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

Early mobilization practice in intensive care units: A large-scale cross-sectional survey in China

BACKGROUND

The field of early rehabilitation has developed slowly in mainland China and there are limited data on the implementation of early mobilization (EM) practice in intensive care unit (ICUs) in China.

AIMS

To investigate the implementation of EM in ICUs in mainland China and to analyse its influencing factors.

DESIGN

A cross-sectional electronic survey was conducted in 444 ICUs across 11 provinces in China. Head nurses provided data on institutional characteristics and EM practice in ICUs. Logistic regression models were used to identify factors associated with the implementation of EM.

RESULTS

In all, 56.98% (253/444) of ICUs implemented EM with comprehensive or complete implementation in 86 ICUs. Of the 191 ICUs that did not use EM, 136 planned to implement EM in the near future. Of the 253 ICUs that used EM, 21.34% of ICUs implemented EM for all eligible patients, while 24.90% would evaluate and carry out EM within 48 h after ICU admission, 39.13% had collaborative EM teams, 34.39% reported the use of EM protocols, 14.63% reported multidisciplinary rounds and 17.39% had medical orders and charging standards for all EM activities. Only 18.18% of ICUs conducted frequent professional training for EM, and abnormal events occurred in 15.41% of ICUs during EM practice. Multivariate logistic regression analysis revealed that an economically strong province, the presence of a dedicated therapist team, more ICU beds and a higher staff-to-bed ratio favoured the implementation of EM. Furthermore, multidisciplinary rounds, well-established medical orders and charging standards, and a high frequency of professional training can lead to the comprehensive promotion and development of EM practice in ICUs.

CONCLUSIONS

Both the implementation rate and quality of EM practice for critically ill patients require improvement. EM practice in Chinese ICUs is still nascent and requires development in a variety of domains.

RELEVANCE FOR CLINICAL PRACTICE

To facilitate the implementation of EM in ICUs, more human resources, especially the involvement of a professional therapist team, should be deployed. In addition, health providers should actively organize multidisciplinary rounds and professional training and formulate appropriate EM medical orders and charging standards.

TRPV1 is involved in abdominal hyperalgesia in a mouse model of lipopolysaccharide-induced peritonitis and influences the immune response via peripheral noradrenergic neurons

AIMS

The transient receptor potential vanilloid subfamily 1 (TRPV1) not only plays a role as a nociceptor but also has some regulatory effects on the immune system. We investigated the effects of TRPV1 on abdominal pain and the immune system in lipopolysaccharide (LPS)-induced peritonitis and the association between TRPV1 and peripheral noradrenergic neurons.

MAIN METHODS

Experiments were performed in 8- to 14-week-old male wild-type (WT) and TRPV1 knockout (KO) mice. The mice were intraperitoneally injected with a non-lethal dose of LPS. Pain assessment and investigation of changes in the immune system were performed. Denervation of sympathetic nerves and the noradrenergic splenic nerve was induced by intraperitoneal administration of 6-hydroxydopamine.

KEY FINDINGS

The levels of serum cytokines were not significantly different in WT mice and TRPV1 KO mice. Abdominal mechanical hyperalgesia was greater in WT mice than in TRPV1 KO mice from 6 h to 3 days. The numbers of macrophages, neutrophils, dendritic cells, and CD4 T cells in the spleens of TRPV1 KO mice were significantly increased compared to those in WT mice 4 days after LPS administration. By noradrenergic denervation, the numbers of those cells in WT mice increased to levels comparable to those in TRPV1 KO mice.

SIGNIFICANCE

In LPS-induced peritonitis, abdominal inflammatory pain was transmitted via TRPV1. In addition, TRPV1 had an anti-inflammatory effect on the spleen in the late phase of peritonitis. This anti-inflammatory effect was thought to be mediated by activation of the sympathetic nervous system and/or noradrenergic splenic nerve induced by TRPV1 activation.

Association between the early mobilization of mechanically ventilated patients and independence in activities of daily living at hospital discharge

Physical dysfunction after discharge from the intensive care unit (ICU) is recognized as a common complication among ICU patients. Early mobilization (EM), defined as the ability to sit on the edge of the bed within 5 days, may help improve physical dysfunction. However, the barriers to, and achievement of, EM and their impact on physical dysfunction have not been fully investigated. This study aimed to investigate the achievement of EM and barriers to it and their impact on patient outcomes in mechanically ventilated ICU patients. We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU between April 2019 and March 2020, were aged ≥ 18 years, and received mechanical ventilation for > 48 h were eligible. The primary outcome was the rate of independent activities of daily living (ADL), defined as a score ≥ 70 on the Barthel index at hospital discharge. Daily changes in barriers of mobilization, including consciousness, respiratory, circulatory, medical staff factors, and device factors (catheter, drain, and dialysis), along with the clinical outcomes were investigated. The association among barriers, mobilization, and Barthel index ≥ 70 was analyzed using multivariable logistic regression analysis. During the study period, 206 patients were enrolled. EM was achieved in 116 patients (68%) on the fifth ICU day. The primary outcome revealed that achieving EM was associated with a Barthel index ≥ 70 at hospital discharge [adjusted odds ratio (AOR), 3.44; 95% confidence interval (CI), 1.70-6.96]. Device factors (AOR, 0.31; 95% CI, 0.13-0.75, respectively) were significantly associated with EM achievement. EM was associated with independent ADL at hospital discharge. Time to first mobilization and barriers to achieving mobilization can be important parameters for achieving ADL independence at discharge. Further research is required to determine the most common barriers so that they can be identified and removed.

Adverse effects of nonsteroidal anti-inflammatory drugs in critically ill patients: A scoping review

PURPOSE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended as opioid-sparing agents. The objective of this scoping review was to conduct a thorough search of the current literature to determine whether in adult critically ill patients there is an association between exposure to NSAIDs vs no NSAIDs and the subsequent development of serious adverse events, particularly gastrointestinal bleeding and acute kidney injury (AKI).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was utilized as a guideline for reporting. Searches were performed in PubMed (National Library of Medicine), Cochrane Library (Wiley), EMBASE (Elsevier), Stat!Ref (Teton), and Access Pharmacy (McGraw Hill) for articles published from January 2016 to August 2022.

RESULTS

Of the 3,062 citations and titles identified in the search, 2,737 titles remained after removal of duplicates, 2,588 were excluded at title and abstract screening, and 149 articles remained for full-text review. None of the studies involved heterogeneous groups of critically ill patients in nonspecialty intensive care unit settings. Most studies evaluated were conducted in the perioperative setting and had limited adverse events reporting, particularly with respect to serious NSAID-related adverse effects of concern in critically ill patients.

CONCLUSION

In published studies primarily involving perioperative patients, there is insufficient detail concerning the definitions and reporting of NSAID-related serious adverse events such as bleeding and AKI. These events are of particular concern in heterogeneous critically ill patient populations predisposed to such complications. In most (if not all) critically ill patients, sustained dosing of NSAIDs should be avoided regardless of COX-1 selectivity due to the paucity of safety data.

Modern Sedation and Analgesia Strategies in Neurocritical Care

PURPOSE OF REVIEW

Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population.

RECENT FINDINGS

In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.

Standardized pharmacological management of delirium after on-pump cardiac surgery reduces ICU stay and ventilation in a retrospective pre-post study

Cardiac surgery patients not only undergo a highly invasive procedure but are at risk for a diversity of postoperative complications. Up to 53% of these patients suffer from postoperative delirium (POD). This severe and common adverse event increases mortality and prolonged mechanical ventilation and extends the intensive care unit stay. The objective of this study was to test the hypothesis that standardized pharmacological management of delirium (SPMD) may reduce the length of stay in the intensive care unit (ICU), duration of postoperative mechanical ventilation, and the incidence of postoperative complications such as pneumonia or bloodstream infections in on-pump cardiac surgery ICU patients. In this retrospective, single-center observational cohort study, 247 patients were examined between May 2018 to June 2020, who underwent on-pump cardiac surgery, suffered from POD, and received pharmacological POD treatment. 125 were treated before and 122 after SPMD implementation in the ICU. The primary endpoint was a composite outcome, including the length of ICU stay, postoperative mechanical ventilation time, and ICU survival rate. The secondary endpoints were complications including postoperative pneumonia and bloodstream infections. Although the ICU survival rate was not significantly different between both groups, the length of ICU stay (control group: 23 ± 27 days; SPMD group: 16 ± 16 days; p = 0.024) and the duration of mechanical ventilation were significantly reduced in the SPMD-cohort (control group: 230 ± 395 h; SPMD group: 128 ± 268 h; p = 0.022). Concordantly, the pneumonic risk was reduced after SPMD introduction (control group: 44.0%; SPMD group: 27.9%; p = 0.012) as well as the incidence for bloodstream infections (control group: 19.2%; SPMD group: 6.6%; p = 0.004). Standardized pharmacological management of postoperative delirium in on-pump cardiac surgery ICU patients reduced the length of ICU stay and duration of mechanical ventilation significantly, leading to a decrease in pneumonic complications and bloodstream infections.

Quality contract 'prevention of postoperative delirium in the care of elderly patients' study protocol: a non-randomised, pre-post, monocentric, prospective trial

INTRODUCTION

Postoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a 'quality contract' (QC) as a new instrument to improve healthcare in Germany. One of the four areas for improvement of in-patient care is the 'Prevention of POD in the care of elderly patients' (QC-POD), as a means to reduce the risk of developing POD and its complications.The Institute for Quality Assurance and Transparency in Health Care identified gaps in the in-patient care of elderly patients related to the prevention, screening and treatment of POD, as required by consensus-based and evidence-based delirium guidelines. This paper introduces the QC-POD protocol, which aims to implement these guidelines into the clinical routine. There is an urgent need for well-structured, standardised and interdisciplinary pathways that enable the reliable screening and treatment of POD. Along with effective preventive measures, these concepts have a considerable potential to improve the care of elderly patients.

METHODS AND ANALYSIS

The QC-POD study is a non-randomised, pre-post, monocentric, prospective trial with an interventional concept following a baseline control period. The QC-POD trial was initiated on 1 April 2020 between Charité-Universitätsmedizin Berlin and the German health insurance company BARMER and will end on 30 June 2023.

INCLUSION CRITERIA

patients 70 years of age or older that are scheduled for a surgical procedure requiring anaesthesia and insurance with the QC partner (BARMER). Exclusion criteria included patients with a language barrier, moribund patients and those unwilling or unable to provide informed consent. The QC-POD protocol provides perioperative intervention at least two times per day, with delirium screening and non-pharmacological preventive measures.

ETHICS AND DISSEMINATION

This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/054/20). The results will be published in a peer-reviewed scientific journal and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04355195.

Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis

OBJECTIVE

Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19.

METHODS

This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates.

RESULTS

A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52).

CONCLUSION

AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit.

IMPACT

Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.

Association of early mobility with the incidence of deep-vein thrombosis and mortality among critically ill patients: a post hoc analysis of PREVENT trial

BACKGROUND

This study assessed the mobility levels among critically ill patients and the association of early mobility with incident proximal lower-limb deep-vein thrombosis and 90-day mortality.

METHODS

This was a post hoc analysis of the multicenter PREVENT trial, which evaluated adjunctive intermittent pneumatic compression in critically ill patients receiving pharmacologic thromboprophylaxis with an expected ICU stay ≥ 72 h and found no effect on the primary outcome of incident proximal lower-limb deep-vein thrombosis. Mobility levels were documented daily up to day 28 in the ICU using a tool with an 8-point ordinal scale. We categorized patients according to mobility levels within the first 3 ICU days into three groups: early mobility level 4-7 (at least active standing), 1-3 (passive transfer from bed to chair or active sitting), and 0 (passive range of motion). We evaluated the association of early mobility and incident lower-limb deep-vein thrombosis and 90-day mortality by Cox proportional models adjusting for randomization and other co-variables.

RESULTS

Of 1708 patients, only 85 (5.0%) had early mobility level 4-7 and 356 (20.8%) level 1-3, while 1267 (74.2%) had early mobility level 0. Patients with early mobility levels 4-7 and 1-3 had less illness severity, femoral central venous catheters, and organ support compared to patients with mobility level 0. Incident proximal lower-limb deep-vein thrombosis occurred in 1/85 (1.3%) patients in the early mobility 4-7 group, 7/348 (2.0%) patients in mobility 1-3 group, and 50/1230 (4.1%) patients in mobility 0 group. Compared with early mobility group 0, mobility groups 4-7 and 1-3 were not associated with differences in incident proximal lower-limb deep-vein thrombosis (adjusted hazard ratio [aHR] 1.19, 95% confidence interval [CI] 0.16, 8.90; p = 0.87 and 0.91, 95% CI 0.39, 2.12; p = 0.83, respectively). However, early mobility groups 4-7 and 1-3 had lower 90-day mortality (aHR 0.47, 95% CI 0.22, 1.01; p = 0.052, and 0.43, 95% CI 0.30, 0.62; p < 0.0001, respectively).

CONCLUSIONS

Only a small proportion of critically ill patients with an expected ICU stay ≥ 72 h were mobilized early. Early mobility was associated with reduced mortality, but not with different incidence of deep-vein thrombosis. This association does not establish causality, and randomized controlled trials are required to assess whether and to what extent this association is modifiable.

TRIAL REGISTRATION

The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103 (registered on 3 November 2013) and Current controlled trials, ID: ISRCTN44653506 (registered on 30 October 2013).

Evaluation of Pain Scales and Outcome in Critically Ill Patients of a Greek ICU

The purpose of the study was to evaluate painful procedures in ICU patients and to investigate their effect as well as the role of analgesia in the outcome. We measured pain level and vital signs before, during and after potentially painful procedures by using the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). We analyzed the correlation of these measurements and of analgesia with the outcome. Twenty-eight patients were subjected to 160 stimuli. There were statistically significant differences in pain scores and most vital signs between the different timepoints (before-during, during-after). Most of them were significantly correlated with each other. Physiotherapy proved to be the most painful procedure. Regarding the outcome, the administration of extra analgesia predicted less days of mechanical ventilation (p = 0.015) and of ICU stay (p = 0.016). The higher change in BPS was correlated with more days of mechanical ventilation [B (95% CI) = 3.640 (1.001-6.280), p = 0.007] and of ICU stay [B (95% CI) = 3.645 (1.035-6.254), p = 0.006]. The higher change in CPOT and the nonuse of extra analgesia were related to increased mortality [OR (95% CI) = 1.492 (1.107-2.011), p = 0.009 and OR (95% CI) = 2.626 (1.013-6.806), p = 0.047]. Increased pain in ICU patients was successfully assessed by the BPS and CPOT and correlated to worse outcomes, which the administration of extra analgesia might improve.

Independent External Validation of a Preoperative Prediction Model for Delirium After Cardiac Surgery: A Prospective Observational Cohort Study

OBJECTIVE

This investigation provided independent external validation of an existing preoperative risk prediction model.

DESIGN

A prospective observational cohort study of patients undergoing cardiac surgery covering the period between April 16, 2018 and January 18, 2022.

SETTING

Two academic hospitals in Switzerland.

PARTICIPANTS

Adult patients (≥60 years of age) who underwent elective cardiac surgery, including coronary artery bypass graft, mitral or aortic valve replacement or repair, and combined procedures.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was the incidence of postoperative delirium (POD) in the intensive or intermediate care unit, diagnosed using the Intensive Care Delirium Screening Checklist. The prediction model contained 4 preoperative risk factors to which the following points were assigned: Mini-Mental State Examination (MMSE) score ≤23 received 2 points; MMSE 24-27, Geriatric Depression Scale (GDS) >4, prior stroke and/or transient ischemic attack (TIA), and abnormal serum albumin (≤3.5 or ≥4.5 g/dL) received 1 point each. The missing data were handled using multiple imputation. In total, 348 patients were included in the study. Sixty patients (17.4%) developed POD. For point levels in the prediction model of 0, 1, 2, and ≥3, the cumulative incidence of POD was 12.6%, 22.8%, 25.8%, and 35%, respectively. The validation resulted in a pooled area under the receiver operating characteristics curve of 0.60 (median CI, 0.525-0.679).

CONCLUSIONS

The evaluated predictive model for delirium after cardiac surgery in this patient cohort showed only poor discriminative capacity but fair calibration.

Receptive Music Therapy for Patients Receiving Mechanical Ventilation in the Intensive Care Unit

BACKGROUND

Live music therapy provided by a board-certified music therapist reduces anxiety, decreases pain, and improves the physiological response of patients in the intensive care unit (ICU).

OBJECTIVES

To examine the effect of live music therapy on the physiological parameters and pain and agitation levels of adult ICU patients receiving mechanical ventilation.

METHODS

A total of 118 patients were randomly assigned to live music therapy or standard care. The music therapy group received 30 minutes of live music therapy tailored to each patient's needs. The Richmond Agitation-Sedation Scale and the Critical Care Pain Observation Tool were completed by critical care nurses immediately before and after each session, and the patients' heart rates, respiratory rates, and oxygenation levels were measured.

RESULTS

Patients who received live music therapy had significantly different scores on the Richmond Agitation-Sedation Scale (P < .001) and the Critical Care Pain Observation Tool (odds ratio, 6.02; P = .002) compared with the standard care group. Significant differences between groups were also reported in heart rate (P < .001). No significant differences were found in oxygen values.

CONCLUSIONS

Live music therapy significantly reduced agitation and heart rate in adult patients receiving mechanical ventilation in the ICU. These findings provide further evidence for the benefits of music therapy in the ICU, including in intubated patients.

When Should We Intubate in Hypoxemic Respiratory Failure?

Intubation during Hypoxemic Respiratory FailureThere is little evidence to guide the common and high-stakes decision to initiate invasive ventilation in hypoxemic respiratory failure. In this Tomorrow's Trial, Yarnell and Patel propose a randomized trial of different physiological thresholds for the initiation of invasive ventilation.

Pharmacologic Interventions to Prevent Delirium in Trauma Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

To compare the relative efficacy of pharmacologic interventions in the prevention of delirium in ICU trauma patients.

DATA SOURCES

We searched Medical Literature Analysis and Retrieval System Online, Embase, and Cochrane Registry of Clinical Trials from database inception until June 7, 2022. We included randomized controlled trials comparing pharmacologic interventions in critically ill trauma patients.

STUDY SELECTION

Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias.

DATA EXTRACTION

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for network analysis were followed. Random-effects models were fit using a Bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) for dichotomous outcomes and mean differences for continuous outcomes, each with 95% credible intervals. Treatment rankings were estimated for each outcome in the form of surface under the cumulative ranking curve values.

DATA SYNTHESIS

A total 3,541 citations were screened; six randomized clinical trials (n = 382 patients) were included. Compared with combined propofol-dexmedetomidine, there may be no difference in delirium prevalence with dexmedetomidine (HR 1.44, 95% CI 0.39-6.94), propofol (HR 2.38, 95% CI 0.68-11.36), nor haloperidol (HR 3.38, 95% CI 0.65-21.79); compared with dexmedetomidine alone, there may be no effect with propofol (HR 1.66, 95% CI 0.79-3.69) nor haloperidol (HR 2.30, 95% CI 0.88-6.61).

CONCLUSIONS

The results of this network meta-analysis suggest that there is no difference found between pharmacologic interventions on delirium occurrence, length of ICU stay, length of hospital stay, or mortality, in trauma ICU patients.

The use of islamic spiritual care practices among critically ill adult patients: A systematic review

Spiritual care is essential to the healthcare plans of critically ill patients and their families. However, spiritual care remains neglected and requires healthcare institutions and providers' attention to be incorporated into healthcare management plans, especially for critically ill Muslim patients and their families. To date, no review has been conducted to discuss spiritual care in adult critical care Muslim patients. Spiritual care and Holy Quran recitation have been reported to be practical non-pharmacological interventions for critically ill Muslim patients. However, there is a need for Islamic healthcare institutions and providers to pay further attention to including spiritual care in the healthcare management plans of their patients. Also, future research is recommended to test the effectiveness of incorporating spiritual care in the healthcare plans of critical care patients.

Delirium Prevention and Management in Frail Surgical Patients

Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.

Adherence to Sedation Targets With Weight-Based Propofol and Dexmedetomidine in Patients With Morbid Obesity

BACKGROUND

Propofol and dexmedetomidine are routinely used in intensive care units (ICUs). Both are lipophilic, potentially leading to accumulation in adipose tissue. Limited evidence exists on what body weight to utilize in patients with morbid obesity.

OBJECTIVE

The purpose of this research was to evaluate the safety and efficacy of weight-based sedation with propofol and dexmedetomidine in ICU patients with morbid obesity.

METHODS

Retrospective review of ICU patients admitted from January 2018 to January 2020 who were sedated for ≥48 hours was performed. The primary outcome was the percentage of time within target sedation during the first 48 hours, stratified by body mass index (BMI) <40 or ≥40 kg/m². Additional outcomes included adverse events and the infusion rate to achieve target sedation. Data were evaluated using descriptive statistics.

RESULTS

A total of 80 patients were analyzed. Patients on propofol with a BMI <40 kg/m² were in their target Richmond Agitation-Sedation Scale (RASS) 11.7% versus 16.1% with a BMI ≥40 kg/m² (P = .580). Patients with a BMI <40 kg/m² on dexmedetomidine were in their target RASS 27.6% versus 10.7% with a BMI ≥40 kg/m² (P = .053).

CONCLUSION AND RELEVANCE

Body mass index did not significantly alter propofol target sedation attainment. However, patients with morbid obesity on dexmedetomidine demonstrated significantly less time in target sedation. An actual body weight dosing strategy of these drugs did not achieve desired target sedation for those with a BMI ≥40 versus BMI <40 kg/m². These findings support future research on the optimal sedation dosing strategy in this patient population.

Success in Supporting Early Mobility and Exercise in a Cardiothoracic Intensive Care Unit

Early mobility contributes to improved patient outcomes and reduced hospital length of stay during acute and intensive care hospitalization. The Bedside Mobility Assessment Tool was implemented in a cardiothoracic intensive care unit during participation in a nationwide evidence-based quality improvement initiative. One outcome included a high level of mobility that was sustained over time. Using the Dynamic Sustainability Framework model, this article describes the key components that contributed to this sustained mobility performance over 4 years.

Evaluation of the Relationship between Baseline Autonomic Tone and Haemodynamic Effects of Dexmedetomidine

Dexmedetomidine, a central α-2 agonist, is used for procedural sedation and for conscious sedation influences on heart rate and blood pressure. Authors verified whether it is possible to predict bradycardia and hypotension with the use of heart rate variability (HRV) analysis for an autonomic nervous system (ANS) activity assessment. The study included adult patients of both sexes with an ASA score of I or II scheduled for ophthalmic surgery to be performed under sedation. The loading dose of dexmedetomidine was followed by a 15 min infusion of the maintenance dose. The frequency domain heart rate variability parameters from the 5-min Holter electrocardiogram recordings before dexmedetomidine administration were used for the analysis. The statistical analysis also included pre-drug heart rate and blood pressure as well as patient age and sex. The data from 62 patients were analysed. There was no relationship between the decrease in heart rate (42% of cases) and initial HRV parameters, haemodynamic parameters or sex and age of patients. In multivariate analysis, the only risk factor for a decrease in mean arterial pressure (MAP) > 15% from the pre-drug value (39% of cases) was the systolic blood pressure before dexmedetomidine administration as well as for a >15% decrease in MAP sustained at more than one consecutive time point (27% of cases). The initial condition of the ANS did not correlate with the incidence of bradycardia or hypotension; HRV analysis was not helpful in predicting the abovementioned side effects of dexmedetomidine.

Oxygenation thresholds for invasive ventilation in hypoxemic respiratory failure: a target trial emulation in two cohorts

BACKGROUND

The optimal thresholds for the initiation of invasive ventilation in patients with hypoxemic respiratory failure are unknown. Using the saturation-to-inspired oxygen ratio (SF), we compared lower versus higher hypoxemia severity thresholds for initiating invasive ventilation.

METHODS

This target trial emulation included patients from the Medical Information Mart for Intensive Care (MIMIC-IV, 2008-2019) and the Amsterdam University Medical Centers (AmsterdamUMCdb, 2003-2016) databases admitted to intensive care and receiving inspired oxygen fraction ≥ 0.4 via non-rebreather mask, noninvasive ventilation, or high-flow nasal cannula. We compared the effect of using invasive ventilation initiation thresholds of SF < 110, < 98, and < 88 on 28-day mortality. MIMIC-IV was used for the primary analysis and AmsterdamUMCdb for the secondary analysis. We obtained posterior means and 95% credible intervals (CrI) with nonparametric Bayesian G-computation.

RESULTS

We studied 3,357 patients in the primary analysis. For invasive ventilation initiation thresholds SF < 110, SF < 98, and SF < 88, the predicted 28-day probabilities of invasive ventilation were 72%, 47%, and 19%. Predicted 28-day mortality was lowest with threshold SF < 110 (22.2%, CrI 19.2 to 25.0), compared to SF < 98 (absolute risk increase 1.6%, CrI 0.6 to 2.6) or SF < 88 (absolute risk increase 3.5%, CrI 1.4 to 5.4). In the secondary analysis (1,279 patients), the predicted 28-day probability of invasive ventilation was 50% for initiation threshold SF < 110, 28% for SF < 98, and 19% for SF < 88. In contrast with the primary analysis, predicted mortality was highest with threshold SF < 110 (14.6%, CrI 7.7 to 22.3), compared to SF < 98 (absolute risk decrease 0.5%, CrI 0.0 to 0.9) or SF < 88 (absolute risk decrease 1.9%, CrI 0.9 to 2.8).

CONCLUSION

Initiating invasive ventilation at lower hypoxemia severity will increase the rate of invasive ventilation, but this can either increase or decrease the expected mortality, with the direction of effect likely depending on baseline mortality risk and clinical context.

Influence of Deep Sedation in Intensive Care Medicine Memories of Critical COVID-19 Survivors

Introduction: Critical care survivors sustain a variety of sequelae after intensive care medicine (ICM) admission, and the Coronavirus Disease 2019 (COVID-19) pandemic has added further challenges. Specifically, ICM memories play a significant role, and delusional memories are associated with poor outcomes post-discharge including a delayed return to work and sleep problems. Deep sedation has been associated with a greater risk of perceiving delusional memories, bringing a move toward lighter sedation. However, there are limited reports on post-ICM memories in COVID-19, and influence of deep sedation has not been fully defined. Therefore, we aimed to evaluate ICM-memory recall in COVID-19 survivors and their relation with deep sedation. Materials/Methods: Adult COVID-19 ICM survivors admitted to a Portuguese University Hospital between October 2020 and April 2021 (second/third "waves") were evaluated 1 to 2 months post-discharge using "ICU Memory Tool," to assess real, emotional, and delusional memories. Results: The study included 132 patients (67% male; median age = 62 years, Acute Physiology and Chronic Health Evaluation [APACHE]-II = 15, Simplified Acute Physiology Score [SAPS]-II = 35, ICM stay = 9 days). Approximately 42% received deep sedation (median duration = 19 days). Most participants reported real (87%) and emotional (77%) recalls, with lesser delusional memories (36.4%). Deeply sedated patients reported significantly fewer real memories (78.6% vs 93.4%, P = .012) and increased delusional memories (60.7% vs 18.4%, P < .001), with no difference in emotional memories (75% vs 80.4%, P = .468). In multivariate analysis, deep sedation had a significant, independent association with delusional memories, increasing their likelihood by a factor of approximately 6 (OR = 6.274; 95% confidence interval = 1.165-33.773, P = .032), without influencing real (P = .545) or emotional (P = .133) memories. Conclusions: This study contributes to a better understanding of the potential adverse effects of deep sedation on ICM memories in critical COVID-19 survivors, indicating a significant, independent association with the incidence of delusional recalls. Although further studies are needed to support these findings, they suggest that strategies targeted to minimize sedation should be favored, aiming to improve long-term recovery.

A comprehensive overview of clinical research on dexmedetomidine in the past 2 decades: A bibliometric analysis

Introduction: Dexmedetomidine is a potent, highly selective α-2 adrenoceptor agonist with sedative, analgesic, anxiolytic, and opioid-sparing properties. A large number of dexmedetomidine-related publications have sprung out in the last 2 decades. However, no bibliometric analysis for clinical research on dexmedetomidine has been published to analyze hot spots, trends, and frontiers in this field. Methods: The clinical articles and reviews related to dexmedetomidine, published from 2002 to 2021 in the Web of Science Core Collection, were retrieved on 19 May 2022, using relevant search terms. VOSviewer and CiteSpace were used to conduct this bibliometric study. Results: The results showed that a total of 2,299 publications were retrieved from 656 academic journals with 48,549 co-cited references by 2,335 institutions from 65 countries/regions. The United States had the most publications among all the countries (n = 870, 37.8%) and the Harvard University contributed the most among all institutions (n = 57, 2.48%). The most productive academic journal on dexmedetomidine was Pediatric Anesthesia and the first co-cited journal was Anesthesiology. Mika Scheinin is the most productive author and Pratik P Pandharipande is the most co-cited author. Co-cited reference analysis and keyword analysis illustrated hot spots in the dexmedetomidine field including pharmacokinetics and pharmacodynamics, intensive care unit sedation and outcome, pain management and nerve block, and premedication and use in children. The effect of dexmedetomidine sedation on the outcomes of critically ill patients, the analgesic effect of dexmedetomidine, and its organ protective property are the frontiers in future research. Conclusion: This bibliometric analysis provided us with concise information about the development trend and provided an important reference for researchers to guide future research.

The Validity of Vital Signs for Pain Assessment in critically Ill Adults: A Narrative Review

OBJECTIVES

Pain assessment in the intensive care unit (ICU) is challenging because many patients are unable to self-report or exhibit pain-related behaviors. In such situations, vital signs (VS) through continuous monitoring are alternative cues for pain assessment. This review aimed to describe the reliability and validity of VS for ICU pain assessment.

DESIGN

Narrative review of the literature.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane.

REVIEW/ANALYSIS METHODS

A narrative review was conducted with a comprehensive search in four databases. Search terms included VS, pain assessment, and ICU.

RESULTS

Out of 1,359 results, 30 studies from 17 countries were included. Heart rate, blood pressure, and respiratory rate were most used for ICU pain assessment. Assessments were performed at rest before procedures, during nociceptive and non-nociceptive procedures, and after procedures. Increases in respiratory rate were clinically significant by more than 25% during nociceptive procedures (e.g., endotracheal suctioning, turning) compared with rest/pre-procedures in five studies. Correlations of VS with self-reported pain (reference standard measure) and behavioral pain scores (alternative measure) were absent or weak.

CONCLUSIONS

VS are not valid indicators for ICU pain assessment. Increases of respiratory rate may be a cue for the detection of pain. However, fluctuations in respiratory rate can be influenced by opioids or controlled ventilation mode. Our results dissuade the use of VS for pain assessment because of the lack of association with ICU pain reference standards. Other physiologic measures of pain in critically ill adults should be explored.

Profile of liver cholestatic biomarkers following prolonged ketamine administration in patients with COVID-19

BACKGROUND

To investigate the possible influence of prolonged ketamine (K) or esketamine (ESK) infusion on the profile of liver cholestatic biomarkers in patients with COVID-19 infection.

METHODS

A retrospective analysis was performed on 135 patients with COVID-19 related ARDS who received prolonged K or ESK infusion. They were compared to 15 COVID-19 ICU patients who did not receive K/ESK while being mechanically ventilated and 108 COVID-19 patients who did not receive mechanical ventilation nor K/ESK. The profile of the liver function tests was analysed in the groups.

RESULTS

Peak values of ALP, GGT and bilirubin were higher in the K/ESK group, but not for AST and ALT. Peak values of ALP were significantly higher among patients who underwent mechanical ventilation and who received K/ESK, compared with mechanically ventilated patients who did not receive K/ESK. There was a correlation between these peak values and the cumulative dose and duration of K/ESK therapy.

CONCLUSIONS

Based on the observations of biliary anomalies in chronic ketamine abusers, prolonged exposure to ketamine sedation during mechanical ventilation may also be involved, in addition to viral infection causing secondary sclerosing cholangitis. The safety of prolonged ketamine sedation on the biliary tract requires further investigations.

Sepsis-Associated Delirium: A Narrative Review

Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial

Background

Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures.

Methods

A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium.

Results

In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery.

Discussion

Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT03704090.

Patient mobilisation in the intensive care unit and evaluation of a multifaceted intervention including Facebook groups: A quasi-experimental study

AIMS

To describe prevalence and time to mobilisation in intensive care unit patients defined as a minimum sitting in an upright position in bed, and evaluate the impact of a multifaceted quality improvement campaign on likelihood of patients being mobilised.

RESEARCH METHODOLOGY/DESIGN

Quality improvement project using a quasi-experimental study design, comparing patient cohorts before (Before) and after (Intervention) a campaign including educational sessions, audit and feedback of intensive care unit quality indicators via closed Facebook-groups and e-mail and local opinion leaders. Secondary analysis of mobilisation data from adult intensive care patient stays extracted from electronical medical charts. Likelihood of being mobilised was analysed with Multivariate Cox-regression model and reported as Sub-hazard Ratio (SHR).

SETTING

Four intensive care units in a university hospital.

MAIN OUTCOME MEASURES

Prevalence and time to first documented mobilisation, defined as at least "sitting in bed" during the intensive care unit stay.

RESULTS

Overall, 929 patients were analysed, of whom 710 (76 %) were mobilised; 73 % (356/ 489) in Before vs 81 % (354/ 440) in Intervention (p = 0.007). Median time to mobilisation was 69.9 (IQR: 30.0, 149.8) hours; 71.7 (33.9, 157.9) in Before and 66.0 (27.1, 140.3) in Intervention (p = 0.104). Higher SAPS II-scores were associated with lower likelihood (SHR 0.98, 95 % CI 0.97-0.99), whereas admissions due to gastroenterological failure (SHR 2.1, 95 % CI 1.4-3.0), neurological failure (SHR 1.5, 95 % CI 1.0-2.2) and other causes (intoxication, postoperative care, haematological-, and kidney failure) (SHR 1.7, 95 % CI 1.13-2.6) were associated with higher likelihood of mobilisation vs respiratory failure.

CONCLUSION

A quality improvement campaign including use of Facebook groups is feasible and may improve mobilisation in intensive care unit patients. Most patients were mobilised within 72 hours following intensive care unit admission, and SAPS II scores and causes for intensive care unit admission were both associated with likelihood of being mobilised.

Early Sedation Depth and Clinical Outcomes in Mechanically Ventilated Patients in a Hospital: Retrospective Cohort Study

PURPOSE

This study aimed to identify the early sedation depth in the first 48 hours of mechanical ventilation and its relationship to clinical outcomes to promote the transition to light sedation.

METHODS

This retrospective single-center cohort study was conducted in two medical intensive care units (MICUs) at a general tertiary hospital, using a standardized sedation protocol. To investigate the early sedation depth, the Sedation Index was used, which can indicate changes over the first 48 hours. Patients were divided into three groups based on tertiles of Sedation Index. The primary outcome was mortality at 30, 90, and 180 days. The secondary outcomes included length of stay in the ICU and ventilator-free days. Kaplan-Meier analysis and multivariable Cox regression were conducted to compare factors influencing mortality.

RESULTS

This study included 394 patients. The deepest sedation group showed more severe illness, delirium, and deeper sedation at admission (p < .001). The survival curve decreased as sedation increased, even within the light sedation levels. In the deepest sedation group, 30-day mortality (hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.33-3.34), 90-day mortality (HR 2.00, 95% CI 1.31-3.06), and 180-day mortality (HR 1.77, 95% CI 1.17-2.67) increased. The length of stay in the ICU and ventilator-free days did not show statistical differences.

CONCLUSIONS

These results indicate that early deep sedation is a modifiable factor that can potentially affect mortality. The protocol for inducing the transition into light sedation must comply with recommendations to improve clinical outcomes.

Analgesia nociception index and high frequency variability index: promising indicators of relative parasympathetic tone

At present, there is no objective and absolute measure of nociception, although various monitoring techniques have been developed. One such technique is the Analgesia Nociception Index (ANI), which is calculated from heart rate variability that reflects the relative parasympathetic tone. ANI is expressed on a non-unit scale of 0-100 (100 indicates maximal relative parasympathetic tone). Several studies indicated that ANI-guided anesthesia may help reduce intraoperative opioid use. The usefulness of ANI in the intensive care unit (ICU) and during surgery has also been reported. However, some limitations of ANI have also been reported; for example, ANI is affected by emotions and some drugs. In 2022, a high frequency variability index (HFVI), which was renamed from ANI and uses the same algorithm as ANI, was commercialized; therefore, ANI/HFVI are currently in the spotlight. Unlike ANI, HFVI can be displayed along with other biometric information on the Root® monitor. ANI/HFVI monitoring may affect the prognosis of not only patients in the perioperative period but those in ICU, those who receive home medical care, or outpatients. In this article, we present an updated review on ANI that has been published in the last decade, introduce HFVI, and discuss the outlooks of ANI/HFVI.

Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey

BACKGROUND

Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM.

METHODS

A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists).

RESULTS

Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained.

CONCLUSION

Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.

Evaluation of Medications Used for Hospitalized Patients With Sleep Disturbances: A Frequency Analysis and Literature Review

PURPOSE

Poor sleep during hospitalization is common and implicated in worse patient outcomes. Despite implementation of non-pharmacologic techniques, medications are still frequently required. The study objective is to assess the frequency of new medications administered for sleep in hospitalized patients and to review literature evaluating these drug therapies in the inpatient setting.

METHODS

This retrospective study included adult inpatients if they received a new medication for sleep during a 5-day period. Patients were excluded if the medication was continued from home or if sleep was not the documented indication. For the literature review, a MEDLINE search was conducted to identify studies pertaining to pharmacotherapy for sleep in hospitalized patients.

RESULTS

Of 1,968 patient-days reviewed, a medication for sleep was given for 166 patient-days (8.4%) in 78 patients. Melatonin was most commonly received (70.5%), followed by benzodiazepines (9.6%). A review of antihistamines, benzodiazepines, melatonin, quetiapine, trazodone, and Z-drugs (non-benzodiazepine hypnotics) was conducted and 23 studies were included.

CONCLUSIONS

Despite widespread use of pharmacotherapy for sleep, there is a paucity of data evaluating use in the inpatient setting. Although there is significant heterogeneity among studies, melatonin has the strongest evidence for use and is an attractive option given its lack of adverse reactions and drug interactions. Benzodiazepines and Z-drugs were also frequently utilized; however, their reduced clearance in the elderly and potential for compounded sedative effects should be weighed heavily against potential sleep benefits. Antipsychotic agents cannot be recommended for routine use due to limited data and the potential for significant adverse effects.

Communication with mechanically ventilated patients in intensive care units: A concept analysis

AIMS

The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients.

DESIGN

The Im & Meleis approach for concept analysis guided the study.

SEARCH METHODS

A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references.

REVIEW METHODS

After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed.

RESULTS

We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units.

CONCLUSION

Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves.

IMPACT

A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this is a concept analysis of previous research.

Knowledge, attitude, and practice toward delirium and subtype assessment among Chinese clinical nurses and determinant factors: A multicentre cross-section study

Background

Delirium, a confused transient state of consciousness, can be divided into hyperactive, hypoactive, mixed, and no motor subtypes, according to different clinical manifestations. Several studies have investigated delirium subtypes in the knowledge dimension, but few studies have investigated delirium subtype in the attitude and practice dimensions. The barriers, knowledge sources, and practice details regarding subtype assessment are unclear.

Objectives

This study had three objectives. First, we planned to investigate the KAP status regarding delirium and subtypes for nurses. Second, we wanted to identify factors affecting clinical nurses' KAP scores. Third, this study expected to explore more details regarding delirium and subtypes assessment, including assessment barriers, assessment instruments, and knowledge sources.

Methods

This multicentre cross-section study was conducted in 10 tertiary hospitals in three provinces, China, from January to April 2022. We investigated 477 nurses from six departments with a high prevalence. The self-developed KAP questionnaire regarding delirium and subtypes assessment had four parts: knowledge, attitude, practice, and source. Its reliability and validity were verified effectively by 2-round Delphi expert consultation.

Results

A total of 477 nurses from the general intensive care unit (ICU), specialty ICU, orthopedics, thoracic surgery, operating room, and geriatrics were 28.3, 22.4, 22.2, 10.5, and 5.2%, respectively. The total KAP score regarding delirium and subtypes assessment was 60.01 ± 6.98, and the scoring rate was 73.18%. The scoring rate for knowledge, attitude, and practice was 58.55, 83.94, and 51.70%, respectively. More than half (54.1%) were unaware of the delirium subtypes assessment instruments. A total of 451 (94.6%) participants recognized the importance of nursing work for delirium prevention. A total of 250 (52.4%) nurses occasionally or sometimes assessed delirium subtypes, and 143 (30.0%) never assessed for delirium subtypes. We found that age, department, technical title, familiarity with delirium, familiarity with delirium subtypes, delirium training, and subtype training affected the total KAP scores. ICU nurses achieved the highest scores.

Conclusion

Chinese nurses' KAP status regarding delirium and subtypes assessment were barely acceptable, and the attitude score was positive, but knowledge and practice needed improvement. Meanwhile, the department was one of the significant KAP factors, and ICU nurses did better in delirium and subtype assessment in knowledge and practice dimension than other departments. Systematic and scientific training processes including subtype content and assessment tools are required. Experience still drives nurses' assessments of delirium and subtype. Adding the delirium assessment into routine tasks should be considered.

The Effect of Mobilization at 6 Months after Critical Illness - Meta-Analysis

BACKGROUND: The comparative efficacy and safety of early active mobilization compared with usual care regarding long-term outcomes for adult critically ill survivors remain uncertain. METHODS: We systematically reviewed randomized clinical trials comparing early active mobilization versus usual care in critically ill adults. The primary outcome was days alive and out of hospital to day 180 after pooling data using random effects modeling. We also performed a Bayesian meta-analysis to describe the treatment effect in probability terms. Secondary outcomes were mortality, physical function, strength, health-related quality of life at 6 months, and adverse events. RESULTS: Fifteen trials from 11 countries were included with data from 2703 participants. From six trials (1121 participants) reporting the primary outcome, the pooled mean difference was an increase of 4.28 days alive and out of hospital to day 180 in those patients who received early active mobilization (95% confidence interval, −4.46 to 13.03; I2=41%). Using Bayesian analyses with vague priors, the probability that the intervention increased days alive and out of hospital was 75.1%. In survivors, there was a 95.1% probability that the intervention improved physical function measured through a patient-reported outcome measure at 6 months (standardized mean difference, 0.2; 95% confidence interval, 0.09 to 0.32; I2=0%). Although no treatment effect was identified on any other secondary outcome, there was a 66.4% possibility of increased adverse events with the implementation of early active mobilization and a 72.2% chance it increased 6-month mortality. CONCLUSIONS: Use of early active mobilization for critically ill adults did not significantly affect days alive and out of hospital to day 180. Early active mobilization was associated with improved physical function in survivors at 6 months; however, the possibility that it might increase mortality and adverse events needs to be considered when interpreting this finding. (PROSPERO number, CRD42022309650.)

Validation of the patient State Index for monitoring sedation state in critically ill patients: a prospective observational study

PURPOSE

The Patient State Index (PSI) is a newly introduced electroencephalogram-based tool for objective and continuous monitoring of sedation levels of patients under general anesthesia. This study investigated the potential correlation between the PSI and the Richmond Agitation‒Sedation Scale (RASS) score in intensive care unit (ICU) patients and established the utility of the PSI in assessing sedation levels.

METHODS

In this prospective observational study, PSI values were continuously monitored via SedLine® (Masimo, Irvine, CA, USA); the RASS score was recorded every 2 h for patients on mechanical ventilation. Physicians and nurses were blinded to the PSI values. Overall, 382 PSI and RASS score sets were recorded for 50 patients.

RESULTS

The PSI score correlated positively with RASS scores, and Spearman's rank correlation coefficient between the PSI and RASS was 0.79 (95% confidence interval [CI]: 0.75‒0.83). The PSI showed statistically significant difference among the RASS scores (Kruskal‒Wallis chi-square test: 242, df = 6, P < 2.2-e16). The PSI threshold for distinguishing light (RASS score ≥ - 2) sedation from deep sedation (RASS score ≤ - 3) was 54 (95% CI: 50-65; area under the curve, 0.92 [95% CI: 0.89‒0.95]; sensitivity, 0.91 [95% CI: 0.86‒0.95]; specificity, 0.81 [95% CI: 0.77-0.86]).

CONCLUSIONS

The PSI correlated positively with RASS scores, which represented a widely used tool for assessing sedation levels, and the values were significantly different among RASS scores. Additionally, the PSI had a high sensitivity and specificity for distinguishing light from deep sedation. The PSI could be useful for assessing sedation levels in ICU patients. University Hospital Medical Information Network (UMIN000035199, December 10, 2018).

Agitation is a Common Barrier to Recovery of ICU Patients

Importance: Agitation is common in mechanically ventilated ICU patients, but little is known about physician attitudes regarding agitation in this setting. Objectives: To characterize physician attitudes regarding agitation in mechanically ventilated ICU patients. Design, Setting, and Participants: We surveyed critical care physicians within a multicenter health system in Western Pennsylvania, assessing attitudes regarding agitation during mechanical ventilation and use of and confidence in agitation management options. We used quantitative clinical vignettes to determine whether agitation influences confidence regarding readiness for extubation. We sent our survey to 332 critical care physicians, of whom 80 (24%) responded and 69 were eligible (had cared for a mechanically ventilated patient in the preceding three months). Main Outcomes and Measures: Respondent confidence in patient readiness for extubation (0-100%, continuous) and frequency of use and confidence in management options (1-5, Likert). Results: Of 69 eligible responders, 61 (88%) agreed agitation is common and 49 (71%) agreed agitation is a barrier to extubation, but only 27 (39%) agreed their approach to agitation is evidence-based. Attitudes regarding agitation did not differ much by practice setting or physician demographics, though respondents working in medical ICUs were more likely (P = .04) and respondents trained in surgery or emergency medicine were less likely (P = .03) than others to indicate that agitation is an extubation barrier. Fifty-three (77%) respondents reported they frequently use non-pharmacologic measures to treat agitation, and 42 (70%) of those who reported they used non-pharmacologic measures during the prior 3 months indicated confidence in their effectiveness. In responses to clinical vignettes, confidence in patient's readiness for extubation was significantly lower if the patient was agitated (P < .001) or tachypneic (P < .001), but the presence of both agitation and tachypnea did not reduce confidence compared with tachypnea alone (P = .24). Conclusions and Relevance: Most critical care physicians consider agitation during mechanical ventilation a common problem and agreed that agitation is a barrier to extubation. Treatment practice varies widely.

Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study

Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving Fi_O2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.

Effectiveness of nursing intervention to reduce delirium in adult critically ill - A protocol for a randomized trial

The incidence of delirium in intensive care patients remains high, and its consequences have a high negative impact on patients, their families, health care teams, and society in general. Because delirium can lead to increased hospital stay, increased days on mechanical ventilation, increased risk of adverse events, increased memory loss and even increased mortality. However, some factors that precipitate delirium can be modified to reduce its presence and duration through non-pharmacological measures. Thus, the present protocol seeks to establish the theoretical and methodological background to develop and test nursing interventions to reduce delirium in adult patients hospitalized in the intensive care unit. For this reason, it is based on the theoretical elements of delirium and a nursing theory, called the Dynamic Symptoms Model (DSM), to understand the phenomenon and how nursing knowledge can be used to intervene. Thus, a nursing intervention proposal is proposed based on the DSM and scientific evidence, and a methodological design of a randomized controlled clinical trial type with parallel groups, which allows measuring the effectiveness of the designed interventions, following methodological and ethical rigor and with adequate control of biases.

Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis

Background

To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients.

Methods

Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872).

Results

Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62-1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality.

Conclusions

Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.

Association between remimazolam and postoperative delirium in older adults undergoing elective cardiovascular surgery: a prospective cohort study

PURPOSE

Postoperative delirium is one of the most common complications after cardiovascular surgery in older adults. Benzodiazepines are a reported risk factor for delirium; however, there are no studies investigating remimazolam, a novel anesthetic agent. Therefore, we prospectively investigated the effect of remimazolam on postoperative delirium.

METHODS

We included elective cardiovascular surgery patients aged ≥ 65 years at Hamamatsu University Hospital between August 2020 and February 2022. Patients who received general anesthesia with remimazolam were compared with those who received other anesthetics (control group). The primary outcome was delirium within 5 days after surgery. Secondary outcomes were delirium during intensive care unit stay and hospitalization, total duration of delirium, subsyndromal delirium, and differences in the Mini-Mental State Examination scores from preoperative to postoperative days 2 and 5. To adjust for differences in the groups' baseline covariates, we used stabilized inverse probability weighting as the primary analysis and propensity score matching as the sensitivity analysis.

RESULTS

We enrolled 200 patients; 78 in the remimazolam group and 122 in the control group. After stabilized inverse probability weighting, 30.3% of the remimazolam group patients and 26.6% of the control group patients developed delirium within 5 days (risk difference, 3.8%; 95% confidence interval -11.5% to 19.1%; p = 0.63). The secondary outcomes did not differ significantly between the groups, and the sensitivity analysis results were similar to those for the primary analysis.

CONCLUSION

Remimazolam was not significantly associated with postoperative delirium when compared with other anesthetic agents.

[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]

Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.