Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit

Objective

Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. The aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients.

Methods

132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). The functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge.

Results

The patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p=0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). The IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no differences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis.

Conclusions

High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. The benefits to functional status remained after 3 month of ICU discharge. Other benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.

An automated ICU agitation monitoring system for video streaming using deep learning classification

OBJECTIVE

To address the challenge of assessing sedation status in critically ill patients in the intensive care unit (ICU), we aimed to develop a non-contact automatic classifier of agitation using artificial intelligence and deep learning.

METHODS

We collected the video recordings of ICU patients and cut them into 30-second (30-s) and 2-second (2-s) segments. All of the segments were annotated with the status of agitation as "Attention" and "Non-attention". After transforming the video segments into movement quantification, we constructed the models of agitation classifiers with Threshold, Random Forest, and LSTM and evaluated their performances.

RESULTS

The video recording segmentation yielded 427 30-s and 6405 2-s segments from 61 patients for model construction. The LSTM model achieved remarkable accuracy (ACC 0.92, AUC 0.91), outperforming other methods.

CONCLUSION

Our study proposes an advanced monitoring system combining LSTM and image processing to ensure mild patient sedation in ICU care. LSTM proves to be the optimal choice for accurate monitoring. Future efforts should prioritize expanding data collection and enhancing system integration for practical application.

Inhaled volatile anesthetics in the intensive care unit

The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.

Considerations and limitations of buprenorphine prescribing for opioid use disorder in the intensive care unit setting: A narrative review

PURPOSE

The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence.

SUMMARY

Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients.

CONCLUSION

There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.

The pupillary dilation reflex to a nociceptive stimulus as a tool for analgesia management: A diagnostic study

BACKGROUND

More than 70% of patients demonstrate pain after endotracheal aspiration. Tools are needed to objectify the need for analgesia in non-communicative critically ill patients.

OBJECTIVE

The objective of this study was to identify the lowest intensity electrical stimulus for detecting pain before daily care interventions.

METHODS

Study of diagnostic tests to assess pupillometry to detect pain through the pupillary dilation response to noxious stimuli versus the Behavioural Pain Scale. Patients older than 18 years, under analgosedation, subjected to invasive ventilation, baseline Behavioural Pain Scale of 3, and Richmond Agitation-Sedation Scale between -1 and -4 were studied. We assessed the Behavioural Pain Scale and the pupillary dilation response to 10, 20, 30, and 40 mA stimuli. We studied the diagnostic performance based on sensitivity and specificity, negative predictive value, positive predictive value, and accuracy of the selected points after the different stimulations. AlgiScan® Pupillometer measured the pupillary dilation response. The presence of pain was considered as a Behavioural Pain Scale score of ≥4. Significance was defined as p <0.05.

RESULTS

Measurements were performed on 31 patients. In the 20 mA stimulus, we found an area under the curve of 0.85 (0.69-1.0). The cut-off point of pupillary dilation was 11.5%, with a sensitivity of 100% (34.2-100) and a specificity of 75.9% (57.9-87.8). This point had an accuracy of 77.4 (60.2-88.6) and a Youden's Index of 0.8.

CONCLUSIONS

Pupillary variation measurement during a 20 mA stimulus could help assess the need for analgesia before potentially painful interventions. Further studies are needed to confirm this.

REGISTRATION

Phase 1 of the project PUPIPAIN ClinicalTrials.gov Identifier: NCT04078113.

Prevalence and risk factors of subsyndromal delirium among postoperative patients: A systematic review and meta-analysis

AIM

The aim of this study is to determine the prevalence and risk factors for subsyndromal delirium in the postoperative patient.

DESIGN

A systematic review and meta-analysis.

METHODS

The Review Manager 5.3 statistics platform and the Newcastle-Ottawa Scale were used for quality evaluation.

DATA SOURCES

The following databases were searched: PubMed, Web of Science, EMBASE, The Cochrane Library, Scopus and EBSCO from January 2000 to December 2021. Additional sources were found by looking at relevant articles' citations.

RESULTS

A total of 1744 titles were originally identified, and five studies including 962 patients were included in the systematic review, with a pooled prevalence of postoperative subsyndromal delirium (PSSD) of 30% (95% CI: 0.28-0.32). Significant risk variables for PSSD were older age, low levels of education (≤9 years), cognitive impairment, higher comorbidity score, and the duration of operation.

CONCLUSION

PSSD is prevalent and is associated with a variety of risk factors as well as low academic performance.

IMPACT

Identification and clinical management of patients with PSSD should be improved. Future research on PSSD risk factors should look at a wider range of intraoperative and postoperative risk factors that can be changed.

PATIENT AND PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Development and testing of a questionnaire assessing knowledge, attitudes, and practices to prevent unplanned oral extubation

BACKGROUND

The prevention of unplanned endotracheal extubation (UEE) is significant for the critical care of intensive care unit (ICU) patients.

AIM

To develop a questionnaire to assess the knowledge, attitude, and practice (KAP) of the nurses regarding of the prevention of UEE in ICU patients with transoral endotracheal intubation (TEI) and to test the validity and reliability of the questionnaire.

STUDY DESIGN

Items relevant to KAP were prepared following a literature review, and then screened using a Delphi expert consultation, pre-test, and factor analysis. The nursing staffs in four tertiary hospitals in Qinghai, Jiangsu, Gansu, and Shandong provinces were surveyed to test the reliability and validity of the questionnaire.

RESULTS

The questionnaire contained 76 items, including 10, 37, and 29 in the dimensions of knowledge, attitude, and practice, respectively. The scale-level content validity index (S-CVI) of the questionnaire was 0.96. The results of exploratory factor analysis (EFA) showed that the Kaiser-Meyer-Olkin value was 0.956, indicating that the sample was adequate and suitable for factor analysis. The result of the Bartlett spherical test was significant (p < .001), indicating that the questionnaire was suitable for further EFA. A total of six common factors were extracted by EFA with a cumulative variance interpretation rate of 85.52%, indicating that the questionnaire had good structural validity. The Cronbach's alpha was 0.981 for the whole questionnaire; and was 0.966, 0.996, and 0.981 for the dimensions of knowledge, attitude, and practice, respectively. The test-retest reliability for the questionnaire was 0.843.

CONCLUSIONS

The developed questionnaire has good reliability and validity and can be used as a scientific tool for the nursing leaders to prevent UEE in ICU patients with TEI.

RELEVANCE TO CLINICAL PRACTICE

The instrument provides a theoretical reference for establishing preventive strategies and management programs in clinical practice.

Exploring critically ill patients' and their relatives' experiences of intensive care unit during COVID-19: A qualitative study

BACKGROUND

Admission to an intensive care unit has physiological and psychological consequences for patients and families, including the family's fear that the patient might die. The COVID-19 pandemic underlined this and furthermore involved visiting restrictions separating patients and families.

AIM

To explore how patients with confirmed COVID-19 and their relatives experienced an intensive care unit stay and its significance for family dynamics.

STUDY DESIGN

A qualitative study was performed during the spring of 2020. Five dyadic interviews were conducted with COVID-19 patients admitted to an intensive care unit and their relatives. The analysis was inspired by Hochman's dyadic analysis.

FINDINGS

The analysis revealed three themes: (1) From ill to critically ill: The trauma of separation and fear of losing loved ones; (2) The relatives' significant role in creating a shared coherent understanding of the admission in ICU due to COVID-19; (3) The nurses' roles as a go-between in maintenance of the family dynamic.

CONCLUSION

Separation challenged family function and destabilized family dynamics. Nurses provided emotional support, information about and contact with the patient and relatives. The patients' distorted perception of reality and lack of memory were reconstructed in new family narratives, which offered relief and stabilization of family dynamics. The nurses entered into a triad with the patient and relatives, which also contributed to maintaining a relational dynamic in the family.

RELEVANCE TO CLINICAL PRACTICE

Maintaining communication between health professionals, relatives and patients, and usage of virtual visits during intensive care unit stay can support the family relationship. Nurse therapeutic conversations might help families' in redefining their family dynamics after ICU admission.

Rapid review of ventilator-induced diaphragm dysfunction

Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.

Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial

PURPOSE

The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI.

METHODS

We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS >  + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization.

RESULTS

A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results.

CONCLUSION

In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.

Perioperative Evaluation of Brain Health

As the global population is aging and surgical needs rise, the occurrence of perioperative neurocognitive disorders (PND) is becoming a significant concern. PND refers to cognitive changes that occur before or after surgery, including neurocognitive disorders, postoperative delirium, and delayed neurocognitive recovery. To address this issue, a brain health assessment initiative within a multidisciplinary team is an emerging concept. Assessing cognitive function, comorbidities, severity of neurocognitive disorders, medications, nutritional status, sleep quality, and other factors can help mitigate the risk of PND and improve patient outcomes.

Survival and Long-Term Functional Status of COVID-19 Patients Requiring Prolonged Extracorporeal Membrane Oxygenation Support

Rationale: Severe cases of acute respiratory distress syndrome (ARDS) may require prolonged (>28 d) extracorporeal membrane oxygenation (ECMO). In nonresolving disease, recovery is uncertain, and lung transplant may be proposed. Objectives: This study aims to identify the variables influencing survival and to describe the functional status of these patients at 6 months. Methods: This was a retrospective, multicenter, observational cohort study including patients requiring ECMO support for coronavirus disease (COVID-19)-related ARDS for >28 days. Multivariate analysis was performed using Cox regression in preselected variables and in least absolute shrinkage and selection operator selected variables. In a post hoc analysis to account for confounders and differences in awake strategy use by centers, treatment effects of the awake strategy were estimated using an augmented inverse probability weighting estimator with robust standard errors clustered by center. Results: Between March 15, 2020 and March 15, 2021, 120 patients required ECMO for >28 days. Sixty-four patients (53.3%) survived decannulation, 62 (51.7%) were alive at hospital discharge, and 61 (50.8%) were alive at 6-month follow-up. In the multivariate analysis, age (1.09; 95% confidence interval [CI], 1.03-1.15; P = 0.002) and an awake ECMO strategy (defined as the patient being awake, cooperative, and performing rehabilitation and physiotherapy with or without invasive mechanical ventilation at any time during the extracorporeal support) (0.14; 95% CI, 0.03-0.47; P = 0.003) were found to be predictors of hospital survival. At 6 months, 51 (42.5%) patients were at home, 42 (84.3%) of them without oxygen therapy. A cutoff point of 47 ECMO days had a 100% (95% CI, 76.8-100%) sensitivity and 60% (95% CI, 44.3-73.6%) specificity for oxygen therapy at 6 months, with 100% specificity being found in 97 days. Conclusions: Patients with COVID-19 who require ECMO for >28 days can survive with nonlimiting lung impairment. Age and an awake ECMO strategy may be associated with survival. Longer duration of support correlates with need for oxygen therapy at 6 months.

Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients.

DATA SOURCES

A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted.

STUDY SELECTION

Selection includes original research, review articles, and guidelines.

DATA EXTRACTION

Information from relevant publications was reviewed, consolidated, and formulated into a narrative review.

DATA SYNTHESIS

We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes.

CONCLUSIONS

Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.

Variation in Sedative and Analgesic Use During the COVID-19 Pandemic and Associated Outcomes

BACKGROUND

Providing analgesia and sedation is an essential component of caring for many mechanically ventilated patients. The selection of analgesic and sedative medications during the COVID-19 pandemic, and the impact of these sedation practices on patient outcomes, remain incompletely characterized.

RESEARCH QUESTION

What were the hospital patterns of analgesic and sedative use for patients with COVID-19 who received mechanical ventilation (MV), and what differences in clinical patient outcomes were observed across prevailing sedation practices?

STUDY DESIGN AND METHODS

We conducted an observational cohort study of hospitalized adults who received MV for COVID-19 from February 2020 through April 2021 within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. To describe common sedation practices, we used hierarchical clustering to group hospitals based on the percentage of patients who received various analgesic and sedative medications. We then used multivariable regression models to evaluate the association between hospital analgesia and sedation cluster and duration of MV (with a placement of death [POD] approach to account for competing risks).

RESULTS

We identified 1,313 adults across 35 hospitals admitted with COVID-19 who received MV. Two clusters of analgesia and sedation practices were identified. Cluster 1 hospitals generally administered opioids and propofol with occasional use of additional sedatives (eg, benzodiazepines, alpha-agonists, and ketamine); cluster 2 hospitals predominantly used opioids and benzodiazepines without other sedatives. As compared with patients in cluster 2, patients admitted to cluster 1 hospitals underwent a shorter adjusted median duration of MV with POD (β-estimate, -5.9; 95% CI, -11.2 to -0.6; P = .03).

INTERPRETATION

Patients who received MV for COVID-19 in hospitals that prioritized opioids and propofol for analgesia and sedation experienced shorter adjusted median duration of MV with POD as compared with patients who received MV in hospitals that primarily used opioids and benzodiazepines.

Validation of PRE-DELIRIC and E-PRE-DELIRIC in a Danish population of intensive care unit patients-A prospective observational multicenter study

BACKGROUND

Delirium is a clinical condition characterized by an acute change in brain function and is frequently observed in critically ill patients. The condition has been associated with negative outcomes, making it crucial to identify patients who are at risk. Two recent prediction models have been developed to estimate the risk of delirium in intensive care unit (ICU) patients; the prediction model for delirium (PRE-DELIRIC) and the early prediction model for delirium (E-PRE-DELIRIC). We aimed to perform an external validation of these models in a Danish cohort of critically ill patients.

METHODS

We conducted a prospective, observational multicenter study to validate the PRE-DELIRIC and E-PRE-DELIRIC models in a population of patients admitted to four general ICUs in the Zealand Region of Denmark. From January 2022 to January 2023 all adult patients acutely admitted to the participating ICUs were assessed for eligibility. Patients had to be admitted to the ICU for >24 h to be included in the study. Included patients were screened with E-PRE-DELIRIC upon ICU admission and PRE-DELIRIC after 24 h of admission and followed throughout their ICU stay with CAM-ICU delirium assessments. Our primary outcomes were the prognostic accuracy measured by Area Under the Receiver Operating Characteristics (AUROC) and the calibration plot for the E-PRE-DELIRIC and PRE-DELIRIC prediction models.

RESULTS

We included 660 patients, of whom 660 were assessed with E-PRE-DELIRIC, and 622 were assessed with PRE-DELIRIC. PRE-DELIRIC showed acceptable discrimination with AUROC of 0.70 (95% CI 0.66 to 0.74) and good calibration. E-PRE-DELIRIC had inadequate discrimination AUROC of 0.63 (95% CI 0.58 to 0.67) and poor calibration.

CONCLUSION

In a Danish cohort, we found that the PRE-DELIRIC model demonstrated acceptable performance and E-PRE-DELIRIC demonstrated poor performance. In critically ill adult patients PRE-DELIRIC may be useful in identifying patients at high risk of delirium.

The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey

BACKGROUND

Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association.

OBJECTIVES

The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units.

METHODS

A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied.

RESULTS

One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001).

DISCUSSION

Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

Utility of Remimazolam for Fast-Track Recovery Following Surgical Aortic Valve Replacement in an Elderly Patient With Severe Aortic Stenosis: A Case Report

Remimazolam is an ultra-short-acting benzodiazepine that has minimal hemodynamic effects and is useful for early extubation after cardiac surgery. We present a case of an elderly patient with severe aortic stenosis (AS) who underwent surgical aortic valve replacement (AVR), was extubated in the operating room, and recovered quickly without postoperative delirium. An 87-year-old woman with severe AS underwent AVR under cardiopulmonary bypass. General anesthesia was induced with remimazolam 10 mg over one minute and fentanyl 100 µg, and maintained with remimazolam 0.4-0.7 mg/kg/hour, fentanyl, and remifentanil. Intraoperative hemodynamic condition was stable without vasopressors. Remimazolam was discontinued after sternum closure. She recovered consciousness five minutes after the completion of the surgery, and the tracheal tube was removed in the operating room. Remimazolam may be useful for fast-track recovery following surgical AVR in an elderly patient with severe AS.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Behavioral pain scale may not be reliable in awake non-verbal intensive care patients: a case control study

BACKGROUND

The evaluation of pain in patients, unable of oral communication, often relies on behavioral assessment. However, some critically ill patients, while non-verbal, are awake and have some potential for self-reporting. The objective was to compare the results of a behavioral pain assessment with self-reporting in awake, non-verbal, critically ill patients unable to use low-tech augmentative and alternative communication tools.

METHODS

Prospective cohort study of intubated or tracheotomized adult, ventilated patients with a RASS (Richmond Agitation Sedation Scale) of -1 to + 1 and inadequate non-verbal communication skills in a surgical intensive care unit of a tertiary care university hospital. For pain assessment, the Behavioral Pain Scale (BPS) was used. Self-reporting of pain was achieved by using an eye tracking device to evaluate the Numeric Rating Scale (NRS) and the pain/discomfort item of the EuroQol EQ-5D-5 L (EQ-Pain). All measurements were taken at rest.

RESULTS

Data was collected from 75 patients. Neither the NRS nor the EQ-Pain (r < .15) correlated with the BPS. However, NRS and EQ-Pain were significantly correlated (r = .78, p = < 0.001), indicating the reliability of the self-reporting by these patients. Neither the duration of intubation/tracheostomy, nor cause for ICU treatment, nor BPS subcategories had an influence on these results.

CONCLUSIONS

Behavioral pain assessment tools in non-verbal patients who are awake and not in delirium appear unreliable in estimating pain during rest. Before a behavioral assessment tool such as the BPS is used, the application of high-tech AACs should be strongly considered.

TRIAL REGISTRATION

German Clinical Trials Register, Registration number: DRKS00021233. Registered 23 April 2020 - Retrospectively registered, https://drks.de/search/en/trial/DRKS00021233 .

A cluster-randomized controlled trial of a nurse-led artificial intelligence assisted prevention and management for delirium (AI-AntiDelirium) on delirium in intensive care unit: Study protocol

BACKGROUND

Delirium is a common complication among intensive care unit (ICU) patients that is linked to negative clinical outcomes. However, adherence to the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS guidelines), which recommend the use of the ABCDEF bundle, is sub-optimal in routine clinical care. To address this issue, AI-AntiDelirium, a nurse-led artificial intelligence-assisted prevention and management tool for delirium, was developed by our research team. Our pilot study yielded positive findings regarding the use of AI-AntiDelirium in preventing patient ICU delirium and improving activities of daily living and increasing intervention adherence by health care staff.

METHODS

The proposed large-scale pragmatic, open-label, parallel-group, cluster randomized controlled study will assess the impact of AI-AntiDelirium on the incidence of ICU delirium and delirium-related outcomes. Six ICUs in two tertiary hospitals in China will be randomized in a 1:1 ratio to an AI-AntiDelirium or a PADIS guidelines group. A target sample size of 1,452 ICU patients aged 50 years and older treated in the ICU for at least 24 hours will be included. The primary outcome evaluated will be the incidence of ICU delirium and the secondary outcomes will be the duration of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, patient activities of daily living, and ICU nurse adherence to the ABCDEF bundle.

DISCUSSION

If this large-scale trial provides evidence of the effectiveness of AI-AntiDelirium, an artificial intelligence-assisted system tool, in decreasing the incidence of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, and patient activities of daily living while increasing ICU nurse adherence to the ABCDEF bundle, it will have a profound impact on the management of ICU delirium in both research and clinical practice.

CLINICAL TRIAL REGISTRATION

ChiCTR1900023711 (Chinese Clinical Trial Registry).

Effect of age and ICU types on mortality in invasive mechanically ventilated patients with sepsis receiving dexmedetomidine: a retrospective cohort study with propensity score matching

Background: Dexmedetomidine is recommended for sedation in patients on mechanical ventilation. Whether age or ICU types could alter mortality in invasive mechanically ventilated patients with sepsis receiving dexmedetomidine is unknown. Methods: We included patients with sepsis receiving invasive mechanical ventilation from the Medical Information Mart for Intensive Care IV database. The exposure was intravenous dexmedetomidine administration during ICU stay. The primary outcome was 28-day mortality. The secondary outcomes were the length of ICU stay and liberation from invasive mechanical ventilation. Propensity score matching (PSM) and Cox proportional hazards regression were used to adjust for confounders and investigate any association. Restricted cubic spline models were used to evaluate potential nonlinear associations. Results: The pre-matched and propensity score-matched cohorts included 5,871 and 2016 patients, respectively. In the PSM cohorts, dexmedetomidine exposure was related to lower 28-day mortality (186 [17.7%] vs. 319 [30.3%]; p < 0.001). Patients receiving dexmedetomidine, regardless of whether they were younger (≤65 years; hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.23-0.42; p < 0.001) or elderly (>65 years; HR, 0.65; 95% CI, 0.52-0.83; p < 0.001), was associated with lower 28-day mortality (61 [10.3%] vs. 168 [28.2%] for younger; 125 [27.2%] vs. 152 [33.0%] for elderly). Patients receiving dexmedetomidine was also associated with lower 28-day mortality (53 [12.6%] vs. 113 [26.5%] for surgical intensive care unit [SICU]; 133 [21.0%] vs. 206 [32.9%] for non-SICU) regardless of whether the first admission to the SICU (HR, 0.36; 95% CI, 0.25-0.50; p < 0.001) or non-SICU (HR, 0.50; 95% CI, 0.40-0.62; p < 0.001). Moreover, both dose and duration of dexmedetomidine administration were related to lower 28-day mortality than no dexmedetomidine in younger patients (p < 0.001), but it not statistically significant in elderly patients. Conclusion: Dexmedetomidine was associated with lower 28-day mortality in critically ill patients with sepsis receiving invasive mechanical ventilation, regardless of whether patients were younger or elderly, the first admission to the SICU or non-SICU.

Concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer: A multicenter, retrospective, observational study

OBJECTIVES

There is concern that hydroxyzine exacerbates delirium, but a recent preliminary study suggested that the combination of haloperidol and hydroxyzine was effective against delirium. This study examined whether the concomitant use of hydroxyzine and haloperidol worsened delirium in patients with cancer.

METHODS

This retrospective, observational study was conducted at 2 general hospitals in Japan. The medical records of patients with cancer who received haloperidol for delirium from July to December 2020 were reviewed. The treatments for delirium included haloperidol alone or haloperidol combined with hydroxyzine. The primary outcome was the duration from the first day of haloperidol administration to the resolution of delirium, defined as its absence for 2 consecutive days. The time to delirium resolution was analyzed to compare the haloperidol group and hydroxyzine combination group using the log-rank test with the Kaplan-Meier method. Secondary outcomes were (1) the total dose of antipsychotic medications, including those other than haloperidol (measured in chlorpromazine-equivalent doses), and (2) the frequencies of detrimental incidents during delirium, specifically falls and self-removal of drip infusion lines. The unpaired t-test and Fisher's exact test were used to analyze secondary outcomes.

RESULTS

Of 497 patients who received haloperidol, 118 (23.7%) also received hydroxyzine. No significant difference in time to delirium resolution was found between the haloperidol group and the hydroxyzine combination group (log-rank test, P = 0.631). No significant difference between groups was found in either chlorpromazine-equivalent doses or the frequency of detrimental incidents.

SIGNIFICANCE OF RESULTS

This study showed that the concomitant use of hydroxyzine and haloperidol did not worsen delirium in patients with cancer.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Physical rehabilitation while awake, intubated and proned for COVID-19-associated severe acute respiratory distress syndrome

This case study demonstrates the implementation of evidence-based guidelines in the intensive care unit setting, including light sedation and early physical rehabilitation while receiving prone positioning and lung protective mechanical ventilation for severe acute respiratory distress syndrome from SARS-CoV-2 infection.

Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.

Postoperative accurate pain assessment of children and artificial intelligence: A medical hypothesis and planned study

Although the pediatric perioperative pain management has been improved in recent years, the valid and reliable pain assessment tool in perioperative period of children remains a challenging task. Pediatric perioperative pain management is intractable not only because children cannot express their emotions accurately and objectively due to their inability to describe physiological characteristics of feeling which are different from those of adults, but also because there is a lack of effective and specific assessment tool for children. In addition, exposure to repeated painful stimuli early in life is known to have short and long-term adverse sequelae. The short-term sequelae can induce a series of neurological, endocrine, cardiovascular system stress related to psychological trauma, while long-term sequelae may alter brain maturation process, which can lead to impair neurodevelopmental, behavioral, and cognitive function. Children's facial expressions largely reflect the degree of pain, which has led to the developing of a number of pain scoring tools that will help improve the quality of pain management in children if they are continually studied in depth. The artificial intelligence (AI) technology represented by machine learning has reached an unprecedented level in image processing of deep facial models through deep convolutional neural networks, which can effectively identify and systematically analyze various subtle features of children's facial expressions. Based on the construction of a large database of images of facial expressions in children with perioperative pain, this study proposes to develop and apply automatic facial pain expression recognition software using AI technology. The study aims to improve the postoperative pain management for pediatric population and the short-term and long-term quality of life for pediatric patients after operational event.

The influence of drugs used for sedation during mechanical ventilation on respiratory pattern during unassisted breathing and assisted mechanical ventilation: a physiological systematic review and meta-analysis

Background

Sedation management has a major impact on outcomes in mechanically ventilated patients, but sedation strategies do not generally consider the differential effects of different sedatives on respiration and respiratory pattern. A systematic review was undertaken to quantitatively summarize the known effects of different classes of drugs used for sedation on respiratory pattern during both spontaneous breathing and assisted mechanical ventilation.

Methods

This was a systematic review and meta-analysis conducted using Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials up to June 2020 to retrieve studies that measured respiratory parameters before and after the administration of opioids, benzodiazepines, intravenous and inhaled anaesthetic agents, and other hypnotic agents (PROSPERO #CRD42020190017). A random-effects meta-analytic model was employed to estimate the mean percentage change in each of the respiratory indices according to medication exposure with and without mechanical ventilation. Risk of bias was assessed using the Cochrane risk of bias assessment tools.

Findings

Fifty-one studies were included in the analysis. Risk of bias was generally deemed to be low for most studies. Respiratory rate decreased with the administration of opioids in both non-ventilated patients (18% decrease, 95% CI 12-24%) and ventilated patients (26% decrease, 95% CI 15-37%) and increased with inhaled anaesthetics in non-ventilated patients (83% increase, 95% CI 49-118%) and ventilated patients (50% increase, 28-72%). In non-ventilated patients, tidal volume decreased following administration of inhaled aesthetics (55% decrease, 95% CI 25-86%), propofol (36% decrease, 95% CI 20-52%), and benzodiazepines (28% decrease, 95% CI 17-40%); in patients receiving assisted mechanical ventilation, tidal volume was not significantly affected by sedation. Administration of other hypnotic agents was not associated with changes in respiratory rate or tidal volume.

Interpretation

Different classes of drugs used for sedation exert differential effects on respiratory pattern, and this may influence weaning and outcomes in mechanically ventilated patients.

Funding

This study did not receive any funding support.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

[Effect of an Intervention Using Voice Recording of a Family Member on Patients Undergoing Mechanical Ventilator Weaning Process]

PURPOSE

This study aimed to determine the impact of an intervention using voice recording of family members on pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation.

METHODS

A randomized control pre-post experimental design was implemented to 53 participants, with 27 and 26 participants in the experimental and control groups, respectively. A 70-second voice recording of a family member, repeated three times at 10-minute intervals was used as an intervention for the experimental group. Meanwhile, participants in the control group used headset for 30 minutes. Structured instruments were utilized to measure pain, anxiety, agitation, and the weaning process. Wilcoxon Signed Ranks test and the Mann-Whitney U test, or χ² test, were used for data analysis.

RESULTS

The experimental group exhibited significant decrease in pain (Z = -3.53, p < .001), anxiety (t = 5.45, p < .001), and agitation (Z = -2.99, p = .003) scores compared with those of the control group. However, there was no significant difference between groups in the weaning process' simplification (χ² = 0.63, p = .727).

CONCLUSION

Intervention using family members' voice recording effectively reduces pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. This can be actively utilized to provide a more comfortable process for patients.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Patient mobilization in the intensive care unit: Assessing practice behavior - A multi-center point prevalence study

OBJECTIVES

To describe intensive care unit mobility clinical practice behaviors and the factors associated with these behaviors that could explain the theory-practice gap.

METHODOLOGY

A multi-center, descriptive, retrospective, one-day point prevalence study.

SETTING

intensive care patients hospitalized for a minimum of 24 hours, in 20 Israeli Adult Intensive Care Units, from six medical centers.

MAIN OUTCOME MEASURES

Maximum patient mobility level during the 24 hours prior to the prevalence study collection day and 48 hours from patient admission; mobility clinical practice behaviors and their inhibiting factors.

RESULTS

The study included 210 patients from a relatively even distribution of admission diagnoses. About half (46%) were intubated and 31% were hemodynamically unstable. Position change was most frequently reported as the maximum mobility level. The use of intubation, ventilation, tracheostomy, and inotropes was positively correlated with the level of mobility. Charlson Comorbidity Index and body mass index were not related to the level of mobility. A multiple regression model including these variables found that only intubation was a significant predictor of mobility level (R2 = 0.52, p < 0.001).

CONCLUSION

There is a gap between clinical practice guidelines and actual intensive care mobility practice behaviors. The association between mobility level and common therapies suggests subjective norms or common practices that could serve as a barrier to guideline implementation and partially explain the gap between clinical practice guidelines and clinical practice behavior.

IMPLICATIONS FOR CLINICAL PRACTICE

Behaviors and their subjective norms can be barriers to the implementation of clinical practice guidelines. Promoting increased provider awareness and policies of proactive mobilization could potentially improve patient outcomes.

Associations of Delirium to Posthospital Outcomes After Acute Stroke: A Scoping Review

ABSTRACT

Background: Delirium is a common and distressing manifestation of acute brain dysfunction that is associated with poor outcomes in various critically ill patient populations. Although patients with acute stroke experience delirium, understanding of delirium in this population is limited. The purpose of this scoping review is to describe existing evidence about delirium and associations with posthospital outcomes after acute stroke. Methods: Arksey and O'Malley's 5-stage framework was used to perform a scoping review. PubMed, CINAHL, and EMBASE electronic databases were searched. Outcome domains of interest included mortality, cognitive function, physical function, mental health, and quality of life. Full-text, peer-reviewed articles with adult stroke sample populations (acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) were included. Results: Nineteen articles, involving 5611 unique patients, were included. Most sample populations included patients with either acute ischemic stroke or intracerebral hemorrhage. Heterogeneous research aims, methods, and outcome measures limit the ability to compare specific findings across studies. However, included studies suggest higher mortality at 12 months, worse cognition, and greater functional impairment in patients who have experienced acute stroke and delirium. Limited information regarding associations of delirium with posthospital mental health outcomes and quality of life precluded the ability to analyze these relationships and warrants further investigation. Conclusion: This review suggests concerning findings about associations of delirium to posthospital outcomes after acute stroke. Better characterization of delirium after acute stroke and analysis of its impact on long-term outcomes are needed.

Use of Valproic Acid for the Management of Delirium and Agitation in the Intensive Care Unit

Purpose: Assess the efficacy and safety of valproic acid (VPA) for delirium and agitation in the intensive care unit (ICU) as compared to the use of other antipsychotics. Materials and Methods: This was a retrospective cohort study of patients treated for delirium and agitation in the ICU. Patients were included if they had a Richmond Agitation-Sedation Scale ≥2 and Confusion Assessment Method for the ICU positive. Patients were split into two groups based on their VPA exposure. The primary outcome was delirium free days. Secondary outcomes included agitation free days, ICU length of stay (LOS), mechanical ventilation duration, and mortality. Results: One hundred eight patients were included, 49 patients in the VPA group and 59 patients in the control group. Baseline characteristics were similar between groups. There was no significant difference in the primary outcome (difference -.15, 95% CI: 0.63-.93, P = .70). There were no significant differences in agitation-free days, mortality, mechanical ventilation duration, or ICU LOS. Conclusions: Our findings suggest that VPA is associated with similar delirium and agitation-free days compared to other non-VPA medications, with some adverse effects. Larger prospective studies are needed to validate the routine use of VPA in this setting.

Association between Patient Race and Ethnicity and Use of Invasive Ventilation in the United States

Rationale: Outcomes for people with respiratory failure in the United States vary by patient race and ethnicity. Invasive ventilation is an important treatment initiated based on expert opinion. It is unknown whether the use of invasive ventilation varies by patient race and ethnicity. Objectives: To measure 1) the association between patient race and ethnicity and the use of invasive ventilation; and 2) the change in 28-day mortality mediated by any association. Methods: We performed a multicenter cohort study of nonintubated adults receiving oxygen within 24 hours of intensive care admission using the Medical Information Mart for Intensive Care IV (MIMIC-IV, 2008-2019) and Phillips eICU (eICU, 2014-2015) databases from the United States. We modeled the association between patient race and ethnicity (Asian, Black, Hispanic, White) and invasive ventilation rate using a Bayesian multistate model that adjusted for baseline and time-varying covariates, calculated hazard ratios (HRs), and estimated 28-day hospital mortality changes mediated by differential invasive ventilation use. We reported posterior means and 95% credible intervals (CrIs). Results: We studied 38,258 patients, 52% (20,032) from MIMIC-IV and 48% (18,226) from eICU: 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% White (31,113). Invasive ventilation occurred in 9.2% (3,511), and 7.5% (2,869) died. The adjusted rate of invasive ventilation was lower in Asian (HR, 0.82; CrI, 0.70-0.95), Black (HR, 0.78; CrI, 0.71-0.86), and Hispanic (HR, 0.70; CrI, 0.61-0.79) patients compared with White patients. For the average patient, lower rates of invasive ventilation did not mediate differences in 28-day mortality. For a patient on high-flow nasal cannula with inspired oxygen fraction of 1.0, the odds ratios for mortality if invasive ventilation rates were equal to the rate for White patients were 0.97 (CrI, 0.91-1.03) for Asian patients, 0.96 (CrI, 0.91-1.03) for Black patients, and 0.94 (CrI, 0.89-1.01) for Hispanic patients. Conclusions: Asian, Black, and Hispanic patients had lower rates of invasive ventilation than White patients. These decreases did not mediate harm for the average patient, but we could not rule out harm for patients with more severe hypoxemia.

Recurrent delirium episodes within the intensive care unit: Incidence and associated factors

PURPOSE

Describe the incidence and factors associated with recurrent delirium in the intensive care unit (ICU).

MATERIALS AND METHODS

Retrospective study of ICU patients diagnosed with delirium. Delirium clearance defined as 48 h of negative delirium assessments following initial episode and recurrent delirium as any positive delirium assessment following clearance. Multivariable logistic regression model assessed independent association of patient and hospital factors on development of recurrent delirium, adjusting for pre-defined covariates.

RESULTS

Among 8591 ICU admissions identified with delirium, 1067 (12.4%) had recurrent symptoms. Factors associated with increased odds of recurrent delirium were age (nonlinear; p = 0.02), shock (OR 1.45, 95% CI [1.20, 1.75]), admission to medical (OR 3.25, 95% CI [2.42, 4.37]), surgical (OR 3.00, 95% CI [2.21, 4.06]), or trauma (OR 2.17, 95% CI [1.58, 3.00]) ICU vs. cardiovascular ICU, increased duration of mechanical ventilation (OR 2.43, 95% CI [2.22, 2.65]), propofol use (OR 1.35, 95% CI [1.02, 1.80]), and antipsychotic medications (haloperidol OR 1.53, 95% CI [1.26, 1.86]; quetiapine OR 2.45, 95% CI [1.98, 3.02]; and olanzapine OR 1.54, 95% CI [1.25, 1.88]).

CONCLUSIONS

Over 10% of delirious ICU patients had recurrent symptoms. Factors associated with recurrence included age, duration of mechanical ventilation and medication exposure.

CLINICAL TRIAL NUMBER

Not applicable.

Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation

OBJECTIVES

Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in Minnesota.

PATIENTS

Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours.

INTERVENTIONS

None.

MEASUREMENTS

Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected.

MAIN RESULTS

Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1-4.5) and ICU length of stay of 4.9 days (3-8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1-0.3) and 30 hours (15.1-51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33-96%), while 64% (37-91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients.

CONCLUSIONS

Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder

TOPIC IMPORTANCE

Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects.

REVIEW FINDINGS

No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings.

SUMMARY

Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations.

Predictive value of the geriatric nutrition risk index for postoperative delirium in elderly patients undergoing cardiac surgery

AIMS

The aims of the study were to determine the relationship between preoperative geriatric nutritional risk index (GNRI) and the occurrence of postoperative delirium (POD) in elderly patients after cardiac surgery and to evaluate the additive value of GNRI for predicting POD.

METHODS

The data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC-IV) database. Patients who underwent cardiac surgery and were aged 65 or older were included. The relationship between preoperative GNRI and POD was investigated using logistic regression. We determined the added predictive value of preoperative GNRI for POD by measuring the changes in the area under the receiver operating characteristic curve (AUC) and calculating the net reclassification improvement (NRI) and integrated discrimination improvement (IDI).

RESULTS

A total of 4286 patients were included in the study, and 659 (16.1%) developed POD. Patients with POD had significantly lower GNRI scores than patients without POD (median 111.1 vs. 113.4, p < 0.001). Malnourished patients (GNRI ≤ 98) had a significantly higher risk of POD (odds ratio, 1.83, 90% CI, 1.42-2.34, p < 0.001) than those without malnutrition (GNRI > 98). This correlation remains after adjusting for confounding variables. The addition of GNRI to the multivariable models slightly but not significantly increases the AUCs (all p > 0.05). Incorporating GNRI increases NRIs in some models and IDIs in all models (all p < 0.05).

CONCLUSIONS

Our results showed a negative association between preoperative GNRI and POD in elderly patients undergoing cardiac surgery. The addition of GNRI to POD prediction models may improve their predictive accuracy. However, these findings were based on a single-center cohort and will need to be validated in future studies involving multiple centers.

Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults

BACKGROUND

Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature.

AIM

The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC).

METHOD

This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill.

RESULTS

One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC.

CONCLUSION

Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.

Application of ensemble learning for predicting GABAA receptor agonists

BACKGROUND

Over the past few decades, agonists binding to the benzodiazepine site of the GABAA receptor have been successfully developed as clinical drugs. Different modulators (agonist, antagonist, and reverse agonist) bound to benzodiazepine sites exhibit different or even opposite pharmacological effects, however, their structures are so similar that it is difficult to distinguish them based solely on molecular skeleton. This study aims to develop classification models for predicting the agonists.

METHODS

306 agonists or non-agonists were collected from literature. Six machine learning algorithms including RF, XGBoost, AdaBoost, GBoost, SVM, and ANN algorithms were employed for model development. Using six descriptors including 1D/2D Descriptors, ECFP4, 2D-Pharmacophore, MACCS, PubChem, and Estate fingerprint to characterize chemical structures. The model interpretability was explored by SHAP method.

RESULTS

The best model demonstrated an AUC value of 0.905 and an MCC value of 0.808 for the test set. The PubMac-based model (PubMac-GB) achieved best AUC values of 0.935 for test set. The SHAP analysis results emphasized that MaccsFP62, ECFP_624, ECFP_724, and PubchemFP213 were the crucial molecular features. Applicability domain analysis was also performed to determine reliable prediction boundaries for the model. The PubMac-GB model was applied to virtual screening for potential GABAA agonists and the top 100 compounds were given.

CONCLUSION

Overall, our ensemble learning-based model (PubMac-GB) achieved comparable performance and would be helpful in effectively identifying agonists of GABAA receptors.

Evaluation of the Efficacy and Safety of Quetiapine in the Treatment of Delirium in Adult ICU Patients: A Retrospective Comparative Study

Background: Quetiapine is commonly prescribed off-label to manage delirium in intensive care unit (ICU) patients. However, limited studies comparing its efficacy and safety to those of other antipsychotics exist in the literature. Method: A retrospective, single-center chart review study was conducted on adults admitted to the ICU between January 2017 and August 2022, who were diagnosed with delirium and treated with a single antipsychotic and had no neurological medical conditions, active alcohol withdrawal, or prior use of antipsychotics. Data were analyzed using SPSS software version 28, with p-values of <0.05 indicating statistical significance. Results: In total, 47 patients were included, of whom 22 (46.8%), 19 (40.4%), 4 (8.5%), and 2 (4.3%) were on quetiapine, haloperidol, risperidone, and olanzapine, respectively. The median number of hours needed to resolve delirium were 12 (21.5), 23 (28), 13 (13.75), and 36 (10) (p = 0.115) for quetiapine, haloperidol, risperidone, and olanzapine, respectively, with haloperidol being used for a significantly shorter median number of days than quetiapine (3 (2.5) days vs. 7.5 (11.5) days; p = 0.007). Of the medication groups, only quetiapine-treated patients received a significantly higher median maintenance compared to the initiation dose (50 (50) mg vs. 50 (43.75) mg; p = 0.039). For the length of stay in the ICU and hospital, delirium-free days, % of ICU time spent in delirium, ventilator-free days, the difference between the highest and baseline QTc intervals, and ICU and hospital mortalities, no significant difference was observed between the groups. Conclusions: Overall, the use of quetiapine in our retrospective study seems to not be advantageous over the other drugs in terms of efficacy and safety outcomes.

Comparing the efficacy of intravenous morphine versus ibuprofen or the combination of ibuprofen and acetaminophen in patients with closed limb fractures: a randomized clinical trial

INTRODUCTION

This study aims to investigate the effectiveness of intravenous ibuprofen or intravenous ibuprofen plus acetaminophen compared to intravenous morphine in patients with closed extremity fractures.

METHODS

A triple-blinded randomized clinical trial was conducted at a tertiary trauma center in Iran. Adult patients between 15 and 60 years old with closed, isolated limb fractures and a pain intensity of at least 6/10 on the visual analog scale (VAS) were eligible. Patients with specific conditions or contraindications were not included. Participants were randomly assigned to receive intravenous ibuprofen, intravenous ibuprofen plus acetaminophen, or intravenous morphine. Pain scores were assessed using the visual analog scale at baseline and 5, 15, 30, and 60 min after drug administration. The primary outcome measure was the pain score reduction after one hour.

RESULTS

Out of 388 trauma patients screened, 158 were included in the analysis. There were no significant differences in age or sex distribution among the three groups. The pain scores decreased significantly in all groups after 5 min, with the morphine group showing the lowest pain score at 15 min. The maximum effect of ibuprofen was observed after 30 min, while the ibuprofen-acetaminophen combination maintained its effect after 60 min. One hour after injection, pain score reduction in the ibuprofen-acetaminophen group was significantly more than in the other two groups, and pain score reduction in the ibuprofen group was significantly more than in the morphine group.

CONCLUSION

The study findings suggest that ibuprofen and its combination with acetaminophen have similar or better analgesic effects compared to morphine in patients with closed extremity fractures. Although morphine initially provided the greatest pain relief, its effect diminished over time. In contrast, ibuprofen and the ibuprofen-acetaminophen combination maintained their analgesic effects for a longer duration. The combination therapy demonstrated the most sustained pain reduction. The study highlights the potential of non-opioid analgesics in fracture pain management and emphasizes the importance of initiation of these medications as first line analgesic for patients with fractures. These findings support the growing trend of exploring non-opioid analgesics in pain management.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05630222 (Tue, Nov 29, 2022). The manuscript adheres to CONSORT guidelines.

Development and validation of nurse's assessment ability questionnaire in delirium subtypes: Based on Delphi expert consensus

BACKGROUND

Delirium, a common occurrence in clinical work, can be divided into three subtypes according to Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5). Each subtype has its special significance and focus. As the primary caregivers and observer of delirious patients, nurses should be able to quickly and accurately indentify each subtype. Therefore, it is necessary to clarify nurses' assessment ability of delirium subtypes. However, there is currently no suitable questionnaire available for investigating nurses' assessment ability of delirium subtypes.

OBJECTIVE

To develop a scientifically validated questionnaire for assessing nursing assessment ability of delirium subtypes based on Knowledge-Attitude-Practice(KAP) Model.

METHODS

The questionnaire was conducted from October 2021 to February 2022 to assess the KAP status of nurses the regarding delirium subtype. A two-round Delphi Method was employed to revise the draft questionnaire, ensuring the importance and rationality of each item. Ten experts specializing in critically ill patients, clinical nursing, and nursing management were invited from seven provinces in China for the Delphi process. Additionally, we validated the reliability and validity of the questionnaire.

RESULTS

The return rate in the first and second rounds were 83% and 100%, respectively. The individual authority coefficients for the two rounds of correspondence ranged from 0.787 to 0.987, while the overall authority coefficient of experts was 0.866. Kendall's coefficient of coordination for the importance scores were found to be 0.192 and 0.156, respectively, whereas those for rationality scores were calculated as 0.149 and 0.141, respectively. Notably, all mean values of importance and rationality scores in the two rounds were exceeded a threshold of 4.10 across both rounds of assessment with coefficient variations (CV) ranging from 0.00 to 0.19 for importance ratings and 0.00 to 0.16 for rationality ratings, both of which were <0.25. Experts proposed modifications to eleven items while introducing four new ones into consideration during this process; thus ensuring that reliability and validity standards were met by the final questionnaire design which consists of a total of thirty-seven items distributed across four dimensions: delirium subtype-related knowledge, assessment attitude, assessment practice, and knowledge source-thereby establishing its clinical relevance as a reliable scientific instrument.

CONCLUSION

The development process is both scientific and theoretical, encompassing reliable expert correspondence results and a diverse range of question formats. As thus, effectively captures the current landscape of delirium subtypes assessment among clinical nurses from multiple perspectives, including knowledge level and source, attitude, assessment behavior, and assessment barriers. It offers comprehensive and detailed insights.

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol

BACKGROUND

Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults.

METHODS AND ANALYSIS

MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).