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

Volatile Anesthetic-Induced Skeletal Muscle Atrophy in Mice and Murine-Derived Myotubes: The Role of the Akt Pathway

BACKGROUND

Volatile anesthetics are gaining attention as sedatives in intensive care units. Sedation is a significant risk factor for skeletal muscle atrophy and weakness in critically ill patients; however, volatile anesthetics' influence on skeletal muscle atrophy remains unclear. Therefore, we investigated their effects on skeletal muscle mass using a murine-derived muscle cell line and mice.

METHODS

C2C12 myotubes were exposed to isoflurane or sevoflurane. Myotube diameter was assessed using immunofluorescence. The expression levels of Atrogin-1, MuRF1, and LC3-II and phosphorylation levels of p70 S6K and Akt were analyzed to evaluate protein degradation and synthesis. To determine whether these effects were mediated through the Akt pathway, experiments with insulin-like growth factor 1 (IGF-1) were performed. Furthermore, mice skeletal muscle exposed to isoflurane or sevoflurane were compared with control mice and short-term immobility mice induced by sciatic nerve denervation (DN) or hindlimb suspension (HS).

RESULTS

Exposure of C2C12 myotubes to 2.8% isoflurane or 5.0% sevoflurane reduced the myotube diameter by 14.4 µm (95% confidential interval [CI], 11.7-17.1, P < .001) and 13.2 µm (95% CI, 10.1-16.2, P < .001), respectively. Exposure to 2.8% isoflurane increased the expressions of Atrogin-1 (2.9-fold [95% CI, 2.1- to 3.8-fold], P < .001), MuRF1 (3.1-fold [95% CI, 2.4- to 3.8-fold], P < .001), and LC3-II (1.6-fold [95% CI, 1.4- to 1.8-fold], P < .001), whereas decreasing phosphorylation of p70 S6K (0.3-fold [95% CI, 0.2- to 0.4-fold], P < .001) and Akt (0.4-fold [95% CI, 0.3- to 0.5-fold], P < .001). Exposure to 5.0% sevoflurane resulted in similar effects. Additionally, IGF-1 counteracted the effects of isoflurane on myotube mass. In mice skeletal muscle, exposure to 1% isoflurane or 1.5% sevoflurane decreased Akt phosphorylation (isoflurane: 0.4-fold [95% CI, 0.1- to 0.8-fold], P = .003; sevoflurane: 0.5-fold [95% CI, 0.4- to 0.6-fold], P = .011) and increased the expression levels of Atrogin-1 (isoflurane: 4.1-fold [95% CI, 3.2- to 5.1-fold], P < .001; sevoflurane: 2.3-fold [95% CI, 1.1- to 3.5-fold], P = .026), MuRF1 (isoflurane: 2.7-fold [95% CI, 1.3- to 4.1-fold], P = .01; sevoflurane: 2.3-fold [95% CI, 1.0- to 3.7-fold], P = .022), and LC3-II (isoflurane: 1.9-fold [95% CI, 0.9- to 3.0-fold], P = .045; sevoflurane: 1.5-fold [95% CI, 1.4- to 1.6-fold], P < .001) while decreasing p70 S6K phosphorylation (isoflurane: 0.5-fold [95% CI, 0.4- to 0.6-fold], P = .013; sevoflurane: 0.7-fold [95% CI, 0.6- to 0.8-fold], P = .008) compared with DN. Similar results were observed when comparing between isoflurane or sevoflurane exposure and HS.

CONCLUSIONS

Volatile anesthetics induce skeletal muscle atrophy by downregulating the Akt pathway, suggesting they may exacerbate skeletal muscle atrophy beyond immobility effects.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

Sedation management and processed EEG-based solutions during venovenous extracorporeal membrane oxygenation: a narrative review of key challenges and potential benefits

Extracorporeal membrane oxygenation (ECMO) is an established technique for managing severe cardiorespiratory failure. However, it is invasive and requires profound analgo-sedation during initiation and often throughout the therapy. Managing sedation in venovenous (VV) ECMO patients is particularly challenging due to the impact of ECMO circuits on pharmacokinetics and specific patient requirements. This can lead to unpredictable sedative effects and require multiple drugs at higher doses. Additionally, sedation is usually managed with traditional scoring methods, which are subjective and invalid during neuromuscular blockade. These uncertainties may impact outcomes. Recent clinical practice increasingly focuses on reducing sedation to enable earlier physiotherapy and mobilisation, particularly in patients awaiting transplants or receiving mechanical circulatory support. In this context, processed electroencephalogram-based (pEEG) sedation monitoring might be promising, having shown benefits in general anaesthesia and intensive care. However, the technology has limitations, and its benefits in ECMO practice have yet to be formally evaluated. This review provides insights into the challenges of ECMO sedation, including pharmacokinetics, unique ECMO requirements, and the implications of inadequate sedation scores. Finally, it includes a brief overview of the practicality and limitations of pEEG monitoring during VV-ECMO, highlighting a significant research gap.

Machine Learning-Based Prediction of Delirium and Risk Factor Identification in Intensive Care Unit Patients With Burns: Retrospective Observational Study

BACKGROUND

The incidence of delirium in patients with burns receiving treatment in the intensive care unit (ICU) is high, reaching up to 77%, and has been associated with increased mortality rates. Therefore, early identification of patients at high risk of delirium onset is essential for improving treatment strategies.

OBJECTIVE

This study aimed to create a machine learning model for predicting delirium in patients with burns during their ICU stay using patient data from the first day of ICU admission and identify predictive factors for ICU delirium in patients with burns.

METHODS

This study focused on 82 patients with burns aged ≥18 years who were admitted to the ICU at Mie University Hospital for ≥24 hours between January 2015 and June 2023. In total, 70 variables were measured in patients upon ICU admission and used as explanatory variables in the ICU delirium prediction model. Delirium was assessed using the Intensive Care Delirium Screening Checklist every 8 hours after ICU admission. A total of 10 different machine learning methods were used to predict ICU delirium. Multiple receiver operating characteristic curves were plotted for various machine learning models, and the area under the curve (AUC) for each was compared. In addition, the top 15 risk factors contributing to delirium onset were identified using Shapley additive explanations analysis.

RESULTS

Among the 10 machine learning models tested, logistic regression (mean AUC 0.906, SD 0.073), support vector machine (mean AUC 0.897, SD 0.056), k-nearest neighbor (mean AUC 0.894, SD 0.060), neural network (mean AUC 0.857, SD 0.058), random forest (mean AUC 0.850, SD 0.074), adaptive boosting (mean AUC 0.832, SD 0.094), gradient boosting machine (mean AUC 0.821, SD 0.074), and naïve Bayes (mean AUC 0.827, SD 0.095) demonstrated the highest accuracy in predicting ICU delirium. Specifically, 24-hour urine output (from ICU admission to 24 hours), oxygen saturation, burn area, total bilirubin level, and intubation upon ICU admission were identified as the major risk factors for delirium onset. In addition, variables, such as the proportion of white blood cell fractions, including monocytes; methemoglobin concentration; and respiratory rate, were identified as important risk factors for ICU delirium.

CONCLUSIONS

This study demonstrated the ability of machine learning models trained using vital signs and blood data upon ICU admission to predict delirium in patients with burns during their ICU stay.

The effectiveness of family participation interventions for the prevention of delirium in intensive care units: A systematic review

AIM

To review the effect of family participation interventions in preventing delirium in Intensive Care Units (ICU).

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the "Synthesis Without Meta-analysis" guidelines. The search was performed using the MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, Web of Science, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases in April 2024. Eligibility criteria included patients admitted to Intensive Care Units, aged 18 or older exposed to risk factors for delirium, and with family members present; studies about family intervention to prevent delirium, that considered family as a partner in care and included interventions; studies that quantitatively assessed the effect of measures on the incidence and duration of delirium; interventional studies. Two authors independently applied these criteria using the Rayyan® application, assessing study quality with Critical Appraisal Skills Programme tools.

RESULTS

Fourteen studies were included, involving 33,232 patients. A meta-analysis was not feasible due to the highly heterogeneous results, but we concluded that the family participation interventions for delirium prevention were grouped into single-component and multi-component interventions. The single-component interventions, such as familiar voice messages, flexible visitation, and family presence, showed a favorable response in reducing delirium. The multicomponent interventions suggesting a positive effect included family visitation with professional-guided orientation; familiar voice messages for reorientation, newspaper reading, and nighttime eye patch use; sensory stimulation program; the ABCDEF bundle; the DyDel program; family education, emotional support, orientation training, cognitive stimulation, and ICU life care participation.

CONCLUSIONS

Several family participation interventions, both single-component and multicomponent, have shown positive effects on outcomes in preventing delirium in ICU patients, particularly in reducing its incidence and duration.

IMPLICATIONS FOR CLINICAL PRACTICE

Identifying the family participation interventions that can prevent delirium allows the development of measures to minimize its occurrence in ICU.

Delirium as a Determinant of Long-Term Cognitive Dysfunction in the Context of Post-intensive Care Syndrome: A Prospective Study in a Latin American Environment

Introduction Cognitive dysfunction represents a major healthcare concern in the 21st century. Prolonged cognitive dysfunction and concomitant psychological and physical disorders in patients admitted to the intensive care unit (ICU) are components of the post-ICU syndrome (PICS). Notwithstanding the numerous published studies in this area, our work is the first to explore the relationship between PICS and delirium in the ICU in Uruguay. This research underscores the significance and potential of our study, which we believe will make a substantial contribution to this field of research in Latin America. Objectives The incidence rates of the cognitive, psychological, and physical sequelae constituting PICS were evaluated, and the relationships between these disorders and delirium in the ICU were studied. Methods This was a prospective cohort study in which patients were followed up for one year after admission to the ICU of Hospital Pasteur between 03/01/2017 and 05/31/2017. The pre-ICU condition of each patient was considered in the analysis. An initial telephone interview was conducted using the following scales: the Hamilton scale was used to assess anxiety, the Pfeiffer scale was used to assess cognitive impairment, and the Barthel scale was used to assess activities of daily living (ADLs). In a second face-to-face interview, the Mini-Mental State Examination (MMSE) and the Beck Depression Scale II (BDS-II) were used. Results Forty-three patients were divided into two groups: 15 (34%) with delirium in the ICU and 28 (66%) without delirium. The association of delirium with different sequelae was evaluated using the corresponding scales: Pfeiffer scale: Cognitive impairment was observed in 7/13 patients (53%) in the delirium group vs. 0/29 patients (0%) in the non-delirious group (p 0.001); MMSE score: Deterioration was observed in 6/7 patients (86%) in the delirium group vs. 1/7 patients (14%) in the non-delirious group (p 0.007). Cognitive impairment was found in 3/6 patients (50%) who presented with delirium in the ICU, while 1/8 patients (13%) who did not present with delirium experienced cognitive impairment (p = 0.036); Hamilton scale: Anxiety was found in 8/15 patients (57%) in the delirium group and 20/29 patients (68%) in the non-delirious group; BDS-II: Depression was found in 12/12 patients (100%) in the delirium group vs. 27/29 patients (93%) in the non-delirious group (p 0.57). Barthel scale: Dependence on others for ADLs was observed in 3/15 patients (20%) in the delirium group vs. 4/29 patients (14%) in the non-delirious group (p = 0.23). Conclusions Cognitive impairment was observed to be associated with delirium in the ICU, opening new avenues for research and possible treatment options. Although dependence on activities of daily living (ADLs) was more common in the delirium group, the difference between the two groups was not significant, highlighting the need for further research to understand the whole picture. Rates of anxiety and depression after ICU stay were also similar between the two groups, providing a baseline for comparison and informing future studies. The study highlights the urgent need for delirium-specific interventions in the ICU to address cognitive dysfunction and improve long-term outcomes in critically ill patients.

Development of an evidence-based nursing practice program for preventing unplanned endotracheal extubations in the intensive care unit: A Delphi method study

AIMS

This study aims to develop an evidence-based nursing practice program to prevent unplanned endotracheal extubation (UEE) among adult patients in the intensive care unit (ICU).

DESIGN

This study uses the Delphi method to develop an evidence-based nursing practice program.

METHODS

A comprehensive review of 18 databases and evidence-based websites was conducted to gather, assess and synthesize evidence on preventing UEEs in adult patients. Using this synthesized evidence, a questionnaire was formulated for further investigation. Subsequently, input was solicited from experts through Delphi surveys to establish an evidence-based nursing practice protocol for preventing UEEs in adult ICU patients. Consistency in consultation results guided subsequent rounds of consultation.

RESULTS

The developed program comprised 43 evidence items categorized into nine dimensions, including risk assessment for unplanned extubation, sedation, analgesia, delirium, balloon management, psychosocial care, early extubation, catheter immobilization and protective restraints. Two rounds of expert inquiry yielded recovery rates of 94.7% and 100% for the first and second questionnaires, respectively. Kendall W values ranged from .224 to .353 (p < .001).

CONCLUSION

This study developed an evidence-based nursing practice program to prevent UEE in adult ICU patients, employing evidence-based practices and Delphi expert consultation methods. However, further validation of the program's effectiveness is warranted.

REPORTING METHOD

Findings were reported according to the Standards for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

Nurses contributed to the study by participating in investigations.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The program developed in this study offers an evidence-based framework for preventing unplanned extubation in hospitals, thereby reducing its incidence and enhancing the quality of nursing care.

Anesthetic Gas Scavenging System for Gas Evacuation in the ICU

Background: Inhaled sedation is increasing in ICUs, with active carbon filters (ACFs) commonly used for evacuating halogenated gases. However, the potential benefits of a waste anesthetic gas system (WAGS) similar to the ones used in operating rooms should be explored. To limit the suction over the flow sensor where the WAGS is connected on ICU ventilators, an anesthetic gas receiving system (AGRS) is required, constituting with the WAGS an active gas receiving and scavenging system (AGRSS). Ensuring that this whole device does not compromise the flow sensor reliability is crucial. The aim of this study was to compare various gas evacuation devices and assess the reliability of AGRSS on ICU ventilators. Methods: In this experimental study, pressures and flows were recorded during the ventilation of a test lung using various ventilator settings and gas evacuation methods: no device (reference condition), ACF, the WAGS alone, AGRSS (WAGS and AGRS together), and the expiratory valve connected to the medical vacuum system with the AGRS in between. Visual comparisons of the pressure and flow curves followed by a statistical analysis comparing median pressures and flows of each device to the reference were performed. Results: The test lung model demonstrated consistent comparability in pressures and flows among all devices, except for the WAGS alone, which exhibited discordance through significant overestimation or underestimation. Conclusions: These findings indicate that using a WAGS with the AGRS system appeared to be reliable for managing gas evacuation in ICUs without compromising pressure or flow delivery. The data from this experimental trial should be confirmed with clinical studies involving human subjects. Given the increasing use of inhaled sedation in ICUs, these results support the daily application of the WAGS with the AGRS for gas evacuation, similar to its established use in anesthesiology.

Investigating Dose Level and Duration of Rehabilitation of Mechanically Ventilated Patients in the ICU

Background: The dose level and duration needed for early rehabilitation of mechanically ventilated patients in the ICU need to be characterized. Therefore, this study aimed to assess the association between mobilization level, rehabilitation time, and dose (defined as the mean mobilization quantification score [MQS]) during ICU admission and the end point walking independence at hospital discharge in subjects needing ICU admission. Methods: This prospective, multi-center, cohort study included 9 ICUs. Consecutive subjects admitted to the ICU between September 2022-March 2023 receiving mechanical ventilation for >48 h were included in the study. The mean MQS score, highest ICU mobility score (IMS) during the ICU stay, time to the first mobilization day, ICU rehabilitation time (minutes of each rehabilitation physical activity from start to finish), frequency/d, baseline characteristics, and walking independence at hospital discharge were assessed. Results: Among the 116 subjects, 64 did and 51 did not walk independently at hospital discharge, respectively. Multiple logistic regression analysis revealed that the mean MQS and time to first mobilization were significantly associated with walking independence at hospital discharge. We observed that mean MQS was better than IMS, rehabilitation time, frequency, and time to first mobilization predicted walking independence based on receiver operating characteristic (ROC) curve comparison. Comparison of the mean MQS with that on the first mobilization day revealed superior predicting power of the mean MQS. The ROC curve cutoff value for the mean MQS was 4.0. Conclusions: This study shows that in subjects mechanically ventilated for >48 h the dose of rehabilitation calculated using the mean MQS during ICU was a better predictor of walking independence at hospital discharge than intensity, duration, or frequency of the mobilization therapy. Mean MQS during ICU stay may be used to measure and titrate optimal mobilization therapy.

The association between cerebral blood flow variations during on-pump coronary artery bypass grafting surgery and postoperative delirium

INTRODUCTION

Postoperative delirium (POD) has a major impact on patient recovery after cardiac surgery. Although its pathophysiology remains unclear, there could be a correlation between cerebral blood flow (CBF) variations during cardio-pulmonary bypass (CPB) and POD. Our study aimed to evaluate whether variations in on-pump CBF, compared to pre-anesthesia and pre-CPB values, are associated with POD following coronary artery bypass grafting (CABG) surgery.

METHODS

This prospective observational cohort study included 95 adult patients undergoing elective on-pump CABG surgery. Right middle cerebral artery blood flow velocity (MCAV) was assessed using Transcranial Doppler before anesthesia induction, before CPB and every fifteen minutes during CPB. Pre-anesthesia and pre-CPB values were chosen as baselines. Individual values, measured during CPB, were converted as percentage changes relative to these baselines and named as %MCAV0 and %MCAV1, respectively. POD was assessed using the Confusion Assessment Method for ICU (CAM-ICU) during the first 48 post-operative hours and with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) on the fifth post-surgical day.

RESULTS

Overall POD incidence was 17.9%. At 30 minutes of CPB, %MCAV0 was higher in POD group than in no-POD group (p = .05). %MCAV0 at 45 minutes of CPB was significantly higher in POD group (87 (±17) %) than in no-POD group (68 (±24) %), p = .04. %MCAV1 at 30 and 45 minutes of CPB were higher in POD group than in no-POD group, at the limit of statistical significance. We found %MCAV1 > 100% in POD group, but not in no-POD group.

CONCLUSIONS

Significant differences in %MCAV0 became evident after 30 minutes of CPB, whereas differences in %MCAV1 at 45 minutes of CPB were at limit of statistical significance. In POD group %MCAV1 was higher than 100% at 30 and 45 minutes of CPB, which is supposed to be a sign of cerebral hyperperfusion. Monitoring CBF during CPB could have prognostic value for POD.

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

RATIONALE

Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

OBJECTIVES

The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

PANEL DESIGN

The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

METHODS

The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

RESULTS

The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

CONCLUSIONS

The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

Extracorporeal Life Support Organization 2024 Guideline for Early Rehabilitation or Mobilization of Adult Patients on Extracorporeal Membrane Oxygenation

DISCLAIMER

This Extracorporeal Life Support Organization guideline describes early rehabilitation or mobilization of patients on extracorporeal membrane oxygenation (ECMO). The guideline describes useful and safe practices put together by an international interprofessional team with extensive experience in the field of ECMO and ECMO rehabilitation or mobilization. The guideline is not intended to define the delivery of care or substitute sound clinical judgment. The guideline is subject to regular revision as new scientific evidence becomes available.

Benzodiazepine-Free Cardiac Anesthesia for Reduction of Postoperative Delirium: A Cluster Randomized Crossover Trial

Importance

Delirium is common after cardiac surgery and associated with adverse outcomes. Intraoperative benzodiazepines may increase postoperative delirium but restricting intraoperative benzodiazepines has not yet been evaluated in a randomized trial.

Objective

To determine whether an institutional policy of restricted intraoperative benzodiazepine administration reduced the incidence of postoperative delirium.

Design, Setting, and Participants

This pragmatic, multiperiod, patient- and assessor-blinded, cluster randomized crossover trial took place at 20 North American cardiac surgical centers. All adults undergoing open cardiac surgery at participating centers during the trial period were included through a waiver of individual patient consent between November 2019 and December 2022.

Intervention

Institutional policies of restrictive vs liberal intraoperative benzodiazepine administration were compared. Hospitals (clusters) were randomized to cross between the restricted and liberal benzodiazepine policies 12 to 18 times over 4-week periods.

Main Outcomes and Measures

The primary outcome was the incidence of delirium within 72 hours of surgery as detected in routine clinical care, using either the Confusion Assessment Method-Intensive Care Unit or the Intensive Care Delirium Screening Checklist. Intraoperative awareness by patient report was assessed as an adverse event.

Results

During the trial, 19 768 patients (mean [SD] age, 65 [12] years; 14 528 [73.5%] male) underwent cardiac surgery, 9827 during restricted benzodiazepine periods and 9941 during liberal benzodiazepine periods. During restricted periods, clinicians adhered to assigned policy in 8928 patients (90.9%), compared to 9268 patients (93.2%) during liberal periods. Delirium occurred in 1373 patients (14.0%) during restricted periods and 1485 (14.9%) during liberal periods (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.01; P = .07). No patient spontaneously reported intraoperative awareness.

Conclusions and Relevance

In intention-to-treat analyses, restricting benzodiazepines during cardiac surgery did not reduce delirium incidence but was also not associated with an increase in the incidence of patient-reported intraoperative awareness. Given that smaller effect sizes cannot be ruled out, restriction of benzodiazepines during cardiac surgery may be considered. Research is required to determine whether restricting intraoperative benzodiazepines at the patient level can reduce the incidence of postoperative delirium.

Trial Registration

ClinicalTrials.gov Identifier: NCT03928236.

Impact of implementing the critical-care pain observation tool in the adult intensive care unit: A nonrandomised stepped-wedge trial

BACKGROUND

Approximately 70% of patients in intensive care units (ICUs) experience untreated pain, often due to severe patient conditions and communication barriers.

AIM

The aim of this study was to implement the Critical-Care Pain Observation Tool (CPOT) to improve pain assessment in patients unable to self-report pain in the ICU.

METHOD

A stepped-wedge trial was conducted in six adult ICUs in Saudi Arabia between February and June 2022. The sequential transition of ICU clusters occurred in February 2022, from control to intervention, until all ICUs were exposed to the intervention. The primary outcome was the number of pain assessments, whereas the secondary outcomes were reassessments. Other outcomes were length of stay, mechanical ventilation duration, and administered doses of sedatives and analgesic agents. Statistical analyses were performed using the Statistical Analysis Software v9.4.

RESULTS

A total of 725 patients unable to self-report pain were included; 65% (n = 469) were male with an average age of 55 years. Implementing CPOT showed a significant increase in the number of pain assessments (rate ratio: 1.77, 95% confidence interval: 1.45, 2.16, p < 0.001) and reassessments (rate ratio: 13.99, 95% confidence interval: 8.14, 24.02, p < 0.001) between intervention and control conditions. There was no significant effect on the ICU length of stay, mechanical ventilation duration, and the amount of sedation (midazolam, propofol, and ketamine) and analgesia (fentanyl) administered.

CONCLUSION

The study indicates that the implementation of the CPOT increased the frequency of pain assessment and reassessment. However, the impact on patient outcomes remains inconclusive. Further investigations focussing on CPOT as the primary pain scale are necessary to determine its holistic impact on patient outcomes over the long term.

TRIAL REGISTRATION

NCT05488834.

CLINICAL TRIAL REGISTRATION NUMBER

This study was registered with the U.S. National Library of Medicine (ClinicalTrial.gov, NCT05488834).

Maintenance of prehospital anaesthesia in trauma patients: inconsistencies and variability in practice

Background

Literature on prehospital anaesthesia predominantly focuses on preparation and induction, while there is limited guidance on anaesthesia maintenance. The hypothesis of this study was that for prehospital trauma patients, protocols and practice for anaesthesia maintenance may vary considerably between services. Hence, we sought to describe the practice of prehospital anaesthesia maintenance for trauma patients in Australia, New Zealand, and the UK.

Methods

An online practice survey of prehospital and retrieval services in Australia, New Zealand, and the UK was conducted from May to September 2022. Branching logic of between five and 140 questions covered services' background information, protocols relating to anaesthesia maintenance, and perceived effectiveness and governance.

Results

Forty-two services were approached with an 81% response rate. While most services (88%) had some form of maintenance protocol, only 14% had one specific for trauma patients. Most services (61%) used a combination of intermittent boluses and continuous infusions. Ketamine and midazolam were the favoured hypnotics, and fentanyl the favoured opioid. However, there was considerable variation in drug selection and dosing, and in the detail contained within protocols. There was high self-reported confidence in effectiveness and governance of anaesthesia maintenance practices.

Conclusions

Protocols for anaesthesia maintenance in prehospital trauma patients show considerable variation in content and detail across the surveyed services. Further consideration of pharmacokinetics and the specific aims of anaesthesia maintenance is warranted. More research is needed to establish the optimal choice of drugs, dosing, delivery, and adjustment criteria for anaesthesia maintenance in prehospital trauma patients.

Concurrent nutrition and physical rehabilitation interventions for patients with critical illness

PURPOSE OF REVIEW

The effects of either physical rehabilitation or nutrition on outcomes in patients with critical illness are variable and remain unclear. The potential for the combination of exercise and nutritional delivered concurrently to provide benefit is provocative, but data are only emerging. Herein, we provide a summary of evidence from 2023 and 2024 on combined physical rehabilitation and nutrition during and following critical illness.

RECENT FINDINGS

While latest trials on physical rehabilitation alone reported conflicting findings, recent nutrition trials found no difference between higher and lower protein delivery and even suggested harm in patients with acute kidney injury. In 2023 and 2024, we identified four studies (one randomized controlled trial) combining physical rehabilitation and nutrition (mainly protein supplementation) within the ICU setting. Overall, these suggested benefits, including reduction of muscle size loss, ICU acquired weakness, delirium, and improved mobility levels, although these benefits did not extend to mortality and hospital length of stay. No recent trials combining physical rehabilitation and nutrition for patients after ICU were identified.

SUMMARY

Current insights on combined physical rehabilitation and nutrition suggest improved clinically relevant outcomes, but further investigations across the continuum of care of patients with critical illness are warranted.

Correlations between clinical insomnia and psychophysiological factors in postoperative patients discharged from the ICU: A cross-sectional study

Aim

Post-intensive care unit (ICU) patients often experience physical or mental dysfunction. This study aims to investigate the relationship between sleep disturbances and mental and physical problems in patients discharged from the ICU to hospital wards, using both subjective and objective sleep measures.

Methods

Patients admitted to the ICU for at least 72 h between November 2021 and June 2022 were included in the study. On the seventh day after ICU discharge, we conducted an objective sleep assessment using an electroencephalogram-based mobile sleep-monitoring device. Patients self-administered severity ratings for fatigue, depression, and post-traumatic stress (PTS) symptoms. Insomnia symptoms were assessed using the insomnia severity index (ISI) before and after ICU admission.

Results

Thirty-five patients (median age 73) were included in the study. Higher ISI scores at ward were significantly correlated with higher levels of fatigue (r = 0.463, P = 0.005), depression (r = 0.343, P = 0.044), and PTS symptoms (r = 0.477, P = 0.004). Among the objective sleep measures, reduced N3 sleep (r = -0.480, P = 0.004) was significantly correlated with more severe PTS symptoms. However, no statistically significant correlations were found between objective sleep indicators and either fatigue or depression.

Conclusion

The observed reduction in N3 sleep and its association with PTS symptoms in this study might have reflected the physical and psychological stress experienced during intensive care. Subjective insomnia severity, which was related to fatigue, depression, and PTS symptoms in the ward, could be an important intervention target after ICU discharge.

Critically ill patients' experiences of discomfort and comfort in the intensive care unit: A qualitative descriptive study

BACKGROUND

The physiological state of critically ill patients is severely impaired by illness or trauma and is uncomfortable. Such experiences cause long-term anxiety and post-traumatic stress disorder.

OBJECTIVE

This study aimed to understand discomfort and comfort based on the experiences of critically ill adult patients in the intensive care unit and to explore ways to improve their comfort.

METHODS

This qualitative descriptive study was conducted with 15 critically ill patients (age range: 46-81 years; six females) in the intensive care unit using semistructured interviews and participant observation. The data collected were analysed using Braun and Clarke's thematic analysis. Data were collected from the intensive care unit and general ward of a university hospital in Japan.

FINDINGS

Six themes related to discomfort and comfort were identified. The three themes related to discomfort were "overlapping uncertainties", "being unable to control physical discomfort", and "having to endure psychologically and situationally". The three themes related to comfort were "feeling connected brings calm", "routine care relieves pain and thirst", and "ease when one can decide for oneself". Participants' discomfort involved physical and psychological factors and was related to treatments, procedures, care, and the environment. Moreover, more than half of the patients endured unmet needs. Comfort was brought about by providing routine care for physical discomforts that critically ill patients often experience, feeling alive and connected to others and encouraging independence.

CONCLUSION

Recognising the potential for physical and psychological discomfort, as well as communication and other difficulties, in critically ill patients is crucial. Patients may also experience discomfort when healthcare providers take the lead, which underscores the importance of involving patients in their care. By showing respect for patients' intentions and involving them in decision-making, healthcare providers can improve patient comfort and promote a more collaborative approach to care.

Haloperidol for the treatment of delirium in ICU patients: a systematic review and meta‑analysis

OBJECTIVES

Haloperidol is the most frequently prescribed medication for managing delirium in the intensive care unit (ICU). However, there is limited and inconclusive evidence regarding its efficacy. A meta-analysis was conducted by pooling data from recent clinical randomized controlled trials to assess the effectiveness of haloperidol in adult ICU patients with delirium.

METHODS

Studies were searched in PubMed, Embase and Cochrane Library databases on August 10, 2024. We performed a meta-analysis to estimate the efficacy of haloperidol for the treatment of ICU adult patients with delirium. This study is registered with INPLASY, number 202480104. The estimates are expressed as odds ratio (OR) or mean difference (MD) with a 95% confidence interval (CI).

RESULTS

A total of 2863 patients were included in the analyses. All the included studies were randomized controlled trials. The frequency of patients diagnosed with delirium used both confusion assessment method of intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) was 34% (n = 2863), and used CAM-ICU only was 66% (n = 2863). There was no difference in short-term (28-30 days) mortality between the two groups [OR = 0.89, 95% CI 0.60-1.32, P = 0.56] and long-term (90 days to 1 year) mortality [OR = 0.87, 95% CI 0.70-1.07, P = 0.19]. Furthermore, the haloperidol group demonstrated an advantage in reducing the length of ICU stay [MD = -1.13, 95% CI - 1.93-- 0.32, P < 0.05] compared to the placebo group, with no statistically significant difference in length of hospital stay [MD = - 0.24, 95% CI -1.71-1.24, P = 0.75].

CONCLUSIONS

Haloperidol showed a significant trend in reducing the length of ICU stay. However, there was no statistical difference between the two groups in terms of delirium reduction.

Pharmacological Management of Sleep-Wake Disturbances in Delirium

Delirium is a heterogeneous syndrome primarily characterized by fluctuations in attention and awareness. Sleep-wake disturbances are a common and significant feature of delirium and can manifest as circadian rhythm inversion, sleep fragmentation, and reduced rapid eye movement (REM) and slow-wave sleep. Some literature suggests that the relationship between sleep disruption and delirium is reciprocal wherein the two reinforce one another and may share an underlying etiology. As there are no FDA-approved medications for delirium or delirium-related sleep disturbances, management is primarily focused on addressing underlying medical concerns and promoting physiologic circadian patterns with non-pharmacological behavioral interventions. In practice, however, medications are often used, albeit with limited evidence to support their use. This literature review explores the pharmacology and pharmacokinetics of several medications with literature investigating their use in delirium: melatonin, ramelteon, dual orexin receptor antagonists (DORAs), and dexmedetomidine. Current evidence suggests a possible benefit of ramelteon or melatonin, dexmedetomidine for patients in the ICU setting, and DORAs as therapeutic options for the re-regulation of sleep-wake cycle disruption in delirium. We discuss pertinent pharmacokinetic and pharmacodynamic factors that may influence clinical decision-making regarding these interventions.

Correlation Between Serum and CSF Concentrations of Midazolam and 1-Hydroxy-Midazolam in Critically Ill Neurosurgical Patients

BACKGROUND

Midazolam (MZ) is commonly used in critically ill neurosurgical patients. Neuro-penetration of MZ and its metabolite, 1-hydroxy-midazolam (1-OH-MZ), is not well characterized.

OBJECTIVE

This study evaluated correlations between serum and cerebrospinal fluid (CSF) concentrations of MZ and 1-OH-MZ and assessed implications on patient sedation.

METHODS

Adults in the neurosurgical intensive care unit (ICU) with external ventricular drains receiving MZ via continuous infusion were prospectively studied. Serum and CSF samples were obtained 12-24 h and 72-96 h after initiation, and concentrations were determined in duplicate by high-performance liquid chromatography with tandem mass spectrometry. Bivariate correlation analyses used Pearson coefficient.

RESULTS

A total of 31 serum and CSF samples were obtained from 18 subjects. At sampling, mean MZ infusion rate was 3.9 ± 4.4 mg/h, and previous 12-h cumulative dose was 51.4 ± 78.2 mg. Mean concentrations of MZ and 1-OH-MZ in serum and CSF were similar between timepoints. Similarly, ratios of 1-OH-MZ to MZ in serum and CSF remained stable over time. Serum MZ (126.2 ± 89.3 ng/mL) showed moderate correlation (r2 = 0.68, P < 0.001) with serum 1-OH-MZ (17.7 ± 17.6 ng/mL) but not CSF MZ (3.9 ± 2.5 ng/mL; r2 = 0.24, P = 0.005) or CSF 1-OH-MZ (2.5 ± 0.6 ng/mL; r2 = 0.47, P = 0.30). CSF MZ did not correlate with CSF 1-OH-MZ (r2 = 0.003, P < 0.001). Mean serum ratio of 1-OH-MZ to MZ (0.14 ± 0.2 ng/mL) did not correlate with CSF ratio (1.06 ± 0.83 ng/mL; r2 = 0.06, P = 0.19). Concentrations and ratios were unrelated to MZ infusion rate or 12-h cumulative dose. Sedation was weakly correlated with CSF 1-OH-MZ, but not with serum MZ, serum 1-OH-MZ, or CSF MZ.

CONCLUSION AND RELEVANCE

Continuous infusions of MZ result in measurable concentrations of MZ and 1-OH-MZ in CSF; however, CSF concentrations of MZ and 1-OH-MZ poorly represent serum concentrations or dosages. Accumulation of MZ and 1-OH-MZ in serum or CSF over time was not evident. Concentrations of MZ and 1-OH-MZ do not predict sedation levels, reinforcing that pharmacodynamic assessments are warranted.

Optimizing Administration and Timing of Post Intubation Analgesia and Sedation in the Emergency Department

INTRODUCTION

Recent literature suggests pain management and sedation in ED patients after rapid sequence intubation are done inconsistently, which impacts patient outcomes negatively. The purpose of this study is to compare rates and timing of post-intubation analgesia and sedation before and after an ED pharmacy practice improvement intervention.

METHODS

We conducted a retrospective study of adult ED patients intubated over an 18-month period. The primary study endpoint was the frequency of post-intubation analgesia and sedation administration before and after implementation of the post-intubation guideline and education. Secondary endpoints included time to analgesia and sedation medication after paralytic administration, comparison between paralytic drugs utilized (succinylcholine and rocuronium), and ED length of stay.

RESULTS

Prior to intervention, the mean percentage of post-intubation analgesia and sedation administration was 58.6% and 94.3%, respectively. After paralytic administration, the time to dose of analgesia was 63 minutes (range 0-288) and 47 minutes for sedation medication (range 0-214). The mean length of stay in the emergency department was 298 minutes (range 12-3143). Following the intervention, 35 patients met inclusion criteria, and the mean percentage of analgesia and sedation administration was 77.1% and 91.4%, respectively. The mean time to analgesia administration improved to 22 minutes (range 0-123), and sedation improved to 20 minutes (range 0-284). The mean emergency department length of stay decreased to 204 minutes (range 46-469). When comparing paralytic used, mean time to analgesia and sedation was longer in those who received rocuronium compared to succinylcholine.

DISCUSSION

An educational lecture along with a novel ED post-intubation clinical guideline improved rates and timing to analgesia and sedation. This provides a unique opportunity for emergency nurses to advocate for early analgesia and sedation in mechanically ventilated patients.

Substance-Use Disorders in Critically Ill Patients: A Narrative Review

Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Pharmacokinetics of Opioid Infusions in the Adult Intensive Care Unit Setting-A Systematic Review

INTRODUCTION

Pharmacokinetics (PKs) of drugs are often altered in the intensive care unit (ICU). Opioids are often used in the ICU, particularly as continuous infusions, and their characteristics lead them to undergo PK alterations. We conducted a systematic review to assess the PK of opioid infusions in the ICU.

METHODS

Embase, MEDLINE, PubMed, CINAHL, and Evidence-Based Medicine Reviews (EBMR) were searched from inception to March 2024. Studies were included if they evaluated PKs of opioid infusions in adult patients in the ICU. Two reviewers independently selected and extracted data.

RESULTS

Out of the 1040 records screened, 17 studies were included. Five studies were conducted on fentanyl, seven on morphine, one on hydromorphone, two on remifentanil, two on alfentanil, and one on sufentanil. Most studies where observational studies or case series. The mean age was 56 years old. Duration of the infusion varied between 3 h and 20 days. PKs of fentanyl, sufentanil, and hydromorphone were significantly impaired, whereas the PKs of morphine, alfentanil, and remifentanil were impaired to a lesser degree. The PK parameter that was most affected by critical illness was the half-life (T½).

CONCLUSIONS

To counter these PK alterations, new therapeutic avenues must be further explored in the ICU to individualize opioid infusions.

Analgesia With Epidural Anesthesia in Lower-Leg Necrotizing Fasciitis: A Case Report

Appropriate methods have not been established despite the necessity of analgesia for debridement in cases of necrotizing fasciitis. A 45-year-old woman was hospitalized for necrotizing fasciitis due to Streptococcus pyogenes. Rapid debridement and antibiotic treatment enabled the patient's quick discharge from the intensive care unit. However, after discharge, she began experiencing considerable pain in the left lower leg, which hindered adequate debridement, resulting in the persistence of necrotic tissue. Epidural anesthesia was administered to alleviate pain and enable debridement. Epidural anesthesia was effective as analgesia in this case, facilitating infection control through debridement and alleviating procedural pain.

Adjuvant non-opioid analgesics decrease in-hospital mortality in targeted patients with acute pancreatitis receiving opioids

OBJECTIVES

Opioid administration in acute pancreatitis (AP) exacerbates its severity, prompting concerns regarding the increased requirement for intensive care and its potential impact on patient survival. We aimed to elucidate the influence of analgesic patterns on mortality among patients with AP hospitalized in the ICU.

METHODS

We included 784 patients (198 receiving opioid monotherapy and 586 receiving opioid polytherapy) from the Medical Information Mart for Intensive Care database. The primary outcome was in-hospital mortality. Propensity score matching was used to account for baseline differences. We used Kaplan-Meier survival curves and multivariate regression models to indicate survival discrepancies and potential associations.

RESULTS

Polytherapy group exhibited prolonged hospital survival (79.8 vs. 57.3 days, P < 0.001); polytherapy was associated with decreasing in-hospital mortality adjusted for confounders (HR = 0.49, 95% CI: 0.26-0.92; P = 0.027). Stratification analysis indicated that patients receiving adjunctive acetaminophen had prolonged hospital survival (opioid vs. opioid + acetaminophen, P < 0.001; opioid vs. opioid + NSAIDs + acetaminophen, P = 0.026). Opioid polytherapy benefited patients with APACHE III scores >83 and those with mean oral morphine equivalent >60 mg/day (HR = 0.17, 95% CI: 0.1-0.3, P < 0.001 and HR = 0.32, 95% CI: 0.2-0.52, P < 0.001, respectively).

CONCLUSION

Our findings suggest that an opioid-based analgesic regimen offers a survival advantage for patients with AP, particularly those in critical condition or with concerns about opioid use. This approach provides a viable clinical strategy for pain management. Further randomized clinical trials are warranted to validate these results.

Chrononutrition in Critical Illness

Circadian rhythms in humans are biological rhythms that regulate various physiological processes within a 24-hour time frame. Critical illness can disrupt the circadian rhythm, as can environmental and clinical factors, including altered light exposure, organ replacement therapies, disrupted sleep-wake cycles, noise, continuous enteral feeding, immobility, and therapeutic interventions. Nonpharmacological interventions, controlling the ICU environment, and pharmacological treatments are among the treatment strategies for circadian disruption. Nutrition establishes biological rhythms in metabolically active peripheral tissues and organs through appropriate synchronization with endocrine signals. Therefore, adhering to a feeding schedule based on the biological clock, a concept known as "chrononutrition," appears to be vitally important for regulating peripheral clocks. Chrononutritional approaches, such as intermittent enteral feeding that includes overnight fasting and consideration of macronutrient composition in enteral solutions, could potentially restore circadian health by resetting peripheral clocks. However, due to the lack of evidence, further studies on the effect of chrononutrition on clinical outcomes in critical illness are needed. The purpose of this review was to discuss the role of chrononutrition in regulating biological rhythms in critical illness, and its impact on clinical outcomes.

Effect of inhaled aromatherapy on sleep quality in critically ill patients: A systematic review and network meta-analysis

AIM

This study aimed to compare the effect of inhaled aromatherapy using various essential oils on the sleep quality of critically ill patients.

BACKGROUND

Inhalation of essential oils significantly promotes the physiological and psychological health of patients in intensive care units (ICUs). However, research identifying and ranking the effects of different essential oils on the sleep quality of critically ill patients is lacking.

DESIGN

This study followed the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions (PRISMA-NMA) guidelines.

METHODS

A comprehensive search of five databases (Embase, MEDLINE, the Cochrane Library, CINAHL and PsycINFO) was conducted from their inception to March 15, 2023 (with an additional eligible study included dated August 14, 2023). Google Scholar was used as a supplementary method. Frequentist NMA was used to determine the effects of various essential oils. Certainty of evidence (CoE) was assessed using Confidence in Network Meta-Analysis (CINeMA).

RESULTS

A total of 11 trials involving 690 critically ill patients were included in the analysis. The NMA of inhaled aromatherapy revealed that the combination of lavender, Matricaria recutita, and neroli essential oils (ratio 6:2:0.5) resulted in the most significant improvement in sleep quality compared to usual care, followed by Rosa damascene, peppermint, Citrus aurantium, pure sunflower oil and lavender oil alone. The overall CoE for the results was rated as low.

CONCLUSIONS

The results of this study indicate that a combination of lavender, Matricaria recutita and neroli essential oils significantly positively affected sleep quality among critically ill patients. Despite the low quality of evidence, inhaled aromatherapy is non-invasive and easy to use.

RELEVANCE TO CLINICAL PRACTICE

Inhaled aromatherapy can effectively improve sleep quality among critically ill patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution applies to this work.

STUDY REGISTRATION

The study protocol was registered to the PROSPERO International Prospective Register of Systematic Reviews (protocol number CRD42023433194).

Validation of the Nociception Level Index for the Detection of Nociception and Pain in Critically Ill Adults: Protocol for an Observational Study

BACKGROUND

In the intensive care unit (ICU), many patients are unable to communicate their pain through self-reporting or behaviors due to their critical care condition, mechanical ventilation, and medication (eg, heavily sedated or chemically paralyzed). Therefore, alternative pain assessment methods are urgently needed for this vulnerable patient population. The Nociception Level (NOL) index is a multiparameter technology initially developed for the monitoring of nociception and related pain in anesthetized patients, and its use in the ICU is new.

OBJECTIVE

This study aims to validate the NOL for the assessment of nociception and related pain in critically ill adults in the ICU. Specific objectives are to examine the ability of the NOL to: (1) detect pain using standard criteria (ie, self-report and behavioral measures), (2) discriminate between nociceptive and nonnociceptive procedures, and (3) generate consistent values when patients are at rest.

METHODS

The NOL will be monitored in three ICU patient groups: (1) Group A, participants able to self-report their pain (the reference standard criterion using the 0-10 Faces Pain Thermometer) and express behaviors; (2) Group B, participants unable to self-report but able to express behaviors (the alternative standard criterion using the Critical-Care Pain Observation Tool); and (3) Group C, participants unable to self-report and express behaviors. The NOL will be tested before, during, and after two types of standard care procedures: (1) nonnociceptive (eg, cuff inflation to measure blood pressure, soft touch) and (2) nociceptive (eg, tube or drain removal, endotracheal or tracheal suctioning). Receiver operating characteristic curve analysis of the NOL will be performed for Groups A and B using pain standard measures as reference criteria. Mixed linear models for repeated measures will be used to compare time points, procedures, and their interaction in each group (A, B, and C). Based on power analyses and considering an attrition rate of 25%, a total sample size of 146 patients (68 in Group A, 62 in Group B, and 16 in Group C) is targeted.

RESULTS

This study was funded in April 2020 but could not be launched until 2022 due to the COVID-19 pandemic. Recruitment and data collection began at the primary site in July 2022 and has been implemented at the secondary sites in 2023 and 2024 and is planned to continue until 2026.

CONCLUSIONS

The primary strength of this study protocol is that it is based on rigorous validation strategies with the use of pain standard criteria (ie, self-report and behavioral measures). If found to be valid, the NOL could be used as an alternative physiologic measure of pain in critically ill adults for whom no other pain assessment methods are available.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05339737; https://clinicaltrials.gov/study/NCT05339737.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60672.

Prioritisation of functional needs for ICU intelligent robots in China: a consensus study based on the national survey and nominal group technique

OBJECTIVE

This study aims to define the prioritisation of the needs for an intelligent robot's functions in the intensive care unit (ICU) from a clinical perspective.

DESIGN

This study introduces a nominal group technique.

SETTING

This study uses national setting.

PARTICIPANTS

This study includes a total of 851 respondents from 34 provinces in China who participated in the survey. A nominal group of 12 members was organised by the research group; there were seven experts with a background in critical care, two junior attending physicians with a background in critical care and three experienced nurses.

RESULTS

A total of 50 needed intelligent robot functions in ICUs were obtained from the questionnaire data. Through three rounds of nominal group voting and discussion, a consensus was reached on 44 items, which were categorised into 29 high-priority needs, 13 medium-priority needs and two low-priority needs. The functionalities in areas such as 'sleep and pain assessment,' 'monitoring of sedation, agitation, and delirium,' and 'robot-assisted rehabilitation and physical therapy' were particularly favoured by the ICU medical and nursing staff.

CONCLUSIONS

This study has defined the functional needs and priorities for ICU intelligent robots from the perspective of ICU clinical medical and nursing staff. It has been concluded that 'disease assessment function' and 'rehabilitation and physical therapy' are most needed by clinical doctors and nurses. The results presented in this study could serve as a useful reference for future research and development of medical robots.

Effects of cipepofol on breathing patterns, respiratory drive, and inspiratory effort in mechanically ventilated patients

Background

Cipepofol is a highly selective gamma-aminobutyric acid A receptor potentiator. As a new sedative drug, detailed studies on its respiratory effects are further needed. The present study aims to investigate the effects of cipepofol on breathing patterns, respiratory drive, and inspiratory effort in mechanically ventilated patients.

Methods

In this one-arm physiological study, cipepofol was initiated at 0.3 mg/kg/h and increased by 0.1 mg/kg/h every 30 min until reaching 0.8 mg/kg/h. Discontinuation criteria were Richmond Agitation and Sedation Scale (RASS) score ≤ -4 or respiratory rate (RR) < 8 breaths/min or pulse oxygen saturation (SpO2) < 90%. The primary outcomes were changes from baseline in respiratory variables [RR, tidal volume (VT), minute ventilation (Vmin), airway occlusion pressure at 100 msec (P0.1), pressure muscle index (PMI), expiratory occlusion pressure (Pocc)] at 30 min after 0.3 mg/kg/h cipepofol infusion. The secondary outcomes included changes in respiratory variables, cardiorespiratory variables, and RASS scores at rates of cipepofol from 0.3 to 0.8 mg/kg/h.

Results

20 patients were enrolled and all of them completed the cipepofol infusion rate at 0.3 mg/kg/h, achieving RASS score of -2 to +1. For the primary outcomes, there was a significant reduction in VT (390.9, [356.6-511.0] vs. 451.6 [393.5-565.9], p = 0.002), while changes in RR (16.7 ± 2.7 vs. 16.2 ± 3.4, p = 0.465) and Vmin (7.2 ± 1.8 vs. 7.5 ± 1.9, p = 0.154) were not significant. The reductions in P0.1 (p = 0.020), PMI (p = 0.019), and Pocc (p = 0.007) were significant. For secondary outcomes, as the infusion rate of cipepofol increased from 0.3 to 0.8 mg/kg/h, there was a further decrease in VT (p = 0.002) and an increase in RR (p < 0.001), while the change in Vmin (p = 0.430) was not significant. RASS score (p < 0.001) was further decreased.

Conclusion

Cipepofol demonstrates the capability to achieve RASS score -2 to +1 in mechanically ventilated adult patients. The effect of cipepofol on breathing patterns was a decrease in VT, while changes in RR and Vmin were insignificant. The effect on respiratory drive and inspiratory effort significantly reduced P0.1, PMI, and Pocc.

Clinical trial registration

ClinicalTrials.gov, identifier NCT06287138. https://clinicaltrials.gov/study/NCT06287138.

Evaluation of the Quality of Delirium Website Content for Patient and Family Education: Cross-Sectional Study

BACKGROUND

Patients and families who have experienced delirium may seek information about delirium online, but the quality and reliability of online delirium-related websites are unknown.

OBJECTIVE

This study aimed to identify and evaluate online delirium-related websites that could be used for patient and family education.

METHODS

We searched Microsoft Bing, Google, and Yahoo using the keywords "delirium" and the misspelled "delerium" to identify delirium-related websites created to inform patients, families, and members of the public about delirium. The quality of identified delirium-related website content was evaluated by 2 authors using the validated DISCERN tool and the JAMA (Journal of the American Medical Association) benchmark criteria. Readability was assessed with the Simple Measure of Gobbledygook, the Flesch Reading Ease score, and the Flesch Kincaid grade level. Each piece of website content was assessed for its delirium-related information using a checklist of items co-designed by a working group, which included patients, families, researchers, and clinicians.

RESULTS

We identified 106 websites targeted toward patients and families, with most hospital-affiliated (21/106, 20%) from commercial websites (20/106, 19%), government-affiliated organizations (19/106, 18%), or from a foundation or advocacy group (16/106, 15%). The median time since the last content update was 3 (IQR 2-5) years. Most websites' content (101/106, 95%) was written at a reading level higher than the recommended grade 6 level. The median DISCERN total score was 42 (IQR 33-50), with scores ranging from 20 (very poor quality) to 78 (excellent quality). The median delirium-related content score was 8 (IQR 6-9), with scores ranging from 1 to 12. Many websites lacked information on the short- and long-term outcomes of delirium as well as how common it is. The median JAMA benchmark score was 1 (IQR 1-3), indicating the quality of the websites' content had poor transparency.

CONCLUSIONS

We identified high-quality websites that could be used to educate patients, families, or the public about delirium. While most delirium-related website content generally meets quality standards based on DISCERN and JAMA benchmark criteria, high scores do not always ensure patient and family-friendliness. Many of the top-rated delirium content were text-heavy and complex in layout, which could be overwhelming for users seeking clear, concise information. Future efforts should prioritize the development of websites with patients and families, considering usability, accessibility, and cultural relevance to ensure they are truly effective for delirium education.

Effectiveness of Early Mobilization and Bed Positioning in the Management of Muscle Weakness in Critically Ill People Under Invasive Mechanical Ventilation in Intensive Care: A Systematic Review of Intervention Literature Protocol

Background: Post Intensive Care Syndrome (PICS) is a set of physical, cognitive, and mental health symptoms that arise following intensive care (ICU) hospitalization. Regarding physical changes, muscle weakness is highlighted, potentially leading to functional impairments during and after hospitalization. Multidisciplinary guidelines recommend early mobilization, a rehabilitation intervention, as a strategy to prevent ICU-acquired muscle weakness and reduce functionality impairments. Objective: This study aims to evaluate the effectiveness of early mobilization and positioning interventions to prevent or minimize ICU-acquired weakness in critically ill patients under invasive mechanical ventilation (IMV). Methods: A systematic review of effectiveness will be conducted following Cochrane recommendations. Searches will be made in MEDLINE (via PubMed), CINAHL, Scopus, and Web of Science. Eligible studies will include randomized controlled trials on the functional management of muscle weakness, muscle strength, and ICU-acquired muscle weakness in adults (≥18 years) who have undergone IMV. Eligible interventions (and comparators) include any manual mobilization and positioning strategy or the use of medical devices. Two reviewers will independently select studies, extract data using a piloted tool and assess bias with the RoB 2 tool. If appropriate, a meta-analysis will be conducted, pooling standardized mean differences using a random-effects model. Results: This review included primary experimental studies manipulating at least one variable, control group studies, or randomized trials comparing early intervention protocols, programs, or plans with standard care or existing approaches in the ICU. Conclusions: This review will provide meaningful comparisons of different mobilization and positioning strategies, evaluating their impact on muscle strength and functionality in critically ill patients. Systematic Review Registration: PROSPERO CRD4202348091.

Weakness acquired in the cardiac intensive care unit: still the elephant in the room?

Over the past two decades, the cardiac critical care population has shifted to increasingly comorbid and elderly patients often presenting with nonprimary cardiac conditions that exacerbate underlying advanced cardiac disease. Consequently, the modern cardiac intensive care unit (CICU) patient has poor outcome regardless of left ventricular ejection fraction. Importantly, delayed liberation from organ support, independent from premorbid health status and admission severity of illness, has been associated with increased morbidity and mortality up to years post-general critical care. Although a constellation of several acquired morbidities is at play, the most prominent enactor of poor long-term outcome in this population appears to be intensive care unit acquired weakness. Although the specific burden of ICU-acquired morbidities in CICU patients is yet to be clearly defined, it seems unfathomable that patients will not accrue some sort of ICU-related morbidity. There is hence an urgent need to better establish the exact benefit and cost of resource-intensive strategies in both short- and long-term survival of the CICU patient. Consequent and standardized documentation of admission comorbidities, severity of illness indicators, relevant ICU-related complications including weakness, and long-term post-ICU morbidity outcomes can help our understanding of the disease continuum and how to better care for the CICU survivor and their families and caregivers. Given increasing budgetary pressure on healthcare systems worldwide, interventions targeting CICU patients should focus on improving patient-centred long-term outcomes in a cost-effective manner. It will require a holistic and transmural continuity of care model to meet the challenges associated with treating critically ill cardiac patients in the future.

Medication-induced causes of delirium in patients with and without dementia: a systematic review of published neurology guidelines

BACKGROUND

While medication is a recognized risk factor of delirium, there is currently a lack of detailed information on managing and preventing medication-induced cases.

AIM

This review summarizes the information provided in neurology guidelines on medication-induced delirium in patients with and without dementia to inform guidance on prevention and management strategies.

METHOD

A systematic literature review was conducted across 114 neurological and medical organisations, Guideline Central and PubMed. Guidelines, consensus guidelines, white papers, frameworks, protocols, standard procedures, action plans and strategic documents detailing the prevention and management of medication-induced delirium in adults with or without dementia were included. Title and full-text screening was completed independently by two reviewers using PICOS. AGREE II was used to assess reporting quality. A data extraction tool was designed based on the Cochrane Effective Practice and Organization of Care Review Group (EPOC) checklist and a mixed methods approach to synthesis adopted. The systematic review protocol was registered with International Prospective Register of Systematic Reviews (PROSPERO) [ID: CRD42022366025].

RESULTS

Out of 143 guidelines identified, 30 were included. Information for 140 individual medications was extracted. Medications most frequently cited included sedatives (n = 24/80%), opioids (n = 22/73,3%), psychoactive drugs (n = 21/70%) + anti-convulsants (n = 14/46,7%), anti-cholinergic agents (n = 20/66,7%), antihistamines (n = 18/60%), and steroids (n = 16/53,3%). Despite a consistently high-quality rating (n = 19, 63,3%), the detail provided often lacks specificity about pharmacological mechanisms, individual risk, dosing instructions, associated symptoms, therapeutic alternatives and avoidable drug-drug combinations. In relation to dementia, detailed information on the use of antipsychotics, cholinesterase inhibitors and benzodiazepines was extracted. No papers were excluded based on their quality.

CONCLUSION

No single guideline contains enough information on the risk, prevention, and management of medication-induced delirium to sufficiently support clinical decision making.

Comparison of oxycodone hydrochloride and flurbiprofen axetil on analgesia in mechanically ventilated patients with respiratory failure in a multicenter study

The design of this study is to compare the effectiveness of two analgesic drugs in the intervention of pain events for patients on mechanical ventilation. 414 patients from three hospitals with respiratory failure requiring mechanical ventilation were randomly assigned to oxycodone hydrochloride or flurbiprofen axetil. The primary endpoints is the difference in the proportion of patients with a Behavioral Pain Scale (BPS) score > 5 within 48 h. The secondary endpoints is to compare the dosage of sedative drugs (midazolam, propofol, dexmedetomidine) and to assess the clinical outcomes such as duration of mechanical ventilation. There was no significant difference in BPS scores between the two groups at enrollment, and BPS scores in oxycodone group were significantly lower than those in flurbiprofen axetil group at 24 and 48 h of enrollment. The proportion of patients with BPS less than 5 points in the Oxycodone hydrochloride group was also significantly lower than that in the flurbiprofen axetil group. For patients with Acute Physiology and Chronic Health Evaluation II (APACHE II) score greater than 10, subgroup analysis showed that the mechanical ventilation time of oxycodone hydrochloride group was significantly lower than that of flurbiprofen axetil group with statistical significance, and the dosage of midazolam was significantly lower than that of flurbiprofen axetil group. The length of ICU stay was significantly lower than that of flurbiprofen axetil group. Oxycodone hydrochloride was more potent than flurbiprofen axetil for analgesia for patients with respiratory failure requiring mechanical ventilation.

Protocolized strategies to encourage early mobilization of critical care patients: challenges and success

Technological advances and interprofessional teamwork have significantly improved survival rates of critically ill patients. However, this progress has also introduced new challenges, such as intensive care unit-acquired weakness, which can contribute to postintensive care syndrome. Both conditions are associated with increased morbidity and mortality, prolonged length of hospital stay, higher social and health care costs, and reduced quality of life for patients and their families. Timely physical therapy plays a crucial role in mitigating intensive care unit-acquired weakness and postintensive care syndrome. Key recommendations for the effective rehabilitation of patients in the intensive care unit include education and training, communication and collaboration, patient screening, planning of activities, distribution of functions focused on teamwork, patient cooperation, safety assessments, patient positioning, functional mobilization, and documentation of outcomes. This narrative review aims to update the current understanding of the influence of physical therapy and critical care teamwork on intensive care unit patients and to provide evidence-based recommendations for promoting early mobilization in the intensive care unit setting.

Understanding the use of sedation boluses in the intensive care unit: A mixed methods study

BACKGROUND

To better understand the impact of sedations in the intensive care unit (ICU), an accurate understanding of the clinical practices surrounding sedation bolus use is essential.

OBJECTIVES

Our primary objectives were to describe how sedation boluses are administered, and to compare observed and nurse-reported practices.

METHODS

We conducted a mixed methods study comprising 150 quantitative observations in a large university-affiliated ICU and 10 semi-structured interviews with nurses recruited in the same ICU and from others in the Province of Quebec (Canada).

RESULTS

During 150 observations, nurses administered 197 boluses. Nurses mostly administered boluses with a volumetric pump (76 %, 95 %CI 69-81 %). In interviews, all nurses expressed favoring volumetric pumps to administer boluses. Nurses documented bolus use in 58 % of observations (58 %, 95 %CI 50-66 %). Propofol and fentanyl were the most frequently used drugs, and all nurses reported that they were the "classic" bolus drugs. The median cumulative propofol and opioid bolus doses given by nurses were respectively 30 mg (95 %CI 25-30), and 50 µg in fentanyl-equivalent (95 %CI 50-50). We observed that nursing or medical interventions were the most common trigger for bolus use (63 %, 95 %CI 55-71 %), and these were among the main reason for bolus use reported in interviews (n = 9, 90 %). Increasing norepinephrine was observed (19 %, 95 %CI 13-26 %) and reported by all nurses as the most frequent interventions after boluses.

CONCLUSIONS

Nurses favor volumetric pumps to administer boluses and propofol and fentanyl were the most used drugs. Documentation of boluses was suboptimal. Sedation boluses often led to norepinephrine titration.

IMPLICATIONS FOR CLINICAL PRACTICE

Sedation boluses administered to patients with continuous infusions of sedations often led to norepinephrine titration, suggesting that they may have implications for patient safety and outcomes. Merging electronic health records entries and volumetric pump data logs or data feeds may be essential to properly capture the exposure of ICU patients to sedation.

Experiences and attitudes towards agitated behaviours in TBI ICU patients (EXSTATIC): understanding various management practices through qualitative interviews with nurses

INTRODUCTION & OBJECTIVES

Agitation is a common complication after an acute TBI in ICU patients. Professionals have a range of strategies to address agitation. Yet the absence of evidence-based guidelines and how these strategies are implemented complicates the management and safety may often be compromised for both ICU professionals and patients. This project explores experiences and attitudes of ICU-nurses to better understand the management of agitated behaviors in acute TBI-patients.

METHODS

Semi-structured interviews were conducted with 12 ICU-nurses from two Level-1 trauma centers in Canada. The interviews explored experiences and perceptions of managing agitation in critically ill TBI-patients. Interviews were analyzed using thematic analysis, facilitating the examination of how management practices interface with contextual variables and clinical strategies.

RESULTS

Five themes were identified: (1) a variety of symptoms differing according to patient profile and time since awakening, (2) different agitation management approaches stem from different concerns, (3) strategies used by nurses to manage agitation, (4) contextual factors influence management, and (5) potential opportunities to improve integrated care model.

CONCLUSIONS

This research describes nurses' perceptions and helps understand management of agitation, by considering underlying contexts and factors affecting TBI-agitated patients management, how ICU itself contributes to agitation and potential areas for improvement.

Regional cerebral oxygen saturation during initial mobilization of critically ill patients is associated with clinical outcomes: a prospective observational study

BACKGROUND

Vital signs help determine the safety of early mobilization in critically ill patients in intensive care units. However, none of these variables directly assess cerebral circulation. Therefore, we aimed to investigate the relationship of regional cerebral oxygen saturation (rSO2) and vital signs with in-hospital death in critically ill patients.

METHODS

This prospective study included critically ill patients admitted to the Uonuma Kikan Hospital Emergency Center who received physical therapy between June 2020 and December 2022. We continuously measured rSO2 during the initial mobilization using a wearable brain near-infrared spectroscopy device. With in-hospital death as the primary endpoint, the association between rSO2 and in-hospital death was assessed in Analysis 1 to determine the rSO2 cut-off value that predicts in-hospital death. In Analysis 2, patients were categorised into survival and non-survival groups to examine the temporal changes in vital signs and rSO2 associated with postural changes during mobilization.

RESULTS

Of the 132 eligible patients, 98 were included in Analysis 1, and 70 were included in Analysis 2. Analysis 1 demonstrated that lower premobilization rSO2 was independently associated with in-hospital death (odds ratio 0.835, 95% confidence interval 0.724-0.961, p = 0.012). Receiver operating characteristic curve analysis identified an optimal rSO2 cut-off value of 57% for predicting in-hospital death (area under the curve 0.818, sensitivity 73%, specificity 83%). Analysis 2 showed that rSO2 changes during mobilization were unrelated to changes in vital signs, suggesting rSO2 as an independent prognostic marker.

CONCLUSIONS

The results suggest that rSO2 measured during initial mobilization is associated with in-hospital death in critically ill patients.

Authors' Reply: Advancing Insights Into Postoperative Sleep Quality and Influencing Factors

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The effect of early rehabilitation on therapeutic outcomes in ICU patients on mechanical ventilation: A meta-analysis

OBJECTIVE

To evaluate the effect of early rehabilitation on therapeutic outcomes of patients in the ICU requiring mechanical ventilation.

METHODS

Electronic databases up to June 15, 2024 were searched. Randomized controlled trials (RCTs) that compared early rehabilitation with standard rehabilitation for patients in the ICU on mechanical ventilation were included. The effects of early rehabilitation on outcomes such as duration of mechanical ventilation (days), ICU length of stay (days), hospital length of stay (days), ICU and in-hospital mortality, and ICU-acquired weakness (ICU-AW) were evaluated using a random-effects model.

RESULTS

Nineteen RCTs met the inclusion criteria for this study, involving 3076 patients in the ICU on mechanical ventilation. Meta-analysis based on the random-effects model showed that early rehabilitation significantly reduced the duration of mechanical ventilation, ICU-AW risk, ICU length of stay, and total hospital length of stay. Analysis of the timing of early rehabilitation indicated that implementing early rehabilitation within ⩽48 or ⩽72 h after ICU admission or mechanical ventilation had varying effects on the duration of mechanical ventilation, ICU length of stay, and total hospital length of stay.

CONCLUSION

Early rehabilitation can improve the therapeutic outcomes for ICU patients on mechanical ventilation. The optimal time for implementing early rehabilitation appears to be 48-72 h after ICU admission or initiation of mechanical ventilation, but further research is needed.

CLINICAL TRIAL NUMBER

INPLASY202470068.

Impact of healthcare system strain on the implementation of ICU sedation practices and encephalopathy burden during the early COVID-19 pandemic

The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, particularly in managing critically ill patients requiring mechanical ventilation early in the pandemic. Surging patient volumes strained hospital resources and complicated the implementation of standard-of-care intensive care unit (ICU) practices, including sedation management. The objective of this study was to evaluate the impact of an evidence-based ICU sedation bundle during the early COVID-19 pandemic. The bundle was designed by a multi-disciplinary collaborative to reinforce best clinical practices related to ICU sedation. The bundle was implemented prospectively with retrospective analysis of electronic medical record data. The setting was the ICUs of a single-center tertiary hospital. The patients were the ICU patients requiring mechanical ventilation for confirmed COVID-19 between March and June 2020. A learning health collaborative developed a sedation bundle encouraging goal-directed sedation and use of adjunctive strategies to avoid excessive sedative administration. Implementation strategies included structured in-service training, audit and feedback, and continuous improvement. Sedative utilization and clinical outcomes were compared between patients admitted before and after the sedation bundle implementation. Quasi-experimental interrupted time-series analyses of pre and post intervention sedative utilization, hospital length of stay, and number of days free of delirium, coma, or death in 21 days (as a quantitative measure of encephalopathy burden). The analysis used the time duration between start of the COVID-19 wave and ICU admission to identify a "breakpoint" indicating a change in observed trends. A total of 183 patients (age 59.0 ± 15.9 years) were included, with 83 (45%) admitted before the intervention began. Benzodiazepine utilization increased for patients admitted after the bundle implementation, while agents intended to reduce benzodiazepine use showed no greater utilization. No "breakpoint" was identified to suggest the bundle impacted any endpoint measure. However, increasing time between COVID-19 wave start and ICU admission was associated with fewer delirium, coma, and death-free days (β =  - 0.044 [95% CI - 0.085, - 0.003] days/wave day); more days of benzodiazepine infusion (β = 0.056 [95% CI 0.025, 0.088] days/wave day); and a higher maximum benzodiazepine infusion rate (β = 0.079 [95% CI 0.037, 0.120] mg/h/wave day). The evidence-based practice bundle did not significantly alter sedation utilization patterns during the first COVID-19 wave. Sedation practices deteriorated and encephalopathy burden increased over time, highlighting that strategies to reinforce clinical practices may be hindered under conditions of extreme healthcare system strain.

"I will get out of this" - The patients' experiences of early mobilisation in intensive care. A hermeneutic study

BACKGROUND

The significance of early mobilisation in intensive care has become increasingly apparent along with a growing understanding of patient experiences within this critical setting. However, there is still a need for more knowledge regarding the complex experiences of the patients. Therefore, this study aimed to gain an in-depth understanding of the significance and deeper meaning of early mobilisation in patients recently treated in intensive care.

METHODS

A qualitative study with a hermeneutic, interpretive approach. Semi-structured interviews were conducted with 30 participants recently treated in the intensive care units, in two different hospitals.

FINDINGS

The analysis yielded three themes: 'Struggling to regain independence and normal life', 'Interaction with healthcare professionals' and 'Early mobilisation in a chaotic, confused context without control'. The first theme captures the participants' experiences, motivations, and the deeper significance of early mobilisation, which was hope, the beginning of recovery and a willingness to fight. The other themes describe the context and circumstances surrounding the participants' mobilisation including the collaboration with healthcare professionals.

CONCLUSION

Early mobilisation's significance and deeper meaning in intensive care were understood as the starting point of recovery. It had the ability to evoke hope and strengthen the fighting spirit, especially when it included leaving bed. The patients' pre-existing understanding that resilience and persistence were crucial for regaining strength and mobility contributed, as well as positive interactions with healthcare professionals that restored human dignity and facilitated involvement and participation contributed.

IMPLICATIONS FOR PRACTICE

Early mobilisation should be used to inspire hope and a willingness to fight for recovery in patients treated in intensive care. Efforts should be made to engage patients in positive interactions with healthcare professionals that encourage this fighting spirit and active participation in early mobilisation. Mobilisations involving patients getting up and leaving bed should be used as much as possible.

Management of sedation during weaning from mechanical ventilation

PURPOSES OF REVIEW

Critically ill patients frequently require mechanical ventilation and often receive sedation to control pain, reduce anxiety, and facilitate patient-ventilator interactions. Weaning from mechanical ventilation is intertwined with sedation management. In this review, we analyze the current evidence for sedation management during ventilatory weaning, including level of sedation, timing of sedation weaning, analgesic and sedative choices, and sedation management in acute respiratory distress syndrome (ARDS).

RECENT FINDINGS

Despite a large body of evidence from the past 20 years regarding the importance of light sedation and paired spontaneous awakening and spontaneous breathing trials (SATs/SBTs) to promote ventilator weaning, recent studies show that implementation of these strategies lag in practice. The recent WEAN SAFE trial highlights the delay between meeting weaning criteria and first weaning attempt, with level of sedation predicting both delays and weaning failure. Recent studies show that targeted interventions around evidence-based practices for sedation weaning improve outcomes, though long-term sustainability remains a challenge.

SUMMARY

Light or no sedation strategies that prioritize analgesia prior to sedatives along with paired SATs/SBTs promote ventilator liberation. Dexmedetomidine may have a role in weaning for agitated patients. Further investigation is needed into optimal sedation management for patients with ARDS.