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Xing H, Zhou W, Fan Y, Wen T, Wang X, Chang G. Development and validation of a postoperative delirium prediction model for patients admitted to an intensive care unit in China: a prospective study. BMJ Open 2019; 9:e030733. [PMID: 31722939 PMCID: PMC6858207 DOI: 10.1136/bmjopen-2019-030733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES We aimed to develop and validate a postoperative delirium (POD) prediction model for patients admitted to the intensive care unit (ICU). DESIGN A prospective study was conducted. SETTING The study was conducted in the surgical, cardiovascular surgical and trauma surgical ICUs of an affiliated hospital of a medical university in Heilongjiang Province, China. PARTICIPANTS This study included 400 patients (≥18 years old) admitted to the ICU after surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was POD assessment during ICU stay. RESULTS The model was developed using 300 consecutive ICU patients and was validated using 100 patients from the same ICUs. The model was based on five risk factors: Physiological and Operative Severity Score for the enumeration of Mortality and morbidity; acid-base disturbance and history of coma, diabetes or hypertension. The model had an area under the receiver operating characteristics curve of 0.852 (95% CI 0.802 to 0.902), Youden index of 0.5789, sensitivity of 70.73% and specificity of 87.16%. The Hosmer-Lemeshow goodness of fit was 5.203 (p=0.736). At a cutoff value of 24.5%, the sensitivity and specificity were 71% and 69%, respectively. CONCLUSIONS The model, which used readily available data, exhibited high predictive value regarding risk of ICU-POD at admission. Use of this model may facilitate better implementation of preventive treatments and nursing measures.
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Affiliation(s)
- Huanmin Xing
- Nursing Department, Henan Provincial People's Hospital, Zhengzhou, Henan, China
- Nursing Department, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Nursing Department, People's Hospital of Henan University, Zhengzhou, Henan, China
| | - Wendie Zhou
- Nursing School, Harbin Medical University, Harbin, Heilongjiang, China
| | - Yuying Fan
- Nursing School, Harbin Medical University, Harbin, Heilongjiang, China
| | - Taoxue Wen
- Department of Quality Control, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xiaohui Wang
- Department of Intensive Care Unit, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Guangming Chang
- The Party Committee, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Variation in Sedation and Neuromuscular Blockade Regimens on Outcome After Cardiac Arrest. Crit Care Med 2019; 46:e975-e980. [PMID: 29979225 PMCID: PMC6138551 DOI: 10.1097/ccm.0000000000003301] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Sedation and neuromuscular blockade protocols in patients undergoing targeted temperature management after cardiac arrest address patient discomfort and manage shivering. These protocols vary widely between centers and may affect outcomes. DESIGN Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were prospectively entered into the International Cardiac Arrest Registry between 2006 and 2016. Additional data about each center's sedation and shivering management practice were obtained via survey. Sedation and shivering practices were categorized as escalating doses of sedation and minimal or no neuromuscular blockade (sedation and shivering practice 1), sedation with continuous or scheduled neuromuscular blockade (sedation and shivering practice 2), or sedation with as-needed neuromuscular blockade (sedation and shivering practice 3). Good outcome was defined as Cerebral Performance Category score of 1 or 2. A logistic regression hierarchical model was created with two levels (patient-level data with standard confounders at level 1 and hospitals at level 2) and sedation and shivering practices as a fixed effect at the hospital level. The primary outcome was dichotomized Cerebral Performance Category at 6 months. SETTING Cardiac arrest receiving centers in Europe and the United states from 2006 to 2016 PATIENTS:: Four-thousand two-hundred sixty-seven cardiac arrest patients 18 years old or older enrolled in the International Cardiac Arrest Registry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The mean age was 62 ± 15 years, 36% were female, 77% out-of-hospital arrests, and mean ischemic time was 24 (± 18) minutes. Adjusted odds ratio (for age, return of spontaneous circulation, location of arrest, witnessed, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation, medical history, country, and size of hospital) was 1.13 (0.74-1.73; p = 0.56) and 1.45 (1.00-2.13; p = 0.046) for sedation and shivering practice 2 and sedation and shivering practice 3, respectively, referenced to sedation and shivering practice 1. CONCLUSION Cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders. These findings should be further investigated in prospective studies.
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Thrane SE, Hsieh K, Donahue P, Tan A, Exline MC, Balas MC. Could complementary health approaches improve the symptom experience and outcomes of critically ill adults? A systematic review of randomized controlled trials. Complement Ther Med 2019; 47:102166. [PMID: 31780011 DOI: 10.1016/j.ctim.2019.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The purpose of this systematic review was to critically evaluate the safety and effectiveness of various complementary health approaches (CHAs) in treating symptoms experienced by critically ill adults. METHODS The review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Electronic databases (PubMed, Web of Science, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Education Resources Information Center, Medline, PsychInfo) were searched for studies published from 1997-2017. Randomized controlled trials (RCTs), in English with terms ICU/critical care, music, Reiki, therapeutic touch, healing touch, aromatherapy, essential oil, reflexology, chronotherapy, or light therapy were eligible for inclusion. Studies conducted outside the ICU, involving multiple CHAs, or enrolling pediatric patients were excluded. Data were extracted and assessed independently by two authors and reviewed by two additional authors. The Cochrane risk of bias tool was used to assess study quality. RESULTS Thirty-two RCTs were included involving 2,987 critically ill adults. CHAs evaluated included music (n = 19), nature based sounds (NBSs) (n = 4), aromatherapy (n = 3), light therapy (n = 2), massage (n = 2), and reflexology (n = 2). Half of all studies had a high risk of bias for randomization but had low or unclear biases for other categories. No study-related adverse events or safety-related concerns were reported. There were statistically significant improvements in pain (music, NBSs), anxiety (music, NBSs, aromatherapy, massage, reflexology), agitation (NBSs, reflexology), sleep (music, aromatherapy, reflexology), level of arousal (music, massage), and duration of mechanical ventilation (music, reflexology). CONCLUSIONS Evidence suggests CHAs may reduce the symptom burden of critically ill adults.
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Affiliation(s)
- Susan E Thrane
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States.
| | - Katie Hsieh
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States
| | - Paige Donahue
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States
| | - Alai Tan
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States
| | - Matthew C Exline
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States
| | - Michele C Balas
- The Ohio State University, College of Nursing, Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, United States
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Kapritsou M, Kalafati M, Giannakopoulou M, Korkolis DP, Kaklamanos I, Siskou T, Konstantinou EA. Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery. J Perianesth Nurs 2019. [DOI: https://doi.org/10.1016/j.jopan.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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González-Martín S, Becerro-de-Bengoa-Vallejo R, Angulo-Carrere MT, Iglesias MEL, Martínez-Jiménez EM, Casado-Hernández I, López-López D, Calvo-Lobo C, Rodríguez-Sanz D. Effects of a visit prior to hospital admission on anxiety, depression and satisfaction of patients in an intensive care unit. Intensive Crit Care Nurs 2019; 54:46-53. [PMID: 31358482 DOI: 10.1016/j.iccn.2019.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/11/2019] [Accepted: 07/02/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the effects of a vists prior to hospital admission on anxiety, depression and satisfaction of patients admitted electively to an intensive care unit (ICU). DESIGN A randomised clinical trial [NCT03605407]. SETTING A sample of 38 patients was recruited who were to be electively admiited to ICU divided into experimental (n = 19 patients receiving one visit prior to hospital ICU admission for surgery) and control (n = 19 patients not receiving a visit prior to hospital ICU admission for surgery) groups. MAIN OUTCOME MEASUREMENTS Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised (IES-R) were self-reported by patients before ICU admission, at 3-days and 90-days after ICU discharge. Critical Care Family Needs Inventory (CCFNI) and Family Satisfaction with Care in the Intensive Care Unit (FS-ICU) were used to measure the users' satisfaction before ICU admission and 3-days after ICU discharge. RESULTS There were statistically significant differences between experimental and control groups for FS-ICU, but not for HADS, IES-R and CCFNI. Indeed, control group patients were more satisfied with regard to emotional support, ease of getting information, control feeling, concerns and questions expression ability and overall score for decision-making satisfaction. CONCLUSIONS The visit prior to hospital admission did not seem to modify anxiety or depression, but may impair satisfaction of ICU patients.
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Affiliation(s)
- Sara González-Martín
- School of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, Spain
| | | | | | | | | | | | - Daniel López-López
- Research, Health and Podiatry Unit, Department of Health Sciences, Faculty of Nursing and Podiatry, Universidade da Coruña, Spain.
| | - César Calvo-Lobo
- Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, University of León, Ponferrada, León, Spain.
| | - David Rodríguez-Sanz
- School of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, Spain
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The Neurological Assessment of the Critically Ill Patient. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Barker M, Dixon AA, Camporota L, Barrett NA, Wan RYY. Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study. Perfusion 2019; 35:104-109. [PMID: 31296116 DOI: 10.1177/0267659119858037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. METHODS Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. RESULTS A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). CONCLUSIONS No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.
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Affiliation(s)
- Mike Barker
- Pharmacy Department, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Alison A Dixon
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Nick A Barrett
- Department of Intensive Care, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Ruth Y Y Wan
- Pharmacy Department, St Thomas' Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Štubljar D, Štefin M, Tacar MP, Cerović O, Grosek Š. Prolonged hospitalization is a risk factor for delirium onset: one-day prevalence study in Slovenian INTENSIVE CARE UNITS. Acta Clin Croat 2019; 58:265-273. [PMID: 31819322 PMCID: PMC6884389 DOI: 10.20471/acc.2019.58.02.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Delirium is a clinical syndrome often underestimated in the intensive care units (ICU). The aim of this study was to determine the prevalence and factors that influence the onset of delirium. A questionnaire was sent to intensivists in Slovenian ICUs, who estimated the prevalence of delirious patients. The questionnaire consisted of demographic data, type of ICU, diagnosis, reason for admission to the ICU, type of anesthesia and surgery, clinical condition, type of supportive therapy, presence of delirium, data on discharge, transfers between departments or patient outcome on day 30. Patient consciousness was assessed by the Richmond Agitation-Sedation Scale (RASS) and the presence of delirium by the validated delirium-screening Confusion Assessment Method for the ICU (CAM-ICU). Replies received from intensivists included data on 103 patients. According to RASS ≥-3, the prevalence of delirium was 9.5% (7 out of 74 patients). There was no difference in the prevalence of delirium between surgical and medical ICU patients (p=0.388). Delirious patients had longer hospital stay (p=0.002) and ICU stay (p=0.032) compared to patients without delirium. All delirious patients survived until day 30, whereas 19 patients without delirium died (p=0.092). Logistic regression analysis dismissed any association of delirium with patient mortality (p=0.998). Age, gender, anesthesia, mechanical ventilation, and type of surgical procedure could not be evaluated as risk factors for delirium. In Slovenian ICUs, a lower proportion of delirium was observed, as reported from similar studies. Risk factors such as gender, age, mechanical ventilation, sedation, anesthesia, or department could not predict delirium. However, prolonged hospitalization of ICU patients could predict the onset of delirium, but the presence of delirium did not increase patient mortality.
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Affiliation(s)
| | - Maruša Štefin
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Marija Pia Tacar
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ognjen Cerović
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Štefan Grosek
- 1In-Medico Department of Research and Development, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Clinical Department of Anesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia; 4Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Abstract
Delirium is a serious complication of acute illness. Little is known, however, regarding the neurobiology of delirium, largely due to challenges in studying the complex inpatient population. Neuroimaging is one noninvasive method that can be used to study structural and functional brain abnormalities associated with delirium. The purpose of this integrative literature review was to examine the content and quality of current structural neuroimaging evidence in delirium. After meeting inclusion criteria, 11 articles were included in the review. Commonly noted structural abnormalities were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures. Limitations of the studies in this review included small sample sizes, inappropriate or questionable delirium measurements, and failure to consider confounding variables. This review provides insight into possible structural changes responsible for the signs and symptoms seen in patients with delirium, but more high-quality studies are needed.
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Affiliation(s)
| | - Todd B Monroe
- 1 The Ohio State University College of Nursing, Columbus, OH, USA
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Chaiwat O, Chanidnuan M, Pancharoen W, Vijitmala K, Danpornprasert P, Toadithep P, Thanakiattiwibun C. Postoperative delirium in critically ill surgical patients: incidence, risk factors, and predictive scores. BMC Anesthesiol 2019; 19:39. [PMID: 30894129 PMCID: PMC6425578 DOI: 10.1186/s12871-019-0694-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 02/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND A common postoperative complication found among patients who are critically ill is delirium, which has a high mortality rate. A predictive model is needed to identify high-risk patients in order to apply strategies which will prevent and/or reduce adverse outcomes. OBJECTIVES To identify the incidence of, and the risk factors for, postoperative delirium (POD) in surgical intensive care unit (SICU) patients, and to determine predictive scores for the development of POD. METHODS This study enrolled adults aged over 18 years who had undergone an operation within the preceding week and who had been admitted to a SICU for a period that was expected to be longer than 24 h. The CAM - ICU score was used to determine the occurrence of delirium. RESULTS Of the 250 patients enrolled, delirium was found in 61 (24.4%). The independent risk factors for delirium that were identified by a multivariate analysis comprised age, diabetes mellitus, severity of disease (SOFA score), perioperative use of benzodiazepine, and mechanical ventilation. A predictive score (age + (5 × SOFA) + (15 × Benzodiazepine use) + (20 × DM) + (20 × mechanical ventilation) + (20 × modified IQCODE > 3.42)) was created. The area under the receiver operating characteristic (ROC) curve (AUC) was 0.84 (95% CI: 0.786 to 0.897). The cut point of 125 demonstrated a sensitivity of 72.13% and a specificity of 80.95%, and the hospital mortality rate was significantly greater among the delirious than the non-delirious patients (25% vs. 6%, p < 0.01). CONCLUSIONS POD was experienced postoperatively by a quarter of the surgical patients who were critically ill. A risk score utilizing 6 variables was able to predict which patients would develop POD. The identification of high-risk patients following SICU admission can provide a basis for intervention strategies to improve outcomes. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20181204006 . Date registered on December 4, 2018. Retrospectively registered.
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Affiliation(s)
- Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand. .,Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Mellada Chanidnuan
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Worapat Pancharoen
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Kittiya Vijitmala
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Praniti Danpornprasert
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Puriwat Toadithep
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Chayanan Thanakiattiwibun
- Integrated Perioperative Geriatric Excellent Research Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Zhang LM, Zhang DX. The Dual Neuroprotective-Neurotoxic Effects of Sevoflurane After Hemorrhagic Shock Injury. J Surg Res 2019; 235:591-599. [DOI: 10.1016/j.jss.2018.10.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/08/2018] [Accepted: 10/25/2018] [Indexed: 12/27/2022]
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Kapritsou M, Kalafati M, Giannakopoulou M, Korkolis DP, Kaklamanos I, Siskou T, Konstantinou EA. Cross-Correlation Among Visual Analog, Observational, and Behavioral Pain Scales of Oncological Patients Undergoing Major Abdominal Surgery. J Perianesth Nurs 2019; 34:774-778. [PMID: 30773406 DOI: 10.1016/j.jopan.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/14/2018] [Accepted: 11/18/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine the perception of postoperative pain intensity between nurses and oncology patients undergoing major abdominal surgery. DESIGN A prospective cross-correlation study with 173 oncology patients undergoing major abdominal surgery, such as hepatectomy or pancreatectomy. METHODS Postoperative pain intensity was evaluated by clinical pain assessment tools such as critical-care pain observation tool (CPOT) and behavioral pain scale (BPS) recorded by the researcher, whereas the visual analog scale was completed by patients. Demographic and clinical data were recorded. FINDINGS The Cronbach's α for CPOT and BPS was α = 0.738 for each. There was a significant correlation between CPOT and BPS (ρ = 0.796, P < .001), whereas the visual analog scale was correlated with CPOT and BPS (ρ = 0.351, P < .001 and ρ = 0.352, P < .001, respectively), showing that nurses did not underestimate patients' pain levels. CONCLUSIONS The management of postoperative pain intensity after major abdominal surgery requires clinical comprehension by nurses to achieve the reduction or suppression of pain.
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Acute Kidney Injury and Delirium: Kidney–Brain Crosstalk. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2019 2019. [DOI: 10.1007/978-3-030-06067-1_31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
BACKGROUND Management of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda. METHODS Data were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test. RESULTS Over a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N = 17, 37.0%) and typhoid intestinal perforation (N = 6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2-4), and the median Surgical Apgar Score was 4 (range 0-6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p < 0.001), unplanned reoperation (28 vs. 10%, p < 0.001) and death (72 vs. 8%, p < 0.001). CONCLUSION Patients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.
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Karamchandani K, Schoaps RS, Bonavia A, Prasad A, Quintili A, Lehman EB, Carr ZJ. Continuation of atypical antipsychotic medications in critically ill patients discharged from the hospital: a single-center retrospective analysis. Ther Adv Drug Saf 2018; 10:2042098618809933. [PMID: 31019677 PMCID: PMC6463330 DOI: 10.1177/2042098618809933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 10/03/2018] [Indexed: 11/28/2022] Open
Abstract
Background: Atypical antipsychotics (AAP) have been associated with reduced duration of
delirium in the intensive care setting. However, long-term use of these
drugs is associated with significant adverse events, including increased
all-cause mortality in the elderly. Inappropriate continuation of AAPs after
discharge from the intensive care unit (ICU) is worrisome and needs to be
addressed. The aim of this work was to assess the prevalence of continuation of AAPs
after hospital discharge and evaluate the associated risk factors. Method: This was a single-center retrospective chart analysis in the setting of adult
ICUs at a tertiary care academic medical center. It involved all adult
patients admitted to the ICU and initiated on AAPs from January 2012 to
December 2014. The measurements were: (1) prevalence of ICU-initiated AAP
continuation following hospital discharge, (2) risk factors associated with
continuation of AAPs following hospital discharge, and (3) risk of
continuation of AAPs in patients ⩾65 years of age. Results: A total of 55% of ICU patients initiated on AAPs were discharged from the
hospital with a prescription for continued AAP therapy. Male sex and
discharge location were highly associated with continuation upon discharge.
Older patients (⩾65 years of age) were not at a higher risk of being
continued on these drugs after discharge. Conclusion: Male sex and discharge to a healthcare facility were associated with a higher
rate of continuation. Research into practical methods to reduce their
continuation upon discharge should be performed to mitigate the long-term
risks of AAP administration.
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Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, H187, Penn State Health Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Robert S Schoaps
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anthony Bonavia
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amit Prasad
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ashley Quintili
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Zyad J Carr
- Department of Anesthesiology & Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Salem A. Communication with invasive mechanically ventilated patients and the use of alternative devices: integrative review. J Res Nurs 2018; 23:614-630. [PMID: 34394481 PMCID: PMC7932057 DOI: 10.1177/1744987118785987] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Communication with patients has always been a major concern in nursing care. Invasive mechanically ventilated (IMV) patients suffer from a communication barrier due to the presence of the endotracheal tube (ETT), which makes them unable to communicate through speech. AIM The purpose of this review is to examine available evidence regarding existing knowledge, skills, perceptions and barriers to IMV patient communication in order to guide the development of strategies that enhance effective communication with these patients. METHODS A review of the published literature was conducted between January 2010 and December 2016. RESULTS The literature support clear and concise communication in all areas of care, especially when patients suddenly become speechless. Invasive mechanically ventilated patients want to be heard, have control over their treatment and contribute to decisions concerning their health. CONCLUSION There is a need for the establishment of an effective nurse -patient communication strategy, which may include determining the mode of communication used by the patient, waiting and giving time to allow a patient to participate in the communication, confirming the message that was communicated with a patient himself/ herself, and the use of assistive and augmented communication to support comprehension when needed.
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Affiliation(s)
- Aziza Salem
- Senior Education Coordinator, King Hussein Cancer Center,
The University of Jordan, Jordan
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68
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Calle GHL, Martin MC, Nin N. Seeking to humanize intensive care. Rev Bras Ter Intensiva 2018; 29:9-13. [PMID: 28444067 PMCID: PMC5385980 DOI: 10.5935/0103-507x.20170003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 10/18/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gabriel Heras La Calle
- Hospital Universitario de Torrejón - Torrejón de Ardoz, Madrid, Spain.,Proyecto HU-CI Humanizando los Cuidados Intensivos - Spain
| | - Mari Cruz Martin
- Hospital Universitario de Torrejón - Torrejón de Ardoz, Madrid, Spain.,Proyecto HU-CI Humanizando los Cuidados Intensivos - Spain
| | - Nicolas Nin
- Proyecto HU-CI Humanizando los Cuidados Intensivos - Spain.,Hospital Español - Montevideo, Uruguay
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Development and feasibility of a smartphone-based test for the objective detection and monitoring of attention impairments in delirium in the ICU. J Crit Care 2018; 48:104-111. [PMID: 30176525 DOI: 10.1016/j.jcrc.2018.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/17/2018] [Accepted: 08/17/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Delirium in the ICU is under-diagnosed. We evaluated feasibility and performance of a novel smartphone-based test for objectively detecting inattention in delirium. MATERIAL AND METHODS DelApp-ICU combines a behavioural assessment and an attention task, whereby participants follow simple commands and count serially presented circles (score range 0-12, lower scores indicating worse performance). We assessed feasibility through staff interviews. Then we performed a preliminary case-control study in patients with and without delirium (ascertained with the Confusion Assessment Method for the ICU) who underwent the DelApp-ICU on up to 4 days. RESULTS Forty-six patients (median age = 57.5 years, range 18-83) were assessed 89 times in total (N's = 46, 29, 10 and 4 for subsequent assessments; 33.7% delirious). DelApp-ICU scores were lower in delirium (N = 20; median = 0.5, Inter-Quartile Range (IQR) = 0-4.75) compared to no delirium (N = 26, median = 12, IQR = 8-12) on days 1, 2 and 3 (p < 0.001, p < 0.001 and p < 0.05, respectively). A DelApp-ICU score ≤6 was 100% sensitive and 96% specific to delirium on day 1. Positive and Negative Predictive Values were 91% and 100%, respectively. DelApp-ICU scores were responsive to changes in CAM-ICU status. CONCLUSIONS DelApp-ICU shows promise for assessing inattention and delirium in ICU patients, including longitudinally monitoring deficits and providing a metric of delirium severity.
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70
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Souza TLD, Azzolin KDO, Fernandes VR. Multiprofessional care for delirium patients in intensive care: integrative review. ACTA ACUST UNITED AC 2018; 39:e20170157. [PMID: 30088606 DOI: 10.1590/1983-1447.2018.2017-0157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 01/15/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the multiprofessional care for the management of critical patients in delirium in the ICU from the evidences found in the literature. METHODS This integrative review was carried out in the period from February 1 to June 30, 2016 through searches on PubMed, Scopus, Web of Science, and CINAHL, with the following descriptors: delirium, critical care e intensive care units, which brought up 17 original papers. RESULTS A bundle and a guideline, two systematic reviews, evidence 1a and four clinical trials, evidence 1b and 2b, cohort and observational studies were found. The multiprofessional care was presented to better understand the diagnosis of delirium, sedation pause, early mobilization, pain, agitation and delirium guidelines, psychomotor agitation, cognitive orientation, sleep promotion, environment and family participation. CONCLUSION The care for delirium is wide and not specific, which determines its multifactorial aspect.
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Affiliation(s)
| | - Karina de Oliveira Azzolin
- Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil
| | - Vivian Rodrigues Fernandes
- Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem, Curso de Graduação em Enfermagem. Porto Alegre, Rio Grande do Sul, Brasil
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71
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Ohtake PJ, Lee AC, Scott JC, Hinman RS, Ali NA, Hinkson CR, Needham DM, Shutter L, Smith-Gabai H, Spires MC, Thiele A, Wiencek C, Smith JM. Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework. Phys Ther 2018; 98:631-645. [PMID: 29961847 DOI: 10.1093/ptj/pzy059] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 03/29/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care. PURPOSE The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS. DATA SOURCES Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017. STUDY SELECTION Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria. DATA EXTRACTION Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted. DATA SYNTHESIS Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment. LIMITATIONS The inclusion of only 15 observational studies in this review may limit the generalizability of the findings. CONCLUSIONS During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.
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Affiliation(s)
- Patricia J Ohtake
- Department of Rehabilitation Science, University at Buffalo, 515 Kimball Tower, Buffalo, NY 14214 (USA)
| | - Alan C Lee
- Department of Physical Therapy, Mount St Mary's University, Los Angeles, California
| | | | - Rana S Hinman
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Naeem A Ali
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Carl R Hinkson
- Respiratory Care, Providence Regional Medical Center Everett, Everett, Washington
| | - Dale M Needham
- Pulmonary & Critical Care Medicine and Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Lori Shutter
- Critical Care Medicine, UPMC/University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Helene Smith-Gabai
- Program in Occupational Therapy, Brenau University, Gainesville, Georgia
| | - Mary C Spires
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | | | - Clareen Wiencek
- School of Nursing, University of Virginia, Charlottesville, Virginia
| | - James M Smith
- Physical Therapy Department, Utica College, Utica, New York
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72
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Salluh JIF, Latronico N. Does this critically ill patient with delirium require any drug treatment? Intensive Care Med 2018; 45:501-504. [PMID: 30043275 DOI: 10.1007/s00134-018-5310-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 07/06/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30, Botafogo, Rio de Janeiro, RJ, 22281-100, Brazil. .,Programa de Pós-Graduação em Clinica médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
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74
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Damico V, Cazzaniga F, Murano L, Ciceri R, Nattino G, Dal Molin A. Impact of a Clinical Therapeutic Intervention on Pain Assessment, Management, and Nursing Practices in an Intensive Care Unit: A before-and-after Study. Pain Manag Nurs 2018; 19:256-266. [DOI: 10.1016/j.pmn.2018.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/17/2022]
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75
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Romagnoli S, Ricci Z. Patients, families and Intensive Care Unit-staff members: from sedation strategies to global interaction for stress control. Minerva Anestesiol 2018; 84:1120-1122. [PMID: 29774735 DOI: 10.23736/s0375-9393.18.12961-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Stefano Romagnoli
- Department of Anesthesia and Intensive Care, University of Florence, Careggi University Hospital, Florence, Italy -
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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76
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Montoro-Lorite M, Canalias-Reverter M. Protocolos de gestión del dolor en demencia avanzada. ENFERMERIA CLINICA 2018; 28:194-204. [DOI: 10.1016/j.enfcli.2017.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 11/28/2022]
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77
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Schmutz A, Dieterich R, Kalbhenn J, Voss P, Loop T, Heinrich S. Protocol based evaluation for feasibility of extubation compared to clinical scoring systems after major oral cancer surgery safely reduces the need for tracheostomy: a retrospective cohort study. BMC Anesthesiol 2018; 18:43. [PMID: 29678147 PMCID: PMC5910593 DOI: 10.1186/s12871-018-0506-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 04/13/2018] [Indexed: 12/18/2022] Open
Abstract
Background Despite risks, complications and negative impact to quality of life, tracheostomy is widely used to bypass upper airway obstruction after major oral cancer surgery (MOCS). Decision to tracheostomy is frequently based on clinical scoring systems which mainly have not been validated by different cohorts. Delayed extubation in the Intensive Care Unit (ICU) may be a suitable alternative in selected cases. We hypothesize that delayed routine ICU extubation after MOCS instead of scoring system based tracheostomy is safe, feasible and leads to lower tracheostomy rates. Methods We retrospectively analyzed our clinical protocol which provides routine extubation of patients after MOCS in the ICU. The primary outcome measure was a composite of early reintubation within 24 h or secondary tracheostomy. Secondary outcome measures included airway obstruction related morbidity and mortality. Predictor variables included tumor localisation, surgical procedure and reconstruction method, length of operation and pre-existing morbidity. Furthermore we assessed the ability of four clinical scoring systems to identify patients requiring secondary tracheostomy. Statistical processing includes basic descriptive statistics, Chi-squared test and multivariate logistic regression analysis. Results Two hundred thirty four cases were enclosed to this retrospective study. Fourteen patients (6%) required secondary tracheostomy, Ten patients (4%) required reintubation within 24 h after extubation. No airway obstruction associated mortality, morbidity and cannot intubate cannot ventilate situation was observed. Seventy five percent of the patients were extubated within 17 h after ICU admission. All evaluated scores showed a poor positive predictive value (0.08 to 0.18) with a sensitivity ranged from 0.13 to 0.63 and specificity ranged from 0.5 to 0.93. Conclusions Our data demonstrate that common clinical scoring systems fail to prevent tracheostomy in patients after MOCS. Application of scoring systems may lead to a higher number of unnecessary tracheostomies. Delayed routine extubation in the ICU after MOCS seems an appropriate and safe approach to avoid tracheostomy and the related morbidity. Electronic supplementary material The online version of this article (10.1186/s12871-018-0506-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Axel Schmutz
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Rolf Dieterich
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Pit Voss
- Department of Oral and Maxillofacial Surgery & Regional Plastic Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Torsten Loop
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Sebastian Heinrich
- Department of Anaesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany.
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Lee H, Ju JW, Oh SY, Kim J, Jung CW, Ryu HG. Impact of timing and duration of postoperative delirium: a retrospective observational study. Surgery 2018; 164:S0039-6060(18)30035-7. [PMID: 29551203 DOI: 10.1016/j.surg.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/09/2018] [Accepted: 02/02/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent reports suggest that not all critically ill patients with delirium share the same consequences. The outcomes of surgical intensive care unit patients with postoperative delirium were evaluated depending on the onset and duration of delirium. METHODS A total of 527 patients who were admitted from the operating theater and cared for in the surgical intensive care unit for >24 hours were evaluated for delirium using the Confusion Assessment Method for intensive care unit, 3 times a day. Patients were analyzed according to the onset time and duration of delirium. Patients were classified into 4 groups according to the onset and duration of delirium: no delirium, early brief delirium (delirium for <1 day on postoperative day 0), late brief delirium (delirium for <1 day after postoperative day 0), and persistent delirium (delirium for ≥1 days). Duration of stay (intensive care unit and hospital) and mortality (intensive care unit, hospital, and 1-year) were outcomes of interest. RESULTS Of the 527 patients, delirium developed in 119 (22.6%) patients. More than two-thirds of the patients developed delirium on postoperative day 0 or 1, and 70% of patients developed delirium for >24 hours (persistent). Persistent delirium was associated with longer intensive care unit (4.6 [1.1-53.3] vs 1.6 [1.1-37.5] days) and hospital duration of stay (24 [3-112] vs 16 [2-225] days) and higher hospital mortality (14.5% vs 2.2%) compared to no delirium (P < .01). CONCLUSION For postoperative intensive care unit patients, intensive care unit and hospital duration of stay did not seem to differ between patients with early brief delirium or no delirium, whereas patients with late brief or persistent delirium seemed to show longer intensive care unit and hospital duration of stay and higher mortality.
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Affiliation(s)
- Hannah Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung-Young Oh
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeongsoo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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79
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Smith JM, Van Aman MN, Schneiderhahn ME, Edelman R, Ercole PM. Assessment of Delirium in Intensive Care Unit Patients: Educational Strategies. J Contin Educ Nurs 2018; 48:239-244. [PMID: 28459497 DOI: 10.3928/00220124-20170418-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. METHOD A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. RESULTS Participants (N = 34) showed a significant increase (p < .001) in confidence in their ability to assess and manage delirium following the multimodal education. No statistical change in knowledge of delirium existed following the education. CONCLUSION A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244.
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80
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Via-Clavero G, Sanjuán-Naváis M, Romero-García M, de la Cueva-Ariza L, Martínez-Estalella G, Plata-Menchaca E, Delgado-Hito P. Eliciting critical care nurses' beliefs regarding physical restraint use. Nurs Ethics 2018; 26:1458-1472. [PMID: 29495933 DOI: 10.1177/0969733017752547] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the reported harms and ethical concerns about physical restraint use in the critical care settings, nurses' intention to apply them is unequal across countries. According to the theory of planned behaviour, eliciting nurses' beliefs regarding the use of physical restraints would provide additional social information about nurses' intention to perform this practice. AIM To explore the salient behavioural, normative and control beliefs underlying the intention of critical care nurses to use physical restraints from the theory of planned behaviour. RESEARCH DESIGN A belief elicitation study was conducted. PARTICIPANTS AND RESEARCH CONTEXT Twenty-six critical care nurses were purposively sampled across gender, work-shift patterns and professional experience in five intensive care units of three hospitals in Spain. Data were obtained from a nine-item open-ended questionnaire and a focus group. Deductive content analysis was performed. ETHICAL CONSIDERATIONS Ethical approval was obtained from the hospital ethics committee. Participants were assured their participation was voluntary. FINDINGS Nurses framed the use of restraints as a way of prioritising patients' physical safety. They referred to contextual factors as the main reasons to justify their application. Nurses perceived that their decision is approved by other colleagues and the patients' relatives. Some nurses started advocating against their use, but felt powerless to change this unsafe practice within an unfavourable climate. Control beliefs were linked to patients' medical condition, availability of alternative solutions, analgo-sedation policies and work organisation. DISCUSSION Safety arguments based on the surrounding work environment were discussed. CONCLUSION Nurses' behavioural and control beliefs were related. Nurses should be trained in alternatives to physical restraint use. The impact of analgo-sedation protocols, relatives' involvement, leadership support and intensive care unit restraint policies on physical restraint practices need to be revised. Further research is required to explore why nurses do not act with moral courage to change this harmful practice.
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Affiliation(s)
- Gemma Via-Clavero
- Nursing Research Group (GRIN-IDIBELL), Hospital Universitari de Bellvitge, Spain; University of Barcelona, Spain
| | - Marta Sanjuán-Naváis
- Nursing Research Group (GRIN-IDIBELL), Hospital Universitari de Bellvitge, Spain
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Denehy L, Granger CL, El-Ansary D, Parry SM. Advances in cardiorespiratory physiotherapy and their clinical impact. Expert Rev Respir Med 2018; 12:203-215. [PMID: 29376440 DOI: 10.1080/17476348.2018.1433034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cardiorespiratory physiotherapy is an evidence-based practice that has evolved alongside changes in medical and surgical management, analgesia, the ageing society and increasing comorbidities of our patient populations. Continued research provides the profession with the ability to adapt to meet the changing patient and community needs. Areas covered: This review focuses on surgical, respiratory and critical care settings discussing the most significant changes over the past decade with an increased focus on rehabilitation across the care continuum and a shift away from providing predominately airway clearance in established disease populations but also providing this in emerging groups. Further important changes are identification and emphases on patient self-management including changing their behaviour to more positively embrace wellness, particularly increasing physical activity levels. This paper outlines these changes and offers speculation on factors that may impact the profession in the future. Expert commentary: The increasing focus on new technologies, physical activity levels, changes to the health systems in different countries and an increasingly comorbid and ageing society will shape the next steps in the evolution of cardiorespiratory physiotherapy. Continued research is vital to keep pace with these changes so that physiotherapists can provide the most effective treatments to improve patient outcomes.
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Affiliation(s)
- Linda Denehy
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
| | - Doa El-Ansary
- b Department of Cardiothoracic Surgery , Royal Melbourne Hospital, Royal Parade , Parkville , Australia
| | - Selina M Parry
- a Department of Physiotherapy, Melbourne School of Health Sciences , The University of Melbourne , Melbourne , Victoria , Australia
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Kassie GM, Nguyen TA, Kalisch Ellett LM, Pratt NL, Roughead EE. Preoperative medication use and postoperative delirium: a systematic review. BMC Geriatr 2017; 17:298. [PMID: 29284416 PMCID: PMC5747155 DOI: 10.1186/s12877-017-0695-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/18/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Medications are frequently reported as both predisposing factors and inducers of delirium. This review evaluated the available evidence and determined the magnitude of risk of postoperative delirium associated with preoperative medication use. METHODS A systematic search in Medline and EMBASE was conducted using MeSH terms and keywords for postoperative delirium and medication. Studies which included patients 18 years and older who underwent major surgery were included. The methodological quality of included studies was assessed independently by two authors using the Newcastle-Ottawa quality assessment scale for cohort studies. RESULTS Twenty-nine studies; 25 prospective cohort, three retrospective cohort and one post hoc analysis of RCT data were included. Only four specifically aimed to assess medicines as an independent predictor of delirium, all other studies included medicines among a number of potential predictors of delirium. Of the studies specifically testing the association with a medication class, preoperative use of beta-blockers (OR = 2.06[1.18-3.60]) in vascular surgery and benzodiazepines RR 2.10 (1.23-3.59) prior to orthopedic surgery were significant. However, evidence is from single studies only. Where medicines were included as one possible factor among many, hypnotics had a similar risk estimate to the benzodiazepine study, with one significant and one non-significant result. Nifedipine use prior to cardiac surgery was found to be significantly associated with delirium. The non-specific grouping of psychoactive medication use preoperatively was generally higher with an associated two-to-seven-fold higher risk of postoperative delirium, while only two studies included narcotics without other agents, with one significant and one non-significant result. CONCLUSIONS There was a limited number of high quality studies in the literature quantifying the direct association between preoperative medication use and postsurgical delirium. More studies are required to evaluate the association of specific preoperative medications on the risk of postoperative delirium so that comprehensive guidelines for medicine use prior to surgery can be developed to aid delirium prevention. TRIAL REGISTRATION This systematic review has been registered on PROSPERO International prospective register of systematic reviews (Registration number: CRD42016051245 ).
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Affiliation(s)
- Gizat M Kassie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia.
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Nicole L Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
| | - Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, 5001, Australia
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83
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Jerath A, Parotto M, Wasowicz M, Ferguson ND. Opportunity Knocks? The Expansion of Volatile Agent Use in New Clinical Settings. J Cardiothorac Vasc Anesth 2017; 32:1946-1954. [PMID: 29449155 DOI: 10.1053/j.jvca.2017.12.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Angela Jerath
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Matteo Parotto
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marcin Wasowicz
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada
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84
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Khan I, Haymore J, Barnaba B, Armahizer M, Melinosky C, Bautista MA, Blaber B, Chang WT, Parikh G, Motta M, Badjatia N. Esophageal Cooling Device Versus Other Temperature Modulation Devices for Therapeutic Normothermia in Subarachnoid and Intracranial Hemorrhage. Ther Hypothermia Temp Manag 2017; 8:53-58. [PMID: 29236581 PMCID: PMC5831898 DOI: 10.1089/ther.2017.0033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Achieving and maintaining normothermia (NT) after subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) often require temperature modulating devices (TMD). Shivering is a common adverse effect of TMDs that can lead to further costs and complications. We evaluated an esophageal TMD, the EnsoETM (Attune Medical, Chicago, IL), to compare NT performance, shiver burden, and cost of shivering interventions with existing TMDs. Patients with SAH or ICH and refractory fever were treated with the EnsoETM. Patient demographics, temperature data, shiver severity, and amounts and costs of medications used for shiver management were prospectively collected. Controls who received other TMDs were matched for age, gender, and body surface area to EnsoETM recipients, and similar retrospective data were collected. All patients were mechanically ventilated. Fever burden was calculated as areas of curves of time spent above 37.5°C or 38°C. Demographics, temperature data, and costs of EnsoETM recipients were compared with recipients of other TMDs. Eight EnsoETM recipients and 24 controls between October 2015 and November 2016 were analyzed. There were no differences between the two groups in demographics or patient characteristics. No difference was found in temperature at initiation (38.7°C vs. 38.5°C, p = 0.4) and fever burden above 38°C (-0.44°C × hours vs. -0.53°C × hours, p = 0.47). EnsoETM recipients showed a nonsignificant trend in taking longer to achieve NT than other TMDs (5.4 hours vs. 2.9 hours, p = 0.07). EnsoETM recipients required fewer shiver interventions than controls (14 vs. 30, p = 0.02). EnsoETM recipients incurred fewer daily costs than controls ($124.27 vs. $232.76, p = 0.001). The EnsoETM achieved and maintained NT in SAH and ICH patients and was associated with less shivering and lower pharmaceutical costs than other TMDs. Further studies in larger populations are needed to determine the EnsoETM's efficacy in comparison to other TMDs.
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Affiliation(s)
- Imad Khan
- 1 Division of Neurocritical Care, Department of Neurology, University of Rochester School of Medicine and Dentistry , Rochester, New York
| | - Joseph Haymore
- 2 Department of Organizational Systems and Adult Health, University of Maryland School of Nursing , Baltimore, Maryland.,3 Advanced Practice Provider Service, Department of Nursing, University of Maryland Medical Center , Baltimore, Maryland
| | - Brittany Barnaba
- 4 Department of Nursing, University of Maryland Medical Center , Baltimore, Maryland
| | - Michael Armahizer
- 5 Department of Pharmacy, University of Maryland Medical Center , Baltimore, Maryland
| | - Christopher Melinosky
- 6 Section of Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, Maryland
| | - Mary Ann Bautista
- 4 Department of Nursing, University of Maryland Medical Center , Baltimore, Maryland
| | - Brigid Blaber
- 4 Department of Nursing, University of Maryland Medical Center , Baltimore, Maryland
| | - Wan-Tsu Chang
- 6 Section of Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, Maryland
| | - Gunjan Parikh
- 6 Section of Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, Maryland
| | - Melissa Motta
- 6 Section of Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, Maryland
| | - Neeraj Badjatia
- 6 Section of Neurocritical Care, Program in Trauma, Department of Neurology, University of Maryland School of Medicine , Baltimore, Maryland
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85
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Parry SM, Huang M, Needham DM. Evaluating physical functioning in critical care: considerations for clinical practice and research. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:249. [PMID: 28978333 PMCID: PMC5628423 DOI: 10.1186/s13054-017-1827-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The evaluation of physical functioning is valuable in the intensive care unit (ICU) to help inform patient recovery after critical illness, to identify patients who may require rehabilitation interventions, and to monitor responsiveness to such interventions. This viewpoint article discusses: (1) the concept of physical functioning with reference to the World Health Organization International Classification of Functioning, Disability and Health; (2) the importance of measuring physical functioning in the ICU; and (3) methods for evaluating physical functioning in the ICU. Recommendations for clinical practice and research are made, along with discussion of future directions.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Minxuan Huang
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes after Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA. .,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA. .,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA. .,Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD, 21205, USA.
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86
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Abstract
EBN engages readers through a range of Online social media activities to debate issues important to nurses and nursing. EBN Opinion papers highlight and expand on these debates.
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Affiliation(s)
- Samantha Freeman
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, England
| | - Angela Teece
- School of Healthcare, University of Leeds, Leeds, UK
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87
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Lizza BD, Jagow B, Hensler D, Cooper CJ, Short EJ, Maas MB, Naidech AM, Wunderink RG. Impact of Multiple Daily Clinical Pharmacist-Enforced Assessments on Time in Target Sedation Range. J Pharm Pract 2017; 31:445-449. [PMID: 28874082 DOI: 10.1177/0897190017729522] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Incorporation of a single daily assessment by a clinical pharmacist to improve adherence with a sedation protocol is associated with reduced duration of mechanical ventilation and intensive care unit (ICU) length of stay (LOS). We test the feasibility of incorporating a clinical pharmacist into more frequent sedation assessments and observed whether there are any potential differences in the sedatives administered. METHODS Prospective, quasi-experimental, pilot study of patients admitted to the medical ICU. Patients were included in the analysis if ≥18 years of age within the first 24 hours of initiation of mechanical ventilation. Our primary intent was to test the clinical feasibility surrounding more frequent sedation assessments by a clinical pharmacist by evaluating potential differences in time in target sedation range and sedative administration. Exploratory efficacy end points included time in target sedation range (0 to -2) using the Richmond Agitation Sedation Scale (RASS) and sedative exposure. Patients were assigned to receive either 3 assessments with a clinical pharmacist per day (intervention) or a single assessment by a clinical pharmacist per day (standard of care). During the assessments, clinical pharmacists participated in the RASS administration and made dosing adjustments according to an established sedation protocol. MAIN RESULTS Seventeen patients were enrolled (n = 6 intervention group, n = 11 standard of care). Duration of mechanical ventilation was similar in the 2 groups (intervention 100.0 hours [52.5-197.5] vs control 76.0 hours [46.0-201.0], P = .95), but patients in the intervention group exhibited a greater percentage time in the target RASS range (intervention 76.0% [53.7-81.5%] vs control 45.2% [35.3-67.0], P = .11) that was not statistically significant. Patients in the intervention group received less fentanyl per day (820.9 µg [227.3-1579.4] vs 1997 µg [1648.2-2477.2], P = .02) than in the control group. CONCLUSION Incorporating a clinical pharmacist into more frequent daily sedation assessments was associated with a reduction in fentanyl administration. There were no observed differences in time in target sedation range or reduction in duration of mechanical ventilation.
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Affiliation(s)
- Bryan D Lizza
- 1 Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,2 Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Benjamin Jagow
- 1 Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - David Hensler
- 1 Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Craig J Cooper
- 1 Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,3 Department of Clinical and Administrative Sciences, Roosevelt University, Schaumburg, IL, USA
| | - Elizabeth J Short
- 1 Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Matthew B Maas
- 4 Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew M Naidech
- 4 Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard G Wunderink
- 2 Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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88
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Kalluri HV, Zhang H, Caritis SN, Venkataramanan R. A physiologically based pharmacokinetic modelling approach to predict buprenorphine pharmacokinetics following intravenous and sublingual administration. Br J Clin Pharmacol 2017; 83:2458-2473. [PMID: 28688108 DOI: 10.1111/bcp.13368] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 11/29/2022] Open
Abstract
AIMS Opioid dependence is associated with high morbidity and mortality. Buprenorphine (BUP) is approved by the Food and Drug Administration to treat opioid dependence. There is a lack of clear consensus on the appropriate dosing of BUP due to interpatient physiological differences in absorption/disposition, subjective response assessment and other patient comorbidities. The objective of the present study was to build and validate robust physiologically based pharmacokinetic (PBPK) models for intravenous (IV) and sublingual (SL) BUP as a first step to optimizing BUP pharmacotherapy. METHODS BUP-PBPK modelling and simulations were performed using SimCyp® by incorporating the physiochemical properties of BUP, establishing intersystem extrapolation factors-based in vitro-in-vivo extrapolation (IVIVE) methods to extrapolate in vitro enzyme activity data, and using tissue-specific plasma partition coefficient estimations. Published data on IV and SL-BUP in opioid-dependent and non-opioid-dependent patients were used to build the models. Fourteen model-naïve BUP-PK datasets were used for inter- and intrastudy validations. RESULTS The IV and SL-BUP-PBPK models developed were robust in predicting the multicompartment disposition of BUP over a dosing range of 0.3-32 mg. Predicted plasma concentration-time profiles in virtual patients were consistent with reported data across five single-dose IV, five single-dose SL and four multiple dose SL studies. All PK parameter predictions were within 75-137% of the corresponding observed data. The model developed predicted the brain exposure of BUP to be about four times higher than that of BUP in plasma. CONCLUSION The validated PBPK models will be used in future studies to predict BUP plasma and brain concentrations based on the varying demographic, physiological and pathological characteristics of patients.
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Affiliation(s)
- Hari V Kalluri
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hongfei Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
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Rohaut B, Raimondo F, Galanaud D, Valente M, Sitt JD, Naccache L. Probing consciousness in a sensory-disconnected paralyzed patient. Brain Inj 2017; 31:1398-1403. [PMID: 28657353 DOI: 10.1080/02699052.2017.1327673] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Diagnosis of consciousness can be very challenging in some clinical situations such as severe sensory-motor impairments. CASE STUDY We report the case study of a patient who presented a total "locked-in syndrome" associated with and a multi-sensory deafferentation (visual, auditory and tactile modalities) following a protuberantial infarction. RESULT In spite of this severe and extreme disconnection from the external world, we could detect reliable evidence of consciousness using a multivariate analysis of his high-density resting state electroencephalogram. This EEG-based diagnosis was eventually confirmed by the clinical evolution of the patient. CONCLUSION This approach illustrates the potential importance of functional brain-imaging data to improve diagnosis of consciousness and of cognitive abilities in critical situations in which the behavioral channel is compromised such as deafferented locked-in syndrome.
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Affiliation(s)
- Benjamin Rohaut
- a Department of Neurology , AP-HP, Groupe hospitalier Pitié-Salpêtrière, Neuro-ICU , Paris , France.,b INSERM, U 1127 , Paris , France.,c Institut du Cerveau et de la Moelle épinière , ICM, PICNIC Lab , Paris , France.,d Faculté de Médecine Pitié-Salpêtrière , Sorbonne Universités , UPMC Univ Paris 06, Paris , France.,e Department of Neurology , Neuro-ICU, Columbia University , New York , NY , USA
| | - Federico Raimondo
- b INSERM, U 1127 , Paris , France.,c Institut du Cerveau et de la Moelle épinière , ICM, PICNIC Lab , Paris , France.,e Department of Neurology , Neuro-ICU, Columbia University , New York , NY , USA.,f Laboratorio de Inteligencia Artificial Aplicada, Departamento de Computación , FCEyN, Universidad de Buenos Aires , Buenos Aires , Argentina.,g CONICET , Buenos Aires , Argentina
| | - Damien Galanaud
- d Faculté de Médecine Pitié-Salpêtrière , Sorbonne Universités , UPMC Univ Paris 06, Paris , France.,h Department of Neuroradiology , AP-HP, Groupe hospitalier Pitié-Salpêtrière , Paris , France
| | - Mélanie Valente
- b INSERM, U 1127 , Paris , France.,c Institut du Cerveau et de la Moelle épinière , ICM, PICNIC Lab , Paris , France
| | - Jacobo Diego Sitt
- b INSERM, U 1127 , Paris , France.,c Institut du Cerveau et de la Moelle épinière , ICM, PICNIC Lab , Paris , France
| | - Lionel Naccache
- b INSERM, U 1127 , Paris , France.,c Institut du Cerveau et de la Moelle épinière , ICM, PICNIC Lab , Paris , France.,d Faculté de Médecine Pitié-Salpêtrière , Sorbonne Universités , UPMC Univ Paris 06, Paris , France.,i Department of Neurophysiology , AP-HP, Groupe hospitalier Pitié-Salpêtrière , Paris , France
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90
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Low brain tissue oxygenation contributes to the development of delirium in critically ill patients: A prospective observational study. J Crit Care 2017; 41:289-295. [PMID: 28668768 DOI: 10.1016/j.jcrc.2017.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/16/2017] [Accepted: 06/11/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE To test the hypothesis that poor brain tissue oxygenation (BtO2) during the first 24h of critical illness correlates with the proportion of time spent delirious. We also sought to define the physiological determinants of BtO2. MATERIALS AND METHODS Adult patients admitted to the ICU within the previous 24h were considered eligible for enrollment if they required mechanical ventilation, and/or vasopressor support. BtO2 was measured using near-infrared spectroscopy, for 24h after enrollment. Hourly vital signs and clinically ordered arterial and central venous blood gases were collected throughout BtO2 monitoring. Patients were screened daily for delirium with the confusion assessment method for the intensive care unit (CAM-ICU). RESULTS BtO2 and the proportion of time spent delirious did not result in a significant correlation (p=0.168). However, critically ill patients who spent the majority of their ICU stay delirious had significantly lower mean BtO2 compared to non-delirious patients, (p=0.017). BtO2 correlated positively with central venous pO2 (p=0.00003) and hemoglobin concentration (p=0.001). Logistic regression indicated that lower BtO2, higher narcotic doses and a history of alcohol abuse were independent risk factors for delirium. CONCLUSIONS Poor cerebral oxygenation during the first 24 hours of critical illness contributes to the development of delirium. TRIAL REGISTRATION This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015.
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91
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Sousa G, Pinho C, Santos A, Abelha FJ. Postoperative delirium in patients with history of alcohol abuse. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:214-222. [PMID: 27641821 DOI: 10.1016/j.redar.2016.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/22/2016] [Accepted: 07/05/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD. METHODS We prospectively evaluated consecutively all postoperative patients admitted in the Post-anesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men (P<.001) and had a higher ASA physical status III/IV (P=.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; P=.002). Age (OR: 5.9; 95%CI: 2.2-15.9; P<.001 for patients ≥65years), ASA physical statusIII/IV (OR: 4.2; 95%CI: 1.7-10.7; P=.002) and alcohol abuse (OR: 4.2; 95%CI: 1.4-12.9; P=.013) were found to be independent predictors for POD. CONCLUSIONS Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD.
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Affiliation(s)
- G Sousa
- Department of Anaesthesiology, Hospital de São João, Oporto, Portugal
| | - C Pinho
- Department of Anaesthesiology, Hospital de São João, Oporto, Portugal
| | - A Santos
- Department of Anaesthesiology, Hospital de São João, Oporto, Portugal
| | - F J Abelha
- Department of Anaesthesiology, Hospital de São João, Oporto, Portugal; Department of Anaesthesiology and Perioperative Medicine, Faculty of Medicine, University of Porto, Oporto, Portugal.
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Bush SH, Marchington KL, Agar M, Davis DHJ, Sikora L, Tsang TWY. Quality of clinical practice guidelines in delirium: a systematic appraisal. BMJ Open 2017; 7:e013809. [PMID: 28283488 PMCID: PMC5353343 DOI: 10.1136/bmjopen-2016-013809] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/13/2017] [Accepted: 02/20/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality. DESIGN Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a 'Rigour of Development' domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. DATA SOURCES Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search. RESULTS 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II 'Rigour' scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were 'Scope and Purpose' (mean 80.1%, range 64-100%) and 'Clarity and Presentation' (mean 76.7%, range 38-97%). The lowest rating domains were 'Applicability' (mean 48.7%, range 8-81%) and 'Editorial Independence' (mean 53%, range 2-90%). The three highest rating guidelines in the 'Applicability' domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies. CONCLUSIONS Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Katie L Marchington
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meera Agar
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
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Zakaria S, Kwong HJ, Sevransky JE, Williams MS, Chandra-Strobos N. Editor's Choice-The cardiovascular implications of sedatives in the cardiac intensive care unit. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:671-683. [PMID: 29064259 DOI: 10.1177/2048872617695231] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients admitted to the cardiac intensive care unit frequently develop multi-organ system dysfunction associated with their cardiac disease. In many cases, invasive mechanical ventilation is required, which often necessitates sedation for patient-ventilator synchrony, reduction of work of breathing, and patient comfort. In this paper, we describe the use of common sedatives available in the endotracheally intubated critically ill patient and emphasize the clinical and cardiovascular effects. We review γ-aminobutyric acid agonists such as etomidate, benzodiazepines, and propofol, the centrally acting α2-agonist dexmedetomidine, and the N-methyl-D-aspartate receptor antagonist ketamine. Additionally, we outline the use of opioids and their role in potentiating other sedatives. We note that some sedatives are associated with increased delirium rates, and emphasize that judicious strategies minimizing sedative use are associated with decreases in morbidity and mortality. We also discuss standardized sedation assessment scales and highlight the importance of sedation weaning. Finally, we offer recommendations for sedation use during therapeutic hypothermia, and discuss the use of adjuvant neuromuscular blocking agents.
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Affiliation(s)
- Sammy Zakaria
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Helaine J Kwong
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
| | | | - Marlene S Williams
- 1 Department of Medicine, Johns Hopkins University School of Medicine, USA
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Sutton LJ, Jarden RJ. Improving the quality of nurse-influenced patient care in the intensive care unit. Nurs Crit Care 2016; 22:339-347. [PMID: 27976489 DOI: 10.1111/nicc.12266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/10/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Quality of care is a major focus in the intensive care unit (ICU). AIM To describe a nurse-initiated quality improvement (QI) project that improved the care of critically ill patients in a New Zealand tertiary ICU. DESIGN A framework for QI was developed and implemented as part of a practice change initiative. METHODS Audit data were collected, analysed and reported across seven nurse-influenced patient care standards. The seven standards were enteral nutrition delivered within 24 h of admission, timely administration of antibiotics, sedation holds for eligible patients, early mobilization and three pressure ulcer prevention strategies. RESULTS Comparison of audit data collected in 2014 and 2015 demonstrated improvements in five of the seven standards. Those standards with the largest practice improvements were related to the following standards: all eligible patients have enteral nutrition commenced within the first 24 h of ICU admission (3% increase); all eligible patients receive antibiotics within 30 min of prescription time (6% increase); all eligible patients have a daily sedation interruption (DSI; 24% increase); and all eligible patients are mobilized daily in their ICU stay (11% increase in percentage of patients mobilized daily). CONCLUSIONS The nursing-initiated QI project demonstrated improved ICU patient care in relation to early enteral nutrition commencement, DSIs and early and daily mobilizing. RELEVANCE TO CLINICAL PRACTICE The use of a nursing QI framework incorporating audit and feedback is one method of evaluating and enhancing the quality of care and improving patient outcomes. This initiative demonstrated the improved quality of nursing care for ICU patients, particularly in relation to early enteral nutrition commencement, timely antibiotics, DSIs and daily mobilizing. It is thus highly relevant to critical care nursing teams, particularly those working to create a culture where change is safe, achievable and valued.
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Affiliation(s)
- Lynsey J Sutton
- Wellington Regional Hospital, Intensive Care Unit, Intensive Care Services, Wellington Regional Hospital, Wellington, New Zealand.,Graduate School of Nursing Midwifery & Health (GSNMH), Victoria University of Wellington, New Zealand
| | - Rebecca J Jarden
- Department of Nursing, School of Clinical Sciences, Auckland University of Technology (AUT), Auckland, New Zealand
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95
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Continuous Infusion Antiepileptic Medications for Refractory Status Epilepticus: A Review for Nurses. Crit Care Nurs Q 2016; 40:67-85. [PMID: 27893511 DOI: 10.1097/cnq.0000000000000143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Status epilepticus requires treatment with emergent initial therapy with a benzodiazepine and urgent control therapy with an additional antiepileptic drug (AED) to terminate clinical and/or electrographic seizure activity. However, nearly one-third of patients will prove refractory to the aforementioned therapies and are prone to a higher degree of neuronal injury, resistance to pharmacotherapy, and death. Current guidelines for refractory status epilepticus (RSE) recommend initiating a continuous intravenous (CIV) anesthetic over bolus dosing with a different AED. Continuous intravenous agents most commonly used for this indication include midazolam, propofol, and pentobarbital, but ketamine is an alternative option. Comparative studies illustrating the optimal agent are lacking, and selection is often based on adverse effect profiles and patient-specific factors. In addition, dosing and titration are largely based on small studies and expert opinion with continuous electroencephalogram monitoring used to guide intensity and duration of treatment. Nonetheless, the doses required to halt seizure activity are likely to produce profound adverse effects that clinicians should anticipate and combat. The purpose of this review was to summarize the available RSE literature focusing on CIV midazolam, pentobarbital, propofol, and ketamine, and to serve as a primer for nurses providing care to these patients.
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96
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Park A, Chapman M, McCredie VA, Debicki D, Gofton T, Norton L, Boyd JG. EEG utilization in Canadian intensive care units: A multicentre prospective observational study. Seizure 2016; 43:42-47. [PMID: 27886628 DOI: 10.1016/j.seizure.2016.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We have previously shown that electroencephalography (EEG) may be an underutilized monitoring modality in a single general medical-surgical ICU, that does not have a specific neurocritical care consultation service or neurocritical care unit. The present study was designed to describe the pattern of EEG utilization across 3 academic ICUs in Ontario, Canada that use different models of neurocritical care. METHOD In this prospective multicentre observational study, ICU patients were screened weekly for 6 non-consecutive weeks to determine if they met the ESICM's recommendations or suggestions for EEG monitoring. If EEGs were performed, the results were recorded. Three models of neurocritical care provision were examined in 3 academic tertiary ICUs. Site 1 is an intensivist-led, medical-surgical ICU with no specific neurocritical care consultation service. The second site is also an intensivist led medical-surgical ICU, but with a formal neurocritical care consultation service. The third site is a virtual neurological and neurotrauma ICU within a medical-surgical ICU, staffed by rotating neurointensivists and general intensivists. RESULTS Of the 375 patients who were screened, 127 patients (34%) met at least one ESICM indication for EEG monitoring. Among the 127 patients, 46 patients (37%) had an EEG performed. Site 1 had the highest proportion of EEGs performed. The most common indication for EEG monitoring was for patients with unexplained altered level of consciousness, in the absence of primary brain injury. For the EEGs performed per ESICM indication, the majority of epileptiform abnormalities were found in patients admitted with status epilepticus. CONCLUSIONS EEG may be underutilized in Canadian ICUs. The impact on patient management and outcomes are unknown.
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Affiliation(s)
- Andrea Park
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Martin Chapman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto M4N 3M5, Canada
| | - Victoria A McCredie
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto M4N 3M5, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Loretta Norton
- Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada; Department of Medicine (Neurology), Queen's University, Kingston, ON, Canada.
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97
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Arora RC, Djaiani G, Rudolph JL. Detection, Prevention, and Management of Delirium in the Critically Ill Cardiac Patient and Patients Who Undergo Cardiac Procedures. Can J Cardiol 2016; 33:80-87. [PMID: 28024558 DOI: 10.1016/j.cjca.2016.08.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/06/2016] [Accepted: 08/25/2016] [Indexed: 02/08/2023] Open
Abstract
Delirium is an acute change in cognitive functioning, characterized by inattention and associated with alterations in awareness and fluctuation in arousal, disorganized thinking, or altered level that preferentially affects older adult patients. In the acutely ill cardiac patient, the incidence of delirium has been reported as high as 73%, depending on the type and sensitivity of delirium assessment. Cardiac patients with delirium experience higher rates of in-hospital and longer-term mortality and are at risk for progressive cognitive impairment, loss of functional independence, and increased hospitalization costs. As such, delirium represents an undesirable outcome in cardiac patients. Care improvements such as identifying risk of delirium at time of admission or in the preoperative setting; training cardiologist, surgeons, anaesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols might reduce the incidence of delirium and its associated morbidity.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - George Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports, Providence VA Medical Center; Center for Gerontology, Brown School of Public Health; and Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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98
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Reddy DRS, Singh TD, Guru PK, Sakusic A, Gajic O, O'Horo JC, Rabinstein AA. Identification of acute brain failure using electronic medical records. J Crit Care 2016; 34:12-6. [PMID: 27288602 DOI: 10.1016/j.jcrc.2016.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 03/04/2016] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Up to 80% of critically ill patients have acute neurologic dysfunction syndromes. We evaluated interrater reliability between the examination by the investigator and the charted assessment by the nurse because the accuracy and reliability of detailed data sets extracted from the electronic medical records represents a keystone for creating EMR-based definitions. MATERIALS AND METHODS We conducted a prospective observational study of intensive care unit (ICU) patients to assess the reliability of charted Confusion Assessment Method for the ICU, Glasgow Coma Scale (GSC), Full Outline of Unresponsiveness, and Richmond Agitation Sedation Scale (RASS) scores, and a composite measure of ABF defined as new-onset coma or delirium. Trained investigator blinded to nursing assessments performed the neurologic evaluations that were compared with nursing documentation. RESULTS A total of 202 observations were performed in 55 ICU patients. Excellent correlation was noted for GCS and Full Outline of Unresponsiveness scores on Bland-Altman plots (Pearson correlation 0.87 and 0.92, respectively). Correlation for Confusion Assessment Method for the ICU was also high (κ= 0.86; 95% confidence interval [CI], 0.70-1.01). Richmond Agitation Sedation Scale had good agreement when scores were dichotomized as oversedated (less than -2) vs not oversedated, with κ= 0.76 (95% CI, 0.54-0.98). Investigator assessment and nurse charting were highly concordant (κ= 0.84; 95% CI, 0.71-0.99). CONCLUSION Neurologic assessments documented on the EMR are reliable.
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Affiliation(s)
- Dereddi Raja Shekar Reddy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN.
| | - Tarun D Singh
- Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN; Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN.
| | - Pramod K Guru
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN.
| | - Amra Sakusic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN.
| | - John C O'Horo
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN; Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Rochester, MN.
| | - Alejandro A Rabinstein
- Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine (METRIC), Mayo Clinic, Rochester, MN; Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN.
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99
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Kizza IB, Muliira JK, Kohi TW, Nabirye RC. Nurses’ knowledge of the principles of acute pain assessment in critically ill adult patients who are able to self-report. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2016. [DOI: 10.1016/j.ijans.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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100
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Pipanmekaporn T, Chittawatanarat K, Chaiwat O, Thawitsri T, Wacharasint P, Kongsayreepong S. Incidence and risk factors of delirium in multi-center Thai surgical intensive care units: a prospective cohort study. J Intensive Care 2015; 3:53. [PMID: 26634124 PMCID: PMC4667416 DOI: 10.1186/s40560-015-0118-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/17/2015] [Indexed: 01/12/2023] Open
Abstract
Background Delirium in intensive care units increases morbidity and mortality risk. The incidence and risk factors of delirium vary among studies. This study therefore aimed to determine the incidence and risk factors of delirium in Thai university-based surgical intensive care units. Methods A multi-center, prospective cohort study was conducted. All patients who had been admitted to surgical intensive care units (SICU) between April 2011 and January 2012 were enrolled. Delirium was diagnosed using the Intensive Care Delirium Screening Checklists (ICDSC). The univariable and multivariable risk regression analyses were analyzed and presented as risk ratio (RR) and 95 % confidence interval (CI). Results The overall incidence of delirium was 3.6 % (162 of 4450, 95 % CI 3.09–4.19 %) whilst the incidences of delirium for patients being admitted ≤48 and >48 h were 0.7 % (21 of 2967, 95 % CI 0.41–1.01 %) and 8.3 % (141 of 1685, 95 % CI 7.04–9.68 %), respectively. The incidence of delirium on each study site was significantly different (range between 0 and 13.9 %, P < 0.001). Delirious patients had a significantly higher age (65.3 ± 15.6 versus 61.8 ± 17.3 years, P = 0.013), higher Acute Physiology and Chronic Health Evaluation II score (APACHE II score) (16 (12–23) versus 10 (7–15), P < 0.001), and higher sequential organ failure assessment score (5 (2–8) versus 2 (1–5), P < 0.001). The median duration of delirium was 3 (1–5) days. Delirious patients had significantly longer duration of ICU stay (8 (5–19) versus 2 (1–4), P < 0.001) and higher ICU mortality rate (23.5 versus 8.1 %, P < 0.001). Sepsis (RR = 3.70, 95 % CI 2.33–5.90, P < 0.001), exposure to sedative medications (RR = 3.54, 95 % CI 2.13–5.87, P < 0.001), higher APACHE II score (RR = 2.79, 95 % CI 1.98–3.95, P < 0.001), thoracic surgery (RR = 1.74, 95 % CI 1.09–2.78, P = 0.021), and emergency surgery (RR = 1.70, 95 % CI 1.09–2.65, P = 0.019) were independent risk factors of delirium in SICU. Conclusions Sepsis, exposure to sedative medications, higher APACHE II score, thoracic surgery, and emergency surgery were independent risk factors of delirium in Thai university-based surgical intensive care units.
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Affiliation(s)
- Tanyong Pipanmekaporn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, 110, Intavarorote Rd, Muang District, Chiang Mai, 50200 Thailand
| | | | - Onuma Chaiwat
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
| | - Thammasak Thawitsri
- Department of Anesthesiology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, 10330 Thailand
| | - Petch Wacharasint
- Department of Anesthesiology, Phramongkutklao Hospital, Bangkok, 10400 Thailand
| | - Suneerat Kongsayreepong
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700 Thailand
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