Why the 2025 Update to the PADIS Guidelines Matters for Adult Intensive Care Unit (ICU) Patients
ICU nurses play a central role in monitoring and managing a variety of symptoms often experienced in the ICU, from managing pain and easing psychological distress to promoting mobility and restful sleep. Addressing these symptoms can significantly improve patient safety, recovery and long-term outcomes. The Society of Critical Care Medicine (SCCM) published evidence-based guidelines for adult ICU patients, first addressing pain, agitation and delirium (PAD), released in 2013, and including immobility and sleep disruption (PADIS) in 2018. The 2025 focused update reviews current evidence on anxiety (a new topic), agitation/sedation, delirium, immobility and sleep disruption.
A Nurse's Journey With PADIS Implementation
I began my nursing career over 20 years ago in critical care, where deep sedation and immobility were routine during mechanical ventilation. Following publication of the original PAD guidelines, our unit's quality improvement committee took action to implement the recommendations. Over several years, we introduced updated order sets, assessment tools and care algorithms, which led to significant reductions in ventilator days and both ICU and hospital lengths of stay. Interdisciplinary teamwork and shared determination were essential to changing practice and unit culture.
My passion for practice change ultimately inspired me to pursue a PhD, with a research focus on developing and testing strategies to promote the adoption of evidence-based ICU interventions — particularly concerning mobility. Serving as a committee member for the focused update of the PADIS guidelines was a meaningful opportunity to bridge my clinical experience and research expertise, and contribute to advancements in critical care.
How to Read Clinical Practice Guidelines: A Nurse's Guide to PADIS 2025
Clinical practice guidelines are essential tools for delivering evidence-based care, but they may not be written in a way to quickly identify the content that directly supports nursing practice in your setting. Consider these strategies as you read the update:
- Focus on the recommendations' strength and quality of evidence: Phrases such as strong recommendation vs. conditional recommendation and high-quality evidence vs. low-quality evidence indicate the experts' level of confidence in the guidance.
- Check the population and setting: Some guideline recommendations may not be relevant to every practice environment or patient population.
- Look for executive summaries or companion documents: These condensed documents are a good place to start for a high-level overview of key recommendations:
What's New in the 2025 PADIS Update
Five recommendations were generated from an interprofessional panel of experts (nurses, physicians, pharmacists, physical therapists, a psychologist and ICU survivors) who systematically reviewed current literature. For the first time, treatment of patients with anxiety was added to their review. In addition, the panel provided conditional recommendations for pharmacologic management of agitation and sleep, and nonpharmacologic management of immobility.
Key Recommendations by Topic
Managing ICU Anxiety: Nonpharmacologic Strategies From the PADIS Update
Anxiety is often one of the most distressing symptoms that patients report, both in the ICU and after hospital discharge. There is insufficient evidence to recommend benzodiazepines for the treatment of patients with anxiety. The panel does suggest using a validated tool to assess anxiety and to consider nonpharmacologic interventions, such as listening to music or using virtual reality, that show potential for managing anxiety.
Dexmedetomidine vs. Propofol: Updated Agitation/Sedation Recommendations for ICU Patients
Dexmedetomidine is suggested over propofol to maintain light sedation in mechanically ventilated adult patients. While dexmedetomidine may cause an increased risk of bradycardia, it also may reduce delirium and improve the time a patient is at a target sedation level. These benefits outweigh the potential risk of bradycardia. Alternative interventions should be considered for patients who require deep sedation or have a high risk of bradycardia.
Delirium in the ICU: What the PADIS Update Says About Antipsychotics
The updated guidelines do not provide a recommendation for or against antipsychotics, such as haloperidol or atypical agents, for treating patients with delirium. Current evidence indicates that these medications have minimal or no effect on patient outcomes, including ICU or hospital length of stay. Additional research is needed to guide strategies for specific delirium subtypes (hypoactive and/or hyperactive).
Enhanced Mobility in the ICU: Evidence-Based Strategies for Practice Change
Mobilization - defined as the process of moving oneself and maintaining or adjusting positions - is a complex, team-based intervention aimed at reducing ICU-acquired weakness. The panel suggests providing enhanced mobilization over usual care. This enhancement may include interventions such as cycling, early initiation, twice-daily sessions, protocol-driven approaches or an extended duration of mobility. Expert panelists concluded that the positive effects of enhanced mobilization on functional outcomes, quality of life and increased likelihood of discharge home outweigh the slight increase in the risk of arrhythmias. However, more research is needed before providing recommendations regarding the optimal dose, timing, duration or delivery of mobility interventions.
Using Melatonin to Improve ICU Sleep and Reduce Delirium: PADIS 2025 Insights
Sleep disruption is a multifactorial problem in the ICU. In addition to the negative impact of environmental factors and patient care activities on sleep, critically ill patients may experience circadian disturbances and decreased levels of melatonin. The panel suggests melatonin as a low-risk intervention to improve sleep quality and reduce delirium. Additional research on melatonin dosing is needed.
Implementing PADIS 2025 in ICU Practice Using the ABCDEF Bundle
The SCCM ICU Liberation Bundle or ABCDEF bundle continues to be a valuable framework for teams to operationalize the 2018 guidelines in daily practice. Background information on the ABCDEF bundle and resources for implementation are summarized in this AACN blog post, "The ABCDEF Bundle: Can it improve delirium and nurse burnout?" and a CSI project, "Rise and Shine: Implementing the ABCDE Bundle."
If your unit is already using the ABCDEF bundle, consider an interdisciplinary review of how updated recommendations for dexmedetomidine, enhanced mobilization and melatonin apply to your patient population and setting. Each recommendation in the updated guidelines is conditional, meaning that recommendations should be tailored to individual patient circumstances. Examine how the recommendations could be implemented in your existing workflows (e.g., order sets, protocols, guidelines and interdisciplinary rounds).
Future Considerations for Symptom Assessment and Management in the ICU
The updated PADIS guidelines also include future research recommendations based on current gaps in the literature. Several future research areas are particularly relevant to nursing practice and include anxiety assessment tools for critically ill adults, implementing enhanced mobility in ICUs with different types of resources, and sleep assessment methods.
While the addition of anxiety in this guideline update addresses a key gap in previous guidelines, a report from the American Thoracic Society identifies a need for a broader, holistic assessment of common ICU symptoms (such as thirst, dyspnea and fear) using validated tools, and it provides communication strategies to facilitate symptom assessment communication during mechanical ventilation.
Future Directions: Research Gaps and Nurse-Led Priorities in ICU Symptom Management
Nurses have a vital role in evidence-based symptom management and patient safety in the ICU and in leading meaningful practice change. Let this overview of the focused update on the PADIS guidelines motivate you to dive deeper into exploring the full guidelines, leverage tools to implement the recommendations in practice, and share your experience in preventing and managing common and distressing symptoms in critical care.
What gaps do you see in your practice that are important for assessing and managing patients' symptoms?
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