Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care

David Wyler, Michael Esterlis, Brittany Burns Dennis, Andrew Ng, Abhijit Lele

A recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to "liberate" patients from the ICU. They "bundle" evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation-to make formal recommendations in clinical practice guidelines or a position statement. The authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen's Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available. Using the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm. PROSPERO CRD42017078909.