokoll ist ein Weaningprotokoll dringend empfohlen, da dies einen &#220;berlebensvorteil bietet <TextLink reference="9"></TextLink>. Im Weaning sind Analgetika und Sedativa mit kurzer kontextsensitiver Halbwertszeit (HWZ) zu bevorzugen. </Pgraph><SubHeadline>Delirtherapie</SubHeadline><Pgraph>Therapeutisch und unter Umst&#228;nden auch prophylaktischen ergibt sich eine gewisse Evidenz f&#252;r den Einsatz von Neuroleptika <TextLink reference="30"></TextLink>. Additiv k&#246;nnen Alpha-2-Agonisten und Benzodiazepine (v.a. im Entzug) eingesetzt werden <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink>. In der Prophylaxe sind z.B. die Aufrechterhaltung des Tag-Nacht-Rhythmus, Reorientierung, kognitive Stimulation und fr&#252;he Mobilisation wichtige Aspekte <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>. Hohen Stellenwert hat auch das Ausschleichen der Analgetika und Sedativa zur Vermeidung eines Entzugsdelirs <TextLink reference="35"></TextLink>. </Pgraph><SubHeadline>Neuromuskul&#228;re Blockade</SubHeadline><Pgraph>Sowohl neue Beatmungsverfahren als auch die Einf&#252;hrung neuer Pharmaka zur Analgesie und Sedierung erm&#246;glichen eine patientenadaptierte Anpassung der Sedierungstiefe an die jeweilige klinische Situation. Intensivpatienten bed&#252;rfen nur noch selten einer tiefen, komat&#246;sen Sedierung mit zus&#228;tzlicher Relaxierung. Muskelrelaxantien stehen erst am Ende der therapeutischen Ma&#223;nahmen, wenn konventionelle Analgesie und Sedierung nicht zum erforderlichen Erfolg f&#252;hren. Muskelrelaxantien stellen keine Alternative zur Analgesie und Sedierung dar.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Economy, quality assurance and implementation"> <MainHeadline>Economy, quality assurance and implementation</MainHeadline><Pgraph>In level 1 university hospitals, about 20 percent of the total hospital budget will be spent on intensive care units, although only about 5 percent of the total number of hospital patients are treated in the ICU <TextLink reference="36"></TextLink>. The drug costs in European intensive care units, according to the EURICUS III survey <TextLink reference="37"></TextLink> are an average of 15.4 percent of the total hospital medication budget. Many of the sedatives, analgesics and neuromuscular blocking agents not only have high initial cost, but also cause indirect costs <TextLink reference="38"></TextLink>. High indirect costs are caused in particular by unwanted medication effects such as increased ventilation times and higher incidence of pneumonia. </Pgraph><Pgraph>In order to achieve the reduction in costs that is external economic forces frequently dictate, a cost effectiveness analysis with special consideration of evidence-based therapies should be performed <TextLink reference="39"></TextLink>. As a general objective, optimal therapy at reasonable prices should be demanded and unnecessary or even harmful therapies should be excluded. </Pgraph><Pgraph>The need for guidelines or standards in the interest of the safety of patients and medical staff is now undisputed consensus <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>. </Pgraph><Pgraph>Scientific evidence however will never be implemented completely into routine clinical practice in the ICU. Several studies have shown how big the gap between &#8220;best evidence&#8221; and &#8220;best practice&#8221; is. Approximately 30&#8211;40&#37; of all patients are not treated according to current best scientific evidence and 20&#8211;25&#37; will still be receiving potentially dangerous therapies <TextLink reference="42"></TextLink>. </Pgraph><Pgraph>The successful implementation of these guidelines requires resources such as personnel, skills such as effective time management and organization features such as high levels of motivation <TextLink reference="43"></TextLink>, <TextLink reference="44"></TextLink>. For the lasting implementation of the guidelines into clinical practice, training in their execution as well as their content is needed (particularly during the early introductory phase) <TextLink reference="45"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="46"></TextLink>. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="&#214;konomie, Qualit&#228;tssicherung und Implementierung"> <MainHeadline>&#214;konomie, Qualit&#228;tssicherung und Implementierung</MainHeadline><Pgraph>In Krankenh&#228;usern der Maximalversorgung werden f&#252;r die Intensivstationen ca. 20 Prozent des Gesamtetats aufgewendet, obwohl nur ca. 5 Prozent aller Krankenhauspatienten in diesem Bereich behandelt werden <TextLink reference="36"></TextLink>. Dabei liegen die Arzneikosten auf europ&#228;ischen Intensivstationen laut der EURICUS III Erhebung <TextLink reference="37"></TextLink> bei durchschnittlich 15,4 Prozent. Viele der Sedativa, Analgetika und neuromuskul&#228;r blockierenden Substanzen haben nicht nur hohe Anschaffungskosten, sondern verursachen auch indirekte Kosten <TextLink reference="38"></TextLink>. Hohe indirekte Kosten werden insbesondere bei Fehlsteuerung, z.B. durch Zunahme der Beatmungsdauer und Erh&#246;hung der Pneumonieinzidenz verursacht.</Pgraph><Pgraph>Um die unter &#246;konomischem Aspekt angestrebte Reduktion der Therapiekosten sinnvoll zu erzielen, ist eine Kosten-Effektivit&#228;ts-Analyse unter besonderer Ber&#252;cksichtigung evidenz-basierter Therapieformen durchzuf&#252;hren <TextLink reference="39"></TextLink>. Als generelle Zielstellung gilt es dabei, eine optimale Behandlung zu angemessenen Preisen zu f&#246;rdern und unn&#246;tige oder gar sch&#228;dliche Therapiema&#223;nahmen auszuschlie&#223;en.</Pgraph><Pgraph>Die Notwendigkeit von Leitlinien bzw. Standards im Interesse der Therapiesicherheit f&#252;r Patienten und medizinisches Personal ist mittlerweile unumstrittener Konsens <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>.</Pgraph><Pgraph>Wissenschaftliche Erkenntnisse werden allerdings nicht 1:1 in den Alltag auf der Intensivstation &#252;bertragen. Verschiedene Studien haben gezeigt, wie gro&#223; die L&#252;cke zwischen &#8222;best evidence&#8220; und &#8222;best practice&#8220; ist. Etwa 30&#8211;40&#37; aller Patienten werden nicht nach dem aktuellen wissenschaftlichen Stand behandelt und 20&#8211;25&#37; erhalten sogar potentiell gef&#228;hrliche Therapien <TextLink reference="42"></TextLink>.</Pgraph><Pgraph>Die Umsetzung der Leitlinie setzt das Vorhandensein von Ressourcen voraus wie Fachpersonal, effektives Zeitmanagement und Motivation <TextLink reference="43"></TextLink>, <TextLink reference="44"></TextLink>. F&#252;r die konsequente Umsetzung der Leitlinien in der klinischen Praxis sind insbesondere in der Einf&#252;hrungsphase neben deren Verbreitung auch Schulungen zu deren Anwendung notwendig <TextLink reference="45"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="46"></TextLink>. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Special populations"> <MainHeadline>Special populations</MainHeadline><SubHeadline>Patients with severe burn injuries </SubHeadline><Pgraph>For burn victims, adequate pain control and minimization of psychological stress is very important <TextLink reference="47"></TextLink>. Efforts should be made minimize metabolic stress and so minimize oxygen consumption. The pain and stress associated with diagnostic and therapeutic interventions must be taken into account. The goals of activation and recovery of coordination must be balanced with the &#8220;stabilization&#8221; of the skin grafts. </Pgraph><Pgraph>A certain level of baseline analgesia will be needed in most cases. In procedures such as dressing changes, wound debridement in the therapy pool, etc. additional analgesia and&#47;or sedation may be required. </Pgraph><SubHeadline>Multiply injured trauma patients </SubHeadline><Pgraph>Compared to other patient groups, critically-ill trauma patients are younger and consequently relatively unique with respect to metabolic activity, pharmacokinetics, pharmacodynamics, and relevant comorbidities. Adequate analgesia and sedation during acute care and follow-up intensive care is an indispensable part of the treatment. Particular emphasis is placed here on the use of the &#8220;conscious sedation&#8221; concept. Therapy should be individually tailored according to the individual pattern of injury, the surgical treatments required and the associated clinical&#47;critical care course. </Pgraph><SubHeadline>Patients with severe traumatic brain injury and&#47;or intracranial hypertension </SubHeadline><Pgraph>Traumatic brain injury is defined by a Glasgow-Coma-Scale &#60;9 and despite all advance in diagnosis and therapy this remains the main cause of death among people aged younger than 45 years <TextLink reference="48"></TextLink>. According to recent statistics in Germany, about 248,000 per year people suffer a brain trauma in Germany, of which 2750 will be fatal.Of these injuries, 91&#37; are classified as mild, 4&#37; as moderate and 5&#37; as severe <TextLink reference="49"></TextLink>. There is undisputed consensus that adequate analgesia and sedation are essential in the intensive therapy of these patients. Nevertheless there are insufficient data to confirm that conscious sedation <Mark2>per se</Mark2> reduces intracranial pressure and improves neurol<TextGroup><PlainText>ogi</PlainText></TextGroup>cal outcome <TextLink reference="50"></TextLink>. Adequate sedation is paramount in all therapeutic algorithms for the treatment of increased intracranial pressure <TextLink reference="51"></TextLink> because psychomotor restlessness, pain and autonomic stress all adversely effect intracranial pressure (ICP), cerebral blood flow (CBF), cerebral perfusion pressure (CPP) and the cerebral metabolic rate for oxygen metabolism (CMRO<Subscript>2</Subscript>). In this respect, adequate analgesia makes an essential contribution to preventing or limiting secondary brain damage. Invasive monitoring of ICP and CPP is, in accordance with the guidelines of the Brain Trauma Foundation, indicated in patients with severe traumatic brain injury <TextLink reference="52"></TextLink>.</Pgraph><Pgraph>The ideal sedative&#47;analgesic in neurosurgical intensive care should </Pgraph><Pgraph><UnorderedList><ListItem level="1">reduce the ICP while maintaining an adequate CPP </ListItem><ListItem level="1">maintain cerebral hemodynamics, including autoregulation </ListItem><ListItem level="1">minimize cerebral metabolic rate for oxygen metabolism (CMRO<Subscript>2</Subscript>)</ListItem><ListItem level="1">have both anticonvulsant and neuroprotective properties</ListItem><ListItem level="1">allow to rapid neurological assessment of patients after discontinuation <TextLink reference="53"></TextLink>. </ListItem></UnorderedList></Pgraph><Pgraph>Since sedation can interfere with neurological assessment, compromises must sometimes be made. A combination therapy should be chosen that includes short-acting agents, to enable a rapid neurological assessment. Therefore combinations of short acting sedatives and analgesics recommended. Sedation protocols performing a daily interruption of sedation <TextLink reference="1"></TextLink> are not sufficiently evaluated in patients with underlying cerebral disease yet. </Pgraph><Pgraph>In addition to adequate analgesia, which is essential in severe cerebral trauma, additional analgesia and sedation must be provided for nursing interventions and any surgical interventions. In the <Mark2>acute phase</Mark2> of intensive treatment deep-sedation (RASS score of &#8211;5) should generally be targeted, especially if intracranial hypertension (ICP &#62;15&#8211;20 mmHg) is present <TextLink reference="52"></TextLink>, <TextLink reference="54"></TextLink>.</Pgraph><Pgraph> </Pgraph><SubHeadline>Pregnant and lactating patients </SubHeadline><Pgraph>During pregnancy and lactation, all necessary measures must be undertaken with regard to the child. Both non-opioids and opioids may be given under certain conditions. Regarding sedation in pregnant women, there is relatively little evidence available. </Pgraph><SubHeadline>Elderly patients</SubHeadline><Pgraph>Clinical age is determined by biological age, comorbidity, medication and external influences. Age-related changes in the cardiovascular, pulmonary, renal and nervous system lead to different pharmacodynamics and pharmacokinetics. There are changes in volume of distribution, therapeutic indices and duration of action for many medications and dosages should be adjusted accordingly. While the monitoring of sedation with standard scores is still acceptable, self-assessment of pain can be complicated by cognitive impairment. Regarding the development of delirium, elderly patients are particularly vulnerable as they often have predisposing risk factors such as neurodegenerative diseases, cerebral hypoperfusion, chronic hypoxia, infection, drug overdose, deafness, etc. Preventive measures such as visual and hearing aids, reorientation and cognitive stimulation are frequently indicated in the elderly <TextLink reference="33"></TextLink>. </Pgraph><Pgraph>The analgesic and sedative therapy should be titrated from lower doses and with smaller titrations. Medications with a short and context-insensitive halftime or regional techniques are preferred in older patients. </Pgraph><SubHeadline>Moribund and dying patients </SubHeadline><Pgraph>If the limits of intensive care treatment methods have been reached, the duties of medical staff change towards helping the dying. </Pgraph><Pgraph>These guidelines must be viewed in the context of published German federal guidelines for the health care professional&#8217;s duty of care in intensive care and in the context of the regulations of the German Medical Association for end-of-life care (<Hyperlink href="http:&#47;&#47;www.dgai.de&#47;06pdf&#47;13&#95;557-Leitlinie.pdf">http:&#47;&#47;www.dgai.de&#47;06pdf&#47;13&#95;557-Leitlinie.pdf</Hyperlink>) <TextLink reference="55"></TextLink>. </Pgraph><SubHeadline>Analgesia and sedation and monitoring of delirium in newborns and in children </SubHeadline><Pgraph>The same standards for monitoring in adults are generally applicable to children of all ages. </Pgraph><SubHeadline2>Monitoring analgesia in neonates and toddlers </SubHeadline2><Pgraph>Pain detection in neonatology and pediatrics is contingent on the developmental age of the patient. The developmental age dependent differences in children&#8217;s concepts of pain are reflected in their pain experience and expression of pain <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>. In the literature, several pain assessment tools for different age groups, diagnostic groups and pain types are available. These include tools for ventilated and non-ventilated patients, acute postoperative patients or patients with procedure-associated pain and patients with chronic pain. </Pgraph><SubHeadline2>Monitoring sedation in neonates and toddlers </SubHeadline2><Pgraph>If sedation is required, individual patient-oriented therapy with 8-hourly review of the sedation goal using a validated monitoring tool is recommended for each age group. </Pgraph><SubHeadline2>Monitoring of delirium in neonates and toddlers </SubHeadline2><Pgraph>Pediatric patients are particularly vulnerable to toxic, metabolic or traumatic cerebral nervous system (CNS) insults and more prone to develop delirium due to fever, regardless of the cause <TextLink reference="60"></TextLink>. It is likely that only the most serious cases are diagnosed and properly treated. Just as in adults, delirium may present in children in a hypo- or hyper-active from, or in a mixed form. In children too, the hypo-active form is often confused with depression, while hyper-active forms are often misinterpreted as uncontrolled pain. </Pgraph><Pgraph>Other causes of delirium are similar to adult patients and should be actively sought (a useful mnemonic for the causes of delirium is: I WATCH DEATH) <TextLink reference="61"></TextLink>. Children of preschool age may be just as vulnerable to delirium as geriatric patients because of cerebral growth and remodeling processes <TextLink reference="60"></TextLink>.</Pgraph><SubHeadline>Analgesic, sedative and delirium therapy in neonates and toddlers </SubHeadline><SubHeadline2>Analgesic treatment in neonates and toddlers </SubHeadline2><Pgraph>Critically ill children, like adults require tailored pain therapy. Most of the basic principles of analgesic therapy in adult medicine are applicable, but there are some differences that require a unique approach. </Pgraph><Pgraph>The pharmacokinetics and pharmacodynamics of analgesics change with age: in neonates, immaturity of some hepatic enzymes result in reduced clearance, while in children from 2 to 6 years, the drug may be metabolized faster due to a higher relative liver weight <TextLink reference="62"></TextLink>. </Pgraph><Pgraph>Pediatric analgesic therapy is also based on the World Health Organization (WHO) ladder for pain therapy (<Hyperlink href="http:&#47;&#47;www.who.int&#47;en&#47;">http:&#47;&#47;www.who.int&#47;en&#47;</Hyperlink>). </Pgraph><Pgraph>Adequate monitoring is essential during analgesic therapy in children due to the potential for serious adverse events. This is particularly true during the use of opioids. </Pgraph><SubHeadline2>Sedative treatment in neonates and toddlers </SubHeadline2><Pgraph>Many diagnostic and therapeutic procedures, or those requiring a co-operative, or very quiet patient, can only be performed under sedation. In some cases, continuous sedation of critically ill children in the pediatric or neonatal intensive care is necessary despite adequate analgesia. Sedation in children requires special personnel and structural conditions <TextLink reference="63"></TextLink>. </Pgraph><SubHeadline2>Delirium therapy in neonates and toddlers </SubHeadline2><Pgraph>There are hardly any data for the incidence of delirium in critically ill children. In a study by Schieveld, a cumulative incidence of 5&#37; at a mean age of 7.6 years was described <TextLink reference="64"></TextLink>. </Pgraph><Pgraph>Due to the limits of the currently available data, only the principle of combined psycho-social measures (presence of family, favorite toys, pictures of home, normal day-night rhythm, etc.) and pharmacological intervention for the treatment of delirium in children can be recommended <TextLink reference="64"></TextLink>, <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>.</Pgraph><Pgraph> </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Spezielle Patientengruppen"> <MainHeadline>Spezielle Patientengruppen</MainHeadline><SubHeadline>Patienten mit schweren Brandverletzungen</SubHeadline><Pgraph>Bei brandverletzten Patienten ist eine suffiziente Schmerzausschaltung mit einer ad&#228;quaten Bewusstseinsd&#228;mpfung mit Ausschaltung psychischer Belastungen wichtig <TextLink reference="47"></TextLink>. Es sollte eine ausreichende vegetative D&#228;mpfung angestrebt werden mit Reduktion eines erh&#246;hten Sauerstoffverbrauchs. Die wichtigen diagnostischen und therapeutischen Interventionen m&#252;ssen toleriert werden mit dem Ziel der Aktivierung und Wiedererlangung der Koordination Im Vordergrund steht nicht zuletzt die &#8222;Stabilisierung&#8220; der Hauttransplantate.</Pgraph><Pgraph>Bei Schwerbrandverletzten kann eine ad&#228;quate &#8222;Basisanalgesie&#8220; erforderlich sein. Bei Prozeduren wie z.B. Verbandswechsel, Wundreinigung im Therapiebad etc. kann aufgrund des &#8222;Prozedurenschmerzes&#8220; eine zus&#228;tzliche Analgesie und&#47;oder Sedierung erforderlich sein.</Pgraph><SubHeadline>Polytraumatisierte Patienten</SubHeadline><Pgraph>Im Vergleich zu anderen Kollektiven kritisch Kranker geh&#246;ren Polytraumapatienten durchschnittlich einer j&#252;ngeren Altersgruppe an, unterscheiden sich unter anderem hinsichtlich Stoffwechselleistung, Pharmakokinetik, Pharmakodynamik und relevanten Komorbidit&#228;ten. Eine ad&#228;quate Analgesie und Sedierung sind in der Akutversorgung und Intensivtherapie dieser Patienten ein wichtiger und unbestrittener Bestandteil der Behandlung. Besonderes Augenmerk ist hierbei auf die Anwendung eines bedarfsadaptierten Analgosedierungs-Konzeptes zu legen. Der Bedarf definiert sich an dieser Stelle aus dem individuellen Verletzungsmuster, der notwendigen chirurgischen Behandlung und dem damit assoziierten klinisch&#47;intensivmedizinischen Verlauf.</Pgraph><SubHeadline>Patienten mit schwerem Sch&#228;del-Hirn-Trauma und&#47;oder intrakranieller Hypertension</SubHeadline><Pgraph>Das schwere Sch&#228;del-Hirn-Trauma (SHT) wird definiert durch einen unmittelbar posttraumatisch erhobenen Glasgow Coma Scale Score &#60;9 und stellt trotz aller Fortschritte in Diagnostik und Therapie die Haupttodesursache der unter 45-j&#228;hrigen dar <TextLink reference="48"></TextLink>. Laut einer aktue<TextGroup><PlainText>lle</PlainText></TextGroup>n Statistik erleiden in Deutschland etwa 248.000 Einwohner pro Jahr ein Sch&#228;del-Hirn-Trauma, davon 2750 mit Todesfolge. Dabei sind 91&#37; als leicht, 4&#37; als mittelschwer und 5&#37; als schwer einzustufen <TextLink reference="49"></TextLink>. Eine ad&#228;quate Analgesie und Sedierung sind in der intensivmedizinischen Therapie dieser Patienten dabei unumstrittener Konsens, auch wenn bislang keine ausreichenden Daten vorliegen, dass die Analgosedierung <Mark2>per se</Mark2> den intrakraniellen Druck senkt und das neurol<TextGroup><PlainText>ogisc</PlainText></TextGroup>he Outcome positiv beeinflusst <TextLink reference="50"></TextLink>. Sie steht daher auch am Anfang vieler Therapiealgorithmen zur Behandlung des erh&#246;hten intrakraniellen Drucks <TextLink reference="51"></TextLink> weil psychomotorische Unruhe, Schmerzen und vegetativer Stress den intrakraniellen Druck (ICP), den zerebralen Blutfluss (CBF) bzw. den zerebralen Perfusionsdruck (CPP) und den zerebralen Stoffwechselgrundumsatz f&#252;r Sauerstoff (CMRO<Subscript>2</Subscript>) ung&#252;nstig beeinflussen k&#246;nnen. Insofern leistet eine ad&#228;quate Analgosedierung einen essentiellen Beitrag zur Vermeidung oder Begrenzung des sekund&#228;ren Hirnschadens. Dabei sollte, wie in den Leitlinien der Brain Trauma Foundation vorgegeben, eine invasive &#220;berwachung des ICP und damit des CPP bei Patienten mit schwerem SHT indiziert <TextLink reference="52"></TextLink>. Das ideale Sedativum&#47;Analgetikum in der Neurointensivmedizin sollte</Pgraph><Pgraph><UnorderedList><ListItem level="1">den ICP senken unter Aufrechterhaltung eines ad&#228;quaten CPP,</ListItem><ListItem level="1">die zerebrale H&#228;modynamik einschlie&#223;lich der Autoregulation erhalten,</ListItem><ListItem level="1">den zerebralen Stoffwechselgrundumsatz f&#252;r Sauerstoff (CMRO<Subscript>2</Subscript>) reduzieren,</ListItem><ListItem level="1">antikonvulsive und</ListItem><ListItem level="1">neuroprotektive Eigenschaften besitzen und</ListItem><ListItem level="1">eine rasche neurologische Beurteilung des Patienten nach Pausierung der Substanz erm&#246;glichen <TextLink reference="53"></TextLink>.</ListItem></UnorderedList></Pgraph><Pgraph>Da eine Analgosedierung unter Umst&#228;nden dem Ziel, den neurologischen Zustand des Patienten zu beurteilen, auf eine Verschlechterung reagieren und aus der Verbesserung einen Therapieerfolg ableiten zu k&#246;nnen, entgegensteht, m&#252;ssen hier Kompromisse eingegangen werden. Daher sollte eine Kombinationstherapie aus m&#246;glichst kurzwirksamen Substanzen gew&#228;hlt werden, um eine rasche neurologische Beurteilbarkeit zu erm&#246;glichen. Hier bieten sich &#8211; je nach Indikation und zu erwartender Dauer von Analgosedierung und Beatmung &#8211; Kombinationen aus einem Sedativum (Propofol, kurzwirksame Benzodiazepine) und einem Analgetikum (Opioide, Ketamin) an. Sedierungskonzepte, die eine t&#228;gliche Unterbrechung der Analgosedierung fordern <TextLink reference="1"></TextLink> sind bei Patienten mit zerebraler Grunderkrankung bislang nicht ausreichend evaluiert worden. </Pgraph><Pgraph>Neben einer ad&#228;quaten Analgesie, die bei schwer Sch&#228;del-Hirn-traumatisierten Patienten aufgrund der bestehenden Verletzungen, fachpflegerischer Ma&#223;nahmen und eventueller chirurgischer Interventionen unerl&#228;sslich ist, wird in der <Mark2>Akutphase</Mark2> der intensivmedizinischen Behandlung eine tiefe Sedierung (entsprechend RASS &#8211;5) angestrebt, insbesondere wenn eine intrakranielle Hypertension mit einem ICP &#62;15&#8211;20 mmHg vorliegt <TextLink reference="54"></TextLink>, <TextLink reference="52"></TextLink>.</Pgraph><SubHeadline>Schwangere und stillende Patientinnen</SubHeadline><Pgraph>In Schwangerschaft und Stillzeit m&#252;ssen alle erforderlichen Ma&#223;nahmen mit R&#252;cksicht auf das Kind durchgef&#252;hrt werden. Sowohl Non-Opioide als auch Opioide k&#246;nnen unter bestimmten Voraussetzungen gegeben werden. Hinsichtlich der Sedierung bei Schwangeren liegen keine ausreichenden Erfahrungen vor.</Pgraph><SubHeadline>&#196;ltere Patienten</SubHeadline><Pgraph>Das klinische Alter setzt sich aus dem biologischen Alter, Komorbidit&#228;t, Komedikation und externen Einfl&#252;ssen zusammen. Die altersbedingten Ver&#228;nderungen im kardiovaskul&#228;ren, pulmonalen, renalen und nervalen System f&#252;hren zu einer anderen Pharmakodynamik und -kinetik der Medikamente. Dies bedingt ver&#228;nderte Verteilungsvolumina, h&#246;here Wirkspiegel und verl&#228;ngerte Wirkungsdauer vieler Medikamente, die in ihrer Dosierung entsprechend angepasst werden m&#252;ssen. W&#228;hrend das Monitoring der Sedierung mit den &#252;blichen Scores durchgef&#252;hrt werden kann, kann die Selbsteinsch&#228;tzung bez&#252;glich der Schmerzen z.B. durch kognitive St&#246;rungen erschwert sein. Hinsichtlich der Entwicklung eines Delirs sind &#228;ltere Patienten besonders gef&#228;hrdet, da sie h&#228;ufig die entsprechende Pr&#228;disposition wie neurodegenerative Erkrankungen (z.B. Demenz), zerebrale Minderperfusion, chronische Hypoxie, Infektionen, Medikamenten&#252;berdosierung, Schwerh&#246;rigkeit, Sehst&#246;rungen etc &#8222;mitbringen&#8220;. Pr&#228;ventive Ma&#223;nahmen wie Seh- und H&#246;rhilfen, Reorientierung, kognitive Stimulation etc sind vor allem bei &#196;lteren indiziert <TextLink reference="33"></TextLink>.</Pgraph><Pgraph>In der analgetischen wie in der sedierenden Therapie sollte daher eine Titration der Medikamente in niedrigen Gesamtdosen durchgef&#252;hrt werden. Gerade beim &#228;lteren Patienten sollten Regionalverfahren und Medikamente mit kurzer kontextsensitiver HWZ bevorzugt eingesetzt werde. </Pgraph><SubHeadline>Moribunde und sterbende Patienten</SubHeadline><Pgraph>Wenn die Grenzen intensivmedizinischer Behandlungsmethoden und zum Teil auch intensivmedizinischer Behandlungspflicht erreicht sind, &#228;ndern sich die Aufgaben des medizinischen Personals hin zur Sterbebegleitung.</Pgraph><Pgraph>Die hier formulierten Leitlinien m&#252;ssen im Zusammenhang mit der Leitlinie zu Grenzen der intensivmedizin<TextGroup><PlainText>ische</PlainText></TextGroup>n Behandlungspflicht (<Hyperlink href="http:&#47;&#47;www.dgai.de&#47;06pdf&#47;13&#95;557-Leitlinie.pdf">http:&#47;&#47;www.dgai.de&#47;06pdf&#47;13&#95;557-Leitlinie.pdf</Hyperlink>) und den von der Bundes&#228;rztekammer ver&#246;ffentlichten Grunds&#228;tzen zur &#228;rztlichen Sterbebegleitung <TextLink reference="55"></TextLink> betrachtet werden.</Pgraph><SubHeadline>Analgesie- und Sedierungs- und Delirmonitoring bei Neugeborenen sowie im Kindesalter</SubHeadline><Pgraph>Generell gelten f&#252;r Kinder jeden Alters dieselben Ma&#223;st&#228;be f&#252;r die Notwendigkeit des Monitorings wie bei Patienten aller anderen Altersgruppen.</Pgraph><SubHeadline>Analgesiemonitoring bei Neugeborenen sowie im Kindesalter</SubHeadline><Pgraph>Schmerzerfassung in der Neonatologie und P&#228;diatrie erfolgt unter der Ber&#252;cksichtigung des Entwicklungsalters des Patienten. Die entwicklungsbedingt unterschiedlichen Wege der Schmerzwahrnehmung und -verarbeitung von Kindern spiegeln sich auch im Schmerzerleben und in der Schmerz&#228;u&#223;erung wieder <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink>, <TextLink reference="59"></TextLink>. In der Literatur werden verschiedene Schmerzbeurteilungsinstrumente f&#252;r unterschiedliche Altersklassen, Patientengruppen und Schmerzsituationen beschrieben, wie z.B. beatmete und nicht-beatmete Patienten, akuter postoperativer oder prozeduraler Schmerz, prolongierter Schmerz.</Pgraph><SubHeadline2>Sedierungsmonitoring bei Neugeborenen sowie im Kindesalter </SubHeadline2><Pgraph>Sofern eine Sedierung erforderlich ist, gilt ebenfalls die Empfehlung zur Erstellung eines individuellen patientenorientierten Therapiekonzeptes mit mindestens 8-st&#252;ndlicher &#220;berpr&#252;fung des Sedierungsziels mit Hilfe eines f&#252;r die jeweilige Altersklasse validierten Scores.</Pgraph><SubHeadline2>Delirmonitoring bei Neugeborenen sowie im Kindesalter </SubHeadline2><Pgraph>P&#228;diatrische Patienten scheinen besonders vulnerabel f&#252;r toxische, metabolische oder traumatische ZNS-Insulte zu sein und entwickeln h&#228;ufiger ein Delir, z.B. aufgrund von Fieber, unabh&#228;ngig von der Ursache <TextLink reference="60"></TextLink>. Wahrscheinlich werden nur die schwersten F&#228;lle diagnostiziert und korrekt behandelt. Ebenso wie bei Erwachsenen treten auch bei Kindern hypo- und hyperaktive Zust&#228;nde bzw. Mischformen auf; und auch hier werden hypoaktive Delirien nicht selten mit einer Depression verwechselt, w&#228;hrend agitierte Formen oft als Schmerz missinterpretiert werden. </Pgraph><Pgraph>Weitere Ursachen f&#252;r ein Delir sind vergleichbar wie beim erwachsenen Patienten m&#246;glich und sollten gepr&#252;ft werden (als Hilfe kann der Merkspruch: I WATCH DEATH dienen <TextLink reference="61"></TextLink>). M&#246;glicherweise sind Kinder im Vorschulalter aufgrund von zerebralen Wachstums- und Umbauprozessen &#228;hnlich vulnerabel f&#252;r ein Delir wie geriatrische Patienten <TextLink reference="60"></TextLink>.</Pgraph><SubHeadline>Analgetische, sedierende und antidelirante Therapie bei Neugeborenen sowie im Kindesalter</SubHeadline><SubHeadline2>Analgetische Therapie bei Neugeborenen sowie im Kindesalter</SubHeadline2><Pgraph>Kritisch kranke Kinder bed&#252;rfen genau wie Erwachsene eine an die individuelle Situation angepasste Schmerztherapie. Die meisten Grundprinzipien der analgetischen Therapie k&#246;nnen dabei aus der Erwachsenenmedizin &#252;bernommen werden, es gibt jedoch einige Unterschiede, die im Einzelfall ein abweichendes Vorgehen erfordern. </Pgraph><Pgraph>Die Pharmakokinetik und Pharmakodynamik von Analgetika ver&#228;ndert sich mit dem Alter: w&#228;hrend Neonaten durch die Unreife einiger hepatischer Enzyme noch eine verminderte Clearance haben k&#246;nnen, verstoffwechseln Kinder zwischen 2 und 6 Jahren die Medikamente infolge einer h&#246;heren relativen Lebermasse in der Regel schneller <TextLink reference="62"></TextLink>.</Pgraph><Pgraph>Eine ad&#228;quate analgetische Therapie orientiert sich auch im Kindesalter am World Health Organization (WHO)-Stufenschema zur Schmerztherapie (<Hyperlink href="http:&#47;&#47;www.who.int&#47;en&#47;">http:&#47;&#47;www.who.int&#47;en&#47;</Hyperlink>).</Pgraph><Pgraph>Eine ausreichende &#220;berwachungsm&#246;glichkeit von Kindern unter Analgetikatherapie ist aufgrund potentieller ernster Nebenwirkungen eine Grundvoraussetzung, dies gilt insbesondere f&#252;r den Einsatz von Opioiden.</Pgraph><SubHeadline2>Sedierende Therapie bei Neugeborenen sowie im Kindesalter</SubHeadline2><Pgraph>Viele diagnostische und therapeutische Verfahren, die einen kooperativen, bzw. sehr ruhigen, Patienten erfordern, k&#246;nnen trotz ausreichender Analgesie nur unter Sedierung durchgef&#252;hrt werden. In einigen F&#228;llen ist sogar die Dauersedierung kritisch kranker Kinder auf der p&#228;diatrischen oder neonatologischen Intensivstation notwendig. Die Durchf&#252;hrung einer Sedierung beim Kind erfordert besondere personelle und strukturell Voraussetzungen <TextLink reference="63"></TextLink>.</Pgraph><SubHeadline2>Antidelirante Therapie bei Neugeborenen sowie im Kindesalter</SubHeadline2><Pgraph>Zur genauen Inzidenz des Delirs bei kritisch kranken Kindern auf der p&#228;diatrischen Intensivstation gibt es kaum Untersuchungen. In einer Studie von Schieveld wurde eine kumulative Inzidenz von 5&#37; bei einem mittleren Alter von 7,6 Jahren (Gesamtanzahl der Patienten: 877, Alter 0&#8211;18 Jahre) beschrieben <TextLink reference="64"></TextLink>.</Pgraph><Pgraph>Bei der aktuellen Datenlage kann derzeit lediglich grunds&#228;tzlich empfohlen werden, eine Kombination aus pyschosozialen (Anwesenheit der Familie, Lieblings-Spielzeug, Fotos von zu Hause, normaler Tag-Nacht-Rhythmus, u.a.) und pharmakologischen Intervention zur Therapie des Delirs im Kindesalter einzusetzen <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, <TextLink reference="64"></TextLink>.</Pgraph><Pgraph> </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Next steps"> <MainHeadline>Next steps</MainHeadline><SubHeadline>Implementation of the guidelines</SubHeadline><Pgraph>To assess any the changes in practice regarding pain, over- and under-sedation and delirium prevention in the intensive care, an investigation will be conducted one year after the release of these 3<Superscript>rd</Superscript> Generation Guidelines. The investigation will be analogous to that performed after the publication of the 2<Superscript>nd</Superscript> Generation Guidelines <TextLink reference="67"></TextLink>. Through this investigation it should be evaluated whether the recommendations of the guidelines have been adopted into practice, and in this way incorporated into the real world therapy and whether a change in patient management is appreciable and what influence on this various approaches to implementation had.</Pgraph><Pgraph> </Pgraph><SubHeadline>Further evaluation needed </SubHeadline><Pgraph>Many of the scores used in the literature do not exist in validated German translations. If there was no validated German version available, it was created by the guideline authors. It is desirable that as many of these instruments as possible are validated in German ICUs over the coming years.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Weiteres Vorgehen"> <MainHeadline>Weiteres Vorgehen</MainHeadline><SubHeadline>Implementierung der Leitlinie (LL)</SubHeadline><Pgraph>Zur Erfassung der Ver&#228;nderung bei den Konzepten zur Analgesie, Sedierung und Delirpr&#228;vention auf der Intensivstation wird eine Untersuchung ein Jahr nach Erscheinen der S3 LL durchgef&#252;hrt werden analog zum Vorgehen nach Erscheinen der S2e-LL <TextLink reference="67"></TextLink>. Durch diese Untersuchung soll &#252;berpr&#252;ft werden, ob die Empfehlungen der LL in der Praxis angenommen, und damit in die Versorgungsrealit&#228;t aufgenommen worden sind und eine Ver&#228;nderung im Behandlungs-Management feststellbar ist und welchen Einfluss hierauf verschiedene Implementierungsans&#228;tze haben.</Pgraph><SubHeadline>Weiterer Evaluationsbedarf</SubHeadline><Pgraph>Viele der in der Literatur verwendeten Scores existieren nicht in einer validierten deutschen &#220;bersetzung. Wenn keine deutsche Version vorhanden war, wurde sie durch die LL Teilnehmer erstellt. Es w&#228;re w&#252;nschenswert, wenn m&#246;glichst viele dieser Messinstrumente in den n&#228;chsten Jahren auf deutsch in der Intensivmedizin validiert w&#252;rden.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Tables and schemes"> <MainHeadline>Tables and schemes</MainHeadline><Pgraph>The detailed recommendations are listed in Attachment 1 <AttachmentLink attachmentNo="1"/>.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Tabellen und Schemata"> <MainHeadline>Tabellen und Schemata</MainHeadline><Pgraph>Die detaillierten Empfehlungen sind in Anhang 1 <AttachmentLink attachmentNo="1"/> aufgef&#252;hrt.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Long version of the guideline</SubHeadline><Pgraph>The long version of the guideline in German language is available from <Hyperlink href="http:&#47;&#47;leitlinien.net&#47;001-012.htm">http:&#47;&#47;leitlinien.net&#47;001-012.htm</Hyperlink>.</Pgraph><SubHeadline>Validity and Update </SubHeadline><Pgraph>These guidelines are based on the best scientific advice currently available for each of the above topics. The Guidelines were approved by the Executive Committees of all participating scientific societies between October and December 2009. They are valid up to December 2014. The DGAI and DIVI will together with the participating societies, nominate a project team and management for the updating of the guidelines. </Pgraph><Pgraph>In the case of new relevant scientific evidence that would require a revision of the recommendations, a direct communication will follow.</Pgraph><SubHeadline>Authorship</SubHeadline><Pgraph>The authors are members of the working group on analgesia, sedation and delirium management in intensive care of the DGAI (Deutsche Gesellschaft f&#252;r An&#228;sthesiologie und Intensivmedizin), DGCH (Deutsche Gesellschaft f&#252;r Chirurgie), DGF (Deutsche Gesellschaft f&#252;r Fachkrankenpflege), DGGG (Deutsche Gesellschaft f&#252;r Gyn&#228;kologie), DIVI (Deutsche Interdisziplin&#228;re Vereinigung f&#252;r Intensiv- und Notfallmedizin), DGIIN (Deutsche Gesellschaft f&#252;r Internistische Intensivmedizin), GNPI (Gesellschaft f&#252;r Neonatologie und p&#228;diatrische Intensivmedizin), DGNC (Deutsche Gesellschaft f&#252;r Neurochirurgie), DGN (Deutsche Gesellschaft f&#252;r Neurologie), DGPPN (Deutsche Gesellschaft f&#252;r Psychiatrie, Psychotherapie und Nervenheilkunde), DGSS (Deutsche Gesellschaft zum Studium des Schmerzes), and DGTHG (Deutsche Gesellschaft f&#252;r Thorax-, Gef&#228;&#223;- und Herzchirurgie).</Pgraph><Pgraph>The two authors first mentioned, J. Martin and A. Heymann, contributed equally to this work.</Pgraph><Pgraph>AWMF support by PD I. Kopp, Institute for Theoretical Medicine, Marburg.</Pgraph><SubHeadline>Conflict of interest</SubHeadline><Pgraph>The declarations of conflict of interest of all participants can be viewed on request, from the respective professional societies. </Pgraph><SubHeadline>Funding </SubHeadline><Pgraph>This guideline was funded by the DGAI independent of any interest groups. </Pgraph><SubHeadline>Acknowledgements</SubHeadline><Pgraph>We are most grateful to Dr. Martin Mac-Guill, Dublin, formerly working at the Charit&#233; University Hospital Berlin, who helped us with the translation.</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 unter <Hyperlink href="http:&#47;&#47;leitlinien.net&#47;001-012.htm">http:&#47;&#47;leitlinien.net&#47;001-012.htm</Hyperlink> verf&#252;gbar.</Pgraph><SubHeadline>G&#252;ltigkeit und Aktualisierung der Leitlinie</SubHeadline><Pgraph>Die vorliegende Leitlinie stellt die wissenschaftlichen Empfehlungen zu den genannten Themenschwerpunkten dar. Von Oktober bis Dezember 2009 wurde die vorliegende Leitlinie durch die Pr&#228;sidien aller beteiligten Fachgesellschaften verabschiedet. Die G&#252;ltigkeit ist bis Dezember 2014 begrenzt. DGAI und DIVI werden gemeinsam mit den partizipierenden Fachgesellschaften f&#252;r die Weiterentwicklung und &#220;berarbeitung der Leitlinien in sp&#228;testens 3 Jahren ein Projektteam und eine Projektleitung benennen.</Pgraph><Pgraph>Im Falle neuer relevanter wissenschaftlicher Erkenntnisse, die eine &#220;berarbeitung der Empfehlungen erforderlich machen, erfolgt eine unmittelbare Mitteilung.</Pgraph><SubHeadline>Autorenschaft</SubHeadline><Pgraph>Die Autoren sind Mitglieder der Arbeitsgruppe &#8222;Analgesie, Sedierung und Delirmanagement in der Intensivmedizin&#8220; der DGAI (Deutsche Gesellschaft f&#252;r An&#228;sthesiologie und Intensivmedizin), DGCH (Deutsche Gesellschaft f&#252;r Chirurgie), DGF (Deutsche Gesellschaft f&#252;r Fachkrankenpflege), DGGG (Deutsche Gesellschaft f&#252;r Gyn&#228;kologie), DIVI (Deutsche Interdisziplin&#228;re Vereinigung f&#252;r Intensiv- und Notfallmedizin), DGIIN (Deutsche Gesellschaft f&#252;r Internistische Intensivmedizin), GNPI (Gesellschaft f&#252;r Neonatologie und p&#228;diatrische Intensivmedizin), DGNC (Deutsche Gesellschaft f&#252;r Neurochirurgie), DGN (Deutsche Gesellschaft f&#252;r Neurologie), DGPPN (Deutsche Gesellschaft f&#252;r Psychiatrie, Psychotherapie und Nervenheilkunde), DGSS (Deutsche Gesellschaft zum Studium des Schmerzes) und DGTHG (Deutsche Gesellschaft f&#252;r Thorax-, Gef&#228;&#223;- und Herzchirurgie).</Pgraph><Pgraph>Die beiden erstgenannten Autoren, J. Martin und A. Heymann, haben die Erstautorenschaft zu gleichen Teilen inne.</Pgraph><Pgraph>AWMF-Unterst&#252;tzung durch PD I. Kopp, Institut f&#252;r theoretische Medizin, Marburg.</Pgraph><SubHeadline>Unabh&#228;ngigkeit</SubHeadline><Pgraph>Die Unabh&#228;ngigkeitserkl&#228;rung aller Teilnehmer der AG kann auf Wunsch bei der federf&#252;hrenden Fachgesellschaft eingesehen werden.</Pgraph><SubHeadline>Finanzierung der Leitlinien</SubHeadline><Pgraph>Diese Leitlinie wurde von der DGAI unabh&#228;ngig von Interessensgruppen finanziert. </Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Kress JP</RefAuthor> <RefAuthor>Pohlman AS</RefAuthor> <RefAuthor>O&#39;Connor MF</RefAuthor> <RefAuthor>Hall JB</RefAuthor> <RefTitle>Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation</RefTitle> <RefYear>2000</RefYear> <RefJournal>N Engl J Med</RefJournal> <RefPage>1471-7</RefPage> <RefTotal>Kress JP, Pohlman AS, O&#39;Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. 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