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

Nurses' experiences of caring for nursing care-dependent ICU patients: A qualitative study

BACKGROUND

Nursing care dependency is a key, yet under-studied, nursing phenomenon. Patients in intensive care units are highly dependent on nursing care. Patients find dependency challenging, experiencing feelings of powerlessness and shame. The nurse-patient care relationship can influence patients' perception of dependency. Understanding how nurses experience their care for dependent patients is crucial, as nurses might not always grasp the impact of their actions on patients' dependency experiences.

AIM

To explore and interpret ICU nurses' perceptions of patients' nursing care dependency and their experiences in caring for nursing care-dependent patients.

STUDY DESIGN

A qualitative interpretative phenomenological study inspired by Merleau-Ponty's philosophical stance was conducted using focus groups with nurses who had been caring for adult patients for at least 6 months in ICUs of two hospitals. Data analysis followed Smith et al.'s guidance. Researchers immersed themselves in the transcripts, noted individual's experiences before transitioning to shared insights, coded significant phrases and generated themes and superordinate themes.

RESULTS

Four focus groups were conducted with 18 nurses with widely ranging ages and work experience. Four superordinate themes emerged: 'Time and context define dependency', 'Empathetic relationships help nurses understand patients' experience of dependency', 'Trusting nurse-patient relationships change the dependency experience' and 'Nurses' skills help patients to recover independence'.

CONCLUSION

This study increases critical care nurses' awareness of the overlooked phenomenon of caring for nursing care dependent patients and offers them an opportunity to reflect on their care for dependent patients and adapt it to patients' experiences. Further studies are needed with nurses and patients in different ICUs, cultures and countries, to gain a broader picture of experiences of nursing care dependency.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses need strong relational skills to offer high-quality care for dependent patients, facilitating meaningful nurse-patient relationships based on empathy and trust. These relationships can significantly impact the patient's experience of dependence.

Adaptation and validation of the Physical Restraint-Theory of Planned Behaviour Questionnaire to the paediatric context

BACKGROUND

Physical restraint is applied in pediatric intensive care units to carry out certain painful procedures and to ensure the maintenance and continuity of life support devices. There is a need to analyse the factors that influence the behaviour or intention to use physical restraint.

AIM

To create and test psychometrically a paediatric version of the Physical Restraint-Theory of Planned Behaviour Questionnaire to assess paediatric critical care nurses' intention to use physical restraint.

STUDY DESIGN

A psychometric study. Five medical-surgical Paeditric Intensive care Units from five hospitals in Spain. The study took place in three phases. In phase 1, the questionnaire was adapted. In phase 2, the content validity of each item was determined, and a pilot test was conducted. In phase 3, we administered the questionnaire and determined its psychometric properties.

RESULTS

The assessment of the intention to use physical restraint was extended to all critical paediatric patients, two items were eliminated from the initial questionnaire, four new items were included, and the clinical scenarios of the intention subscale were expanded from three to six. Overall content validity index for the full instrument of 0.96 out of 1. The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is made up of four subscales (attitude, subjective norms (SN), perceived behavioural control (PBC), and intention) subdivided into 7 factors and 51 items. The internal consistency for the attitude subscale obtained a Cronbach's Alpha of 0.80 to 0.73, for the SN it was 0.72 to 0.89, for the PBC it was from 0.80 to 0.73 and for the intention subscale it was 0.75.

CONCLUSIONS

The Paediatric Physical Restraint-Theory of Planned Behaviour Questionnaire is an instrument composed of seven factors and 51 items that validly and reliably assesses the intention of paediatric nurses to apply PR in PICUs.

RELEVANCE FOR CLINICAL PRACTICE

Having this instrument will help health centres move towards restraint-free care by allowing managers to assess professionals' attitudes, beliefs, and intentions around the use of PR in PICUs.

Volatile anesthetics for lung- and diaphragm-protective sedation

This review explores the complex interactions between sedation and invasive ventilation and examines the potential of volatile anesthetics for lung- and diaphragm-protective sedation. In the early stages of invasive ventilation, many critically ill patients experience insufficient respiratory drive and effort, leading to compromised diaphragm function. Compared with common intravenous agents, inhaled sedation with volatile anesthetics better preserves respiratory drive, potentially helping to maintain diaphragm function during prolonged periods of invasive ventilation. In turn, higher concentrations of volatile anesthetics reduce the size of spontaneously generated tidal volumes, potentially reducing lung stress and strain and with that the risk of self-inflicted lung injury. Taken together, inhaled sedation may allow titration of respiratory drive to maintain inspiratory efforts within lung- and diaphragm-protective ranges. Particularly in patients who are expected to require prolonged invasive ventilation, in whom the restoration of adequate but safe inspiratory effort is crucial for successful weaning, inhaled sedation represents an attractive option for lung- and diaphragm-protective sedation. A technical limitation is ventilatory dead space introduced by volatile anesthetic reflectors, although this impact is minimal and comparable to ventilation with heat and moisture exchangers. Further studies are imperative for a comprehensive understanding of the specific effects of inhaled sedation on respiratory drive and effort and, ultimately, how this translates into patient-centered outcomes in critically ill patients.

Prevalence and risk factors of the use of physical restraint and impact of a decision support tool: A before-and-after study

BACKGROUND

Physical restraint is frequently used in intensive care units to prevent patients' life-threatening removal of indwelling devices. In France, their use is poorly studied. Therefore, to evaluate the need for physical restraint, we have designed and implemented a decision support tool.

AIMS

Besides describing the prevalence of physical restraint use, this study aimed to assess whether the implementation of a nursing decision support tool had an impact on restraint use and to identify the factors associated with this use.

STUDY DESIGN

A large observational, multicentre study with a repeated one-day point prevalence design was conducted. All adult patients hospitalized in intensive care units were eligible for this study. Two study periods were planned: before (control period) and after (intervention period) the deployment of the decision support tool and staff training. A multilevel model was performed to consider the centre effect.

RESULTS

During the control period, 786 patients were included, and 510 were in the intervention period. The prevalence of physical restraint was 28% (95% CI: 25.1%-31.4%) and 25% (95% CI: 21.5%-29.1%) respectively (χ2 = 1.35; p = .24). Restraint was applied by the nurse and/or nurse assistant in 96% of cases in both periods, mainly to wrists (89% vs. 83%, p = .14). The patient-to-nurse ratio was significantly lower in the intervention period (1:3.0 ± 1 vs. 1:2.7 ± 0.7, p < .001). In multivariable analysis, mechanical ventilation was associated with physical restraint (aOR [95% CI] = 6.0 [3.5-10.2]).

CONCLUSION

The prevalence of physical restraint use in France was lower than expected. In our study, the decision support tool did not substantially impact physical restraint use. Hence, the decision support tool would deserve to be assessed in a randomized controlled trial.

RELEVANCE TO CLINICAL PRACTICE

The decision to physically restrain a patient could be protocolised and managed by critical care nurses. A regular evaluation of the level of sedation could allow the most deeply sedated patients to be exempted from physical restraint.

Ketamine Analgo-sedation for Mechanically Ventilated Critically Ill Adults: A Rapid Practice Guideline from the Saudi Critical Care Society and the Scandinavian Society of Anesthesiology and Intensive Care Medicine

BACKGROUND

This Rapid Practice Guideline (RPG) aimed to provide evidence‑based recommendations for ketamine analgo-sedation (monotherapy and adjunct) versus non-ketamine sedatives or usual care in adult intensive care unit (ICU) patients on invasive mechanical ventilation (iMV) and to identify knowledge gaps for future research.

METHODS

The RPG panel comprised 23 multinational multidisciplinary panelists, including a patient representative. An up-to-date systematic review and meta-analysis constituted the evidence base. The Grading Recommendations, Assessment, Development, and Evaluation approach, and the evidence-to-decision framework were used to assess the certainty of evidence and to move from evidence to decision/recommendation. The panel provided input on the balance of the desirable and undesirable effects, certainty of evidence, patients' values and preferences, costs, resources, equity, feasibility, acceptability, and research priorities.

RESULTS

Data from 17 randomized clinical trials (n=898) and 9 observational studies (n=1934) were included. There was considerable uncertainty about the desirable and undesirable effects of ketamine monotherapy for analgo-sedation. The evidence was very low certainty and downgraded for risk of bias, indirectness, and inconsistency. Uncertainty or variability in values and preferences were identified. Costs, resources, equity, and acceptability were considered varied. Adjunctive ketamine therapy had no effect on mortality (within 28 days) (relative risk [RR] 0.99; 95% confidence interval [CI] 0.76 to 1.27; low certainty), and may slightly reduce iMV duration (days) (mean difference [MD] -0.05 days; 95% CI -0.07 to -0.03; low certainty), and uncertain effect on the cumulative dose of opioids (mcg/kg/h morphine equivalent) (MD -11.6; 95% CI -20.4 to -2.7; very low certainty). Uncertain desirable effects (cumulative dose of sedatives and vasopressors) and undesirable effects (adverse event rate, delirium, arrhythmia, hepatotoxicity, hypersalivation, use of physical restraints) were also identified. A possibility of important uncertainty or variability in patient-important outcomes led to a balanced effect that favored neither the intervention nor the comparison. Cost, resources, and equity were considered varied.

CONCLUSION

The RPG panel provided two conditional recommendations and suggested (1) against using ketamine as monotherapy analgo-sedation in critically ill adults on iMV when other analgo-sedatives are available; and (2) using ketamine as an adjunct to non-ketamine usual care sedatives (e.g., opioids, propofol, dexmedetomidine) or continuing with non-ketamine usual care sedatives alone. Large-scale trials should provide additional evidence.

Impact of a financial incentive on early rehabilitation and outcomes in ICU patients: a retrospective database study in Japan

BACKGROUND

Early mobilisation of intensive care unit (ICU) patients has been recommended in clinical practice guidelines. Therefore, the Japanese universal health insurance system introduced an additional fee for early mobilisation and/or rehabilitation, which can be claimed by hospitals when starting rehabilitation of ICU patients within 48 hours after their ICU admission. However, the effect of this fee is unknown.

OBJECTIVE

To measure the proportion of ICU patients who received early rehabilitation and the impact on length of ICU stay, the length of hospital stay and discharged to home after the introduction of the financial incentive (additional fee for early mobilisation and/or rehabilitation).

DESIGN/METHODS

We included patients who were admitted to ICU within 2 days of hospitalisation between April 2016 and January 2020. We conducted interrupted time series analyses to assess the effects of the introduction of the financial incentive.

RESULTS

The proportion of patients who received early rehabilitation immediately increased after the introduction of the financial incentive (rate ratio (RR) 1.293, 95% CI 1.240 to 1.349). The RR for proportion of patients received early rehabilitation was 1.008 (95% CI 1.005 to 1.011) in the period after the introduction of the financial incentive compared with period before its introduction. There was no statistically significant change in the mean length of ICU stay, the mean length of hospital stay and the proportion of patients who were discharged to home.

CONCLUSION

After the introduction of the financial incentive, the proportion of ICU patients who received early rehabilitation increased. However, the effects of the financial incentive on the length of ICU stay, the length of hospital stay and the proportion of patients who were discharged to home were limited.

Nociception level index variations in ICU: curarized vs non-curarized patients - a pilot study

PURPOSE

Pain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring.

METHODS

This retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients.

RESULTS

NOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent's infusion, only NOL properly identified nociception. In the former group, EEG's relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL.

CONCLUSION

NOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them.

Recommendations for pharmacogenetic testing in clinical practice guidelines in the US

PURPOSE

Pharmacogenetic testing can identify patients who may benefit from personalized drug treatment. However, clinical uptake of pharmacogenetic testing has been limited. Clinical practice guidelines recommend biomarker tests that the guideline authors deem to have demonstrated clinical utility, meaning that testing improves treatment outcomes. The objective of this narrative review is to describe the current status of pharmacogenetic testing recommendations within clinical practice guidelines in the US.

SUMMARY

Guidelines were reviewed for pharmacogenetic testing recommendations for 21 gene-drug pairs that have well-established drug response associations and all of which are categorized as clinically actionable by the Clinical Pharmacogenetics Implementation Consortium. The degree of consistency within and between organizations in pharmacogenetic testing recommendations was assessed. Relatively few clinical practice guidelines that provide a pharmacogenetic testing recommendation were identified. Testing recommendations for HLA-B*57:01 before initiation of abacavir and G6PD before initiation of rasburicase, both of which are included in drug labeling, were mostly consistent across guidelines. Gene-drug pairs with at least one clinical practice guideline recommending testing or stating that testing could be considered included CYP2C19-clopidogrel, CYP2D6-codeine, CYP2D6-tramadol, CYP2B6-efavirenz, TPMT-thiopurines, and NUDT15-thiopurines. Testing recommendations for the same gene-drug pair were often inconsistent between organizations and sometimes inconsistent between different guidelines from the same organization.

CONCLUSION

A standardized approach to evaluating the evidence of clinical utility for pharmacogenetic testing may increase the inclusion and consistency of pharmacogenetic testing recommendations in clinical practice guidelines, which could benefit patients and society by increasing clinical use of pharmacogenetic testing.

Perioperative dexmedetomidine-induced delirium in a patient with schizophrenia: a case report

BACKGROUND

Dexmedetomidine is a selective α2 receptor agonist with sedative, analgesic, anxiolytic, and anti-sympathetic effects. Dexmedetomidine is widely used for various surgical procedures performed under general anaesthesia and sedation in the intensive care unit. Dexmedetomidine was known to relieve or improve the symptoms of delirium. Schizophrenia is a common psychiatric disease, and the number of surgical patients with schizophrenia is increasing gradually. Dexmedetomidine-induced delirium in patients with schizophrenia is a particular case.

CASE PRESENTATION

This patient was a 75-year-old woman (height: 156 cm; weight: 60 kg) with a 5-year history of schizophrenia. Her schizophrenia was well controlled with medications. She was scheduled for open reduction and internal fixation for a patellar fracture. Spinal anaesthesia was administered for surgery, and dexmedetomidine was administered intravenously to maintain sedation. The patient became delirious half an hour after the surgery began. The intravenous infusion of dexmedetomidine was discontinued immediately, intravenous propofol was subsequently administered, and the patient stopped experiencing dysphoria and fell asleep. After surgery, the patient stopped using propofol and recovered smoothly. She was transferred back to the general ward and was discharged from the hospital without any abnormal conditions on the 9th day after surgery.

CONCLUSIONS

To the best of our knowledge, this is the first report of a patient with schizophrenia who developed delirium during the infusion of a normal dose of dexmedetomidine without an intravenous injection of any other sedative. The exact mechanism causing dexmedetomidine-induced delirium remains unclear, and this adverse reaction is rare and easy to ignore. Clinicians and pharmacists should be vigilant in identifying this condition.

ICU patients receiving remifentanil do not experience reduced duration of mechanical ventilation: a systematic review of randomized controlled trials and network meta-analyses based on Bayesian theories

Background

The purpose of this network meta-analysis (NMA) was to evaluate the efficacy of intravenous opioid μ-receptor analgesics in shortening the duration of mechanical ventilation (MV) in ICU patients.

Methods

Randomized controlled trials comparing the efficacy of remifentanil, sufentanil, morphine, and fentanyl on the duration of MV in ICU patients were searched in Embase, Cochrane, Pubmed, and Web of Science electronic databases. The primary outcome was MV duration. The Bayesian random-effects framework was used to evaluate relative efficacy.

Results

In total 20 studies were included in this NMA involving 3,442 patients. Remifentanil was not associated with a reduction in the duration of MV compared with fentanyl (mean difference (MD) -0.16; 95% credible interval (CrI): -4.75 ~ 5.63) and morphine (MD 3.84; 95% CrI: -0.29 ~ 10.68). The secondary outcomes showed that, compared with remifentanil, sufentanil can prolong the duration of extubation. No regimen significantly shortened the ICU length of stay and improved the ICU mortality, efficacy, safety, and drug-related adverse events.

Conclusion

Among these analgesics, remifentanil did not appear to be associated with a reduction in MV duration. Clinicians should carefully titrate the analgesia of MV patients to prevent a potentially prolonged duration of MV due to excessive or inadequate analgesic therapy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42021232604.

Intensive care of a patient undergoing combined multi-organ cluster ("larynx-trachea-thyroid-hypopharynx-esophagus") transplantation: A case report

OBJECTIVE

The aim of this study was to summarize the intensive care experience of a patient undergoing combined multi-organ cluster ("larynx-trachea-thyroid-hypopharynx-esophagus") transplantation.

METHODS

The intensive care management plan for this case was developed by a multidisciplinary team, with focus on 6 aspects: (1) stabilizing the circulation and reducing anastomotic tension by position management to improve the survival chances of transplanted organs, (2) adopting goal-directed analgesia and sedation protocols, as well as preventing anastomotic fistula, (3) implementing a bedside ultrasound-guided nutrition plan, (4) employing "body-mind" synchronous rehabilitation to facilitate functional recovery, (5) taking antirejection treatment and protective isolation measures, (6) monitoring and nursing thyroid function.

RESULTS

During the intensive care, the patient's vital signs were stable. The patient was successfully weaned from the ventilator and transferred to the general ward for further treatment at 9 days postoperatively, and discharged upon recovery at 58 days postoperatively. The patient was in good condition during follow-up.

CONCLUSION

This study provides reference for the care of patients who undergo similar transplantation in the future.

Fospropofol disodium versus propofol for long-term sedation during invasive mechanical ventilation: A pilot randomized clinical trial

STUDY OBJECTIVE

Fospropofol disodium is a propofol prodrug that is water-soluble and has a reduced risk of bacterial contamination and hypertriglyceridemia compared with propofol. Prior to implementing a large randomized trial, we investigated the feasibility, initial efficacy, and safety of fospropofol disodium compared with propofol in long-term mild-to-moderate sedation in intensive care units (ICUs).

DESIGN

Single-centered, prospective, unblind, randomized, parallel-group clinical trial.

SETTING

The general ICU of university-affiliated teaching hospital.

PATIENTS

Adult patients (n = 60) expected to have mechanical ventilation for >24 h were enrolled and randomly assigned to the fospropofol or propofol group.

INTERVENTIONS

The fospropofol group received continuous fospropofol disodium infusions and the propofol group received continuous propofol infusions. The sedation goal was a score of -3 to 0 on the Richmond Agitation and Sedation Scale (RASS).

MEASUREMENTS

The primary outcome was the percentage of time spent in the target sedation range without rescue sedation. Safety outcomes were based on adverse events. Blood samples were collected to measure formate concentration in plasma.

MAIN RESULTS

The median dose was 4.33 (IQR, 3.08-4.94) mg/kg/h in the fospropofol group and 1.96 (IQR, 1.44-2.94) mg/kg/h in the propofol group. The median percentage of time spent in the target RASS range without rescue sedation was identical in both groups, with 83.33% (IQR, 74.43%-100.00%) in the fospropofol group and 83.33% (IQR, 77.45%-100.00%) in the propofol group (p = 0.887). At least one adverse event was identifed in 23 (76.7%) fospropofol patients and 27 (90.0%) propofol patients. The most common adverse events were tachycardia and hypotension. No paresthesia, catheter-related bloodstream infection or propofol infusion syndrome in both groups was reported. Three patients in the fospropofol group had mild hypertriglyceridemia, and nine patients in propofol group had hypertriglyceridemia (mild in eight patients and moderate in one patient) (10% versus 30%, p = 0.104). The formate concentration in plasma was very low, and no significant difference was identified at any time point between the two groups.

CONCLUSIONS

Fospropofol disodium appears to be a feasible, effective and safe sedative for patients receiving invasive mechanical ventilation with long-term sedation.

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

INTRODUCTION

Given the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population.

PATIENTS AND METHODS

Four electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome).

RESULTS

Twenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48-89] at rest to 41 [25-72] during tracheal suctioning in paralyzed patients, and from 71 [53-85] at rest to 40 [31-52] in non-paralyzed patients.

CONCLUSIONS

ANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Intensive care unit interventions to improve quality of dying and death: scoping review

BACKGROUND

Intensive care units (ICUs) have mortality rates of 10%-29% owing to illness severity. Postintensive care syndrome-family affects bereaved relatives, with a prevalence of 26% at 3 months after bereavement, increasing the risk for anxiety and depression. Complicated grief highlights issues such as family presence at death, inadequate physician communication and urgent improvement needs in end-of-life care. However, no study has comprehensively reviewed strategies and components of interventions to improve end-of-life care in ICUs.

AIM

This scoping review aimed to analyse studies on improvement of the quality of dying and death in ICUs and identify interventions and their evaluation measures and effects on patients.

METHODS

MEDLINE, CINAHL, PsycINFO and Central Journal of Medicine databases were searched for relevant studies published until December 2023, and their characteristics and details were extracted and categorised based on the Joanna Briggs model.

RESULTS

A total of 24 articles were analysed and 10 intervention strategies were identified: communication skills, brochure/leaflet/pamphlet, symptom management, intervention by an expert team, surrogate decision-making, family meeting/conference, family participation in bedside rounds, psychosocial assessment and support for family members, bereavement care and feedback on end-on-life care for healthcare workers. Some studies included alternative assessment by family members and none used patient assessment of the intervention effects.

CONCLUSION

This review identified 10 intervention strategies to improve the quality of dying and death in ICUs. Many studies aimed to enhance the quality by evaluating the outcomes through proxy assessments. Future studies should directly assess the quality of dying process, including symptom evaluation of the patients.

Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study

BACKGROUND

The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools.

OBJECTIVE

The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity.

RESEARCH METHOD

CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed.

DESIGN

A prospective observational study performed between October and December 2020.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity.

RESULTS

In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively.

CONCLUSION

Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

BACKGROUND

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes.

METHODS

This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete.

FINDINGS

Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo.

INTERPRETATION

In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults.

FUNDING

National Institutes of Health and the US Department of Veterans Affairs.

Post-ICU Care: Why, What, When and How? ISCCM Position Statement

How to cite this article: Ramakrishnan N, Abraham BK, Barokar R, Chanchalani G, Jagathkar G, Shetty RM, et al. Post-ICU Care: Why, What, When and How? ISCCM Position Statement. Indian J Crit Care Med 2024;28(S2):S279-S287.

Light, sleep and circadian rhythm in critical illness

PURPOSE OF REVIEW

Sleep and circadian disruption (SCD) are associated with worse outcomes in the ICU population. We discuss sleep, circadian physiology, the role of light in circadian entrainment and its possible role in treating SCD, with special attention to the use of light therapies and ICU design.

RECENT FINDINGS

The American Thoracic Society recently published an official research statement highlighting key areas required to define and treat ICU SCD. Recent literature has been predominantly observational, describing how both critical illness and the ICU environment might impair normal sleep and impact circadian rhythm. Emerging consensus guidance outlines the need for standardized light metrics in clinical trials investigating effects of light therapies. A recent proof-of-concept randomized controlled trial (RCT) showed improvement in delirium incidence and circadian alignment from ICU room redesign that included a dynamic lighting system (DLS).

SUMMARY

Further investigation is needed to define the optimal physical properties of light therapy in the ICU environment as well as timing and duration of light treatments. Work in this area will inform future circadian-promoting design, as well as multicomponent nonpharmacological protocols, to mitigate ICU SCD with the objective of improving patient outcomes.

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

Nursing diagnoses as factors associated with delirium among intensive care unit patients with sepsis: A retrospective correlational study

AIMS

To examine whether nursing diagnoses were associated with delirium in patients with sepsis.

BACKGROUND

Nursing diagnosis is a nurse's clinical judgement about clients' current or potential health conditions. Delirium is regarded as an important nurse-sensitive outcome. Nonetheless, nursing diagnoses associated with delirium have not yet been identified.

DESIGN

Retrospective correlational study.

METHODS

This study was carried out from December 2021 to January 2023. We analysed electronic health records of patients with sepsis admitted to the intensive care units (ICUs) of a tertiary hospital in Seoul, South Korea. Delirium was defined based on the Intensive Care Delirium Screening Checklist score. Nursing diagnoses established within 24 h of admission to the ICU were included and were based on the North American Nursing Diagnosis Association diagnostic classification. The data were analysed using logistic regression. Demographics, comorbidities, procedures and physiological measures were adjusted. Regression model was evaluated via receiver operating characteristic curve, Nagelkerke R2, accuracy and F1 score.

RESULTS

The prevalence of delirium in patients with sepsis was 51.8%. Ineffective breathing patterns, decreased cardiac output and impaired skin integrity were significant nursing diagnoses related to delirium. Age ≥ 65 years, Acute Physiology and Chronic Health Evaluation II score, mechanical ventilation, continuous renal replacement therapy, physical restraint and comatose state were also associated with delirium in patients with sepsis. The area under the receiver operating characteristic curve was 0.806.

CONCLUSION

Ineffective breathing patterns, decreased cardiac output and impaired skin integrity could manifest as prodromal symptoms of delirium among patients with sepsis.

IMPACT

The prodromal symptoms of delirium revealed through nursing diagnoses can be efficiently used to identify high-risk groups for delirium. The use of nursing diagnosis system should be recommended in clinical practice caring for sepsis patients.

REPORTING METHODS

STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Dynamic delirium - Nursing intervention to reduce delirium in patients critically Ill, a randomized control trial

OBJECTIVE

To determine the effectiveness of a nursing intervention based on the Dynamic Symptom Model (DSM) and scientific evidence versus daily care in reducing the incidence and duration of delirium in intensive care patients.

METHOD

We designed the intervention named "DyDel" (By Dynamic Delirium) based on the theoretical approach of the DSM and from scientific evidence. A double-masked clinical trial of parallel groups was developed to test DyDel, with 213 patients older than 18 admitted to the intensive care unit (ICU) randomized to the study groups. The intervention group received DyDel each shift from day 0 until discharged from the ICU, while the control group received daily care in the ICU. At the same time, all participants were followed to measure primary (incidence and duration of delirium) and secondary outcomes (level of sedation and pain, days of mechanical ventilation, stay in ICU, and physical restriction).

RESULTS

Overall, the study population were older than 60 years (60.3 ± 15.2 years), the male gender (59.6 %), and the diagnosis of acute myocardial infarction (73.7 %) were predominant. Comparing groups of study, the incidence of delirium was lower in the intervention group (5.6 %) than in the control group (14.8 %) (p = 0.037). The intervention group had lower days with delirium (0.07 ± 0.308) than the control group (0.34 ± 1.28) (p = 0.016), lower pain intensity (p = 0.002) and lower days of physical restraints (p = 0.06).

CONCLUSION

Non-pharmacological care, like the DyDel intervention, includes the family and focuses on the different patient's needs, which can help to reduce the incidence and duration of delirium in patients admitted to adult ICUs.

IMPLICATIONS FOR CLINICAL PRACTICE

DyDel was non-pharmacological and included the family. The DyDel's activities were focused on physiological, psychological, spiritual, and social needs and the experience and trajectory of delirium. The nurse can give humanized care in the ICU by applying DyDel.

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.

Association of Early Dexmedetomidine Utilization With Clinical Outcomes After Moderate-Severe Traumatic Brain Injury: A Retrospective Cohort Study

BACKGROUND

Traumatic brain injury (TBI) is an expensive and common public health problem. Management of TBI oftentimes includes sedation to facilitate mechanical ventilation (MV) for airway protection. Dexmedetomidine has emerged as a potential candidate for improved patient outcomes when used for early sedation after TBI due to its potential modulation of autonomic dysfunction. We examined early sedation patterns, as well as the association of dexmedetomidine exposure with clinical and functional outcomes among mechanically ventilated patients with moderate-severe TBI (msTBI) in the United States.

METHODS

We conducted a retrospective cohort study using data from the Premier dataset and identified a cohort of critically ill adult patients with msTBI who required MV from January 2016 to June 2020. msTBI was defined by head-neck abbreviated injury scale (AIS) values of 3 (serious), 4 (severe), and 5 (critical). We described early continuous sedative utilization patterns. Using propensity-matched models, we examined the association of early dexmedetomidine exposure (within 2 days of intensive care unit [ICU] admission) with the primary outcome of hospital mortality and the following secondary outcomes: hospital length of stay (LOS), days on MV, vasopressor use after the first 2 days of admission, hemodialysis (HD) after the first 2 days of admission, hospital costs, and discharge disposition. All medications, treatments, and procedures were identified using date-stamped hospital charge codes.

RESULTS

The study population included 19,751 subjects who required MV within 2 days of ICU admission. The patients were majority male and white. From 2016 to 2020, the annual percent utilization of dexmedetomidine increased from 4.05% to 8.60%. After propensity score matching, early dexmedetomidine exposure was associated with reduced odds of hospital mortality (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.47-0.74; P < .0001), increased risk for liberation from MV (hazard ratio [HR], 1.20; 95% CI, 1.09-1.33; P = .0003), and reduced LOS (HR, 1.11; 95% CI, 1.01-1.22; P = .033). Exposure to early dexmedetomidine was not associated with odds of HD (OR, 1.14; 95% CI, 0.73-1.78; P = .56), vasopressor utilization (OR, 1.10; 95% CI, 0.78-1.55; P = .60), or increased hospital costs (relative cost ratio, 1.98; 95% CI, 0.93-1.03; P = .66).

CONCLUSIONS

Dexmedetomidine is being utilized increasingly as a sedative for mechanically ventilated patients with msTBI. Early dexmedetomidine exposure may lead to improved patient outcomes in this population.

Efficacy of Continuous Infusion Ketamine for Analgosedation in the Medical Intensive Care Unit: A Propensity-Weighted Analysis

Background: Few randomized controlled trials have evaluated the use of ketamine vs opiate-based analgosedation. Methods: A retrospective cohort analysis of 169 mechanically ventilated patients admitted to the medical intensive care unit (MICU) at an academic medical center was conducted to evaluate efficacy of ketamine vs opiate-based analgosedation by comparing the percentage of time within target sedation range. The primary outcome was percentage of time within target sedation range (RASS -1 to +1) within first 72 hours of primary sedation initiation. Secondary outcomes including percentage of time under-sedated, over-sedated, and in coma; use of concomitant analgesic, sedative, and antipsychotic agents; presence of delirium; percentage of CPOT scores at goal; and hemodynamic effects were also evaluated. Results: After weighting, the mean percentage of time at RASS goal for ketamine patients was 43.0% compared to 41.4% for opiate-based sedation patients. Ketamine was not significantly non-inferior to opiate-based sedation for the mean percentage of time at RASS goal (P = .11). The median percentage of CPOT scores at goal was 13.3% higher in the ketamine group (P = .042). Patients in the ketamine group received significantly less additional sedative agents than the patients in the opiate-based sedation group. Conclusion: A similar percent of time at RASS goal was found for the ketamine analgosedation group compared to the opiate-based sedation group, although this did not reach statistical signicance for non-inferiority due to lack of statistical power. This study found a higher percentage of CPOT scores within goal with less additional sedative agents required compared to an opiate-based sedation regimen.

Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator

Background and purpose

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

Methods

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

Result

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

Conclusion

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

How to cite this article

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Association of early oral intake after extubation and independent activities of daily living at discharge among intensive care unit patients: A single centre retrospective cohort study

PURPOSE

We investigated the association between the time to first post-extubation oral intake, barriers to oral intake, and the rate of activities of daily living (ADL) independence at discharge (Barthel Index score <70).

METHOD

Consecutive patients admitted to the intensive care unit, aged ≥18 years, and mechanically ventilated for ≥48 hr were retrospectively enrolled. The time to first oral intake, barriers to oral intake, daily changes, and clinical outcomes were assessed. Multiple logistic regression analysis adjusted for baseline characteristics was used to determine the association between time to first post-extubation oral intake and ADL independence.

RESULT

Among the 136 patients, 74 were assigned to the ADL independence group and 62 to the dependence group. The time to first post-extubation oral intake was significantly associated with ADL independence (adjusted p = < 0.001) and was a predictor of ADL independence at discharge. Respiratory and dysphagia-related factors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.15-0.82, p = 0.015 and OR 0.07; CI 0.01-0.68, p = 0.021, respectively) were significantly associated with the ADL independence at discharge.

CONCLUSION

Respiratory and dysphagia-related factors, as barriers to the initiation of oral intake after extubation, were significantly associated with ADL independence at discharge.

Sinus Arrest Related to Dexmedetomidine Infusion in an Infant; a Case Report and Review of Current Literature

Background: Dexmedetomidine, an alpha 2 agonist, has emerged as a desirable sedative agent in the pediatric intensive care unit due to its minimal effect on respiratory status and reduction in delirium. Bradycardia and hypotension are common side effects, however there are emerging reports of more serious cardiovascular events, including sinus arrest and asystole. These case reports have been attributed to high vagal tone or underlying cardiac conduction dysfunction. Objectives: To describe the development of sinus arrest during sedation with dexmedetomidine in a patient without clinical features of high vagal tone, underlying cardiac conduction dysfunction, or intervening episodes of bradycardia. Case Presentation: An 11 month-old patient requiring sedation during mechanical ventilation for acute respiratory failure secondary to Adenovirus. To facilitate sedation, a dexmedetomidine infusion was initiated at .5 mcg/kg/hr and increased to maximum 1 mcg/kg/hr. Within 8 hours of initiating therapy, the patient had three episodes of sinus arrest. There was no intervening bradycardia between episodes and no further episodes occurred following discontinuation of dexmedetomidine. The patient did not have any clinical features associated with high vagal tone or underlying cardiac conduction dysfunction. Conclusions: As result of these findings, understanding risk factors for bradycardia, or more serious hemodynamic instability with dexmedetomidine infusions, is important to help identify high risk patients and weigh the associated risks and benefits of its administration.

Quetiapine Twice Daily Versus Bedtime Dosing in the Treatment of ICU Delirium

Background: Although guidelines recommend twice daily (BID) dosing of quetiapine for treatment of intensive care unit (ICU) delirium in most patients, once daily dosing at bedtime (HS) is commonly prescribed to reduce daytime somnolence. No studies have evaluated differences in outcomes. Objectives: To determine if twice daily vs bedtime dosing of quetiapine reduces the duration of ICU delirium. Methods: Retrospective analysis of ICU patients treated with twice daily vs bedtime dosing of quetiapine for ICU delirium. Health records were analyzed between January 1, 2017, and December 31, 2021. Exclusions included alcohol withdrawal, history of psychiatric conditions requiring medication, receipt of <24 hours of therapy, alternative dosing schedules, and death or transfer from the ICU <24 hours after beginning quetiapine. The primary outcome was recovery of delirium per Confusion Assessment Method (CAM-ICU). Secondary outcomes included lengths of stay, mechanical ventilation duration, in-hospital death, and QTc prolongation. Results: Baseline characteristics differed for sex (30.4% vs 61.1% female) and admission diagnosis (39% vs. 17% COVID-19, respectively). Time to delirium recovery was 3.5 days for BID vs 2.5 days for QHS dosing (P = .484). Secondary outcomes of ICU (16 vs. 19 days) and hospital (22 vs. 25 days) lengths of stay, duration of mechanical ventilation (10 vs. 14), delirium recovery (70% vs. 56%), in-hospital death (61% vs. 50%), and QTc prolongation did not differ significantly between groups. Conclusions: Twice daily vs bedtime dosing of quetiapine did not significantly alter delirium outcomes, suggesting similar efficacy. Larger sample sizes are needed to confirm these results.

Ketamine Use in Adult and Pediatric Patients Receiving Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review

Background: Analgesia and sedation are often critical elements of therapy for patients undergoing extracorporeal membrane oxygenation (ECMO). Aside from potential drug-drug interactions, the PK changes associated with ECMO make appropriate analgosedative selection challenging. Ketamine is less lipophilic and has lower protein binding than alternative agents, and may be less impacted by the PK changes during ECMO. Objective: To systematically identify all instances of ketamine use during ECMO support in the literature to elucidate associated efficacy and safety outcomes and prevalence of use, as well as commonly used dosing strategies and pharmacokinetic data. Methods: Web of Science, Cochrane Library, Scopus, Ovid MEDLINE, PubMed, and OVID Embase were searched through 02/2023 using keywords ketamine and ECMO or extracorporal life support (ECLS). Case reports, case series, and studies were included that had (1) original data, (2) included patients that were on ECMO and continuous infusion ketamine, and (3) reported pertinent ketamine related clinical endpoints or prevalence of use. Results: Of the 307 articles screened, 25 were identified as relevant and 11 met our inclusion criteria. Heterogeneity of patient population, ketamine indication, reported outcomes, and reported safety endpoints were identified in the included articles. Commonly reported information includes indications, pharmacokinetics, dosing, adverse effects and use in pediatrics for ketamine, and suspected opioid sparing effect. Conclusion: Our review has found a lack of consistency in reporting and results in adult and pediatric patients. Increased consistency in reporting and larger studies are required to increase our knowledge of ketamine use in both the adult and pediatric patient population.

Characterization of Awareness and Depth of Blockade During Neuromuscular Blockade Infusions in Critically Ill Children

OBJECTIVE

The Society of Critical Care Medicine released the first guideline for the prevention and -management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients but offered conditional recommendations for sedation practices and monitoring during neuromuscular blockade. This study aimed to characterize sedation practices, patient awareness, and depth of blockade with neuromuscular blocking agent (NMBA) infusion administration in a single pediatric and cardiac intensive care unit.

METHODS

This retrospective chart review of critically ill pediatric patients queried orders for continuous infusion NMBA. Analgosedation agent(s), dose, and dose changes were assessed, along with depth of blockade monitoring via Train of Four (TOF) and awareness via Richmond Agitation and Sedation Scale (RASS).

RESULTS

Thirty-one patients were included, of which 27 (87%) had a documented sedation agent infusing at time of NMBA initiation and 17 patients (54%) were receiving analgesia. The most common agents used were rocuronium (n = 28), dexmedetomidine (n = 23), and morphine (n = 14). RASS scores were captured in all patients; however, 9 patients (29%) had recorded positive scores and 1 patient (3%) never achieved negative scores. TOF was only captured for 11 patients (35%), with majority of the scores being 0 or 4.

CONCLUSIONS

Majority of the study population did not receive recommended depth of blockade monitoring via TOF. Similarly, RASS scores were not consistent with deep sedation in half of the patients. The common use of dexmedetomidine as a single sedation agent calls into question the appropriateness of current sedation practices during NMBA continuous infusions.

Association Between Pupil Light Reflex and Delirium in Adults With Traumatic Brain Injury: Preliminary Findings

ABSTRACT

BACKGROUND: Delirium is a common neurological complication in patients admitted to the intensive care unit (ICU) after moderate to severe traumatic brain injury (TBI). Although current clinical guidelines prioritize delirium prevention, no specific tool is tailored to detect early signs of delirium in TBI patients. This preliminary 2-phase observational study investigated the correlation between the pupillary light reflex (PLR), measured with a pupillometer during mechanical ventilation, and the development of postextubation delirium in TBI patients. METHODS: A convenience sample of 26 adults with moderate to severe TBI under mechanical ventilation was recruited during their ICU stay. In phase I, PLR measurements were performed in the first 3 days of ICU admission using automated infrared pupillometry. In phase II, 2 raters independently extracted delirium data in the 72 hours post extubation period from medical records. Delirium was confirmed with a documented medical diagnosis. Point-biserial correlations ( rpb ) were used to examine the association between PLR scores and the presence of postextubation delirium. Student t tests were also performed to compare mean PLR scores between patients with and without delirium. RESULTS: Ten TBI patients (38%) were diagnosed with postextubation delirium, whereas 16 (62%) were not. Significant correlations between delirium and 2 PLR variables were found: pupil constriction percentage ( rpb (24) = -0.526, P = .006) and constriction velocity ( rpb (24) = -0.485, P = .012). The t test also revealed a significant difference in constriction percentage and velocity scores between TBI patients with and without delirium ( P ≤ .01). CONCLUSION: Our findings suggest that the use of pupillometry in the first 3 days of mechanical ventilation during an ICU stay may help identify TBI patients at risk for delirium after extubation. Although further research is necessary to support its validity, this technological tool may enable ICU nurses to better screen TBI patients for delirium and prevent its development.

Pragmatic approach to mobilizing individuals with critical illness due to COVID-19: clinical perspective

PURPOSE

To provide pragmatic guidance for acute rehabilitation management and implementation of early mobility for individuals with critical illness due to COVID-19.

METHODS

Clinical perspective developed through reflective clinical practice and narrative review of best available evidence.

RESULTS

Current clinical practice guidelines do not provide guidance for implementation of early mobility interventions for individuals with critical illness due to COVID-19 who require enhanced ventilatory support or support of inhaled pulmonary artery vasodilators. Many individuals who may benefit from implementation of early mobility interventions are excluded by strict interpretation of current guidelines.

CONCLUSIONS

Risk vs benefit of implementing early mobility interventions in individuals with critical illness due to COVID-19 can be mitigated through coordinated efforts of interdisciplinary teams to promote shared decision-making through therapeutic alliances with patients and their families. Clinicians must clearly define the goals of care, understand the limitations of monitoring equipment in the intensive care unit, prepare to titrate levels of oxygen based on an individual's physiologic response to mobility interventions, and help individuals maintain external goal-directed focus of attention to optimize outcomes of early mobility interventions.

Postintensive care syndrome in patients and family members. Analysis of COVID-19 and non-COVID-19 cohorts, with face-to-face follow-up at three months and one year

OBJECTIVE

Compare prevalence and profile of post-intensive care patient (P-PICS) and family/caregiver (F-PICS) syndrome in two cohorts (COVID and non-COVID) and analyse risk factors for P-PICS.

DESIGN

Prospective, observational cohort (March 2018-2023), follow-up at three months and one year.

SETTING

14-bed polyvalent Intensive Care Unit (ICU), Level II Hospital.

PATIENTS OR PARTICIPANTS

265 patients and 209 relatives. Inclusion criteria patients: age > 18 years, mechanical ventilation > 48 h, ICU stay > 5 days, delirium, septic shock, acute respiratory distress syndrome, cardiac arrest. Inclusion criteria family: those who attended.

INTERVENTIONS

Follow-up 3 months and 1 year after hospital discharge.

MAIN VARIABLES OF INTEREST

Patients: sociodemographic, clinical, evolutive, physical, psychological and cognitive alterations, dependency degree and quality of life. Main caregivers: mental state and physical overload.

RESULTS

64.9% PICS-P, no differences between groups. COVID patients more physical alterations than non-COVID (P = .028). These more functional deterioration (P = .005), poorer quality of life (P = .003), higher nutritional alterations (P = .004) and cognitive deterioration (P < .001). 19.1% PICS-F, more frequent in relatives of non-COVID patients (17.6% vs. 5.5%; P = .013). Independent predictors of PICS-P: first years of the study (OR: 0.484), higher comorbidity (OR: 1.158), delirium (OR: 2.935), several reasons for being included (OR: 3.171) and midazolam (OR: 4.265).

CONCLUSIONS

Prevalence PICS-P and PICS-F between both cohorts was similar. Main factors associated with the development of SPCI-P were: higher comorbidity, delirium, midazolan, inclusion for more than one reason and during the first years.

Strategies to Improve Sleep Quality in Intensive Care Unit Patients

BACKGROUND

Patients in intensive care units are exposed to many factors that can negatively affect the quality of their sleep.

OBJECTIVE

To describe the latest findings regarding sleep quality improvement in intensive care unit patients.

METHODS

An integrative literature review was conducted in the CINAHL, PubMed, Cochrane Library, and MEDLINE databases in April and May 2023. The following keywords were used: intensive care units, promotion, sleep quality, and sleep. The Critical Appraisal Skills Programme tool was used to assess the quality of individual studies.

RESULTS

Of 159 articles identified, 10 were included in the final analysis. The findings were grouped into 4 thematic categories: consequences of poor sleep quality, factors affecting sleep quality, pharmacologic ways to improve sleep quality, and nonpharmacologic ways to improve sleep quality.

DISCUSSION

Various pharmacologic and nonpharmacologic treatments are used in clinical settings. Nonpharmacologic interventions include sleep masks, earplugs, reductions in alarm volume, and reductions in nighttime interventions. Relaxation techniques include aromatherapy, music therapy, and acupressure.

CONCLUSIONS

The most effective way to improve sleep for intensive care unit patients is to use a combination of pharmacologic and nonpharmacologic interventions. Among the latter, the use of earplugs and sleep masks is simplest.

A Case Report and Review of the Literature of ICU Delirium

This case report focuses on what patients and family members may experience when a neurological trauma transpires and resultant intensive care (ICU) delirium occurs. It is the personal account of the patient (A.B.) and spouse's (R.G.B.) perspectives when the patient (A.B) suffered a vertebral artery aneurysm and hemorrhage and experienced intensive care unit (ICU) delirium after being in the ICU for 22 days. This case report provides the patient's and spouse's perspectives regarding delirium, i.e., A.B.'s inability to discern reality, loss of memory, paranoia and hallucinations, agency and recovery, post-ICU syndrome, and post-traumatic stress disorder (PTSD). Clinical diagnosis by the neurosurgeon indicated delirium, with treatment consisting of sleep sedation and uninterrupted sleep. A.B. was able to regain consciousness yet experienced post-traumatic stress disorder up to one year afterward. Consistent family participation in the patient's delirium care is crucial. Family member care and family-centered strategies are provided with implications for future research and health care.

Effect of occupational therapy on the occurrence of delirium in critically ill patients: a systematic review and meta-analysis

Aim

Delirium poses a major challenge to global health care, yet there is currently a dearth of single effective interventions or medications. Particularly, addressing delirium induced by critical illness is a complex process. Occupational therapy is considered to have a high potential for use in the prevention of delirium, as it involves both cognitive training and training in ADL. To comprehensively analyze the effect of occupational therapy on delirium prevention, we evaluated the effects of occupational therapy vs. standard non-pharmacological prevention on incidence and duration of delirium, clinical outcomes and rehabilitation outcomes in critically ill patients.

Methods

The data sources, including PubMed/Medline, Web of Science, EMBASE, and Cochrane Library, were comprehensively searched from their inception until 15 October 2023. Following the PICOS principle, a systematic screening of literature was conducted to identify relevant studies. Subsequently, the quality assessment was performed to evaluate the risk of bias in the included literature. Finally, outcome measures from each study were extracted and comprehensive analysis was conducted using Review Manager 5.4.

Results

A total of four clinical trials met the selection criteria. The pooled analysis indicated no significant difference in the incidence and duration of delirium between the OT group and standard non-pharmacological interventions. A comprehensive analysis of clinical outcomes revealed that OT did not significantly reduce the length of hospital stay or ICU stay. Meanwhile, there was no significant difference in mortality rates between the two groups. It is noteworthy that although grip strength levels did not exhibit significant improvement following OT intervention, there were obvious enhancements observed in ADL and MMSE scores.

Conclusion

Although occupational therapy may not be the most effective in preventing delirium, it has been shown to significantly improve ADL and cognitive function among critically ill patients. Therefore, we contend that occupational therapy is a valuable component of a comprehensive multidisciplinary approach to managing delirium. In the future, high-quality researches are warranted to optimize the implementation of occupational therapy interventions for delirium prevention and further enhance their benefits for patients.

Early physical rehabilitation dosage in the intensive care unit associates with hospital outcomes after critical COVID-19

OBJECTIVE

To examine the relationship between physical rehabilitation parameters including an approach to quantifying dosage with hospital outcomes for patients with critical COVID-19.

DESIGN

Retrospective practice analysis from March 5, 2020, to April 15, 2021.

SETTING

Intensive care units (ICU) at four medical institutions.

PATIENTS

n = 3780 adults with ICU admission and diagnosis of COVID-19.

INTERVENTIONS

We measured the physical rehabilitation treatment delivered in ICU and patient outcomes: (1) mortality; (2) discharge disposition; and (3) physical function at hospital discharge measured by the Activity Measure-Post Acute Care (AM-PAC) "6-Clicks" (6-24, 24 = greater functional independence). Physical rehabilitation dosage was defined as the average mobility level scores in the first three sessions (a surrogate measure of intensity) multiplied by the rehabilitation frequency (PT + OT frequency in hospital).

MEASUREMENTS AND MAIN RESULTS

The cohort was a mean 64 ± 16 years old, 41% female, mean BMI of 32 ± 9 kg/m2 and 46% (n = 1739) required mechanical ventilation. For 2191 patients who received rehabilitation, the dosage and AM-PAC at discharge were moderately, positively associated (Spearman's rho [r] = 0.484, p < 0.001). Multivariate linear regression (model adjusted R2 = 0.68, p < 0.001) demonstrates mechanical ventilation (β = - 0.86, p = 0.001), average mobility score in first three sessions (β = 2.6, p < 0.001) and physical rehabilitation dosage (β = 0.22, p = 0.001) were predictive of AM-PAC scores at discharge when controlling for age, sex, BMI, and ICU LOS.

CONCLUSIONS

Greater physical rehabilitation exposure early in the ICU is associated with better physical function at hospital discharge.

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

BACKGROUND

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

AIM

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

METHODS

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

RESULTS

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43-100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34-66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0-10 cm), 5 (2-7) and 6 (2.3-7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0-6 cm), 8 (5-10) and 4 (3-5) respectively.

CONCLUSION

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

Effect of esketamine combined with dexmedetomidine on delirium in sedation for mechanically ventilated ICU patients: protocol for a nested substudy within a randomized controlled trial

BACKGROUND

Use of sedatives and analgesics is associated with the occurrence of delirium in critically ill patients receiving mechanical ventilation. Dexmedetomidine reduces the occurrence of delirium but may cause hypotension, bradycardia, and insufficient sedation. This substudy aims to determine whether the combination of esketamine with dexmedetomidine can reduce the side effects and risk of delirium than dexmedetomidine alone in mechanically ventilated patients.

METHODS

This single-center, randomized, active-controlled, superiority trial will be conducted at The First Affiliated Hospital of Nanjing Medical University. A total of 134 mechanically ventilated patients will be recruited and randomized to receive either dexmedetomidine alone or esketamine combined with dexmedetomidine, until extubation or for a maximum of 14 days. The primary outcome is the occurrence of delirium, while the second outcomes include the number of delirium-free days; subtype, severity, and duration of delirium; time to first onset of delirium; total dose of vasopressors and antipsychotics; duration of mechanical ventilation; ICU and hospital length of stay (LOS); accidental extubation, re-intubation, re-admission; and mortality in the ICU at 14 and 28 days.

DISCUSSION

There is an urgent need for a new combination regimen of dexmedetomidine due to its evident side effects. The combination of esketamine and dexmedetomidine has been applied throughout the perioperative period. However, there is still a lack of evidence on the effects of this regimen on delirium in mechanically ventilated ICU patients. This substudy will evaluate the effects of the combination of esketamine and dexmedetomidine in reducing the risk of delirium for mechanically ventilated patients in ICU, thus providing evidence of this combination to improve the short-term prognosis. The study protocol has obtained approval from the Medical Ethics Committee (ID: 2022-SR-450).

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05466708, registered on 20 July 2022.

Preventive Effects of Ramelteon, Suvorexant, and Lemborexant on Delirium in Hospitalized Patients With Physical Disease: A Retrospective Cohort Study

BACKGROUND

New sleep-inducing drugs (eg, ramelteon, suvorexant, and lemborexant) have been shown to prevent delirium in high-risk groups. However, no single study has simultaneously evaluated the delirium-preventing effects of all novel sleep-inducing drugs in hospitalized patients. Therefore, this study aimed to clarify the relationship between sleep-inducing drugs and delirium prevention in patients hospitalized in general medical-surgical settings for nonpsychiatric conditions who underwent liaison interventions for insomnia.

METHODS

This retrospective cohort study included patients treated in general medical-surgical settings for nonpsychiatric conditions with consultation-liaison psychiatry consult for insomnia. Delirium was diagnosed by fully certified psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders 5 th edition. The following items were retrospectively examined from medical records as factors related to delirium development: type of sleep-inducing drugs, age, sex, and delirium risk factors. The risk factors of delirium development were calculated using adjusted odds ratios (aORs) via multivariate logistic regression analysis.

RESULTS

Among the 710 patients analyzed, 257 (36.2%) developed delirium. Suvorexant (aOR, 0.61; 95% confidence interval [CI], 0.40-0.94; P = 0.02) and lemborexant (aOR, 0.23; 95% CI, 0.14-0.39; P < 0.0001) significantly reduced the risk of developing delirium. Benzodiazepines (aOR, 1.90; 95% CI, 1.15-3.13; P = 0.01) significantly increased this risk. Ramelteon (aOR, 1.30; 95% CI, 0.84-2.01; P = 0.24) and Z-drugs (aOR, 1.27; 95% CI, 0.81-1.98; P = 0.30) were not significantly associated with delirium development.

CONCLUSIONS

The use of suvorexant and lemborexant may prevent delirium in patients with a wide range of medical conditions.

Mitigating Intensive Care Unit Noise: Design-Led Modeling Solutions, Calculated Acoustic Outcomes, and Cost Implications

OBJECTIVES, PURPOSE, OR AIM

The study aimed to decrease noise levels in the ICU, anticipated to have adverse effects on both patients and staff, by implementing enhancements in acoustic design.

BACKGROUND

Recognizing ICU noise as a significant disruptor of sleep and a potential hindrance to patient recovery, this study was conducted at a 40-bed ICU in Fiona Stanley Hospital in Perth, Australia.

METHODS

A comprehensive mixed-methods approach was employed, encompassing surveys, site analysis, and acoustic measurements. Survey data highlighted the importance of patient sleep quality, emphasizing the negative impact of noise on work performance, patient connection, and job satisfaction. Room acoustics analysis revealed noise levels ranging from 60 to 90 dB(A) in the presence of patients, surpassing sleep disruption criteria.

RESULTS

Utilizing an iterative 3D design modeling process, the study simulated significant acoustic treatment upgrades. The design integrated effective acoustic treatments within patient rooms, aiming to reduce noise levels and minimize transmission to adjacent areas. Rigorous evaluation using industry-standard acoustic software highlights the design's efficacy in reducing noise transmission in particular. Additionally, cost implications were examined, comparing standard ICU construction with acoustically treated options for new construction and refurbishment projects.

CONCLUSIONS

This study provides valuable insights into design-based solutions for addressing noise-related challenges in the ICU. While the focus is on improving the acoustic environment by reducing noise levels and minimizing transmission to adjacent areas. It is important to clarify that direct measurements of patient outcomes were not conducted. The potential impact of these solutions on health outcomes, particularly sleep quality, remains a crucial aspect for consideration.

Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States

OBJECTIVES

To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients.

DESIGN

Retrospective, multicenter, observational study using the Premier AI Healthcare Database.

SETTING

The study was conducted in U.S. ICUs.

PATIENTS

Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU.

CONCLUSIONS

In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.

Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study

BACKGROUND

Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive.

METHODS

Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles.

RESULTS

A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16).

CONCLUSIONS

In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive.

EDITOR’S PERSPECTIVE

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study

Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.

Benzodiazepine Dependence After Cardiothoracic Intensive Care: A Nationwide Cohort Study

BACKGROUND

This study aimed to describe benzodiazepine use after cardiothoracic intensive care unit (ICU) care, including factors associated with new long-term high-potency benzodiazepine use after critical care, and to determine whether benzodiazepine use is associated with an increased risk of death.

METHODS

A nationwide retrospective cohort study was conducted of all cardiothoracic ICU patients in Sweden between 2010 and 2018. All patients older than 18 years who survived the first 3 months after admission to a cardiothoracic ICU were eligible for inclusion. A total of 36,135 patients were screened, and 4163 were ineligible.

RESULTS

In the final study cohort of 31,972 benzodiazepine-naive patients admitted to critical care, 578 patients had persistent high-potency benzodiazepine use. The proportion of new persistent benzodiazepine users was 5% in the first 3 months after ICU care, followed by a decline to a consistent level of 2% at 2 years of follow-up. Factors associated with persistent benzodiazepine use included higher age, female sex, psychiatric and somatic comorbidities, substance abuse, and preadmission opioid and low-potency benzodiazepine use. Adjusted hazard ratio for death 6 to 18 months after admission for new persistent benzodiazepine users was 2.2 (95% CI, 1.5-3.1; P < .001).

CONCLUSIONS

High-potency benzodiazepine consumption is increased 2 years after admission to cardiothoracic ICU care despite lack of support for long-term use of benzodiazepines. Being older and female, prior opioid use, and comorbid conditions were among risk factors for persistent benzodiazepine use. Persistent benzodiazepine users had an increased risk of death.