The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients

Predicting Agitation-Sedation Levels in Intensive Care Unit Patients: Development of an Ensemble Model

Background

Agitation and sedation management is critical in intensive care as it affects patient safety. Traditional nursing assessments suffer from low frequency and subjectivity. Automating these assessments can boost intensive care unit (ICU) efficiency, treatment capacity, and patient safety.

objectives

The aim of this study was to develop a machine-learning based assessment of agitation and sedation.

Methods

Using data from the Taichung Veterans General Hospital ICU database (2020), an ensemble learning model was developed for classifying the levels of agitation and sedation. Different ensemble learning model sequences were compared. In addition, an interpretable artificial intelligence approach, SHAP (Shapley additive explanations), was employed for explanatory analysis.

Results

With 20 features and 121,303 data points, the random forest model achieved high area under the curve values across all models (sedation classification: 0.97; agitation classification: 0.88). The ensemble learning model enhanced agitation sensitivity (0.82) while maintaining high AUC values across all categories (all >0.82). The model explanations aligned with clinical experience.

Conclusions

This study proposes an ICU agitation-sedation assessment automation using machine learning, enhancing efficiency and safety. Ensemble learning improves agitation sensitivity while maintaining accuracy. Real-time monitoring and future digital integration have the potential for advancements in intensive care.

Ventilator settings for fibreoptic bronchoscopy during mechanical ventilation: a study protocol for a pragmatic randomised double-blind controlled trial VentSetFib

INTRODUCTION

Fibreoptic bronchoscopy (FOB) is a challenging procedure during mechanical ventilation (MV) as it considerably reduces the endotracheal tube's internal diameter, causing a drastic increase in respiratory resistance, which may compromise the delivery of ventilatory assistance. According to respiratory physiology principles applied to MV, the reduction of inspiratory flow and tidal volume is likely to reduce airway pressure during the inspiratory phase when respiratory resistances increase. Based on this assumption, we propose new ventilator settings aimed at reducing airway pressure during FOB. This study represents the first investigation to test special ventilator settings in order to facilitate FOB during MV.

METHODS AND ANALYSIS

This is a single-centre randomised double-blind controlled trial, in which intubated patients undergoing an FOB will be assigned (1/1) either to receive the new ventilatory strategy or to stay on the ventilator settings previously selected by the attending physician. The intervention group will be applied the specific ventilator settings (inspiratory flow ≤25 L/min, tidal volume=5 mL/Kg, 1 s≤inspiratory time≤1.3 s, respiratory frequency=16 c/min, positive end-expiratory pressure=5 cm H2O). The primary endpoint will be the reduction of the occurrence of a serious adverse event (inability to deliver ventilatory support, significant arterial desaturation or haemodynamics instability) during FOB, prompting the interruption of the procedure. The primary endpoint will be validated a posteriori by an external adjudication committee. The sample size was estimated at a minimum of 42 patients to demonstrate a 50% reduction in the occurrence of such a serious adverse event with a power of 90% and an alpha risk of 0.05 (χ2 test). Considering the possibility of technical problems in 10% of cases, 46 patients will be included.

ETHICS AND DISSEMINATION

The study has been approved by the national ethics committee for the protection of the individuals (ID number: 2024-A00747-40). Written informed consent will be obtained from all patients. The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06562725.

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.

Efficacy and safety of esketamine for emergency endotracheal intubation in ICU patients: a double-blind, randomized controlled clinical trial

Emergency endotracheal intubation in critically ill patients are dangerous procedures with a greater risk of severe hypotension The efficacy and safety of esketamine with sympathoexcitatory effects for rapid sequence induction in critically ill patients remain unclear. In this prospective double-blinded randomized controlled trial, adult patients were randomly assigned to receive either esketamine or midazolam/sufentanil admixture for induction. The primary outcomes were the effects of induction with esketamine or midazolam/sufentanil admixture on hemodynamic responses (heart rate (HR) and mean arterial pressure (MAP) during and after induction). Secondary outcomes were the duration of ventilation support, length of intensive care unit (ICU) stay, 28-day mortality. We enrolled 80 patients, of whom 38 were assigned to the esketamine group and 42 to the midazolam/sufentanil admixture group. The MAP in group esketamine was significantly higher than that in group midazolam/sufentanil admixture during the induction, and at 1 min, 5 min and 10 min after intubation. No significant differences in HR between groups were observed. The duration of ventilation support [105.3 (interquartile range (IQR) 40.9 - 248.3) hours vs. 211.5 (IQR 122.1 - 542.1) hours, P = 0.002] and the length of ICU stay [7.0 (IQR 4.0 - 16.3) days vs. 15.0 (IQR 8.0 - 26.0) days, P = 0.002] were significantly decreased in group esketamine, compared to that in group midazolam/sufentanil admixture. In group esketamine, less norepinephrine [0.00 (IQR 0.00 - 0.10) µg/kg/min vs. 0.09 (IQR 0.00 - 0.29) µg/kg/min, P = 0.016] was needed. There was no significant difference in 28-day mortality between the two groups. No serious adverse events occurred. In conclusion, esketamine is a hemodynamically stable induction agent in critically ill patients, which could reduce the length of ICU stay and the duration of ventilation support.Trial registration: clinicaltrials.gov (19/07/2022; NCT05464979).

Incidence and factors associated with agitation in patients on mechanical ventilators in Amhara Region, North-West Ethiopia: a multi-center study

Agitation is a common psychomotor disorder among critically ill patients on mechanical ventilators, posing significant risks to patients and adding strain to clinical services. Despite its importance, there is a lack of data on the incidence and contributing factors of agitation in the study area and across Ethiopia. This study, therefore, aims to assess the incidence and factors associated with agitation in patients on mechanical ventilators in the intensive care units of comprehensive specialized hospitals in the Amhara Region, North-West Ethiopia. A multi-center prospective follow-up study was conducted among 253 critically ill adult patients on mechanical ventilators in the Amhara region of Ethiopia from April 17, 2024, to July 16, 2024. Data were collected using a semi-structured questionnaire through chart reviews, observations, and interviews. Participants were selected using a consecutive sampling technique. The data were entered into Epi-Data version 4.6 and transferred to Stata version 17 for analysis. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with agitation. Variables with a p value of less than 0.2 in the bivariable analysis were included in the multivariable analysis. Crude and adjusted odds ratios with 95% confidence intervals were used to identify factors associated with agitation. The results were presented in the form of text, tables, and figures. In the multivariable analysis, variables with a p value of less than 0.05 were considered statistically significant predictors. The overall incidence of agitation among patients on mechanical ventilators in intensive care units was 87.35% (95% CI 82.6, 91.2). Anxiety (Adjusted Odds Ratio (AOR) 3.5; 95% CI 1.28, 9.45), delirium (AOR 3.01; 95% CI 1.13, 7.97), pain (AOR 3.23; 95% CI 1.18, 8.85), hyperthermia (AOR 3.49; 95% CI 1.004, 12.15), hyponatremia (AOR 3.64; 95% CI 1.009, 13.11), and the use of restraints (AOR 3.49; 95% CI 1.11, 8.67) were statistically significant factors associated with agitation. In this study, the majority of participants experienced agitation. To reduce the incidence of agitation, we recommend addressing or preventing the development of anxiety, pain, delirium, hyperthermia, and hyponatremia, as well as minimizing the use of restraints in intensive care units.

Applying positive end-expiratory pressure before and during endotracheal tube removal versus extubation with concomitant aspiration: protocol for the randomised controlled multicentre EXSUPEEP trial

INTRODUCTION

The optimal method for removing the endotracheal tube (ETT) during extubation in the intensive care unit (ICU) remains uncertain. Two methods are described for removing the ETT in ICU, namely the 'Traditional technique' with continuous aspiration during cuff deflation and ETT removal; and the 'PEEP' method, which consists in applying positive end-expiratory pressure (PEEP) before and during cuff deflation and ETT removal. Our hypothesis is that applying PEEP during extubation in the ICU would improve clinical outcome.

METHODS AND ANALYSIS

This is a prospective, multicentre, randomised, open-label, controlled, superiority trial, analysed by intention-to-treat, comparing ETT removal with concomitant suction vs application of PEEP before and during ETT removal. In total, 424 patients will be recruited and randomly assigned in a 1:1 ratio to one of two groups, according to the strategy of ETT removal. The primary outcome is the number of days free from any mechanical ventilation within 28 days following extubation. Secondary outcomes include the reintubation rate up to 7 days after ETT removal, the cumulative duration of non-invasive ventilation up to 7 days following extubation, the rate of acute respiratory failure, the rate of acquired pneumonia during the first 7 days following ETT removal, the length of stay in ICU and in hospital and all-cause mortality at 28 days following ETT removal.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee 'CPP Ile de France II'. Patients will be included after providing written informed consent. The results will be submitted for publication in peer-reviewed journals, and in national and international congresses.

TRIAL REGISTRATION NUMBER

NCT05147636.

Investigating the safety of physical rehabilitation with critically ill patients receiving vasoactive drugs: An exploratory observational feasibility study

BACKGROUND

Physical rehabilitation of critically ill patients may improve physical outcomes; however, the relative benefits and risks with patients requiring vasoactive drugs is currently unknown. A feasibility study is needed to inform the design of a future trial required to address this issue.

METHODS

A two-phase exploratory observational feasibility study was carried out: A retrospective study to clarify the current practice of rehabilitation with patients receiving vasoactive drugs to inform future trial interventions and design.A prospective study exploring recruitment and outcome measurement. Intensive care patients receiving vasoactive drugs were recruited and asked about the acceptability of a future trial. The feasibility of using an adverse event tool was measured during rehabilitation. Patients were followed up after 60 days to describe the feasibility of measuring outcomes for a future trial.

RESULTS

Retrospective study (n = 78): Twenty-one percent of patients took part in physical rehabilitation whilst receiving vasoactive drugs. Of 321 days with vasoactive drugs administered, physical rehabilitation occurred on 27 days (8%). Prospective study (n = 40): Eighty-one percent of participants indicated acceptability of being recruited into a future trial (n = 37). Eighty-eight percent of clinicians found it acceptable to randomise patients into either early rehabilitation or standard care. The adverse event tool was implemented by researchers with 2% loss of information. Finally, a 100% follow-up rate at day 60 was achieved for mortality outcomes. Follow-up rates were 70% for the EQ-5D (5 level), 65% for the World Health Organisation's Disability Assessment Schedule 2.0 and RAND 36-item Health Survey 1.0 and 26% for the 6-minute walk test.

CONCLUSIONS

This study found a low frequency of physical rehabilitation occurring with intensive care patients receiving vasoactive drugs. A high proportion of clinicians and patients found a future RCT within this patient group acceptable. Mortality and patient-reported outcomes were the most feasible to measure.

Identification and quantification of physical activity in critically ill burn patients: A feasibility study

BACKGROUND

Physical activity is essential in burn care to counteract the effects of severe burns and inactivity during hospitalization. However, detailed knowledge of performed physical activities is lacking. This study evaluated the feasibility of a dual accelerometer-based method to assess type, frequency, and duration of physical activity in critically ill burn patients during hospitalization.

METHODS

A prospective observational study was conducted at the burn center of the Martini Hospital, Groningen, The Netherlands. Eligible were patients with a total body surface area (TBSA) burned of ≥ 15 % or an indication for intensive care. Patients wore two accelerometers, one on the chest and one on the diagonally opposite thigh. An algorithm converted accelerometer data into type, frequency, and duration of activities common for intensive care patients. An activity diary was used to assess non-wear time and its content, e.g., surgery.

RESULTS

Five patients (20-60 years, 13-31 % TBSA burned, LOS 30-65 days) were included. Per patient, 14-49 days (17,380-61,796 min) could be analyzed of which 7-14 % was non-wear time. During wear time, 86-95 % of activities could be identified and quantified. However, processing the data was labor-intensive.

CONCLUSION

The dual accelerometer-based method proved feasible for research purposes. For clinical application, further refinement of data processing is required.

AMETIS Preplanned Ancillary Study: Impact of Agitation During Mechanical Thrombectomy Under Sedation

BACKGROUND

Mechanical thrombectomy is the treatment of choice for ischemic strokes of the anterior circulation with proximal occlusion. Mechanical thrombectomy can be performed under sedation, which can lead to episodes of periprocedural agitation. The aim of this study is to describe the prevalence of agitation and determine the consequences during and after mechanical thrombectomy.

METHODS

This is an ancillary study to the AMETIS study (Anesthesia Management in Endovascular Therapy for Ischemic Stroke). We evaluated the patients from the sedation group of this randomized trial; some patients presented at least 1 episode of agitation during the procedure (determined by a Richmond Agitation-Sedation Scale score >1) prospectively collected. We explored the association between agitation and a composite outcome (Thrombolysis in Cerebral Infarction score <2b and/or arterial perforation) through univariate and multivariate analyses, accounting for confounders (agitation, age, National Institutes of Health Stroke Scale score, local thrombus) identified a priori by the acyclic diagram method.

RESULTS

Among the 138 participants (average age, 71±14 years; 72 [52%] male; average National Institutes of Health Stroke Scale score, 15±6), 53 (38%) experienced at least 1 agitation episode. Agitation was neither a risk factor of Thrombolysis in Cerebral Infarction score <2b and/or arterial perforation in univariate and multivariate analyses (adjusted odds ratio, 1.29 [0.57-2.92]; P=0.5), nor a risk of unfavorable outcome (adjusted OR, 0.7 [0.18-2.56]; P=0.56). Although, agitated patients had a higher incidence of conversion with intubation (21% versus 5%; OR, 5.3 [1.7-20]; P<0.01) and significantly worse radiological image quality (62% versus 17%; OR, 8.37 [3.9-19.1]; P<0.01).

CONCLUSIONS

Our study found a high frequency of agitation during mechanical thrombectomy under sedation. Despite the absence of any significant link with prognosis, Thrombolysis in Cerebral Infarction score, and perforations, there is more conversion to general anesthesia with intubation and poorer quality images.

A pilot trial exploring the use of music in the emergency department and its association with delirium and other clinical outcomes

OBJECTIVE

To assess potential feasibility of a targeted music intervention trial in older ED patients and association with clinical outcomes.

METHODS

Prospective pragmatic trial of adults aged ≥65 years in the ED, with prevalent delirium or increased risk of incident delirium, receiving either 2-h music intervention via headphones or usual care. The primary outcomes were (i) feasibility as assessed by actual use of the intervention (target 70% of offered patients) and (ii) incident delirium in delirium-free patients.

RESULTS

Among 211 initially screened patients, 44 were included. The initially planned randomised controlled trial proved difficult due to poor intervention adherence, resulting in a move to patient self-selection to routine care or 2-h music intervention. There were 19 control (13 prevalent delirium) and 25 intervention participants (20 prevalent delirium); 2-h target intervention duration was achieved in 17/25 (68%) patients (8/25 achieving <2 h). Among those without prevalent delirium, incident delirium occurred in 1/6 of control and 4/5 of intervention (P = 0.08). There were no between-group differences in terms of improved or resolved delirium, pain scores or agitation/sedation scores (all P > 0.1).

CONCLUSIONS

Self-selected use of a targeted music intervention was feasible in a cohort of older ED patients. While we were likely underpowered to detect associations between intervention and outcome, collection of selected outcome measures proved feasible; these may be helpful in larger scale studies. Exploration of barriers and facilitators to use, as well as preferred delivery methods, are likely to be helpful in wider investigations of music therapy in this high-risk cohort.

Propranolol As an Anxiolytic to Reduce the Use of Sedatives for Critically Ill Adults Receiving Mechanical Ventilation (PROACTIVE): An Open-Label Randomized Controlled Trial

OBJECTIVES

Surges in demand for sedatives for mechanical ventilation during the COVID-19 pandemic caused shortages of sedatives globally. Propranolol, a nonselective beta-adrenergic blocker, has been associated with reduced agitation and sedative needs in observational studies. We aimed to test whether propranolol could reduce the dose of sedatives needed in mechanically ventilated patients.

DESIGN

Open-label randomized controlled trial.

SETTING

Three academic hospitals.

SUBJECTS

Any nonparalyzed patient receiving mechanical ventilation and requiring high-dose sedatives.

INTERVENTIONS

Enteral propranolol 20-60 mg every 6 hours titrated to effect in the intervention group; all participants received protocol-titrated sedation with propofol or midazolam.

MEASUREMENTS AND MAIN RESULTS

Mean change in 24 hours dose of sedative from baseline to day 3, proportion of sedation scores within target, and occurrence rate of adverse events. We enrolled a planned 72 patients between January 2021 and October 2022. Sixty-nine percent were male with a mean (sd) age of 54 years (15.91 yr). Most were admitted for COVID or non-COVID pneumonia. Intervention participants received propranolol for a mean of 10 days (mean daily dose, 90 mg). There was a significantly larger decrease in sedative dose from baseline (54% vs. 34%; p = 0.048) and more sedation assessments within target range (48% vs. 35%; p < 0.0001) in the intervention group compared with controls. There were no differences in mortality or adverse events.

CONCLUSIONS

Propranolol is an inexpensive drug that effectively lowered the need for sedatives in critically ill patients managed in the COVID-19 pandemic. Propranolol may help preserve limited supplies of sedatives while achieving target sedation.

Severe Traumatic Brain Injury Outcomes in Patients with Premorbid Psychiatric Illness

OBJECTIVE

Individuals with psychiatric illnesses (PIs) have increased rates of traumatic brain injury (TBI). Nonetheless, the influence of underlying PI on TBI outcomes is poorly understood.

METHODS

We analyzed the medical records of 633 adult-severe TBI patients admitted to our institution between 2010 and 2021. We identified patients with premorbid PI (Psych (+) group, n = 129) and a subset with only a substance use disorder (SUD (+) group, n = 60) and compared them to patients without PI (Psych (-) group, n = 480). Outcome measures included discharge Glasgow Coma Scale (GCS), length of stay, in-hospital survival, and Glasgow Outcome Scale-Extended (GOS-E).

RESULTS

The Psych (+) group had increased in-hospital survival (69.8% vs. 55.0%, P = 0.003) and fewer patients with severe (3-8) discharge-GCS (28.7% vs. 46.0%, P < 0.001). The SUD (+) group had increased in-hospital survival (70.0% vs. 55.0%, P = 0.028) and fewer patients with severe discharge-GCS (28.3% vs. 46.0%, P = 0.009). However, the Psych (+) (21.0 vs. 10.0 days, P < 0.001) and SUD (+) (16.0 v. 10.0 days, P = 0.011) groups had longer length of stay. The Psych (+) group had a higher mean GOS-E at discharge (2.7 vs. 2.4, P = 0.004), 6-months (3.8 vs. 3.0, P = 0.006) and 1-year (3.4 vs. 2.3, P = 0.027). The SUD (+) group also had a higher mean GOS-E at discharge (2.8 vs. 2.4, P = 0.034), six months (3.8 vs. 3.0, P = 0.035), and one year (3.5 vs. 2.3, P = 0.008). Additionally, there were no significant differences in injury severity or computed tomography scan findings.

CONCLUSIONS

Individuals with PI and SUD appeared to have better outcomes but more complicated hospital stays following severe TBI. Future studies should investigate the mechanisms underlying these outcomes.

The Role of Propofol in Alcohol Withdrawal Syndrome: A Systematic Review

The objective of this review was to evaluate the efficacy and safety of propofol in the treatment of critically ill patients diagnosed with alcohol withdrawal syndrome (AWS). A review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, and Embase, MEDLINE (PubMed), Cochrane CENTRAL, and Web of Science were queried for results through June 2024. Studies providing efficacy or safety data associated with propofol with a reported diagnosis of AWS in critically ill patients were included. Studies evaluating pediatric patients, those without quantitative and qualitative outcome data, and those not readily translatable to English were excluded. Five retrospective cohort analyses of 218 patients were included in this systematic review. Patients were found to have both significant and non-significant increases in time to resolution of AWS symptoms when treated with propofol versus the AWS standard of care. Adjunct treatment with propofol was generally associated with reductions in total benzodiazepine use and increases in both ICU length of stay and duration of mechanical ventilation. The results of this systematic review provide the evidence necessary to support the use of propofol as an efficacious and safe medication in the management of severe and refractory AWS. Further investigation is required to determine optimal dosing strategies and durations of therapy. The results of this systematic review demonstrate the clinical utility of propofol as part of the management strategy for severe and refractory AWS.

Ambulation Protocol for Adult Patients Receiving Extracorporeal Membrane Oxygenation: A Quality Improvement Initiative

BACKGROUND

For patients receiving extracorporeal membrane oxygenation, early mobility decreases mechanical ventilation time, delirium incidence, and length of intensive care unit stay and improves physical functioning. Individual centers use institutional guidelines to develop ambulation protocols. Local Problem A quality improvement initiative was used to evaluate an ambulation protocol for adult intensive care unit patients receiving extracorporeal membrane oxygenation.

METHODS

Adult patients receiving extracorporeal membrane oxygenation who walked according to the protocol were compared with a historical control group of patients who walked without the protocol. Data analysis included descriptive statistics and independent t tests. Outcomes included adverse safety events, number of patients and ambulation sessions, standing and ambulation time, and distance.

RESULTS

From January to March 2021, 13 of 46 patients receiving extracorporeal membrane oxygenation (28%) walked according to the protocol. In the control group, 14 of 147 patients (10%) walked in 2019; 21 of 144 patients (15%) walked in 2020. Some characteristics of the control group (hospitalized before the COVID-19 pandemic) differed from those of the protocol group (hospitalized during the pandemic). Mean number of ambulation sessions was not significantly different between groups (protocol group, 10; control group, 9). Differences in mean standing time (protocol group, 121.23 minutes; control group, 210.80 minutes), ambulation time (protocol group, 11.77 minutes; control group, 198.70 minutes), and ambulation distance were not significant.

CONCLUSIONS

Standing time, ambulation time, and distance were not significantly different between the groups. The extracorporeal membrane oxygenation ambulation protocol demonstrated clinical significance by increasing the number of patients walking.

Impact of new lighting technology versus traditional fluorescent bulbs on sedation and delirium in the ICU

BACKGROUND

Critically ill patients frequently encounter disruptions in their circadian rhythms in the intensive care unit (ICU) environment. New lighting systems have been developed to enhance daytime light levels and to promote circadian alignment.

OBJECTIVES

To investigate the impact of implementing an innovative lighting technology that mimics natural light and reproduce the colour of the sky.

DESIGN

Prospective, observational, non-randomized comparative trial. ICU patients were exposed to either a cutting-edge lighting system based on new technology (intervention group) or a conventional lighting system using fluorescent bulbs (control group).

SETTING

An Italian intensive care unit with ten beds and five windowless rooms, thereby denying access to natural light. Three rooms had new lighting technology.

MAIN OUTCOME MEASURES

The two groups were compared to assess the prevalence or absence of delirium and the need for sedatives during ICU stay. The secondary aim was to assess the presence of anxiety, depression, and post-traumatic stress disorder in patients at 3, 6, and 12 months after ICU discharge.

RESULTS

86 patients were included: 52 (60 %) in the intervention group and 34 (40 %) in the control group. Seventy-nine patients (82 %) were alive at ICU discharge. Fourteen patients (16 %) developed delirium (intervention group: n = 8 [15 %] vs. control group: n = 6 [18 %] in the control group, (P=0.781). The use of sedative drugs and neuromuscular blocking agents was similar in both the groups. No differences in the incidence of anxiety, depression, or post-traumatic stress disorders were observed among patients who underwent follow-up visits.

CONCLUSIONS

Compared to traditional fluorescent tube lighting, the innovative lighting system did not provide any significant benefit in reducing the frequency of delirium or the necessity for sedative medications.

IMPLICATIONS FOR CLINICAL PRACTICE

A single intervention, the use of lights that mimic sunny light and the sky, did not result in a statistically significant reduction in the incidence of delirium. Delirium has a multifactorial aetiology, necessitating interventions that are multifaceted and address different domains.

Safety of endoscopist-directed nurse-administered sedation in an Italian referral hospital: An audit of 2 years and 19,407 procedures

BACKGROUND AND STUDY AIMS

Balanced propofol sedation (BPS) administered by adequately trained non-anaesthesiologist personnel has gained popularity in GI endoscopy because of its shorter procedure and recovery time, high patient satisfaction, and low rate of adverse events (AEs), despite being considered controversial. We report data from an audit of endoscopist-directed (ED) nurse-administered sedation in an Italian referral hospital.

PATIENTS AND METHODS

Consecutive endoscopic procedures performed between 2020 and 2022 were considered. Under the guidance of the endoscopist, the nurse administered midazolam/fentanyl, followed by a progressive top-up dosage of a 10-20 mg bolus of propofol to achieve moderate to deep sedation. The endoscopists and nurses were all certified in our hospital with a continuous and scheduled training from 2006.

RESULTS

During the study period, a total of 19,407 examinations (7,803 EGDS, 10,439 colonoscopies, 77 PEG, 697 EUS, and 365 ERCP) and 14,415 patients were included. Of these, 29.4 % of patients were classified as ASA I, 66.5 % as ASA II, and 5.1 % as ASA III. Hypotension was recorded in 1,293 (6 %) examinations and bradycardia in 176 (0.9 %) patients. Eleven patients (0.06 %) had minor respiratory adverse events. Two patients (0.01 %) had major AEs requiring orotracheal intubation.

CONCLUSIONS

ED-BPS is safe in low-risk patients. Major AEs occurred in 0.01 % of procedures.

Comparison of the incidence of recovery agitation with two different doses of ketamine in procedural sedation: A randomized clinical trial

OBJECTIVES

The objective was to compare the incidence of recovery agitation and efficacy of two different intravenous (IV) doses of ketamine (0.5 mg/kg vs. 1 mg/kg) in adult patients who presented to the emergency department (ED) requiring procedural sedation with ketamine.

METHODS

This randomized, prospective clinical trial included patients aged 18-75 years who required procedural sedation with ketamine in the ED. Patients were randomized to receive IV ketamine at either 0.5 mg/kg (low dose) or 1 mg/kg (high dose). The primary outcome was the incidence of recovery agitation, assessed by the Richmond Agitation-Sedation Scale (RASS) at 5, 15, and 30 min following the procedure, in both dosage groups. Secondary outcomes included overall efficacy, sedation duration, and changes in vital signs.

RESULTS

A total of 108 patients were enrolled in the study, 54 in each group. The median (IQR) RASS scores at 5, 15, and 30 min were -4 (-5 to -4), -1 (-1.3 to 0), and 0 (-1 to 0.5), respectively, in the low-dose group and -4 (-5 to -4), -1 (-3 to 0), and 0 (0 to 0), respectively, in the high-dose group. The incidence of recovery agitation was similar between the low- and high-dose groups (difference 1.9%, 95% confidence interval [CI] -14.8% to 18.4%). No significant difference was observed in sedation duration between the two groups (difference 0%, 95% CI -3.0% to 4.0%). While no additional ketamine was required in the high-dose group, four patients (7.4%) in the low-dose group required an additional half-dose (difference 7.4%, 95% CI -2.3% to 18.7%). Changes in vital signs were similar between the two groups.

CONCLUSIONS

There was no significant difference in recovery agitation, sedation duration, and changes in vital signs between 0.5 and 1 mg/kg IV ketamine for procedural sedation in the ED.

Early weaning from invasive mechanical ventilation via high-flow nasal oxygen versus conventional weaning in patients with hypoxemic respiratory failure: a prospective randomized controlled study

OBJECTIVE

Although the efficacy of high-flow nasal oxygen therapy in delaying or avoiding intubation in patients with hypoxemic respiratory failure has been studied, its potential for facilitating early weaning from invasive mechanical ventilation remains unexplored.

METHODS

In this randomized controlled trial, 80 adults with acute hypoxemic respiratory failure requiring invasive mechanical ventilation for > 48 hours were enrolled and divided into two groups: conventional weaning and early weaning via high-flow nasal oxygen. In the conventional weaning group, the spontaneous breathing trial was performed after the PaO2/FiO2 ratio was ≥ 200, whereas in the high-flow nasal oxygen group, the spontaneous breathing trial was conducted earlier when the PaO2/FiO2 ratio was 150 - 200. Following each successful spontaneous breathing trial, patients were extubated and put on oxygen supplementation via a venturi mask or high-flow nasal oxygen on the basis of their group allocation. The primary objective was to compare extubation failure (reintubation within 48 hours). The secondary objectives were to compare total invasive mechanical ventilation, oxygen requirement and sedation requirement days, ventilator-associated pneumonia incidence, invasive mechanical ventilation-free days, intensive care unit length of stay, and intensive care unit all-cause mortality.

RESULTS

Extubation failure was not significantly different between the high-flow nasal oxygen group and the conventional weaning group [12.5% versus 25%, respectively; odds ratio (95%CI) 0.5 (0.19 - 1.33)] (p = 0.25). Early weaning from invasive mechanical ventilation via high-flow nasal oxygen was associated with significantly increased invasive mechanical ventilation-free days and total oxygen requirement days (p = 0.02 and p = 0.01, respectively). No significant between-group differences were observed in total invasive mechanical ventilation days, ventilator-associated pneumonia incidence, intensive care unit length of stay, sedation duration, or all-cause mortality.

CONCLUSION

Among patients with acute hypoxemic respiratory failure, early extubation with high-flow nasal oxygen is a feasible and superior alternative to the conventional method of weaning, as it increases the number of invasive mechanical ventilation-free days.

Effect of a multimodal analgesia strategy on remifentanil daily consumption in mechanically ventilated adult ICU patients: study protocol for a randomised, placebo-controlled, double-blind, parallel-group clinical trial

INTRODUCTION

Intensive care unit (ICU) patients under mechanical ventilation experience mild-to-severe pain. International guidelines emphasise the importance and benefits of multimodal analgesia to minimise opioid consumption and its side effects. However, no recommendation about drugs or protocol has been formulated. The aim of the Opioid-Free Analgesia in Intensive Care Unit study is to assess the feasibility of a standardised multimodal analgesia strategy and its benefits following the impact of remifentanil sparing in ICU patients.

METHODS AND ANALYSIS

50 mechanically ventilated adult patients will be recruited in a randomised, placebo-controlled, double-blind, feasibility trial. In the interventional group, patients will receive a standardised multimodal analgesia, initially receiving nefopam and tramadol, implementing with ketamine if patients remain painful, and then implementing with remifentanil with escalating doses in case of insufficient analgesia. In the control group, patients will receive remifentanil, implementing doses gradually to achieve analgesia. The primary outcome will be the daily consumption of remifentanil between the 24th and 48th hour after inclusion. Secondary outcomes will include drug tolerance, mechanical ventilation duration, ICU and hospital length of stay, 28-day and 90-day mortalities and 90-day opioid consumption.

ETHICS AND DISSEMINATION

The study protocol was accepted by the Nîmes University Hospital's research committee, the French ethics committee (Institutional Review Board OUEST IV) and the French National Agency for the Safety of Medicines and Health Products (ANSM).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05825560.

Personalized neuron-specific enolase level based on EEG pattern for prediction of poor outcome after cardiac arrest

BACKGROUND

After cardiac arrest (CA), the European recommendations suggest to use a neuron-specific enolase (NSE) level > 60 µg/L at 48-72 h to predict poor outcome. However, the prognostic performance of NSE can vary depending on electroencephalogram (EEG). The objective was to determine whether the NSE threshold which predicts poor outcome varies according to EEG patterns and the effect of electrographic seizures on NSE level.

METHODS

A retrospective study was conducted in a tertiary CA center, using a prospective registry of 155 adult patients comatose 72 h after CA. EEG patterns were classified according to the Westhall classification (benign, malignant or highly malignant). Neurological outcome was evaluated using the CPC scale at 3 months (CPC 3-5 defining a poor outcome).

RESULTS

Participants were 64 years old (IQR [53; 72,5]), and 74% were male. 83% were out-of-hospital CA and 48% were initial shockable rhythm. Electrographic seizures were observed in 5% and 8% of good and poor outcome patients, respectively (p = 0.50). NSE blood levels were significantly lower in the good outcome (median 20 µg/L IQR [15; 30]) compared to poor outcome group (median 110 µg/l IQR [49;308], p < 0,001). Benign EEG was associated with lower level of NSE compared to malignant and highly malignant patterns (p < 0.001). The NSE level was not significantly increased in patients with seizures as compared with malignant patterns (p = 0.15). In patients with a malignant EEG, a NSE > 45.2 µg/L was predictive of unfavorable outcome with 100% specificity and a higher sensitivity (70.8%) compared to the recommended NSE cut-off of 60 µg/l (Se = 66%). Combined to electrographic seizures, a NSE > 53.5 µg/L predicts poor outcome with 100% specificity and a higher sensitivity (77.7%) compared to the recommended cut-off (Se = 66.6%). Combined to a benign EEG, a NSE level > 78.2 µg/L was highly predictive of a poor outcome with a higher specificity (Sp = 100%) compared to the recommended cut-off (Sp = 94%).

CONCLUSION

In comatose patients after AC, a personalized approach of NSE according to EEG pattern could improve the specificity and sensitivity of this biomarker for poor outcome prediction. Compared to others malignant EEG, no significant difference of NSE level was observed in case of electrographic seizures.

A Critical Reappraisal of Haloperidol for Delirium Management in the Intensive Care Unit: Perspective from Psychiatry

Delirium is a complex neuropsychiatric syndrome with multifactorial pathophysiology, encompassing a wide range of neuropsychiatric symptoms, and its management remains a significant challenge in critical care. Although often managed with antipsychotics, like haloperidol, current research has predominantly focused on dopamine dysregulation as the primary driver of delirium, overlooking its broader neuroanatomical and neurochemical underpinnings. This has led to a majority of research focusing on haloperidol as a treatment for intensive care unit (ICU) delirium. Our review critically evaluates the role of haloperidol in ICU delirium management, particularly in light of recent large-scale randomized controlled trials (RCTs) that have primarily focused on delirium-free days and mortality as the primary endpoints. These studies highlight an limited understanding of the true nature of delirium treatment, which requires a broader, neuropsychiatric approach. We argue that future research should shift focus to neuropsychiatric symptoms such as agitation and psychosis and explore the clinical and functional benefits of reducing these distressing symptoms. Additionally, the stratification of delirium by subtypes and etiology, the enhancement of detection tools, and the adoption of multi-intervention and multi-disciplinary care approaches should be prioritized. Despite the methodological flaws in these studies, the findings support the safety of haloperidol in the ICU setting, with minimal risk of adverse events, particularly cardiac and neuropsychiatric. Moving forward, delirium research must integrate modern neuroscientific understanding and adopt more multi-disciplinary input and nuanced, patient-centered approaches to truly advance clinical care and outcomes.

Sedation in Home Care Surgical Procedures for a Patient With Dental Phobia: A Case Report

An 88-year-old woman received dental evaluation at home after missing out on regular dental checks due to a stroke 3 years ago. Her orofacial complaints included pain in the right side of the face and a desire to use dental prosthetics. Her comorbidities included systemic arterial hypertension and sequels from episodes of a thrombotic stroke and an acute myocardial infarction. Medications used were a beta-blocker, an angiotensin-converting enzyme inhibitor, a statin, and an antiplatelet agent. During the initial evaluation, the patient was alert, using a wheelchair, and was quite anxious and apprehensive, reporting episodes of dental phobia. On intraoral examination, findings consistent with the orofacial pain mentioned by the patient were observed. Sequentially, a treatment plan was developed to address the oral condition. The treatment was initiated with basic periodontal therapy and restorative procedures, performed with non-pharmacological stress reduction management. However, due to the patient's behavior during previous follow-ups, it was decided to perform extractions under sedation with antihistamine and nitrous oxide in the home setting. The procedure was conducted with vital signs monitoring, and the use of antiplatelet drugs was not suspended. Local bleeding control measures were applied, and the postoperative period occurred without complications. Besides promoting accessibility, home dental care provides treatment in a safe environment for the patient, which enhances comfort and reduces patient anxiety. Additionally, using sedation with antihistamine and nitrous oxide achieved an adequate level of relaxation for more effective stress control during the extractions.

Adherence to Lung Protective Ventilation in ARDS: A Mixed Methods Study Using Real-Time Continuously Monitored Ventilation Data

Background: Lung-protective ventilation is a standard intervention for mitigating ventilator-induced lung injury in patients with ARDS. Despite its efficacy, adherence to contemporary evidence-based guidelines remains suboptimal. We aimed to identify factors that affect the adherence of staff to applying lung-protective ventilation guidelines by analyzing real-time, continuously monitored ventilation data over a 5-year longitudinal period. Methods: We conducted retrospective cohort and qualitative studies. Subjects with billing code J80 who survived at least 48 h of continuous mandatory ventilation with volume control in critical care settings between January 1, 2018, and December 31, 2022, were eligible. Tidal volume was measured dynamically (1-min resolution) and averaged hourly. The lung-protective ventilation setting studied was ≤6 mL/kg predicted body weight. A subgroup analysis was conducted by considering COVID-19 status. Focus groups of critical-care providers were convened to investigate the possible reasons for the non-utilization of lung-protective ventilation. Results: Among 1,055 subjects, 42.4% were on lung-protective ventilation settings at 48 h. Male sex was correlated with lung-protective ventilation (odds ratio [OR] 1.63, 95% CI 1.08-2.47), whereas age ≥60 y was associated with no lung-protective ventilation use (OR 0.61, 95% CI 0.39-0.94] in the subjects with non-COVID-19 etiologies. Improved staff adherence was observed in the subjects with COVID-19 early in the pandemic when COVID-19 (OR 1.48, 95% CI 1.07-2.04), male sex (OR 2.42, 95% CI 1.79-3.29), and neuromuscular blocking agent use within 48 h (OR 1.69, 95% CI 1.25-2.29) were correlated with staff placing subjects on lung-protective ventilation. However, lung-protective ventilation use occurred less frequently by staff managing subjects with cancer (OR 0.59, 95% CI 0.35-0.99) and hypertension (OR 0.62, 95% CI 0.45-0.85). Focus groups supported these findings and highlighted the need for an accurate height measurement on unit admission to determine the appropriate target tidal volume. Conclusions: Staff are not yet universally adherent to lung-protective ventilation best practices. Strategies, for example, continuous monitoring, with frequent feedback to clinical teams may help.

Patients' and relatives' experiences of cognitive impairment following an intensive care unit admission. A qualitative study

BACKGROUND

Cognitive impairment poses a significant challenge following critical illness in the intensive care unit. A knowledge gap exists concerning how patients experience cognitive impairments.

OBJECTIVES

The aim was to explore patients' and relatives' experiences of patients' cognitive impairment due to critical illness following an intensive care unit admission.

METHODS

A qualitative multicentre study was conducted in Denmark with 3- and 6-month follow-ups using single and dyadic interviews. A phenomenological hermeneutic approach was adopted using a Ricoeur-inspired textual in-depth analysis method. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

RESULTS

Three themes emerged from interviews with 18 patients and 14 relatives: 'It feels like living in a parallel world', 'Getting back to a normal everyday life with a vulnerable self', and 'Managing everyday life using self-invented strategies'. Patients used self-invented strategies to manage their vulnerability and newly acquired cognitive impairments when no help or support was provided specifically targeting their cognitive impairments. Not being as cognitively capable as they previously had been turned their lives upside down. Losing control and not being themselves made them vulnerable. Patients did not want to burden others. However, support from relatives was invaluable in their recovery and rehabilitation.

CONCLUSIONS

Patients experienced multiple cognitive impairments affecting their adaption to everyday life. They strove to overcome their vulnerability using a variety of self-invented strategies and activities.

Efficacy of repetitive transcranial magnetic stimulation in preventing postoperative delirium in elderly patients undergoing major abdominal surgery: A randomized controlled trial

BACKGROUND

Postoperative delirium (POD) is a serious complication in elderly patients after major surgery, associated with high morbidity and mortality. Treatment and prevention methods are limited. Repetitive transcranial magnetic stimulation (rTMS) shows potential in enhancing cognitive function and improving consciousness.

OBJECTIVE

To evaluate whether early postoperative rTMS has a protective effect against POD and to explore its potential mechanisms.

METHODS

Patients aged 60 years or older, scheduled for major abdominal surgery, were randomly assigned to receive rTMS at 100 % RMT, 10 Hz, with 2000 pulses targeting the DLPFC after extubation in PACU, either as active rTMS(n = 61) or sham rTMS (n = 61). The primary outcome was the incidence of POD during the first 3 postoperative days.

RESULTS

In the modified intention-to-treat analysis of 122 patients (mean [SD] age, 70.2 [4.1] years; 53.3 % women), POD incidence was lower in the rTMS group (11.5 %) compared to the sham rTMS group (29.5 %) (relative risk, .39; 95 % CI, .18 to .86; P = .01). rTMS patients had higher BDNF (8.47 [2.68] vs. 5.76 [1.42] ng/mL; P < .001) and lower NfL (.05 [.04] vs. .06 [.04] ng/mL; P = .02) levels. Mediation analysis suggests that rTMS may reduce POD by increasing brain-derived neurotrophic factor (z = -3.72, P < .001) rather than decreasing neurofilament light (z = 1.92, P = .06).

CONCLUSIONS

Immediate postoperative rTMS can reduce the incidence of POD in elderly patients undergoing major abdominal surgery, probably by upregulating brain-derived neurotrophic factor levels.

The Chinese Mandarin COMHON Index and Braden Scale to assess pressure injury risk in intensive care: An inter-rater reliability and convergent validity study

BACKGROUND

The COMHON Index is an intensive-care-specific pressure injury risk assessment tool, which has demonstrated promising psychometric properties. It has been translated into Chinese Mandarin but requires inter-rater reliability testing and comparison to the standard care instrument (Braden Scale) before clinical use.

OBJECTIVES

This study aimed to test and compare the inter-rater reliability and convergent validity of the Chinese Mandarin versions of the COMHON Index and Braden Scale.

METHODS

The study was conducted in a Chinese comprehensive intensive care unit. Based on a sample size calculation, five registered nurse raters with at least 6-months experience independently conducted risk assessments for 20 adult patients using both the COMHON Index and Braden Scale. Intraclass correlations (ICC) for inter-rater reliability, standard errors of measurement (SEM), and minimally detectable change (MDC) were calculated. Convergent validity was assessed using Pearson Product Moment Correlation for sum scores and Spearman's rho for subscales.

RESULTS

Inter-rater reliability of COMHON Index and Braden Scale sum scores was very high (ICC [1,1] = 0.973; [95% confidence interval 0.949-0.988]; SEM 0.54; MDC 1.50) and high (ICC [1,1] = 0.891; [95% confidence interval 0.793-0.951]; SEM 0.93; MDC 2.57), respectively. All COMHON-Index subscales demonstrated ICC values >0.6, whereas two Braden Scale subscales (Mobility, Activity) were below this threshold. Instrument sum scores were strongly correlated (Pearson's r = -0.76 [r2 = 0.58]; p < 0.001), as were three subscale item pairs (mobility rs= -0.56 [r2 = 0.32]; nutrition rs= -0.63 [r2 = 0.39]; level of consciousness/sensory perception rs= -0.67 [r2 = 0.45] p < 0.001).

CONCLUSION

Both the COMHON Index and Braden Scale demonstrated high levels of inter-rater reliability and measured similar constructs. However, the COMHON Index demonstrated superior inter-rater reliability and the results suggest that it better detects changes in patient condition and subsequently pressure injury risk. Further testing is recommended.

Pharmacological and non-pharmacological interventions in patients undergoing nasal surgeries for prevention of emergence agitation: a systematic review and network meta-analysis

BACKGROUND

Emergence agitation is a common complication after nasal surgeries, marked by increased agitation and a heightened risk of injuries. Factors like urinary catheter, endotracheal tube, postoperative pain, and younger age contribute to its occurrence. Due to the variety of preventive approaches reported in the literature, a network meta-analysis is essential.

METHODS

This systematic review employs a network meta-analysis design, following Cochrane Handbook and PRISMA-NMA criteria. Inclusion criteria involve randomized controlled studies on pharmacological and non-pharmacological interventions for preventing emergence agitation in nasal surgeries. Electronic searches, including PubMed, Scopus, Embase, Cochrane Library, and Web of Science, without language or date restrictions, were conducted. Two independent reviewers selected studies, and data extraction was performed using standardized tables. Bayesian NMA, MetaInsight web app, and Cochrane Foundation Risk of Bias Assessment Tool were applied for data analysis and bias assessment.

RESULTS

After a rigorous selection process, 17 Randomized Controlled Trials (RCTs) encompassing 2,122 patients and 14 interventions were included. The best ranked treatments identified were intraoperative dexmedetomidine (1 μg.kg-1 for 10 minutes as a bolus, followed by 0.4 μg.kg-1.h-1), bilateral nasociliary and maxillary nerve block, ketamine (0.5 mg.kg-1 administered 20 minutes before the end of surgery), nasal compression for 40 minutes before anesthesia induction, and suction above the cuff of the endotracheal tube.

CONCLUSIONS

Both pharmacological and non-pharmacological interventions emerged as effective strategies in mitigating emergence agitation after nasal surgeries, offering clinicians valuable options for improving postoperative outcomes in this patient population.

Lack of correlation between central venous minus arterial PCO2 to arterial minus central venous O2 content ratio and respiratory quotient in patients with septic shock: A prospective observational study

OBJECTIVE

Central venous-arterial PCO2 to arterial-central venous O2 content ratio (Pcv-aCO2/Ca-cvO2) is commonly used as a surrogate for respiratory quotient (RQ) and tissue oxygenation. Although Pcv-aCO2/Ca-cvO2 might be associated with hyperlactatemia and outcome, neither the interchangeability with RQ nor the correlation with conclusive variables of anaerobic metabolism has never been demonstrated in septic shock. Our goal was to compare Pcv-aCO2/Ca-cvO2 and RQ in patients with septic shock.

DESIGN

Prospective, observational study.

SETTING

Two adult ICUs.

PATIENTS

Forty-seven patients with septic shock on mechanical ventilation with stable respiratory settings and vasopressor dose after initial resuscitation.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

We measured arterial and central venous gases, Hb, and O2Hb. Pcv-aCO2/Ca-cvO2 and the ratio of central venous-arterial CO2 content to arterial-central venous O2 content (Ccv-aCO2/Ca-cvO2) were calculated. RQ was determined by indirect calorimetry.

RESULTS

Pcv-aCO2/Ca-cvO2 and Ccv-aCO2/Ca-cvO2 were not correlated with RQ (R2 = 0.01, P = 0.50 and R2 = 0.01, P = 0.58, respectively), showing large bias and wide 95 % limits of agreement with RQ (1.09, -1.10-3.27 and 0.42, -1.53-2.37). A multiple linear regression model showed Hb, and central venous PCO2 and O2Hb, but not RQ, as Pcv-aCO2/Ca-cvO2 determinants (R2 = 0.36, P = 0.0007).

CONCLUSIONS

In patients with septic shock, Pcv-aCO2/Ca-cvO2 did not correlate with RQ and was mainly determined by factors that modify the dissociation of CO2 from Hb. Pcv-aCO2/Ca-cvO2 seems to be a poor surrogate for RQ; therefore, its values should be interpreted with caution.

Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study

BACKGROUND

Pain, delirium, and sedation should be assessed routinely using validated assessment scales. Inappropriately managed pain, delirium, and sedation in critically ill patients can have serious consequences regarding mortality, morbidity, and increased healthcare costs. Despite the benefits of a bundled approach to pain, delirium, and sedation assessments, few studies have explored nurses' perceptions of using validated scales for such assessments. Furthermore, no studies have examined nurses' perceptions of undertaking these assessments as a bundled approach.

OBJECTIVES

The objective of this study was to explore nurses' knowledge, perceptions, attitudes, and experiences regarding the use of validated pain, delirium, and sedation assessment tools as a bundled approach in the intensive care unit (ICU).

METHODS

A qualitative exploratory descriptive design was adopted. We conducted four focus groups and 10 individual interviews with 23 nurses from a 26-bed adult ICU at an Australian metropolitan tertiary teaching hospital. Data were analysed using thematic analysis techniques.

FINDINGS

Four themes were identified: (i) factors impacting nurses' ability to undertake pain, delirium, and sedation assessments in the ICU; (ii) use, misuse, and nonuse of tools and use of alternative strategies to assess pain, delirium, and sedation; (iii) implementing assessment tools; and (iv) consequences of suboptimal pain, delirium, and sedation assessments. A gap was found in nurses' use of validated scales to assess pain, delirium, and sedation as a bundled approach, and they were not familiar with using a bundled approach to assessment.

CONCLUSION

The practice gap could be addressed using a carefully planned implementation strategy. Strategies could include a policy and protocol for assessing pain, delirium, and sedation in the ICU, engagement of change champions to facilitate uptake of the strategy, reminder and feedback systems, further in-service education, and ongoing workplace training for nurses.

Rocking Motion Therapy for Delirious Patients in the ICU: A Multicenter Randomized Clinical Trial

OBJECTIVES

Rocking motion therapy has been shown to calm people with dementia but has never been investigated in delirious patients in the ICU. The aim of this clinical trial was to investigate the efficacy and safety of a rocking motion vs. nonrocking motion chair on the duration of delirium and intensity of agitation in ICU patients with delirium. We hypothesized that rocking motion therapy would increase the number of days alive without coma or delirium at 2 weeks of follow-up.

DESIGN

This was a multicenter, investigator initiated, parallel-group randomized controlled trial.

SETTING/PATIENTS

ICU patients 18 years or older with a positive delirium assessment.

INTERVENTIONS

Participants were assigned to either a minimum of 20 minutes rocking motion therapy or a minimum of 20 minutes in the same chair without rocking motion therapy turned on daily.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was days alive without coma or delirium 2 weeks after randomization. We enrolled 149 patients; 73 were randomly assigned to rocking motion therapy and 76 to nonrocking motion therapy. Primary outcome data were available in 141 patients.

CONCLUSIONS

Among patients with delirium in the ICU, the use of rocking motion therapy did not lead to a statistically significantly greater number of days alive without coma or delirium at the 2 weeks of follow-up than nonrocking motion therapy.

The Presence/Absence of an Awake-State Dominant EEG Rhythm in Delirious Patients Is Related to Different Symptoms of Delirium Evaluated by the Intensive Care Delirium Screening Checklist (ICDSC)

(1) Background: Delirium is a serious condition in patients undergoing treatment for somatic diseases, leading to poor prognosis. However, the pathophysiology of delirium is not fully understood and should be clarified for its adequate treatment. This study analyzed the relationship between confusion symptoms in delirium and resting-state electroencephalogram (EEG) power spectrum (PS) profiles to investigate the heterogeneity. (2) Methods: The participants were 28 inpatients in a general hospital showing confusion symptoms with an Intensive Care Delirium Screening Checklist (ICDSC) score of 4 or above. EEG was measured at Pz in the daytime awake state for 100 s with the eyes open and 100 s with the eyes closed on the day of the ICDSC evaluation. PS analysis was conducted consecutively for each 10 s datum. (3) Results: Two resting EEG PS patterns were observed regarding the dominant rhythm: the presence or absence of a dominant rhythm, whereby the PS showed alpha or theta peaks in the former and no dominant rhythm in the latter. The patients showing a dominant EEG rhythm were frequently accompanied by hallucination or delusion (p = 0.039); conversely, those lacking a dominant rhythm tended to exhibit fluctuations in the delirium symptoms (p = 0.020). The other ICDSC scores did not differ between the participants with these two EEG patterns. (4) Discussion: The present study indicates that the presence and absence of a dominant EEG rhythm in delirious patients are related to different symptoms of delirium. Using EEG monitoring in the care of delirium will help characterize its heterogeneous pathophysiology, which requires multiple management strategies.

Overtime work of anesthesiologists is associated with increased delirium in older patients admitted to intensive care unit after noncardiac surgery: a secondary analysis

BACKGROUND

Overtime work is common in anesthesiologists due to shortage of manpower. Herein, we analyzed if overtime work of anesthesiologists was associated with delirium development in older patients after surgery.

METHODS

This was a secondary analysis of the database from a randomized trial. Seven hundred older patients (aged ≥ 65 years) who were admitted to the intensive care unit (ICU) after elective noncardiac surgery were enrolled in the underlying trial. Anesthesiologists who worked continuously for more than 8 h by the end of the surgery were marked as "work overtime". Delirium was assessed with the Confusion Assessment Method for the ICU twice daily during the first 7 postoperative days. The association between overtime work of anesthesiologists and development of postoperative delirium was analyzed with multivariable logistic regression models.

RESULTS

All 700 patients (mean age 74.3 years, 39.6% female) were included in this analysis. Anesthesiologists of 281 patients (40.1%) were marked as "work overtime" at the end of surgery. When compared with patients whose anesthesiologists didn't work overtime, patients whose anesthesiologist worked overtime had a higher incidence of delirium within 7 days (20.3% [57/281] vs. 12.9% [54/419], P = 0.009). After correction for confounding factors, both overtime work (OR 1.87, 95% CI 1.19-2.94, P = 0.007) and prolonged continuous working hours of anesthesiologists (OR 1.08, 95% CI 1.01-1.15, P = 0.020) were associated with an increased risk of postoperative delirium.

CONCLUSIONS

Overtime work of anesthesiologists was associated with an increased risk of delirium development in older patients admitted to ICU after major noncardiac surgery.

TRIAL REGISTRATION

The underlying trial was registered with Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=8734 ; ChiCTR-TRC-10000802; March 18, 2010).

The effectiveness of postoperative delirium prevention, diagnosis, and intervention protocol in patients monitored in the intensive care unit after cardiac surgery: a quasi-experimental study

BACKGROUND

The incidence of delirium is high in the intensive care unit (ICU) after cardiac surgery. The development of evidence-based care protocols for delirium management and training of nurses in this regard can ensure effective management of delirium. This quasi-experimental study aimed to assess the effectiveness of a postoperative delirium prevention, diagnosis, and intervention protocol in patients undergoing monitoring in the ICU after cardiac surgery.

METHODS

This study included 64 patients who underwent cardiac surgery and met the inclusion criteria, along with 14 nurses working in the ICU. Patients were divided into control (n = 32) and intervention (n = 32) groups. The study comprised three phases: determining the incidence of delirium in the control group and the delirium diagnosis status of the nurses; providing training to nurses on postoperative delirium prevention, diagnosis and intervention protocol; implementing a preliminary study of the protocol; and finally, implementing the protocol in the intervention group. Statistical significance was set at p < 0.05.

RESULTS

While there was no significant agreement in delirium diagnosis between researcher and nurses in the control group (kappa: 0.207) (p > 0.05), significant agreement was observed in the intervention group (kappa: 1.00) (p < 0.001). The delirium diagnosis rate of the nurses was 14.3% in the control group and 100% in the intervention group, which was a significant difference. The incidence of delirium was 21.9% in the control group and 9.4% in the intervention group, although the difference was not significant.

CONCLUSION

Postoperative delirium prevention, diagnosis, and intervention protocol effectively enhance delirium diagnosis compliance among researchers and nurses and improve the accuracy of delirium diagnosis among postcardiac surgery ICU patients. The implementation of this protocol is recommended for delirium management in such patients.

TRIAL REGISTRATION

This study was retrospectively registered at Clinicaltrials.gov on 19.02.2024 (Clinical Trials ID: NCT06268119).

Efficacy and safety of a non-immersive virtual reality-based neuropsychological intervention for cognitive stimulation and relaxation in patients with critical illness: study protocol of a randomized clinical trial (RGS-ICU)

BACKGROUND

Experiencing a critical illness may be a stressful life event that is also associated with cognitive dysfunction during and after the intensive care unit (ICU) stay. A deep-tech solution based on non-immersive virtual reality, gamification and motion capture called Rehabilitation Gaming System for Intensive Care Units (RGS-ICU) has been developed that includes both cognitive stimulation and relaxation protocols specifically designed for patients with critical illness. This study aims to evaluate whether the cognitive and relaxation protocols of the RGS-ICU platform are 1) effective in improving neuropsychological outcomes during and after ICU stay and 2) safe for patients with critical illness.

METHODS

This is a study protocol for a multicenter longitudinal randomized clinical trial. At least 80 patients with critical illness will be included: 40 experimental subjects and 40 control subjects. Patients in the experimental group will receive daily 20-min sessions of cognitive stimulation and relaxation with the RGS-ICU platform adjuvant to standard ICU care in their own rooms during the ICU stay and until discharge from the ICU or up to a maximum of 28 days after randomization, provided they are alert and calm. Patients in the experimental group will be constantly monitored as part of standard ICU care to ensure the safety of the intervention and that no avoidable adverse events occur. Patients in the control group will receive standard ICU care. The primary outcome is objective cognition 12 months after ICU discharge, assessed with a composite index including measures of attention, working memory, learning/memory, executive function and processing speed. The secondary outcome is the safety of the intervention, assessed by considering the number of sessions terminated early due to unsafe events in physiological parameters. Other outcomes are comfort experienced during the ICU stay, and subjective cognition, mental health (anxiety, depression and post-traumatic stress disorder), functionality and health-related quality of life 12 months after ICU discharge.

DISCUSSION

The expected results are 1) better neuropsychological outcomes during and after the ICU stay in patients in the experimental group compared to patients in the control group and 2) that the cognitive and relaxation protocols of the RGS-ICU platform are safe for patients with critical illness.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06267911. Registered on February 20, 2024.

The Effects of Opioid-Free Anesthesia with Dexmedetomidine and Esketamine on Postoperative Anesthetic-Related Complications for Hip Surgery in the Elderly

Purpose

The routine perioperative use of opioids has recently been questioned due to opioid-related side effects, which can be potentially harmful in geriatric patients. This study aimed to evaluate the effects of opioid-free anesthesia in geriatric patients undergoing hip surgery.

Patients and Methods

A total of 121 patients, aged 60 years or older, undergoing elective hip surgery were randomized to receive either opioid-free anesthesia with dexmedetomidine and esketamine (OFA group) or balanced anesthesia with opioids (CON group). All patients received a preoperative fascia iliaca block and postoperative patient-controlled analgesia using tramadol. The primary outcome was the incidence of a composite of anesthetic-related complications (nausea and vomiting, hypoxemia, ileus, urinary retention and delirium) within 48 hours postoperatively. The hemodynamics, postoperative pain and quality of life were also assessed.

Results

The incidence of composite adverse events was significantly reduced in the OFA group compared with the CON group (35.0% vs 62.3%, estimated difference: 27.3%, 95% confidence interval: 10.2%-44.4%, P = 0.003). Notably, patients in the OFA group experienced less postoperative nausea and vomiting (P = 0.040), and hypoxemia (P = 0.025) compared with those in the CON group. However, the incidences of postoperative ileus, urinary retention and delirium were comparable between the two groups. Also, patients in the OFA group had less pain in motion at 24 h postoperatively, as well as less risks of intraoperative hypotension and bradycardia (P <0.05). No significant differences in the postoperative quality of life were observed between the two groups.

Conclusion

Opioid-free anesthesia with dexmedetomidine and esketamine reduced postoperative anesthetic-related complications and provided improved hemodynamic stability in geriatric patients undergoing hip surgery.

Evaluation of Delirium Risk Factors in Intensive Care Patients

Objective

The negative effects of delirium in intensive care unit (ICU) patients necessitate the identification and management of risk factors. This study aimed to determine the incidence of delirium and its associated modifiable and non-modifiable factors in the ICU setting to provide valuable insights for better patient care and outcomes.

Methods

Patients admitted to the ICU underwent delirium screening twice daily. Comprehensive records of modifiable and non-modifiable risk factors were maintained throughout the ICU stay.

Results

The incidence of delirium was 32.5%. Age [odds ratio (OR) 1.04, confidence interval (CI) 1.02-1.06, P < 0.001)]. Illiteracy (OR 4, CI 1.19-13.35, P=0.02), hearing impairment (OR 3.37, CI 1.71-7.01, P=0.001), visual impairment (OR 3.90, CI 2.13-7.15, P < 0.001), hypertension (OR 2.56, CI 1.42-4.62, P=0.002), Sequential Organ Failure Assessment score (OR 1.21, CI 1.08-1.36, P=0.001), Acute Physiology and Chronic Health Evaluation II score (OR 1.20, CI 1.12-1.28, P < 0.001), presence of a nasogastric catheter/drain (OR 2.15, CI 1.18-3. 90, P=0.01), tracheal aspiration (OR 3.63, CI 1.91-6.90, P < 0.001), enteral nutrition (OR 2.54, CI 1.12-5.76, P=0.02), constipation (OR 1.65, Cl 1.11-2.45, P=0.02), oliguria (OR 1.56, Cl 1.06-2.28, P=0.02), midazolam infusion (OR 3. 4, Cl 1.16-10.05, P=0.02), propofol infusion (OR 2.91 Cl 1.03-8.19, P=0.04), albumin use (OR 2.39, Cl 1.11-5.14 P=0.02) and steroid use (OR 2.17, Cl 1.06-4.40, P=0.03) were found to be independent risk factors for delirium.

Conclusion

This study highlights several risk factors contributing to delirium, such as age, sensory impairment, educational level, procedural interventions, and medications. Oral nutrition and mobilization are effective strategies for reducing delirium incidence in the ICU.

Management of pain and sedation in the intensive care unit

Advances in our approach to treating pain and sedation when caring for patients in the intensive care unit (ICU) have been propelled by decades of robust trial data, knowledge gained from patient experiences, and our evolving understanding of how pain and sedation strategies affect patient survival and long term outcomes. These data contribute to current practice guidelines prioritizing analgesia-first sedation strategies (analgosedation) that target light sedation when possible, use of short acting sedatives, and avoidance of benzodiazepines. Together, these strategies allow the patient to be more awake and able to participate in early mobilization and family interactions. The covid-19 pandemic introduced unique challenges in the ICU that affected delivery of best practices and patient outcomes. Compliance with best practices has not returned to pre-covid levels. After emerging from the pandemic and refocusing our attention on optimal pain and sedation management in the ICU, it is imperative to revisit the data that contributed to our current recommendations, review the importance of best practices on patient outcomes, and consider new strategies when advancing patient care.

Association between oxidative stress and postoperative delirium in joint replacement using diacron-reactive oxygen metabolites and biological antioxidant potential tests

Postoperative delirium (POD) is a significant complication of surgery that most severely affects older adults and patients with cognitive impairment. This study investigated the relationship between POD and oxidative stress, hypothesizing that increased oxidative stress, measured using diacron-reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) tests, is associated with the incidence of POD. This prospective cohort study, involving female patients who underwent unilateral or bilateral joint replacement, was conducted at the Osaka University Graduate School of Medicine from June 2022 to July 2023. Blood samples were collected preoperatively and postoperatively to measure oxidative stress markers using the REDOXLIBRA system. The primary endpoint was the association between changes in oxidative stress markers and the occurrence of POD as diagnosed using the Confusion Assessment Method for the Intensive Care Unit and Richmond Agitation-Sedation Scale. Of the 144 patients screened, 60 were eligible, of which 5 developed POD (8.3%). Analysis of oxidative stress markers revealed no significant changes between preoperative and postoperative values of d-ROMs (mean increase + 6.3 ± 54.2 U CARR) and BAP (mean decrease - 37.4 ± 322.9 µM) tests, or BAP/d-ROMs ratio (mean decrease - 0.4 ± 1.7). Further, no significant differences were observed in oxidative stress markers between patients who underwent unilateral and bilateral procedures. However, patients with POD exhibited a significantly higher increase in d-ROMs than those without complications (p = 0.015), whereas changes in BAP and BAP/d-ROM ratios were not statistically significant. Although general oxidative stress markers do not significantly change postoperatively, increased d-ROM levels are associated with POD occurrence, indicating that oxidative stress could be a contributing factor to its development. This study underscores the need for further research into specific oxidative markers that may predict POD and guide the development of targeted interventions to prevent this debilitating condition.Trial registration Name of the registry Association Between Changes in Blood Oxidative Stress and Postoperative Delirium Following Joint Replacement Surgery: A Retrospective Study. Trial registration number 22021. Date of registration 6/29/2022. URL of trial registry record https://bvits.dmi.med.osaka-u.ac.jp/esct/Apply/project.aspx?PROJECT_ID=6987 .

Pharmacogenomic variation and sedation outcomes during early intensive care unit admission: A pragmatic study

Unpredicted responses to sedatives and analgesics are common in critically ill patients on mechanical ventilation (MV) and may be attributed to genetic variation. Our primary aim was to investigate the association between the pharmacogenomic (PGx) variation and sedation outcomes. The secondary aim was to capture intensive care unit (ICU) participants' perceptions of PGx. This was a prospective, observational PGx association study. Adult ICU patients receiving acute MV and sedatives/analgesics were enrolled. The number of altered PGx phenotypes in genes relevant to fentanyl, propofol, and midazolam (CYP2D6, CYP3A4/5, COMT, OPRM1, and CYP2B6) were tested with logistic regression for association with achieving ≥60% and ≥70% of time within Richmond Agitation-Sedation Scale (RASS) target range (0 to -2) in the first 24 and 48 h of MV. Participants' perceptions of PGx testing and satisfaction with the return of PGx results were collected. Participants (n = 78) had a median of 2 altered PGx phenotypes. Fentanyl and propofol combination was the most frequently administered regimen. There were non-significant associations of worse sedation outcomes with an increasing number of altered PGx phenotypes (i.e., adjusted odds ratio of achieving target RASS range = 0.46 to 0.96 for each altered phenotype increase at both 24 and 48 h). Individuals participating in the post-discharge survey had positive perceptions toward PGx. There were no associations between sedation outcomes and PGx variants in the studied 6 genes. Larger studies are needed to investigate the impact of these genes and to evaluate additional genes. ICU participants had positive attitudes and perceptions toward PGx.

Efficacy of ultrasound guided sphenopalatine ganglion block in management of emergence agitation after sinoscopic nasal surgery: a randomized double-blind controlled study

BACKGROUND

Nasal surgery has a reported high incidence of agitation during emergence from general anesthesia. Emergence Agitation (EA) increases the risk of surgical site bleeding, falling off the operating table, removal of catheters and intravenous lines, and self-extubation. This study investigated the role of nerve block in EA.

OBJECTIVES

This study evaluated the effect of ultrasound-guided sphenopalatine ganglion block (SPGB) on EA after sinoscopic nasal surgery. The primary outcome was the incidence of EA. Secondary outcomes included the quality of the surgical field, bleeding volume, inhalational anesthesia, MAC, VAS in the PACU, postoperative analgesia duration, and total 24 -h opioid consumption.

PATIENTS AND METHODS

This double-blind, randomized controlled study enrolled 120 patients, of whom 110 completed the study. They were randomly allocated into two equal groups: G1, which received general anesthesia and a bilateral sphenopalatine ganglion block (SPBG) with 5 mL lidocaine 2% on each side, and G2 (control), which received general anesthesia and a bilateral sphenopalatine saline injection of 5 mL on each side.

RESULTS

A significant decrease in the incidence of EA was found in G1 compared to G2 (20% vs. 64%). Intraoperative bleeding volume was significantly lower, and surgical field quality was significantly higher in G1 compared to G2. Pain severity was significantly lower in G1 in the PACU, and 24 h postoperative opioid consumption was significantly reduced compared to G2. Additionally, postoperative analgesia duration was significantly longer in G1 than in G2 (9 h vs. 3 h).

CONCLUSION

SPGB effectively reduced EA incidence, severity, and duration after sinoscopic nasal surgery. Furthermore, SPGB reduced intraoperative bleeding, improved surgical field quality, prolonged postoperative analgesia, and reduced 24 -h opioid consumption after sinoscopic nasal surgery.

REGISTRATION

National Clinical Trial Registry, NCT04168879.

Effects of dexmedetomidine versus propofol on outcomes in critically ill patients with different sedation depths: a propensity score-weighted cohort study

OBJECTIVE

We explored the effects of dexmedetomidine (DEX) versus propofol on outcomes in critically ill patients and to assess whether these effects are dissimilar under different sedation depths.

METHODS

A stabilized inverse probability of treatment weighting cohort study was conducted using data from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. Adult intensive care unit (ICU) patients who were administered DEX or propofol as the primary sedative were identified. Various statistical methods were used to evaluate the effects of DEX versus propofol on outcomes.

RESULTS

Data on 107 and 2318 patients in DEX and propofol groups, respectively, were analyzed. Compared to the propofol group, the DEX group exhibited longer ventilator-free days on day 28 and a shorter ICU stay. Conversely, it showed null associations of DEX with the risk of 90-day ICU mortality, the odds of persistent organ dysfunction on day 14 and acute kidney injury, and the duration of vasopressor-free days on day 28. Subgroup analyses revealed that DEX positively impacted persistent organ dysfunction on day 14, ventilator-free days on day 28, and ICU stay in the subgroup with a Richmond Agitation Sedation Scale (RASS) score of ≥-2. However, DEX negatively impacted 90-day ICU mortality, persistent organ dysfunction on day 14, and ventilator-free days on day 28 in the subgroup with a RASS score of <-2.

CONCLUSION

Our results indicated that, compared with propofol, DEX had beneficial and adverse impacts on certain ICU outcomes in critically ill patients, and these impacts appeared to depend on sedation depths.

The Effect of Music on Postoperative Agitation, Pain, and Opioid Use among Patients Undergoing Total Knee Replacement

BACKGROUND

Postoperative pain and agitation is an ongoing issue among patients undergoing total knee replacement (TKR). Use of complementary therapies such as music may improve outcomes when combined with medical therapy.

AIM

The purpose of this quality improvement (QI) initiative was to evaluate postoperative use of classical music among adult patients who have undergone TKR on reported agitation, pain, and opioid use.

DESIGN

A prospective evidence-based QI initiative.

SETTING

A midwestern hospital post-anesthesia care unit.

PARTICIPANTS

Postoperative patients who had undergone TKR.

METHODS

Classical piano music was played postoperatively using an MP3 device. Adult patients who were undergoing TKR were consecutively offered music during their recovery period in the PACU. Agitation was measured using the Richmond Agitation Sedation Score (RASS). Patient perceived pain was measured on a scale of 0-10 with 0 being no pain and 10 being extreme pain. Opioid use was measured using the morphine milligram equivalents (MME).

FINDINGS

A total of (n=40) patients received music and (n=50) patients received standard care without music. RASS was significantly lower in the music group than in the baseline non-music group X2 (1, N = 89) = 17.8, p < .001. Patient reported pain scores were significantly lower in the music group, 3.98(SD = 2.71), compared to the baseline non-music group, 6.27(SD = 2.60). Opioid use was also significantly decreased in the music group to MME 9.51(SD = 8.62) compared to the baseline non-music group 13.38 (SD = 9.71).

CONCLUSION

Music is an effective nonpharmacologic intervention in decreasing agitation, pain, and opioid use among patients undergoing TKR. These findings provide evidence for nurses to incorporate music as an adjunctive approach to enhance the patient's experience and improve outcomes.

Magnesium sulfate infusion for emergence agitation in adult patients after general anesthesia: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Emergence agitation following general anesthesia poses significant risks to both patients and medical staff. While extensive research has explored the efficacy of magnesium sulfate (MgSO4) in managing pediatric emergence agitation, its effectiveness in adults remains uncertain. Therefore, this meta-analysis seeks to evaluate the efficacy of MgSO4 in mitigating emergence agitation following general anesthesia in adult populations.

EVIDENCE ACQUISITION

A systematic search was conducted across PubMed, Embase, Cochrane Library, and Web of Science databases to identify randomized controlled trials (RCTs) comparing MgSO4 or placebo infusion during surgical procedures involving adult patients under general anesthesia. Key outcomes assessed included the incidence of emergence agitation, agitation severity scores, extubation duration, and postoperative nausea and vomiting (PONV). Statistical analyses were conducted using Review Manager 5.4.1 (Cochrane, London, UK), with heterogeneity evaluated using I2 statistics. Significance was defined at P<0.05 for Odds Ratios (OR), mean differences (MD), and standard mean differences (SMD).

EVIDENCE SYNTHESIS

Five RCTs encompassing 605 participants were included. MgSO4 resulted in a lower emergence agitation incidence (OR=0.29 [95% CI: 0.12;0.72]; P=0.007). There were no significant differences between groups for patient's agitation severity scores (SMD=-0.69 [95% CI: -1.82; 0.44]; P=0.23), extubation time (MD=1.16 [95% CI: -1.06; 3.37]; P=0.30), or PONV incidence (OR=0.52 [95% CI: 0.15-1.76]; P=0.29).

CONCLUSIONS

Magnesium sulfate infusion during general anesthesia was associated with lower incidence of emergence agitation in adults. However, no significant differences were observed regarding emergence agitation severity scores, PONV, or extubation time.

Postoperative Sedation in General Care Wards: A Retrospective Cohort Study

BACKGROUND

We hypothesized that deeper sedation in the postanesthesia care unit (PACU) increases the risk of subsequent sedation in general care wards (ward sedation) and that patients with ward sedation have more postoperative adverse events than those without ward sedation.

METHODS

We reviewed the health records of adult patients who underwent procedures with general anesthesia at Mayo Clinic from May 5, 2018, through December 31, 2020, and were discharged from the PACU to the general care ward. Patient groups were dichotomized as with ward sedation (Richmond Agitation-Sedation Scale [RASS], ≤-2) and without ward sedation (RASS, ≥-1) within the first 24 hours after PACU discharge. Multivariable logistic regression was used to assess the association between clinical variables and ward sedation.

RESULTS

A total of 23,766 patients were included in our analysis, of whom 1131 had ward sedation (incidence, 4.8 [Poisson 95% confidence interval, CI, 4.5-5.0]) per 100 patients after general anesthesia. Half of the ward sedation episodes occurred within 32 minutes after PACU discharge. The risk of ward sedation increased with the depth of PACU sedation. The odds ratios (95% CI) of ward sedation for patients with a PACU RASS score of -1 was 0.98 (0.75-1.27); -2, 1.87 (1.44-2.43); -3, 2.98 (2.26-3.93); and ≤-4, 3.97 (2.91-5.42). Adverse events requiring an emergency intervention occurred more often for patients with ward sedation (n = 92, 8.1%) than for those without ward sedation (n = 326, 1.4%; P < .001).

CONCLUSIONS

Among patients who met our criteria for PACU discharge, deeper sedation during anesthesia recovery was associated with an increased risk of ward sedation. Patients who had ward sedation had worse outcomes than those without ward sedation.

Feasibility of In-Hospital Administration of a Tool to Predict Persistent Post-ICU Functional Impairment Among Older ICU Survivors: A Pilot Study

BACKGROUND

A recent international consensus conference called for the development of risk prediction models to identify ICU survivors at increased risk of each of the post-ICU syndrome domains. We previously developed and validated a risk prediction tool for functional impairment after ICU admission among older adults.

RESEARCH QUESTION

In this pilot study, we assessed the feasibility of administering the risk prediction tool in the hospital to older adults who had just survived critical illness. An exploratory objective was to evaluate whether augmentation of the model with additional hospital-related factors improved discrimination.

STUDY DESIGN AND METHODS

Between January and October 2020, 50 adults aged 65 years and older underwent in-hospital administration of the risk prediction tool. Survivors were called monthly for 6 months after discharge. Feasibility was defined as completion of all tool components by ≥ 70% of enrolled participants. Persistent functional impairment was defined as failure to return to the functional baseline from before the ICU stay at the 6-month interview based on seven daily activities. The model was sequentially refit after adding three in-hospital factors as predictors, one at a time and then all together. Model discrimination was assessed with receiver operating characteristic curves.

RESULTS

The tool met the a priori feasibility threshold, with 92.0% of enrolled participants completing all eight components. In the exploratory analysis, the addition of Acute Physiology and Chronic Health Evaluation II score, presence of delirium, and maximum in-hospital mobility resulted in a 5% gain in discrimination that did not achieve statistical significance (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.68-0.82; P = .09).

INTERPRETATION

Our results indicate that the risk prediction tool is feasible for use in the hospital setting, enabling the identification of ICU survivors at high risk of persistent functional impairment at 6 months after discharge. Augmentation with hospital-related factors improved model discrimination, but did not achieve statistical significance in this pilot study. Future studies should evaluate the augmented model in larger cohorts.

Deep learning models using intracranial and scalp EEG for predicting sedation level during emergence from anaesthesia

Background

Maintaining an appropriate depth of anaesthesia is important for avoiding adverse effects from undermedication or overmedication during surgery. Electroencephalography (EEG) has become increasingly used to achieve this balance. Investigating the predictive power of intracranial EEG (iEEG) and scalp EEG for different levels of sedation could increase the utility of EEG monitoring.

Methods

Simultaneous iEEG, scalp EEG, and Observer's Assessment of Alertness/Sedation (OAA/S) scores were recorded during emergence from anaesthesia in seven patients undergoing placement of intracranial electrodes for medically refractory epilepsy. A deep learning model was constructed to predict an OAA/S score of 0-2 vs 3-5 using iEEG, scalp EEG, and their combination. An additional five patients with only scalp EEG data were used for independent validation. Models were evaluated using the area under the receiver-operating characteristic curve (AUC).

Results

Combining scalp EEG and iEEG yielded significantly better prediction (AUC=0.795, P<0.001) compared with iEEG only (AUC=0.750, P=0.02) or scalp EEG only (AUC=0.764, P<0.001). The validation scalp EEG only data resulted in an AUC of 0.844. Combining the two modalities appeared to capture spatiotemporal advantages from both modalities.

Conclusions

The combination of iEEG and scalp EEG better predicted sedation level than either modality alone. The scalp EEG only model achieved a similar AUC to the combined model and maintained its performance in additional patients, suggesting that scalp EEG models are likely sufficient for real-time monitoring. Deep learning approaches using multiple leads to capture a wider area of brain activity may help augment existing EEG monitors for prediction of sedation.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion

PURPOSE

Dexmedetomidine is often used for longer than its labeled indication of 24 hours, raising concerns for potential withdrawal. Data are limited regarding this syndrome in adult patients. This study aimed to further characterize dexmedetomidine withdrawal in critically ill adult patients after prolonged use.

METHODS

This was an institutional review board-exempt, single-center, retrospective chart review conducted at a tertiary academic medical center. Adult intensive care unit (ICU) patients on dexmedetomidine for ≥72 hours in 2019 were screened for inclusion. Exclusion criteria were interruption of dexmedetomidine for >6 hours, indications for dexmedetomidine other than sedation, or patients with neurological or burn injury. The major end point was the incidence of dexmedetomidine withdrawal, defined as meeting ≥2 of the following criteria within 24 hours of discontinuation: newly positive Confusion Assessment Method for ICU, Richmond Agitation Sedation Scale score of ≥+2, hypertension, and tachycardia. Minor end points were incidence of individual withdrawal signs as previously described, additional sedatives or antipsychotics required, dose and duration of dexmedetomidine infusion, length of ventilation, ICU and hospital length of stay, and new onset of the following: fever, vomiting, loose stools/diarrhea, diaphoresis, or seizure.

FINDINGS

Of the 152 patients included, dexmedetomidine withdrawal occurred in 54 patients (35.5%). Rebound hypertension was the most common withdrawal sign (47 patients [87.0%]). In the withdrawal group, significantly more patients required additional β-blockers (29 [53.7%] vs 10 [10.2%]; P < 0.01), were reinitiated on dexmedetomidine (16 [29.6%] vs 10 [10.2%]; P < 0.01), and required a start or increased dose of clonidine (6 [11.1%] vs 3 [3.1%]; P = 0.04). There was no significant difference in the cumulative dose or duration of dexmedetomidine between the groups. Length of ventilation was longer in the withdrawal group (171 hours [83.7-280.8 hours] vs 159 hours [149.0-335.7 hours]; P < 0.01), but there was no difference in ICU or hospital length of stay.

IMPLICATIONS

Prolonged use of dexmedetomidine was associated with withdrawal syndrome in 35.5% of patients in our study. Larger trials are needed to confirm the risk factors for dexmedetomidine withdrawal and identify measures to prevent withdrawal.

Early deep-to-light sedation versus continuous light sedation for ICU patients with mechanical ventilation: A cohort study

BACKGROUND

Sedation strategies have not been well established for patients being treated with invasive mechanical ventilation (MV). This study aimed to compare the potential effects of alternative sedation strategies - including early deep-to-light sedation (DTLS), continuous deep sedation (CDS) and continuous light sedation (CLS, the currently recommended strategy) - on ventilator, intensive care unit (ICU) or hospital mortality.

METHODS

A cohort study was conducted using two large validated ICU databases, including the Registry of Healthcare-associated Infections in ICUs in China (ICU-HAI) and the Medical Information Mart for Intensive Care (MIMIC). Patients who received MV for more than 3 days with one of three sedation strategies were included. Multivariable survival analyses with inverse probability-weighted competing risk models were conducted separately for ICU-HAI and MIMIC cohorts. Adjusted estimates were pooled using fixed-effects models.

RESULTS

In total, 6700 patients (2627 ICU-HAI, 4073 MIMIC) were included in the cohort study, of whom 2689 received CLS, 2079 CDS and 1932 DTLS. Compared to CLS, DTLS was associated with lower ICU mortality (9.3% vs. 11.0%; pooled adjusted HR 0.78, 95% CI 0.66-0.94) and hospital mortality (16.0% vs. 14.1%; 0.86, CI 0.74-1.00); and CDS was associated with higher ventilator mortality (32.8% vs. 7.0%; 4.65, 3.91-5.53), ICU mortality (40.6% vs. 11.0%; 3.39, 2.95-3.90) and hospital mortality (46.8% vs. 14.1%; 3.27, 2.89-3.71) than CLS. All HRs were qualitatively consistent in both cohorts.

CONCLUSIONS

Compared to the continuous light sedation, early deep-to-light sedation strategy was associated with improved patient outcomes, and continuous deep sedation was confirmed with poorer patient outcomes.