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

COVID-19 in the Critically Ill Pregnant Patient

Pregnant women are at increased risk for severe coronavirus disease 2019 (COVID-19) and COVID-19-related complications. Their increased risk in conjuncture with the normal physiologic changes in pregnancy poses unique challenges for the management of the critically ill pregnant patient. This article will review the initial management of pregnant patients who develop acute hypoxic respiratory failure and subsequent treatment of those that deteriorate to acute respiratory distress syndrome and require advanced therapies. Moreover, fetal monitoring and timing of delivery will be reviewed.

Use of dexmedetomidine for sedation in mechanically ventilated adult ICU patients: a rapid practice guideline

PURPOSE

The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM‑RPG) was to formulate evidence‑based guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU).

METHODS

We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and web‑based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities.

RESULTS

The ICM‑RPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: "In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia".

CONCLUSION

This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities.

Epidemiology of mechanical ventilation in Argentina. The EpVAr multicenter observational study

OBJETIVE

To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population.

DESIGN

A prospective, multicenter, observational study was carried out.

SETTING

Intensive Care.

PATIENTS

We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals.

INTERVENTIONS

None.

VARIABLES

All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND.

RESULTS

The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001).

CONCLUSIONS

The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies.

Opioid Prescribing Patterns Before, During, and After Critical Illness: An Observational Study

OBJECTIVES:

The association between opioid therapy during critical illness and persistent opioid use after discharge is understudied relative to ICU opioid exposure and modifiable risk factors. Our objectives were to compare persistent opioid use after discharge among patients with and without chronic opioid use prior to admission (OPTA) and identify risk factors associated with persistent use.

DESIGN:

Retrospective cohort study.

SETTING:

Medical, trauma/surgical, or neurologic ICU at an academic hospital.

PARTICIPANTS:

Adult patients surviving hospital admission.

INTERVENTIONS:

Opioid use during the ICU and post-ICU stays.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was persistent opioid use accounting for greater than 70% of days 4–6 months after discharge. Among 2,975 included patients, 257 (8.6%) were classified as OPTA, and 305 (10.2%) persistently filled opioid prescriptions, including 186/257 (72%) OPTA and 119/2,718 (4.4%) with no chronic opioid fills prior to admission. Among all patients, OPTA was strongly associated with persistent opioid use (odds ratio, 57.2 [95% CI, 41.4–80.0]). Multivariable logistic regression revealed that male sex, surgical procedure, and ICU opioid-free days were associated with reduced persistent opioid use for OPTA patients. Age and ICU opioid-free days were associated with reduced persistent opioid use for non-OPTA patients. Total ICU opioid dose and dose per day of ICU exposure were not associated with persistent use for either group.

CONCLUSIONS:

In this mixed cohort of ICU patients, 10.2% persistently filled opioid prescriptions 4–6 months after discharge. Although ICU opioid doses were not associated with persistent use, duration of ICU opioid administration is a modifiable risk factor that may reduce persistent opioid use after critical illness.

Hyperinflammation Reduces Midazolam Metabolism in Critically Ill Adults with COVID-19

BACKGROUND AND OBJECTIVE

Many patients treated for COVID-19 related acute respiratory distress syndrome in the intensive care unit are sedated with the benzodiazepine midazolam. Midazolam undergoes extensive metabolism by CYP3A enzymes, which may be inhibited by hyperinflammation. Therefore, an exaggerated proinflammatory response, as often observed in COVID-19, may decrease midazolam clearance. To develop a population pharmacokinetic model for midazolam in adult intensive care unit patients infected with COVID-19 and to assess the effect of inflammation, reflected by IL-6, on the pharmacokinetics of midazolam.

METHODS

Midazolam blood samples were collected once a week between March 31 and April 30 2020. Patients were excluded if they concomitantly received CYP3A4 inhibitors, CYP3A4 inducers and/or continuous renal replacement therapy. Midazolam and metabolites were analyzed with an ultra-performance liquid chromatography-tandem mass spectrometry method. A population pharmacokinetic model was developed, using nonlinear mixed effects modelling. IL-6 and CRP, markers of inflammation, were analyzed as covariates.

RESULTS

The data were described by a one-compartment model for midazolam and the metabolites 1-OH-midazolam and 1-OH-midazolam-glucuronide. The population mean estimate for midazolam clearance was 6.7 L/h (4.8-8.5 L/h). Midazolam clearance was reduced by increased IL-6 and IL-6 explained more of the variability within our patients than CRP. The midazolam clearance was reduced by 24% (6.7-5.1 L/h) when IL-6 increases from population median 116 to 300 pg/mL.

CONCLUSIONS

Inflammation, reflected by high IL-6, reduces midazolam clearance in critically ill patients with COVID-19. This knowledge may help avoid oversedation, but further research is warranted.

Sleep Spindles and K-Complexes Are Favorable Prognostic Biomarkers in Critically Ill Patients

SUMMARY

In this narrative review, we summarize recent research on the prognostic significance of biomarkers of sleep in continuous EEG and polysomnographic recordings in intensive care unit patients. Recent studies show the EEG biosignatures of non-rapid eye movement 2 sleep (sleep spindles and K-complexes) on continuous EEG in critically ill patients better predict functional outcomes and mortality than the ictal-interictal continuum patterns. Emergence of more complex and better organized sleep architecture has been shown to parallel neurocognitive recovery and correlate with functional outcomes in traumatic brain injury and strokes. Particularly interesting are studies which suggest intravenous dexmedetomidine may induce a more biomimetic non-rapid eye movement sleep state than intravenous propofol, potentially providing more restorative sleep and lessening delirium. Protocols to improve intensive care unit sleep and neurophysiological studies evaluating the effect of these on sleep and sleep architecture are here reviewed.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: (1) delirium prevention, (2) pharmacological treatment, (3) non-pharmacological treatment, and (4) barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

The Pharmacist’s Role in the Implementation of FASTHUG-MAIDENS, a Mnemonic to Facilitate the Pharmacotherapy Assessment of Critically Ill Patients: A Cross-Sectional Study

FASTHUG is a mnemonic used by intensive care physicians to ensure the proper management of patients admitted to an Intensive Care Unit (ICU). FASTHUG-MAIDENS is a modified version that incorporates key pharmacotherapeutic elements such as delirium management, drug dosing, and drug interactions for an appropriate medication assessment of critically ill patients. An analytical cross-sectional study of hospitalized patients was carried out to determine aspects related to the pharmacotherapeutic management of critically ill patients that required to be optimized, to design and implement a protocol based on the FASTHUG-MAIDENS mnemonic. A total of 435 evaluations were performed to assess the status of current critical patient management. The main parameters with opportunities to be improved were analgesia, feeding, and sedation. With the implementation of MAIDENS, the parameters of analgesia, sedation, and thromboprophylaxis showed an increase in the percentage of optimal management. Furthermore, 103 drug-related problems were detected, and most of them were associated with feeding (21.3%), glucose control (11.7%), and delirium (9.7%). The FASTHUG MAIDENS protocol implementation allows for the evaluation of more vital aspects in the management of critically ill patients. The daily review of patients admitted to the ICU by a clinical pharmacist (CP) using the FASTHUG-MAIDENS checklist instead of the FASTHUG mnemonic facilitates the identification of DRPs for the performance of possible interventions by the CP to improve the pharmacotherapeutic management.

Upcoming and urgent challenges in critical care research based on COVID-19 pandemic experience

While the coronavirus disease 2019 (COVID-19) pandemic placed a heavy burden on healthcare systems worldwide, it also induced urgent mobilisation of research teams to develop treatments preventing or curing the disease and its consequences. It has, therefore, challenged critical care research to rapidly focus on specific fields while forcing critical care physicians to make difficult ethical decisions. This narrative review aims to summarise critical care research -from organisation to research fields- in this pandemic setting and to highlight opportunities to improve research efficiency in the future, based on what is learned from COVID-19. This pressure on research revealed, i.e., i/ the need to harmonise regulatory processes between countries, allowing simplified organisation of international research networks to improve their efficiency in answering large-scale questions; ii/ the importance of developing translational research from which therapeutic innovations can emerge; iii/ the need for improved triage and predictive scores to rationalise admission to the intensive care unit. In this context, key areas for future critical care research and better pandemic preparedness are artificial intelligence applied to healthcare, characterisation of long-term symptoms, and ethical considerations. Such collaborative research efforts should involve groups from both high and low-to-middle income countries to propose worldwide solutions. As a conclusion, stress tests on healthcare organisations should be viewed as opportunities to design new research frameworks and strategies. Worldwide availability of research networks ready to operate is essential to be prepared for next pandemics. Importantly, researchers and physicians should prioritise realistic and ethical goals for both clinical care and research.

Antipsychotic prescribing practices and patient, family member and healthcare professional perceptions of antipsychotic prescribing in acute care settings: a scoping review protocol

INTRODUCTION

Antipsychotic medications are commonly prescribed off-label in acutely ill patients for non-psychiatric clinical indications such as delirium or insomnia. New prescription initiation of antipsychotics in acute care settings increases the proportion of patients discharged home on antipsychotics without approved clinical indication. Long-term use of antipsychotics is associated with increased risk of sudden cardiac death, falls and cognitive impairment. An understanding of acute care off-label antipsychotic prescribing practices and healthcare professional, patient and family perceptions related to antipsychotic prescribing and deprescribing is necessary to facilitate in-hospital deprescribing initiatives.

METHODS AND ANALYSIS

We present the protocol for a scoping review following the methodology proposed by Arksey and O'Malley and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search five databases including MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science from inception to 3 July 2021 (ie, planned search date). We will include both peer-reviewed and non-peer-reviewed qualitative and quantitative studies to identify antipsychotic prescribing practices, and to describe healthcare professional, patient and family perceptions towards antipsychotic prescribing and deprescribing in the acute care setting. Protocols, systematic and scoping reviews will be excluded. Two reviewers will calibrate and perform study screening and data abstraction for quantitative and qualitative outcomes of eligible studies. Quantitative outcomes will include study identifiers, demographics and descriptive statistics of antipsychotic prescribing practices. Qualitative synthesis describing perceptions on antipsychotic prescribing practices will include deductive thematic analysis with mapping of themes to the domains of the Theoretical Domains Framework, a 14-domain behaviour and behaviour change framework.

ETHICS AND DISSEMINATION

No ethical approval will be required for this study as only data from published studies in which informed consent was obtained by primary investigators will be retrieved and analysed. The results of this scoping review will inform integrated knowledge translation initiatives aimed at in-hospital antipsychotic medication deprescribing.

Parents’ Views with Music Therapy in the Pediatric Intensive Care Unit: A Retrospective Cohort Study

Purpose: Music therapy intervention (MT) could be used as an adjunctive therapy in PICU for anxiety and pain management. The aim of the study was to examine the perception of MT by children’s parents in a PICU of a tertiary care teaching hospital. Methods: This is a retrospective cohort study summarizing the results of an institutional quality improvement initiative. Questionnaires were distributed to parents whose children were exposed to MT. Results: From April 2019 to July 2021, 263 patients received a total of 603 h of MT. Twenty-five questionnaires were distributed to parents over a 4-month period (February–June 2021). A total of 19 (76%) parents completed the questionnaire. The majority of parents thought that MT helped their child to communicate (89%), feel less isolated (100%) and cope with stress during hospitalization (100%). The majority of parents also thought that MT contributed to physical recovery (90%) and alleviated feelings of anxiety (90%). Parents also believed that MT should be offered as an out-patient service. Conclusions: Our study agrees with other studies on the positive potentials of MT in PICU. Music therapy intervention could be used to promote children’s and parents’ psychological well-being. Further studies are warranted to evaluate the impact of MT on long-term post-ICU outcomes.

Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications

Reverse triggering is an underdiagnosed form of patient-ventilator asynchrony in which a passive ventilator-delivered breath triggers a neural response resulting in involuntary patient effort and diaphragmatic contraction. Reverse triggering may significantly impact patient outcomes, and the unique physiology underscores critical potential implications for drug-device-patient interactions. The purpose of this review is to summarize what is known of reverse triggering and its pharmacotherapeutic consequences, with a particular focus on describing reported cases, physiology, historical context, epidemiology, and management. The PubMed database was searched for publications that reported patients presenting with reverse triggering. The current body of evidence suggests that deep sedation may predispose patients to episodes of reverse triggering; as such, providers may consider decreasing sedation or modifying ventilator settings in patients exhibiting ventilator asynchrony as an initial measure. Increased clinician awareness and research focus are necessary to understand appropriate management of reverse triggering and its association with patient outcomes.

Validation of a delirium predictive model in patients admitted to surgical intensive care units: a multicentre prospective observational cohort study

OBJECTIVE

To internally and externally validate a delirium predictive model for adult patients admitted to intensive care units (ICUs) following surgery.

DESIGN

A prospective, observational, multicentre study.

SETTING

Three university-affiliated teaching hospitals in Thailand.

PARTICIPANTS

Adults aged over 18 years were enrolled if they were admitted to a surgical ICU (SICU) and had the surgery within 7 days before SICU admission.

MAIN OUTCOME MEASURES

Postoperative delirium was assessed using the Thai version of the Confusion Assessment Method for the ICU. The assessments commenced on the first day after the patient's operation and continued for 7 days, or until either discharge from the ICU or the death of the patient. Validation was performed of the previously developed delirium predictive model: age+(5×SOFA)+(15×benzodiazepine use)+(20×DM)+(20×mechanical ventilation)+(20×modified IQCODE>3.42).

RESULTS

In all, 380 SICU patients were recruited. Internal validation on 150 patients with the mean age of 75±7.5 years resulted in an area under a receiver operating characteristic curve (AUROC) of 0.76 (0.683 to 0.837). External validation on 230 patients with the mean age of 57±17.3 years resulted in an AUROC of 0.85 (0.789 to 0.906). The AUROC of all validation cohorts was 0.83 (0.785 to 0.872). The optimum cut-off value to discriminate between a high and low probability of postoperative delirium in SICU patients was 115. This cut-off offered the highest value for Youden's index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%).

CONCLUSIONS

The model developed by the previous study was able to predict the occurrence of postoperative delirium in critically ill surgical patients admitted to SICUs.

TRIAL REGISTRATION NUMBER

Thai Clinical Trail Registry (TCTR20180105001).

Effects of nonpharmacological interventions on sleep improvement and delirium prevention in critically ill patients: A systematic review and meta-analysis

OBJECTIVE

Sleep disturbance and delirium are common problems experienced by critically ill patients in the intensive care unit (ICU). These interrelated issues increase the length of stay in the ICU but might also negatively affect long-term health outcomes. The objective of this study was to identify the nonpharmacological interventions provided to improve sleep or prevent delirium in ICU patients or both and integrate their effect sizes.

REVIEW METHODS

This study was a registered systematic review and meta-analysis. We searched MEDLINE, CINAHL, EMBASE, Web of Science, and Cochrane Library from their inception until December 2021. We included randomised controlled trials and nonrandomised controlled trials-(RCT) that provided nonpharmacological interventions and reported sleep or delirium as outcome variables. Studies not published in English or whose full text was not available were excluded. The quality of the evidence was assessed with version 2 of the Cochrane risk-of-bias tool for RCTs and the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I).

RESULTS

The systematic review included 118 studies, and the meta-analysis included 100 studies. Overall nonpharmacological interventions had significant effects on subjective sleep quality (standardised mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56), delirium incidence (odds ratio = 0.62, 95% CI = 0.53 to 0.73), and delirium duration (standardised mean difference = -0.68, 95% CI = -0.93 to -0.43). In individual interventions, aromatherapy, music, and massage effectively improved sleep. Exercise, family participation, information giving, cognitive stimulation, bright light therapy, architectural intervention, and bundles/protocols effectively reduced delirium. Light/noise blocking was the only intervention that ensured both sleep improvement and delirium prevention.

CONCLUSIONS

Our results suggest nonpharmacological interventions improve sleep and prevent delirium in ICU patients. We recommend that ICU nurses use nonpharmacological interventions that promote person-environment compatibility in their clinical practice. The results of our review can guide nurses in adopting interventions related to sleep and delirium.

PROSPERO REFERENCE NUMBER

CRD42021230815.

Validation Testing of the European Portuguese Critical-Care Pain Observation Tool

Aim. The study aim was to validate the Portuguese version of the Critical-Care Pain Observation Tool (CPOT) in the critically ill adult population of Portugal. Methods. A prospective, observational cohort study was conducted to evaluate the CPOT in mechanically ventilated patients who were admitted to an intensive care unit. A consecutive sample of 110 patients was observed at rest pre-procedure, during a nociceptive procedure (NP) which includes turning/positioning and endotracheal or tracheal suctioning and 20 min post-procedure. Two raters participated in the data collection. The discriminative validity, criterion validity, convergent validity and inter-rater reliability of the CPOT were examined. Results. The inter-rater reliability was excellent (0.93 ≤ α ≤ 1.00) at rest and fair to moderate (0.39 ≤ α ≤ 0.60) during the NP. The CPOT could discriminate between conditions with higher scores during the NP when compared to CPOT scores at rest (p < 0.001). The optimal CPOT cut-off score was >2, with a sensitivity of 71% and a specificity of 80%, and self-reported pain was the gold standard criterion. Significant correlations (<0.40) were found between CPOT scores, the heart rate and the respiratory rate during the nociceptive procedure. Conclusions. The CPOT appears to be a valid alternative for both ventilated and non-ventilated patients who are unable to communicate.

Respiratory distress observation scales to predict weaning outcome

Background

Whether dyspnea is present before starting a spontaneous breathing trial (SBT) and whether it may affect the outcome of the SBT is unknown. Mechanical Ventilation—Respiratory Distress Observation Scale (MV-RDOS) has been proposed as a reliable surrogate of dyspnea in non-communicative intubated patients. In the present study, we sought (1) to describe the evolution of the MV-RDOS during a SBT and (2) to investigate whether MV-RDOS can predict the outcome of the SBT.

Methods

Prospective, single-center study in a twenty-two bed ICU in a tertiary center. Patients intubated since more 48 h who had failed a first SBT were eligible if they meet classical readiness to wean criteria. The MV-RDOS was assessed before, at 2-min, 15-min and 30-min (end) of the SBT. The presence of clinically important dyspnea was inferred by a MV-RDOS value ≥  2.6.

Results

Fifty-eight patients (age 63 [51–70], SAPS II 66 [51–76]; med [IQR]) were included. Thirty-three (57%) patients failed the SBT, whose 18 (55%) failed before 15-min. Twenty-five (43%) patients successfully passed the SBT. A MV-RDOS ≥ 2.6 was present in ten (17%) patients before to start the SBT. All these ten patients subsequently failed the SBT. A MV-RDOS ≥ 2.6 at 2-min predicted a SBT failure with a 51% sensibility and a 88% specificity (AUC 0.741 95% confidence interval [CI] 0.616–0.866, p = 0.002). Best cut-off value at 2-min was 4.3 and predicted SBT failure with a 27% sensibility and a 96% specificity.

Conclusion

Despite patients met classical readiness to wean criteria, respiratory distress assessed with the MV-RDOS was frequent at the beginning of SBT. Measuring MV-RDOS before to initiate a SBT could avoid undue procedure and reduce patient’s exposure to unnecessary mechanical ventilation weaning failure and distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04028-7.

The effectiveness of music interventions on stress response in intensive care patients: A systematic review and meta-analysis

AIM AND OBJECTIVE

To investigate the effectiveness of music interventions on physiological and psychological stress response in intensive care unit (ICU) patients.

BACKGROUND

ICU patients are exposed to several physiological and psychological stressors during their treatments. Music interventions can be implemented to control these negative effects.

DESIGN

Systematic review and meta-analysis conducted according to PRISMA Guidelines.

METHOD

This meta-analysis was conducted per PRISMA guidelines. Seven electronic literature databases, reference lists of similar reviews, grey literature and the Clinical Trials Registry were searched for potential studies up to 30 September 2021. Studies were expected to meet PICOS inclusion criteria. Two reviewers independently assessed the risk of bias of the included studies by using the Cochrane Collaboration tool. Overall, meta-analysis and subgroup analyses (comparator group and music session frequency) were performed using RevMan 5.4. Meta-analysis was conducted when data were available; otherwise, a narrative description was provided.

RESULTS

Twenty-five articles were included in this review. Music intervention was found to provide reductions in anxiety levels concerning psychological stress. However, it was found that music had an effect only on the systolic blood pressure level concerning the physiological stress and had no effect on the diastolic blood pressure, respiration rate or heart rate. In the subgroup analysis performed against the comparator groups, it was found that music decreased the anxiety level compared to the standard care group but was not effective compared to the noise reduction group. It was found that multiple music sessions reduced the anxiety level better than a single music session.

CONCLUSIONS

Music interventions involving multiple sessions can be used as a nursing intervention to control the anxiety levels of ICU patients.

RELEVANCE TO THE CLINICAL PRACTICE

Using music to reduce anxiety and stress levels may reduce the pharmacological need (for sedative or antipsychotic medications) and the risk of associated side effects in ICU patients.

Uncontrolled pain in critically ill patients and acute kidney injury: a hypothesis-generating cohort study

Background

In critically ill patients, acute pain occurs frequently, causes sympathetic activation, release of inflammatory mediators, and potential organ dysfunction, with the kidneys potentially sensitive to inflammation-mediated injury. This study aimed to explore the association between acute pain in critically ill patients and the occurrence of acute kidney injury (AKI).

Methods

Data from a retrospective cohort of adult patients admitted between June 2013 and June 2016 to the Intensive Care Unit (ICU) of a tertiary hospital in São Paulo, Brazil, were analyzed. The main exclusion criteria were ICU length of stay < 48 h, coma, and prior kidney dysfunction. The outcome (AKI) was defined as an elevation in the baseline serum creatinine level of ≥ 0.3 mg/dl and/or > 50% at any time after the first 48 h in the ICU. Multivariable logistic regression and hierarchical cluster analysis were performed.

Results

The isolated incidence of pain was 23.6%, and the incidence of pain duration > 5 days was 10.6%. AKI occurred in 31.7% of the cohort. In multivariable logistic analysis, duration of pain > 5 days (OR 5.25 CI 2.19–12.57 p < 0.01) and mechanical ventilation (MV) ≥ 3 days (OR 5.5 CI 2.3–13.5 p < 0.01) were the variables with positive association with AKI. The hierarchical cluster analysis reinforced the relation between AKI, MV and duration of pain.

Conclusions

Pain is an especially important issue in critically ill patients and in this exploratory study it appears to be associated with AKI development. The search for more rigorous pain control in ICU is crucial and can influence organ dysfunction.

Graphical Abstract

Efforts to improve sleep quality in a medical intensive care unit: effect of a protocol of non-pharmacological interventions

PURPOSE

This study aimed to evaluate the effect of a protocol of nonpharmacological interventions to improve sleep quality in the intensive care unit (ICU). Due to its close relationship with sleep quality, the effects of the same interventions on noise levels and delirium rates were also evaluated in this study.

METHODS

This pretest-posttest design with a control group was carried out in a medical ICU over 8 months. Data were collected using Acute Physiology and Chronic Health Evaluation II, the Glasgow Coma Scale, the Richmond Agitation-Sedation Scale, the Richards-Campbell Sleep Questionnaire (RCSQ), the Confusion Assessment Method for the Intensive Care Unit, and noise measurement devices. In the first phase of the study, patients receiving standard care in the ICU were followed. After the first stage, a training session was held for nurses to raise awareness and information. Then, the sleep-promoting protocol created by the researchers was applied. The ambient noise level was measured continuously.

RESULTS

A total of 78 patients with a mean age of 70.0 ± 13.2 years were followed in the ICU for an average of 7.3 ± 3.8 days. With protocol implementation, the ambient noise level in the ICU was reduced from 70.9 ± 3.8 dB(A) to 62.7 ± 3.5 dB(A) (p < 0.01); the RCSQ scores of the patients increased from 48.3 ± 1.4 to 62.1 ± 1.8 (p < 0.01). Although statistically nonsignificant, efforts to improve sleep quality also reduced the development of delirium by 15%.

CONCLUSION

It is possible to improve sleep quality and reduce noise levels in an ICU with a protocol consisting of multicomponent nonpharmacological interventions.

Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials

Conventional gabaminergic sedatives such as benzodiazepines and propofol are commonly used in mechanically ventilated patients in the intensive care unit (ICU). Dexmedetomidine is an alternative sedative that may achieve lighter sedation, reduce delirium, and provide analgesia. Our objective was to perform a comprehensive systematic review summarizing the large body of evidence, determining if dexmedetomidine reduces delirium compared to conventional sedatives. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov and the WHO ICTRP from inception to October 2021. Independent pairs of reviewers identified randomized clinical trials comparing dexmedetomidine to other sedatives for mechanically ventilated adults in the ICU. We conducted meta-analyses using random-effects models. The results were reported as relative risks (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs). In total, 77 randomized trials (n = 11,997) were included. Compared to other sedatives, dexmedetomidine reduced the risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty), the duration of mechanical ventilation (MD - 1.8 h, 95% CI  - 2.89 to  - 0.71; low certainty), and ICU length of stay (MD  - 0.32 days, 95% CI  - 0.42 to  - 0.22; low certainty). Dexmedetomidine use increased the risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty). In mechanically ventilated adults, the use of dexmedetomidine compared to other sedatives, resulted in a lower risk of delirium, and a modest reduction in duration of mechanical ventilation and ICU stay, but increased the risks of bradycardia and hypotension.

Adherencia al paquete de medidas ABCDEF durante la pandemia de COVID-19

Introducción

El objetivo de este estudio fue describir el conocimiento y el uso reportado del paquete de medidas ABCDEF en las unidades de cuidados intensivos (UCI) de adultos de la República Argentina durante la pandemia por SARS-CoV-2.

Métodos

Se realizó un estudio cualitativo a través de una encuesta nacional dirigida a profesionales de la salud.

Resultados

Se recibieron 396 cuestionarios completos de profesionales de 21 provincias argentinas y la Ciudad Autónoma de Buenos Aires. El 66% de los participantes contestaron que conocen el paquete y lo aplican con diferentes grados de implementación. El 42,9% informó que usa al menos una herramienta validada para evaluar el dolor. Más de la mitad de los encuestados afirman realizar vacaciones de sedación y pruebas de ventilación espontánea diariamente. Las escalas de sedación fueron utilizadas por el 66,6% de los participantes en forma rutinaria. El 62% utiliza herramientas validadas para la detección de delirium. Respecto de la movilización temprana y ejercicio de los pacientes, el 91,8% de los profesionales entrevistados comunicaron que realizan rehabilitación neuromuscular en su UCI. Finalmente, solamente el 6,8% informó que su unidad estaba abierta las 24 horas para las visitas familiares. Las principales barreras a la aplicación del paquete de medidas fueron los recursos humanos y hospitalarios limitados, la resistencia al cambio, la falta de información y el aislamiento por COVID-19.

Conclusión

El 66% de los participantes contestó que conoce el paquete y lo aplica con diferentes grados de implementación.

Recognizing Intensive Care Unit Delirium: Are Critical Care Nurses Ready?

BACKGROUND

Delirium remains significantly undetected in the intensive care unit (ICU). Little is known regarding the level of delirium care knowledge among critical care nurses in Taiwan.

PURPOSE

This study was designed to investigate the level of knowledge about delirium care among critical care nurses using a multiple-choice question quiz.

METHODS

A descriptive, cross-sectional approach was used, and data were collected using a web-based survey. The demographic characteristics including age, years worked as critical care nurse, gender, advanced ICU training, educational level, and type of ICU, along with a delirium care knowledge quiz, were collected. The quiz consisted of 16 items measuring (a) symptoms, types, and outcomes; (b) high-risk groups; (c) predisposing and precipitating factors; and (d) assessment and detection of delirium. Data were collected between October 6 and November 16, 2020.

RESULTS

In total, 324 critical care nurses completed the survey. The rate of correct response on the delirium care quiz for each domain was measured: (a) symptoms, types, and outcomes: 67.1%; (b) high-risk groups: 76.2%; (c) predisposing and precipitating factors: 78.9%; and (d) assessment and detection: 41.5%. The item with the lowest correct response rate was related to the interpretation of delirium assessments.

CONCLUSION/IMPLICATIONS FOR PRACTICE

The findings of this study suggest that future studies and education should focus on the use and interpretation of the assessment using a valid delirium assessment tool to improve the ability of critical care nurses to detect delirium in ICU settings.

Symptom experiences of critically-ill hematologic malignancy patients: A scoping review

CONTEXT

Critically-ill patients with hematologic malignancies are increasingly admitted to intensive care units globally. Unrelieved symptoms during intensive care treatment may contribute to poor outcomes.

OBJECTIVE

To better understand the symptom experience(s) for critically-ill patients with hematologic malignancies.

METHODS

A scoping review was conducted searching Medline, CINAHL, PychInfo, Embase, and ProQuest databases, the Cochrane Library, and the grey literature between January 1st, 1990 and July 15th, 2020. Two authors independently reviewed articles for inclusion and verified abstracted data.

RESULTS

Seventeen articles met inclusion criteria, including 11 cohort studies, 1 case-control study, and five review articles. No qualitative or mixed-method studies were retrieved. Symptoms were reported as the primary outcome across two studies (17%). Reported hematologic malignancy subtypes included leukemia and/or myelodysplastic syndrome (9, 53%), lymphoma (8, 47%), multiple myeloma (7, 41%), and aplastic anemia (2, 12%). The principal indication for ICU admission was respiratory failure, followed by cardiogenic shock/cardiac failure, endocrine disturbances, sepsis, and neurological failure. Only one study used validated tools for evaluating symptoms. Thirty-four symptoms were reported: altered level of consciousness/coma (35%); diarrhea (35%); nausea (35%); dyspnea (35%); vomiting (29%); and pain (29%). Two articles (13%) identified symptom clusters.

CONCLUSION

There is minimal research that measures and explores the symptom experiences of critically-ill patients with hematologic malignancies. New research in this domain is needed to inform targeted symptom care for this vulnerable patient population.

Dexmedetomidine in Prevention of Postoperative Delirium: A Systematic Review

Delirium is defined by the DSM-5 as a fluctuating course of disturbance in attention, cognition, and awareness that develops over a short period without any pre-existing neurocognitive disorder. As people age, there is an increased risk of complications that may occur following a surgical procedure and one such acute complication is delirium. Studies are emerging to reduce the incidence of postoperative delirium, and one such preventive measures implemented in recent years include the administration of dexmedetomidine, a high selectivity α-2 adrenoceptor agonist. This study aims to review the efficacy of Dexmedetomidine in the prevention of postoperative delirium in randomized controlled trials in patients older than 18 years of age. The literature was explored in three online databases, namely, PubMed, Science Direct, and Scopus. Appropriate keywords and MesH terms were employed to scrutinize relevant articles that demonstrated the effects of dexmedetomidine in the prevention of postoperative delirium. The data was restricted to randomized controlled trials and clinical trials published from 2017 to 2021 in human patients older than >18 years of age undergoing non-cardiac-related procedures. The randomized clinical trials were critically assessed with the Cochrane risk of bias tool. We proceeded to screen 428 records with the assessment of the PRISMA chart and filtered out 420 papers to obtain a total of eight studies where we identified data such as sample size, types of surgeries in which the patients were involved, the delirium assessment tool, the plan of the administration of dexmedetomidine and the outcomes evaluated in each study. The Confusion Assessment Method (CAM) was the prevailing assessment tool used with the sole purpose to evaluate the incidence of postoperative delirium as the primary outcome, and assessment of inflammatory cytokines, sleep quality, and pain scales were considered as secondary outcomes. The dosage of dexmedetomidine varied among studies, and it displayed varying impacts on postoperative delirium and the secondary outcomes as well. Limitations include varying ages and ethnicities of the population. It was concluded that dexmedetomidine prevents the development of postoperative delirium in elderly patients undergoing non-cardiac surgical interventions by modulating important predisposing factors such as neuroinflammation, pain, and sleep quality. No funding was made for this study.

Monitoring of sedation in mechanically ventilated patients using remote technology

PURPOSE OF REVIEW

Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected.

RECENT FINDINGS

High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity.

SUMMARY

Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.

Comparison of Dexmedetomidine Versus Propofol in Mechanically Ventilated Patients With Sepsis: A Meta-Analysis of Randomized Controlled Trials

Purpose: The aim of the present study was to evaluate the effects of dexmedetomidine compared with propofol in mechanically ventilated patients with sepsis.

Methods: We searched PubMed, EMBASE, and Cochrane Library for randomized controlled trials comparing the effects of dexmedetomidine versus propofol in septic patients requiring mechanical ventilation from inception to December 2021. The primary outcome was 28/30-day mortality and secondary outcomes were ventilator-free days and the length of ICU stay. Pooled relative risk (RR), mean deviation (MD), along with 95% confidence intervals (CI) were used to express outcomes by the software of Review Manager 5.3.

Results: Seven studies with a total of 1,212 patients were eligible for meta-analysis. The results primarily showed that dexmedetomidine had no significant effects on the 28/30-day mortality (RR = 1.04 [0.85–1.26], p = 0.70, I² = 3%). As for secondary outcomes, the administration of dexmedetomidine was not associated with longer-ventilator-free days (MD = 0.50 [−2.15, 3.15], p = 0.71, I² = 24%) compared with propofol. However, our results revealed dexmedetomidine could shorten the length of ICU stay (MD = −0.76 [−1.34, −0.18], p = 0.01, I² = 33%).

Conclusion: Administration of dexmedetomidine for sedation in septic patients who required mechanical ventilation had no effect on 28/30-day mortality and ventilator-free days, but it could shorten the length of ICU stay.

A machine learning approach to identifying delirium from electronic health records

The identification of delirium in electronic health records (EHRs) remains difficult due to inadequate assessment or under-documentation. The purpose of this research is to present a classification model that identifies delirium using retrospective EHR data. Delirium was confirmed with the Confusion Assessment Method for the Intensive Care Unit. Age, sex, Elixhauser comorbidity index, drug exposures, and diagnoses were used as features. The model was developed based on the Columbia University Irving Medical Center EHR data and further validated with the Medical Information Mart for Intensive Care III dataset. Seventy-six patients from Surgical/Cardiothoracic ICU were included in the model. The logistic regression model achieved the best performance in identifying delirium; mean AUC of 0.874 ± 0.033. The mean positive predictive value of the logistic regression model was 0.80. The model promises to identify delirium cases with EHR data, thereby enable a sustainable infrastructure to build a retrospective cohort of delirium.

Delirium is a commonly observed complication in hospitalized patients, especially with intensive care. While signs and symptoms of delirium could be observed and well managed during the hospital stay, less is known about the long-term complication of delirium after discharge. In order to monitor the long-term sequelae of delirium, the correct identification of delirium patients is crucial. Currently, the retrospective identification of delirium patients is limited due to the under-coding of delirium diagnosis in electronic health records. We proposed a simple machine-learning model to retrospectively identify patients who experienced delirium during their intensive care unit stay. The model could be used to identify missed delirium cases and the establishment of a delirium cohort for long-term monitoring and surveillance.

Long-term ketamine infusion-induced cholestatic liver injury in COVID-19-associated acute respiratory distress syndrome

Background

A higher-than-usual resistance to standard sedation regimens in COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) has led to the frequent use of the second-line anaesthetic agent ketamine. Simultaneously, an increased incidence of cholangiopathies in mechanically ventilated patients receiving prolonged infusion of high-dose ketamine has been noted. Therefore, the objective of this study was to investigate a potential dose–response relationship between ketamine and bilirubin levels.

Methods

Post hoc analysis of a prospective observational cohort of patients suffering from COVID-19-associated ARDS between March 2020 and August 2021. A time-varying, multivariable adjusted, cumulative weighted exposure mixed-effects model was employed to analyse the exposure–effect relationship between ketamine infusion and total bilirubin levels.

Results

Two-hundred forty-three critically ill patients were included into the analysis. Ketamine was infused to 170 (70%) patients at a rate of 1.4 [0.9–2.0] mg/kg/h for 9 [4–18] days. The mixed-effects model revealed a positively correlated infusion duration–effect as well as dose–effect relationship between ketamine infusion and rising bilirubin levels (p < 0.0001). In comparison, long-term infusion of propofol and sufentanil, even at high doses, was not associated with increasing bilirubin levels (p = 0.421, p = 0.258). Patients having received ketamine infusion had a multivariable adjusted competing risk hazard of developing a cholestatic liver injury during their ICU stay of 3.2 [95% confidence interval, 1.3–7.8] (p = 0.01).

Conclusions

A causally plausible, dose–effect relationship between long-term infusion of ketamine and rising total bilirubin levels, as well as an augmented, ketamine-associated, hazard of cholestatic liver injury in critically ill COVID-19 patients could be shown. High-dose ketamine should be refrained from whenever possible for the long-term analgosedation of mechanically ventilated COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04019-8.

Cost-effectiveness of clinical interventions for delirium: A systematic literature review of economic evaluations

OBJECTIVE

Little is known about the economic value of clinical interventions for delirium. This review aims to synthesise and appraise available economic evidence, including resource use, costs, and cost-effectiveness of interventions for reducing, preventing, and treating delirium.

METHODS

Systematic review of published and grey literature on full and partial economic evaluations. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Fourteen economic evaluations (43% full, 57% partial) across nine multicomponent and nonpharmacological intervention types met inclusion criteria. The intervention costs ranged between US$386 and $553 per person in inpatient settings. Multicomponent delirium prevention intervention and the Hospital Elder Life Program (HELP) reported statistically significant cost savings or cost offsets somewhere else in the health system. Cost savings related to inpatient, outpatient, and out-of-pocket costs ranged between $194 and $6022 per person. The average CHEERS score was 74% (±SD 10%).

CONCLUSION

Evidence on a joint distribution of costs and outcomes of delirium interventions was limited, varied and of generally low quality. Directed expansion of health economics towards the evaluation of delirium care is necessary to ensure effective implementation that meets patients' needs and is cost-effective in achieving similar or better outcomes for the same or lower cost.

Development of a scale measuring the difficulties faced by nurses who care for patients with delirium in intensive care units

BACKGROUND

Delirium in patients in the intensive care unit is associated with adverse outcomes. Nurses experience many difficulties in caring for those with delirium, which can lead to nurse burnout, prevent effective care for patients, and negatively impact the patient. The identification of factors creating challenges for nurses is, therefore, important to enable intervention.

OBJECTIVES

The aim of this study was to develop a new scale to assess the difficulties faced by nurses caring for patients with delirium in the intensive care unit and to examine its reliability and validity.

METHODS

We based our draft scale items on literature reviews and interviews. Four experts evaluated the collected items. After a pilot study, 211 nurses working in intensive care units in Japan completed the questionnaire. Subsequent statistical analysis of results included factor validity, construct validity, known-group validity, internal consistency, and test-retest reliability.

RESULTS

Exploratory factor analysis extracted a scale of 33 items with eight factors and an additional scale of four items with one factor. The analysis of construct validity suggested a possible association with the Strain of Care for Delirium Index. In the known-group validity, a comparison with two groups based on experience in the intensive care unit found significant differences among the five factors. Internal consistency (Cronbach's α = 0.68-.87) and test-retest reliability (intraclass correlation coefficients = .46-.62) were confirmed.

CONCLUSION

We developed a difficulty scale for nurses caring for patients with delirium in the intensive care unit and confirmed its reliability and validity. The difficulty factors were developed with the intention to identify educational interventions for nurses and the introduction of new organisational resources, such as manpower and providing emotional support and feedback to nurses.

Study protocol to test the efficacy of self-administration of dexmedetomidine sedative therapy on anxiety, delirium, and ventilator days in critically ill mechanically ventilated patients: an open-label randomized clinical trial

BACKGROUND

Administration of sedative and opioid medications to patients receiving mechanical ventilatory support in the intensive care unit is a common clinical practice.

METHODS

A two-site randomized open-label clinical trial will test the efficacy of self-management of sedative therapy with dexmedetomidine compared to usual care on anxiety, delirium, and duration of ventilatory support after randomization. Secondary objectives are to compare self-management of sedative therapy to usual care on level of alertness, total aggregate sedative and opioid medication exposure, and ventilator-free days up to day 28 after study enrolment. Exploratory objectives of the study are to compare self-management of sedative therapy to usual care on 3- and 6-month post-discharge physical and functional status, psychological well-being (depression, symptoms of post-traumatic stress disorder), health-related quality of life, and recollections of ICU care. ICU patients (n = 190) who are alert enough to follow commands to self-manage sedative therapy are randomly assigned to self-management of sedative therapy or usual care. Patients remain in the ICU sedative medication study phase for up to 7 days as long as mechanically ventilated.

DISCUSSION

The care of critically ill mechanically ventilated patients can change significantly over the course of a 5-year clinical trial. Changes in sedation and pain interventions, oxygenation approaches, and standards related to extubation have substantially impacted consistency in the number of eligible patients over time. In addition, the COVID-19 pandemic resulted in mandated extended pauses in trial enrolment as well as alterations in recruitment methods out of concern for study personnel safety and availability of protective equipment. Patient triaging among healthcare institutions due to COVID-19 cases also has resulted in inconsistent access to the eligible study population. This has made it even more imperative for the study team to be flexible and innovative to identify and enrol all eligible participants. Patient-controlled sedation is a novel approach to the management of patient symptoms that may be able to alleviate mechanical ventilation-induced distress without serious side effects. Findings from this study will provide insight into the efficacy of this approach on short- and long-term outcomes in a subset of mechanically ventilated patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02819141. Registered on June 29, 2016.

Design and Rationale of the Sevoflurane for Sedation in Acute Respiratory Distress Syndrome (SESAR) Randomized Controlled Trial

Preclinical studies have shown that volatile anesthetics may have beneficial effects on injured lungs, and pilot clinical data support improved arterial oxygenation, attenuated inflammation, and decreased lung epithelial injury in patients with acute respiratory distress syndrome (ARDS) receiving inhaled sevoflurane compared to intravenous midazolam. Whether sevoflurane is effective in improving clinical outcomes among patients with ARDS is unknown, and the benefits and risks of inhaled sedation in ARDS require further evaluation. Here, we describe the SESAR (Sevoflurane for Sedation in ARDS) trial designed to address this question. SESAR is a two-arm, investigator-initiated, multicenter, prospective, randomized, stratified, parallel-group clinical trial with blinded outcome assessment designed to test the efficacy of sedation with sevoflurane compared to intravenous propofol in patients with moderate to severe ARDS. The primary outcome is the number of days alive and off the ventilator at 28 days, considering death as a competing event, and the key secondary outcome is 90 day survival. The planned enrollment is 700 adult participants at 37 French academic and non-academic centers. Safety and long-term outcomes will be evaluated, and biomarker measurements will help better understand mechanisms of action. The trial is funded by the French Ministry of Health, the European Society of Anaesthesiology, and Sedana Medical.

Prevalence of post-intensive care syndrome in mechanically ventilated patients with COVID-19

Coronavirus disease 19 (COVID-19) patients usually require long periods of mechanical ventilation and sedation, which added to steroid therapy, favours a predisposition to the development of delirium and subsequent mental health disorders, as well as physical and respiratory sequelae. The aim of this study was to determine the prevalence of post-intensive care syndrome (PICS) at 3 months after hospital discharge, in a cohort of mechanically ventilated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). An ambispective, observational study was conducted in three hospitals with intensive care unit (ICU) follow-up clinics. We studied adults who survived a critical illness due to SARS-CoV-2 infection requiring invasive mechanical ventilation. A physical (muscle strength and pulmonary function), functional [12-Item Short Form Health Survey (SF-12), and Barthel score], psychological [hospital anxiety and depression (HADS) and posttraumatic stress disorder symptom severity scales], and cognitive [Montreal cognitive assessment (MoCA) test] assessment were performed. A total of 186 patients were evaluated at 88 days (IQR 68-121) after hospital discharge. Mean age was 59 ± 12 years old, 126 (68%) patients were men, and median length of mechanical ventilation was 14 days (IQR 8-31). About 3 out of 4 patients (n = 139, 75%) met PICS criteria. Symptoms of cognitive and psychiatric disorders were found in 59 (32%) and 58 (31%) patients, respectively. Ninety-one (49%) patients had muscle weakness. Pulmonary function tests in patients with no respiratory comorbidities showed a normal pattern in 93 (50%) patients, and a restrictive disorder in 62 (33%) patients. Also, 69 patients (37%) were on sick leave, while 32 (17%) had resumed work at the time of assessment. In conclusion, survivors of critical illness due to SARS-CoV-2 infection requiring mechanical ventilation have a high prevalence of PICS. Physical domain is the most frequently damaged, followed by cognitive and psychiatric disorders. ICU follow-up clinics enable the assistance of this vulnerable population.

Tracheostomy decreases continuous analgesia and sedation requirements

BACKGROUND

The goals of sedation in the critically ill surgical patient are to minimize pain, anxiety, and agitation without hindering cardiopulmonary function. One potential benefit of tracheostomy over endotracheal intubation is the reduction of sedation and analgesia, however, there is little data to support this supposition. We hypothesized that patients undergoing tracheostomy would have a rapid reduction in sedation and analgesia following tracheostomy.

METHODS

A retrospective review of tracheostomies performed at a single level 1 trauma center from January 2013- June 2018 was completed. An evaluation of Glasgow Coma Score (GCS), Richmond Agitation-Sedation Score (RASS), and Confusion Assessment Method for the ICU (CAM-ICU) 72 hours pre- to 72 hours post-tracheostomy was performed. The total daily dose of sedation, anxiolytic, and analgesic medications administered were recorded. Mixed-effects models were used to evaluate longitudinal drug does over time (hours).

RESULTS

468 patients included for analysis with a mean age of 58.8 ± 18.3 years. There was a significant decrease in propofol and fentanyl utilization from 24-hours pre to 24-hours post-tracheostomy in both dose and number of patients receiving these continuous intravenous medications. Similarly, total morphine milligram equivalents (MME) use and continuous midazolam significantly decreased from 24-hours pre- to 24-hours post-tracheostomy. By contrast, intermittent enteral quetiapine and methadone administration increased after tracheostomy. Importantly, RASS, GCS, and CAM scoring were also significantly improved as early as 24 hours post-tracheostomy. Total MME use was significantly elevated in patients less than 65 years of age and in male patients pre-tracheostomy compared to female patients. Patients admitted to the MICU had significantly higher MME use compared to those in the SICU pre-tracheostomy.

CONCLUSIONS

Tracheostomy allows for a rapid and significant reduction in intravenous sedation and analgesia medication utilization. Post-tracheostomy sedation can transition to intermittent enteral medications, potentially contributing to the observed improvements in postoperative mental status and agitation.

LEVEL OF EVIDENCE

Level 3, therapeutic.

Therapeutic Gases and Inhaled Anesthetics as Adjunctive Therapies in Critically Ill Patients

The administration of exogenous oxygen to support adequate gas exchange is the cornerstone of respiratory care. In the past few years, other gaseous molecules have been introduced in clinical practice to treat the wide variety of physiological derangement seen in critical care patients.Inhaled nitric oxide (NO) is used for its unique selective pulmonary vasodilator effect. Recent studies showed that NO plays a pivotal role in regulating ischemia-reperfusion injury and it has antibacterial and antiviral activity.Helium, due to its low density, is used in patients with upper airway obstruction and lower airway obstruction to facilitate gas flow and to reduce work of breathing.Carbon monoxide (CO) is a poisonous gas that acts as a signaling molecule involved in many biologic pathways. CO's anti-inflammatory and antiproliferative effects are under investigation in the setting of acute respiratory distress and idiopathic pulmonary fibrosis.Inhaled anesthetics are widely used in the operative room setting and, with the development of anesthetic reflectors, are now a valid option for sedation management in the intensive care unit.Many other gases such as xenon, argon, and hydrogen sulfide are under investigation for their neuroprotective and cardioprotective effects in post-cardiac arrest syndrome.With all these therapeutic options available, the clinician must have a clear understanding of the physiologic basis, therapeutic potential, and possible adverse events of these therapeutic gases. In this review, we will present the therapeutic gases other than oxygen used in clinical practice and we will describe other promising therapeutic gases that are in the early phases of investigation.

A case for continuing statin medications in the intensive care unit: Reducing the risk for delirium

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The objective of this review is to detail the utility of statin medications in the prevention and treatment of intensive care unit (ICU) delirium.

SUMMARY

Delirium is a syndrome characterized by altered mental status, inattention, and disorganized thinking. It is particularly concerning in the ICU where specific risk factors are much more prevalent. Nonpharmacological therapy is the mainstay of treatment, aimed at increasing patient awareness; pharmacological therapies have also been explored with varying success. The utility of statin medications in this scenario has been investigated because of the numerous pleiotropic effects of these drugs. Although the benefits in terms of treating delirium are uncertain, statins may be good candidates for prevention. The peak anti-inflammatory effect of statins is delayed, so initiating a statin on admission will likely have little protective benefit, whereas continuation of a home regimen seems more likely to exert an effect.

CONCLUSION

Statin medications are very commonly used, and, while their role in treating delirium is unclear, continuation of these medications from a home regimen is reasonable to decrease the odds of delirium in the intensive care population.

Non-Pharmacological Nursing Interventions to Prevent Delirium in ICU Patients-An Umbrella Review with Implications for Evidence-Based Practice

Delirium in ICU patients is a complication associated with many adverse consequences. Given the high prevalence of this complication in critically ill patients, it is essential to develop and implement an effective management protocol to prevent delirium. Given that the cause of delirium is multifactorial, non-pharmacological multicomponent interventions are promising strategies for delirium prevention. (1) Background: To identify and evaluate published systematic review on non-pharmacological nursing interventions to prevent delirium in intensive care unit patients. (2) Methods: An umbrella review guided by the Joanna Briggs Institute was utilized. Data were obtained from PubMed, Scopus, EBSCO, Web of Science, Cochrane Library, and Google Scholar. The last search was conducted on 1 May 2022. (3) Results: Fourteen reviews met the inclusion criteria. Multicomponent interventions are the most promising methods in the fight against delirium. The patient's family is an important part of the process and should be included in the delirium prevention scheme. Light therapy can improve the patient's circadian rhythm and thus contribute to reducing the incidence of delirium. (4) Conclusions: Non-pharmacological nursing interventions may be effective in preventing and reducing the duration of delirium in ICU patients.

Association between Early Mobilization in the ICU and Psychiatric Symptoms after Surviving a Critical Illness: A Multi-Center Prospective Cohort Study

This is a prospective multicenter cohort study aiming to investigate the association between early mobilization (EM), defined as a rehabilitation level of sitting at the edge of the bed or higher within 72 h of ICU admission, and psychiatric outcome. Consecutive patients, admitted to the ICU for more than 48 h, were enrolled. The primary outcome was the incidence of psychiatric symptoms at 3 months after hospital discharge defined as the presence of any of three symptoms: depression, anxiety, or post-traumatic stress disorder (PTSD). Risk ratio (RR) and multiple logistic regression analysis were used. As a sensitivity analysis, two methods for inverse probability of treatment weighting statistics were performed. Of the 192 discharged patients, 99 (52%) were assessed. The patients who achieved EM had a lower incidence of psychiatric symptoms compared to those who did not (25% vs. 51%, p-value 0.008, odds ratio (OR) 0.27, adjusted p = 0.032). The RR for psychiatric symptoms in the EM group was 0.49 [95% Confidence Interval, 0.29–0.83]. Sensitivity analysis accounting for the influence of death, loss to follow-up (OR 0.28, adjusted p = 0.008), or potential confounders (OR 0.49, adjusted p = 0.046) consistently showed a lower incidence of psychiatric symptoms in the EM group. EM was consistently associated with fewer psychiatric symptoms.

Protective effects of dexmedetomidine in vital organ injury: crucial roles of autophagy

Vital organ injury is one of the leading causes of global deaths. Accumulating studies have demonstrated that dexmedetomidine (DEX) has an outstanding protective effect on multiple organs for its antiinflammatory and antiapoptotic properties, while the underlying molecular mechanism is not clearly understood. Autophagy, an adaptive catabolic process, has been found to play a crucial role in the organ-protective effects of DEX. Herein, we present a first attempt to summarize all the evidence on the proposed roles of autophagy in the action of DEX protecting against vital organ injuries via a comprehensive review. We found that most of the relevant studies (17/24, 71%) demonstrated that the modulation of autophagy was inhibited under the treatment of DEX on vital organ injuries (e.g. brain, heart, kidney, and lung), but several studies suggested that the level of autophagy was dramatically increased after administration of DEX. Albeit not fully elucidated, the underlying mechanisms governing the roles of autophagy involve the antiapoptotic properties, inhibiting inflammatory response, removing damaged mitochondria, and reducing oxidative stress, which might be facilitated by the interaction with multiple associated genes (i.e., hypoxia inducible factor-1α, p62, caspase-3, heat shock 70 kDa protein, and microRNAs) and signaling cascades (i.e., mammalian target of rapamycin, nuclear factor-kappa B, and c-Jun N-terminal kinases pathway). The authors conclude that DEX hints at a promising strategy in the management of vital organ injuries, while autophagy is crucially involved in the protective effect of DEX.

Sequential use of midazolam and dexmedetomidine for long-term sedation may reduce weaning time in selected critically ill, mechanically ventilated patients: a randomized controlled study

Background

Current sedatives have different side effects in long-term sedation. The sequential use of midazolam and dexmedetomidine for prolonged sedation may have distinct advantages. We aimed to evaluate the efficacy and safety of the sequential use of midazolam and either dexmedetomidine or propofol, and the use of midazolam alone in selected critically ill, mechanically ventilated patients.

Methods

This single-center, randomized controlled study was conducted in medical and surgical ICUs in a tertiary, academic medical center. Patients enrolled in this study were critically ill, mechanically ventilated adult patients receiving midazolam, with anticipated mechanical ventilation for ≥ 72 h. They passed the spontaneous breathing trial (SBT) safety screen, underwent a 30-min-SBT without indication for extubation and continued to require sedation. Patients were randomized into group M-D (midazolam was switched to dexmedetomidine), group M-P (midazolam was switched to propofol), and group M (sedation with midazolam alone), and sedatives were titrated to achieve the targeted sedation range (RASS − 2 to 0).

Results

Total 252 patients were enrolled. Patients in group M-D had an earlier recovery, faster extubation, and more percentage of time at the target sedation level than those in group M-P and group M (all P < 0.001). They also experienced less weaning time (25.0 h vs. 49.0 h; HR1.47, 95% CI 1.05 to 2.06; P = 0.025), and a lower incidence of delirium (19.5% vs. 43.8%, P = 0.002) than patients in group M. Recovery (P < 0.001), extubation (P < 0.001), and weaning time (P = 0.048) in group M-P were shorter than in group M, while the acquisition cost of sedative drug was more expensive than other groups (both P < 0.001). There was no significant difference in adverse events among these groups (all P > 0.05).

Conclusions

The sequential use of midazolam and dexmedetomidine was an effective and safe sedation strategy for long-term sedation and could provide clinically relevant benefits for selected critically ill, mechanically ventilated patients.

Trial registration

NCT02528513. Registered August 19, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03967-5.