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

Predictors of delirium after cardiac surgery in patients with sleep disordered breathing

Introduction

Delirium ranks among the most common complications after cardiac surgery. Although various risk factors have been identified, the association between sleep disordered breathing (SDB) and delirium has barely been examined so far. Here, our objectives were to determine the incidence of post-operative delirium and to identify the risk factors for delirium in patients with and without SDB.

Methods

This subanalysis of the ongoing prospective observational study CONSIDER-AF (ClinicalTrials.govidentifierNCT02877745) examined risk factors for delirium in 141 patients undergoing cardiac surgery. The presence and type of SDB were assessed with a portable SDB monitor the night before surgery. Delirium was prospectively assessed with the validated Confusion Assessment Method for the Intensive Care Unit on the day of extubation and for a maximum of 3 days.

Results

Delirium was diagnosed in 23% of patients: in 16% of patients without SDB, in 13% with obstructive sleep apnoea and in 49% with central sleep apnoea. Multivariable logistic regression analysis showed that delirium was independently associated with age ≥70 years (OR 5.63, 95% CI 1.79–17.68; p=0.003), central sleep apnoea (OR 4.99, 95% CI 1.41–17.69; p=0.013) and heart failure (OR 3.3, 95% CI 1.06–10.35; p=0.039). Length of hospital stay and time spent in the intensive care unit/intermediate care setting were significantly longer for patients with delirium.

Conclusions

Among the established risk factors for delirium, central sleep apnoea was independently associated with delirium. Our findings contribute to identifying patients at high risk of developing post-operative delirium who may benefit from intensified delirium prevention strategies.

Family Members' Experiences with Observing Pain Behaviors Using the Critical-Care Pain Observation Tool

BACKGROUND

Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales.

AIMS

This study aimed to describe family members' observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit.

DESIGN

A mixed methods cross-sectional explanatory design was used.

SETTING

A medical-surgical intensive care unit in Canada.

PARTICIPANTS/SUBJECTS

Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report.

METHODS

Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report.

RESULTS

Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management.

CONCLUSIONS

Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Sedation and Analgesia for Mechanically Ventilated Patients in the Emergency Department

Mechanically ventilated patients can experience significant pain and anxiety associated with their care. These symptoms should be aggressively treated, but can be challenging to manage without a systematic approach. This article reviews recent literature, current guidelines, and best practices in managing pain, agitation, and anxiety in mechanically ventilated patients in the emergency department.

Intravenous Acetaminophen-Induced Hypotension: A Review of the Current Literature

Objective: Recent literature suggests that intravenous (IV) administration may cause hypotension in hospitalized patients; data further suggest that this effect is most pronounced in the critically ill. The purpose of this review is to identify and evaluate current literature that addresses the incidence and implications of IV acetaminophen-induced hypotension. Data Sources: A literature search of MEDLINE, Cochrane, and EMBASE databases was performed (2002-2019) using the following terms: acetaminophen, paracetamol, intravenous, and hypotension. Abstracts and peer-reviewed publications were reviewed. Study Selection and Data Extraction: Relevant English-language studies conducted in humans evaluating the hemodynamic effects of IV acetaminophen were considered. Data Synthesis: A majority of the 19 studies included in this review identified a statistically significant drop in hemodynamic variables after the administration of 500 to 1000 mg IV acetaminophen as measured by changes in systolic blood pressure, diastolic blood pressure, or mean arterial pressure. Of the trials reporting vasopressor use, the authors found a significant increase in vasopressor requirements following IV acetaminophen administration. Relevance to Patient Care and Clinical Practice: This review represents the first comprehensive review of IV acetaminophen-induced hypotension. The findings raise the question of whether IV acetaminophen is an appropriate choice for inpatient pain or temperature management in the critically ill. Conclusions: Available evidence indicates that the administration of IV acetaminophen may be harmful in the critically ill. Additional monitoring is likely required when using IV acetaminophen in this specific population, particularly if a patient is hemodynamically unstable prior to administration.

Recent Advances in Preventing and Managing Postoperative Delirium

Postoperative delirium is a common and harrowing complication in older surgical patients. Those with cognitive impairment or dementia are at especially high risk for developing postoperative delirium; ominously, it is hypothesized that delirium can accelerate cognitive decline and the onset of dementia, or worsen the severity of dementia. Awareness of delirium has grown in recent years as various medical societies have launched initiatives to prevent postoperative delirium and alleviate its impact. Unfortunately, delirium pathophysiology is not well understood and this likely contributes to the current state of low-quality evidence that informs perioperative guidelines. Along these lines, recent prevention trials involving ketamine and dexmedetomidine have demonstrated inconsistent findings. Non-pharmacologic multicomponent initiatives, such as the Hospital Elder Life Program, have consistently reduced delirium incidence and burden across various hospital settings. However, a substantial portion of delirium occurrences are still not prevented, and effective prevention and management strategies are needed to complement such multicomponent non-pharmacologic therapies. In this narrative review, we examine the current understanding of delirium neurobiology and summarize the present state of prevention and management efforts.

Prevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines

Delirium is an acute, confusional state characterized by altered consciousness and a reduced ability to focus, sustain, or shift attention. It is associated with a number of complex underlying medical conditions and can be difficult to recognize. Many critically ill patients (e.g., up to 80% of patients in the intensive care unit [ICU]) experience delirium due to underlying medical or surgical health problems, recent surgical or other invasive procedures, medications, or various noxious stimuli (e.g., underlying psychological stressors, mechanical ventilation, noise, light, patient care interactions, and drug-induced sleep disruption or deprivation). Delirium is associated with a longer duration of mechanical ventilation and ICU admittance as well as an increased risk of death, disability, and long-term cognitive dysfunction. Therefore, the early recognition of delirium is important and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management. This review presents a brief overview of delirium and an update of the literature with reference to the 2018 Society of Critical Care Medicine Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Intensive care unit-acquired weakness: unanswered questions and targets for future research

Intensive care unit-acquired weakness (ICU-AW) is the most common neuromuscular impairment in critically ill patients. We discuss critical aspects of ICU-AW that have not been completely defined or that are still under discussion. Critical illness polyneuropathy, myopathy, and muscle atrophy contribute in various proportions to ICU-AW. Diagnosis of ICU-AW is clinical and is based on Medical Research Council sum score and handgrip dynamometry for limb weakness and recognition of a patient's ventilator dependency or difficult weaning from artificial ventilation for diaphragmatic weakness (DW). ICU-AW can be caused by a critical illness polyneuropathy, a critical illness myopathy, or muscle disuse atrophy, alone or in combination. Its diagnosis requires both clinical assessment of muscle strength and complete electrophysiological evaluation of peripheral nerves and muscles. The peroneal nerve test (PENT) is a quick simplified electrophysiological test with high sensitivity and good specificity that can be used instead of complete electrophysiological evaluation as a screening test in non-cooperative patients. DW, assessed by bilateral phrenic nerve magnetic stimulation or diaphragm ultrasound, can be an isolated event without concurrent limb muscle involvement. Therefore, it remains uncertain whether DW and limb weakness are different manifestations of the same syndrome or are two distinct entities. Delirium is often associated with ICU-AW but a clear correlation between these two entities requires further studies. Artificial nutrition may have an impact on ICU-AW, but no study has assessed the impact of nutrition on ICU-AW as the primary outcome. Early mobilization improves activity limitation at hospital discharge if it is started early in the ICU, but beneficial long-term effects are not established. Determinants of ICU-AW can be many and can interact with each other. Therefore, future studies assessing early mobilization should consider a holistic patient approach with consideration of all components that may lead to muscle weakness.

Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care

The 2018 Paris Intensive Care symposium entitled "Update in Neurocritical Care" was organized in Paris, June 21-22, 2018, under the auspices of the French Intensive Care Society. This 2-day post-graduate educational symposium comprised several chapters, aiming first to provide all-board intensivists with current standards for the clinical assessment of altered consciousness states (including coma and delirium) and peripheral nervous system in critically ill patients, monitoring of brain function (specifically, electro-encephalography) and best practices for sedation-analgesia-delirium management. An update on the treatment of specific severe brain pathologies-including ischaemic/haemorrhagic stroke, cerebral venous thrombosis, hypoxic-ischaemic brain injury, immune-mediated and infectious encephalitis and refractory status epilepticus-was also provided. Finally, we discuss how to approach some difficult decisions, namely the role of decompressive craniectomy and prognostication models in patients with head injury. For each chapter, the scope of the present review was to provide important issues and key messages, provide most recent and relevant literature in the field, and briefly describe new developments in the field.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

AIMS

Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR.

METHOD

An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units.

RESULTS

One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium.

CONCLUSIONS

The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review

INTRODUCTION

Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research.

OBJECTIVE

To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management.

METHODS

The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review.

RESULTS

Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep.

CONCLUSION

A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.

Qualitative descriptive study to explore nurses' perceptions and experience on pain, agitation and delirium management in a community intensive care unit

OBJECTIVES

The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients.

DESIGN

A qualitative descriptive study.

SETTING

This study took place in a community hospital ICU located in a medium size Canadian city.

PARTICIPANTS

Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated.

METHODS

A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns.

RESULTS

Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families.

CONCLUSIONS

Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.

Impact of a Mobility Team on Intensive Care Unit Patient Outcomes

Mobility for critically ill patients has been found to be safe, beneficial, and feasible, although a culture of immobility prevails in many adult intensive care units (ICU) because of staffing challenges and lack of physical therapy and occupational therapy involvement. Clinical practice guidelines recommended early mobility for ICU patients to improve long- and short-term outcomes. Addition of a mobility team to the licensed physical therapy and occupational therapy staff and interprofessional ICU team improved patient outcomes and staff satisfaction, and reduced facility cost related to employee injuries.

What have we learned from network meta-analyses applied to critical care?

It is widely accepted in modern medicine that medical decisions must be supported by scientific evidence. Identifying the best intervention when several options are available constitute a great challenge for every clinician. Traditional meta-analysis (TMA) allows summarizing evidence from studies that compare the same two interventions for one event (head to head studies or direct comparisons). Network meta-analysis (NMA) is a relatively new procedure that allows to compare multiple interventions for one event, even when non-head to head studies have been conducted (indirect evidence). Other advantages of NMA include increasing the accuracy of the results and ranking all the interventions according to their effectiveness. These features are of paramount importance as: 1) they summarize information from events (e.g. diseases or outcomes) that has more than two possible interventions (e.g. treatments or procedures); 2) they strengthen the level of guideline recommendations; and 3) they identify new hypotheses based on indirect comparison. As this is a narrative review, all manuscripts have been selected from PubMed according to our best knowledge with the aim to illustrate different features, options or applications of NMA in critical care. First, we provide a description of the usefulness, interpretation, assumptions and main plots related to NMAs. Second, we analyzed some examples of NMAs related to critical care medicine. Third, we include a pragmatic approach about how results from NMAs can improve the clinical practice as well an R script with a database to conduct an NMAs and reproduce figures and tables that have been shown here. As a conclusion, NMA is an established, robust, objective and reproducible statistic technique that has been applied to several critical care areas. Clinical practice guidelines have started to include NMA evidence to support their recommendations. In future years, it seems highly probable that this technique will increase it applicability in almost all areas of critical care medicine.

Dexmedetomidine for the prevention of delirium in critically ill patients - A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially prevent delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in preventing delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the prevention of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic Reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients, if dexmedetomidine versus placebo can reduce the incidence of delirium and improve clinical outcomes. We will include all randomised trials assessing the use of dexmedetomidine in the prevention of delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. We will use the Cochrane risk of bias tool to evaluate trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a "Summary of Findings"-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE.

DISCUSSION

This systematic review can potentially aid clinicians in decision-making and benefit the many critically ill patients at risk of delirium.

Dexmedetomidine for the management of delirium in critically ill patients-A protocol for a systematic review

BACKGROUND

Delirium is a common complication in critically ill patients and carries an increased risk of mortality and morbidity. Dexmedetomidine can potentially treat delirium by diminishing predisposing factors. The evidence regarding the use of dexmedetomidine in the management of delirium is conflicting. This protocol aims to identify the beneficial and harmful effects of dexmedetomidine in the management of delirium.

METHODS

This protocol uses the recommendations of the Cochrane Collaboration, the Preferred Report Items of Systematic reviews with Meta-Analysis Protocols, and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess in critically ill patients with delirium, if dexmedetomidine vs placebo is effective in managing delirium and improving clinical outcomes. We will include all relevant randomised clinical trials assessing the use of dexmedetomidine in treating delirium. To identify trials, we will search the Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Science Journal Database, and BIOSIS. Two authors will screen the literature and extract data. The Cochrane risk of bias tool will be used to evaluate included trials. Extracted data will be analysed using Review Manager 5 and Trial Sequential Analysis. We will create a 'Summary of Findings'-table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using GRADE assessment.

DISCUSSION

This systematic review can potentially aid clinicians in decision making and benefit the many critically ill patients developing delirium.

Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit

CONTEXT

Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited.

OBJECTIVES

The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors.

METHODS

Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS≤8), altered consciousness (9≤GCS≤12), or conscious (13≤GCS≤15).

RESULTS

A sample of 147 patients participated (65 conscious, 56 altered consciousness, and 26 unconscious). Active behaviors (e.g., face expressions and body movements) were more frequent in conscious patients. High-percentage interrater agreement (80%-98%) was obtained for most behaviors. The total number of active behaviors was significantly higher during turning and other nociceptive procedures compared with rest (Wilcoxon = 9.873, P < 0.001) and soft touch (Wilcoxon = 9.486, P < 0.001) regardless of levels of consciousness. The strongest predictors of pain intensity (n = 33) were grimace, mouth opening, orbit tightening, eye weeping, and eyes tightly closed; these behaviors were moderately correlated with self-reported pain intensity (Spearman rho = 0.47).

CONCLUSION

These findings may guide the revision of existing pain scales to make their content more suited for this population.

Does volatile sedation with sevoflurane allow spontaneous breathing during prolonged prone positioning in intubated ARDS patients? A retrospective observational feasibility trial

Background

Lung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). The optimal respirator mode, however, remains controversial. Pressure-supported spontaneous breathing (PS) during ARDS provides several advantages, but is difficult to achieve during PP because of respiratory depression as a side effect of sedative drugs. This study was designed to evaluate the feasibility and safety of PS during PP in ARDS patients sedated with inhaled sevoflurane.

Results

Overall, we have observed 4339 h of prone positioning in 62 patients who had a median of four prone episodes during treatment. Within 3948 h (91%), patients were successfully brought into a pressure-supported spontaneous breathing mode. The median duration of each prone episode was 17 h (IQR 3). Median duration of pressure-supported spontaneous breathing per episode was 16 h (IQR 5). Just one self-extubation occurred during 276 episodes of PP.

Conclusions and implications

Pressure-supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with or without ECMO can be achieved during volatile sedation with sevoflurane. This finding may provide a basis upon which to question the latest dogma in ARDS treatment. Our concept must be further investigated and compared to controlled ventilation with regard to driving pressure, lung-protective parameters, muscle weakness and mortality before it can be routinely applied.

Psychiatric symptoms and their association with sleep disturbances in intensive care unit survivors

Background

Sleep disturbances in critically ill patients are associated with poorer long-term clinical outcomes and quality of life. Studies are needed to better characterize associations and risk factors for persistent sleep disturbances after intensive care unit (ICU) discharge. Psychiatric disorders are frequently associated with sleep disturbances, but the role of psychiatric symptoms in sleep disturbances in ICU survivors has not been well-studied.

Objective

To examine the association between psychiatric symptoms and sleep disturbances in ICU survivors.

Methods

112 adult ICU survivors seen from July 2011 to August 2016 in the Critical Care Recovery Center, an ICU survivor clinic at the Eskenazi Hospital in Indianapolis, IN, USA, were assessed for sleep disturbances (insomnia, hypersomnia, difficulty with sleep onset, difficulty with sleep maintenance, and excessive daytime sleepiness) and psychiatric symptoms (trauma-related symptoms and moderate to severe depressive symptoms) 3 months after ICU discharge. A multivariate logistic regression model was performed to examine the association between psychiatric symptoms and sleep disturbances. Analyses were controlled for age, hypertension, history of depression, and respiratory failure.

Results

ICU survivors with both trauma-related and depression symptoms (OR 16.66, 95% CI 2.89–96.00) and trauma-related symptoms alone (OR 4.59, 95% CI 1.11–18.88) had a higher likelihood of sleep disturbances. Depression symptoms alone were no longer significantly associated with sleep disturbances when analysis was controlled for trauma-related symptoms.

Conclusion

Trauma-related symptoms and trauma-related plus moderate to severe depressive symptoms were associated with a higher likelihood of sleep disturbances. Future studies are needed to determine whether psychiatric symptoms are associated with objective changes on polysomnography and actigraphy and whether adequate treatment of psychiatric symptoms can improve sleep disturbances.

Pharmacological Prevention of Postoperative Delirium: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

The high prevalence of delirium among postoperative patients has increased morbidity and mortality. The kind of drug that can effectively reduce the incidence of delirium has become the focus of discussion in recent years. However, a consensus in this respect has yet to be reached.

Methods

Randomized controlled trials (RCTs) were retrieved from the PubMed, Cochrane Library, ClinicalTrials.gov, and Embase databases from their inception through October 12, 2018. We included RCTs of pharmacological prevention for postoperative delirium in adults (at least 18 years), and the Cochrane risk of bias tool was used to evaluate the methodological quality of trials. The primary outcomes were the risk ratios (RRs) of incidence of postoperative delirium, and the secondary outcomes were the RRs of mortality and adverse events in the intervention and control groups.

Results

Thirty-eight trials, which comprised 20302 patients and 18 different drugs, were included in the analysis. Of the 38 studies, 17 were rated as low risk with respect to methodological quality. Dexmedetomidine administration (RR 0.58, 95%CI 0.44-0.76, P<0.01) was associated with a significantly lower incidence of postoperative delirium than the control conditions. However, the findings from the studies with a low risk of bias did not show a significant difference in this beneficial effect (RR 0.64, 95%CI 0.39-1.04, P=0.07). The antipsychotic drugs olanzapine (RR 0.44, 95%CI 0.30- 0.65, P<0.01) and risperidone (RR 0.42, 95%CI 0.19-0.92, P=0.03) had promising effects, but there was a lack of sufficient evidence to obtain a definitive conclusion. The beneficial effect of other drugs, including haloperidol, methylprednisolone, dexamethasone, gabapentin, ketamine, cyproheptadine, donepezil, hypertonic saline, melatonin, nimodipine, ondansetron, pregabalin, rivastigmine, TJ-54, and tryptophan, was not proven on the basis of present evidence.

Conclusion

Among the pharmacological prophylactic measures for postoperative delirium, dexmedetomidine, olanzapine, and risperidone showed higher efficacy than other drugs. However, more high-quality evidence is needed to confirm these results.

Negotiated mobilisation: An ethnographic exploration of nurse-patient interactions in an intensive care unit

AIMS AND OBJECTIVES

To explore nurse-patient interactions in relation to the mobilisation of nonsedated and awake, mechanically ventilated patients in the intensive care unit.

BACKGROUND

Lighter sedation has enabled the early mobilisation of mechanically ventilated patients, but little is known about the nurses' role and interaction with critically ill patients in relation to mobilisation.

DESIGN AND METHODS

The study had a qualitative design using an ethnographic approach within the methodology of interpretive description. Data were generated in two intensive care units in Denmark, where a strategy of no sedation was applied. Participant observation was conducted during 58 nurse-patient interactions in relation to mobilisation between nurses (n = 44) and mechanically ventilated patients (n = 25). We conducted interviews with nurses (n = 16) and patients (n = 13) who had been mechanically ventilated for at least 3 days. The data were analysed using inductive, thematic analysis. The report of the study adhered to the COREQ checklist.

FINDING

We identified three themes: "Diverging perspectives on mobilisation" showed that nurses had a long-term and treatment-oriented perspective on mobilisation, while patients had a short-term perspective and regarded mobilisation as overwhelming in their present situation. "Negotiation about mobilisation" demonstrated how patients actively negotiated the terms of mobilisation with the nurse. "Inducing hope through mobilisation" captured how nurses encouraged mobilisation by integrating aspects of the patient's daily life as a way to instil hope for the future.

CONCLUSIONS

Exploring the nurse-patient interactions illustrated that mobilisation is more than physical activity. Mobilisation is accomplished through nurse-patient collaborations as a negotiated, complex and meaningful achievement, which is driven by the logic of care, leading to hope for the future.

RELEVANCE TO CLINICAL PRACTICE

The study demonstrated the important role of nurses in achieving mobilisation in collaboration and through negotiation with mechanically ventilated patients in the intensive care unit.

Critical Care of Patients After Pulmonary Thromboendarterectomy

Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.

Rates of new antipsychotic prescriptions and continuation at discharge from a medical unit in a community teaching hospital serving rural counties

Introduction

Antipsychotics are commonly used during hospitalization to manage a variety of acute indications and may be inadvertently continued at discharge. The purpose of this study was to identify the rate at which patients admitted to nonpsychiatric units were continued on newly prescribed antipsychotics at discharge from a rural community teaching hospital.

Methods

This study was a retrospective chart review of adult patients admitted to a large community teaching hospital and initiated on an antipsychotic from August 1, 2016, to August 31, 2017. Exclusion criteria were patients admitted to psychiatric or obstetrics/gynecology services, with a diagnosis of a psychotic disorder, or on an antipsychotic prior to hospitalization. The primary outcome measure was the number of new antipsychotic prescriptions during hospitalization that were continued at discharge. Secondary outcomes included antipsychotic characteristics and initiation indications. Descriptive statistics were used to describe antipsychotic use and demographic data.

Results

Of 100 patients included, 3 patients were discharged on an antipsychotic. Two patients had questionable indications, and 1 patient had a new psychotic disorder diagnosis. Of all antipsychotics newly initiated during hospitalization, haloperidol was the most commonly prescribed antipsychotic. The majority of doses were scheduled as 1-time or as-needed doses. Approximately 20% of antipsychotics were administered orally. No relevant indication was found for 35% of patients newly initiated on antipsychotics, and documented indications included agitation, psychosis, delirium, and anxiety.

Discussion

In an institution that largely serves a rural population, antipsychotic prescribing at discontinuation was not worse than what has been previously reported in other regions of the United States. Limitations for this study include the retrospective nature, single-center study, and small sample size. Although there was a lack of continuation after discharge, there was also a deficit of documentation with 35% of the antipsychotic initiations having no documented indication.

Beyond Opioids for Pain Management in Adult Critically Ill Patients

Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.

An Analysis of Psychoactive Medications Initiated in the ICU but Continued Beyond Discharge: A Pilot Study of Stewardship

BACKGROUND

Psychoactive medications (PM) are frequently administered in the intensive care unit (ICU) to provide comfort. Interventions focused on preventing their continuation after the acute phase of illness are needed.

OBJECTIVE

To determine the frequency that patients with ICU-initiated PM are continued upon ICU and hospital discharge.

METHODS

This single-center, prospective, observational study assessed consecutive adult ICU patients who received scheduled PM. Frequency of PM continued at ICU and hospital discharge was recorded. The patient's primary treatment team was contacted by the pharmacist within 72 hours of ICU discharge to establish rationale for continued use or to suggest discontinuation.

RESULTS

Of the 60 patients included, 72% were continued on PM at ICU discharge and 30% at hospital discharge. The pharmacist contacted 40% of treatment teams after ICU discharge and intervention resulted in PM discontinued in 50% of patients. Post ICU discharge, the indication of 41% of patients' PM was unknown by the non-ICU care team or incorrect. Medical ICU patients or those transferred to an outside facility were more likely remain on PM at hospital discharge.

CONCLUSION

PM are frequently continued during transitions of care and often without knowledge of the initial indication. Future studies should establish effective PM stewardship methods.

Physiotherapy treatment approaches for survivors of critical illness: a proposal from a Delphi study

Purpose: The aim of this study was to develop practical recommendations for physiotherapy for survivors of critical illness after hospital discharge. Methods: A modified Delphi consensus study was performed. A scoping literature review formed the basis for three Delphi rounds. The first round was used to gather input from the panel to finalize the survey for the next two rounds in which the panel was asked to rank each of the statements on an ordinal scale with the objective to reach consensus. Consensus was defined as a SIQR of ≤ 0.5. Ten Dutch panelists participated in this study: three primary care physiotherapists, four intensive care physiotherapists, one occupational therapist, one ICU-nurse and one former ICU-patient. All involved professionals have treated survivors of critical illness. Our study was performed in parallel with an international Delphi study with hospital-based health-care professionals and researchers. Results: After three Delphi rounds, consensus was reached on 95.5% of the statements. This resulted in practical recommendations for physiotherapy for critical illness survivors in the primary care setting. The panel agreed that the handover should include information on 14 items. Physiotherapy treatment goals should be directed toward improvement of aerobic capacity, physical functioning, activities in daily living, muscle strength, respiratory and pulmonary function, fatigue, pain, and health-related quality of life. Physiotherapy measurements and interventions to improve these outcomes are suggested. Conclusion: This study adds to the knowledge on post-ICU physiotherapy with practical recommendations supporting clinical decision-making in the treatment of survivors of critical illness after hospital discharge.

Pulmonary and Physical Rehabilitation in Critically Ill Patients

Some patients admitted to the intensive care unit (ICU) because of an acute illness, complicated surgery, or multiple traumas develop muscle weakness affecting the limbs and respiratory muscles during acute care in the ICU. This condition is referred to as ICU-acquired weakness (ICUAW), and can be evoked by critical illness polyneuropathy (CIP), critical illness myopathy (CIM), or critical illness polyneuromyopathy (CIPNM). ICUAW is diagnosed using the Medical Research Council (MRC) sum score based on bedside manual muscle testing in cooperative patients. The MRC sum score is the sum of the strengths of the 12 regions on both sides of the upper and lower limbs. ICUAW is diagnosed when the MRC score is less than 48 points. However, some patients require electrodiagnostic studies, such as a nerve conduction study, electromyography, and direct muscle stimulation, to differentiate between CIP and CIM. Pulmonary rehabilitation in the ICU can be divided into modalities intended to remove retained airway secretions and exercise therapies intended to improve respiratory function. Physical rehabilitation, including early mobilization, positioning, and limb exercises, attenuates the weakness that occurs during critical care. To perform mobilization in mechanically ventilated patients, pretreatment by removing secretions is necessary. It is also important to increase the strength of respiratory muscles and to perform lung recruitment to improve mobilization in patients who are weaned from the ventilator. For these reasons, pulmonary rehabilitation is important in addition to physical therapy. Early recognition of CIP, CIM, and CIPNM and early rehabilitation in the ICU might improve patients’ functional recovery and outcomes.

Chronic Pain and Chronic Opioid Use After Intensive Care Discharge - Is It Time to Change Practice?

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33-73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

Multimodal Analgesia and Opioid Use in Critically Ill Trauma Patients

BACKGROUND

Opioids are the mainstay of pain management in critically ill trauma patients. However, the risks of opioid use mandate a different approach. Multimodal analgesia employs a combination of opioid and nonopioid agents using different mechanisms that have synergistic effects in treating pain. This study examines the effects of multimodal analgesia on the opioid requirements of critically ill trauma patients.

STUDY DESIGN

This was a pre-post cohort study of adult trauma ICU patients before and after implementation of a multimodal pain management order set. Patients were excluded if their hospital stay was less than 5 days, head Abbreviated Injury Scale score was greater than 1, or pre-injury medications included methadone or buprenorphine. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period on days 2 through 5 of admission and the last 24 hours before discharge using standardized ratios. The primary endpoint was cumulative OME doses over the second through fifth days of admission.

RESULTS

There were 65 patients in the pre-group and 62 in the post-group. Median cumulative OME dose was significantly lower in the post-group (125.6 mg, interquartile range [IQR] 45.0 to 415.0 mg) compared with the pre-group (481.5 mg, IQR 174.8 to 881.3 mg), p < 0.001. Patients who received 3 or more multimodal agents had a lower cumulative OME dose (116.3 mg, IQR 52.5 to 496.5 mg) compared with those who were on 1 to 2 multimodal agents (363 mg, IQR 115.5 to 743 mg) or 0 multimodal agents (479 mg, IQR 185 to 736.5 mg), p = 0.024. There were no differences between pre-group and post-group mean pain scores on hospital day 5 (4.48 ± 0.34 vs 3.50 ± 0.38, p = 0.058) or at hospital discharge (3.43 ± 0.34 vs 3.56 ± 0.32, p = 0.789).

CONCLUSIONS

Implementation of a multimodal pain management strategy significantly reduced opioid use in critically ill trauma patients without compromising patient comfort.

The Use of Volatile Anesthetics as Sedatives for Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) remains to pose a high morbidity and mortality without any targeted therapies. Sedation, usually given intravenously, is an important part of clinical practice in intensive care unit (ICU), and the effect of sedatives on patients’ outcomes has been studied intensively. Although volatile anesthetics are not routine sedatives in ICU, preclinical and clinical studies suggested their potential benefit in pulmonary pathophysiology. This review will summarize the current knowledge of ARDS and the role of volatile anesthetic sedation in this setting from both clinical and mechanistic standpoints. In addition, we will review the infrastructure to use volatile anesthetics.

Pharmacological interventions for prevention and management of delirium in intensive care patients: a systematic overview of reviews and meta-analyses

OBJECTIVES

We assessed the evidence from reviews and meta-analyses of randomised clinical trials on the effects of pharmacological prevention and management of delirium in intensive care unit (ICU) patients.

METHODS

We searched for reviews in July 2017 in: Cochrane Library, MEDLINE, Embase, Science Citation Index, BIOSIS Previews, CINAHL and LILACS. We assessed whether reviews were systematic according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and assessed the methodological quality using ROBIS.

OUTCOME MEASURES

Primary outcomes: all-cause mortality, serious adverse events, prevention of delirium and management of delirium.

SECONDARY OUTCOMES

quality of life; non-serious adverse events and cognitive function.

RESULTS

We included 378 reviews: 369 narrative reviews, eight semisystematic reviews which failed on a maximum of two arbitrary PRISMA criteria and one systematic review fulfilling all 27 PRISMA criteria. For the prevention of delirium, we identified the one systematic review and eight semisystematic reviews all assessing the effects of alpha-2-agonists. None found evidence of a reduction of mortality (systematic review RR 0.99, 95% CI 0.79 to 1.24). The systematic review and three semisystematic reviews found no evidence of an effect for the prevention of delirium (systematic review RR 0.85, 0.63 to 1.14). Conversely, four semisystematic reviews found a beneficial effect. Serious adverse events, quality of life, non-serious adverse events and cognitive function were not assessed. We did not identify any systematic or semisystematic reviews addressing other pharmacological interventions for the prevention of delirium. For the management of manifest delirium, we did not identify any systematic or semisystematic review assessing any pharmacological agents.

CONCLUSION

Based on systematic reviews, the evidence for the use of pharmacological interventions for prevention or management of delirium is poor or sparse. A systematic review with low risk of bias assessing the effects of pharmacological prevention of delirium and management of manifest delirium in ICU patients is urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42016046628.

Acute Confusional States in Hospital

BACKGROUND

Acute confusional state (delirium) is an acute disturbance of brain function. The incidence of such states varies according to the group of patients con- cerned: it ranges from 30% to 80% among patients in intensive care and from 5.1% to 52.2% among surgical patients, depending on the type of procedure. The earlier German term "Durchgangssyndrom" (usually rendered as "transitory psychotic syn- drome") tended to imply a self-limited and thus relatively harmless condition. In fact, however, delirium is associated with longer hospital stays, poorer treatment out- comes, and higher mortality. Approximately 25% of patients who have experienced an acute confusional state have residual cognitive deficits thereafter.

METHODS

This review is based on publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and in the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

Validated instruments are available for the reliable diagnosis of an acute confusional state, e.g., the Confusion Assessment Method for the ICU (CAM-ICU) for patients in intensive care and the 3D-CAM or CAM-S for patients on regular hospital wards. The prevention and treatment of this condition are achieved primarily by a nonpharmacological, multidimensional approach including early mobilization, reorientation, improvement of sleep, adequate pain relief, and the avoidance of polypharmacy. A meta-analysis has shown that these measures lower the incidence of delirium by 44%. The authors find no basis in the current literature for recommending prophylactic medication, although current data promisingly suggest that the incidence of delirium in surgical patients can be lowered by the perioperative administration of dexmedetomidine (odds ratio 0.35). The pharmaco- therapy of acute confusional states involves a careful choice of drug based on the clinical manifestations in the individual case.

CONCLUSION

The key elements of success in the treatment of acute confusional states in the hospital are adequate prevention, rapid diagnosis, the identification of precipitating factors, and the rapid initiation of both causally oriented and symptom- directed treatment.

Melatonin in Critical Care

Melatonin is involved in regulation of a variety of physiologic functions, including circadian rhythm, reproduction, mood, and immune function. Exogenous melatonin has demonstrated many clinical effects. Numerous clinical studies have documented improved sleep quality following administration of exogenous melatonin. Recent studies also demonstrate the analgesic, anxiolytic, antiinflammatory, and antioxidative effects of melatonin. This article reviews the principal properties of melatonin and how these could find clinical applications in care of the critically ill patients.

Intravenous Olanzapine in a Critically Ill Patient: An Evolving Route of Administration

Purpose: The purpose of the article is to describe the successful use of parenteral olanzapine intravenously (IV) in a critically ill patient with severe agitated delirium. Summary: A 70-year-old man was admitted to the medical intensive care unit requiring plasmapheresis with platelet counts consistently below 20 000/µL secondary to thrombotic thrombocytopenic purpura (TTP). The patient had experienced agitated delirium requiring treatment, which was complicated by electrocardiogram (EKG) findings of a prolonged QTc interval. The antipsychotics the patient was receiving were believed to be responsible and, as such, the team desired an option that would have a lesser chance of worsening QTc (baseline-corrected QT) interval. Olanzapine was chosen and given IV versus the U.S. Food and Drug Administration (FDA)-approved parenteral route of intramuscular (IM) due to concern of bleeding. The patient's delirious state responded to treatment to varying degrees and showed no increase in EKG abnormalities. To our knowledge, there is a paucity of published literature regarding this route of administration. Conclusion: Intramuscular olanzapine used IV may be a safe and effective option for the treatment of acutely agitated, delirious, critically ill patient.

Attempts to Limit Opioid Prescribing in Critically Ill Patients: Not So Easy, Not So Fast

OBJECTIVE

To discuss why opioids have been considered the long-standing first-line therapy for treating acute, severe nociceptive pain in critically ill patients and discuss considerations for limiting opioid overuse in the intensive care unit setting.

DATA SOURCES

Articles were identified through searches of PubMed and EMBASE from database inception until December 2018. Additional references were located through a review of the bibliographies of articles and clinical practice guidelines.

STUDY SELECTION AND DATA EXTRACTION

Original research articles excluding case reports were included if they concerned nonopioid agents for pain management in critically ill patients. The focus was on studies not included in the most recent pain management guidelines.

DATA SYNTHESIS

Ten studies were retrieved. Nonopioid therapies or opioid-sparing therapies have been touted as possible alternatives for critically ill patients, but they have particular adverse effects concerns in critically ill patients, often lack parenteral dosage forms, and frequently require dose adjustment or avoidance in patients with renal or hepatic dysfunction. Relevance to Patient Care and Clinical Practice: There is a well-recognized opioid epidemic that has been the subject of much discussion. Attempts to control the epidemic have focused on limiting opioid prescribing and using nonopioid alternatives, but there are special considerations when treating severe pain in critically ill patients that often preclude nonopioid analgesics.

CONCLUSIONS

There continues to be an unmet need for medications that are as effective as opioids for severe nociceptive pain in critically ill patients but without the adverse effect and abuse concerns. Until such medications are available, clinicians need to optimize prescribing of opioid and nonopioid analgesics.

Comparison of Cognitive Impairments After Intensive Care Unit Sedation Using Dexmedetomidine and Propofol Among Older Patients

Despite the high prevalence of cognitive impairment among older adults, little is known about the association of the selection of dexmedetomidine and propofol on cognitive functions of patients after a critical illness. Patients aged ≥70 years who received intensive care unit (ICU) care from Cangzhou Central Hospital between 2013 and 2016 were enrolled and randomized into a dexmedetomidine group and a propofol group with matched demographic and clinical characteristics. At discharge from the ICU and 4 weeks later, the cognitive status of patients was assessed and compared using the Montreal Cognitive Assessment system. There were 164 patients included in the dexmedetomidine group and 159 patients in the propofol group. No significant difference was observed between the 2 groups in terms of age, female sex, body weight, educational level, ICU and hospital stay, comorbidities, and medications. Further, patients from the 2 groups at ICU discharge did not demonstrate significant difference on the Montreal Cognitive Assessment component scores, which showed significant differences between the 2 groups 4 weeks later (P < .05). Moreover, dexmedetomidine and propofol showed different levels of impacts on the cognitive function of patients discharged from the postanesthesia care unit, neurological ICU, and medical ICU. This study demonstrated that patients discharged from the ICU who received propofol for sedation showed less impairment on the cognitive functions when compared with patients who received dexmedetomidine during ICU care 4 weeks after discharge. Despite some limitations, this study provides insights to the decision-making process in the selection of appropriate sedation strategy, especially for the elderly patients.

Delirium in the critically ill patient

Delirium is an acute and transient brain dysfunction that is characterized by disturbances in consciousness, affecting both its content (i.e., attention) and level (i.e., arousal). It affects as many as 50% of those admitted to an intensive care unit (ICU). Once believed to be an inconsequential outcome of critical illness, it is now recognized that delirium is harmful in both the short- and long-term. Despite occurring frequently in critically ill patients, delirium often goes unrecognized. Well-validated delirium screening tools, designed for use in the ICU, should be used to reliably detect delirium. The first step in delirium treatment is to identify and address potentially modifiable risk factors. Multiple trials have shown that benzodiazepines are a risk factor for delirium in a dose-dependent manner. Sedation with nonbenzodiazepine-based strategies are an effective means by which to reduce delirium. Nonpharmacologic strategies such as those which seek to reduce sensory impairment, sleep deprivation, and immobility are effective. Pharmacologic treatment with antipsychotics, though commonly used, is not supported by findings from placebo-controlled trials. Recent data support from multiple trials support the use of the "ABCDEF bundle" as a means by which to reduce delirium.

National Approach to Standardize and Improve Mechanical Ventilation

NASAM (National Approach to Standardize and Improve Mechanical Ventilation) is a national collaborative quality improvement project in Saudi Arabia. It aims to improve the care of mechanically ventilated patients by implementing evidence-based practices with the goal of reducing the rate of ventilator-associated events and therefore reducing mortality, mechanical ventilation duration and intensive care unit (ICU) length of stay. The project plans to extend the implementation to a total of 100 ICUs in collaboration with multiple health systems across the country. As of March 22, 2019, a total of 78 ICUs have registered from 6 different health sectors, 48 hospitals, and 27 cities. The leadership support in all health sectors for NASAM speaks of the commitment to improve the care of mechanically ventilated patients across the kingdom.

The effect of local anesthetic continuous wound infusion for the prevention of postoperative pneumonia after on-pump cardiac surgery with sternotomy: the STERNOCAT randomized clinical trial

PURPOSE

Postoperative pain after cardiac surgery, exacerbated by cough and sternal mobilization, limits clearance of bronchopulmonary secretions and may predispose to postoperative pneumonia. In this study, we tested the ability of local anesthetic continuous wound infusion to prevent pneumonia after cardiac surgery with sternotomy and cardiopulmonary bypass (CPB) owing to better analgesia and bronchopulmonary drainage.

METHODS

In this randomized, double-blind, placebo-controlled trial conducted in five academic centers, patients undergoing cardiac surgery with sternotomy and CPB were enrolled from February 2012 until November 2014, and were followed over 30 days. Patients were assigned to a 48-h infusion (10 ml h-1) of L-bupivacaine (12.5 mg h-1) or placebo (saline) via a pre-sternal multiperforated catheter. Anesthesia and analgesia protocols were standardized. The primary end point was the incidence of pneumonia during the study period, i.e., until hospital discharge or 30 days. We hypothesized a 30% reduction in the incidence of pneumonia.

RESULTS

Among 1493 randomized patients, 1439 completed the trial. Pneumonia occurred in 36/746 patients (4.9%) in the L-bupivacaine group and in 42/739 patients (5.7%) in the placebo group (absolute risk difference taking into account center and baseline risk of postoperative pneumonia, - 1.3% [95% CI - 3.4; 0.8] P = 0.22). In the predefined subgroup of patients at high risk, L-bupivacaine decreased the incidence of pneumonia (absolute risk difference, - 5.6% [95% CI - 10.0; - 1.1], P = 0.01).

CONCLUSIONS

After cardiac surgery with sternotomy, continuous wound infusion of L-bupivacaine failed to decrease the incidence of pneumonia. These findings do not support the use of local anesthetic continuous wound infusion in this indication. Further study should investigate its effect in high-risk patients.

TRIAL REGISTRATION

EudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.