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

Prophylactic melatonin for delirium in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

Up to 80% of patients in the intensive care unit (ICU) suffer from delirium. Studies on the preventative use of melatonin in the ICU have produced mixed results. We performed a systematic review and meta-analysis to evaluate whether early administration of melatonin reduces the prevalence of delirium in critically ill patients.

METHODS

We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing melatonin or melatonin agonists to placebo in ICU setting. The population included adult patients in the ICU. The primary outcome was the prevalence of delirium. Secondary outcomes included duration of delirium, delirium-free day, serum melatonin concentration, need for sedation, duration of mechanical ventilation, hospital and ICU length of stay (LOS), all-cause mortality, sleep quality, and adverse events. Trial sequential analysis (TSA) was performed on the primary outcome to prevent the risk of random error and multiplicity phenomenon as a result of repeated significance testing across all the included trials.

RESULTS

Twelve trials with a total of 2538 patients were analyzed. When all trials were pooled, the incidence of delirium in ICU patients who received melatonin was significantly lower than in those who received placebo (risk ratio, 0.77; 95% confidence interval: 0.61-0.96; I2 = 56%). There were no significant differences in secondary outcomes including duration of delirium, duration of mechanical ventilation, ICU LOS, hospital LOS, and mortality. TSA indicated that Z-curve crossed the traditional boundary, but did not cross the monitoring boundary for benefit, which indicated that it is still inconclusive that melatonin affects the incidence of delirium.

CONCLUSIONS

This meta-analysis found that early administration of melatonin may result in a decreased delirium prevalence in critically ill patients. However, the sensitivity analysis of high-quality studies did not support this finding. In addition, TSA demonstrated that the result may have false-positive error. Therefore, this finding should be interpreted with caution. Further studies are needed to examine the effectiveness of prophylactic melatonin on the prevalence and duration of ICU delirium in the future.

Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update

PURPOSE

The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP).

SUMMARY

RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care.

CONCLUSION

While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.

A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings

BACKGROUND

Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z).

RESULTS

Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions.

CONCLUSIONS

Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk.

A Narrative Review of the Impact of Extracorporeal Membrane Oxygenation on the Pharmacokinetics and Pharmacodynamics of Critical Care Therapies

Objective:

Extracorporeal membrane oxygenation (ECMO) utilization is increasing on a global scale, and despite technological advances, minimal standardized approaches to pharmacotherapeutic management exist. This objective was to create a comprehensive review for medication dosing in ECMO based on the most current evidence.

Data Sources:

A literature search of PubMed was performed for all pertinent articles prior to 2022. The following search terms were utilized: ECMO, pharmacokinetics, pharmacodynamics, sedation, analgesia, antiepileptic, anticoagulation, antimicrobial, antifungal, nutrition. Retrospective cohort studies, case-control studies, case series, case reports, and ex vivo investigations were reviewed.

Study Selection and Data Extraction:

PubMed (1975 through July 2022) was the database used in the literature search. Non-English studies were excluded. Search terms included both drug class categories, specific drug names, ECMO, and pharmacokinetics.

Data Synthesis:

Medications with high protein binding (>70%) and high lipophilicity (logP > 2) are associated with circuit sequestration and the potential need for dose adjustment. Volume of distribution changes with ECMO may also impact dosing requirements of common critical care medications. Lighter sedation targets and analgosedation may help reduce sedative and analgesia requirements, whereas higher antiepileptic dosing is recommended. Vancomycin is minimally affected by the ECMO circuit and recommendations for dosing in critically ill adults are reasonable. Anticoagulation remains challenging as optimal aPTT goals have not been established.

Relevance to Patient Care and Clinical Practice:

This review describes the anticipated impacts of ECMO circuitry on sedatives, analgesics, anticoagulation, antiepileptics, antimicrobials, antifungals, and nutrition support and provides recommendations for drug therapy management.

Conclusions:

Medication pharmacokinetic/pharmacodynamic parameters should be considered when determining the potential impact of the ECMO circuit on attainment of therapeutic effect and target serum drug concentrations, and should guide therapy choices and/or dose adjustments when data are not available.

Sleep cycle in children with severe acute bronchopneumonia during mechanical ventilation at different depths of sedation

BACKGROUND

To investigate the characteristics of sleep cycle in children with severe acute bronchopneumonia treated with invasive mechanical ventilation at different sedation depths.

METHODS

We included 35 pediatric patients with severe acute bronchopneumonia treated using mechanical ventilation in Pediatric Intensive Care Unit of Shengjing Hospital of China Medical University. They were divided into deep sedation group (n = 21; ramsay score 5-6) and light sedation group (n = 14; ramsay score3-4) based on sedation depth achieved during mechanical ventilation. Long-term video electroencephalography (EEG) monitoring was performed within the first 24 h after starting mechanical ventilation and after weaning from mechanical ventilation and discontinuing sedatives and analgesics. The results were analyzed and compared with those of normal children to analyze changes in sleep cycle characteristics at different sedation depths and mechanical ventilation stages.

RESULTS

There were 29 cases altered sleep architecture. The deep sedation group had a significantly higher incidence of sleep architecture altered, total sleep duration, and non-rapid eye movement sleep-1 (NREM-1) loss incidence than the light sedation group. Moreover, the deep sedation group had a significantly lower awakening number and rapid eye movement sleep (REM) percentage than the light sedation group. The sleep cycle returned to normal in 27 (77%) patients without NREM-1 or REM sleep loss.

CONCLUSIONS

Deep sedation during mechanical ventilation allows longer total sleep duration, fewer awakenings, and an increased deep sleep proportion, but sleep architecture is severely altered. After weaning from mechanical ventilation and sedative discontinuation, lightly sedated children exhibit better sleep recovery.

Factors Related to Hospitalisation-Associated Disability in Patients after Surgery for Acute Type A Aortic Dissection: A Retrospective Study

The in-hospital mortality rate among patients after surgery for acute type A aortic dissection (ATAAD) has improved chronologically. However, the relationship between the incidence of hospitalisation-associated disability (HAD) and acute cardiac rehabilitation in patients after surgery for ATAAD has not been reported. Therefore, this study evaluated factors related to HAD in patients after surgery for ATAAD. This single-centre retrospective observational study included 483 patients who required emergency surgery for ATAAD. HAD occurred in 104 (21.5%) patients following cardiovascular surgery. Factors associated with HAD were age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.09; p = 0.001), noninvasive positive pressure ventilation (NPPV; OR, 2.15; 95% CI, 1.10-4.19; p = 0.025), postoperative delirium (OR, 2.93; 95% CI, 1.60-5.37; p = 0.001), and timing of walking onset (OR, 1.29; 95% CI, 1.07-1.56; p = 0.008). Furthermore, a late walking onset was associated with a higher risk of developing HAD and more severe functional decline. Early rehabilitation based on appropriate criteria has possibility of preventing HAD.

Is There a Role for Medication in Managing Delirium with Dementia?

People with dementia are more likely to develop delirium. We conducted a brief literature search and give a pragmatic overview of the key issues. Making rational and safe prescribing decisions is highly influenced by organisational culture and embedded staff practices. Comprehensive assessment for unmet physical, psychological, and social needs is an important intervention in itself. Taking a broad overview of possible pharmacological interventions should include stopping inappropriate medications and prescribing for key drivers of the underlying causes of delirium. Prescribing psychotropic medications may be indicated where there is significant distress or risk to the person with dementia and risk to those around them. It is vital to consider the dementia subtype and, where possible, involve family and friend carers in the decision-making process. Medications should be prescribed at the lowest possible dose for the least amount of time after carefully weighing risks versus benefits and documenting these. While these cases are challenging for staff and families, it can be rewarding to improve the quality of life and lessen distress for the person with dementia. There are also opportunities for informing family and friend carers, educating the wider multidisciplinary team, and promoting organisational change.

Investigating the rate of skeletal muscle atrophy in men and women in the intensive care unit: a prospective observational study

Muscle atrophy greatly affects the prognosis of patients in the intensive care unit, but the rate of change remains unclear. In this prospective observational study, we used ultrasound to measure the change in muscle thickness of the rectus femoris (RF) and vastus intermedius (VI) in 284 patients who were admitted to the SICU of Taoyuan General Hospital between January 1 and June 30, 2020. Patients were excluded if there is a wound at the right thigh which hinders the ultrasonography probe from placing. Daily rates of muscle atrophy were calculated using linear analysis and the ratios of change were plotted against the period of hospitalization. Patient characteristics were adjusted using propensity score matching and differences between men and women were analyzed. A linear mixed model was used to calculate the influence of other factors on muscle loss. The average daily atrophy rates of the RF and VI were 0.84% and 0.98%, respectively. The rate of atrophy was the highest in the third and fourth weeks. Daily atrophy rates of the RF and VI were approximately three times higher in women than in men. Protective factors of muscle atrophy included higher BMI and lower initial thickness of the RF and VI. Our study depicts the trend of muscle atrophy in the ICU and suggests more discussion in prevention to be conducted especially for women.

Incidence, Associated Factors, and Outcome of Delirium among Patients Admitted to ICUs in Oman

Background

The incidence of delirium is high up to 46.3% among patients admitted to ICU. Delirium is linked to negative patient outcomes like increased duration of mechanical ventilation use, prolonged ICU stay, increased mortality rate, and healthcare costs. Despite the importance of delirium and its consequences that are significant, there is a scarcity of studies which explored delirium in Oman.

Objectives

This study was conducted to assess the incidence of delirium, the association between the selected predisposing factors and precipitating factors with delirium, determine the predicators of delirium, and evaluate its impacts on ICU mortality and ICU length of stay among ICU patients in Oman.

Methods

A multicenter prospective observational design was used. A total of 153 patients were assessed two-times a day by bedside ICU nurses through the Intensive Care Delirium Screening Checklist (ICDSC).

Results

The results revealed that the delirium incidence was 26.1%. Regression analysis showed that sepsis, metabolic acidosis, nasogastric tube use, and APACHE II score were independent predictors for delirium among ICU patients in Oman and delirium had significant impacts on ICU length of stay and mortality rate.

Conclusion

Delirium is common among ICU patients and it is associated with negative consequences. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Association of Incident Delirium With Short-term Mortality in Adults With Critical Illness Receiving Mechanical Ventilation

IMPORTANCE

Intensive care unit (ICU)-acquired delirium and/or coma have consequences for patient outcomes. However, contradictory findings exist, especially when considering short-term (ie, in-hospital) mortality and length of stay (LOS).

OBJECTIVE

To assess whether incident delirium, days of delirium, days of coma, and delirium- and coma-free days (DCFDs) are associated with 14-day mortality, in-hospital mortality, and hospital LOS among patients with critical illness receiving mechanical ventilation.

DESIGN, SETTING, AND PARTICIPANTS

This single-center prospective cohort study was conducted in 6 ICUs of a university-affiliated tertiary hospital in Taiwan. A total of 267 delirium-free patients (aged ≥20 years) with critical illness receiving mechanical ventilation were consecutively enrolled from August 14, 2018, to October 1, 2020.

EXPOSURES

Participants were assessed daily for the development of delirium and coma status over 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively.

MAIN OUTCOMES AND MEASURES

Mortality rates (14-day and in-hospital) and hospital LOS using electronic health records.

RESULTS

Of 267 participants (median [IQR] age, 65.9 [57.4-75.1] years; 171 men [64.0%]; all of Taiwanese ethnicity), 149 patients (55.8%) developed delirium for a median (IQR) of 3.0 (1.0-5.0) days at some point during their first 14 days of ICU stay, and 105 patients (39.3%) had coma episodes also lasting for a median (IQR) of 3.0 (1.0-5.0) days. The 14-day and in-hospital mortality rates were 18.0% (48 patients) and 42.1% (112 of 266 patients [1 patient withdrew from the study]), respectively. The incidence and days of delirium were not associated with either 14-day mortality (incident delirium: adjusted hazard ratio [aHR], 1.37; 95% CI, 0.69-2.72; delirium by day: aHR, 1.00; 95% CI, 0.91-1.10) or in-hospital mortality (incident delirium: aHR, 1.00; 95% CI, 0.64-1.55; delirium by day: aHR, 1.02; 95% CI, 0.97-1.07), whereas days spent in coma were associated with an increased hazard of dying during a given 14-day period (aHR, 1.16; 95% CI, 1.10-1.22) and during hospitalization (aHR, 1.10; 95% CI, 1.06-1.14). The number of DCFDs was a protective factor; for each additional DCFD, the risk of dying during the 14-day period was reduced by 11% (aHR, 0.89; 95% CI, 0.84-0.94), and the risk of dying during hospitalization was reduced by 7% (aHR, 0.93; 95% CI, 0.90-0.97). Incident delirium was associated with longer hospital stays (adjusted β = 10.80; 95% CI, 0.53-21.08) when compared with no incident delirium.

CONCLUSIONS AND RELEVANCE

In this study, despite prolonged LOS, ICU delirium was not associated with short-term mortality. However, DCFDs were associated with a lower risk of dying, suggesting that future research and intervention implementation should refocus on maximizing DCFDs to potentially improve the survival of patients receiving mechanical ventilation.

The Challenges of Managing Pain in the Intensive Care Unit

Pain management in the intensive care unit can be challenging. It is important to assess and reassess the patient for pain using the appropriate pain assessment tool for the patient's condition. It is critical to use these tools for compliance to best practice recommendations by The Joint Commission, the Society of Critical Care Management, and the American Association of Critical Care Nurses. Critical care nurses need to know the types of pain and how everyday nursing care and procedures affect the patient's pain level. This article reviews the types and characteristics of pain, the best practice guidelines, and shares a pathway for the best management of a patient's pain.

Attenuating Muscle Mass Loss in Critical Illness: the Role of Nutrition and Exercise

PURPOSE OF REVIEW

Impaired recovery following an intensive care unit (ICU) admission is thought related to muscle wasting. Nutrition and physical activity are considered potential avenues to attenuate muscle wasting. The aim of this review was to present evidence for these interventions in attenuating muscle loss or improving strength and function.

RECENT FINDINGS

Randomised controlled trials on the impact of nutrition or physical activity interventions in critically ill adult patients on muscle mass, strength or function are presented. No nutrition intervention has shown an effect on strength or function, and the effect on muscle mass is conflicting. RCTs on the effect of physical activity demonstrate conflicting results; yet, there is a signal for improved strength and function with higher levels of physical activity, particularly when commenced early. Further research is needed to elucidate the impact of nutrition and physical activity on muscle mass, strength and function, particularly in combination.

Early onset delirium incidence and risk factors in hematology oncology patients admitted to the intensive care unit: A retrospective cohort study

Background

Delirium occurs frequently in intensive care unit (ICU) patients; however, there are limited data evaluating its impact on critically ill hematology-oncology patients. We aimed to determine the incidence and risk factors for early-onset delirium development in hematology-oncology patients admitted to the ICU.

Methods

This single-center, retrospective cohort study evaluated the primary outcome of incident delirium within 7 days of ICU admission in adults admitted to the hematology-oncology medical or surgical ICU. Patients with delirium (DEL) were compared to those without (No-DEL) for evaluation of secondary endpoints including hospital mortality, ICU, and hospital length of stay (LOS). Multivariable logistic regression modeling was performed to identify independent risk factors for delirium.

Results

Delirium occurred in 125 (51.2%) of 244 patients. Inhospital mortality was significantly higher in the DEL vs. No-DEL group (32.8% vs. 15.1%, P = 0.002). Median (1st and 3rd quartiles) ICU and hospital LOS were significantly longer in the delirium group, respectively (6 [4-10] days vs. 3 [2-5] days, P < 0.001, and 21 [14-36] days vs. 12 [8-22] days, P < 0.001). Higher Sequential Organ Failure Assessment score, high-dose corticosteroids, mechanical ventilation (MV), and brain metastases were each independently, associated with an increased delirium risk.

Conclusion

Hematology-oncology patients admitted to the ICU frequently develop delirium. Consistent with literature in nonhematology-oncology critically ill patients, identified independent risk factors for delirium were MV and organ dysfunction. Risk factors unique to the critically ill hematology-oncology patient population include high-dose corticosteroids and brain metastases. Further research is needed to evaluate strategies to mitigate delirium development in this population based on risk assessment.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

OBJECTIVES

To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement.

METHOD

Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals).

RESULTS

A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521).

CONCLUSIONS

Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID-19 patients: A retrospective cohort study

BACKGROUND

Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium.

METHODS

Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels.

RESULTS

A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/212) patients received PP. Mechanical ventilation (OR 3.81 [1.16-12.52]) and PP (OR 7.38 [2.4-22.68]) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP.

CONCLUSION

PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium.

IMPLICATION STATEMENT

PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.

The incidence of propofol infusion syndrome in critically-ill patients

PURPOSE

PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses.

MATERIALS AND METHODS

Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS.

RESULTS

The incidence of PRIS was 2.9% with a PRIS-associated mortality rate of 36.8%. In PRIS patients, propofol was administered at a median dose of 36.4 μg/kg/min and over a median duration of 147.0 h. The development of PRIS was observed at a median of 125.0 h post-propofol initiation and a cumulative dose of 276.5 mg/kg. The development of metabolic acidosis (78.9%), cardiac dysfunction (52.6%), hypertriglyceridemia (100%), and rhabdomyolysis (26.3%) were observed in our PRIS patients.

CONCLUSION

PRIS can often be overlooked and underdiagnosed. It is important to monitor for early signs of PRIS in patients who are on prolonged propofol infusion. Prompt recognition and interventions can minimize the dangers resulting from PRIS.

New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study

BACKGROUND

Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge.

OBJECTIVE

Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge.

DESIGN

Retrospective cohort.

PARTICIPANTS

Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF.

MAIN MEASURES

Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge.

KEY RESULTS

Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge.

CONCLUSIONS

Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.

Targeting the gut microbiome in the management of sepsis-associated encephalopathy

Brain injury resulting from sepsis, or sepsis-associated encephalopathy (SAE), occurs due to impaired end-organ perfusion, dysregulated inflammation affecting the central nervous system (CNS), blood-brain barrier (BBB) disruption, mitochondrial dysfunction, oxidative stress, accumulation of toxic neuropeptides and impaired toxin clearance secondary to sepsis-induced hepatic and renal dysfunction. The gut microbiome becomes pathologically altered in sepsis, which likely contributes to the pathogenesis of SAE. Herein, we review the literature detailing dysregulation of microbiota-gut-brain axis (MGBA) in SAE and highlight potential therapeutic strategies to modulate the gut microbiome to mitigate sepsis-induced brain injury.

A nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to intensive care: A stepped-wedge cluster randomised trial

BACKGROUND

Delirium is an acute change in behaviour, characterised by a fluctuating course, inattention, and disorganised thinking. For critically ill adults in the intensive care, the incidence of delirium has been reported to be at least 30% and is associated with both short-term and long-term complications, longer hospital stay, increased risk of mortality, and long-term cognitive problems.

AIM

The objective of this study was to determine the effectiveness of a nurse-led delirium-prevention protocol in reducing the incidence and duration of delirium among adults admitted to intensive care.

METHODS

A hybrid stepped-wedge cluster randomised controlled trial was conducted to assess the effectiveness of the implementation and dissemination of the nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adults intensive care units in the southwest of Sydney, Australia.

RESULTS

Between May 2019 and February 2020, over a 10-month period, 2618 admissions, among 2566 patients, were included in the study. After an initial 3-month baseline period, each month there was a random crossover to the nurse-led intervention in one of the four intensive care units, and by the 7th month of the trial, all units were exposed to the intervention for at least 3 months. The incidence of acute delirium was observed to be 10.7% (95% confidence interval [CI] = 9.1-12.4%), compared to 14.1% (95% CI = 12.2-16.2%) during the preintervention (baseline) period (adjusted rate ratio [adjRR] = 0.78, 95% CI = 0.57-1.08, p = 0.134). The average delirium-free-days for these preintervention and postintervention periods were 4.1 days (95% CI = 3.9-4.3) and 4.4 days (95% CI = 4.2-4.5), respectively (adjusted difference = 0.24 days [95% CI = -0.12 to 0.60], p = 0.199).

CONCLUSION

Following the introduction of a nurse-led, nonpharmacological intervention to reduce the burden of delirium, among adults admitted to intensive care, we observed no statistically significant decrease in the incidence of delirium or the duration of delirium.

Supporting Decision-Making About Patient Mobility in the Intensive Care Unit Nurse Work Environment: Work Domain Analysis

Background

Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.

Objective

The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.

Methods

We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.

Results

Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.

Conclusions

Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions.

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

OBJECTIVE

To investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients.

METHODS

One hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed.

RESULTS

The early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37).

CONCLUSIONS

Early rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.

Safety and feasibility of continuous ketamine infusion for analgosedation in medical and cardiac ICU patients who received mechanical ventilation support: A retrospective cohort study

Purpose

To assess the effect of continuous ketamine administration in patients admitted to medical and cardiac intensive care units (ICUs) and received mechanical ventilation support.

Methods

We conducted a retrospective cohort study between March 2012 and June 2020 at an academy-affiliated tertiary hospital. Adult patients who received mechanical ventilation support for over 24 h and continuous ketamine infusion for at least 8 h were included. The primary outcome was immediate hemodynamic safety after continuous ketamine infusion. The secondary outcomes included immediate delirium, pain, and use of sedation.

Results

Of all 12,534 medical and cardiac ICU patients, 564 were eligible for the analysis. Ketamine was used for 33.3 (19.0–67.5) h and the median continuous infusion dose was 0.11 (0.06–0.23) mcg/kg/h. Of all patients, 469 (83.2%) received continuous ketamine infusion concomitant with analgosedation. Blood pressure and vasopressor inotropic scores did not change after continuous ketamine infusion. Heart rate decreased significantly from 106.9 (91.4–120.9) at 8 h before ketamine initiation to 99.8% (83.9–114.4) at 24 h after ketamine initiation. In addition, the respiratory rate decreased from 21.7 (18.6–25.4) at 8 h before ketamine initiation to 20.1 (17.0–23.0) at 24 h after ketamine initiation. Overall opioid usage was significantly reduced: 3.0 (0.0–6.0) mcg/kg/h as fentanyl equivalent dose at 8 h before ketamine initiation to 1.0 (0.0–4.1) mcg/kg/h as fentanyl equivalent dose at 24 h post-ketamine initiation. However, the use of sedatives and antipsychotic medications did not decrease. In addition, ketamine did not increase the incidence of delirium within 24 h after ketamine infusion.

Conclusion

Ketamine may be a safe and feasible analgesic for medical and cardiac ICU patients who received mechanical ventilation support as an opioid-sparing agent without adverse hemodynamic effects.

Knowledge, attitudes and practices of ICU nurses regarding subsyndromal delirium among 20 hospitals in China: a descriptive cross-sectional survey

OBJECTIVES

This study sought to investigate nurses' knowledge, attitudes and practices, and analyse the influencing factors for subsyndromal delirium (SSD).

DESIGN

A descriptive cross-sectional survey.

SETTING

E-questionnaires were distributed to intensive care unit (ICU) nurses from 20 tertiary-grade, A-class hospitals in Henan Province, China.

PARTICIPANTS

A total of 740 ICU nurses participated in the questionnaire survey.

MAIN OUTCOME MEASURES

Each dimension score is converted to a percentage scale. A score of ≤60% on each dimension of the questionnaire was considered a negative score, <80% was considered a intermediate score and ≥80% was considered an excellent score.

RESULTS

A total of 733 questionnaires were included in the study. More than half of the nurses were at the intermediate level, and a few nurses were at the excellent level. Nurses self-assessed their level of knowledge was intermediate. In the attitudes dimension, nurses' attitudes were negative. The results of the practical dimension showed that most nurses could carry out the clinical practice. Multiple linear regression analysis showed that educational level and received SSD training were influencing factors.

CONCLUSIONS

ICU nursing staff overestimated their knowledge of SSD and showed a negative attitude towards it. Various forms of education and training are necessary.

Immunological risk factors for sepsis-associated delirium and mortality in ICU patients

Background

A major challenge in intervention of critical patients, especially sepsis-associated delirium (SAD) intervention, is the lack of predictive risk factors. As sepsis and SAD are heavily entangled with inflammatory and immunological processes, to identify the risk factors of SAD and mortality in the intensive care unit (ICU) and determine the underlying molecular mechanisms, the peripheral immune profiles of patients in the ICU were characterized.

Methods

This study contains a cohort of 52 critical patients who were admitted to the ICU of the First Affiliated Hospital of Jinan University. Comorbidity, including sepsis and SAD, of this cohort was diagnosed and recorded. Furthermore, peripheral blood samples were collected on days 1, 3, and 5 of admission for peripheral immune profiling with blood routine examination, flow cytometry, ELISA, RNA-seq, and qPCR.

Results

The patients with SAD had higher mortality during ICU admission and within 28 days of discharge. Compared with survivors, nonsurvivors had higher neutrophilic granulocyte percentage, higher CRP concentration, lower monocyte count, lower monocyte percentage, lower C3 complement level, higher CD14^loCD16⁺ monocytes percentage, and higher levels of IL-6 and TNFα. The CD14^hiCD16^- monocyte percentage manifested favorable prediction values for the occurrence of SAD. Differentially expressed genes between the nonsurvival and survival groups were mainly associated with immune response and metabolism process. The longitudinal expression pattern of SLC2A1 and STIMATE were different between nonsurvivors and survivors, which were validated by qPCR.

Conclusions

Nonsurvival critical patients have a distinct immune profile when compared with survival patients. CD14^hiCD16^- monocyte prevalence and expression levels of SLC2A1 and STIMATE may be predictors of SAD and 28-day mortality in ICU patients.

Critical care nurses' experiences of physical restraint in intensive care units: A qualitative systematic review and meta-synthesis

INTRODUCTION

Physical restraint is widely used in intensive care units. Critical care nurses are the primary decision makers and practitioners of physical restraint. However, little is known about the qualitative evidence of their experience of physical restraint.

AIMS

To aggregate, synthesise and interpret the qualitative evidence of studies that explored critical care nurses' experiences of physical restraint in intensive care units.

METHODS

A qualitative systematic review and meta-synthesis was conducted following Joanna Briggs Institute methodology and reported following the ENTREQ statement. Qualitative studies published in the English and Chinese were systematically searched in eight databases. PubMed, Web of Science, CINAHL, EMBASE, PsycINFO, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature Database from inception to November 2021. Two reviewers independently assessed the study eligibility and performed the data extraction and the quality appraisal. A meta-aggregative approach was used to synthesise findings. The review protocol was registered prospectively with PROSPERO (CRD42021278671).

RESULTS

Thirteen studies were included. A total of 48 intact and definite codes were extracted and classified into ten sub-categories. Four themes were finally identified: intention, alternatives, determinants, and reflection.

CONCLUSION

The intention of critical care nurses to use physical restraint is primarily driven by patient safety. Nurses will consider alternatives; however, many determinants urge nurses to implement physical restraint. Nurses prefer to sacrifice patients' comfort to ensure their safety. When nurses reflect on what they have done, some experience moral distress, but most rationalise their decision making. Further studies should explore the safety of alternatives, reduce the use of physical restraint, and pay more attention to nurses' moral distress through these insights.

RELEVANCE TO CLINICAL PRACTICE

Developing alternatives, providing relevant training for nurses, physicians, patients, and families to facilitate a restraint-free culture, and developing high-quality guidelines and regulations are essential strategies to reduce the use of physical restraint in ICUs.

Remimazolam besylate versus propofol for long-term sedation during invasive mechanical ventilation: a pilot study

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of remimazolam besylate compared with propofol in maintaining mild-to-moderate sedation in patients receiving long-term mechanical ventilation.

METHODS

In this single-centered randomized pilot study, adult patients mechanically ventilated longer than 24 h were randomized to receive remimazolam besylate or propofol. The target sedation range was - 3 to 0 on the Richmond Agitation and Sedation Scale (RASS). The primary outcome was the percentage of time in the target sedation range without rescue sedation. The secondary outcomes were ventilator-free days at day 7, the length of ICU stay and 28-day mortality.

RESULTS

Thirty patients were assigned to each group. No difference was identified between the remimazolam group and propofol group in median age [60.0 (IQR, 51.5-66.3) years vs. 64.0 (IQR, 55.0-69.3) years, respectively, p = 0.437] or the median duration of study drug infusion [55.0 (IQR, 28.3-102.0) hours vs. 41.0 (IQR, 24.8-74.3) hours, respectively, p = 0.255]. The median percentage of time in the target RASS range without rescue sedation was similar in remimazolam and propofol groups [73.2% (IQR, 41.5-97.3%) vs. 82.8% (IQR, 65.6-100%), p = 0.269]. No differences were identified between the two groups in terms of ventilator-free days at day 7, length of ICU stay, 28-day mortality or adverse events.

CONCLUSIONS

This pilot study suggested that remimazolam besylate was effective and safe for long-term sedation in mechanically ventilated patients compared with propofol.

An Automated Algorithm for Determining Sleep Using Single-Channel Electroencephalography to Detect Delirium: A Prospective Observational Study in Intensive Care Units

The relationship between polysomnography-based objective sleep and delirium in the intensive care unit (ICU) is inconsistent across studies, suggesting limitations in manually determining the sleep stage of critically ill patients. We objectively measured 24-h sleep using a single-channel electroencephalogram (SleepScope [SS]) and an under-mattress sleep monitor (Nemuri SCAN [NSCAN]), both of which have independent algorithms that automatically determine sleep and wakefulness. Eighteen patients (median age, 68 years) admitted to the ICU after valvular surgery or coronary artery bypass grafting were included, and their sleep time was measured one day after extubation. The median total sleep times (TSTs) measured by SS (TST-SS) and NSCAN were 548 (48−1050) and 1024 (462−1257) min, respectively. Two patients with delirium during the 24-h sleep measurement had very short TST-SS of 48 and 125 min, and the percentage of daytime sleep accounted for >80% in both SS and NSCAN. This preliminary case series showed marked sleep deprivation and increased rates of daytime sleeping in ICU patients with delirium. Although data accuracy from under-mattress sleep monitors is contentious, automated algorithmic sleep/wakefulness determination using a single-channel electroencephalogram may be useful in detecting delirium in ICU patients and could even be superior to polysomnography.

Critical illness and bone metabolism: where are we now and what is next?

Critical illness refers to the clinical signs of severe, variable and life-threatening critical conditions, often accompanied by insufficiency or failure of one or more organs. Bone health of critically ill patients is severely affected during and after ICU admission. Therefore, clinical work should focus on ICU-related bone loss, and early development and implementation of related prevention and treatment strategies: optimized and personalized nutritional support (high-quality protein, trace elements and intestinal prebiotics) and appropriate physiotherapy and muscle training should be implemented as early as possible after ICU admission and discharge. At the same time, the drug regulates excessive metabolism and resists osteoporosis.

ICU quasi-speciality nurses' knowledge, attitudes and practices regarding early mobilization: A cross-sectional survey

AIM

Early mobilization (EM) improves critical illness survivors' clinical outcomes. This study examines ICU quasi-specialty nurses' EM-related knowledge, attitudes and practices (KAP).

DESIGN

This cross-sectional study was conducted at a provincial ICU specialty nurse training site from 2019 to 2021. KAP data were collected using a self-report questionnaire.

METHODS

Participants were registered nurses enrolled in the training programme; 485 nurses from 188 hospitals completed the questionnaire.

RESULTS

Of the participants, 37.7% had EM training, and 30.7% reported their wards performed EM. Median (IQR) scores for knowledge, attitudes and practices were 14.0 (4.0), 47.0 (9.0) and 37.0 (8.0), belonging to medium, high and medium levels. Scores were lowest for EM scope, implementation indicators and out-of-bed mobilization. There were significant deviations in KAP scores amongst nurses at different levels of hospitals with EM training and whose departments performed EM. Significant positive correlations between knowledge and practice, and attitude and practice were identified.

Acquired agitation in acute respiratory distress syndrome with COVID-19 compared to influenza patients: a propensity score matching observational study

BACKGROUND

A growing body of evidence reports that agitation and encephalopathy are frequent in critically ill Covid-19 patients. We aimed to assess agitation's incidence and risk factors in critically ill ARDS patients with Covid-19. For that purpose, we compared SARS-CoV-2 acute respiratory distress syndrome (ARDS) patients with a population of influenza ARDS patients, given that the influenza virus is also known for its neurotropism and ability to induce encephalopathy.

METHODS

We included all the patients with laboratory-confirmed Covid-19 infection and ARDS admitted to our medical intensive care unit (ICU) between March 10th, 2020 and April 16th, 2021, and all the patients with laboratory-confirmed influenza infection and ARDS admitted to our ICU between April 10th, 2006 and February 8th, 2020. Clinical and biological data were prospectively collected and retrospectively analyzed. We also recorded previously known factors associated with agitation (ICU length of stay, length of invasive ventilation, SOFA score and SAPS II at admission, sedative and opioids consumption, time to defecation). Agitation was defined as a day with Richmond Agitation Sedation Scale greater than 0 after exclusion of other causes of delirium and pain. We compared the prevalence of agitation among Covid-19 patients during their ICU stay and in those with influenza patients.

RESULTS

We included 241 patients (median age 62 years [53-70], 158 males (65.5%)), including 146 patients with Covid-19 and 95 patients with Influenza. One hundred eleven (46.1%) patients had agitation during their ICU stay. Patients with Covid-19 had significantly more agitation than patients with influenza (respectively 80 patients (54.8%) and 31 patients (32.6%), p < 0.01). After matching with a propensity score, Covid-19 patients remained more agitated than influenza patients (49 (51.6% vs 32 (33.7%), p = 0.006). Agitation remained independently associated with mortality after adjustment for other factors (HR = 1.85, 95% CI 1.37-2.49, p < 0.001).

CONCLUSION

Agitation in ARDS Covid-19 patients was more frequent than in ARDS influenza patients and was not associated with common risk factors, such as severity of illness or sedation. Systemic hyperinflammation might be responsible for these neurological manifestations, but there is no specific management to our knowledge.

Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury

INTRODUCTION

Traumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations.

METHODS

A retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures.

RESULTS

A total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations.

CONCLUSIONS

Using a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.

Development and validation of a nomogram to predict postoperative delirium in type B aortic dissection patients underwent thoracic endovascular aortic repair

Objective

Postoperative delirium (POD) is a common postoperative complication after cardiovascular surgery with adverse outcomes. No prediction tools are currently available for assessing POD in the type B aortic dissection (TBAD) population. The purposes of this study were to develop and validate a nomogram for predicting POD among TBAD patients who underwent thoracic endovascular aortic repair (TEVAR).

Methods

The retrospective cohort included 631 eligible TBAD patients who underwent TEVAR from January 2019 to July 2021. 434 patients included before 2021 were in the develop set; 197 others were in the independent validation set. Least absolute shrinkage and selection operator (LASSO) and logistic regression were applied to identify the most useful predictive variables for constructing the nomogram. Discrimination and the agreement of the model was assessed with the area under the receiver operating characteristic curve (AUC), Brier score and the Hosmer-Lemeshow goodness-of-fit test. The results were validated using a bootstrap resampling and the validation set.

Results

The incidence rate of POD observed in the development and validation cohort were 15.0% and 14.2%, respectively. Seven independent risk factors, including age ≥60 years, syncope or coma, postoperative blood transfusion, atelectasis, estimated glomerular filtration rate (eGFR) &lt;80 ml/min/1.73 m2, albumin &lt;30 g/L, and neutrophil to lymphocyte ratio, were included in the nomogram. The model showed a good discrimination with an AUC of 0.819 (95% CI, 0.762–0.876) in the developed set, and adjusted to 0.797 (95% CI, 0.735–0.849) and 0.791 (95% CI, 0.700–0.881) in the internal validation set and the external validation, respectively. Favorable calibration of the nomogram was confirmed in both the development and validation cohorts.

Conclusion

The nomogram based on seven readily available predictors has sufficient validity to identify POD risk in this population. This tool may facilitate targeted initiation of POD preventive intervention for healthcare providers.

Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients.

METHODS AND ANALYSES

We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.

Discomfort improvement for critically ill patients using electronic relaxation devices: results of the cross-over randomized controlled trial E-CHOISIR (Electronic-CHOIce of a System for Intensive care Relaxation)

Purpose

To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU).

Methods

Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements.

Results

Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety (p < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain (p = 0.001) and DEEPSEN© with a decrease in lack of rest (p = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]).

Conclusion

Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms.

Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients.

Effectiveness depends on the type of symptom and the characteristics of the devices.

Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.

Clinical phenotypes of delirium in patients admitted to the cardiac intensive care unit

Background

Limited data are available on clinical phenotype for delirium that occurs frequently among patients admitted to the cardiac intensive care unit (CICU). The objective of this study was to investigate the clinical pictures of delirium, and their association with clinical outcomes in CICU patients.

Methods

A total of 4,261 patients who were admitted to the CICU between September 1 2012 to December 31 2018 were retrospectively registered. Patients were excluded if they were admitted to the CICU for less than 24 hours or had missed data. Ultimately, 2,783 patients were included in the analysis. A day of delirium was defined as any day during which at least one CAM-ICU assessment was positive. The clinical risk factors of delirium were classified by the delirium phenotype, as follows; hypoxic, septic, sedative-associated, and metabolic delirium.

Results

The incidence of delirium was 24.4% at the index hospitalization in all CICU patients, and 22.6% within 7 days after CICU admission. The most common delirium phenotype was septic delirium (17.2%), followed by hypoxic delirium (16.8%). Multiple phenotypes were observed during most delirium days. Delirium most frequently occurred in patients with heart failure. Of all patients affected by delirium within 7 days, both ICU and hospital mortality significantly increased according to the combined number of delirium phenotypes.

Conclusions

Delirium occurred in a quarter of patients admitted to the modern CICU and was associated with increased in-hospital mortality. Therefore, more efforts are needed to reduce the clinical risk factors of delirium, and to prevent it in order to improve clinical outcomes in the CICU.

[Enhanced recovery after surgery (ERAS®) in cardiac anesthesia]

Enhanced Recovery After Cardiac Surgery (ERACS) is a multidisciplinary and multiprofessional treatment approach in cardiac surgery. Recently, a transfer and adaptation of enhanced recovery after surgery (ERAS) protocols from other disciplines, such as colorectal surgery, to cardiac surgery has been performed in different settings. First, prehabilitation programs have been established and investigated to improve patients' physical, psychological and nutritional status including treatment of preoperative anemia. Second, intraoperative therapeutic steps are described, such as infection reduction bundles, rigid sternal closure and guidance of perioperative anesthesia. For this, the use of short-acting agents, goal-directed fluid management and multimodal anesthesia are among the important measures. Third, early recovery and restoration of patient autonomy are achieved with early extubation and mobilization, efficient postoperative analgesia and diagnosis and treatment of delirium.The introduction of an ERACS protocol is a team effort requiring a protocol adapted to the institutional conditions and a willingness to perform a shift of culture in perioperative care. So far, the successful establishment of ERACS protocols in minimally invasive cardiac surgery has been reported and encourages the development of protocols of specific patient groups, such as pediatric cardiac surgery or left ventricular assist device implantation.

Nurses' Perceptions of the Management of Acute Pain in Emergency Departments: Cross-sectional Study

AIM

This study aimed to describe registered nurses' perceptions of acute pain management in emergency departments.

DESIGN

The study design was a cross-sectional survey carried out in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. One hundred one nurses from 5 different emergency departments participated in the survey.

METHODS

Data were analyzed using descriptive methods, nonparametric tests, and principal component analysis.

RESULTS

Continuing education was significantly related to pain management. Nurses who had received continuing pain management education thought more often that challenges in pain management impact patients' acute pain management than those who had not received education. Nurses reported that patients received inadequate pain medication. The most used nonpharmacological methods were ice therapy and postural care. The nurses reported that music and conversation with the patient ameliorated the patients' acute pain. Nurses stated that their lack of knowledge concerning pain management and workload affected their acute pain management.

CONCLUSION

Study results emphasize the need to develop ongoing pain management education for registered nurses and in addition to further research of nonpharmacological alleviation method in emergency departments.

Zwang in der Intensivmedizin: unzulässig, aber wir tun es

In welchen Formen wird Zwang auf Intensivstationen wahrgenommen? Formeller und informeller Zwang sowie Zwangsbehandlung existieren auf Intensivstationen und werden sowohl von den Patienten als auch von dem Team wahrgenommen. Formeller Zwang umfasst Maßnahmen wie Fixierungen, Sedierung und Umgebung. Informeller Zwang entsteht durch Beeinflussung, wie z. B. Manipulationen, unzureichende oder falsche Information, mangelnde Kommunikation und Drohung. Längerfristige, d. h. > 30 Minuten, freiheitsbeschränkende, -entziehende Maßnahmen sowie Zwangsbehandlung sind genehmigungspflichtig.

Begründung für die Anwendung von Zwang Die Anwendung von Zwang auf der Intensivstation bedeutet einen Spagat zwischen Patientenautonomie und dem Schutz des Patienten (Fürsorge).

Situation mit Risiko für Zwang erkennen Auf Intensivstationen sind Phasen mit Agitation, Delir, aber auch Demenz oder depressive Phasen, Hypoaktivität bei Patienten, alltäglich. Zwangsmaßnahmen in Notsituationen dürfen nur nach entsprechender Prüfung der juristischen und medizinethischen Kriterien eingesetzt werden und nur, wenn es keine Alternativen (Ultima Ratio) für deren Einsatz gibt. Die Anwendung von Zwang als Ultima Ratio umfasst die Überprüfung der Entscheidungsfähigkeit und die Einschätzung/Prüfung der kritischen Situation.

Zwang als Ultima Ratio Freiheitseinschränkende und freiheitsentziehende Maßnahmen sowie Zwangsmaßnahmen dürfen nur in Ausnahmesituationen der Einwilligungsunfähigkeit und bei „drohendem erheblichen Gesundheitsschaden“ angewendet werden.

Prophylaxe und Konzepte zur Vermeidung von Zwang auf der Intensivstation Eine Behandlung auf der Intensivstation basiert auf einer aktuellen Indikation mit medizinischer Evidenz sowie den sich daraus ableitenden Standards und Prozess-Strukturen. Zur Vermeidung von formellem und informellem Zwang ist es entscheidend, ein Menschenbild im interprofessionellen Team zu etablieren, welches den Respekt vor dem Patienten und seiner Autonomie wahrt und dies in den Alltag und die Ausbildungskonzepte umsetzt. Konzepte, um die Anwendung von Zwang zu erkennen, zu benennen und um Zwang zu vermeiden, umfassen: Erkennen von Risikosituationen für Zwang, Standards zur Vermeidung von Zwang auf der Intensivstation, Aus- und Weiterbildung in Kommunikation.

Survivorship After Critical Illness and Post-Intensive Care Syndrome

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

BACKGROUND

Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation.

METHODS

In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment.

RESULTS

It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907).

CONCLUSIONS

Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.