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

A Retrospective, Single-Center Assessment of Changes in Pain, Agitation, and Delirium Management Before and During the COVID-19 Pandemic

IMPORTANCE

Recent studies have found an association between COVID-19 infection and deeper sedation in mechanically ventilated patients, raising concerns about the impact of the COVID-19 pandemic on pain, agitation, and delirium (PAD) management practices overall.

OBJECTIVES

This study aimed to assess differences in PAD management in patients without COVID-19 infection in pre- and peri-COVID-19 pandemic timeframes.

DESIGN, SETTING, AND PARTICIPANTS

This was a single-center, retrospective, pre-/post-cohort analysis of mechanically ventilated adult patients without COVID-19 infection admitted to an ICU in Boston, MA. The "pre" and "post" groups enrolled patients in 2019 and 2021, respectively. All PAD data during the first 7 days of mechanical ventilation (MV) were collected.

MAIN OUTCOMES AND MEASURES

The primary outcome was ventilator-free days (VFDs) during the first 28 days. A multivariable linear regression analysis was performed to assess VFD while controlling for confounders. Secondary outcomes included depth of sedation, total dose of sedatives, and in-hospital mortality.

RESULTS

There were 339 patients included in the final analysis. There was no difference in VFD between the pre- and post-groups (22.2 vs. 22.6 d; p = 0.92); this was confirmed by multivariable linear regression (p = 0.91). Patients in the post-group experienced significantly deeper levels of sedation compared with the pre-group (58% vs. 53%; p < 0.01) within the first 48 hours of MV. The median number of Richmond Agitation-Sedation Scale assessments per 24-hour period was greater in the pre-group (13 vs. 12 assessments; p = 0.02) within the first 48 hours of MV. There were no significant differences in total cumulative dose of sedatives or in-hospital mortality between the two groups.

CONCLUSIONS AND RELEVANCE

This study suggests that PAD practices, including depth of sedation and frequency of assessment, differed between pre- and post-COVID-19 groups in patients without COVID-19. Outcomes including VFD, mortality, and hospital length of stay were not affected. Further studies are needed to understand the broader impact of the COVID-19 pandemic on PAD management practices.

Creating a Culture of an Awake and Walking Intensive Care Unit: In-Hospital Strategies to Mitigate Post-Intensive Care Syndrome

The ABCDEF bundle and Awake and Walking intensive care unit (ICU) approach aim to prevent the long-term consequences of critical illness (ie, post-intensive care syndrome) by promoting patient wakefulness, cognition, and mobility. Humanizing the ICU experience is the key, preserving patients' function and autonomy. Successful implementation requires cultivating an ICU culture focused on avoiding sedatives and initiating prompt mobilization, addressing organizational barriers through tailored strategies. Overall, these patient-centered, mobility-focused models offer a holistic solution to the complex challenge of preventing post-intensive care syndrome and supporting critical illness survivors.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Impact of ICU-Based Extracorporeal Membrane Oxygenation and Blood Purification Therapy on the Time Required for Early Rehabilitation

Background Early rehabilitation in an intensive care unit (ICU) can shorten the ICU stay and reduce the associated risks and costs. However, mobilization has been shown to be slower and less successful in patients receiving blood purification therapy or extracorporeal membrane oxygenation (ECMO), and the ideal duration of rehabilitation has not been determined. To examine this, the time required for rehabilitation in patients receiving ECMO and blood purification therapy in the ICU was examined. Materials and methods This was a post-hoc analysis of the IPAM study (Investigating Physical Activity of Mechanical Ventilation Patients in the ICU). The IPAM study with data from hospitalization between September 2022 and March 2023 is a multicenter observational prospective cohort study. Inclusion criteria were subjects who were supported by mechanical ventilation in the ICU for ≥48 hours. The exclusion criteria were age <18 years, loss of walking independence at least two weeks before admission, neurological complications or lack of communication skills due to preexisting mental conditions, terminal stage, and ongoing coronavirus infection. These cases were divided into an ECMO/blood purification group, in which ECMO and blood purification were performed upon admission to the ICU, and a group that did not receive these interventions. The primary endpoint was the daily duration of rehabilitation activity. The secondary endpoints were the daily durations of preparation and rehabilitation activity and the total ICU stay. Results Following case selection, 121 cases were analyzed, 28 in the ECMO/blood purification group and 93 in the control group. Total daily rehabilitation time and ICU stay were significantly longer in the ECMO/blood purification group. Among all cases, eight (1%) adverse events occurred during the 959 rehabilitation interventions. No adverse events such as death, cardiopulmonary resuscitation, falls, or intubation-related problems occurred. Kaplan-Meier curve analysis revealed that sitting (p = 0.042), standing (p = 0.001), and walking (p = 0.001) were significantly delayed in the ECMO/blood purification group. Conclusion Patients receiving ECMO/blood purification in the ICU require more rehabilitation activity each day, including longer preparation time.

The Impact of Listening to Quran Recitation during Pain-Inducing Procedure among Patients Receiving Mechanical Ventilation Support: An Interventional Study

Background

Pain experienced by intubated patients is caused by several extrinsic sources, including nursing care procedures such as endotracheal suctioning. Several nonpharmacological therapies, including listening to Quran recitation, have never been tested for their pain relief effects among intubated patients, despite these therapies being cost-effective, easy to implement, and free of adverse effects. This study aimed to examine the pain-relieving effect of listening to Quran recitation during pain-inducing procedures in patients receiving mechanical ventilation support.

Materials and Methods

This pilot study used an experimental design with 32 intubated patients at King Abdullah University Hospital in Irbid, Jordan. The Behavioral Pain Scale and Ramsay Sedation Scale were used to assess pain levels and sedation, and physiologic parameters were monitored before and during endotracheal suctioning.

Results

The findings showed significant differences in Behavioral Pain Scale (BPS) scores and heart rate measures between the intervention and control groups after controlling for the level of sedation. The patients in the intervention group scored lower pain and HR measures than those in the control group (F5,26 = 11.47, p < 0.001).

Conclusions

The findings showed significant improvement in the levels of pain and heart rate measures among intubated patients who are exposed to Quran recitation. Complementary medicine is essential to the healthcare plans of critically ill patients and their families. Holy Quran recitation has been reported to be a useful nonpharmacological intervention for critically ill Muslim patients.

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

OBJECTIVES

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

DESIGN

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

SETTING/PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

[Post-Intensive Care Syndrome: functional impairments of critical illness survivors]

With a decrease in mortality of critically ill patients in recent years, intensive care medicine research has shifted its focus on functional impairments of intensive care units (ICU) survivors. ICU survivorship is characterized by long-term impairments of cognition, mental health, and physical health. Since 2012, these impairments have been summarized with the umbrella term Post-Intensive Care Syndrome (PICS). Mental health impairments frequently entail new are aggravated symptoms of depression, anxiety, and posttraumatic stress disorder. Beyond impairments in the three PICS domains, critical illness survivors frequently suffer from chronic pain, dysphagia, and nutritional deficiencies. Furthermore, they have a higher risk for osteoporosis, bone fractures, and diabetes mellitus. Taken together, these sequelae reduce their health-related quality of life. Additionally, ICU survivors are challenged by social problems such as isolation, economic problems such as treatment costs and lost earnings, and return to previous employment. Yet, patients and caregivers have described post-ICU care as inadequate and fragmented. ICU follow-up clinics could improve post-ICU care, but there is insufficient evidence for their effectiveness. Thus far, large high-quality trials with multicomponent and interdisciplinary post-ICU interventions have mostly failed to improve patient outcomes. Hence, preventing PICS and minimizing risk factors by optimizing ICU care is crucial, e.g. by implementing the ABCDE bundle. Future studies need to identify effective components of post-ICU recovery interventions and determine which patient populations may benefit most from ICU recovery services.

Delirium Management Quality Improvement Project to Improve Awareness and Screening in a Medical ICU

Background/Objectives: Although delirium is common during critical illness, standard-of-care detection and prevention practices in real-world intensive care unit (ICU) settings remain inconsistent, often due to a lack of provider education. Despite availability for over 20 years of validated delirium screening tools such as the Confusion Assessment Method in the ICU (CAM-ICU), feasible and rigorous educational efforts continue to be needed to address persistent delirium standard-of-care practice gaps. Methods: Spanning an 8-month quality improvement project period, our single-ICU interdisciplinary effort involved delivery of CAM-ICU pocket cards to bedside nurses, and lectures by experienced champions that included a live delirium detection demonstration using the CAM-ICU, and a comprehensive discussion of evidence-based delirium prevention strategies (e.g., benzodiazepine avoidance). Subsequent engagement by health system leadership motivated the development of an electronic health record dataset to evaluate unit-level outcomes, including CAM-ICU documentation and benzodiazepine administration. Results: Using a dataset that spanned 9 pre- and 37 post-project months and included 3612 patients, 4470 admissions, and 33,913 patient days, we observed that delirium education was followed by a dramatic rise in CAM-ICU documentation, from <1% for daytime and nighttime shifts to peaks of 73% and 71%, respectively (p < 0.0001 for trend), and a fall in the proportion of mechanically ventilated patients ever receiving benzodiazepine infusions (69% to 41%; p < 0.0001). Conclusions: An interdisciplinary delirium project comprising rigorous lectures on standard-of-care practices can yield significant improvements in documentation and sedative administration. This approach can help ICUs jumpstart efforts to build awareness and address longstanding gaps in standard-of-care delirium practices.

Long-term stability of esketamine in polypropylene syringes at 5 ± 3°C

OBJECTIVE

Esketamine (Vesierra) is a molecule, used alone or in combination, to induce and maintain general anaesthesia and to relieve pain in emergency medicine. The aim of this study is to evaluate the long-term physicochemical stability of a 1 mg/mL solution of esketamine diluted in 0.9% sodium chloride (NaCl) and stored in polypropylene syringes at 5±3°C during 65 days (64+1 day at 22±3°C) and 72 hours at 22±3°C (room temperature), in order to centralise preparation under aseptic conditions in hospital pharmacy.

METHODS

Ten syringes were prepared under aseptic conditions. Five syringes were stored at 22±3°C for 3 days, and the five others were stored at 5±3°C for 64 days (+ 1 day at room temperature). The stability was periodically investigated. Particle appearance or colour changes were checked by visual inspection. A research of crystals was performed under the microscope. pH was followed to assess its stability. The turbidity of the solutions was estimated by a measure of optical densities at 350, 410 and 550 nm. The molecule concentrations were measured by ultra-high performance liquid chromatography (UHPLC) coupled with a photodiode array detection (PDA), using a newly developed method.

RESULTS

Based on microscopic examination, no crystals were observed, during the observation period. pH and absorbances at 350, 410 and 550 nm were also stable. Macroscopically, there was no change in colour and appearance of opacity, turbidity or precipitation. Statistical analysis indicates that 1 mg/mL esketamine solutions were chemically stable under these conditions, given that less than 5% of the solutions have lost more than 10% of their initial content during the study based on the prediction interval.

CONCLUSIONS

One mg/mL solutions of esketamine hydrochloride are physically and chemically stable after production, for at least 72 hours at 22±3°C and 64 days at 5±3°C (+ 1 day at room temperature).

Anesthesia management using remimazolam for coronary artery bypass grafting and aortic valve replacement in a patient with severe cardiac dysfunction: A case report

Remimazolam, a short-acting benzodiazepine approved for use in general anesthesia in Japan in 2020, has cardiovascular stability superior to conventional anesthetics. Anesthesia management using remimazolam of a patient with impaired cardiac function and several complications is reported. A man in his 50s with hypertension, diabetes mellitus, and chronic kidney disease (G 5) on dialysis came to our hospital with a chief complaint of exertional dyspnea and chest tightness, and a close examination showed stenoses of three coronary arteries. The patient was managed under anesthesia using remimazolam as a sedative because anesthetics could easily induce circulatory failure. Cardiopulmonary bypass was initiated without causing any circulatory failure, and coronary artery bypass grafting and aortic valve replacement were performed. The patient was successfully weaned with a small dose of catecholamine. Remimazolam was selected for this patient because of its minimal effect on cardiac rhythm, and the anesthesia was safely administered.

Development of evidence-based standards for inpatient physiotherapy services: a systematic review and content analysis of clinical practice guidelines

OBJECTIVE

Performance standards are critical to service design and quality improvement. There are no published standards defining the care inpatients should receive from physiotherapists in Aotearoa New Zealand. This study aims to explore the potential of using clinical practice guidelines (CPGs) to develop a set of evidence-based standards for physiotherapy in inpatient settings.

DESIGN

A systematic review and content analysis of CPGs.

DATA SOURCES

Scholarly databases (Web of Science, CINAHL and Scopus, PEDro) and grey literature (guideline databases - NICE, SIGN, ECRI guideline trust, Guidelines International Network (GIN)) were searched between July and September 2021.

ELIGIBILITY CRITERIA

CPGs related to conditions and treatments common to physiotherapy in a secondary care setting were included. Mental health conditions, paediatrics, COVID-19 and conditions common to tertiary care were excluded.

DATA EXTRACTION AND SYNTHESIS

A pragmatic approach was taken to group guidelines aligned with common physiotherapy services and select only the most recent and comprehensive guidelines for final analysis. The quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II). Data from guideline recommendations of relevance to inpatient physiotherapy were grouped into themes. Summative 'statements' were drafted to represent the content of each theme; these were given a confidence rating based on the number of supporting guidelines and the strength or grade of evidence awarded by the guideline group.

RESULTS

The recommendations of 32 CPGs yielded 27 statements.

CONCLUSION

Twenty-seven statements represent a distillation of the best evidence-based practice recommendations from CPGs in inpatient physiotherapy. Statements of physiotherapy dosage (frequency, intensity and duration) are not available for many areas of practice; researchers and CPG groups should consider the importance of these data for service commissioning.  .

Managing Intracranial Pressure Crisis

PURPOSE OF REVIEW

The objective of this review is to provide a comprehensive management protocol for the treatment of intracranial pressure (ICP) crises based on the latest evidence.

RECENT FINDINGS

The review discusses updated information on various aspects of critical care management in patients experiencing ICP crises, including mechanical ventilation, fluid therapy, hemoglobin targets, and hypertonic saline infusion, the advantages of ICP monitoring, the critical ICP threshold, and bedside neuromonitoring. All aspects of critical care treatment, including hemodynamic and respiratory support and adjustment of ICP reduction therapy, may impact patient outcomes. ICP monitoring allows ICP values, trends, waveforms, and CPP calculation, which are helpful to guide patient care. Advanced neuromonitoring devices are available at the bedside to diagnose impaired intracranial compliance and intracranial hypertension, assess brain function, and optimize cerebral perfusion. Future research should focus on developing appropriate intervention protocols for both invasive and noninvasive neuromonitoring in managing ICP crisis patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Sex specific differences in short-term mortality after ICU-delirium

INTRODUCTION

Delirium is a frequent complication in critically ill patients and is associated with adverse outcomes such as long-term cognitive impairment and increased mortality. It is unknown whether there are sex-related differences in intensive care unit (ICU) delirium and associated outcomes. We aimed to assess sex-specific differences in short-term mortality following ICU-delirium.

METHODS

We conducted a retrospective cohort study using the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. Adult ICU patients who were diagnosed with delirium using the Confusion Assessment Method for the ICU (CAM-ICU) were included. The primary outcome was 30-day mortality following delirium onset. To control for baseline differences in demographics, illness severity, and comorbidities, we applied 1:1 propensity score matching. Cox proportional hazards regression models were used to evaluate the association between sex and mortality.

RESULTS

A total of 8950 ICU patients with delirium were analyzed, of whom 42.6% were women. In univariable analysis, women had higher crude mortality (26.0% vs. 23.4%; HR 1.16, 95% CI 1.071-1.267, p < 0.001). After propensity score matching, the cohort included 3811 women and 3811 men. In adjusted analysis, risk for thirty-day mortality remained higher in women (HR 1.16, 95% CI 1.064-1.273, p < 0.001).

CONCLUSION

Our study suggests that women with ICU-delirium have a significantly higher risk of short-term mortality than men. Acknowledging the limitations inherent to observational studies with potential for residual confounding, further research is needed to understand the biological and clinical factors driving this disparity and to inform sex-specific interventions for ICU-delirium.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Clinical prediction scores predicting weaning failure from invasive mechanical ventilation: Role and limitations

Invasive mechanical ventilation (IMV) has become integral to modern-day critical care. Even though critically ill patients frequently require IMV support, weaning from IMV remains an arduous task, with the reported weaning failure (WF) rates being as high as 50%. Optimizing the timing for weaning may aid in reducing time spent on the ventilator, associated adverse effects, patient discomfort, and medical care costs. Since weaning is a complex process and WF is often multi-factorial, several weaning scores have been developed to predict WF and aid decision-making. These scores are based on the patient's physiological and ventilatory parameters, but each has limitations. This review highlights the current role and limitations of the various clinical prediction scores available to predict WF.

Management of pain and sedation in the intensive care unit

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

Valproic Acid for Hyperactive Delirium and Agitation in Critically Ill Patients

BACKGROUND

Delirium and agitation are common syndromes in critically ill patients. Valproic acid (VPA) has shown benefit in intensive care unit (ICU)-associated delirium and agitation, but further evaluation is needed.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and safety of VPA for hyperactive delirium and agitation in critically ill adult patients.

METHODS

A retrospective cohort study at NYU Langone Health was conducted in critically ill patients treated with VPA for hyperactive delirium or agitation from October 1, 2017 to October 1, 2022. The primary outcome was effectiveness of VPA, defined as a reduction in the total number of any concomitant psychoactive medication by day 3 of VPA treatment. Secondary outcomes included the effect of VPA on the doses of concomitant medications and adverse events.

RESULTS

A total of 87 patients were included in the final analysis. By day 3 of VPA treatment, a 33% reduction (P < .001) in the total number of concomitant psychoactive medications was observed. VPA decreased the need for sedatives, as assessed by midazolam equivalents, but no significant changes were seen with dexmedetomidine alone, opioids, or antipsychotics. A 10 mg/kg loading dose was utilized in 36% of the cohort and its use decreased the risk for initiating additional psychoactive medications by day 3 of therapy (OR 2.8, 95% CI 1.0-7.8, P = .047), with benefits noted as early as 48 h after initiation. Adverse events were low in the total cohort (10.3%).

CONCLUSION AND RELEVANCE

The addition of VPA to a complex pharmacologic regimen for hyperactive delirium and agitation is safe and can assist in the prevention of polypharmacy and overall workload in critically ill patients admitted primarily for cardiogenic shock and respiratory failure requiring mechanical ventilation.

Optimizing brain protection after cardiac arrest: advanced strategies and best practices

Cardiac arrest (CA) is associated with high incidence and mortality rates. Among patients who survive the acute phase, brain injury stands out as a primary cause of death or disability. Effective intensive care management, including targeted temperature management, seizure treatment and maintenance of normal physiological parameters, plays a crucial role in improving survival and neurological outcomes. Current guidelines advocate for neuroprotective strategies to mitigate secondary brain injury following CA, although certain treatments remain subjects of debate. Clinical examination and neuroimaging studies, both invasive and non-invasive neuromonitoring methods and serum biomarkers are valuable tools for predicting outcomes in comatose resuscitated patients. Neuromonitoring, in particular, provides vital insights for identifying complications, personalizing treatment approaches and forecasting prognosis in patients with brain injury post-CA. In this review, we offer an overview of advanced strategies and best practices aimed at optimizing brain protection after CA.

Relevance of Preoperative Cognitive Impairment for Predicting Postoperative Delirium in Surgical Medicine: A Prospective Cohort Study

BACKGROUND

Post-operative delirium is a dreaded complication after surgery in older patients. The identification of risk factors for delirium and comprehensive geriatric assessment is an extensive part of recent research. However, the preoperative assessment of risk factors, such as impaired cognition, is frequently not standardized.

METHODS

A comprehensive preoperative assessment was performed in 421 surgical patients to investigate the impact of preoperative cognitive impairment (PCI) on the risk of delirium and to evaluate appropriate screening tools (Six-item screener (SIS) and clock-drawing test (CDT)).

RESULTS

Both screening tools showed a significantly increased risk of delirium with p < 0.001 (OR 12.5, 95% [6.42; 24.4]) in SIS and p = 0.042 (OR 2.02, 95%CI [1.02; 4.03]) in CDT for existing cognitive impairment. A higher level of care (p < 0.001) and statutory care (p < 0.001, OR 5.42, 95%CI [2.34; 12.6]) also proved to be significant risk factors. The ROC curves of the two tests show AUC values of 0.741 (SIS) and 0.630 (CDT). The COP values for the SIS are 4 points with a Youden index of 0.447; for the CDT, the COP is 2 (Youden index = 0.177).

CONCLUSIONS

The recording of PCI should be a central component of the preoperative geriatric assessment. The tools used are simple yet effective and can be easily implemented in routine clinical practice. By reliably identifying patients at risk, the available resources can be personalized and used in a targeted approach.

High level of systemic immune inflammation index elevates delirium risk among patients in intensive care unit

Evidence regarding the effect of systemic immune-inflammation index on delirium occurrence is limited. This study aimed to investigate the association between SII and delirium in intensive care unit (ICU) patients.

METHODS

Information was extracted from Medical Information Mart for Intensive Care-IV. Four logistic regression model was established and incorporated with subgroup analysis and restricted cubic spline (RCS). The cutoff value of SII was acquired from receiver operator characteristic curve (ROC), and propensity score matching (PSM) was utilized to attenuate the confounding effect. Survival analysis was utilized to evaluate the relationship between SII and 30-day or 90-day all-cause mortality.

RESULTS

Among the 7,518 participants, 1,685 cases of delirium occurred. Individuals in the highest quartile of SII exhibited a heightened delirium risk, with a significant multivariable-adjusted odds ratio (OR) of 3.12(2.24,4.33). Tendency analysis, subgroup analysis and PSM together confirmed the positive relationship. Results of Cox regression displayed the risk of both 30-day and 90-day mortality increased about 50% in the higher-SII group.

CONCLUSION

Higher levels of SII is positively associated with the occurrence of delirium and increased all-cause mortality risk.

Knowledge, attitudes and practices on prevention and control of high-consequence infectious diseases and critical care among intensive care personnel in Rwanda: a cross-sectional survey

Introduction

Intensive care personnel in countries prone to outbreaks of high-consequence infectious diseases (HCIDs), such as Ebola virus disease, stand at the forefront of caring for affected patients. This study describes the knowledge, attitudes and practices (KAP) of intensive care personnel in Rwanda on the management and infection prevention and control (IPC) of HCIDs.

Methods

A cross-sectional survey was carried out among staff working in the 4 operational intensive care units in September 2022. The self-administered questionnaire collected information on participants' background and their KAP on critical care (CC), HCIDs and IPC.

Results

Of the 107 participants, 67 (62.6%) had less than 4 years' work experience in CC. 41 (38.3%) of them had attended trainings on IPC since 2020. In univariate analyses, a higher knowledge score was associated with being a physician, years of working in CC and differed by hospital. A large proportion perceived their knowledge on CC as good or very good (58.0%) and their everyday risk of acquiring an infection as at least high (48.6%). Overall, 72.9% reported compliance with hand hygiene measures. However, around a quarter of participants reported rarely or never avoiding recapping of needles or never or rarely taking additional precautions during aerosol-generating procedures.

Conclusions

Staff had a moderate knowledge base and might benefit from continuous learning on CC and HCIDs. The perception of high risk of infection at work stands in contrast with lack of compliance with basic IPC practices which should be reinforced to avoid preventable and potentially fatal infections.

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

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

Brain health: A concern for anaesthesiologists and intensivists

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this concern to the attention of practitioners. This learning track included an online Focus Meeting on Brain Health (November 25, 2023). We here provide readers with a digest of the information that was delivered during that meeting in an opinion paper driven by the authors' own reading of the literature. It is divided according to the meeting's sessions, including how to improve the health of an injured brain, how to keep a young or old brain healthy, how to keep a healthy adult brain unimpaired, how monitoring can impact brain health in the operating room and in the intensive care unit, and how to keep the anaesthesia and ICU caregivers' brain healthy. Each part is a brief and focused summary. The main delivered messages are that the management of injured brain patients involves an adequate choice of sedation, adequate brain monitoring, and focused attention to specific points depending on the underlying pathology; that several measures can be undertaken to protect the brain of the very young needing anaesthesia; that it is possible to detect older patients at risk of postoperative neurocognitive disorders, and that dedicated perioperative management by a multidisciplinary expert team may improve their outcomes; that apparently healthy adult brains may suffer during anaesthesia; that the electroencephalogram may track peri-operative brain dysfunction, and that female patients should be given special care in this respect; that multimodal brain monitoring helps to detect pathological processes and to maintain brain homeostasis; and that burnout in anaesthesiologists can be effectively fought using personal, organisational, managerial and legal approaches.

Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review

ABSTRACT

Many patients experience acute pain, which has been associated with numerous negative consequences. Pain education has been proposed as a strategy to improve acute pain management. However, studies report limited effects with educational interventions for acute pain in adults, which can be explained by the underuse of the person-centered approach. Thus, we aimed to systematically review and synthetize current evidence from quantitative, qualitative and mixed-methods studies describing patients' needs and preferences for acute pain education in adults. We searched original studies and gray literature in 7 databases, from January 1990 to October 2023. Methodological quality was assessed with the Mixed Methods Appraisal Tool. A total of 32 studies were included (n = 1847 patients), two-thirds of which were qualitative studies of high methodological quality. Most of the studies were conducted over the last 15 years in patients with postsurgical and posttraumatic pain, identified as White, with a low level of education. Patients expressed the greatest need for education when it came to what to expect in pain intensity and duration, as well how to take the medication and its associated adverse effects. The most frequently reported educational preferences were for in-person education while involving caregivers and to obtain information first from physicians, then by other professionals. This review has highlighted the needs and preferences to be considered in pain education interventions, which should be embedded in an approach cultivating communication and partnership with patients and their caregivers. The results still need to be confirmed with different patient populations.

Neuromuscular Blockade in Adult Respiratory Distress Syndrome

Although current clinical practice guidelines have discordant conclusions, a judicious approach to using NMBA infusions may include reserving their use for patients with early severe ARDS who are already deeply sedated and for patients under light sedation who have significant ventilator dyssynchrony, despite attempts to adjust both ventilator settings and sedation requirements. Based on current evidence, the duration of NMBA use should be limited to 48 hours, whenever possible.

Prevalence of use of physical restraints in pediatric intensive care units and correlated variables: A Spanish multicenter study

OBJECTIVE

To calculate the prevalence of physical restraint (PR) use in Spanish PICUs and (2) to analyze the correlation between the prevalence of PR use and the sociodemographic, clinical variables of the patients and the PICU structural and organizational variables.

METHODS

We conducted a multicenter prevalence study from January 2022 to January 2023 in Spanish PICUs. The method of data collection was by direct observation, review of the patient's medical history, and asking the professionals involved in the patient's care. Three weekly 24-hour prevalence observations (morning, afternoon, and night) were conducted for 6 months.

RESULTS

A total of 336 patients were included in the study, obtaining an overall crude prevalence of PR use of 16 % (95 %CI: 15 %-17.7 %). Pediatric patients with respiratory pathology received the highest number of hours of PR, with significant differences observed when comparing respiratory cases with post-surgical cases. Statistical significance was also observed when comparing the mean scores of hours of PR according to admission diagnosis (p = 0.01), with respiratory patients being the ones who were restrained the longest (24 h [20-24]) and infectious patients the least (15 h [14-20]). Patients who receive PR upon admission remain in this situation for more hours (24 h [15-24] and in the PICUs that specifically recorded PR application, fewer hours of PR occurred (20 h [4-24]).

CONCLUSIONS

The use of PR is still present in the PICUs analyzed, with a crude prevalence of 16%. Factors such as the reason for admission, the use of respiratory support, and the reason for application of PR were linked to the hours of use of PR.

IMPLICATIONS FOR CLINICAL PRACTICE

Knowing the prevalence of PR use will make professionals aware that it is still necessary to implement policies that avoid its use to prevent the side effects they have in pediatric patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors Affecting Delirium Care Core Competency Among Nurses: A Descriptive Correlational Study

Nurses require optimal competency to deliver safe and high-quality care to patients with delirium. However, the factors influencing delirium care core competency remain unclear. This study aims to investigate the factors influencing core competency in delirium care among nurses. This study was conducted as a descriptive correlational study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A convenience sample of 202 Korean nurses from 15 hospitals completed a structured, web-based, self-administered questionnaire. The survey covered general characteristics, delirium care knowledge, moral sensitivity, barriers to delirium care, and core competency in delirium care. Multiple regression analysis identified the factors affecting core competency in delirium care. Results showed that barriers to delirium care, moral sensitivity, academic qualifications, and clinical ladder level were significant factors, accounting for 18.1% of the variance in delirium care core competency. To improve delirium care among nurses, using individual, team, and organizational approaches to address perceived barriers and moral sensitivity is crucial. Competency-based training programs and administrative support are crucial for enhancing the competency of nurses who are novices and those with associate degrees.

Post-ICU Syndrome and the "3 Ds" in Geriatric Psychiatry: A Complicated Case Report of Major Depression With Psychosis in a 96-Year-Old Woman

In the growing field of geriatric psychiatry, the "3 Ds"-depression, dementia, and delirium-are a complex clinical challenge, especially in patients with medical comorbidities. This is a case report of a 96-year-old Saudi woman with chronic kidney disease, heart failure, and recurrent hyponatremia presented with worsening sleep, depression, persecutory delusions, and hallucinations following an intensive care unit (ICU) stay for urinary tract infection. Examination revealed cognitive decline and depressive symptoms, with sodium at 123 mmol/L. After a psychiatric evaluation, she was diagnosed with major depressive disorder with psychosis, likely exacerbated by hyponatremia and ICU-related stress. She was treated with sertraline, olanzapine, and sodium correction. One-month follow-up showed significant improvement in mood, sleep, and resolution of psychotic symptoms, restoring her quality of life. In conclusion, this case highlights the challenges between these conditions and the importance of comprehensive assessment in geriatric care.

Incidence of Hypertriglyceridemia in Patients on Propofol, Clevidipine, or Both

BACKGROUND

Propofol and clevidipine (PC) are commonly used in the treatment of critically ill patients. While both medications are lipid emulsions, there is limited evidence concerning the incidence of hypertriglyceridemia (HTG) when these agents are used individually or concurrently.

OBJECTIVE

The objective of this study is to determine the effects of propofol, clevidipine, or concurrent PC on triglycerides (TGs) and related outcomes in critically ill adults.

METHODS

This was a retrospective cohort study conducted at an academic medical center. Patients were included if they received ≥24 hours of continuous propofol and/or clevidipine. Excluded were those without TG levels after ≥24 hours of infusion, baseline HTG, acute pancreatitis at admission, or receiving total parenteral nutrition with lipids. The primary outcome was incidence of HTG (defined as a TG level >400 mg/dL). Secondary outcomes included median and peak TG levels, hospital length of stay, intensive care unit length of stay, total lipid infused, time to peak TG level, peak lipase level, and development of pancreatitis.

RESULTS

In total, 190 patients were studied: 109 in the propofol group, 50 in the clevidipine group, and 31 in the PC group. Incidence of HTG was similar (19 [17.4%] vs 6 [12%] vs 4 [12.9%] patients, P = 0.6246). Peak and median TG levels were similar for propofol, clevidipine, and PC groups (216 mg/dL vs 189.5 mg/dL vs 205 mg/dL, P = 0.7069; 177 mg/dL vs 185.5 mg/dL vs 177 mg/dL, P = 0.6791).

CONCLUSIONS AND RELEVANCE

There was a similar incidence of HTG in all groups. The results of this study suggest that the concurrent use of PC should not modify the frequency of TG level monitoring.

Impact of sedation depth on neurological outcome in post-cardiac arrest patients - A retrospective cohort study

AIMS

Whether targeted temperature management (TTM) might improve neurologic prognosis in patients after cardiac arrest is currently under debate. Data concerning sedation depth during TTM is rare. This study aimed to compare the impact of different sedation depths on neurological outcomes in post-cardiac arrest patients undergoing TTM.

METHODS

In this retrospective, before-and-after registry study, all patients receiving TTM on a medical ICU between 08/2016 and 03/2021 were included. This study evaluated the following sedation targets: RASS-target during TTM -5 until 08/2019 and RASS-target -4 since 09/2019. The primary endpoint was favorable neurological outcome at ICU discharge, defined as a Cerebral Performance Category (CPC) score of 1 or 2.

RESULTS

403 patients were included (RASS-target -5: N = 285; RASS-target -4: N = 118). Favorable neurological outcome was documented in 54/118 (45.8 %) patients in the group with a RASS-target of -4 compared to 111/285 (38.9 %) in the group with a RASS-target of -5. After adjustment for age, sex, initial shockable rhythm, bystander CPR, duration of CPR and mean arterial pressure 12 h after CPR, favorable neurological outcome was associated with RASS-target -4 (OR 1.82 (95 % CI: 1.02-3.23); p = 0.042). ICU survival was similar in both groups while 30-day survival was associated with RASS-target -4 (OR 1.81 (1.01-3.26); p = 0.047).

CONCLUSION

Lighter sedation strategies during TTM after cardiac arrest might improve outcome and should be further investigated.

Behavioral pain scales, vital signs, and pupilometry to pain assessment in the critically ill patient: A cross sectional study

BACKGROUND

Detecting pain in sedated critically ill patients requires utmost attention.

AIM

To assess the pain in mechanically ventilated critically ill patients with the Behavioral Pain Scale (BPS), Behavioral Indicators Pain Scale (ESCID), the pupillary dilation response (PDR), and vital signs.

DESIGN

Cross-sectional study METHODS: The study was conducted between March and December 2019, involving patients with a baseline BPS of 3, ESCID of 0, and RASS between -1 and -4. Patients with mobility limitations or altered pupillary reflexes were excluded. We measured before and after non-painful stimulation (NP) followed by 10-20-30-40 mA stimuli and endotracheal aspirate (ETA). The primary outcome was the pain measured with BPS and ESCID scales and PDR with AlgiScan® pupilometer defined as BPS≥4, ESCID≥1, and PDR≥11,5 %. We performed a descriptive study and analyzed the agreement between pain detection methods.

RESULTS

Thirty-one patients were included, and 183 measurements were recorded. The scales showed minimal changes. Approximately 30 % of patients reported pain at a 30 mA stimulus, increasing to over 70 % after ETA. The PDR ranged from 2 % to 6-33% on the ETA, even in pain-free patients, with pain incidence between 70 % and 100 % for the 40 mA and ETA stimuli. Vital signs did not show relevant changes. The PDR had over 90 % agreement with scales for no pain. For higher-intensity stimuli, agreement ranged from 60 % to 80 %. Disagreement occurred when there was no pain by scales (BPS<4; ESCID<1) and pain with PDR (PDR≥11.5).

CONCLUSIONS

Pain behavioral scores and vital signs were low in critically ill patients. PDR detected a nociceptive pain response in no-pain patients.

Choice of Postintubation Sedation Strategy by Sex: A Conjoint Analysis

PURPOSE

To assess if patient sex is an important attribute in physician decision-making for postintubation sedation strategies in the emergency department and intensive care units.

METHODS

We designed a survey of eight fictional cases utilizing a fractional factorial design varying fictional patient sex, race/ethnicity, and history of substance use disorder. We surveyed emergency medicine and critical care fellows and attendings at three geographically diverse academic medical centers in the US. We analyzed data using conjoint analysis to assess importance weights (IW). For this analysis, we compared physician beliefs of stated importance of sex to IW derived from cases.

FINDINGS

Eighty-six participants started the survey; 75 (87.2%) participants completed demographic information and at least one vignette and were included in analysis. Most physicians were white, male, worked primarily in an emergency department and were attending physicians. Sex had the lowest weight in affecting decisions when considering using midazolam (IW = 3.2%) or propofol (IW = 3.6%) as postintubation sedation strategies, and the second lowest weight when considering fentanyl (IW = 7.3%). Respondents stated they believed physicians rarely considered patient sex when making decisions about postintubation sedation.

IMPLICATIONS

Physicians managing postintubation sedation reported sex rarely affected decision-making when choosing propofol, midazolam, or fentanyl as sedation strategies, despite evidence that these medications are metabolized differently in females. Further research is needed to identify ideal postintubation sedation strategies that account for patient sex.

Sex-based Differences in the Use of Best Practices in Mechanically Ventilated Adults in the Intensive Care Unit: An Analysis of the Toronto Multicenter iCORE Database

Rationale: Patients who are critically ill and require admission to an intensive care unit (ICU) should receive the same quality of care regardless of their sex. Objectives: To determine, using population data from a multicenter database in Ontario, Canada, whether sex is associated with differences in the use of eight best practices and other interventions during the ICU care of mechanically ventilated women and men. Methods: Using a cohort of patients receiving mechanical ventilation in eight ICUs, our coprimary outcomes were differences in compliance with eight evidence-based practices between women and men (opioid administration, use of continuous sedation or opioids, sedation minimization, spontaneous breathing trials, stress ulcer prophylaxis, deep venous thrombosis [DVT] prophylaxis, physical restraint, and mobilization). All analyses were adjusted for confounders using logistic regression and restricted to patients eligible for each best practice Results: We included 19,070 (11,910 men, 7,160 women) patients who were mechanically ventilated for >4 hours. Men and women had similar opioid administration, sedation minimization, stress ulcer prophylaxis, DVT prophylaxis, and mobilization. Women were less likely to receive continuous infusions of sedation or opioids than men (adjusted odds ratio [OR], 0.86; 95% confidence interval [CI], 0.78-0.95) and less likely to be physically restrained (adjusted OR, 0.82; 95% CI, 0.74-0.89). Conclusions: In this cohort of mechanically ventilated patients, the use of evidence-based practices was similar between women and men, except for a higher use of continuous sedative or opioid infusions and physical restraints in men.

Updates on Post-Intensive Care Syndrome After Acute Respiratory Distress Syndrome: Epidemiology, Core Outcomes, Interventions, and Long-Term Follow-Up

Acute respiratory distress syndrome (ARDS) survivors often experience post-intensive care syndrome (PICS), is defined as new or worsened impairments in physical, cognitive and/or mental health status persisting beyond hospital discharge. These impairments negatively impact survivors' quality of life and their return to work or usual activities. Moreover, family members are also impacted as recognized by the term, PICS-Family (PICS-F). PICS poses an increased burden on the health care system and has a negative societal impact. There are ongoing efforts to understand risk factors for PICS-related impairments; design and evaluate interventions for specific impairments (including the use of an ARDS survivorship core outcome set); and refine and evaluate ICU recovery clinics to support and treat survivors and their families.

Functionality loss due to COVID-19 hospitalisation in older adults recovers with inpatient rehabilitation: A systematic review and meta-analysis

INTRODUCTION

Older adults are more likely to acquire the severe manifestation of COVID-19 and the hospitalised survivors experience significant functionality loss. Thus, we aimed to identify the level of functionality in older adults hospitalised due to COVID-19, and the effect of inpatient rehabilitation upon functional recovery.

METHODS

A search was performed on July 2024, across five databases to retrieve studies assessing functionality in patients during COVID-19 hospitalisation, with or without rehabilitation.

RESULTS

At admission, higher functionality was significantly higher for survivors than non survivors (standardized mean difference (SMD): 0.83 [0.56; 1.09]). The effect of inpatient rehabilitation on functionality was tested among 38 arms across studies. Inpatient rehabilitation improved functionality SMD across all indexes (1.47 [1.18; 1.77], P ≤ 0.001), with greatest effect in the patients >70 years (2.84 [1.74, 3.93], P = 0.006), compared to their counterparts.

CONCLUSION

Hospitalisation due to COVID-19 reduced functionality to a higher extent in older adults above 70 years. Inpatient rehabilitation was effective to improve functionality in both age groups.

PROTOCOL REGISTRATION

PROSPERO CRD42021278619.

Sedation Vacations in Neurocritical Care: Friend or Foe?

PURPOSE OF REVIEW

To evaluate the role of sedation vacations in optimizing patient outcomes and enhancing the quality of care in neurological intensive care units (ICUs). We discuss the importance of sedation management in neurocritical care, considering recent research findings and clinical guidelines.

RECENT FINDINGS

Recent studies have highlighted the significance of sedation interruption protocols in improving patient outcomes in the ICU setting. Evidence suggests that daily sedation interruptions can reduce the duration of mechanical ventilation, ICU length of stay, and mortality rates. However, the implementation of these protocols requires careful consideration of patient-specific factors and a multidisciplinary approach. Sedation vacations play a critical role in neurocritical care by reducing mechanical ventilation duration, ICU stay length, and mortality rates. Despite the benefits, the presence of complications must be addressed to avoid adverse outcomes. Continued research is necessary to refine these strategies and improve guideline quality, ensuring safe and effective sedation management in critically ill neurological patients.

Pain Assessment in the Patient Unable to Self- Report: Clinical Practice Recommendations in Support of the ASPMN 2024 Position Statement

Recognizing and managing pain is especially challenging for vulnerable populations who cannot communicate their discomfort. Because there is no valid and reliable objective measure of pain, the American Society for Pain Management Nursing advocates for comprehensive assessment practices articulated in a Hierarchy of Pain Assessment. These practices must gather relevant information to infer the presence of pain and evaluate a patient's response to treatment. Nurses and other healthcare providers must be advocates for those who cannot communicate their pain experience.

Managing Chronic Pain in Ventilated Critical Care Patients

Pain experienced by mechanically ventilated patients in intensive care units (ICUs) is often overlooked, but it is a significant issue. With over 5 million annual ICU admissions in the United States, the prevalence of pain during hospitalization and its aftermath is a pressing concern. Chronic pain in ICU survivors has been linked to post-traumatic stress disorder, poor quality of life, and long-term impairments known as postintensive care syndrome. Barriers to effective pain management include psychological factors, sedation restrictions, and inadequate use of valid assessment tools.

Pharmacologic Treatment Strategies for Delirium in Hospitalized Adults: Past, Present, and Future

Despite the use of multidomain prevention strategies, delirium still frequently occurs in hospitalized adults. With delirium often associated with undesirable symptoms and deleterious outcomes, including cognitive decline, treatment is important. Risk-factor reduction and the protocolized use of multidomain, nonpharmacologic bundles remain the mainstay of delirium treatment. There is a current lack of strong evidence to suggest any pharmacologic intervention to treat delirium will help resolve it faster, reduce its symptoms (other than agitation), facilitate hospital throughput, or improve post-hospital outcomes including long-term cognitive function. With the exception of dexmedetomidine as a treatment of severe delirium-associated agitation in the ICU, current practice guidelines do not recommend the routine use of any pharmacologic intervention to treat delirium in any hospital population. Future research should focus on identifying and evaluating new pharmacologic delirium treatment interventions and addressing key challenges and gaps surrounding delirium treatment research.

Delirium in the ICU: how much do we know? A narrative review

Delirium in critical ill patients is a complex and common neurological syndrome in the intensive care unit (ICU) that is caused by a range of structural or functional abnormalities. ICU Delirium is associated with reduced compliance, prolonged hospital stays, greater use or delayed withdrawal of sedatives, higher rates and durations of mechanical ventilation, and higher rates of mortality. The aetiology and pathogenesis of ICU delirium are unclear, and the lack of better prediction, prevention, and treatment measures leads to a non-standardized control of delirium. By searching the relevant literature, we aim in this narrative review to describe progress in the pathogenesis, predictive biomarkers, diagnosis, and treatment of ICU delirium.

Evaluation of Dexmedetomidine Withdrawal and Management After Prolonged Infusion

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy and safety of guanfacine in hospitalized patients with delirium: A scoping review

Objective

To assess current evidence regarding guanfacine use in hospitalized patients with delirium.

Introduction

Delirium is a common and important complication of critical illness. Central alpha-2 agonists are often used for symptomatic management. Guanfacine is an enteral central alpha-2 agonist approved for the treatment of attention deficit hyperactivity disorders. However, its use for delirium treatment has not been systematically assessed.

Inclusion criteria

All studies of guanfacine to treat patients with delirium during hospitalization. We excluded reviews, letters, commentaries, correspondence, conference abstracts, expert opinions or editorials.

Methods

We performed a systematic search of the literature using: MEDLINE (Ovid), Embase (Ovid), CENTRAL and SCOPUS (Elsevier) from inception until 29 February, 2024. Two independent reviewers assessed the identified citations and abstracts. Data on study and patient characteristics, as well as efficacy and safety outcomes, were extracted. Efficacy was defined by guanfacine's ability to relieve delirium and improve clinical outcomes, including intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Safety was assessed for hemodynamic stability or other reported side effects.

Results

We screened 908 articles and included two case reports, one case series, two retrospective descriptive cohorts, and one retrospective analytic cohort. Guanfacine therapy was associated with delirium attenuation and a reduction in the use of sedative agents. Median dosage was 1.5 mg daily, with a median time to delirium improvement of 3 days. However, guanfacine therapy was not associated with decreased ICU or hospital LOS. The most frequently reported adverse events were mild hypotension and bradycardia.

Conclusion

There is limited data on the efficacy of guanfacine for the treatment of delirium. However, given its pharmacologic properties and its available safety data, controlled investigations may be justified.

Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation

PURPOSE

Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness.

METHODS

The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care.

RESULTS

A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences.

CONCLUSION

The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Lung and Diaphragm Protection During Mechanical Ventilation in Patients with Acute Respiratory Distress Syndrome

Patients with acute respiratory distress syndrome often require mechanical ventilation to maintain adequate gas exchange and to reduce the workload of the respiratory muscles. Although lifesaving, positive pressure mechanical ventilation can potentially injure the lungs and diaphragm, further worsening patient outcomes. While the effect of mechanical ventilation on the risk of developing lung injury is widely appreciated, its potentially deleterious effects on the diaphragm have only recently come to be considered by the broader intensive care unit community. Importantly, both ventilator-induced lung injury and ventilator-induced diaphragm dysfunction are associated with worse patient-centered outcomes.

Comparing the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock: a randomized controlled trial

BACKGROUND

Ketamine and fentanyl are commonly used for sedation and induction of anesthesia in critically ill patients. This study aimed to compare the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock.

METHODS

This randomized controlled trial included mechanically ventilated adults with septic shock receiving sedation. Patients were randomized to receive either 1 mg/kg ketamine bolus or 1 mcg/kg fentanyl bolus. Cardiac output (CO), stroke volume (SV), heart rate (HR), and mean arterial pressure (MAP) were measured at the baseline, 3, 6, 10, and 15 min after the intervention. Delta CO was calculated as the change in CO at each time point in relation to baseline measurement. The primary outcome was delta CO 6 min after administration of the study drug. Other outcomes included CO, SV, HR, and MAP.

RESULTS

Eighty-six patients were analyzed. The median (quartiles) delta CO 6 min after drug injection was 71(37, 116)% in the ketamine group versus - 31(- 43, - 12)% in the fentanyl group, P value < 0.001. The CO, SV, HR, and MAP increased in the ketamine group and decreased in the fentanyl group in relation to the baseline reading; and all were higher in the ketamine group than the fentanyl group.

CONCLUSION

In patients with septic shock, ketamine bolus was associated with higher CO and SV compared to fentanyl bolus.

CLINICAL TRIAL REGISTRATION

Date of registration: 24/07/2023.

CLINICALTRIALS

gov Identifier: NCT05957302. URL: https://clinicaltrials.gov/study/NCT05957302 .