Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults

Delivery of evidence-based critical care practices across the United Kingdom: A UK-wide multi-site service evaluation in adult units

Background

The ICU Liberation Bundle was developed to improve outcomes for patients admitted to critical care. Despite a lack of Bundle adoption in the UK, the individual evidence-based practices (EBPs) within the bundle are defined as standards of care by the UK Intensive Care Society. There are limited data on the delivery of these EBPs.

Objective

To evaluate current delivery of the EBPs of the ICU Liberation bundle in a sample of hospitals in the UK National Health Service (NHS) presenting delivery of EBP's between hospitals, their stability of delivery across multiple weeks and in comparison to US hospitals in the original ICU Liberation Bundle study.

Methods

Multi-centre service evaluation, using modified definitions of compliance from the ICU Liberation Bundle study. We sampled six representative units from across the UK; data collection totalled 1116 patient days. Data were analysed using descriptive statistics.

Results

Across all six units, patients received a median of 42.9% (IQR 40%-60%) of all possible bundle EBPs. Unit bundle proportional compliance (number of components completed/eligible number of components) ranged from 40.0% (IQR 28.6%-50.0%) to 71.4% (IQR 57.1%-80.0%). Units completed spontaneous awakening trials most regularly in 80.1% of eligible patients (149/186). Delirium assessments were the least adhered to EBP with only 32.2% (359/1116) of patients receiving at least two validated delirium assessments per day. Full bundle compliance was lower in the UK cohort in comparison to the original trial (4% vs 8%).

Discussion

We identified substantial variation in the delivery of seven evidence-based practices that are considered standards of care in the UK. Variation existed between hospitals and within each hospital over time. These data begin to describe the current state of EBP adherence in a selection of critical care units.

Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society

BACKGROUND

Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients.

METHODS

We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals.

RESULTS

We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain.

CONCLUSIONS

We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

Clear Minds: Unravelling Delirium in Older Adults

With an explosive population growth of older adults, the incidence rates of neuropsychiatric syndromes, particularly delirium, are increasing in the community and hospital settings. Delirium is an acute disturbance in cognition and attention that may signify a serious medical, life-threatening condition and may mimic psychiatric-mental health issues. Although its prevalence rate is lower in the community, delirium affects up to 87% of hospitalized older adults and can cost up to $152 billion each year. Despite its common occurrence, delirium is often undetected in 50% to 60% across all care settings, delaying treatment and resulting in poor patient outcomes, such as increased mortality, prolonged hospital stays, cognitive and functional impairment, decreased quality of life, and institutionalization. The current article addresses strategies to recognize delirium and presents evidence-based approaches and future considerations for delirium management. [Journal of Psychosocial Nursing and Mental Health Services, 62(11), 11-18.].

Sedation in the ICU

AbstractSedation practices are key to improving intensive care unit (ICU) outcomes. Adequate treatment of pain, minimization of sedation, delirium prevention, and improved patient interaction to ensure early rehabilitation and faster ventilator liberation are evidenced-based components of ICU care. Here we review components of appropriate ICU sedation including the use of multicomponent care bundles such as the ABCDEF bundle with a focus on changes in ICU practice that followed the Covid-19 pandemic.

World delirium awareness and quality survey in 2023-a worldwide point prevalence study

BACKGROUND

Delirium, an acute brain dysfunction, is proposed to be highly prevalent in clinical care and shown to significantly increase the risk of mortality and dementia.

OBJECTIVES

To report on the global prevalence of clinically documented delirium and delirium-related clinical practices in wards caring for paediatric and adult patients in healthcare facilities.

DESIGN

A prospective, cross-sectional, 39-question survey completed on World Delirium Awareness Day, 15 March 2023.

PARTICIPANTS

Clinicians or researchers with access to clinical data.

MAIN OUTCOME AND MEASURE

The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. (4 h) and 8:00 p.m. (±4 h). Secondary outcomes included delirium-related care practices and barriers to use. Descriptive statistics were calculated and multilevel modelling was completed.

RESULTS

1664 wards submitted surveys from 44 countries, reporting on delirium assessments at 8:00 a.m. (n = 36 048) and 8:00 p.m. (n = 32 867); 61% reported use of validated delirium assessment tools. At 8:00 a.m., 18% (n = 2788/15 458) and at 8:00 p.m., 17.7% (n = 2454/13 860) were delirium positive. Top prevention measures were pain management (86.7%), mobilisation (81.4%) and adequate fluids (80.4%). Frequently reported pharmacologic interventions were benzodiazepines (52.7%) and haloperidol (46.2%). Top barriers included the shortage of staff (54.3%), lack of time to educate staff (48.6%) and missing knowledge about delirium (38%).

CONCLUSION AND RELEVANCE

In this study, approximately one out of five patients were reported as delirious. The reported high use of benzodiazepines needs further evaluation as it is not aligned with best-practice recommendations. Findings provide a benchmark for future quality improvement projects and research.

Impact of Veterans Affairs Geriatric Research, Education, and Clinical Centers: Incubators of innovation in geriatrics

Since their inception in 1975, the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers (GRECCs) have served as incubators of innovation in geriatrics. Their contributions to the VA mission were last reviewed in 2012. Herein, we describe the continuing impact of GRECCs in research, clinical, and educational areas, focusing on the period between 2018 and 2022. GRECC research spans the continuum from bench to bedside, with a growing research portfolio notable for highly influential publications. GRECC education connects healthcare professions trainees and practicing clinicians, as well as Veterans and their caregivers, to engaging learning experiences. Clinical advancements, including age-friendly care, span the continuum of care and leverage technology to link disparate geographical sites. GRECCs are uniquely positioned to serve older adults given their alignment with the largest integrated health system in the United States and their integration with academic health centers. As such, the GRECCs honor Veterans as they age by building VA capacity to care for the increasing number of aging Veterans seeking care from VA. GRECC advancements also benefit non-VA healthcare systems, their academic affiliates, and non-Veteran older adults. GRECCs make invaluable contributions to advancing geriatric and gerontological science, training healthcare professionals, and developing innovative models of geriatric care.

Parental Perspectives From the Survey of Sleep Quality in the PICU Validation Study on Environmental Factors Causing Sleep Disruption in Critically Ill Children

OBJECTIVES

Sleep promotion bundles being tested in PICUs use elements adapted from adult bundles. As children may react differently than adults in ICU environments, this study investigated what parents report disrupted the sleep of their child in a PICU.

DESIGN

Secondary analysis of a multicenter validation study of the Survey of Sleep quality in the PICU.

SETTING

Four Northeastern U.S. PICUs, one hospital-based pediatric sleep laboratory.

PATIENTS

Parents sleeping at the bedside of a child in the PICU or hospital-based sleep laboratory.

INTERVENTIONS

Anonymous one-time survey eliciting parts of hospital or ICU environments that have been described as disruptive to sleep in validated adult ICU and pediatric inpatient questionnaires.

MEASUREMENTS AND MAIN RESULTS

Level of sleep disruption was scored by Likert scale, with higher scores indicating more disruption. Age, demographics, baseline sleep, and PICU exposures were used to describe causes of sleep disruption in a PICU. Of 152 PICU parents, 71% of their children's sleep was disrupted significantly by at least one aspect of being in the PICU. The most prevalent were "being in pain or uncomfortable because they are sick" (38%), "not sleeping at home" (30%), "alarms on machines" (28%), and "not sleeping on their home schedule" (26%). Only 5% were disrupted by excessive nocturnal light exposure. Overall sleep disruption was not different across four PICUs or in those receiving sedation. The validation study control group, healthy children undergoing polysomnography, had less sleep disruption than those in a PICU despite sleeping in a hospital-based sleep laboratory.

CONCLUSIONS

There are multiple aspects of critical care environments that affect the sleep of children, which are different from that of adults, such as disruption to home schedules. Future interventional sleep promotion bundles should include sedated children and could be applicable in multicenter settings.

Delirium and Weakness Acquired in the Intensive Care Unit: Individual and Combined Effects on 90-Day Mortality in Survivors of Critical Illness

AIMS

To compare the individual and combined effects on 90-day mortality among four critically ill survivor groups: normal (without ICU-acquired delirium or ICU-acquired weakness), delirium-only (with ICU-acquired delirium only), weakness-only (with ICU-acquired weakness only) and delirium-weakness (combined ICU-acquired delirium and weakness).

METHODS

A prospective cohort study consecutively recruited delirium-free critically ill patients admitted to six medical ICUs at a university hospital. Delirium was assessed once daily for 14 days (or until death or ICU discharge) using the Confusion Assessment Method for the ICU. Participants who were discharged from the ICUs were assessed for weakness using the Medical Research Council scale. A summed score below 48 defines ICU-acquired weakness. These survivors were evaluated again for 90-day mortality. The study is reported using the STROBE checklist.

RESULTS

Delirium developed in 107 (43.2%) participants during their first 14 days of ICU stay; 55 (22.2%) met criteria for weakness by ICU discharge. Participants with delirium were at increased risk for also developing ICU-acquired weakness, and the 90-day mortality was 18.2%. Independent of age and Acute Physiology and Chronic Health Evaluation II score at ICU admission, delirium-only and weakness-only were not associated with higher 90-day mortality, while participants in the delirium-weakness group had a 3.69-fold higher risk of death, compared to those who were normal during the ICU stay. A non-significant interaction was found, suggesting the joint effect of delirium and weakness on mortality is not higher than the sum of both effects individually.

CONCLUSIONS

Mortality is substantially high among critically ill survivors who experience both delirium and weakness, although no additive effect on mortality was observed when these conditions occur together. Our findings highlight the urgent need to optimise ICU care by prioritising the prevention, early identification and management of these two common ICU-acquired conditions.

PATIENT CONTRIBUTION

Study participation and completion of all assessments.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04206306.

INhaled Sedation versus Propofol in REspiratory failure in the Intensive Care Unit (INSPiRE-ICU1): protocol for a randomised, controlled trial

INTRODUCTION

Sedation in mechanically ventilated adults in the intensive care unit (ICU) is commonly achieved with intravenous infusions of propofol, dexmedetomidine or benzodiazepines. Significant limitations associated with each can impact their usage. Inhaled isoflurane has potential benefit for ICU sedation due to its safety record, sedation profile, lack of metabolism and accumulation, and fast wake-up time. Administration in the ICU has historically been restricted by the lack of a safe and effective delivery system for the ICU. The Sedaconda Anaesthetic Conserving Device-S (Sedaconda ACD-S) has enabled the delivery of inhaled volatile anaesthetics for sedation with standard ICU ventilators, but it has not yet been rigorously evaluated in the USA. We aim to evaluate the efficacy and safety of inhaled isoflurane delivered via the Sedaconda ACD-S compared with intravenous propofol for sedation of mechanically ventilated ICU adults in USA hospitals.

METHODS AND ANALYSIS

INhaled Sedation versus Propofol in REspiratory failure in the ICU (INSPiRE-ICU1) is a phase 3, multicentre, randomised, controlled, open-label, assessor-blinded trial that aims to enrol 235 critically ill adults in 14 hospitals across the USA. Eligible patients are randomised in a 1.5:1 ratio for a treatment duration of up to 48 (±6) hours or extubation, whichever occurs first, with primary follow-up period of 30 days and additional follow-up to 6 months. Primary outcome is percentage of time at target sedation range. Key secondary outcomes include use of opioids during treatment, spontaneous breathing efforts during treatment, wake-up time at end of treatment and cognitive recovery after treatment.

ETHICS AND DISSEMINATION

Trial protocol has been approved by US Food and Drug Administration (FDA) and central (Advarra SSU00208265) or local institutional review boards ((IRB), Cleveland Clinic IRB FWA 00005367, Tufts HS IRB 20221969, Houston Methodist IRB PRO00035247, Mayo Clinic IRB Mod22-001084-08, University of Chicago IRB21-1917-AM011 and Intermountain IRB 033175). Results will be presented at scientific conferences, submitted for publication, and provided to the FDA.

TRIAL REGISTRATION NUMBER

NCT05312385.

Physical Restraint Use in Hospitalized Patients: A Study of Routinely Collected Health Records Data

BACKGROUND

The use of restraints in hospitalized patients is associated with physical and psychological adversity for patients and staff. The minimization of restraint use is a key goal in the hospital setting. Reaching this goal requires an accurate assessment of existing patterns of use across clinical settings.

OBJECTIVE

This study reports the rate of physical restraints among patients hospitalized within a multi-entity healthcare network along with stratification by care context, diagnostic, and demographic factors, and examines the sensitivity and specificity of ICD-10 code Z78.1 "physical restraint status" for defining physical restraints relative to electronic health record (EHR) documentation.

DESIGN

The EHR was used for a retrospective analysis of all adults hospitalized between 2017 and 2022.

PARTICIPANTS

Hospitalized adults.

MAIN MEASURES

Patient demographics, structured diagnostic information, care area, length of stay, and in-hospital mortality, Z78.1 coding for physical restraints, restraint documentation in orders and flowsheets.

KEY RESULTS

Among 742,607 hospitalizations, 6.3% (n=47,041) involved the use of physical restraint based on coding or EHR documentation. Treatment in the intensive care unit (ICU) included restraint in 39% of encounters whereas treatment outside the ICU included restraint use in 1.3% of encounters. Besides critical illness, demographic factors including increasing age (adjusted odds ratio (aOR)=1.21 [1.19-1.23]), male gender (aOR=1.56, [1.52-1.60]), unknown race (aOR=1.27 [1.19-1.35]), and preferred language other than English (aOR=1.24, [1.18-1.29]) were associated with higher odds of restraint utilization. As compared to EHR orders or documentation of restraint, the ICD-10 code for physical restraint had a sensitivity of 1.5% and a specificity of 99.99%.

CONCLUSION

Among adults admitted to acute care hospitals, clinical, demographic, and operational factors were associated with increased odds of restraint, with care in the ICU associated with greatly increased odds of restraint. Research into restraint utilization using coded administrative claims data is likely limited by the sensitivity of physical restraint coding.

Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review

Millions of critically ill patients are discharged from intensive care units (ICUs) every year. These ICU survivors may suffer from a condition known as post-intensive care syndrome (PICS) which includes a wide range of cognitive, psychological, and physical impairments. This article will provide an extensive review of PICS. ICU survivors may experience cognitive deficits in memory and attention, with a slow-down of mental processing and problem-solving. From psychological perspectives, depression, anxiety, and post-traumatic stress disorder are the most common issues suffered after ICU discharge. These psycho-cognitive impairments might be coupled with ICU-acquired weakness (polyneuropathy and/or myopathy), further reducing the quality of life, the ability to return to work, and other daily activities. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. The development of PICS (and PICS-F) is likely multifactorial, and both patient- and ICU-related factors may influence it. Whilst the prevention of PICS is complex, it is important to identify the patients at higher risk of PICS, and clinicians should be aware of the tools available for diagnosis. Stakeholders should implement strategies to achieve PICS prevention and to support its effective treatment during the recovery phase with dedicated pathways and supporting care.

Effectiveness of the ABCDEF Bundle to Manage and Prevent Delirium: Pre- and Postintervention Quasi-Experimental Study

To investigate effectiveness of the ABCDEF bundle to manage and prevent delirium.

BACKGROUND

ICU delirium is a common hospital problem that 80% of critically ill patients in the ICU experience. The ABCDEF bundle is one of the tools that included in Delirium guidelines to manage critically ill patients.

RESEARCH DESIGN

Pre- and post intervention a quasi-experimental design was utilized in the present study.

SETTING

This study was conducted in the intensive care units of Assiut University Hospital.

METHODS

A total of 60 mechanically ventilated patients were recruited using inclusion and exclusion criteria. The ABCDEF bundle was implemented every day for the first 7 days of ICU admission, and patient sedation and delirium status were assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Sedation instrument measures were utilized in data collection.

RESULTS

Significant differences were found in the incidence of delirium: 20% in the study group versus 70% in the control group. The increased mean of days without delirium ICU stay was 4.6333 in the study group and 1.1000 in the control group, with P value = .001.

CONCLUSION

The mechanically ventilated patients exposed to the implementation of the ABCDE bundle experienced fewer delirium signs than before the ABCDE bundle was implemented.

Revisiting the philosophy of technology and nursing: Time to move beyond romancing resistance or resisting romance

Technology remains enmeshed in our daily lives and given its continuing presence in clinical practice and rapid technological proliferation; it becomes relevant for nurses to examine techno-onto-epistemology in relation to the discipline of nursing. This is critical considering the intersection of technology and nursing remains an area of ongoing discussion revealing a need for further philosophical reflection. To this end, this paper sought to examine the philosophy of technology from the engineering and humanities perspectives to contribute to the discussion regarding its intersection with the onto-epistemology of nursing. Although technology seems to be constantly present in nursing practice, two opposing perspectives reflecting a love-hate relationship is highlighted: technological optimism (promotes technology) and technological romanticism (dissuades technology). Based on Mitcham's interpretation of 'mutual relationship' and 'being-with', a potential way to break away from the binary perspectives is to view the intersection of/relationship between technology and nursing as being on a continuum rather than entirely monolithic entities. Caring is presented as multidimensional reflecting actions and attitudes. Arguably, some caring actions may intersect with the engineering perspective to suggest that technology can support nurses in their roles, that is, by imitating some of what nurses do, but not to replace them. From the humanities perspective, technology is presented as a way of being with humans exercising control over what technology has to offer. Put together, it is clearly time to break away from the love-hate relationship between nursing and technology. Although this emphasises a great need to build the technological competency of nurses, there is an even greater call for nurses to reflect on and voice the epistemological, ontological, axiological, and ethical issues that the application of technology raises for the discipline.

Meeting complex multidimensional needs in older patients and their families during and beyond critical illness

PURPOSE OF REVIEW

To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions.

RECENT FINDINGS

Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients.

SUMMARY

The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.

Delirium Associated with COVID-19 in Critically ill Children: An Observational Cohort Study

OBJECTIVE

Delirium is an under-recognized problem in critically ill children. Although delirium is common in adults hospitalized with COVID-19, the relationship between pediatric COVID-19 and delirium has not been described. To address this gap, we characterized delirium in critically ill children with different manifestations of COVID-19 and investigated associations among demographic, disease, and treatment factors. We hypothesized that multisystem inflammatory syndrome in children (MIS-C) would be associated with a higher incidence of delirium given its underlying pathophysiology of hyperinflammation.

DESIGN

Retrospective, single-center cohort study.

SETTING

Quaternary-care pediatric intensive care unit (PICU).

PATIENTS

Children less than 18 years of age hospitalized in the PICU between March 2020 and March 2023 with either active SARS-CoV-2 infection or serological evidence of prior infection.

MEASUREMENTS AND MAIN RESULTS

The cohort included 149 PICU hospitalizations among children with evidence of COVID-19. Patients were categorized by reason for PICU admission: 75 (50%) for COVID-19 respiratory disease, 36 (24%) MIS-C, and 38 (26%) any other primary reason with positive COVID-19 testing. Delirium was diagnosed in 43 (29%) patients. Delirium incidence was highest in patients requiring invasive mechanical ventilation (IMV) (56% vs 7.5% in patients who did not require IMV, p < .001). Patients who were exposed to opioids, dexmedetomidine, paralytics or benzodiazepines more frequently experienced delirium compared to those unexposed (p < .001, p < .001, p < .001 and p  =  .001, respectively). After multivariable adjustment, delirium was associated with IMV (HR 3 [95% CI 1.5-5.7]), female sex (HR 2.4 [1.2-4.7]), and developmental disability (HR 3.4 [95% CI 1-11.1]). There was no association between delirium and reason for PICU hospitalization.

CONCLUSIONS

Delirium was common among children hospitalized with COVID-19. The overall incidence was much less than has been reported in adults with COVID-19. Delirium reduction efforts should focus on children with developmental disability and minimizing ongoing risks during IMV.

Long-term impact of COVID-19 on nursing and care delivery: A national survey among anaesthetic and critical care nurses

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has put an exceptional strain on intensive care delivery and has significantly impacted nursing practice in the intensive care unit, consequently affecting nurses' working environment and health. Little is known about the long-term impact on the nursing workforce and care delivery in intensive care and anaesthetic departments.

AIM/OBJECTIVE

This cross-sectional study aimed to describe the long-term impact of the COVID-19 pandemic on the nursing profession and nursing care from the perspectives of anaesthetic and critical care nurses.

METHODS

In this study, an online questionnaire with open- and close-ended questions was distributed to registered nurses working in anaesthesia and intensive care between February 8 and March 7, 2022. The data were analysed using content analysis and descriptive statistics.

RESULTS

Of the 514 registered nurses who responded to the questionnaire, 256 (50%) worked in anaesthesia care and 215 (42%) in intensive care. The long-term impact of COVID-19 was expressed in three categories: nursing care on hold, insights and experiences forming a new professional identity, and the impact of organisational conditions on the profession. Critical care nurses considered nursing care comparable to that before the COVID-19 pandemic. Nurse anaesthetics experienced changes in nursing tasks and activities compared to that before the COVID-19 pandemic.

CONCLUSIONS

Nursing care is still influenced by the pandemic due to the lack of resources and persistent high workload and needs to be reclaimed and prioritised. Re-establishing high-quality nursing care is a shared responsibility of the organisation and nursing profession, and the organisation needs to create prerequisites for this. Furthermore, nurses' views and insights into their profession developed both positively and negatively during the pandemic, which must be further considered, including the profession's values.

Delirium in the United States: Results From the 2023 Cross-Sectional World Delirium Awareness Day Prevalence Study

BACKGROUND

Delirium is an acute brain dysfunction associated with an increased risk of mortality and future dementia.

OBJECTIVES

To describe the prevalence of clinically documented delirium in the United States on World Delirium Awareness Day 2023.

METHODS

This is a sub-analysis of a prospective, cross-sectional, online, international survey. All health care settings were eligible, with the exception of operating rooms and outpatient clinics. Health care clinicians, administrators, and researchers completed the survey. The primary outcome was the prevalence of clinically documented delirium at 8:00 a.m. and 8:00 p.m. on March 15, 2023. Secondary outcomes were related to health care delivery. Descriptive statistics are reported. Differences between unit types (non-intensive care unit vs intensive care unit) were examined for all outcomes.

RESULTS

Ninety-one hospital units reported on 1318/1213 patients. The prevalence of clinically documented delirium was 16.4% (n = 216/1318) at 8:00 a.m. and 17.9% (n = 217/1213) at 8:00 p.m. (P = 0.316) and significantly differed between age groups, reported discipline, unit, and hospital types. Significant differences were identified between non-intensive care unit and intensive care unit settings in the use of delirium-related protocols, nonpharmacologic and pharmacologic management, educational processes, and barriers to evidence-based delirium care.

CONCLUSIONS

To our knowledge, this is the first epidemiologic survey of clinically documented delirium across two time points in the United States. Delirium remains a significant burden and challenge for health care systems. The high percentage of units using delirium management protocols suggests administrator and clinician awareness of evidence-based strategies for its detection and mitigation. We provide recommendations for future studies and quality improvement projects to improve clinical recognition and management of delirium.

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Patient, Practice, and Organizational Factors Associated With Early Mobility Performance in Critically Ill Adults

BACKGROUND

Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied.

OBJECTIVES

To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance.

METHODS

A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated.

RESULTS

In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance.

CONCLUSIONS

Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance.

Intensive care nurses' perceptions and awareness of delirium and delirium prevention guidelines

BACKGROUND

Delirium is an acute and fluctuating disturbance of cognition and is a common occurrence in critically ill patients. It is a manifestation of an acute brain dysfunction often attributed to higher survival rates and a subsequently aging population. Intensive Care Unit (ICU) treatment and survival often contributes towards development of delirium, and lack of or inappropriate management can translate into the development of long-term psychological effects that last even after discharge. While a lot is already known about this topic, and several assessment tools exist, these are not being consistently used by ICU nurses and as a result delirium often goes unrecognized, with unwarranted consequences.

AIMS

The study aimed to explore the perception of delirium among ICU nurses, and the extent of their awareness about guidelines to assess and prevent delirium in ICU patients. It also sought to understand the application of delirium guidelines in ICU practice.

STUDY DESIGN

A quantitative, exploratory, self-reporting survey was conducted among 145 ICU nurses from one critical care unit in the Republic of Ireland.

RESULTS

The overall response rate was 71% (103/145). Most nurses (85%) who participated in this survey believed delirium was expected. However, only 45% acknowledged it is a complication. Only 31% of nurses monitored delirium using a validated scale and few observed this as a part of routine care. Most nurses had received education; however, this did not translate to their clinical practice.

CONCLUSIONS

Guidelines on managing delirium may not be routinely implemented in the ICU settings of hospitals in the Republic of Ireland.

RELEVANCE TO CLINICAL PRACTICE

As the findings suggest, a gap exists between theory and practice, necessary revision of policy or creating a new policy, supplemental educational sessions such as bedside sessions, e-learning module, study day or seminars need to be organized to improve nurses' awareness related to delirium and delirium prevention guidelines.

Delirium and Coronavirus Disease 2019: Looking Back, Moving Forward

During the coronavirus disease 2019 pandemic, crisis changes in clinical care increased rates of delirium in the intensive care unit (ICU). Deep sedation, unfamiliar environments with visitor restrictions, and such factors due to high workload and health system strain contributed to the occurrence of delirium doubling in the ICU. As the pandemic wanes, health care systems and ICU leadership must emphasize post-pandemic recovery, integrating lessons learned about delirium management, evidence-based care, and family involvement. Strategies to empower clinicians, creatively deliver care, and integrate families pave the way forward for a more holistic approach to patient care in the post-pandemic era.

Nurses' experiences of caring for nursing care-dependent ICU patients: A qualitative study

BACKGROUND

Nursing care dependency is a key, yet under-studied, nursing phenomenon. Patients in intensive care units are highly dependent on nursing care. Patients find dependency challenging, experiencing feelings of powerlessness and shame. The nurse-patient care relationship can influence patients' perception of dependency. Understanding how nurses experience their care for dependent patients is crucial, as nurses might not always grasp the impact of their actions on patients' dependency experiences.

AIM

To explore and interpret ICU nurses' perceptions of patients' nursing care dependency and their experiences in caring for nursing care-dependent patients.

STUDY DESIGN

A qualitative interpretative phenomenological study inspired by Merleau-Ponty's philosophical stance was conducted using focus groups with nurses who had been caring for adult patients for at least 6 months in ICUs of two hospitals. Data analysis followed Smith et al.'s guidance. Researchers immersed themselves in the transcripts, noted individual's experiences before transitioning to shared insights, coded significant phrases and generated themes and superordinate themes.

RESULTS

Four focus groups were conducted with 18 nurses with widely ranging ages and work experience. Four superordinate themes emerged: 'Time and context define dependency', 'Empathetic relationships help nurses understand patients' experience of dependency', 'Trusting nurse-patient relationships change the dependency experience' and 'Nurses' skills help patients to recover independence'.

CONCLUSION

This study increases critical care nurses' awareness of the overlooked phenomenon of caring for nursing care dependent patients and offers them an opportunity to reflect on their care for dependent patients and adapt it to patients' experiences. Further studies are needed with nurses and patients in different ICUs, cultures and countries, to gain a broader picture of experiences of nursing care dependency.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses need strong relational skills to offer high-quality care for dependent patients, facilitating meaningful nurse-patient relationships based on empathy and trust. These relationships can significantly impact the patient's experience of dependence.

"The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist"

Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.

ICU patients receiving remifentanil do not experience reduced duration of mechanical ventilation: a systematic review of randomized controlled trials and network meta-analyses based on Bayesian theories

Background

The purpose of this network meta-analysis (NMA) was to evaluate the efficacy of intravenous opioid μ-receptor analgesics in shortening the duration of mechanical ventilation (MV) in ICU patients.

Methods

Randomized controlled trials comparing the efficacy of remifentanil, sufentanil, morphine, and fentanyl on the duration of MV in ICU patients were searched in Embase, Cochrane, Pubmed, and Web of Science electronic databases. The primary outcome was MV duration. The Bayesian random-effects framework was used to evaluate relative efficacy.

Results

In total 20 studies were included in this NMA involving 3,442 patients. Remifentanil was not associated with a reduction in the duration of MV compared with fentanyl (mean difference (MD) -0.16; 95% credible interval (CrI): -4.75 ~ 5.63) and morphine (MD 3.84; 95% CrI: -0.29 ~ 10.68). The secondary outcomes showed that, compared with remifentanil, sufentanil can prolong the duration of extubation. No regimen significantly shortened the ICU length of stay and improved the ICU mortality, efficacy, safety, and drug-related adverse events.

Conclusion

Among these analgesics, remifentanil did not appear to be associated with a reduction in MV duration. Clinicians should carefully titrate the analgesia of MV patients to prevent a potentially prolonged duration of MV due to excessive or inadequate analgesic therapy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42021232604.

Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU)

STUDY OBJECTIVES

Observational data suggest pediatric intensive care unit-related sleep and circadian disruption (PICU-SCD) affects many critically ill children. Multicenter trials exploring PICU-SCD have been impractical because measuring sleep in this setting is challenging. This study validates a questionnaire for caregivers to describe children's sleep in the PICU.

METHODS

This prospective, multicenter, case-control study enrolled caregivers of children in 4 PICUs or in a hospital-based sleep laboratory (controls). Survey items were compiled from validated adult ICU and pediatric in- and outpatient sleep questionnaires. Control responses were compared to polysomnography to determine accuracy. A score was calculated by summing the level of disruption of sleep timing, duration, efficiency, quality, and daytime sleepiness and irritability.

RESULTS

In responses from 152 PICU and 61 sleep laboratory caregivers, sleep survey items had acceptable internal reliability (α = 0.75) and reproducibility on retest surveys (interclass correlation coefficient > 0.600). Caregivers could not assess sleep of sedated children. Factor analysis identified 3 subscales of PICU-SCD. Control parents had good agreement with polysomnography sleep onset time (κ = 0.823) and sleep onset latency (κ = 0.707). There was a strong correlation between sleep scores derived by parental reporting to those by polysomnography (r = .844, P < .001). Scores had a linear association with caregiver-reported child sleep quality. There were no site-specific differences in sleep quality. Nearly all respondents found the survey easy to understand and of appropriate length.

CONCLUSIONS

The Survey of Sleep Quality in the Pediatric Intensive Care Unit provides a reliable, accurate description of inpatient sleep disruption in nonsedated children, generalizable across PICUs. It offers practical means to quantify PICU-SCD daily in future investigations.

CITATION

Hassinger AB, Mody K, Gomez R, et al. Validation of the Survey of Sleep Quality in the Pediatric Intensive Care Unit (SSqPICU). J Clin Sleep Med. 2024;20(8):1251-1258.

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

BACKGROUND

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes.

METHODS

This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete.

FINDINGS

Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo.

INTERPRETATION

In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults.

FUNDING

National Institutes of Health and the US Department of Veterans Affairs.

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Guideline on positioning and early mobilisation in the critically ill by an expert panel

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator

Background and purpose

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

Methods

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

Result

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

Conclusion

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

How to cite this article

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

Postintensive care syndrome in patients and family members. Analysis of COVID-19 and non-COVID-19 cohorts, with face-to-face follow-up at three months and one year

OBJECTIVE

Compare prevalence and profile of post-intensive care patient (P-PICS) and family/caregiver (F-PICS) syndrome in two cohorts (COVID and non-COVID) and analyse risk factors for P-PICS.

DESIGN

Prospective, observational cohort (March 2018-2023), follow-up at three months and one year.

SETTING

14-bed polyvalent Intensive Care Unit (ICU), Level II Hospital.

PATIENTS OR PARTICIPANTS

265 patients and 209 relatives. Inclusion criteria patients: age > 18 years, mechanical ventilation > 48 h, ICU stay > 5 days, delirium, septic shock, acute respiratory distress syndrome, cardiac arrest. Inclusion criteria family: those who attended.

INTERVENTIONS

Follow-up 3 months and 1 year after hospital discharge.

MAIN VARIABLES OF INTEREST

Patients: sociodemographic, clinical, evolutive, physical, psychological and cognitive alterations, dependency degree and quality of life. Main caregivers: mental state and physical overload.

RESULTS

64.9% PICS-P, no differences between groups. COVID patients more physical alterations than non-COVID (P = .028). These more functional deterioration (P = .005), poorer quality of life (P = .003), higher nutritional alterations (P = .004) and cognitive deterioration (P < .001). 19.1% PICS-F, more frequent in relatives of non-COVID patients (17.6% vs. 5.5%; P = .013). Independent predictors of PICS-P: first years of the study (OR: 0.484), higher comorbidity (OR: 1.158), delirium (OR: 2.935), several reasons for being included (OR: 3.171) and midazolam (OR: 4.265).

CONCLUSIONS

Prevalence PICS-P and PICS-F between both cohorts was similar. Main factors associated with the development of SPCI-P were: higher comorbidity, delirium, midazolan, inclusion for more than one reason and during the first years.

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

BACKGROUND

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

AIM

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

METHODS

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

RESULTS

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43-100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34-66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0-10 cm), 5 (2-7) and 6 (2.3-7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0-6 cm), 8 (5-10) and 4 (3-5) respectively.

CONCLUSION

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

Gaps in cognitive care among older patients undergoing spine surgery

INTRODUCTION

Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under-recognized. It is well established that applying delirium preventive interventions to at-risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment.

METHODS

We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications.

RESULTS

Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients.

DISCUSSION

Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence-based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication.

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study

Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.

Postarrest Care Bundle Improves Quality of Care and Clinical Outcomes in the Normothermia Era

PURPOSE

Temperature targets in patients with cardiac arrest and return of spontaneous circulation (ROSC) have changed. Changes to higher temperature targets have been associated with higher breakthrough fevers and mortality. A post-ROSC normothermia bundle was developed to improve compliance with temperature targets.

METHODS

In August 2021, "ad hoc" normothermia at the discretion of the attending intensivist was initiated. In December 2021, a post-ROSC normothermia protocol was implemented, incorporating a rigorous, stepwise approach to fever prevention (temperature ≥ 37.8). We conducted a before-after cohort study of all adult patients post-ROSC who survived to intensive care unit admission between August 1, 2021, and April 1, 2022. They were divided into "ad hoc" and "protocol" groups. Clinical outcomes compared included fevers, active cooling, and paralytic use.

RESULTS

Fifty-eight post-ROSC patients were admitted; 24 in the "ad hoc" and 34 in the "protocol" groups. Patient demographics were similar between groups. The "ad hoc" group had more shockable rhythms (67% vs 24%, P = .001) and cardiac catheterizations (42% vs 15%, P = .03). The "protocol" group were significantly less likely to have a fever at 40 h (6% vs 40%, P < .001) and 72 h (14% vs 65%, P ≤ .001). Patients in the normothermia "protocol" used significantly less neuromuscular blocking agents (24% vs 50%, P = .05). The normothermia "protocol" resulted in similar mortality (56% vs 58%, P = 1.0).

CONCLUSION

Use of a normothermia "protocol" resulted in fewer fevers and less neuromuscular blocker administration compared to "ad hoc" management. A protocolized approach for improved quality of care should be considered in institutions adopting normothermia.

Post-sepsis psychiatric disorder: Pathophysiology, prevention, and treatment

Post-sepsis psychiatric disorder, encompassing anxiety, depression, post-traumatic stress disorder and delirium, is a highly prevalent complication secondary to sepsis, resulting in a marked increase in long-term mortality among affected patients. Regrettably, psychiatric impairment associated with sepsis is frequently disregarded by clinicians. This review aims to summarize recent advancements in the understanding of the pathophysiology, prevention, and treatment of post-sepsis mental disorder, including coronavirus disease 2019-related psychiatric impairment. The pathophysiology of post-sepsis psychiatric disorder is complex and is known to involve blood-brain barrier disruption, overactivation of the hypothalamic-pituitary-adrenal axis, neuroinflammation, oxidative stress, neurotransmitter dysfunction, programmed cell death, and impaired neuroplasticity. No unified diagnostic criteria for this disorder are currently available; however, screening scales are often applied in its assessment. Modifiable risk factors for psychiatric impairment post-sepsis include the number of experienced traumatic memories, the length of ICU stay, level of albumin, the use of vasopressors or inotropes, daily activity function after sepsis, and the cumulative dose of dobutamine. To contribute to the prevention of post-sepsis psychiatric disorder, it may be beneficial to implement targeted interventions for these modifiable risk factors. Specific therapies for this condition remain scarce. Nevertheless, non-pharmacological approaches, such as comprehensive nursing care, may provide a promising avenue for treating psychiatric disorder following sepsis. In addition, although several therapeutic drugs have shown preliminary efficacy in animal models, further confirmation of their potential is required through follow-up clinical studies.

S. S, Begum M, Chakraborty SR, Chowdhury H, Chowdhury MAR, Deb P, Akhter Farzana N, Ghose A, Harun Or Roshid M, Hoque Tipu MR, Hosain S, Hossain MM, Moinul Islam M, Kumar Tirupakuzhi Vijayaraghavan B, Mohsin M, Mund M, Nasrin S, Kumar Nath R, Nayak S, Pani N, Ahmmad Sarker S, Dondorp A, Tripathy S, Faiz MA. Understanding patient and family experiences of critical care in Bangladesh and India: What are the priority actions to promote person-centred care?

Patients' experiences in the intensive care unit (ICU) can enhance or impair their subsequent recovery. Improving patient and family experiences on the ICU is an important part of providing high quality care. There is little evidence to guide how to do this in a South Asian critical care context. This study addresses this gap by exploring the experiences of critically ill patients and their families in ICUs in Bangladesh and India. We elicit suggestions for improvements from patients, families and staff and highlight examples of practices that support person-centred care. This multi-site hospital ethnography was carried out in five ICUs in government hospitals in Bangladesh and India, selected using purposive sampling. Qualitative data were collected using non-participant observation and semi-structured interviews and analysed using reflexive thematic analysis. A total of 108 interviews were conducted with patients, families, and ICU staff. Over 1000 hours of observation were carried out across the five study sites. We identified important mediators of patient and family experience that span many different aspects of care. Factors that promote person-centred care include access to ICU for families, support for family involvement in care delivery, clear communication with patients and families, good symptom management for patients, support for rehabilitation, and measures to address the physical, environmental and financial needs of the family. This study has generated a list of recommendations that can be used by policy makers and practitioners who wish to implement person-centred principles in the ICU.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Generalized music therapy to reduce neuroactive drug needs in critically ill patients. Study protocol for a randomized trial

BACKGROUND

Critically ill patients are exposed to several physical and emotional stressors, needing analgesic and sedative drugs to tolerate invasive procedures and the harsh intensive care unit (ICU) environment. However, this pharmacological therapy presents several side effects: guidelines suggest using a light sedation target, keeping critically ill patients calm, conscious, and cooperative. Personalized music therapy (MT) can reduce stress and anxiety, decreasing the need for drugs. The aim of the current investigation is to compare different approaches for MT in the ICU: a personalized approach, with music selected by patients/families and listened through headphones, or a generalized approach, with ambient music chosen by a music therapist and transmitted through speakers.

PRIMARY OUTCOME

number of days "free from neuroactive drugs" in the first 28 days after ICU admission.

SECONDARY OUTCOMES

total amount of neuroactive drugs (midazolam, propofol, morphine, fentanyl, haloperidol), stress during ICU stay (sleep at night, anxiety and agitation, use of physical restraints, stressors evaluated at discharge), the feasibility of generalized MT (interruptions requested by staff members and patients/families).

METHODS

Randomized, controlled trial with three groups of critically ill adults: a control group, without MT; a personalized MT group, with music for at least 2 h per day; a generalized MT group, with music for 12.5 h/day, subdivided into fifteen 50-min periods.

DISCUSSION

One hundred fifty-three patients are expected to be enrolled. This publication presents the rationale and the study methods, particularly the strategies used to build the generalized MT playlist. From a preliminary analysis, generalized MT seems feasible in the ICU and is positively received by staff members, critically ill patients, and families.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03280329. September 12, 2017.

Pain monitoring in intensive care: How does the nociception level index affect treatment and prognosis? A randomized, controlled, double-blind trial

BACKGROUND

Effective pain management is vital in critical care settings, particularly post-surgery. Clinicians should maintain objective and efficient standards to assess pain in a patient-centered manner, in order to effectively manage this complex issue. A newer technology, the nociception level (NOL) index, shows promise in achieving this task through its multi-parameter evaluation.

METHODS

This study was a prospective, controlled, randomized trial involving two groups of patients (n=30 each) in a diverse intensive care unit. Participants were over 18 years old with American Society of Anesthesiology scores ranging from I to III and were scheduled for critical care follow-up after general anesthesia. All subjects followed a standard analgesia protocol that included rescue analgesia. Drug administration was guided by a numeric rating scale and the critical care pain observation tool in the Control Group, while it was guided by nociception level index monitoring in the NOL Group.

RESULTS

Pain scores between the two groups did not significantly differ. However, within the NOL Group, pain scores and noci-ception values displayed a strong positive correlation. Notably, total analgesic consumption was significantly lower in the NOL Group (p=0.036).

CONCLUSION

Monitoring pain using the nociception level index is an effective method for detecting pain compared to standard pain scores utilized in critical care. Its guidance facilitates personalized analgesic titration. Additionally, the potential of nociception level index guidance to reduce the duration of intensive care and hospital stays may be linked to its effects on delirium, a connection that awaits further exploration in future studies.

Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs

Objectives: The intensive care unit (ICU) Liberation "ABCDEF" Bundle improves outcomes in critically ill adults. We aimed to identify common barriers to Pediatric ICU Liberation Bundle element implementation, to describe differences in barrier perception by ICU staff role, and to describe changes in reported barriers over time. Study Design: A 91-item survey was developed based on existing literature, iteratively revised, and tested by the PICU Liberation Committee at Seattle Children's Hospital, a tertiary free-standing academic children's hospital. Voluntary surveys were administered electronically to all ICU staff twice over 4-week periods in 2017 and 2020. Survey Respondents: 119 (2017) and 163 (2020) pediatric and cardiac ICU staff, including nurses (n = 142, 50%), respiratory therapists (RTs) (n = 46, 16%), attending and fellow physicians, hospitalists, and advanced practice providers (APPs) (n = 62, 22%), physical, occupational, and speech-language pathology therapists (n = 25, 9%), and pharmacists (n = 7, 2%). Measurements and Main Results: Respondents widely agreed that increased workload (78%-100% across roles), communication (53%-84%), and lack of RT-directed ventilator weaning (68%-88%) are barriers to implementation. Other barriers differed by role. In 2020, nurses reported liability (59%) and personal injury (68%) concerns, patient severity of illness (24%), and family discomfort with ICU liberation practices (41%) more frequently than physicians and APPs (16%, 6%, 8%, and 19%, respectively; P < .01 for all). Between 2017 and 2020, some barriers changed: RTs endorsed discomfort with early mobilization less frequently (50% vs 11%, P = .028) and nurses reported concern for patient harm less frequently (51% vs 24%, P = .004). Conclusions: Implementation efforts aimed at addressing known barriers, including educating staff on the safety of early mobility, considering respiratory therapist-directed ventilator weaning, and standardizing interdisciplinary discussion of Pediatric ICU Liberation Bundle elements, will be needed to overcome barriers and improve ICU Liberation Bundle implementation.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PURPOSE

The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada.

MATERIAL AND METHODS

We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record.

RESULTS

44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events.

CONCLUSIONS

An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

Patient characteristics associated with posttraumatic stress symptoms in intensive care unit survivors during a one-year follow-up: A multicenter study

BACKGROUND

Intensive care unit (ICU) patients are at risk of suffering from posttraumatic stress symptoms (PTSS) after ICU survival.

OBJECTIVES

To describe the prevalence of high levels of PTSS the first year after ICU admission. Further, to identify specific combinations of patient characteristics (latent classes based on pre-ICU data, demographics, and clinical characteristics), and to investigate possible associations among these classes and PTSS at 3, 6, and 12 months after ICU admission.

METHODS

Self-reported PTSS were measured with Impact of Event Scale-Revised (IES-R). PTSS and possible predictive factors (pre-ICU data, demographics, and clinical characteristics) were analyzed using descriptive statistics, latent class analysis, and linear mixed model for repeated measures.

RESULTS

High PTSS levels (IES-R ≥ 33) were reported by 14.9 % (95 % confidence interval [CI] [10.0; 21.1]), 16.7 % (95 % CI [11.5; 23.1]), and 18.4 % (95 % CI [12.9; 25.0]) of patients (sample 1, n = 174) at 3, 6, and 12 months, respectively. Three latent classes were identified (sample 2, n = 417). PTSS were significantly associated with class 2 (male with longer hospital stay) at 6 months and class 3 (age≥70, lower level of education, higher Simplified Acute Physiology Score, being mechanically ventilated) at all three measurement times.

CONCLUSIONS

The prevalence of high levels of PTSS is the greatest 12 months after ICU admission. Health professionals can use this information to be aware of specific groups of ICU patients reporting PTSS during the first year and follow up on these.

Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention

Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It significantly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources. Therefore, early intervention and assessment of PICS is crucial. This paper aims to provide clinical professionals with a reference base by focusing on the clinical symptoms, diagnostic assessment, and preventative measures of PICS.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Robotic Pet Therapy in the Intensive Care Unit

Background

Robotic pet therapy could aid in the nonpharmacologic treatment of pain, agitation, delirium, immobility, and sleep disruption (PADIS) in the intensive care unit (ICU), similar to traditional pet therapy.

Observations

The North Florida/South Georgia Veterans Health System implemented a robotic pet therapy program for patients requiring ICU care. Details of this program are described in this article, including evaluating its impact on PADIS management.

Conclusions

Robotic pet therapy can be successfully implemented in the ICU and could be a simple, safe, and beneficial nonpharmacologic intervention for PADIS.

Early Mobility Index and Patient Outcomes: A Retrospective Study in Multiple Intensive Care Units

BACKGROUND

Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear.

OBJECTIVE

To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs.

METHODS

In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays.

RESULTS

In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs.

CONCLUSIONS

More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.