Comfort and patient-centred care without excessive sedation: the eCASH concept

Abstract

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH-early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

Keywords: Analgesia; ICU; Pain; Sedation; eCASH.

Fig. 1

The eCASH concept: early implementation to manage and prevent pain, anxiety, agitation, delirium and immobility and facilitate patient-centred care. (#Moderate or deep sedation remains relevant for some situations, including the management of severe respiratory failure with ventilator–patient dyssynchrony, prevention of awareness in patients receiving neuromuscular blocking agents, status epilepticus, surgical conditions necessitating strict immobilization and some cases of severe brain injury with intracranial hypertension)

Fig. 2

The eCASH implementation map commences upon ICU admission and focuses on coordinated effective analgesia and pain management and titrated minimal and light sedation. Dashed double-headed arrows identify factors and/or interventions that need to be considered concurrently. (#Moderate and deep sedation remains relevant for specific clinical situations, as noted in Fig. 1)