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

Postoperative delirium under general anaesthesia by remimazolam versus propofol: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Remimazolam, an ultra-short-acting benzodiazepine, has similar clinical effects to propofol for sedation in general anaesthesia. However, it remains uncertain whether remimazolam could increase postoperative delirium (POD) compared with propofol.

OBJECTIVES

The purpose of our study was to compare the incidence of POD between remimazolam and propofol as sedative agents in general anaesthesia.

STUDY DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were searched for prospective RCTs published through September 16, 2024. RCTs reporting the incidence of POD and comparing remimazolam with propofol for general anaesthesia were included. Odds ratio (ORs) were calculated using a random-effects model. The primary outcome was the incidence of POD. The secondary outcomes included time to extubation, awakening time, and adverse events such as intraoperative hypotension.

RESULTS

A total of six RCTs involving 1107 patients were included in this meta-analysis. For the primary outcome, the incidence of POD did not differ between the remimazolam and propofol groups (OR, 0.92; 95 % confidence interval [CI], 0.58-1.44). Regarding the secondary outcomes, remimazolam was associated with a lower incidence of intraoperative hypotension compared with propofol (OR, 0.31; 95 % CI, 0.21-0.46). There were no significant differences in other secondary outcomes. In the sensitivity analysis on three RCTs including only older patients (≥60 years old), there was no significant difference in the incidence of POD (OR, 1.00; 95 % CI, 0.52-1.93).

CONCLUSION

Perioperative remimazolam administration did not increase POD and reduced the risk of intraoperative hypotension compared to propofol. Further large-scale RCTs are warranted to explore the association of remimazolam and POD. Systematic review protocol: PROSPERO CRD42024544122.

Dexmedetomidine Improves Microcirculatory Alterations in Patients With Initial Resuscitated Septic Shock

Trial registration: Clinicaltrials.gov NCT02270281. Registered October 16, 2014.

Assessment of sleep quality using cardiopulmonary coupling and its predictive value for delirium in ICU patients

OBJECTIVE

To assess sleep quality in intensive care unit (ICU) patients using cardiopulmonary coupling (CPC) analysis and explore its predictive value for delirium.

METHOD

ICU patients (n = 135) were divided into the delirium group (n = 44) and control group (n = 91) based on the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). CPC analysis was used to evaluate the sleep quality of all participants.

RESULT

Intergroup comparisons showed that total sleep time, stable sleep time, and sleep efficiency were significantly lower in the delirium group than in the control group, whereas unstable sleep time, rapid eye movement sleep time, wake-up time, stable sleep latency, and apnea-hypopnea index (AHI) were significantly higher in the delirium group than in the control group. Logistic regression analysis showed that advanced age and AHI were risk factors for delirium, whereas stable sleep time was a protective factor for delirium. Receiver operating characteristic (ROC) analysis showed that stable sleep time and stable sleep latency had a certain predictive value for delirium; the area under the ROC curve (AUC) for stable sleep time was higher (0.888 vs. 0.704). The cut-off value for stable sleep time was 0.65 h, with a sensitivity of 84.1 % and specificity of 81.3 %.

CONCLUSION

ICU patients with delirium have poorer sleep quality than patients without delirium. Stable sleep time derived from the CPC has a high predictive value for delirium and may serve as an objective indicator for its diagnosis.

Buprenorphine in the Intensive Care Unit: Commentary on the Unanswered Questions

The removal of the X-waiver in the Mainstreaming Addiction Treatment (MAT) Act of 2023 has substantial implications for buprenorphine prescribing as one of the options to treat opioid use disorder. The purpose of this commentary is to discuss the unanswered questions regarding buprenorphine in the intensive care unit (ICU) including how the passage of the MAT Act will affect ICU providers, which patients should receive buprenorphine, what is the most appropriate route of administration and dose of buprenorphine, what medications interact with buprenorphine, and how can transitions of care be optimized for these patients.

ICU Delirium

Delirium is not a harmless transient event during ICU hospitalization; rather, it is a severe complication of critical illness associated with increased mortality, morbidity, and persistent disability. Despite being recognized for decades, it remains underdiagnosed. Employing validated tools for detection helps reduce missed cases. Early detection facilitates prompt management. Sedatives, opioids, and antipsychotics should be avoided whenever possible. Optimizing environmental triggers, minimizing iatrogenicity, and treating underlying critical illness constitute the basis of the currently recommended approach to diminish the burden of delirium in ICU patients.

The association between pain, analgesia, and delirium among critically ill adults: a systematic review and meta-analysis

PURPOSE

We performed a systematic review with meta-analysis examining the relationship between pain or pain medications and delirium occurence, duration, and severity.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials from inception to May 15, 2023. We included randomised or observational studies among critically ill adults, that reported data on pain or exposure to analgesics, and reported delirium presence, duration, or severity with no language or region restrictions.

PROSPERO ID

CRD42022367715. Two authors independently screened records and extracted data. Risk of bias was evaluated using Risk of Bias 2 or the Risk of Bias In Non-randomized Studies of Interventions. We pooled data using the Hartung-Knapp Sidik-Jonkmann random effects model. PRISMA was followed.

RESULTS

From 8,054 citations, 90 studies (119,230 patients) published between 2001 and 2023 were included in the systematic review. 41 studies were included in the primary meta-analysis examining prevalent delirium: seven studies evaluated pain; 12 studies evaluated fentanyl; and five studies evaluated morphine. There was a trend to association between pain and delirium occurrence (OR 2.49, 95% CI 0.98-6.30), and a significant association between pain and incident delirium (OR 3.70, 95% CI 1.73-7.93). Fentanyl (OR 2.49, 95% CI 1.45-4.27) and morphine (OR 2.13, 95% CI 1.21-3.75) were associated with delirium occurrence. Risk of bias was critical for many studies.

CONCLUSIONS

We observed an association between pain and incident delirium among critically ill adults. Exposure to morphine or fentanyl (but no other pain medications) was associated with increased risk of delirium occurrence.

Delirium in Neurocritical Care: Uncovering Undisclosed Psychotropic Substance and Medication Use and Stress Exposure by Hair Analysis

OBJECTIVE

In intensive care, delirium is frequent, prolongs the stay, increases health care costs, and worsens patient outcome. Several substances and medications as well as stress can impact the risk of delirium; however, assessment of previous exposure to psychotropic agents and stress by self-reports or third-party information is not always reliable. Hair analysis can be used to objectively assess medication and substance use (including chronic alcohol consumption), and allows for the determination of stress-related long-term changes in steroid hormones and endocannabinoids.

METHODS

Consecutive adult patients with acute brain injury admitted to the neurocritical care unit were included. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit. Liquid chromatography coupled with tandem mass spectrometry was used to investigate psychoactive substances and medications, ethyl glucuronide, steroid hormones, and endocannabinoids in hair samples. Univariable and multivariable analyses were used to reveal any associations with the occurrence of delirium.

RESULTS

Of 50 consecutive patients, 21 (42%) were diagnosed with delirium. Detection of antipsychotics or antidepressants in hair was more frequent in patients with delirium (antidepressants: 43% vs. 14%, p = 0.040; antipsychotics: 29% vs. 0%, p = 0.021). These patients also displayed higher ethyl glucuronide levels (p = 0.049). Anandamide (AEA) concentrations were higher in patients with delirium (p = 0.005), whereas oleoylethanolamide (p = 0.045) and palmitoylethanolamide (PEA) (p = 0.017) concentrations were lower in patients with delirium. Backward stepwise logistic regression analysis revealed antidepressants and AEA/PEA to be independent relevant predictors of delirium.

CONCLUSIONS

Hair analysis provides crucial and otherwise unattainable information regarding chronic stress and the use of psychotropic substances and medications. Undisclosed antidepressant/antipsychotic use or intense chronic alcohol consumption is susceptible to treatment (continuation of medication or provision of low-dose benzodiazepines in case of alcohol). Chronic stress can be evaluated using stress markers and endocannabinoids in hair, potentially allowing for personalized delirium risk stratification and preventive measures.

Agitation: Neurobiology and current management guidelines

There have been important updates in the guidelines for the management of agitation in emergency room settings, including psychiatric emergency services. This manuscript provides a synthesis of current recommendations, combined with a detailed breakdown of the neurobiology of agitation, linking these neuroscientific dimensions with the pharmacological profiles of the drugs recommended by practice guidelines (as well as the profiles of other important agents). Since Project BETA (Best Practices in Evaluation and Treatment of Agitation) guidelines were published in 2012 (by the American Association for Emergency Psychiatry), there have been several developments in the standard of care, including an increase in use of ketamine and droperidol. Recommended treatment strategies for clinicians will be presented, including consideration of how to address specific causes of agitation.

Alpha2 Agonist Use in Critically Ill Adults: A Focus on Sedation and Withdrawal Prevention

The management of sedation in critically ill adults poses a unique challenge to clinicians. Dexmedetomidine, an α2 agonist, has a unique mechanism and favorable pharmacokinetics, making it an attractive intravenous option for sedation and delirium in the intensive care unit. However, patients may be at risk for withdrawal with prolonged use, adding to the complexity of sedation and agitation management in this patient population. Enteral α2 agents have the benefit of cost savings and ease of administration, thus playing a role in the ability to decrease intravenous sedative use and prevent dexmedetomidine withdrawal. Clonidine and guanfacine are the two most common enteral α2 agents utilized for this purpose, however, there is a paucity of evidence regarding the comparative benefit between the two agents. The decision to use one vs the other agent should be determined based on their differing pharmacology, pharmacokinetics, and side effect profile. The most effective dosing strategy for these agents is also unknown. Ultimately, more robust literature is required to determine enteral α2 agonists place in therapy. This narrative review evaluates the currently available literature on the use of α2 agonists in critically ill adults with an emphasis on sedation, delirium, and withdrawal.

Pressure Support Ventilation During Extracorporeal Membrane Oxygenation Support in Patients With Acute Respiratory Distress Syndrome

In the initial phases of veno-venous extracorporeal membrane oxygenation (VV ECMO) support for severe acute respiratory distress syndrome (ARDS), ultraprotective controlled mechanical ventilation (CMV) is typically employed to limit the progression of lung injury. As patients recover, transitioning to assisted mechanical ventilation can be considered to reduce the need for prolonged sedation and paralysis. This study aimed to evaluate the feasibility of transitioning to pressure support ventilation (PSV) during VV ECMO and to explore variations in respiratory mechanics and oxygenation parameters following the transition to PSV. This retrospective monocentric study included 191 adult ARDS patients treated with VV ECMO between 2009 and 2022. Within this population, 131 (69%) patients were successfully switched to PSV during ECMO. Pressure support ventilation was associated with an increase in respiratory system compliance ( p = 0.02) and a reduction in pulmonary shunt fraction ( p < 0.001). Additionally, improvements in the cardiovascular Sequential Organ Failure Assessment score and a reduction in pulmonary arterial pressures ( p < 0.05) were recorded. Ninety-four percent of patients who successfully transitioned to PSV were weaned from ECMO, and 118 (90%) were discharged alive from the intensive care unit (ICU). Of those who did not reach PSV, 74% died on ECMO, whereas the remaining patients were successfully weaned from extracorporeal support. In conclusion, PSV is feasible during VV ECMO and potentially correlates with improvements in respiratory function and hemodynamics.

First out-of-bed mobilisation in adults with severe acquired brain injury in Scandinavian neurointensive care units: A survey of current clinical practice (FOOBScan)

BACKGROUND

The harm-benefit balance for early out-of-bed mobilisation of patients with severe acquired brain injury (ABI) in neurointensive care units (neuro-ICUs) is unclear, and there are no clinical guidelines. This study aimed to survey the current clinical practice and perceptions among clinicians involved in first out-of-bed mobilisation in Scandinavian neuro-ICUs.

METHODS

This was a cross-sectional, anonymous, web-based survey; the reporting follows the recommended CROSS checklist. Clinicians involved in the first out-of-bed mobilisation in all 14 Scandinavian neuro-ICUs were eligible to participate. The questionnaire was distributed to local contact persons. Respondents were asked about their clinical practice regarding the first out-of-bed mobilisation, and perceived harms and benefits of early mobilisation.

RESULTS

One hundred eighty clinicians (53% nurses, 31% physicians, and 14% therapists) completed the questionnaire. Eighty-one percent indicated that more than half of patients underwent their first out-of-bed mobilisation in the neuro-ICU. More respondents from Denmark than the remaining countries indicated that both physicians, nurses and physiotherapists contributed to the decision on when to mobilise. Intracranial pressure, cerebral perfusion pressure, sedation, presence of vasospasm and arterial blood pressure were the most used safety clinical indicators for deciding about mobilisation. Clinicians stated several positive effects of mobilisation, for example, improved bowel movements, level of consciousness, motor function, and reduced risk of pneumonia, contractures, delirium, and deep vein thrombosis.

CONCLUSIONS

Mobilisation out of bed is frequently performed in patients with severe ABI in Scandinavian neuro-ICUs. The perceived clinical safety indicators for mobilisation were ICP, CPP, level of sedation, presence of vasospasms, and ABP.

How to prevent and how to treat dyspnea in critically ill patients undergoing invasive mechanical ventilation

PURPOSE OF REVIEW

To summarize current data regarding the prevalence, risk factors, consequences, assessment and treatment of dyspnea in critically ill patients receiving invasive mechanical ventilation.

RECENT FINDINGS

In intubated patients, dyspnea is frequent, perceived as intense, and associated with unfavorable outcomes such as immediate and unbearable distress (e.g. fear of dying), prolonged weaning, and delayed severe psychological consequences ( i.e. posttraumatic stress disorders). In noncommunicative patients, dyspnea is named respiratory-related brain suffering (RRBS) and can be detected using dyspnea observations scales. Before initiating pharmacological treatments, nonpharmacological interventions may be tried as they are efficient to alleviate dyspnea.

SUMMARY

As opposed to pain, dyspnea has often been overlooked in terms of detection and management, resulting in its significant underestimation in daily practice. When it is diagnosed, dyspnea can be relieved through straightforward interventions, such as adjusting ventilator settings. Assessing dyspnea in patients undergoing invasive mechanically ventilated may be challenging, especially in noncommunicative patients (RRBS). Implementing a systematic dyspnea assessment in routine, akin to pain, could serve as a first step to reduce RRBS and prevent potential severe psychological consequences. In addition to pharmacological treatments like opioids, a promising approach is to modulate both the sensory (air on the face, trigeminal nerve stimulation) and the affective (relaxing music, hypnosis, directed empathy) components of dyspnea.

Family-Led Coaching of Patients During Weaning From Sedation and Mechanical Ventilation in the ICU

Background: ICU patients are weaned from sedation and mechanical ventilation through spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs). Weaning can be distressing for patients and their families. Family-led coaching could reassure patients and reduce stress for families by engaging them in patient care. This study developed and piloted a family-led coaching tool to support patients undergoing SATs/SBTs. Methods: Patient and family member dyads were recruited from 2 medical-surgical ICUs in Calgary, Canada (February 3-August 1, 2023). Surveys were administered to collect family (1) demographics, (2) anxiety and satisfaction with ICU care, (3) feedback on the tool, and (4) attitudes about family presence during SATs/SBTs (also collected from clinicians). Tool feasibility was determined by calculating the proportions of (1) eligible patients who were recommended for participation in the study by clinicians and (2) families approached who consented to participate in the study. Results: One thousand one hundred fifty patients were admitted to the study ICUs during the study period of which 819 received mechanical ventilation, and 42 were recommended by bedside clinicians for participation in the study. Twenty-five dyads were approached, 21 dyads consented to participate, and one withdrew consent before data collection. Of the enrolled families, 12 (60%) reported the coaching tool to be useful, and 5 (25%) recommended minor suggestions such as "shortening" the tool. Fourteen (70%) families reported positive experiences (through open-ended feedback) with being present for the SAT/SBT. State-Trait Anxiety Inventory (Y1) scores (scale range 20-80 points) significantly decreased in families from the first (pre coaching) to the second (post coaching) measures (mean decrease 8.2 points, SD 10.3, P = .001). All clinicians indicated they were comfortable with family presence and/or coaching during SATs/SBTs. Conclusion: Family-led coaching of patients during SATs/SBTs appears to be feasible, favorably perceived by families and clinicians, and potentially associated with lower family anxiety.

Mechanisms underlying neurocognitive dysfunction following critical illness: a systematic review

INTRODUCTION

Cognitive impairment is a significant healthcare problem globally and its prevalence is projected to affect over 150 million people worldwide. Survivors of critical illness are impacted frequently by long-term neurocognitive dysfunction regardless of presenting illness, but the mechanisms are poorly understood. The goal of this review was to synthesise the existing evidence regarding potential mechanisms underlying neurocognitive dysfunction following critical illness in order to guide potential avenues for future research.

METHODS

We performed a systematic search of the literature for studies published between 1 January 1974 and 15 July 2023. We included publications involving adult patients with critical illness due to any aetiology that assessed for cognitive impairment following recovery from illness, and explored or investigated potential underlying causative mechanisms. The quality and risk of bias of the individual studies was assessed using the Newcastle-Ottawa scale.

RESULTS

Of the 7658 reviewed references, 37 studies comprising 4344 patients were selected for inclusion. Most studies were single centre with sample sizes of < 100 patients. The proportion of patients with long-term cognitive impairment ranged from 13% to 100%. A wide variety of theoretical mechanisms were explored, with biomarkers and neuroimaging utilised most frequently. Many studies reported associations between investigated mechanisms and reduced cognition; several of these mechanisms have been implicated in other forms of long-term neurodegenerative conditions. Increased levels of inflammatory cytokines during acute illness and white matter hyperintensities on neuroimaging following recovery were the associations reported most commonly.

DISCUSSION

The underlying pathophysiology of neurocognitive decline after critical illness is not yet understood fully. The mechanisms implicated in other neurodegenerative conditions suggest that this may represent an accelerated version of the same processes. Large scale studies are required to further elucidate the cause of this significant problem for survivors of critical illness.

Gut microbiota-derived 3-indoleacetic acid confers a protection against sepsis-associated encephalopathy through microglial aryl hydrocarbon receptors

BACKGROUND

The gut microbiota significantly contributes to the pathogenesis of central nervous system disorders. Among the bioactive molecules produced by the gut microbiota, 3-indoleacetic acid (IAA) has been shown to attenuate oxidative stress and inflammatory responses. This experiment aimed to determine the impacts of IAA on sepsis-associated encephalopathy (SAE) and the underlying mechanisms.

METHODS

A total of 34 septic patients and 24 healthy controls were included in the analysis of the clinical correlation between fecal IAA and septic encephalopathy. Fecal microbiota transplantation was used to verify the role of the gut microbiota and its metabolites in SAE. Male C57BL/6 mice aged six to eight weeks, pre-treated with IAA via oral gavage, were subjected to the cecal ligation and puncture (CLP) procedures. This treatment was administered either in combination with an aryl hydrocarbon receptor (AhR) antagonist, CH223191, or a CSF1R inhibitor, PLX3397, to eliminate microglia. Both immunofluorescence staining and enzyme-linked immunosorbent assays were used to evaluate microglia activation and inflammatory cytokine secretion. Behavioral assessments were conducted to quantify neurological deficits.

RESULTS

A decreased fecal level of IAA was observed in the patients with sepsis-associated delirium (SAD), a manifestation of SAE. A reduced IAA level was significantly associated with worsen clinical outcomes. Fecal microbiota transplantation from the SAD patients induced an SAE-like phenotype in mice, but supplementing exogenous IAA improved the SAE-like phenotype, mediated by microglia. IAA effectively binded with the aryl hydrocarbon receptor (AhR). Furthermore, IAA increased the nuclear activity of AhR in the lipopolysaccharide (LPS)-treated microglial cells, leading to reduced secretion of inflammatory cytokines. The AhR inhibitor CH223191 counteracted the protective effect of IAA against SAE in mice.

CONCLUSIONS

Gut microbiota-derived IAA confers a protection against SAE by activating AhR in microglia, improving neuronal and cognitive impairments. Thus, IAA holds the promise as a potential therapeutic agent for managing SAE.

Propofol, Triglycerides, and Acute Pancreatitis: A Multicenter Epidemiologic Analysis

Rationale: Propofol is one of the first-line sedative-hypnotic agents for critically ill adults requiring mechanical ventilation. Although propofol can elevate triglyceride levels, and the latter is a risk factor for pancreatitis, the association between propofol and acute pancreatitis is unclear. Objectives: We sought to determine the clinical impact and potential associations between propofol infusion, hypertriglyceridemia, and acute pancreatitis. Methods: This is an observational multicenter study of adults (⩾18 yr old) who were admitted to an intensive care unit, who required mechanical ventilation and received continuous propofol infusion for at least 24 hours. The primary outcomes were the frequency of hypertriglyceridemia (>400 mg/dl) and acute pancreatitis. Further analyses were done to determine the clinical impact of elevated triglyceride levels (i.e., sedation changes) and risk factors for pancreatitis development. Results: Of 11,828 patients included, 33.2% (n = 3,922) had triglyceride levels measured, of whom 21.7% (n = 851) had hypertriglyceridemia at 4.5 days (SD = 6.8) after propofol initiation. Of those still requiring sedation, 70.4% (n = 576/818) received alternative sedatives after developing hypertriglyceridemia. Pancreatitis occurred in 1.2% of patients (n = 47/3,922) and was more frequent in those with hypertriglyceridemia (3.2%, 27/851; vs. 0.7%, 20/3,071; P < 0.001). After adjustment for potential confounding variables, each 100 mg/dl increase in triglyceride levels was associated with an 11% increase in risk of pancreatitis. Propofol dose was not associated with pancreatitis development. Conclusions: Acute pancreatitis is uncommon in patients receiving propofol infusion, and it occurs over a wide range of triglyceride levels, indicating a multifactorial pathophysiology. Hypertriglyceridemia frequently prompts the use of alternative sedatives. Further study is needed to determine how to best monitor and treat hypertriglyceridemia in critically ill patients receiving propofol infusion.

Prevalence and risk factors of subsyndromal delirium in ICU: A systematic review and meta-analysis

OBJECTIVE

To systematically assess the prevalence and risk factors for subsyndromal delirium (SSD) in the intensive care unit.

DESIGN

A systematic reviewand meta-analysis.

METHODOLOGY

This systematic review and meta-analysis was conducted in eight databases, including PubMed, Web of Science, Ovid,Scopus, China Knowledge Resource Integrated Database, Wanfang Database,Weipu Database and Chinese Biomedical Database. All original observational studies of subsyndromal delirium in the ICU were included, with languages limited to English and Chinese. The methodological quality was assessed by the Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality recommendation checklist. Meta-analysis was performed using Stata software (version 18.0).

RESULT

A total of 27 studies involving 7,286 participants were included in this review. The pooled prevalence of SSD was 32.4 % (95 %CI: 27.1 %-37.7 %).Fourteen studies reported 34 independent risk factors, and the following ten factors were significantly associated with SSD: older age, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, lower Mini-mental Status Examination (MMSE) score, pain, mechanical ventilation, hypoproteinemia, blood transfusion, longer ICU stay, infection, and physical restraint.

CONCLUSION

We conducted a systematic review and meta-analysis to evaluate the prevalence of SSD in the ICU and identified 10 risk factors associated with SSD. However, the studies have significant heterogeneity, future research should be conducted in multicenter with large samples to strengthen the current evidence.

IMPLICATIONS FOR CLINICAL PRACTICE

Subsyndromal delirium is a frequently occurring adverse event in the ICU, so it is recommended that clinicians and nurses incorporate the assessment of SSD into their daily routine. In this study, we also identified ten risk factors associated with SSD, and some of which could be modified or intervened. These findings provide a basis for ICU medical staff to identify patients at high risk of SSD and then implement individualized interventions to reduce the prevalence of SSD.

Vasopressor utilization in septic shock patients receiving propofol versus midazolam

PURPOSE

The purpose of this study was to evaluate the effect of propofol versus midazolam on vasopressor requirements in patients with septic shock to better guide sedative selection.

METHODS

This was a multicenter, retrospective, observational, IRB-approved, non-inferiority cohort study. Included individuals were ≥ 18 years of age, had a diagnosis of septic shock, and exclusive administration of propofol or midazolam for at least 12 h. The primary outcome was maximum increase in vasopressor requirements within the first 12 h following sedative initiation.

RESULTS

For the primary outcome of maximum increase in norepinephrine equivalents (NEE) within 12 h, propofol was non-inferior to midazolam (0.09 vs. 0.129 μg/kg/min, p = 0.002). No difference was seen between the propofol and midazolam groups for the secondary outcome of maximum increase in NEE within 3 h (0.02 vs 0.04 μg/kg/min, p = 0.208), however, the propofol group had a significantly lower increase within 6 h (0.06 vs 0.086 μg/kg/min, p = 0.043) and 24 h (0.11 vs 0.25 μg/kg/min, p = 0.013).

CONCLUSION

In patients with septic shock, vasopressor requirement increases with propofol were non-inferior to midazolam within the first 12 h.

Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design

BACKGROUND

Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores.

METHODS

BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase.

RESULTS

Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection).

CONCLUSIONS

The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Analgosedation and delirium practices in critically ill patients in the Pan-American and Iberian setting, and factors associated with oversedation after the COVID-19 pandemic: Results from the PANDEMIC study

Oversedation has adverse effects on critically ill patients. The Analgosedation and Delirium Committee of the FEPIMCTI (Pan-American and Iberian Federation of Critical Care Medicine and Intensive Care) conducted a cross-sectional study through a survey addressed to ICU physicians: PANDEMIC (Pan-American and Iberian Study on the Management of Analgosedation and Delirium in Critical Care [fepImCti]). HYPOTHESIS: Worsening of these practices in the course of the pandemic and that continued afterwards, with further oversedation. OBJECTIVES: Perception of analgosedation and delirium practices in Pan-American and Iberian ICUs before, during and after the COVID-19 pandemic, and factors associated with persistent oversedation after the pandemic. Of the 1008 respondents, 25% perceived oversedation after the pandemic (95%CI 22.4-27.8). This perception was higher in South America (35.8%, P < .001). Main risk factor: habit acquired during the pandemic (adjusted OR [aOR] 3.16, 95%CI 2.24-4.45, P < .001). Main protective factor: delirium monitoring before the pandemic (aOR 0.70, 95%CI 0.50-0.98, P = .038). The factors identified in this study provide a basis for targeting future interventions.

Physical Restraint in a Pediatric Intensive Care Unit: A Cross-Sectional, Observational Study in China

BACKGROUND

Research data on the extent of and protocols related to physical restraint (PR) in pediatric intensive care units (PICUs) are scarce. Most previous studies in China on this topic have focused on the prevalence, reasons, and background of PR use among adult patients.

PURPOSE

This study was designed to delineate the application of PR and the factors associated with PR use in PICUs in China.

METHODS

A cross-sectional study was conducted in one PICU at West China Hospital, Sichuan University, from January 2020 to December 2020. A total of 1,086 pediatric patients in the PICU were included in this study. Data collection was performed over 11 months, utilizing PR observation forms and patient records. Descriptive statistical analysis was used to obtain the data, and logistic regression models were used to analyze the independent risk factors for PR.

RESULTS

Of the 1,086 participants, 750 (69.1%) experienced being restrained, and 83.5% of the restrained participants who were pediatric patients were restrained for more than 50% of their time during their PICU stay. The results of logistic regression analysis identified age (1-6 years: OR = 2.090, 95% CI [1.508, 2.897], p < .001; 7-17 years: OR = 0.523, 95% CI [0.358, 0.765], p = .001), use of mechanical ventilation ( OR = 2.126, 95% CI [1.480, 3.055], p < .001), use of drainage tubes ( OR = 1.916, 95% CI [1.445, 2.541], p < .001), and sedation ( OR = 1.494, 95% CI [1.101, 2.026], p = .010) as significantly correlated with the use of PR in the PICU. For the 750 patients who experienced being restrained, PR initiation was documented with a written medical order, and in 604 cases (80.5%), the restraints were removed without similar documentation.

CONCLUSIONS

The use of PR is common in PICUs in China, with more than half of pediatric patients being restrained during their stay. Age, mechanical ventilation, use of drainage tubes, and use of sedative drugs were identified as significantly associated with PR use. Developing standardized procedures/guidelines for PR use in Chinese PICUs and enhancing medical staff education on PR practices are imperative.

Reliability, validity and practicability of the Chelsea Critical Care Physical Assessment tool (CPAx) following an e-learning programme: A clinimetric study

OBJECTIVES

To investigate inter- and intra-rater reliability, content and concurrent validity, and practicability of the Chelsea Critical Care Physical Assessment tool (CPAx) - a measurement instrument for physical function and activity for patients with a critical illness - from multidisciplinary, German-speaking healthcare professionals.

METHODS

This was a prospective, longitudinal, clinimetric study. Participants who completed a novel German CPAx e-learning were invited to participate in a voluntary, web-based, piloted, two-round survey. The two rounds were separated by 3-4 weeks to limit recollection of the two patient videos within the e-learning. Following informed consent, we collected participants' characteristics, their CPAx ratings and scoring-duration for the two video cases, content validity indexes along with questions on the practicability of the CPAx. Data was analysed descriptively, quantitatively using Bayesian methods, and qualitatively with an inductive content approach.

RESULTS

In total, 61 clinicians (53 (87 %) physiotherapists, 6 (10 %) nurses, 2 (3 %) occupational therapists) from Switzerland (37 (64 %)), Germany (13 (22 %)), and Austria (8 (14 %)) participated. Inter- (n = 61) and intra-rater (n = 35) reliability for the CPAx were excellent (intraclass correlation coefficients of > 0.8). Content validity index of the CPAx showed a high relevance (> 0.9), though novice users slightly differed from the expert rating (concurrent validity). Healthcare professionals described the CPAx as a practical tool to plan and evaluate physical rehabilitation with a total scoring duration of 5 min, whereby lack of routine, time, and application were seen as barriers in clinical practice.

CONCLUSIONS

This study demonstrated the German CPAx as a highly reliable (between and within raters), relevant and practical tool across professions, settings, and countries. These results support an online training, whereby future work should focus on consensus and application into clinical practice.

IMPLICATIONS FOR CLINICAL PRACTICE

Following an e-learning, the CPAx can be used reliably by multidisciplinary, German-speaking healthcare professionals potentially enhancing physical rehabilitation.

Postcompetency Index System for Assessing Pain Resource Nurses' Competence: A Delphi Study

OBJECTIVE

The aim was to establish a competency index system for pain resource nurses (PRNs) in China.

BACKGROUND

PRNs play a crucial role in enhancing pain management in Chinese hospitals. Their professional competence significantly impacts the quality of pain management in the hospital. However, a clear evaluation system for assessing the abilities of PRNs is lacking. Establishing a scientific and systematic evaluation system for nurse competencies is essential for selection, training, and assessment within hospitals.

METHODS

Utilizing the iceberg competency model, a competency index for PRNs was developed through literature analysis and semistructured interviews. Two rounds of Delphi consultations were conducted with 19 experts in pain management and medical psychology from 12 provinces in China to establish competency indicators and weight values.

RESULTS

After the Delphi consultations, the postcompetency index system for PRNs comprised 5 primary indices, 15 secondary indices, and 51 tertiary indices. The primary indices include professional theoretical knowledge, practical skills, job execution ability, professional development, and professional attitudes. The effective response rates for the two Delphi rounds were 100% and 84.2%, respectively. The authority coefficient values were 0.89 and 0.91, respectively. The Kendall harmony coefficients for expert opinions were 0.155, 0.212, and 0.188, and 0.524, 0.267, and 0.302 across levels, with statistical significance (p < .05) after consistency testing.

CONCLUSIONS

The postcompetency index system for PRNs developed in this study is reliable and scientifically grounded. It provides an objective quantitative basis for training and evaluating PRNs.

Barriers to nurse-led delirium management in intensive care units: an integrative systematic review using COM-B model

BACKGROUND

Development of effective guideline for delirium management is still seeking nowadays. As nurses are in the first confrontation line for delirium, their prospective in identifying barriers are essential in developing integrated strategies and clinical guidelines.

OBJECTIVE

To explore the barriers focusing on intensive care unit (ICU) nurses' point of views to provide an evidence-based support for effective nurse-led delirium management in ICU settings.

METHODS

Whittemore and Knafl framework was recruited to build up this integrative review. PRISMA guidelines were followed to search about barriers of nurse-led delirium management. Articles published up to June 2024 in five databases; Web of Science, Scopus, PubMed, CINAHL and EMBASE using related keywords were involved. Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of articles included in this review and then reported nurse-led delirium barriers were mapped according to COM-B model.

RESULTS

Twenty-three articles out of 1,020 research articles were included in this review after carefully checked according to the exclusion and inclusion criteria. based on MMAT, 7 articles achieved 100%, 11 articles were achieved 80%, and 5 articles achieved 60%. Nurses' knowledge deficit is the most common psychological capability barriers of nurse-led delirium management, while complexity of delirium screening tools was found to be a physical capability barriers. High workload, lack of staff, lack of time, lack of documentation and lack/ shortage of guidelines were barriers mapped to physical opportunity, while communication barriers in particular patient's intubation and sedation were mapped to social opportunity barriers. Motivation was represented by addressing delirium as a major problem, self-confidence, psychological support and considering nurse's views.

CONCLUSIONS

Nurse's knowledge deficit, complexity of delirium screening tools, high workload, lack of time, lack of documentation, lack/ shortage of guideline, and impaired communication were barriers of nurse led delirium management. This study is promising in ease of application in clinical practice since delirium barriers in ICU settings were well-presented in a COM-B framework that may facilitate therapeutic strategies and related decision making.

Intensive care unit acquired weakness and physical rehabilitation in the ICU

Approximately half of critically ill adults experience intensive care unit acquired weakness (ICUAW). Patients who develop ICUAW may have negative outcomes, including longer duration of mechanical ventilation, greater length of stay, and worse mobility, physical functioning, quality of life, and mortality. Early physical rehabilitation interventions have potential for improving ICUAW; however, randomized trials show inconsistent findings on the efficacy of these interventions. This review summarizes the latest evidence on the definition, diagnosis, epidemiology, pathophysiology, risks factors, implications, and management of ICUAW. It specifically highlights research gaps and challenges, with considerations for future research for physical rehabilitation interventions.

Risk factors for delirium in patients with COVID-19: A systematic review and meta-analysis

Delirium is one of the serious neurological complications of Coronavirus Disease 2019 (COVID-19) and is associated with significant morbidity and mortality in patients with COVID-19, especially in older patients. There is currently no meta-analysis of risk factors for delirium in patients with COVID-19. This study aimed to identify potential risk factors for delirium in patients with COVID-19 through a meta-analysis of observational clinical studies. In conducting this analysis, literature searches were conducted in PubMed, Embase, Cochrane Library, and Web of Science, and study quality was assessed using the Newcastle-Ottawa Quality Scale (NOS). Data were extracted independently by two reviewers and pooled using either fixed effects or random effects models based on the results of heterogeneity testing. As a result of this meta-analysis, a total of 21 studies were included, including 10,147 patients. The analysis revealed the identification of 26 predisposing factors and 54 precipitating factors associated with COVID-19-related delirium. Notably, the administration of hydrocortisone and azithromycin, among other specific medications designated for COVID-19, exhibited a potential to be positively associated with the incidence of delirium in patients afflicted with COVID-19. In conclusion, the present study identified potential predisposing and precipitating factors linked with delirium in COVID-19 patients. It is anticipated that these results will have a considerable impact on the management and treatment of delirium in COVID-19 patients.

Dose-response analysis of music intervention for improving delirium in intensive care unit patients: A systematic review and meta-analysis

BACKGROUND

Delirium is a common and severe condition among adult intensive care unit (ICU) patients. Music intervention, as a non-pharmacological approach, has the potential to reduce delirium, but the optimal dosage and type of intervention remain unclear.

AIM

To explore the effects of music intervention at different doses and types on reducing delirium in ICU patients.

STUDY DESIGN

This study was conducted as a systematic review and meta-analysis. Databases including Cochrane Library, EBSCO, Embase, PubMed, Web of Science, Airiti Library, China National Knowledge Infrastructure and Wanfang Data were searched until 29 February 2024. Study quality was assessed using the Cochrane Risk of Bias 2.0 criteria. Data were analysed using RevMan 5.4.1 and Comprehensive Meta-Analysis 3.0.

RESULTS

Fourteen studies involving 1434 ICU patients were included. Four studies were of good quality (low risk of bias), seven were of moderate quality (unclear risk) and three were of low quality (high risk). Pooled analysis showed that music interventions significantly reduced the risk of delirium (12 studies, RR = .49, 95% confidence interval [CI] [.40, .61]). Slow-tempo music had the strongest effect (11 studies, RR = .46, 95% CI [.37, .57]). The optimal intervention dosage involves conducting music interventions twice daily (12 studies, RR = .46, 95% CI [.34, .63]), with each session lasting 30 min (12 studies, RR = .41, 95% CI [.30, .55]). Additionally, a pooled analysis showed that a 7-day music intervention (6 studies, RR = .43, 95% CI [.26, .71]) was the most effective in reducing the risk of delirium.

CONCLUSIONS

Music intervention reduces delirium in ICU patients, especially with two 30-min sessions daily for 7 days. However, the certainty of evidence is low, highlighting the need for further high-quality research.

RELEVANCE TO CLINICAL PRACTICE

Music intervention is a simple, non-invasive method that may help reduce delirium in ICU patients. However, given the low certainty of the current evidence, it should be used cautiously, and further research is needed to validate its effectiveness before routine implementation.

A pharmacist's guide to mitigating sleep dysfunction and promoting good sleep in the intensive care unit

PURPOSE

To review causes, risk factors, and consequences of sleep disruption in critically ill patients; evaluate the role of nonpharmacological and pharmacological therapies for management of sleep in the intensive care unit (ICU); and discuss the role of pharmacists in implementation of sleep bundles.

SUMMARY

Critically ill patients often have disrupted sleep and circadian rhythm alterations that cause anxiety, stress, and traumatic memories. This can be caused by factors such as critical illness, environmental factors, mechanical ventilation, and medications. Methods to evaluate sleep, including polysomnography and questionnaires, have limitations that should be considered. Multicomponent sleep bundles with a focus on nonpharmacological therapy aiming to reduce nocturnal noise, light, and unnecessary patient care may improve sleep disorders in critically ill patients. While pharmacological agents are often used to facilitate sleep in critically ill patients, evidence supporting their use is often of low quality, which limits use to patients who have sleep disruption refractory to nonpharmacological therapy. Dedicated interprofessional teams are needed for implementation of sleep bundles in the ICU. Extensive pharmacotherapeutic training and participation in daily patient care rounds make pharmacists vital members of the team who can help with all components of the bundle. This narrative review discusses evidence for elements of the multicomponent sleep bundle and provides guidance on how pharmacists can help with implementation of nonpharmacological therapies and management of neuroactive medications to facilitate sleep.

CONCLUSION

Sleep bundles are necessary for patients in the ICU, and dedicated interprofessional teams that include pharmacists are vital for successful creation and implementation.

Timing of neurosurgical interventions for intracranial hypertension: the intensivists' and neurosurgeons' view

PURPOSE OF REVIEW

The aim of this study was to highlight clinical considerations regarding medical versus surgical management of elevated intracranial pressure (ICP), describe limitations of medical management, and summarize evidence regarding timing of neurosurgical interventions.

RECENT FINDINGS

The optimal ICP management strategy remains elusive, and substantial practice variations exist. Common risks of medical treatments include hypotension/shock, cardiac arrhythmias and heart failure, acute renal failure, volume overload, hypoxemia, and prolonged mechanical ventilation.In traumatic brain injury (TBI), recent randomized controlled trials (RCT) did not demonstrate outcome benefits for early, prophylactic decompressive craniectomy, but indicate a role for secondary decompressive craniectomy in patients with refractory elevated ICP. A recent meta-analysis suggested that when an extraventricular drain is required, insertion 24 h or less post-TBI may result in better outcomes.In large ischemic middle cerebral artery strokes, pooled analyses of three RCTs showed functional outcome benefits in patients less than 60 years who underwent prophylactic DC within less than 48 h. In intracranial hemorrhage, a recent RCT suggested outcome benefits for minimally invasive hematoma evacuation within less than 24 h.

SUMMARY

More data are needed to guide ICP targets, treatment modalities, predictors of herniation, and surgical triggers; clinical decisions should consider individual patient characteristics, and account for risks of medical and surgical treatments.

Metal Oxide Nanocatalysts for the Electrochemical Detection of Propofol

Propofol is one of the most widely used intravenous drugs for anaesthesia and sedation and is one of the most commonly used drugs in intensive care units for the sedation of mechanically ventilated patients. The correct dosage of propofol is of high importance, but there is currently a lack of suitable point-of-care techniques for determining blood propofol concentrations. Here, we present a cytochrome P450 2B6/carbon nanotube/graphene oxide/metal oxide nanocomposite sensor for discrete measurement of propofol concentration. Propofol is converted into a quinol/quinone redox couple by the enzyme and the nanocomposite enables sensitive and rapid detection. The metal oxide nanoparticles are synthesised via green synthesis and a variety of metal oxides and mixed metal oxides are investigated to determine the optimal nanocatalyst. Converting propofol into the redox couple allows for the measurement to take place over different potential ranges, enabling interference from common sources such as paracetamol and uric acid to be avoided. It was found that nanocomposites containing copper titanium oxide nanoparticles offered the best overall performance and electrodes functionalised with such nanocomposites demonstrated a limit of detection in bovine serum of 0.5 µg/mL and demonstrated a linear response over the therapeutic range of propofol with a sensitivity of 4.58 nA/μg/mL/mm2.

Survivorship After Cardiogenic Shock

Advances in critical care therapies for patients with cardiogenic shock (CS), including temporary mechanical circulatory support and multidisciplinary shock teams, have led to improved survival to hospital discharge, ranging from 60% to 70%. After their index hospitalization, however, survivors of CS may continue to face cardiac as well as extracardiac sequelae of these therapies and complications for years to come. Most studies in CS have focused primarily on survival, with limited data on long-term recovery measures among survivors. In other forms of critical illness, research indicates that many intensive care unit survivors experience impairments in multiple domains, such as cognitive function, physical ability, and mental health. These impairments, collectively referred to as Post-Intensive Care Syndrome, in turn impact survivors' quality of life and future prognosis. This review identifies unique aspects of CS-related survivorship, highlights lessons learned from other forms of critical illness, and outlines future research directions to determine specific strategies to enhance recovery and survivorship after CS.

Development and validation of machine-learning models for predicting the risk of hypertriglyceridemia in critically ill patients receiving propofol sedation using retrospective data: a protocol

INTRODUCTION

Propofol is a widely used sedative-hypnotic agent for critically ill patients requiring invasive mechanical ventilation (IMV). Despite its clinical benefits, propofol is associated with increased risks of hypertriglyceridemia. Early identification of patients at risk for propofol-associated hypertriglyceridemia is crucial for optimising sedation strategies and preventing adverse outcomes. Machine-learning (ML) models offer a promising approach for predicting individualised patient risks of propofol-associated hypertriglyceridemia.

METHODS AND ANALYSIS

We propose the development of an ML model aimed at predicting the risk of propofol-associated hypertriglyceridemia in ICU patients receiving IMV. The study will use retrospective data from four Mayo Clinic sites. Nested cross validation (CV) will be employed, with a tenfold inner CV loop for model tuning and selection as well as an outer loop using leave-one-site-out CV for external validation. Feature selection will be conducted using Boruta and least absolute shrinkage and selection operator-penalised logistic regression. Data preprocessing steps include missing data imputation, feature scaling and dimensionality reduction techniques. Six ML algorithms will be tuned and evaluated. Bayesian optimisation will be used for hyperparameter selection. Global model explainability will be assessed using permutation importance, and local model explainability will be assessed using SHapley Additive exPlanations.

ETHICS AND DISSEMINATION

The proposed ML model aims to provide a reliable and interpretable tool for clinicians to predict the risk of propofol-associated hypertriglyceridemia in ICU patients. The final model will be deployed in a web-based clinical risk calculator. The model development process and performance measures obtained during nested CV will be described in a study publication to be disseminated in a peer-reviewed journal. The proposed study has received ethics approval from the Mayo Clinic Institutional Review Board (IRB #23-0 07 416).

Summary of the Best Evidence for Non-Pharmacological Management of Sleep Disturbances in Intensive Care Unit Patients

AIM

To retrieve, evaluate and summarise the best evidence for non-pharmacological management of sleep disturbances in ICU patients, and to provide basis for clinical nursing practice.

DESIGN

This study was an evidence summary followed by the evidence summary reporting standard of Fudan University Center for Evidence-based Nursing.

METHODS

All evidence on non-pharmacological management of sleep disturbances in ICU patients from both domestic and international databases and relevant websites was systematically searched, including guidelines, expert consensuses, best practice, clinical decision-making, evidence summaries and systematic review.

DATA SOURCES

UpToDate, BMJ Best Practice, Joanna Briggs Institute, Scottish Intercollegiate Guidelines Network, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence, Yi Maitong Guidelines Network, Registered Nurses Association of Ontario, Canadian Medical Association: Clinical Practice Guideline, Guidelines International Network, WHO, the Cochrane Library, CINAHL, Embase, PubMed, Web of Science, CNKI, WanFang database, VIP database, SinoMed, The American Psychological Association, European Sleep Research Society, American Academy of Sleep Medicine and National Sleep Foundation were searched from the establishment of the databases to June 1, 2024.

RESULTS

A total of 18 pieces of literature were included, involving 4 guidelines, 2 expert consensuses, 1 best practice and 11 systematic reviews. 25 pieces of evidence covering 4 categories of risk factors, sleep monitoring, non-pharmaceutical intervention, education and training were summarised.

CONCLUSION

This study summarises the best evidence for non-pharmacological management of sleep disturbances in ICU patients. In clinical application, medical staff should make professional judgements and fully combine clinical situations and patient preferences to select evidence, laying a theoretical foundation for later empirical research to reduce the incidence of sleep disturbances in ICU patients and improve the sleep quality of critically ill patients.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Medical staff can refer to the best evidence to provide reasonable non-pharmacological management plans for sleep disturbances in ICU patients, improving their sleep quality and life satisfaction.

IMPACT

The management of sleep disturbances in critically ill patients has not received sufficient attention and standardisation. This study summarises 25 pieces of the best evidence for non-pharmacological management of sleep disturbances in critically ill patients. Accurate and standardised evaluation and monitoring are the foundation of sleep management for ICU patients. This summary of evidence can help ICU nurses enhance their clinical practice.

REPORTING METHOD

This evidence summary followed the evidence summary reporting specifications of Fudan University Center for Evidence-based Nursing, which were based on the methodological process for the summary of the evidence produced by the Joanna Briggs Institute. This study was based on the evidence summary reporting specifications of the Fudan University Center for the Evidence-based Nursing; the registration number is 'ES20231708'.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

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.

Effectiveness of non-pharmacological intervention protocol for prevention of postoperative delirium in the surgical intensive care unit

Postoperative delirium (POD) is a common adverse event in patients admitted to the intensive care unit (ICU). We aimed to determine the effectiveness of a multicomponent non-pharmacological intervention protocol to reduce the incidence of POD in elderly patients admitted to the surgical ICU (SICU). This before-and-after cohort study included 300 patients aged ≥ 65 years who were admitted to the SICU within 7 days postoperatively with an anticipated SICU stay > 24 h. During the pre-intervention period, patients received medical care based on the attending physicians. While during the intervention, patients received the same medical care plus a multicomponent non-pharmacological intervention protocol. POD was monitored twice daily using the Confusion Assessment Method for the ICU. Demographic and clinical data during SICU stay were collected and compared between the pre-intervention and intervention periods. The primary outcome was POD incidence. The secondary outcomes were POD duration, delirium-free days, and other clinical outcomes. The incidences of POD during the pre-intervention and intervention periods were not different (40.0% vs. 38.0%, P = 0.723; OR 0.92, 95% CI 0.58-1.46). Multivariate regression analyses with two different models demonstrated that the multicomponent non-pharmacological intervention protocol was not associated with POD prevention (OR 0.70, 95% CI 0.39-1.25 for Model 1 and OR 0.63, 95% CI 0.37-1.08 for Model 2). The protocol was associated with lower incidence of SICU events, particularly self-removal of endotracheal tube and nosocomial infection. Implementation of the multicomponent non-pharmacological intervention protocol was not associated with POD prevention in elderly patients admitted to the SICU.Trial registration Thai Clinical Trials Registry. Trial No. TCTR20181201001. Retrospective registered 01 December 2018.

Comparative risks and clinical outcomes of midazolam versus other intravenous sedatives in critically ill mechanically ventilated patients: A systematic review and meta-analysis of randomized trials

OBJECTIVES

This systematic review synthesized literature evidence and compared midazolam's risks and clinical outcomes with other sedatives in critically ill mechanically ventilated patients.

METHODS

We included randomized controlled trials (RCTs) from databases of PubMed, Embase, Cochrane Library, Web of Science, and CINAHL without language restrictions. We used relative risk (RR) for binary outcomes and standardized mean difference (SMD) for continuous outcomes, with corresponding 95% confidence interval (CI).

RESULTS

17 RCTs involving 1509 patients were included. Compared to other sedatives, midazolam significantly increased the incidence of delirium (RR 2.39, 95 % CI, 1.75 to 3.26), the time up to extubation (SMD 1.99, 95 % CI, 0.81 to 3.16) and ICU length of stay (SMD 0.63, 95 % CI, 0.20 to 1.08), but significantly reduced the incidence of bradycardia (RR 0.52, 95 % CI, 0.36 to 0.76). No differences were identified in hypotension incidence (RR 0.69, 95 % CI, 0.37 to 1.31) or duration of mechanical ventilation (SMD 0.28, 95 % CI, -0.22 to 0.78).

CONCLUSIONS

Midazolam caused a higher risk of delirium, a longer time up to extubation, and ICU length of stay, but a lower incidence of bradycardia. No significant evidence indicated midazolam was associated with a higher risk of hypotension or increased duration of mechanical ventilation.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians should balance midazolam's potential risks with its benefits. While other sedatives may be catering to patients at a higher delirium risk, midazolam remains indispensable for hemodynamically compromised patients, such as those with bradycardia. Precise sedation management is crucial for patient safety and outcomes.

Patient perspectives on stress after ICU and a short primary care based psychological intervention - results from a qualitative sub‑study of the PICTURE trial

BACKGROUND

Approximately 20-25% of patients who survive medical treatment at an intensive care unit (ICU) develop post-traumatic stress symptoms. There is currently a gap in follow-up care for them. As part of the PICTURE study, general practitioners (GPs) carried out a brief interview-based intervention. The aim of this sub-study is to record the most distressing memories of ICU treatment from the patient's perspective and their evaluation of a GP-based brief psychological intervention.

METHODS

Participants were recruited from the intervention group of the main PICTURE study using selective sampling. All of them had experienced an ICU stay with mechanical ventilation and severe organ failure in the previous two years. They were interviewed about their experience of psychological stress during their ICU stay and their retrospective evaluation of the intervention. Semi-structured, guideline-based telephone interviews were conducted for this purpose, processed, and analyzed using the structuring qualitative content analysis based on Mayring.

FINDINGS

When asked N = 8 patients about the most stressful memory of their stay at ICU, the main themes were helplessness, pain, fixation, inability to communicate and sleep disturbances. The question of amnesia regarding the stay in the ICU was answered affirmatively by half of the interviewees but was not experienced as stressful. The brief trauma-focused intervention carried out by their GPs was well received by all respondents.

CONCLUSIONS

The interviewees confirm that aversive traumatizing experiences are often associated with intensive care treatment and reinforce each other. These are due to the treatment setting but should be reduced wherever possible. In view of chronification and the lack of specific follow-up treatment options for these patients and the long waiting times for psychotherapy, the implementation of low-threshold treatment options by GPs appears to be ideally suited to closing this gap in care, particularly for patients with mild to moderate symptoms of a post-traumatic stress disorder.

TRIAL REGISTRATION

The main trial was registered at ClinTrials gov (NCT03315390) and at the German Register of Clinical Trials (DRKS, DRKS00012589) on 17/10/2017.

Procedural sedative effect of remimazolam in ICU patients on invasive mechanical ventilation: a randomised, prospective study

BACKGROUND

Invasive procedures and environmental factors in the intensive care unit (ICU) may cause anxiety and discomfort in patients, who often require sedation therapy. The aim of this study was to assess the safety of remimazolam tosilate for procedural sedation in ICU patients receiving mechanical ventilation following endotracheal intubation. Eighty patients from a single centre were randomly assigned to either the propofol group or the remimazolam group. Blood tests were conducted to evaluate changes in lactate, blood lipids, liver and kidney function, and inflammatory markers, and patients' vital signs were observed over several periods. This study compared the incidence of delirium, the impact on liver and kidney function, circulatory effects, and changes in blood lipids between the two groups. These findings have optimised the selection of medications, providing ICU patients with more options for sedation therapy.

METHODS

In this single-centre randomised controlled trial, intubated patients were randomly assigned to the remimazolam group or the propofol group. Under the same analgesic regimen, the two groups received remimazolam and propofol for procedural sedation.

RESULTS

Our primary outcome was the mean arterial pressure (MAP), which significantly differed on Days 4 and 7 (P = 0.021, control group vs. experimental group = 85.23 ± 11.24 vs. 94.36 ± 13.18, P = 0.023, 83.55 ± 8.94 vs. 92.66 ± 7.02). With respect to liver and kidney function, the ∆AST value in the remimazolam group was significantly lower than that in the control group on Day 7 (P = 0.023). There were significant differences in triglyceride (TG) levels on Days 4 and 7 (P = 0.020) and in the ∆LDL on Day 7 (P = 0.027). Furthermore, the rates of dyslipidaemia and delirium in the remimazolam group were lower than those in the propofol group (85.0%, n = 40 vs. 90.0%, n = 40; 27.5%, n = 40 vs. 55%, n = 40).

CONCLUSION

Remimazolam is a novel benzodiazepine that has demonstrated promising applications in general anaesthesia and procedural sedation; however, its use in ICU sedation is still in the early stages of research. Current evidence suggests that remimazolam is a safe sedative that is particularly well suited for patients with haemodynamic instability. Large sample-size randomised clinical trials are warranted.

Effects of nursing interventions applied at night on sleep quality and sleep effort of patients in the intensive care unit

This study aimed to evaluate the effect of nursing care interventions applied at night on the sleep quality and sleep effort of intensive care patients. This study is descriptive and cross-sectional in nature. The sample size consists of 82 intensive care patients. Personal information form, Glasgow Coma Scale, Richard-Campbell Sleep Scale, Glasgow Sleep Effort Scale were applied to the patients. In the analysis of the data, Independent Samples t test, One-Way Analysis of Variance (ANOVA), Pearson Correlation test, and multilinear regression analysis were used. Based on the findings of the examined patients, it was concluded that care interventions may disrupt the sleep of intensive care patients. It is thought that determining the care interventions that disrupt the sleep of intensive care patients may contribute to better planning of care and preserving the sleep patterns of the patients. Basd on our results, nursing education programs and intensive care unit introductory courses should be reviewed to understand the importance of sleep. In this context, reducing unnecessary interventions and diagnostic procedures at night, evaluating and managing pain, using questionnaires for daily bedside evaluation of sleep quality, and implementing interventions that support sleep quality and sleep should be an integral part of nursing care. Insomnia is a significant stressor in the intensive care unit. Therefore, it is important for nurses, who are primarily responsible for care, to determine the sleep quality of patients, evaluate the factors that reduce sleep quality, and implement preventive interventions to ensure patient comfort. It is expected that this study will lead to plans for grouping nursing care interventions in a way that will not affect sleep.

Evaluating the effectiveness of a clinical decision support system (AI-Antidelirium) to improve Nurses' adherence to delirium guidelines in the intensive care unit

OBJECTIVES

To evaluate the impact of Artificial Intelligence Assisted Prevention and Management for Delirium (AI-AntiDelirium) on improving adherence to delirium guidelines among nurses in the intensive care unit (ICU).

RESEARCH METHODOLOGY/DESIGN

Between November 2022 and June 2023, A cluster randomized controlled trial was undertaken.

SETTING

A total of 38 nurses were enrolled in the interventional arm, whereas 42 nurses were recruited for the control arm in six ICUs across two hospitals in Beijing, comparing nurses' adherence and cognitive load in units that use AI-AntiDelirium or the control group.

MAIN OUTCOME MEASURES

The AI-AntiDelirium tailored delirium preventive or treated interventions to address patients' specific risk factors. The adherence rate of delirium interventions was the primary endpoint. The other endpoints were adherence to risk factors assessment, ICU delirium assessment, and nurses' cognitive load. The repeated measures analysis of variance was utilized to explore the influence of time, group, and time × group interaction on the repeated measurement variable (e.g., adherence, cognitive load).

RESULTS

A cumulative total of 1040 nurse days were analyzed for this study. The adherence to delirium intervention of nurses in AI-AntiDelirium groups was higher than control units (75 % vs. 58 %, P < 0.01). When compared to control groups, AI-AntiDelirium was found to be significantly effective in both decreasing extraneous cognitive load (P < 0.01) and improving germane cognitive load (P < 0.01).

CONCLUSIONS

This study supports the effectiveness of AI-AntiDelirium in enhancing nurses' adherence to evidence-based, individualized delirium intervention and also reducing extraneous cognitive load.

IMPLICATIONS FOR CLINICAL PRACTICE

A nurse-led systemshould be applied by nursing administrators to improve compliance with nursing interventions among ICU nurses.

The Role of Regional Anesthesia in ICU Pain Management

PURPOSE OF REVIEW

The purpose of this review is to provide the most recent update and summary on the consideration, benefits and application of regional anesthesia in the ICU setting, as it pertains to the management of perioperative pain.

RECENT FINDINGS

Regional anesthesia and analgesia have become ubiquitous in the perioperative setting, with numerous indications and benefits. As integral part of the multimodal analgesia approach, various regional blocks have been increasingly utilized in critically ill patients. We focus this review on various regional techniques employed for critically ill patients after cardiac, thoracic, and major abdominal surgery, including neuraxial and novel truncal blocks. Effective pain management in critically ill patients poses many challenges and is extremely important. Regional anesthesia, in combination with other analgesia modalities, while still under-utilized, can help reduce acute perioperative pain, stress response, opioid use and related side effects and expedite recovery and improve clinical outcomes.

Protocol for the development and validation of machine-learning models for predicting the risk of hypertriglyceridemia in critically ill patients receiving propofol sedation using retrospective data

Introduction

Propofol is a widely used sedative-hypnotic agent for critically-ill patients requiring invasive mechanical ventilation (IMV). Despite its clinical benefits, propofol is associated with increased risks of hypertriglyceridemia. Early identification of patients at risk for propofol-associated hypertriglyceridemia is crucial for optimizing sedation strategies and preventing adverse outcomes. Machine learning (ML) models offer a promising approach for predicting individualized patient risks of propofol-associated hypertriglyceridemia.

Methods and analysis

We propose the development of a ML model aimed at predicting the risk of propofol-associated hypertriglyceridemia in ICU patients receiving IMV. The study will utilize retrospective data from four Mayo Clinic sites. Nested cross-validation (CV) will be employed, with a 10-fold inner CV loop for model tuning and selection as well as an outer loop using leave-one-site-out CV for external validation. Feature selection will be conducted using Boruta and LASSO-penalized logistic regression. Data preprocessing steps include missing data imputation, feature scaling, and dimensionality reduction techniques. Six ML algorithms will be tuned and evaluated. Bayesian optimization will be used for hyperparameter selection. Global model explainability will be assessed using permutation importance, and local model explainability will be assessed using SHapley Additive exPlanations (SHAP).

Ethics and dissemination

The proposed ML model aims to provide a reliable and interpretable tool for clinicians to predict the risk of propofol-associated hypertriglyceridemia in ICU patients. The final model will be deployed in a web-based clinical risk calculator. The model development process and performance measures obtained during nested cross-validation will be described in a study publication to be disseminated in a peer-reviewed journal. The proposed study has received ethics approval from the Mayo Clinic Institutional Review Board (IRB #23-007416).

Strengths and limitations of this study

Robust external validation using a nested cross-validation (CV) framework will help assess the generalizability of models produced from the modeling pipeline across different hospital settings.A diverse set of machine learning (ML) algorithms and advanced hyperparameter tuning techniques will be employed to identify the most optimal model configuration.Integration of feature explainability will enhance the clinical applicability of the ML models by providing transparency in predictions, which can improve clinician trust and encourage adoption.Reliance on retrospective data may introduce biases due to inconsistent or erroneous data collection, and the computational intensity of the validation approach may limit replication and future model expansion in resource-constrained settings.

Family involvement in preventing delirium in critically ill patients: A systematic review and meta-analysis

BACKGROUND

Humanized care is a novel concept in the prevention of delirium, with family involvement being a crucial component. Currently, there is controversy regarding the effectiveness of family involvement in preventing delirium among critically ill patients, and the impact of varying levels of family involvement on delirium prevention remains unclear.

OBJECTIVE

The purpose of this study is twofold: (a) to investigate the influence of family involvement on delirium among critically ill patients, and (b) to explore the effectiveness of different levels of family involvement in preventing delirium in these patients.

DESIGN

A systematic review and meta-analysis.

METHODS

From database inception to July 2024, a comprehensive search was conducted across PubMed, EMBASE, CINAHL, Web of Science, and the Cochrane CENTRAL database. Randomized controlled trials that examined family involvement were included in the review.

RESULTS

This review included a total of 11 randomized controlled trials, encompassing 3113 critically ill patients. Family involvement was found to significantly reduce the incidence of delirium among critically ill patients (RR = 0.46, 95%CI = 0.31 to 0.69), decrease the duration of delirium (WMD = -2.18, 95 % CI = -4.14 to -0.22), and shorten the length of Intensive Care Unit (ICU) stay (WMD = -1.46, 95%CI = -2.43 to -0.50). Three different levels of family involvement-direct participation in care (RR = 0.37, 95%CI = 0.26 to 0.51), family visits and companionship (RR = 0.56, 95 % CI = 0.25 to 1.25), and indirect participation (RR = 0.77, 95 % CI = 0.29 to 2.07)-varies in their effectiveness for delirium prevention.

CONCLUSIONS

Family involvement significantly impacts delirium prevention in critically ill patients. The effectiveness of delirium prevention varies depending on the level of family involvement, with direct participation of family members in caregiving demonstrating a more pronounced effect in reducing delirium incidence among critically ill patients.

REGISTRATION

The review protocol has been registered in the PROSPERO International prospective register of systematic reviews (CRD42024563095).

Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study

INTRODUCTION

The purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients.

METHODS

We conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed.

RESULTS

In total, 162 patients were included and divided into delirium (n=54) and nondelirium (n=108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients.

CONCLUSION

The incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.

Induction Agents for Tracheal Intubation in Critically Ill Patients

OBJECTIVES

Concise definitive review of the use of induction agents in critically ill patients undergoing tracheal intubation and their association with outcomes.

DATA SOURCES

Original publications were retrieved through a PubMed search with search terms related to induction agents for tracheal intubation in critically ill patients.

STUDY SELECTION

We included randomized controlled trials and observational studies that reported patient outcomes.

DATA EXTRACTION

Data from included studies, including choice of induction agents and clinically relevant outcomes, were extracted.

DATA SYNTHESIS

Etomidate and ketamine have been the most studied induction agents in critical care during last years. Recent studies on etomidate investigated the clinical impact of its recognized adrenal suppression in terms of morbidity and mortality. Etomidate may carry a non-negligible mortality risk without definitive hemodynamic benefits compared with ketamine. Available data then support the use of ketamine over etomidate, since the difference in the hemodynamic profile seems to be of minor clinical relevance. No multicenter randomized studies are available comparing propofol to other induction agents but evidence from a large observational study identified an association of propofol with post-intubation cardiovascular instability in critically ill patients. Despite the observational nature of these findings cannot exclude the role of confounders, the association of propofol with post-induction cardiovascular instability is pharmacologically plausible, justifying its avoidance in favor of drugs with a better safety profile in critical care such as ketamine.

CONCLUSIONS

Although no definitive conclusions can be drawn based on the available evidence, recent evidence pointed out the potential negative effect of etomidate on survival and the association of propofol with cardiovascular instability. Ketamine may be considered the drug with a safer profile, widespread availability and low cost but future research should provide definitive data on optimal drug selection, its dosage in the context of critical illness and concomitant interventions to minimize the risk of peri-intubation complications.

Long-Term Cognitive Function Among Critical Illness Survivors

Cognitive impairment is common after critical illness and persists beyond the period of acute illness. Clinicians caring for this patient population are encouraged to screen for cognitive impairment and provide supportive measures to mitigate its distressing effects. Further research is needed to evaluate the laboratory and neuroimaging correlates of post-intensive care unit (ICU) cognitive impairment, which may in turn lead to personalized interventions to address this debilitating complication of critical illness. Further research is needed to evaluate the laboratory and neuroimaging correlates of post-ICU cognitive impairment, which may, in turn, lead to personalized interventions to address this debilitating complication of critical illness.

Author Response: Continuous Infusion of Propofol or Dexmedetomidine should not be the First Choice to Prevent Postoperative Delirium in Patients after Hip Fracture

How to cite this article: Ekkapat G, Chokengarmwong N. Author Response: Continuous Infusion of Propofol or Dexmedetomidine should not be the First Choice to Prevent Postoperative Delirium in Patients after Hip Fracture. Indian J Crit Care Med 2025;29(1):88-89.

Advancing Delirium Treatment Trials in Older Adults: Recommendations for Future Trials From the Network for Investigation of Delirium: Unifying Scientists (NIDUS)

OBJECTIVES

To summarize the delirium treatment trial literature, identify the unique challenges in delirium treatment trials, and formulate recommendations to address each in older adults.

DESIGN

A 39-member interprofessional and international expert working group of clinicians (physicians, nurses, and pharmacists) and nonclinicians (biostatisticians, epidemiologists, and trial methodologists) was convened. Four expert panels were assembled to explore key subtopics (pharmacological/nonpharmacologic treatment, methodological challenges, and novel research designs).

METHODS

To provide background and context, a review of delirium treatment randomized controlled trials (RCTs) published between 2003 and 2023 was conducted and evidence gaps were identified. The four panels addressed the identified subtopics. For each subtopic, research challenges were identified and recommendations to address each were proposed through virtual discussion before a live, full-day, and in-person conference. General agreement was reached for each proposed recommendation across the entire working group via moderated conference discussion. Recommendations were synthesized across panels and iteratively discussed through rounds of virtual meetings and draft reviews.

RESULTS

We identified key evidence gaps through a systematic literature review, yielding 43 RCTs of delirium treatments. From this review, eight unique challenges for delirium treatment trials were identified, and recommendations to address each were made based on panel input. The recommendations start with design of interventions that consider the multifactorial nature of delirium, include both pharmacological and nonpharmacologic approaches, and target pathophysiologic pathways where possible. Selecting appropriate at-risk patients with moderate vulnerability to delirium may maximize effectiveness. Targeting patients with at least moderate delirium severity and duration will include those most likely to experience adverse outcomes. Delirium severity should be the primary outcome of choice; measurement of short- and long-term clinical outcomes will maximize clinical relevance. Finally, plans for handling informative censoring and missing data are key.

CONCLUSIONS

By addressing key delirium treatment challenges and research gaps, our recommendations may serve as a roadmap for advancing delirium treatment research in older adults.

Electrophisiological monitoring of pain in non-communicative critically ill patients

Electrophysiological monitoring of pain provides objective measures that allow for pain control and adjustment of analgesia in non-communicative patients. Among the available electrophysiological devices, automated infrared pupillometry, Analgesia Nociception Index (ANI), and Nociception Level Index (NOL®) stand out. These non-invasive measurement systems analyze the sympathetic or parasympathetic nervous system response to painful stimuli by observing pupillary dilatation and reactivity (pupillometry), heart rate during respiration (ANI), or a combination of multiple parameters from the nociceptive-autonomic medullary circuit (NOL®). These methods have mainly been used in the monitoring of nociception related to procedures in critically ill patients. Furthermore, they have allowed for the prediction, adjustment, and customization of analgesia administration prior to painful procedures. To obtain accurate measurements and properly interpret the values provided by these devices, it is important to consider certain limitations in their use, such as the administration of specific medications or the presence of certain pathologies, due to their influence on the autonomic nervous system response. It is also important to note that the reported level of evidence is limited, as randomized clinical trials in the context of intensive care unit regarding these devices are currently lacking.