title: 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.
authors.affiliation: Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium. jlvincen@ulb.ac.be.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vincent
authors.affiliation: Program of Critical Care, Faculty of Medicine, Nursing and Health Sciences, Monash Medical Centre, Monash University, Melbourne, VIC, 3800, Australia.
authors.forename: Yahya
authors.initials: Y
authors.lastname: Shehabi
authors.affiliation: Anaesthetics, Critical Care and Pain Medicine, Centre for Inflammation Research and School of Clinical Sciences, Edinburgh University, Edinburgh, UK.
authors.forename: Timothy S
authors.initials: TS
authors.lastname: Walsh
authors.affiliation: Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA.
authors.forename: Pratik P
authors.initials: PP
authors.lastname: Pandharipande
authors.affiliation: Department of Intensive Care Medicine, St George's Hospital, London, UK.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Ball
authors.affiliation: Department of Intensive Care Medicine, Gelre Hospitals, Apeldoorn, The Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: Spronk
authors.affiliation: Département d'Anesthésie Réanimation Chirurgicale, Hôpital Bichat-Claude Bernard, Université Paris-Diderot, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France.
authors.forename: Dan
authors.initials: D
authors.lastname: Longrois
authors.affiliation: Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
authors.forename: Thomas
authors.initials: T
authors.lastname: Strøm
authors.affiliation: Department of Pediatric ICU, Intensive Care and Anesthesia, Catholic University of Rome, Rome, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Conti
authors.affiliation: Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital, Vienna, Austria.
authors.forename: Georg-Christian
authors.initials: GC
authors.lastname: Funk
authors.affiliation: Department of Anesthesiology and Surgical-Trauma Intensive Care, University Hospital Clinic Valencia, Valencia, Spain.
authors.forename: Rafael
authors.initials: R
authors.lastname: Badenes
authors.affiliation: Department of Anesthesia and Intensive Care, European Hospital Georges Pompidou, Paris Descartes University, Paris, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Mantz
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Spies
authors.affiliation: Department of Intensive Care Medicine, Berne University Hospital and University of Berne, Berne, Switzerland.
authors.forename: Jukka
authors.initials: J
authors.lastname: Takala
mesh_terms: D000698:Analgesia / Q000379:methods; D000701:Analgesics, Opioid / Q000009:adverse effects; D001569:Benzodiazepines / Q000009:adverse effects; D016292:Procedural Sedation; D003422:Critical Care / Q000592:standards*; D054810:Deep Sedation / Q000009:adverse effects; D003693:Delirium / Q000188:drug therapy; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007362:Intensive Care Units / Q000592:standards*; D007649:Ketamine / Q000627:therapeutic use; D059408:Pain Management / Q000379:methods; D000070659:Patient Comfort; D018802:Patient-Centered Care / Q000379:methods*; D011595:Psychomotor Agitation / Q000188:drug therapy; D012307:Risk Factors; D013997:Time Factors
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives; D001569:Benzodiazepines; D007649:Ketamine
keywords: Analgesia; ICU; Pain; Sedation; eCASH