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

Prospective multicenter study of heart rate variability with ANI monitor as predictor of mortality in critically ill patients with COVID-19

The purpose of this study is to demonstrate that the most critically ill patients with COVID-19 have greater autonomic nervous system dysregulation and assessing the heart rate variability, allows us to predict severity and 30-day mortality. This was a multicentre, prospective, cohort study. Patients were divided into two groups depending on the 30-day mortality. The heart rate variability and more specifically the relative parasympathetic activity (ANIm), and the SDNN (Energy), were measured. To predict severity and mortality multivariate analyses of ANIm, Energy, SOFA score, and RASS scales were conducted. 112 patients were collected, the survival group (n = 55) and the deceased group (n = 57). The ANIm value was higher (p = 0.013) and the Energy was lower in the deceased group (p = 0.001); Higher Energy was correlated with higher survival days (p = 0.009), and a limit value of 0.31 s predicted mortalities with a sensitivity of 71.9% and a specificity of 74.5%. Autonomic nervous system and heart rate variability monitoring in critically ill patients with COVID-19 allows for predicting survival days and 30-day mortality through the Energy value. Those patients with greater severity and mortality showed higher sympathetic depletion with a predominance of relative parasympathetic activity.

Practice Integration as an Effective Educational Strategy

Bundles are composed of individually established practices supported by research that, when combined, structure patient care. Implementing bundles improves patient outcomes. The ABCDEF initiative is an example of a bundled approach that improves outcomes of critically ill patients that are related to the likelihood of hospital death within 7 days, delirium and coma days, physical restraint use, intensive care unit readmission, and discharge disposition, with outcomes being proportional to the number of appropriate components performed. The purpose of this quality improvement project was to implement practice integration as an educational strategy to increase nursing knowledge of complex topics and, specifically, components of the ABCDEF bundle. Nurses' knowledge of all the BDE components of the ABCDEF bundle increased after implementing practice integration. Findings from this project support the use of resources to implement practice integration as an educational strategy for comprehensive concepts, specifically the BDE components of the ABCDEF bundle.

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey

BACKGROUND

The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized.

METHODS

Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point.

RESULTS

Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients.

CONCLUSIONS

The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Excessive Sedation as a Risk Factor for Delirium: A Comparison between Two Cohorts of ARDS Critically Ill Patients with and without COVID-19

Excessive sedation is associated with poor outcome in critically ill acute respiratory distress syndrome (ARDS) patients. Whether this prognostic effect varies among ARDS patients with and without COVID-19 has yet to be determined. We compared the prognostic value of excessive sedation—in terms of delirium, length of stay in intensive care unit (ICU-LOS) and ICU mortality—between COVID-19 and non-COVID-19 critically ill ARDS patients. This was a second analysis of prospectively collected data in four European academic centers pertaining to 101 adult critically ill ARDS patients with and without COVID-19 disease. Depth of sedation (DOS) and delirium were monitored through processed electroencephalogram (EEG) and the Confusion Assessment Method for ICU (CAM-ICU). Our main exposure was excessive sedation and how it relates to the presence of delirium, ICU-LOS and ICU mortality. The criterion for excessive sedation was met in 73 (72.3%) patients; of these, 15 (82.2%) and 58 (69.1%) were in non-COVID-19 and COVID-19 ARDS groups, respectively. The criteria of delirium were met in 44 patients (60.3%). Moreover, excessive sedation was present in 38 (86.4%) patients with delirium (p < 0.001). ICU death was ascertained in 41 out of 101 (41.0%) patients; of these, 37 (90.2%) had excessive sedation (p < 0.001). The distribution of ICU-LOS among excessive-sedated and non-sedated patients was 22 (16−27) vs. 14 (10.5−19.5) days (p < 0.001), respectively. In a multivariable framework, excessive sedation was independently associated with the development of delirium (p = 0.001), increased ICU mortality (p = 0.009) and longer ICU-LOS (p = 0.000), but only in COVID-19 ARDS patients. Independent of age and gender, excessive sedation might represent a risk factor for delirium in COVID-19 ARDS patients. Similarly, excessive sedation shows to be an independent predictor of ICU-LOS and ICU mortality. The use of continuous EEG-based depth of sedation (DOS) monitoring and delirium assessment in critically ill COVID-19 patients is warranted.

Early sedation in traumatic brain injury: a multicentre international observational study

Objectives: We aimed to investigate the use of sedation in patients with severe traumatic brain injury (TBI), focusing on the choice of sedative agent, dose, duration, and their association with clinical outcomes. Design: Multinational, multicentre, retrospective observational study. Settings: 14 trauma centres in Europe, Australia and the United Kingdom. Participants: A total of 262 adult patients with severe TBI and intracranial pressure monitoring. Main outcome measures: We described how sedative agents were used in this population. The primary outcome was 60-day mortality according to the use of different sedative agents. Secondary outcomes included intensive care unit and hospital length of stay, and the Extended Glasgow Outcome Scale at hospital discharge. Results: Propofol and midazolam were the most commonly used sedatives. Propofol was more common than midazolam as first line therapy (35.4% v 25.6% respectively). Patients treated with propofol had similar Acute Physiology and Chronic Health Evaluation (APACHE) II and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) scores to patients treated with midazolam, but lower Injury Severity Score (ISS) (median, 26 [IQR, 22-38] v 34 [IQR, 26-44]; P = 0.001). The use of propofol was more common in heavier patients, and midazolam use was strongly associated with opioid co-administration (OR, 12.9; 95% CI, 3.47-47.95; P < 0.001). Sixty-day mortality and hospital mortality were predicted by a higher IMPACT score (P < 0.001) and a higher ISS (P < 0.001), but, after adjustment, were not related to the choice of sedative agent. Conclusions: Propofol was used more often than midazolam, and large doses were common for both sedatives. The first choice was highly variable, was affected by injury severity, and was not independently associated with 60-day mortality.

Two-stage prediction model for postoperative delirium in patients in the intensive care unit after cardiac surgery

OBJECTIVES

Postoperative delirium is a common severe complication in patients in the intensive care unit after cardiac surgery. We developed a two-stage prediction model and quantified the risk of developing postoperative delirium to assist in early prevention before and after surgery.

METHODS

We conducted a prospective cohort study and consecutively recruited adult patients after cardiac surgery. The Confusion Assessment Method for patients in the intensive care unit was used to diagnose delirium 5 days postoperatively. The stage I model was constructed using patient demographics, health conditions and laboratory results obtained preoperatively, whereas the stage II model was built on both pre- and postoperative predictors. The model was validated internally using the bootstrap method and externally using data from an external cohort.

RESULTS

The two-stage model was developed with 654 patients and was externally validated with 214 patients undergoing cardiac surgery. The stage I model contained 6 predictors, whereas the stage II model included 10 predictors. The stage I model had an area under the receiver operating characteristic curve of 0.76 (95% confidence interval: 0.68-0.81), and the stage II model's area under the receiver operating characteristic curve increased to 0.85 [95% confidence interval (CI): 0.81-0.89]. The external validation resulted in an area under the curve of 0.76 (95% CI: 0.67-0.86) for the stage I model and 0.78 (95% CI: 0.69-0.86) for the stage II model.

CONCLUSIONS

The two-stage model assisted medical staff in identifying patients at high risk for postoperative delirium before and 24 h after cardiac surgery. This model showed good discriminative power and predictive accuracy and can be easily accessed in clinical settings.

TRIAL REGISTRATION

The study was registered with the US National Institutes of Health ClinicalTrials.gov (NCT03704324; registered 11 October 2018).

Analgosedation in Critically Ill Adults Receiving Extracorporeal Membrane Oxygenation Support

Extracorporeal membrane oxygenation (ECMO) is an increasingly utilized intervention for cardiopulmonary failure. Analgosedation during ECMO support is essential to ensure adequate pain and agitation control and ventilator synchrony, optimize ECMO support, facilitate patient assessment, and minimize adverse events. Although the principles of analgosedation are likely similar for all critically ill patients, ECMO circuitry alters medication pharmacodynamics and pharmacokinetics. The lack of clinical guidelines for analgosedation during ECMO, especially at times of medication shortage, can affect patient management. Here, we review pharmacological considerations, protocols, and special considerations for analgosedation in critically ill adults receiving ECMO support.

Use of the AGREE II instrument to evaluate critical care practice guidelines addressing pharmacotherapy

RATIONALE, AIMS AND OBJECTIVES

Clinical practice guidelines (CPGs) have been evaluated for reporting transparency and methodological quality in a number of studies in various disciplines, but few studies have focused on critical care and none on pharmacotherapy-related guidelines specifically. The objective of this study was to evaluate the quality of critical care CPGs with a focus on pharmacotherapy using the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument.

METHOD

A cross-sectional study of CPGs published from 2013 through August 2021 was conducted. Following establishment of interrater reliability, guidelines were independently evaluated by three reviewers to rate guidelines on criteria set forth by the AGREE II instrument. Domain scores and item scores were calculated using the AGREE II user manual, and results described with descriptive statistics.

RESULTS

Out of 192 guidelines identified, 73 met inclusion criteria and were screened using the AGREE II instrument. Most guidelines were authored by a professional organization or government agency. Domain quality scores were calculated for each domain as recommended by the AGREE II instrument. Domain 4 (clarity of presentation) had the highest AGREE II domain score with a median score of 87.0% (interquartile range: 79.6%-92.6%). Domain 5 (applicability) received the lowest domain score with a mean score of 41.8 ± 21.1%. The majority of guidelines were recommended for use as published or with modifications, while only six guidelines (8.2%) were not recommended for use.

CONCLUSIONS

The majority of critical care guidelines that include pharmacotherapy recommendations were recommended for use by study authors when the AGREE II instrument was applied. While guidelines generally scored highly in clarity of presentation, additional time and effort should focus on providing solutions to guideline implementation and inclusion of patient preferences.

Intensive Care Unit Caregivers Perception of Patient Discomfort: A Qualitative Study

BACKGROUND

Being hospitalized in an intensive care unit ICU often involves pain and discomfort. While pain is commonly alleviated with analgesics, discomfort is more difficult to diagnose and treat, thus potentially leading to incorrect analgesic administration.

AIM

To describe intensive care unit practitioners' perceptions of discomfort in the ICU, and their methods to discern between pain and non-pain discomfort.

METHODS

Twenty-five intensive care unit practitioners (7 doctors and 18 nurses) were interviewed from medical and general intensive care units at one institution in Jerusalem, Israel. Data collection was performed using semi-structured interviews. Interviews were audio-recorded and transcribed. Transcriptions were coded and categorized by two researchers independently. Content analysis identified common themes.

RESULTS

Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychologic feelings, with further subcategories. Physiologic and non-physiologic signs such as facial expression and motor activity helped to diagnose discomfort. Trial and error and cause and effect were used to differentiate pain from other sources of discomfort.

CONCLUSIONS

Practitioners saw pain as a dominant source of discomfort. Treating overall discomfort should focus on improving the quality of the total intensive care unit experience. Strategies to diagnose non-pain discomfort and pain were similar. Differentiating pain from non-pain discomfort is essential in order to provide appropriate treatment for pain and non-pain-related discomfort.

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

Gabapentin to treat acute alcohol withdrawal in hospitalized patients: A systematic review and meta-analysis

BACKGROUND

Gabapentin is an antiepileptic medication with evidence of benefit in alcohol use disorder patients. The mechanism of action of gabapentin may also benefit patients suffering from acute alcohol withdrawal syndrome (AWS).

METHODS

A systematic review and meta-analysis were conducted to examine if gabapentin can effectively replace/reduce the use of benzodiazepines for the treatment of acute alcohol withdrawal symptoms in hospitalized patients. Time to alcohol withdrawal symptom resolution, amount of benzodiazepines administered, rate of resolution of alcohol withdrawal symptoms, serious withdrawal-related complications, and hospital length of stay (LOS) were examined.

RESULTS

Eight retrospective studies (n = 2030) were included in this meta-analysis. There were no studies that examined study outcomes for patients who received only gabapentin and no benzodiazepines; in all studies, gabapentin-treated patients may have received benzodiazepines prior to gabapentin. There were no significant differences between gabapentin-treated and benzodiazepine-treated groups in time to symptom resolution, amount benzodiazepines administered, withdrawal-related complications, or LOS. There was a significant difference in the rate of symptom resolution favoring gabapentin-treated patients (p = 0.05); however, this analysis included only one study. Subgroup analyses of severe AWS patients revealed a significant decrease in LOS (p = 0.04) and a decrease in amount of benzodiazepines administered (p = 0.02) in gabapentin-treated patients, but these analyses included only one study. Subgroup analysis of patients receiving only gabapentin without benzodiazepines found a significantly decreased LOS in the gabapentin group compared to the benzodiazepine group (p < 0.001), but this analysis included only two studies.

CONCLUSIONS

There is insufficient evidence to support the widespread use of gabapentin to treat inpatients suffering AWS. All studies included in this meta-analysis are retrospective with high risk of confounding. Well-designed, randomized, controlled studies of gabapentin to treat patients with AWS are required.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review

Background

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery.

Objective

Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients.

Design

We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients.

Settings

General adult intensive care units.

Participants

Health care professionals working in adult intensive care units.

Methods

Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis.

Results

Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation.

Conclusions

A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence.

Tweetable abstract

Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

Delirium detection using GAMMA wave and machine learning: A pilot study

Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.

Communicating with mechanically ventilated patients who are awake. A qualitative study on the experience of critical care nurses in Cyprus during the COVID-19 pandemic

BACKGROUND

Modern protocols for light sedation in combination with the increased number of COVID-19 infected patients hospitalized in Intensive Care Units (ICUs) have increased the number of patients who are mechanically ventilated and awake. Nurses require specific skills to care for this vulnerable group of patients. At the same time, nurses report feeling inadequate and frustrated when they attempt to establish communication with mechanically ventilated, conscious patients.

STUDY OBJECTIVES

The purpose of this study was to explore the strategies nurses use when taking care of conscious, intubated patients in the intensive care unit and the barriers they encounter in their effort to communicate.

METHODS

For this study, a qualitative design was employed. Data were collected using in-depth semi-structured interviews with 14 intensive care nurses working at ICUs in four different hospitals of Cyprus. The data were analyzed by applying thematic analysis.

RESULTS

We identified several strategies of unaided (movements-lips, hands, legs-facial expressions, gestures, touching) and aided forms of communication (pen and paper, boards, tablets, mobiles) used by nurses to communicate with patients. However, barriers to communication were reported by the participating nurses mainly pertaining to patients and nurses' characteristics as well as the ICU environment. The health protocols imposed by the pandemic added more obstacles to the communication between nurses and patients mostly related to the use of protective health equipment.

CONCLUSIONS

The results of this study point to the difficulties nurses in Cyprus face when trying to communicate with conscious patients during mechanical ventilation. It appears that the lack of nurses' training and of appropriate equipment to facilitate augmentative and alternative communication leave the complex communication needs of critically ill patients unaddressed. However, further research including patients' opinions, after they recover, would bring more clarity on this topic. Our study adds evidence to the communication crisis created by the protective health protocols imposed by the pandemic. As such, it highlights the need to educate nurses in augmentative and alternative ways of communication to address communication with mechanically ventilated, conscious patients during their ICU stay.

Reliability and validity of the Korean version of the Functional Status Score for the ICU after translation and cross-cultural adaptation

PURPOSE

The Functional Status Score for the Intensive Care Unit (FSS-ICU) evaluates the physical function of ICU patients. The objective of the study was to translate and cross-culturally adapt the FSS-ICU into Korean and assess its reliability and validity.

METHODS

An expert committee supervised the forward and backward translation process and the final translated version. Experienced physiotherapists assessed patients (n= 31) from a medical ICU using the Korean version of FSS-ICU. Intra-class correlation coefficients (ICCs) and Bland-Altman's plots were used to evaluate reliability, and Cronbach's alpha for internal consistency. Construct validity was evaluated using Spearman's correlation coefficients.

RESULTS

Two physiotherapists in each of the two university hospitals independently assessed 31 medical ICU patients, with a mean FSS-ICU total score of 23 (range: 4-35). The FSS-ICU Korean version demonstrated excellent internal consistency, with Cronbach's alpha of 0.897 for the total FSS-ICU score, and a range of 0.844-0.892 with deletion of each individual activity within the FSS-ICU. Intra-rater and inter-rater reliability were excellent for all of five FSS-ICU activities and the total score, with an ICC range of 0.930-0.993. Bland-Altman's plots revealed a mean difference in FSS-ICU total score of 0.2 (95% limits of agreement: -1.9 to 2.3) between two physiotherapists. The Korean version of FSS-ICU had good convergent and divergent validity with moderate to strong correlation with mobility and muscle strength measures, and poor correlation with unrelated measures.

CONCLUSIONS

The Korean version of the FSS-ICU showed excellent intra-rater and inter-rater reliability, internal consistency, and construct validity for medical ICU patients. The results of this study, along with prior publications, support that the FSS-ICU Korean version is a valid and reliable assessment tool for the ICU environment.Implications for rehabilitationIntensive care unit patients usually experience decreased muscle strength and physical function.The Korean version of the Functional Status Score for the Intensive Care Unit (FSS-ICU) is suitable for use with Korean speakers and has a valid, reliable measurement tool for physical function of intensive care unit patients.A well-standardized training with videos and written materials is important to ensure correct implementation of the Korean version of the FSS-ICU.

Overview of the Medical Management of the Critically Ill Patient

The medical management of the critically ill patient focuses predominantly on treatment of the underlying condition (e g, sepsis or respiratory failure). However, in the past decade, the importance of initiating early prophylactic treatment for complications arising from care in the intensive care unit setting has become increasingly apparent. As survival from critical illness has improved, there is an increased prevalence of postintensive care syndrome-defined as a decline in physical, cognitive, or psychologic function among survivors of critical illness. The Intensive Care Unit Liberation Bundle, a major initiative of the Society of Critical Care Medicine, is centered on facilitating the return to normal function as early as possible, with the intent of minimizing iatrogenic harm during necessary critical care. These concepts are universally applicable to patients seen by nephrologists in the intensive care unit and may have particular relevance for patients with kidney failure either on dialysis or after kidney transplant. In this article, we will briefly summarize some known organ-based consequences associated with critical illness, review the components of the ABCDEF bundle (the conceptual framework for Intensive Care Unit Liberation), highlight the role nephrologists can play in implementing and complying with the ABCDEF bundle, and briefly discuss areas for additional research.

Development and Evaluation of an Intensive Care Unit Video Series to Educate Staff on Delirium Detection

Background

Delirium affects up to 80% of patients who are mechanically ventilated in the intensive care unit (ICU) but often goes undetected because of incomplete and/or inaccurate clinician evaluation and documentation. A lack of effective, feasible, and sustainable educational methods represents a key barrier to efforts to optimize, scale, and sustain delirium detection competencies. Progress with such barriers may be addressed with asynchronous video-based education.

Objective

To evaluate a novel ICU Delirium Video Series for bedside providers via a knowledge assessment quiz and a feedback questionnaire.

Methods

An interdisciplinary team scripted and filmed an educational ICU Delirium Video Series, providing detailed instruction on delirium detection using the validated CAM-ICU (Confusion Assessment Method for the ICU). A cohort of bedside nurses subsequently viewed and evaluated the ICU Delirium Video Series using a feedback questionnaire and a previously developed knowledge assessment quiz pre- and post-video viewing.

Results

Twenty nurses from four ICUs viewed the ICU Delirium Video Series and completed the pre-post quiz and questionnaire. Ten (50%) respondents had 10 or more years of ICU experience, and seven (35%) reported receiving no CAM-ICU education locally. After video viewing, overall pre-post scores improved significantly (66% vs. 79%; P < 0.0001). In addition, after video viewing, more nurses reported comfort in their ability to evaluate and manage patients with delirium.

Conclusion

Viewing the ICU Delirium Video Series resulted in significant improvements in knowledge and yielded valuable feedback. Asynchronous video-based delirium education can improve knowledge surrounding a key bedside competency.

Return to work after coronary artery bypass grafting and aortic valve replacement surgery: A scoping review

BACKGROUND

Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work.

METHODS

A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes.

RESULTS

Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce.

CONCLUSIONS

A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery.

Opioid tolerance and opioid-induced hyperalgesia: Is TrkB modulation a potential pharmacological solution?

Opioids are widely prescribed for moderate to severe pain in patients with acute illness, cancer pain, and chronic noncancer pain. However, long-term opioid use can cause opioid tolerance and opioid-induced hyperalgesia (OIH), contributing to the opioid misuse and addiction crisis. Strategies to mitigate opioid tolerance and OIH are needed to reduce opioid use and its sequelae. Currently, there are few effective pharmacological strategies that reduce opioid tolerance and OIH. The intrinsic tyrosine kinase receptor B (TrkB) ligand, brain-derived neurotrophic factor (BDNF), has been shown to modulate pain. The BDNF-TrkB signaling plays a role in initiating and sustaining elevated pain sensitivity; however, increasing evidence has shown that BDNF and 7,8-dihydroxyflavone (7,8-DHF), a potent blood-brain barrier-permeable ligand to TrkB, exert neuroprotective, anti-inflammatory, and antioxidant effects that may protect against opioid tolerance and OIH. As such, TrkB signaling may be an important therapeutic avenue in opioid tolerance and OIH. Here, we review 1) the mechanisms of pain, opioid analgesia, opioid tolerance, and OIH; 2) the role of BDNF-TrkB in pain modulation; and 3) the neuroprotective effects of 7,8-DHF and their implications for opioid tolerance and OIH.

Reducing the effect of immortal time bias affects the analysis of prevention of delirium by suvorexant in critically ill patients: A retrospective cohort study

BACKGROUND

Studies assessing the effect of suvorexant on delirium prevention included patients treated before development of delirium, which can introduce immortal time bias. The objective of the present study was to evaluate the effect of suvorexant on delirium, comparing patients treated before the onset of delirium with patients treated within 72h of admission using the same dataset.

METHODS

Data from adult patients admitted to the ICU from August 2018 to July 2021 were retrospectively analyzed. In "any time before" analysis, the incidence of delirium was compared for patients who received suvorexant at any time during their ICU stay (suvorexant) (unless delirium developed before treatment) with patients who either did not receive suvorexant or received suvorexant after development of delirium (control). This design was used in previously published studies. In "within 72h" analysis, the incidence of delirium was compared for patients who received suvorexant within 72 hours of admission (suvorexant) and patients who did not receive suvorexant or received it more than 72 hours after admission (control). Patients who developed delirium during the initial 72 hours were excluded from "within 72h" analysis (N = 799).

RESULTS

"Within 72h" analysis included 1,255 patients, and "any time before" analysis included 2,054 patients (of 6599 admissions). The unadjusted hazard ratio of "any time before" analysis was 0.16 and the 95% confidence interval was 0.13-0.21 (p<0.01). The adjusted hazard ratio was 0.21, and the 95% confidence interval was 0.16-0.27 (p<0.01). "Within 72h" analysis had an unadjusted hazard ratio of 0.54 and the 95% confidence interval was 0.36-0.82 (p<0.01). However, this association lost statistical significance after adjustment for potential confounders (adjusted hazard ratio 1.02, 95% confidence interval 0.65-1.59, p = 0.93).

CONCLUSION

Reducing the effect of immortal time bias led to a significantly reduced effect of suvorexant for the prevention of delirium.

Optimal, Early Postoperative Management of Cardiac Transplant and Durable Left Ventricular Assist Recipients

PURPOSE OF REVIEW

Summarize developments in the early postoperative care of patients undergoing cardiac transplantation or left ventricular assist device implantation. Provide a practical approach with personal insights to highly complex patients at risk for prolonged hospitalization.

RECENT FINDINGS

Advancements in technology allow for percutaneous mechanical circulatory support of both the right and left ventricles either isolated or combined via subclavian and neck vessels. Since the adult heart allocation system has been changed to reduce waitlist mortality, the use of temporary mechanical circulatory support has increased. This has influenced preoperative optimization by enabling ambulation and majorly changed postoperative strategy. New doors have been opened for a multidisciplinary approach to facilitate rapid weaning of inotropic medications, limitation of sedation, early liberation from mechanical ventilation, and mobilization. Individualized percutaneous mechanical circulatory support offers new possibilities for the early postoperative management of highly complex patients undergoing cardiac transplantation or durable left ventricular assist device implantation.

A critical appraisal of clinical practice guidelines on insomnia using the RIGHT statement and AGREE II instrument

OBJECTIVE

Clinical Practice Guidelines (CPGs) have an indispensable role in guiding the selection of various treatments for insomnia, however, little is known about the quality of released insomnia CPGs. This study aims to critically appraise the quality of existing insomnia CPGs and identify quality limitations.

METHODS

PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang, China Biology Medicine disc, and 6 databases of international guideline developing institutions were systematically searched. CPGs on the diagnosis or treatment of insomnia were included. Reviewers independently extracted basic information and development methods, and assessed methodological quality and reporting quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and Reporting Items for practice Guidelines in Healthcare (RIGHT) checklist respectively. Intraclass correlation coefficients (ICCs) were used to measure the agreement among reviewers and assess inter-rater reliability.

RESULTS

Twenty-six CPGs were identified that focused on adults, children, or children with autistic spectrum disorder, patients in the intensive care unit, patients with cancer and pregnant, lactating or menopausal women. Twenty-two CPGs used nine grading systems to rate the level of evidence and strength of recommendation. 53.85% CPGs were classified as "recommended with modification" according to the AGREE II scores (ICC from 0.64 to 0.90), and 2 CPGs were "recommended". The "clarity of presentation" domain achieved the highest mean score (67.9% ± 11.04%) but the "applicability" domain (37.1% ± 12.67%) achieved the lowest. The average reporting rate of RIGHT items in all guidelines was 67.87%.

CONCLUSIONS

The quality of guidelines varied substantially. Guideline developers should realize the importance of guideline applicability, patients' preferences and values.

Prediction models for postoperative delirium after cardiac surgery: Systematic review and critical appraisal

BACKGROUND

Many studies have developed or validated prediction models to estimate the risk of delirium after cardiac surgery, but the quality of the model development and model applicability remain unknown.

OBJECTIVES

To systematically review and critically evaluate currently available prediction models for delirium after cardiac surgery.

DATA SOURCES

PubMed, EMBASE, and MEDLINE were systematically searched. This systematic review was registered in PROSPERO (Registration ID: CRD42021251226).

STUDY SELECTION

Prospective or retrospective cohort studies were considered eligible if they developed or validated prediction models or scoring systems for delirium in the ICU. We included studies involving adults (age ≥18 years) undergoing cardiac surgery and excluded studies that did not validate a prediction model.

DATA EXTRACTION

Data extraction was independently performed by two authors using a standardized data extraction form based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies checklist. Quality of the models was assessed with the Prediction Model Risk of Bias Assessment Tool (PROBAST).

DATA SYNTHESIS

Of 5469 screened studies, 13 studies described 10 prediction models. The postoperative delirium incidence varied from 11.3 % to 51.6 %. The most frequently used predictors were age and cognitive impairment. The reported areas under the curve or C-statistics were between of 0.74 and 0.91 in the derivation set. The reported AUCs in the external validation set were between 0.54 and 0.90. All the studies had a high risk of bias, mainly owing to poor reporting of the outcome domain and analysis domain; 10 studies were of high concern regarding applicability.

CONCLUSIONS

The current models for predicting postoperative delirium in the ICU after cardiac surgery had a high risk of bias according to the PROBAST. Future studies should focus on improving current prediction models or developing new models with rigorous methodology.

Ketamine Infusion for Sedation and Analgesia during Mechanical Ventilation in the ICU: A Multicenter Evaluation

Methods

We reviewed the electronic medical record of critically ill adults who received a continuous infusion of ketamine for ≥24 hours during invasive mechanical ventilation in three hospitals over a two-year period. We captured data including ketamine indication, dose, unintended effects, and adjustments to coadministered sedatives or opioids. We analyzed these data to determine the incidence of reported unintended effects of ketamine infusion (primary outcome) and changes in exposure to coadministered sedatives or opioids during ketamine use (secondary outcome).

Results

95 mechanically ventilated adults received a ketamine infusion for a median duration of 75 hours (interquartile range [IQR] 44-115) at a mean ± standard deviation (SD) infusion rate of 1.3 ± 0.5 mg/kg/hour for the first 24 hours. At least one unintended effect attributed to ketamine was documented in 24% of cases, most frequently tachycardia (6%) and sialorrhea (6%). Other sedative or opioid infusions were administered with ketamine in 76% and 92% of cases, respectively. Comparing the total amount of sedative or opioid administered in the 24 hours prior to ketamine infusion with the total amount administered during the first 24 hours on ketamine, there were no significant differences in propofol, midazolam, or dexmedetomidine exposure, but the average fentanyl exposure was higher after ketamine (2740 ± 1812 mcg) than before (1975 ± 1860 mcg) (absolute difference 766 mcg, 95% confidence interval [CI] 442 to 1089 mcg).

Conclusions

In this multicenter cohort of critically ill, mechanically ventilated adults, ketamine infusion was primarily used as an adjunct to conventional sedative and opioid infusions, with noticeable but unintended effects potentially related to ketamine in nearly one-quarter of cases.

Novel insights on association and reactivity of Bispectral Index, frontal electromyogram, and autonomic responses in nociception-sedation monitoring of critical care patients

Background

Assessing nociception and sedation in mechanically ventilated patients in the ICU is challenging, with few reliable methods available for continuous monitoring. Measurable cardiovascular and neurophysiological signals, such as frontal EEG, frontal EMG, heart rate, and blood pressure, have potential in sedation and nociception monitoring. The hypothesis of this explorative study is that derived variables from the aforementioned signals predict the level of sedation, as described by the Richmond Agitation-Sedation score (RASS), and respond to painful stimuli during critical care.

Methods

Thirty adult postoperative ICU patients on mechanical ventilation and receiving intravenous sedation, excluding patients with primary neurological disorders, head injury, or need for continuous neuromuscular blockage. Bispectral Index (BIS), EMG power (EMG), EMG-derived Responsiveness Index (RI), and averaged blood pressure variability (ARV) were tested against RASS measurements. The aforementioned variables together with blood pressure and Surgical Pleth Index (SPI) were explored before and after painful stimuli (for example bronchoscopy, or pleural puncture) at varying RASS levels, to test variable responsiveness.

Results

BIS, EMG, and RI predicted RASS levels with a prediction probability (PK) of 0.776 for BIS, 0.761 for EMG, and 0.763 for RI. In addition, BIS, EMG, and ARV demonstrated responsiveness to painful stimuli during deep sedation (RASS score ≤ -3).

Conclusion

Variables derived from EEG and EMG are associated with sedation levels, as described by the RASS score. Furthermore, these variables, along with ARV, react with consistency to painful stimuli during deep sedation (RASS -5 to -3), offering novel tools for nociception-sedation monitoring of mechanically ventilated ICU patients requiring deep sedation.

Delirium in Adults With COVID-19-Related Acute Respiratory Distress Syndrome: Comparison With Other Etiologies

BACKGROUND AND OBJECTIVES

Neurologic complications have been associated with COVID-19, including delirium. Such complications have been reported to be frequent among intensive care unit (ICU)-admitted patients. We hypothesized that the rate of neurologic complications would be higher in COVID-19 associated acute respiratory distress syndrome (ARDS) than those who develop ARDS from a different cause.

METHODS

We conducted a retrospective cohort study in the adult ICU of Lausanne University Hospital, including all consecutive patients fulfilling the Berlin criteria for ARDS hospitalized between December 2017 and June 2021, stratifying exposure between COVID-19 or not. The primary outcome was delirium onset during ICU stay, defined by the confusion assessment method (CAM-ICU). Exploratory outcomes included development of neurologic complications of the central nervous system (stroke, hemorrhage, and vasculitis), critical illness weakness, and 30- and 180-day all-cause mortality.

RESULTS

Three hundred eleven patients were included in the study (253 with COVID-19 and 58 with other causes) and CAM-ICU could be assessed in 231 (74.3% in COVID-19 vs 74.1% in non-COVID-19). The proportion of patients developing delirium was similar in patients with COVID-19 and controls in univariate comparison (69.1% vs 60.5%, p = 0.246). Yet, patients with COVID-19 had a higher body mass index, lower ICU severity, longer mechanical ventilation, and higher sedation doses (propofol and dexmedetomidine). After adjusting for these factors in a multivariable analysis, the risk of delirium remained comparable across groups (adjusted OR [95% CI]: 0.86 [0.35-2.1]). Similarly, COVID-19-related ARDS had no effect on all-cause mortality at 30 days (adjusted OR: 0.87 [0.39-1.92]) and 180 days (adjusted OR: 0.67 [0.33-1.35]). Finally, neurologic complications affecting the CNS (adjusted OR: 1.15 [0.25-5.29]) and critical illness weakness (adjusted OR: 2.99 [0.97-9.1]) were not higher in the COVID-19 group.

DISCUSSION

Compared with other etiologies, patients with COVID-19 did not have higher incidence of delirium and other neurologic complications, after accounting for underlying disease severity in patients with ARDS. Management of COVID-19-associated ARDS needed longer invasive ventilation and higher sedation, which could explain higher rates of delirium in uncontrolled studies.

Early Active Mobilization during Mechanical Ventilation in the ICU

BACKGROUND

Intensive care unit (ICU)-acquired weakness often develops in patients who are undergoing invasive mechanical ventilation. Early active mobilization may mitigate ICU-acquired weakness, increase survival, and reduce disability.

METHODS

We randomly assigned 750 adult patients in the ICU who were undergoing invasive mechanical ventilation to receive increased early mobilization (sedation minimization and daily physiotherapy) or usual care (the level of mobilization that was normally provided in each ICU). The primary outcome was the number of days that the patients were alive and out of the hospital at 180 days after randomization.

RESULTS

The median number of days that patients were alive and out of the hospital was 143 (interquartile range, 21 to 161) in the early-mobilization group and 145 days (interquartile range, 51 to 164) in the usual-care group (absolute difference, -2.0 days; 95% confidence interval [CI], -10 to 6; P = 0.62). The mean (±SD) daily duration of active mobilization was 20.8±14.6 minutes and 8.8±9.0 minutes in the two groups, respectively (difference, 12.0 minutes per day; 95% CI, 10.4 to 13.6). A total of 77% of the patients in both groups were able to stand by a median interval of 3 days and 5 days, respectively (difference, -2 days; 95% CI, -3.4 to -0.6). By day 180, death had occurred in 22.5% of the patients in the early-mobilization group and in 19.5% of those in the usual-care group (odds ratio, 1.15; 95% CI, 0.81 to 1.65). Among survivors, quality of life, activities of daily living, disability, cognitive function, and psychological function were similar in the two groups. Serious adverse events were reported in 7 patients in the early-mobilization group and in 1 patient in the usual-care group. Adverse events that were potentially due to mobilization (arrhythmias, altered blood pressure, and desaturation) were reported in 34 of 371 patients (9.2%) in the early-mobilization group and in 15 of 370 patients (4.1%) in the usual-care group (P = 0.005).

CONCLUSIONS

Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU. The intervention was associated with increased adverse events. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; TEAM ClinicalTrials.gov number, NCT03133377.).

Rationale for integration of palliative care in the medical intensive care: A narrative literature review

Despite the remarkable technological advancement in the arena of critical care expertise, the mortality of critically ill patients remains high. When the organ functions deteriorate, goals of care are not fulfilled and life-sustaining treatment becomes a burden on the patient and caregivers, then it is the responsibility of the physician to provide a dignified end to life, control the symptoms of the patient and provide psychological support to the family members. Palliative care is the best way forward for these patients. It is a multidimensional specialty which emphasizes patient and family-based care and aims to improve the quality of life of patients and their caregivers. Although intensive care and palliative care may seem to be at two opposite ends of the spectrum, it is necessary to amalgamate the postulates of palliative care in intensive care units to provide holistic care and best benefit patients admitted to intensive care units. This review aims to highlight the need for an alliance of palliative care with intensive care in the present era, the barriers to it, and models proposed for their integration and various ethical issues.

Remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the ICU: a prospective dose‒response study

This single-center study aimed to determine the effective dose and safety of remimazolam besylate for the sedation of postoperative patients undergoing invasive mechanical ventilation in the intensive care unit (ICU). Mechanically ventilated patients admitted to the ICU after surgery were included. The Narcotrend index (NTI) was used to assess the depth of sedation, and the Richmond Agitation-Sedation Scale (RASS) score was also recorded. Remimazolam besylate was administered initially at a loading dose of 0.02 mg/kg, followed by a gradual increase of 0.005 mg/kg each time until the targeted depth of sedation was achieved (NTI 65-94). A maintenance dose of remimazolam besylate was administered starting at 0.2 mg/kg/h, followed by increments or subtractions of 0.05 mg/kg/h each time until a satisfactory depth of sedation was achieved and maintained for at least 30 min. The demographic data, anesthesia, surgery types, hemodynamics and respiratory parameters were recorded. Adverse events and adverse drug reactions were monitored for safety. Twenty-three patients were eventually included in this study covering a period of 1 year. A satisfactory depth of sedation was achieved by a single intravenous infusion of remimazolam besylate at a loading dose of 0.02-0.05 mg/kg followed by a maintenance dose of 0.20-0.35 mg/kg/h. There were no significant changes in hemodynamic and respiratory parameters within 10 min after the administration of remimazolam besylate. In addition, a significant correlation was observed between the NTI and the RASS score for assessing sedation (r = 0.721, P < 0.001). The NTI showed a predictive probability for a RASS score of 0.817. Remimazolam besylate was effective for mild/moderate sedation of invasively mechanically ventilated postoperative patients in the ICU while maintaining excellent respiratory and hemodynamic stability. The NTI can be used as a good tool for the objective evaluation of the depth of sedation and agitation.

Sedation With Dexmedetomidine in Critically Ill Burn Patients Reduced Delirium During Weaning From Mechanical Ventilation

INTRODUCTION

Weaning of mechanical ventilation while maintaining appropriate pain control and preventing delirium is one of the most challenging aspects of burn care. Dexmedetomidine, an α₂-adrenergic receptor agonist used for sedation may improve intensive care unit (ICU) patients' arousal status and enhance patient comfort.

OBJECTIVES

To determine the efficacy of dexmedetomidine vs. standardized usual care (midazolam or propofol) in maintaining sedation and reducing delirium in burn patients while weaning off mechanical ventilation.

MATERIAL AND METHODS

A total of 56 mechanically ventilated patients who fulfilled the criteria for weaning were enrolled in the study. Group 1 (26 patients) received dexmedetomidine 1 mcg/kg over 15 minutes as a loading dose, followed by 0.4-0.1 mcg/kg/h. Group 2 (30 patients) received usual sedation with midazolam 0.08 mg/kg/h or propofol 15- 30 mcg /kg/min).

RESULTS

 Dexmedetomidine was not associated with a significantly shorter duration of mechanical ventilation (Mean {IQR}: 9.3 {4,12} versus 7.5 {4,10}, p=0.3). Patients who received dexmedetomidine had a lower delirium rate (38,4% on Day 1 to 7,7% on Day 5) in comparison with patients from the usual care group (53,3% on Day 1 to 20% on Day 5) during the five days after the onset of weaning process (p=0.02) and had less need for supplemental use of analgesia (23.1% versus 53.3%, p=0.045) and antipsychotic agents (15.4% versus 53.3%, p=0.01). The most notable adverse effect of dexmedetomidine was bradycardia.

CONCLUSIONS

Dexmedetomidine may provide effective light sedation and is associated with fewer sedation-related adverse effects in burn patients. Sedation with dexmedetomidine during the weaning process in adult burn patients was associated with lower delirium rates, a trend towards the earlier withdrawal of mechanical ventilation but did not seem to improve the total duration of mechanical ventilation.

Validation of a Risk Assessment Tool for Unplanned Endotracheal Extubation: An Observational Study

The purpose of this study was to validate and determine the sensitivity and specificity of the risk assessment tool for unplanned endotracheal extubation. Unplanned endotracheal extubation is a common adverse event. The rate of unplanned endotracheal extubation is an indicator to measure patient safety and medical quality. This study was conducted in five intensive care units in a tertiary-A hospital. A total of 227 samples encounters were obtained from 147 unique patients. The content validity was 0.91, and the item content validity ranged from 0.80 to 1.00. Cronbach's α was .58, the interrater reliability was .93. The area under the curve was 0.89 (95% CI [0.84, 0.94], p < 0.01), the sensitivity was 87.80%, and the specificity was 74.20%. This tool presented good reliability and validity and can be used to assess the risk of unplanned endotracheal extubation in patients with artificial airways.

Sleep of Intensive Care Patients: A Qualitative Study Based on Experiences of Nurses

BACKGROUND

Intensive care patients experience a high rate of poor sleep quality. As the sleep quality is improved with nursing practices, patients' recovery and the length of stay in the intensive care unit (ICU) may be positively influenced, and patients may benefit from treatment and care at the highest level. Therefore, it is important to explore the experiences and evaluation of nurses working in ICUs.

OBJECTIVES

This study was carried out to explore the experiences and evaluations of ICU nurses about patients' sleep.

METHODS

The study is a qualitative study conducted in a descriptive phenomenological design. The data were collected using the individual in-depth interview method with the semistructured interview form. Thematic analysis was performed to analyze the data. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used.

RESULTS

The analysis revealed 4 main themes, which are (1) importance of sleep, (2) evaluation of sleep, (3) reasons for poor sleep, and (4) sleep promotion interventions.

CONCLUSIONS

This study revealed that nurses are aware of the importance of sleep; however, they do not evaluate sleep and try to improve sleep quality only based on their own knowledge and experience rather than on evidence-based approaches. However, their interventions are not sufficient and they are restricted because of physical conditions and intensive care procedures.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study

OBJECTIVE

To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU.

DESIGN

Retrospective cohort study.

SETTING

Medical-surgical ICUs in Alberta, AB, Canada.

PATIENTS

A population of 25,537 unique patients admitted at least once to an Alberta ICU.

METHODS

We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39-0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] -1.87 d; 95% CI, -2.01 to -1.81; p < 0.001) and telephone calls (AMD -1.41 d; 95% CI, -1.52 to -1.31; p < 0.001) were associated with decreased duration of delirium in all patients.

CONCLUSIONS

The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

Sleep in the intensive care unit

PURPOSE OF REVIEW

Sleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU) affects physiology and clinical outcomes, as well as the most recent advances in sleep and circadian rhythm promoting interventions including therapeutics.

RECENT FINDINGS

On a molecular level, clock genes dysrhythmia and altered immunity are clearly linked, particularly in sepsis. Melatonin may also be associated with insulin sensitivity in ICU patients. Clinically, changes in sleep architecture are associated with delirium, and sleep-promoting interventions in the form of multifaceted care bundles may reduce its incidence. Regarding medications, one recent randomized controlled trial (RCT) on melatonin showed no difference in sleep quality or incidence of delirium.

SUMMARY

Further investigation is needed to establish the clinical relevance of sleep and circadian disruption in the ICU. For interventions, standardized protocols of sleep promotion bundles require validation by larger multicenter trials. Administratively, such protocols should be individualized to both organizational and independent patient needs. Incorporating pharmacotherapy such as melatonin and nocturnal dexmedetomidine requires further evaluation in large RCTs.

Development and validation of a RASS-related nomogram to predict the in-hospital mortality of neurocritical patients: a retrospective analysis based on the MIMIC-IV clinical database

BACKGROUND

Richmond agitation-sedation scale (RASS) is a simple and widely used tool for evaluating sedation and agitation in adult ICU patients. Early deep sedation has been shown to be an important independent predictor of death, however, studies on the role of RASS in the prognostic assessment of neurocritical patients are lacking. The purpose of this study was to investigate the relationship between RASS and in-hospital mortality in neurocritical patients, and to develop and validate an effective predictive model based on this.

METHODS

This was a retrospective study of neurocritical patients from a large clinical database. A total of 2651 patients were collected, including general demographic characteristics, past medical history, biochemical test data and physical examination within 24 h of admission, and related medical records. Univariate and multivariate logistic regression analyses were used to screen out significant variables. Finally, 11 significant predictors were included into the logistic regression to establish the nomogram.

RESULTS

The area under the curve (AUC) of the nomogram was 0.9087(0.8950-0.9224) and the corrected c index was 0.9043, which gave the model better discriminatory ability compared with critical care related scales, such as SOFA and SAPSII scores. Besides, tools including calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were used to verify that the model had good discrimination, calibration, and clinical applicability.

CONCLUSIONS

RASS score was an independent prognostic predictor of in-hospital death in neurocritical patients, and patients who are deeply sedated have a worse prognosis. RASS-related nomogram could be applied to predict the prognosis of neurocritical patients and to take effective intervention measures in early stage.

Nurses' assessment of subsyndromal delirium and barriers to assessment: A cross-sectional survey in the intensive care unit

AIMS

The aims of the study are to investigate the current status of nurses' assessment of subsyndromal delirium (SSD) in the intensive care unit (ICU) and explore possible barriers to assessment.

BACKGROUND

SSD is a dynamic, recognizable disorder commonly seen in the ICU that can lead to poor patient outcomes. Timely recognition and management can prevent its progression.

METHODS

A cross-sectional survey design was used to collect data from ICU registered nurses in southwest China. The online survey containing an analysis of the current status of SSD assessment and barriers was completed by 237 nurses.

RESULTS

A total of 51.5% of nurses chose to assess SSD using an assessment tool, the most commonly used being the Confusion Assessment Method for the Intensive Care Unit; the frequency of assessment was mostly once a day (66, 41.0%) and often at shift change (178, 87.3%). There were statistically significant differences in the barrier factor scores by assessment frequency, assessment method, status of training in SSD, ability of SSD-related knowledge to meet clinical needs and willingness to receive SSD training.

CONCLUSION

Our study confirms that the current state of assessment of SSD in the ICU is unsatisfactory, with nurses' lack of assessment knowledge and skills, poor organization and management, and the complexity of patients' conditions being barriers.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should systematically conduct training programmes on effective SSD assessment knowledge and skills, incorporate SSD assessment into the daily workflow, have standardized assessment tools, develop standardized processes and assign dedicated staff to monitor, audit and provide feedback on SSD assessments.

Exploring perceptions regarding family-based delirium management in the intensive care unit

Background

Delirium is a common complication in patients treated in the intensive care unit (ICU). Family members can help alleviate patient anxiety and may be able to aid in the management of delirium. This study aimed to explore the perceptions of former ICU patients and their families together, regarding the involvement of family in delirium management.

Method

Nine audio-recorded, semi-structured interviews took place with former ICU patients together with a family member. Participants were interviewed after their intensive care follow-up clinic appointment in an East Midlands hospital in England. Interviews were transcribed, coded and analysed using thematic analysis.

Results

Three themes were identified: 'understanding about delirium'; 'influencers of delirium management: family and healthcare professionals' and 'family-based delirium care'. Participants expressed that family have a valuable role to play in the management of delirium in the ICU. However, education and guidance is needed to support the family in how delirium can be managed and the current treatment options available. It is important for ICU staff to gain an understanding of the patient's life and personality to personalise delirium management to the needs of the patient and their family.

Conclusion

This study found that family presence and knowledge about the patient may be beneficial to delirium management in the ICU. Further research should investigate the effectiveness of the strategies and interventions to understand their influence on delirium management in ICU patients.

Analysis of adherence to an early mobilization protocol in an intensive care unit: Data collected prospectively over a period of three years by the clinical information system

OBJECTIVE

To determinate the adherence and barriers of our early mobilization protocol in patients who had received mechanical ventilation >48h in routine daily practice through clinical information system during all Intensive Care Unit (ICU) stay.

DESIGN

Observational and prospective cohort study.

SETTING

Polyvalent ICU over a three-year period (2017-2019).

PATIENTS

Adult patients on mechanical ventilation >48h who met the inclusion criteria for the early mobilization protocol.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Demographics, adherence to the protocol and putative hidden adherence, total number of mobilizations, barriers, artificial airway/ventilatory support at each mobilization level and adverse events.

RESULTS

We analyzed 3269 stay-days from 388 patients with median age of 63 (51-72) years, median APACHE II 23 (18-29) and median ICU stay of 10.1 (6.2-16.5) days. Adherence to the protocol was 56.6% (1850 stay-days), but patients were mobilized in only 32.2% (1472) of all stay-days. The putative hidden adherence was 15.6% (509 stay-days) which would increase adherence to 72.2%. The most common reasons for not mobilizing patients were failure to meeting the criteria for clinical stability in 241 (42%) stay-days and unavailability of physiotherapists in 190 (33%) stay-days. Adverse events occurred in only 6 (0.4%) stay-days.

CONCLUSIONS

Data form Clinical Information System showed although adherence was high, patients were mobilized in only one-third of all stay-days. Knowing the specific reason why patient were not mobilized in each stay-day allow to develop concrete decisions to increase the number of mobilizations.

Association of delirium screening on hospitalized adults and postacute care utilization: A retrospective cohort study

BACKGROUND

Patients with delirium have increased hospital length of stay (LOS), morbidity and mortality. Impact of delirium on postacute care (PAC) utilization is not fully characterized. Impact of screening for delirium on general medicine patients is unknown. The objective of this study was to assess impact of screening for delirium on inpatient PAC utilization.

METHODS

This was a single center, retrospective cohort study at an academic tertiary care center in Charleston, SC. Patients were selected from adults hospitalized from home and discharged alive between June 2014 and June 2018. The brief confusion assessment method (bCAM) screening was conducted and documented by nursing on admission and every shift thereafter. Outcome measure was the proportion of patients discharged to facility.

RESULTS

Of 93,388 non-ICU adult admission between June 2014 and June 2018, 4.4% of those not screened for delirium were discharged to facility versus 15.0% in those screened and 41.4% in those screening positive. Multivariable regression analysis showed that patients screened for delirium were 2.3 times more likely to discharge to facility (95% CI (2.145, 2.429)) while those with a positive bCAM were 3.3 times more likely than those with a negative bCAM to discharge to facility (95% CI (2.949, 3.712)).

CONCLUSIONS

After adjusting for demographics, medication orders and comorbidities there was an association between screening for delirium, positive delirium screen and discharge to facility. An appreciation of where and why patients are discharged is imperative to optimize both patient care and cost utilization.

Usability Testing of an iPad Communication Application for Mechanically Ventilated Patients

BACKGROUND

Patient communication challenges during mechanical ventilation can negatively impact symptom management and psychological recovery. Alternative communication (AC) aids have the potential to improve mechanically ventilated (MV) patient experiences.

OBJECTIVES

This study evaluated the feasibility and usability of a communication application on a tablet (iPad).

METHOD

A single-group pilot study was guided by the augmentative and alternative communication acceptance model. We recruited patients from 1 medical intensive care unit. Existing communication application software (Proloquo2Go) was tailored to MV patients' needs. Usability testing included patient communication of 5 messages with data collected on success, message completion time, and patient feedback.

RESULTS

Ten patients with a mean age of 50 years (SD, 16.7) were enrolled. Of the 7 patients able to complete usability testing, 85.7% found the device easy to use, and 100% wanted the iPad available for their use when on the ventilator. Three patients were extubated immediately after usability testing. Two patients preferred other modes of communication (writing). Two patients used the iPad as their primary mode of communication during the remainder of their time on the ventilator. Nurse feedback on the communication application was positive.

DISCUSSION

Tablet-based communication applications can be successfully used by MV patients and should be considered as 1 tool to support effective patient communication during mechanical ventilation. Future research is needed to identify which patients may be most likely to benefit from the availability of these devices.

Interprofessional Team Collaboration and Work Environment Health in 68 US Intensive Care Units

BACKGROUND

Safe, reliable, high-quality critical care delivery depends upon interprofessional teamwork.

OBJECTIVE

To describe perceptions of intensive care unit (ICU) teamwork and healthy work environments and evaluate whether perceptions vary by profession.

METHODS

In August 2015, Assessment of Interprofessional Team Collaboration Scale (AITCS) and the American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) surveys were distributed to all interprofessional members at the 68 ICUs participating in the ICU Liberation Collaborative. Overall scores range from 1 (needs improvement) to 5 (excellent).

RESULTS

Most of the 3586 surveys completed were from registered nurses (51.2%), followed by respiratory therapists (17.8%), attending physicians (10.5%), rehabilitation therapists (8.3%), pharmacists (4.9%), nursing assistants (3.1%), and physician trainees (4.1%). Overall, respondents rated teamwork and work environment health favorably (mean [SD] scores: AITCS, 3.92 [0.64]; HWEAT, 3.45 [0.79]). The highest-rated AITCS domain was "partnership/shared decision-making" (mean [SD], 4.00 [0.63); lowest, "coordination" (3.67 [0.80]). The highest-scoring HWEAT standard was "effective decision-making" (mean [SD], 3.60 [0.79]); lowest, "meaningful recognition" (3.30 [0.92]). Compared with attending physicians (mean [SD] scores: AITCS, 3.99 [0.54]; HWEAT, 3.48 [0.70]), AITCS scores were lower for registered nurses (3.91 [0.62]), respiratory therapists (3.86 [0.76]), rehabilitation therapists (3.84 [0.65]), and pharmacists (3.83 [0.55]), and HWEAT scores were lower for respiratory therapists (3.38 [0.86]) (all P ≤ .05).

CONCLUSIONS

Teamwork and work environment health were rated by ICU team members as good but not excellent. Care coordination and meaningful recognition can be improved.

Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study

How to cite this article: Karim HMR, Mitra JK. Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study. Indian J Crit Care Med 2022;26(11):1227-1228.

Dexmedetomidine decreases the 50% effective dose (ED50) of intravenous propofol required to prevent tracheal intubation response in Beagles

OBJECTIVE

To determine the 50% effective dose (ED50) of intravenous propofol required for successfully preventing tracheal intubation response in Beagles co-induced with dexmedetomidine.

ANIMALS

36 adult male Beagles.

PROCEDURES

The dogs were randomly assigned to either group D1, group D2, or group C (received 1 µg/kg, 2 µg/kg dexmedetomidine intravenously, or the same amount of normal saline as dexmedetomidine, 10 mL). The first dog in each group received 6 mg/kg of propofol for induction. The pump speed of propofol was 600 mL/h. The dosage varied with increments or decrements of 0.5 mg/kg based on the Dixon up-and-down method. The duration of eye-opening after propofol administration was recorded. Changes in heart rate (HR) and respiratory rate (RR) were recorded at 5 timepoints: after entering the operation room and prior to propofol administration (T1), 1 and 3 min after propofol administration (T2 and T3), 3 and 5 min after intubation (T4 and T5).

RESULTS

The required ED50 of propofol that prevented tracheal intubation response in D1, D2, and C groups were 6.4 mg/kg (95% CI, 6.1 to 6.7 mg/kg), 5.8 mg/kg (95% CI, 5.67 to 6 mg/kg), and 8.3 mg/kg (95% CI, 8 to 8.5 mg/kg), respectively. The recovery time of group D2 was significantly longer than that of groups D1 and C (P < .05). The differences in HR among the 3 groups were significant from T2 up to T5 timepoint (P < .05). The differences in RR among the 3 groups were significant at T2 and T3 timepoints (P < .05).

CLINICAL RELEVANCE

Dexmedetomidine pre-injection reduces the amount of propofol required for endotracheal intubation response in Beagles, thereby reducing the respiratory inhibition induced by propofol.

Time-of-day dependent effects of midazolam administration on myocardial injury in non-cardiac surgery

Background

Animal studies have shown that midazolam can increase vulnerability to cardiac ischemia, potentially via circadian-mediated mechanisms. We hypothesized that perioperative midazolam administration is associated with an increased incidence of myocardial injury in patients undergoing non-cardiac surgery (MINS) and that circadian biology may underlie this relationship.

Methods

We analyzed intraoperative data from the Multicenter Perioperative Outcomes Group for the occurrence of MINS across 50 institutions from 2014 to 2019. The primary outcome was the occurrence of MINS. MINS was defined as having at least one troponin-I lab value ≥0.03 ng/ml from anesthesia start to 72 h after anesthesia end. To account for bias, propensity scores and inverse probability of treatment weighting were applied.

Results

A total of 1,773,118 cases were available for analysis. Of these subjects, 951,345 (53.7%) received midazolam perioperatively, and 16,404 (0.93%) met criteria for perioperative MINS. There was no association between perioperative midazolam administration and risk of MINS in the study population as a whole (odds ratio (OR) 0.98, confidence interval (CI) [0.94, 1.01]). However, we found a strong association between midazolam administration and risk of MINS when surgery occurred overnight (OR 3.52, CI [3.10, 4.00]) or when surgery occurred in ASA 1 or 2 patients (OR 1.25, CI [1.13, 1.39]).

Conclusion

Perioperative midazolam administration may not pose a significant risk for MINS occurrence. However, midazolam administration at night and in healthier patients could increase MINS, which warrants further clinical investigation with an emphasis on circadian biology.