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Heavner MS, Louzon PR, Gorman EF, Landolf KM, Ventura D, Devlin JW. A Rapid Systematic Review of Pharmacologic Sleep Promotion Modalities in the Intensive Care Unit. J Intensive Care Med 2024; 39:28-43. [PMID: 37403460 DOI: 10.1177/08850666231186747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Background: The Society of Critical Care Medicine Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep recommend protocolized non-pharmacologic sleep improvement. Pharmacologic interventions are frequently initiated to promote sleep but the evidence supporting these strategies remains controversial. Purpose: To systematically search and synthesize evidence evaluating pharmacologic sleep promotion modalities in critically ill adults. Methods: A rapid systematic review protocol was used to search Medline, Cochrane Library, and Embase for reports published through October 2022. We included randomized controlled trials (RCTs) and before-and-after cohort studies evaluating pharmacologic modalities intended to improve sleep in adult intensive care unit (ICU) patients. Sleep-related endpoints were the primary outcome of interest. Study and patient characteristics and relevant safety and non-sleep outcome data were also collected. The Cochrane Collaboration Risk of Bias or Risk of Bias in Non-Randomized Studies of Interventions were used to assess the risk of bias for all included studies. Results: Sixteen studies (75% RCTs) enrolling 2573 patients were included; 1207 patients were allocated to the pharmacologic sleep intervention. Most studies utilized dexmedetomidine (7/16; total n = 505 patients) or a melatonin agonist (6/16; total n = 592 patients). Only half of the studies incorporated a sleep promotion protocol as standard of care. Most (11/16, 68.8%) studies demonstrated a significant improvement in ≥1 sleep endpoint (n = 5 dexmedetomidine, n = 3 melatonin agonists, n = 2 propofol/benzodiazepines). Risk of bias was generally low for RCTs and moderate-severe for cohort studies. Conclusions: Dexmedetomidine and melatonin agonists are the most studied pharmacologic sleep promotion modalities, but current evidence does not support their routine administration in the ICU to improve sleep. Future RCTs evaluating pharmacologic modalities for ICU sleep should consider patients' baseline and ICU risks for disrupted sleep, incorporate a non-pharmacologic sleep improvement protocol, and evaluate the effect of these medication interventions on circadian rhythm, physiologic sleep, patient-perceived sleep quality, and delirium.
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Affiliation(s)
- Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Patricia R Louzon
- Critical Care and Emergency Department, AdventHealth Orlando, Orlando, FL, USA
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | - Kaitlin M Landolf
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Davide Ventura
- Department of Cardiology, AdventHealth Orlando, Orlando, FL, USA
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Northeastern University, Boston, MA, USA
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Wu TT, Vernooij LM, Duprey MS, Zaal IJ, Gélinas C, Devlin JW, Slooter AJC. Relationship Between Pain and Delirium in Critically Ill Adults. Crit Care Explor 2023; 5:e1012. [PMID: 38053750 PMCID: PMC10695586 DOI: 10.1097/cce.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVES Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium. DESIGN Prospective cohort study. SETTING A 32-bed academic medical-surgical ICU. PATIENTS Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated. RESULTS Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose. CONCLUSIONS After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.
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Affiliation(s)
- Ting Ting Wu
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Matthew S Duprey
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Irene J Zaal
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Intensive Care Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
- Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - John W Devlin
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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3
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Yu H, Simpao AF, Ruiz VM, Nelson O, Muhly WT, Sutherland TN, Gálvez JA, Pushkar MB, Stricker PA, Tsui F(R. Predicting pediatric emergence delirium using data-driven machine learning applied to electronic health record dataset at a quaternary care pediatric hospital. JAMIA Open 2023; 6:ooad106. [PMID: 38098478 PMCID: PMC10719078 DOI: 10.1093/jamiaopen/ooad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
Objectives Pediatric emergence delirium is an undesirable outcome that is understudied. Development of a predictive model is an initial step toward reducing its occurrence. This study aimed to apply machine learning (ML) methods to a large clinical dataset to develop a predictive model for pediatric emergence delirium. Materials and Methods We performed a single-center retrospective cohort study using electronic health record data from February 2015 to December 2019. We built and evaluated 4 commonly used ML models for predicting emergence delirium: least absolute shrinkage and selection operator, ridge regression, random forest, and extreme gradient boosting. The primary outcome was the occurrence of emergence delirium, defined as a Watcha score of 3 or 4 recorded at any time during recovery. Results The dataset included 54 776 encounters across 43 830 patients. The 4 ML models performed similarly with performance assessed by the area under the receiver operating characteristic curves ranging from 0.74 to 0.75. Notable variables associated with increased risk included adenoidectomy with or without tonsillectomy, decreasing age, midazolam premedication, and ondansetron administration, while intravenous induction and ketorolac were associated with reduced risk of emergence delirium. Conclusions Four different ML models demonstrated similar performance in predicting postoperative emergence delirium using a large pediatric dataset. The prediction performance of the models draws attention to our incomplete understanding of this phenomenon based on the studied variables. The results from our modeling could serve as a first step in designing a predictive clinical decision support system, but further optimization and validation are needed. Clinical trial number and registry URL Not applicable.
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Affiliation(s)
- Han Yu
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | - Victor M Ruiz
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Tori N Sutherland
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Julia A Gálvez
- Department of Anesthesiology & Critical Care, Children’s Hospital & Medical Center, Omaha, NE 68114, United States
| | - Mykhailo B Pushkar
- Department of Anesthesiology, Intensive Care and Pediatric Anesthesiology, Kharkiv National Medical University, Kharkiv, 61022, Ukraine
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Fuchiang (Rich) Tsui
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, United States
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, United States
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Malone D, Costin BN, MacElroy D, Al‐Hegelan M, Thompson J, Bronshteyn Y. Phenobarbital versus benzodiazepines in alcohol withdrawal syndrome. Neuropsychopharmacol Rep 2023; 43:532-541. [PMID: 37368937 PMCID: PMC10739082 DOI: 10.1002/npr2.12347] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 06/29/2023] Open
Abstract
AIM Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment for alcohol withdrawal syndrome (AWS). Currently, existing research offers only modest guidance on the safety and effectiveness of phenobarbital in managing AWS in hospital settings. The study objective was to assess if a phenobarbital protocol for the treatment of AWS reduces respiratory complications when compared to a more traditionally used benzodiazepine protocol. METHODS A retrospective cohort study analyzing adults who received either phenobarbital or benzodiazepine-based treatment for AWS over a 4-year period, 2015-2019, in a community teaching hospital in a large academic medical system. RESULTS A total of 147 patient encounters were included (76 phenobarbital and 71 benzodiazepine). Phenobarbital was associated with a significantly decreased risk of respiratory complications, defined by the occurrence of intubation (15/76 phenobarbital [20%] vs. 36/71 benzodiazepine [51%]) and decreased incidence of the requirement of six or greater liters of oxygen when compared with benzodiazepines (10/76 [13%] vs. 28/71 [39%]). There was a significantly higher incidence of pneumonia in benzodiazepine patients (15/76 [20%] vs. 33/71 [47%]). Mode Richmond Agitation Sedation Scale (RASS) scores were more frequently at goal (0 to -1) between 9 and 48 h after the loading dose of study medication for phenobarbital patients. Median hospital and ICU length of stay were significantly shorter for phenobarbital patients when compared with benzodiazepine patients (5 vs. 10 days and 2 vs. 4 days, respectively). CONCLUSION Parenteral phenobarbital loading doses with an oral phenobarbital tapered protocol for AWS resulted in decreased risk of respiratory complications when compared to standard treatment with benzodiazepines.
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Affiliation(s)
| | - Blair N. Costin
- Duke Regional HospitalDurhamNorth CarolinaUSA
- Duke University HospitalDurhamNorth CarolinaUSA
| | | | - Mashael Al‐Hegelan
- Duke Regional HospitalDurhamNorth CarolinaUSA
- Duke University HospitalDurhamNorth CarolinaUSA
| | - Julie Thompson
- Duke University School of NursingDurhamNorth CarolinaUSA
| | - Yuriy Bronshteyn
- Duke University HospitalDurhamNorth CarolinaUSA
- Durham Veterans Health AdministrationDurhamNorth CarolinaUSA
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5
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Eriksson J, Rimes-Stigare C, Rysz S, von Oelreich E. Benzodiazepine Dependence After Cardiothoracic Intensive Care: A Nationwide Cohort Study. Ann Thorac Surg 2023:S0003-4975(23)01162-1. [PMID: 37977256 DOI: 10.1016/j.athoracsur.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/26/2023] [Accepted: 11/06/2013] [Indexed: 11/19/2023]
Abstract
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.
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Affiliation(s)
- Jesper Eriksson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
| | - Claire Rimes-Stigare
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Rysz
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden; Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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6
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Dhungel O, Shrestha N, Sharma P, Pathak P, Sapkota N. Delirious Mania in an Elderly, Challenges in Diagnosis and Treatment. Case Rep Psychiatry 2023; 2023:8984062. [PMID: 38028755 PMCID: PMC10667045 DOI: 10.1155/2023/8984062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
Delirious mania is an acute neurobehavioral syndrome which can have the features of mania, delirium, psychosis and catatonia. There are no diagnostic and treatment guidelines of delirious mania which can lead to delayed treatment, increasing morbidity and mortality. The primary goal of this report is to raise awareness among healthcare professionals and improve patient outcomes for this potentially life-threatening condition. In this case report, we present an octogenarian female, a case of bipolar disorder, current episode manic, who had impaired orientation, delusion of persecution, and altered sleep-wake cycle. She was treated with a combination of mood stabilizer and antipsychotic and discharged after 24 days of admission.
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Affiliation(s)
- Omkar Dhungel
- Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
| | - Najina Shrestha
- Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
| | - Pawan Sharma
- Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
| | - Pankaj Pathak
- Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
| | - Nidesh Sapkota
- Department of Psychiatry, Patan Academy of Health Sciences, School of Medicine, Lalitpur, Nepal
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7
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Wen J, Ding X, Liu C, Jiang W, Xu Y, Wei X, Liu X. A comparation of dexmedetomidine and midazolam for sedation in patients with mechanical ventilation in ICU: A systematic review and meta-analysis. PLoS One 2023; 18:e0294292. [PMID: 37963140 PMCID: PMC10645332 DOI: 10.1371/journal.pone.0294292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The use of dexmedetomidine rather than midazolam may improve ICU outcomes. We summarized the available recent evidence to further verify this conclusion. METHODS An electronic search of PubMed, Medline, Embase, Cochrane Library, and Web of Science was conducted. Risk ratios (RR) were used for binary categorical variables, and for continuous variables, weighted mean differences (WMD) were calculated, the effect sizes are expressed as 95% confidence intervals (CI), and trial sequential analysis was performed. RESULTS 16 randomized controlled trials were enrolled 2035 patients in the study. Dexmedetomidine as opposed to midazolam achieved a shorter length of stay in ICU (MD = -2.25, 95%CI = -2.94, -1.57, p<0.0001), lower risk of delirium (RR = 0.63, 95%CI = 0.50, 0.81, p = 0.0002), and shorter duration of mechanical ventilation (MD = -0.83, 95%CI = -1.24, -0.43, p<0.0001). The association between dexmedetomidine and bradycardia was also found to be significant (RR 2.21, 95%CI 1.31, 3.73, p = 0.003). We found no difference in hypotension (RR = 1.44, 95%CI = 0.87, 2.38, P = 0.16), mortality (RR = 1.02, 95%CI = 0.83, 1.25, P = 0.87), neither in terms of adverse effects requiring intervention, hospital length of stay, or sedation effects. CONCLUSIONS Combined with recent evidence, compared with midazolam, dexmedetomidine decreased the risk of delirium, mechanical ventilation, length of stay in the ICU, as well as reduced patient costs. But dexmedetomidine could not reduce mortality and increased the risk of bradycardia.
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Affiliation(s)
- Jiaxuan Wen
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xueying Ding
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Chen Liu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Wenyu Jiang
- School of Public Health, Weifang Medical University, Weifang, P. R. China
| | - Yingrui Xu
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xiuhong Wei
- School of Nursing, Weifang Medical University, Weifang, P. R. China
| | - Xin Liu
- Department of Neonatology, Weifang People’s Hospital, P. R. China
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8
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Dresden SM. Optimizing the Care of Persons Living with Dementia in the Emergency Department. Clin Geriatr Med 2023; 39:599-617. [PMID: 37798067 DOI: 10.1016/j.cger.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies and Outcomes Research, 211 East Ontario Street, Suite 200, Chicago, IL 60611, USA.
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Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
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Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Sonneville R, Benghanem S, Jeantin L, de Montmollin E, Doman M, Gaudemer A, Thy M, Timsit JF. The spectrum of sepsis-associated encephalopathy: a clinical perspective. Crit Care 2023; 27:386. [PMID: 37798769 PMCID: PMC10552444 DOI: 10.1186/s13054-023-04655-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/19/2023] [Indexed: 10/07/2023] Open
Abstract
Sepsis-associated encephalopathy is a severe neurologic syndrome characterized by a diffuse dysfunction of the brain caused by sepsis. This review provides a concise overview of diagnostic tools and management strategies for SAE at the acute phase and in the long term. Early recognition and diagnosis of SAE are crucial for effective management. Because neurologic evaluation can be confounded by several factors in the intensive care unit setting, a multimodal approach is warranted for diagnosis and management. Diagnostic tools commonly employed include clinical evaluation, metabolic tests, electroencephalography, and neuroimaging in selected cases. The usefulness of blood biomarkers of brain injury for diagnosis remains limited. Clinical evaluation involves assessing the patient's mental status, motor responses, brainstem reflexes, and presence of abnormal movements. Electroencephalography can rule out non-convulsive seizures and help detect several patterns of various severity such as generalized slowing, epileptiform discharges, and triphasic waves. In patients with acute encephalopathy, the diagnostic value of non-contrast computed tomography is limited. In septic patients with persistent encephalopathy, seizures, and/or focal signs, magnetic resonance imaging detects brain injury in more than 50% of cases, mainly cerebrovascular complications, and white matter changes. Timely identification and treatment of the underlying infection are paramount, along with effective control of systemic factors that may contribute to secondary brain injury. Upon admission to the ICU, maintaining appropriate levels of oxygenation, blood pressure, and metabolic balance is crucial. Throughout the ICU stay, it is important to be mindful of the potential neurotoxic effects associated with specific medications like midazolam and cefepime, and to closely monitor patients for non-convulsive seizures. The potential efficacy of targeted neurocritical care during the acute phase in optimizing patient outcomes deserves to be further investigated. Sepsis-associated encephalopathy may lead to permanent neurologic sequelae. Seizures occurring in the acute phase increase the susceptibility to long-term epilepsy. Extended ICU stays and the presence of sepsis-associated encephalopathy are linked to functional disability and neuropsychological sequelae, underscoring the necessity for long-term surveillance in the comprehensive care of septic patients.
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Affiliation(s)
- Romain Sonneville
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France.
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France.
| | - Sarah Benghanem
- Department of Intensive Care Medicine, Cochin University Hospital, APHP, 75014, Paris, France
| | - Lina Jeantin
- Department of Neurology, Rothschild Foundation, Paris, France
| | - Etienne de Montmollin
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Marc Doman
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Augustin Gaudemer
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department Radiology, Bichat-Claude Bernard University Hospital, APHP, 75018, Paris, France
| | - Michael Thy
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
| | - Jean-François Timsit
- INSERM UMR 1137, Université Paris Cité, 75018, Paris, France
- Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, APHP, 46 Rue Henri Huchard, 75877, Paris Cedex, France
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11
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Bohny P, Boettger S, Jenewein J. Dose-dependent QTc interval prolongation under haloperidol and pipamperone in the management of delirium in a naturalistic setting. Front Psychiatry 2023; 14:1257755. [PMID: 37854439 PMCID: PMC10579563 DOI: 10.3389/fpsyt.2023.1257755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/20/2023] [Indexed: 10/20/2023] Open
Abstract
Objective Delirium is an acute, life-threatening neuropsychiatric disorder frequently occurring among hospitalized patients. Antipsychotic medications are often recommended for delirium management but are associated with cardiovascular risks. This study aimed to investigate the frequency and magnitude of QTc interval prolongation and clinically relevant side effects occurring in delirium patients managed with haloperidol and/or pipamperone. Methods This descriptive retrospective cohort study evaluated 102 elderly (mean age: 73.2 years) inpatients with delirium treated with either haloperidol, pipamperone, a combination of both, or neither in a naturalistic setting over the course of up to 20 days or until the end of delirium. Results A total of 86.3% of patients were treated with haloperidol and/or pipamperone at a mean daily haloperidol-equipotent dose of 1.2 ± 1 mg. Non-cardiovascular side effects were registered in 2.9% of all patients and correlated with higher scores on the Delirium Observation Screening Scale. They did not occur more frequently under antipsychotic treatment. The frequency of QTc interval prolongation was comparably common among all groups, but prolongation magnitude was higher under antipsychotic treatment. It was positively correlated with antipsychotic dosage and the total number of QTc interval-prolonging substances administered. Critical QTc interval prolongation was registered in 21.6% (n = 19) of patients in the group treated with antipsychotics compared to 14.3% (n = 2) of patients in the unmedicated group; however, the difference was not statistically significant. Polypharmacy was associated with a higher risk of critical QTc interval prolongation and increased mortality during delirium. Conclusion Delirium treatment with haloperidol and/or pipamperone was not associated with a higher risk of QTc-interval prolongation in this naturalistic patient sample but was greater in magnitude and correlated with equipotent dosage and the number of QT interval-prolonging substances used. Polypharmacy was associated with higher mortality and increased risk of critical QTc prolongation.
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Affiliation(s)
- Philipp Bohny
- Center for Psychiatry and Psychotherapy, Triaplus Clinic Zugersee, Zug, Switzerland
- Department of Consultation-Liaison-Psychiatry and Psychosomatic Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Soenke Boettger
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Josef Jenewein
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Privatklinik Hohenegg, Meilen, Switzerland
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12
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Franz ND, Alaniz C, Miller JT, Farina N. Association Between Sedative Medication Administration and Delirium Development in a Medical Intensive Care Unit. J Pharm Pract 2023; 36:1164-1169. [PMID: 35466784 DOI: 10.1177/08971900221096978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Delirium develops frequently in intensive care unit (ICU) patients. Societal guidelines have suggested that benzodiazepines may cause delirium. This study investigates if a change in sedation administration use over time is associated with changes in delirium incidence. Methods: This was a retrospective cohort study conducted over a 4 year time period in a medical ICU. All data was abstracted from a local data warehouse. The primary outcome of the study was the association between annual cumulative benzodiazepine use and incidence of delirium during the study period. Data was analyzed using descriptive characteristics and Spearman's correlation coefficient. Additionally, multivariate logistic regression was performed to identify independent risk factors for delirium development. Results: From 2015 to 2018, annual total benzodiazepine administration decreased from 62,215 mg to 18,105 mg lorazepam equivalents (p = <.01). The cumulative dose of dexmedetomidine increased, with 657,262 mcg administered in 2015 and 1,476,951 mcg in 2018 (p < .01). No differences in annual delirium incidence were found. Risk factors that were significantly correlated with delirium following multivariate logistic regression included acute respiratory distress syndrome, renal failure, hepatic failure, septic shock, severe alcohol withdrawal, vasopressor use, corticosteroid use, benzodiazepine use, antipsychotic use, opiate use, and propofol use. Conclusions: A profound change in sedation medication paradigm did not influence delirium rates in a medical ICU.
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Affiliation(s)
- Nicholas D Franz
- CHI Health Creighton University Medical Center - Bergan Mercy, Omaha, NE, USA
| | - Cesar Alaniz
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - James T Miller
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicholas Farina
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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13
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Nakamura T, Yoshizawa T, Toya R, Terasawa M, Takahashi K, Kitazawa K, Suzuki K, Sasayama D, Washizuka S. Orexin receptor antagonists versus antipsychotics for the management of delirium in intensive care unit patients with cardiovascular disease: A retrospective observational study. Gen Hosp Psychiatry 2023; 84:96-101. [PMID: 37413718 DOI: 10.1016/j.genhosppsych.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/02/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Although antipsychotics are often used in the pharmacological treatment of delirium, recent reports suggest the efficacy of orexin receptor antagonists. This study investigated whether orexin receptor antagonists could be a possible treatment option for delirium. METHOD A nonblinded nonrandomized routine clinical treatment was performed. Patients treated in intensive care units (ICU) for cardiovascular disease and receiving psychiatric intervention were studied retrospectively. The scores from the Intensive Care Delirium Screening Checklist (ICDSC) were compared between patients treated with orexin receptor antagonists and those treated with antipsychotics. RESULTS The mean (standard deviation) ICDSC scores were 4.5 (1.8) at day -1 and 2.6 (2.6) at day 7 for orexin receptor antagonist group (n = 25) and 4.6 (2.4) at day -1 and 4.1 (2.2) at day 7 for antipsychotic group (n = 28). The orexin receptor antagonist group showed significantly lower ICDSC scores than the antipsychotic group (p = 0.021). CONCLUSION While precise efficacy cannot be determined from our retrospective, observational, and uncontrolled pilot study, this analysis encourages a future double-blind randomized placebo-controlled trial of orexin-antagonists for delirium treatment.
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Affiliation(s)
- Toshinori Nakamura
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan.
| | - Tomonari Yoshizawa
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Risa Toya
- Department of Nursing, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Miho Terasawa
- Department of Pharmacy, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kazuhito Takahashi
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kasumi Kitazawa
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Kazuhiro Suzuki
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Daimei Sasayama
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Shinsuke Washizuka
- Department of Psychiatry, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
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14
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Choo YH, Seo Y, Oh HJ. Deep Sedation in Traumatic Brain Injury Patients. Korean J Neurotrauma 2023; 19:185-194. [PMID: 37431376 PMCID: PMC10329893 DOI: 10.13004/kjnt.2023.19.e19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 07/12/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of mortality and disability in adults. In cases of severe TBI, preventing secondary brain injury by managing intracranial hypertension during the acute phase is a critical treatment challenge. Among surgical and medical interventions to control intracranial pressure (ICP), deep sedation can provide comfort to patients and directly control ICP by regulating cerebral metabolism. However, insufficient sedation does not achieve the intended treatment goals, and excessive sedation can lead to fatal sedative-related complications. Therefore, it is important to continuously monitor and titrate sedatives by measuring the appropriate depth of sedation. In this review, we discuss the effectiveness of deep sedation, techniques to monitor the depth of sedation, and the clinical use of recommended sedatives, barbiturates, and propofol in TBI.
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Affiliation(s)
- Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea
| | - Hyuk-Jin Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea
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15
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Glaser I. [Polypharmacy and Delirium in the Elderly]. PRAXIS 2023; 112:335-339. [PMID: 37042399 DOI: 10.1024/1661-8157/a003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Polypharmacy and Delirium in the Elderly Abstract: Delirium often occurs in elderly hospitalized patients. Multimorbidity and associated polypharmacy are known risk factors for developing delirium. Moreover, delirium itself often leads to the prescription of additional drugs. This article aims to enlighten the interrelation of delirium and polypharmacy in the context of recent evidence. It also tries to show possibilities of deprescribing.
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16
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Aoki Y, Kurita T, Nakajima M, Imai R, Suzuki Y, Makino H, Kinoshita H, Doi M, Nakajima Y. Association between remimazolam and postoperative delirium in older adults undergoing elective cardiovascular surgery: a prospective cohort study. J Anesth 2023; 37:13-22. [PMID: 36220948 DOI: 10.1007/s00540-022-03119-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Postoperative delirium is one of the most common complications after cardiovascular surgery in older adults. Benzodiazepines are a reported risk factor for delirium; however, there are no studies investigating remimazolam, a novel anesthetic agent. Therefore, we prospectively investigated the effect of remimazolam on postoperative delirium. METHODS We included elective cardiovascular surgery patients aged ≥ 65 years at Hamamatsu University Hospital between August 2020 and February 2022. Patients who received general anesthesia with remimazolam were compared with those who received other anesthetics (control group). The primary outcome was delirium within 5 days after surgery. Secondary outcomes were delirium during intensive care unit stay and hospitalization, total duration of delirium, subsyndromal delirium, and differences in the Mini-Mental State Examination scores from preoperative to postoperative days 2 and 5. To adjust for differences in the groups' baseline covariates, we used stabilized inverse probability weighting as the primary analysis and propensity score matching as the sensitivity analysis. RESULTS We enrolled 200 patients; 78 in the remimazolam group and 122 in the control group. After stabilized inverse probability weighting, 30.3% of the remimazolam group patients and 26.6% of the control group patients developed delirium within 5 days (risk difference, 3.8%; 95% confidence interval -11.5% to 19.1%; p = 0.63). The secondary outcomes did not differ significantly between the groups, and the sensitivity analysis results were similar to those for the primary analysis. CONCLUSION Remimazolam was not significantly associated with postoperative delirium when compared with other anesthetic agents.
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Affiliation(s)
- Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
| | - Tadayoshi Kurita
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Mikio Nakajima
- Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development, Tokyo, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Ryo Imai
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hiroshi Makino
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Hiroyuki Kinoshita
- Department of Anesthesiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
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17
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Yang JJ, Lei L, Qiu D, Chen S, Xing LK, Zhao JW, Mao YY, Yang JJ. Effect of Remimazolam on Postoperative Delirium in Older Adult Patients Undergoing Orthopedic Surgery: A Prospective Randomized Controlled Clinical Trial. Drug Des Devel Ther 2023; 17:143-153. [PMID: 36712948 PMCID: PMC9880012 DOI: 10.2147/dddt.s392569] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Background Postoperative delirium is common in older adult patients and associated with a poor prognosis. The use of benzodiazepine was identified as an independent risk factor for delirium, but there is no randomized controlled trial regarding the relationship between remimazolam, a new ultra-short acting benzodiazepine, and postoperative delirium. We designed a randomized controlled trial to evaluate if remimazolam increases the incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery with general anesthesia. Patients and Methods We enrolled 320 patients aged more than 60 with American Society of Anesthesiologists physical status I-III who underwent orthopedic surgery. Patients were randomized to two groups to receive intraoperative remimazolam or propofol, respectively. Our primary outcome was the incidence of delirium within 3 days after surgery. Secondary outcome was emergence quality including the incidence of emergence agitation, extubation time, and length of post-anesthesia care unit (PACU) stay. Adverse events were also recorded. Results The incidence of postoperative delirium was 15.6% in the remimazolam group and 12.4% in the propofol group (Risk ratio, 1.26; 95% CI, 0.72 to 2.21; Risk difference, 3.2%; 95% CI, -4.7% to 11.2%; P = 0.42). No significant differences were observed for time of delirium onset, duration of delirium, and delirium subtype between the two groups. Patients in remimazolam group had a lower incidence of hypotension after induction and consumed less vasoactive drugs intraoperatively, but had a longer postoperative extubation time and PACU stay. Conclusion General anesthesia with remimazolam was not associated with an increased incidence of postoperative delirium compared with propofol in older adult patients undergoing orthopedic surgery.
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Affiliation(s)
- Jin-Jin Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Lei Lei
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Di Qiu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Sai Chen
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Li-Ka Xing
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Jing-Wei Zhao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Yuan-Yuan Mao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China,Henan Province International Joint Laboratory of Pain, Cognition and Emotion, Zhengzhou, People’s Republic of China,Correspondence: Jian-Jun Yang, Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, People’s Republic of China, Tel +8613783537619, Email
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18
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Shi X, Zhang L, Zeng X, Li Y, Hu W, Xi S. NEUROLOGIC IMPAIRMENT IN PATIENTS WITH EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION SUPPORT: CLINICAL FEATURES AND LONG-TERM OUTCOMES. Shock 2023; 59:41-48. [PMID: 36703277 DOI: 10.1097/shk.0000000000002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ABSTRACT Introduction: The present study aimed to explore the clinical features and long-term outcomes associated with neurologic impairment in patients with cardiac arrest (CA) who received extracorporeal cardiopulmonary resuscitation (ECPR). Methods: A total of 37 adult CA patients who underwent venoarterial extracorporeal membrane oxygenation and were admitted to our department between January 2015 and February 2022 were divided according to neurologic impairment. Baseline and CPR- and ECMO-related characteristics were compared between the two groups. Long-term neurologic outcomes were collected via telephone follow-ups. Results: Twenty-four (64.9%) ECPR-supported patients developed neurologic impairments. The two groups differed significantly in median age (P = 0.026), proportion of intra-aortic balloon pump (IABP) support (P = 0.011), proportion of continuous renal replacement therapy (P = 0.025), and median serum creatinine (Cr) level (P = 0.012) pre-ECMO. The 28-day mortality (P = 0.001), hospital mortality (P = 0.003), median duration from CA to restoration of spontaneous circulation (P = 0.029), proportion of patients with nonpulsatile perfusion (NP) >12 hours (P = 0.040), and median ECMO duration (P = 0.047) were higher in the neurologic impairment group. In contrast, the group without neurologic impairment exhibited a longer median intensive care unit length of stay (P = 0.047), longer median hospital LOS (P = 0.031), and more successful ECMO weaning (P = 0.049). Moreover, NP >12 hours combined with IABP support (odds ratio [OR], 14.769; 95% confidence interval [CI], 1.417~153.889; P = 0.024) and serum Cr level (OR, 1.028; 95% CI, 1.001~1.056; P = 0.043) were independent risk factors for neurologic impairment. Furthermore, neurologic impairment was associated with significantly worse 90-day survival (hazards ratio, 4.218; 95% CI, 1.745~10.2; P = 0.0014). Conclusions: The incidence of neurologic impairment was higher in patients who received ECPR and was closely related to 28-day mortality and discharge survival. NP >12 hours combined with IABP support and serum Cr levels were independent risk factors for neurologic impairments in ECPR-supported patients. Neurologic impairment significantly adversely affected the long-term outcomes of ECPR-supported patients after discharge.
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Affiliation(s)
- Xiaobei Shi
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lili Zhang
- Intensive Care Unit, Beijing First Hospital of Integrated Chinese and Western Medicine, Beijing, China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Smit L, Wiegers EJA, Trogrlic Z, Rietdijk WJR, Gommers D, Ista E, van der Jagt M. Prognostic significance of delirium subtypes in critically ill medical and surgical patients: a secondary analysis of a prospective multicenter study. J Intensive Care 2022; 10:54. [PMID: 36539913 PMCID: PMC9764534 DOI: 10.1186/s40560-022-00644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 11/02/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The prognostic implication of delirium subtypes in critically ill medical and surgical patients is scarcely investigated. The objective was to determine how delirium subtypes are associated with hospital mortality and other clinical outcomes. METHODS We performed a secondary analysis on data from a prospective multicenter study aimed at implementation of delirium-oriented measures, conducted between 2012 and 2015 in The Netherlands. We included adults (≥ 18 years) admitted to the medical or surgical intensive care unit (ICU). Exclusion criteria were neurological admission diagnosis, persistent coma or ICU readmissions. Delirium was assessed using the Confusion Assessment Method-ICU or Intensive Care Delirium Screening Checklist, and delirium subtypes (hypoactive, hyperactive, or mixed) were classified using the Richmond Agitation-Sedation Scale. The main outcome was hospital mortality. Secondary outcomes were ICU mortality, ICU length of stay, coma, mechanical ventilation, and use of antipsychotics, sedatives, benzodiazepines and opioids. RESULTS Delirium occurred in 381 (24.4%) of 1564 patients (52.5% hypoactive, 39.1% mixed, 7.3% hyperactive). After case-mix adjustment, patients with mixed delirium had higher hospital mortality than non-delirious patients (OR 3.09, 95%CI 1.79-5.33, p = 0.001), whereas hypoactive patients did not (OR 1.34, 95%CI 0.71-2.55, p = 0.37). Similar results were found for ICU mortality. Compared to non-delirious patients, both subtypes had longer ICU stay, more coma, increased mechanical ventilation frequency and duration, and received more antipsychotics, sedatives, benzodiazepines and opioids. Except for coma and benzodiazepine use, the most unfavourable outcomes were observed in patients with mixed delirium. CONCLUSIONS Patients with mixed delirium had the most unfavourable outcomes, including higher mortality, compared with no delirium. These differences argue for distinguishing delirium subtypes in clinical practice and future research. Trial registration ClinicalTrials.gov NCT01952899.
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Affiliation(s)
- Lisa Smit
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Eveline J. A. Wiegers
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Zoran Trogrlic
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Wim J. R. Rietdijk
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Erwin Ista
- grid.416135.40000 0004 0649 0805Intensive Care Unit, Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center, Rotterdam, The Netherlands ,grid.5645.2000000040459992XSection of Nursing Science, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- grid.5645.2000000040459992XDepartment of Intensive Care Adults, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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Kaneko S, Morimoto T, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effect of remimazolam on the incidence of delirium after transcatheter aortic valve implantation under general anesthesia: a retrospective exploratory study. J Anesth 2022; 37:210-218. [PMID: 36463532 DOI: 10.1007/s00540-022-03148-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/27/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE Delirium after transcatheter aortic valve implantation (TAVI) should be prevented because it is associated with worse patient outcomes. Perioperative administration of benzodiazepines is a risk factor for postoperative delirium; however, the association between remimazolam, a newer ultrashort-acting benzodiazepine for general anesthesia, and postoperative delirium remains unclear. This study aimed to evaluate whether remimazolam administration during TAVI under general anesthesia affected the incidence of postoperative delirium. METHODS This single-center retrospective study recruited all adult patients who underwent transfemoral TAVI (TF-TAVI) under general anesthesia between March 2020 and May 2022. Patients were divided into the remimazolam (R) and propofol (P) groups according to the sedative used for anesthesia. In the R group, all patients received flumazenil after surgery. The primary endpoint was the incidence of delirium within 3 days after surgery. Factors associated with delirium after TF-TAVI were examined by multiple logistic regression analysis. RESULTS Ninety-eight patients were included in the final analysis (R group, n = 40; P group, n = 58). The incidence of postoperative delirium was significantly lower in the R group than in the P group (8% vs. 26%, p = 0.032). Multiple logistic regression analysis revealed that remimazolam (odds ratio 0.17, 95% CI 0.04-0.80, p = 0.024) was independently associated with the incidence of postoperative delirium, even after adjustment for age, sex, preoperative cognitive function, history of stroke, and TF-TAVI approach. CONCLUSION Remimazolam may benefit TF-TAVI in terms of postoperative delirium; however, its usefulness must be further evaluated in extensive prospective studies.
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Affiliation(s)
- Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Takayuki Morimoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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21
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DiConti-Gibbs A, Chen KY, Coffey CE. Polypharmacy in the Hospitalized Older Adult. Clin Geriatr Med 2022; 38:667-684. [DOI: 10.1016/j.cger.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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22
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Tiberio PJ, Prendergast NT, Girard TD. Pharmacologic Management of Delirium in the Intensive Care Unit. Clin Chest Med 2022; 43:411-424. [PMID: 36116811 DOI: 10.1016/j.ccm.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit. It concludes by outlining some emerging treatments of delirium.
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Affiliation(s)
- Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Timothy D Girard
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, 3520 Fifth Avenue, 101 Keystone Building, Pittsburgh, PA, 15213, USA.
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23
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Shen J, An Y, Jiang B, Zhang P. Derivation and validation of a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty. Front Surg 2022; 9:919886. [PMID: 36061065 PMCID: PMC9437918 DOI: 10.3389/fsurg.2022.919886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionPostoperative delirium is a common complication of patients undergoing hip fracture surgery or arthroplasty and is related to decreased survival time and physical function. In this study, we aim to build and validate a prediction score of postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty.MethodsA retrospective cohort of geriatric patients undergoing hip fracture surgery or hip arthroplasty was established. Variables of included patients were collected as candidate predictors of postoperative delirium. The least absolute shrinkage and selection operator (LASSO) regression and logistic regression were used to derive a predictive score for postoperative delirium. The accuracy of the score was evaluated by the area under the curve (AUC) of the receiver operating curve (ROC). We used bootstrapping resamples for model calibration. The prediction score was validated in an extra cohort.ResultsThere were 1,312 patients in the derivation cohort, and the incidence of postoperative delirium was 14.33%. Of 40 variables, 9 were identified as predictors, including preoperative delirium, cerebrovascular accident (CVA) with the modified Rankin scale, diabetes with a random glucose level, Charlson comorbidity index (CCI), age, application of benzodiazepines in surgery, surgical delay ≥2 days, creatine ≥90 μmol/L, and active smoker. The prediction score achieved a mean AUC of 0.848 in the derivation cohort. In the validation cohort, the mean AUC was 0.833. The prediction model was well-calibrated in the two cohorts.ConclusionBased on retrospective data, a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty was derived and validated. The performance of the scoring system outperformed the models from previous studies. Although the generalization ability of the score needs to be tested in similar populations, the scoring system will enable delirium risk stratification for hip fracture patients and facilitate the development of strategies for delirium prevention.
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Affiliation(s)
- Jiawei Shen
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Baoguo Jiang
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing, China
- National Center for Trauma Medicine, Beijing, China
- Correspondence: Baoguo Jiang Peixun Zhang
| | - Peixun Zhang
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
- Key Laboratory of Trauma and Neural Regeneration, Peking University, Beijing, China
- National Center for Trauma Medicine, Beijing, China
- Correspondence: Baoguo Jiang Peixun Zhang
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24
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Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, Gondal G, Charie S, Shrivastava A, Divatia JV. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022; 26:906-912. [PMID: 36042768 PMCID: PMC9363797 DOI: 10.5005/jp-journals-10071-24264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India. Materials and methods After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 µg/kg/min of Noradrenaline infusion), ASA I and II patients aged 18-80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2-0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved. Results Fifty patients received isoflurane infusion for a median of 720 (IQR 630-900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5-85) minutes], to follow simple verbal commands [20 (IQR 5-180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10-470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium. Conclusion Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible. How to cite this article Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, et al. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022;26(8):906-912.
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Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India,Atul Prabhakar Kulkarni, Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India, Phone: +91 9869077526, e-mail:
| | - Shilpushp Jagannath Bhosale
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kushal Rajeev Kalvit
- Department of Anesthesiology, Critical Care Medicine and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Tarun Kumar Sahu
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rakesh Mohanty
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Meshach M Dhas
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gautam Gondal
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Swapna Charie
- Division of Critical Care Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anjana Shrivastava
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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25
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LaBuzetta JN, Malhotra A, Zee PC, Maas MB. Optimizing Sleep and Circadian Health in the NeuroICU. Curr Treat Options Neurol 2022; 24:309-325. [PMID: 35855215 PMCID: PMC9283559 DOI: 10.1007/s11940-022-00724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 12/04/2022]
Abstract
Purpose of Review This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit. Recent Findings Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption. Summary The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, San Diego, USA
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, USA
| | - Phyllis C. Zee
- Department of Neurology, Division of Sleep Medicine, Northwestern University, Chicago, USA
| | - Matthew B. Maas
- Department of Neurology, Division of Neurocritical Care, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
- Department of Anesthesiology, Section of Critical Care Medicine, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
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Kotfis K, van Diem-Zaal I, Williams Roberson S, Sietnicki M, van den Boogaard M, Shehabi Y, Ely EW. The future of intensive care: delirium should no longer be an issue. Crit Care 2022; 26:200. [PMID: 35790979 PMCID: PMC9254432 DOI: 10.1186/s13054-022-04077-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/30/2022] [Indexed: 01/02/2023] Open
Abstract
In the ideal intensive care unit (ICU) of the future, all patients are free from delirium, a syndrome of brain dysfunction frequently observed in critical illness and associated with worse ICU-related outcomes and long-term cognitive impairment. Although screening for delirium requires limited time and effort, this devastating disorder remains underestimated during routine ICU care. The COVID-19 pandemic brought a catastrophic reduction in delirium monitoring, prevention, and patient care due to organizational issues, lack of personnel, increased use of benzodiazepines and restricted family visitation. These limitations led to increases in delirium incidence, a situation that should never be repeated. Good sedation practices should be complemented by novel ICU design and connectivity, which will facilitate non-pharmacological sedation, anxiolysis and comfort that can be supplemented by balanced pharmacological interventions when necessary. Improvements in the ICU sound, light control, floor planning, and room arrangement can facilitate a healing environment that minimizes stressors and aids delirium prevention and management. The fundamental prerequisite to realize the delirium-free ICU, is an awake non-sedated, pain-free comfortable patient whose management follows the A to F (A-F) bundle. Moreover, the bundle should be expanded with three additional letters, incorporating humanitarian care: gaining (G) insight into patient needs, delivering holistic care with a 'home-like' (H) environment, and redefining ICU architectural design (I). Above all, the delirium-free world relies upon people, with personal challenges for critical care teams to optimize design, environmental factors, management, time spent with the patient and family and to humanize ICU care.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Szczecin, Poland.
| | - Irene van Diem-Zaal
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Marek Sietnicki
- Department of Architecture, West Pomeranian University of Technology in Szczecin, Szczecin, Poland
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Center for Health Services Research, Nashville, TN, USA.,Division of Allergy, Department of Medicine, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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27
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Baseline Anxiety and Depression and Risk for ICU Delirium: A Prospective Cohort Study. Crit Care Explor 2022; 4:e0743. [PMID: 35923592 PMCID: PMC9307302 DOI: 10.1097/cce.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES: Anxiety and depression are common mental disorders in adults admitted to the ICU. Although depression increases postsurgical delirium and anxiety does not, their associations with ICU delirium in critically ill adults remain unclear. We evaluated the association between ICU baseline anxiety and depression and ICU delirium occurrence. DESIGN: Subgroup analysis of a prospective cohort study. SETTING: Single, 36-bed mixed ICU. PATIENTS: Nine-hundred ninety-one ICU patients admitted with or without delirium between July 2016 and February 2020; patients admitted after elective surgery or not assessed for anxiety/depression were excluded. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTs: The Hospital Anxiety and Depression Scale questionnaire was administered at ICU admission to determine baseline anxiety and depression. All patients were assessed with the Confusion Assessment Method for the ICU (CAM-ICU) q8h; greater than or equal to 1 +CAM-ICU assessment and/or scheduled antipsychotic use represented a delirium day. Multivariable logistic and Quasi-Poisson regression models, adjusted for ICU days and nine delirium risk variables (“Pre-ICU”: age, Charlson Comorbidity Index, cognitive impairment; “ICU baseline”: Acute Physiology and Chronic Health Evaluation-IV, admission type; “Daily ICU”: opioid and/or benzodiazepine use, Sequential Organ Failure Assessment score, coma), were used to evaluate associations between baseline anxiety and/or depression and ICU delirium. Among the 991 patients, 145 (14.6%) had both anxiety and depression, 78 (7.9%) had anxiety only, 91 (9.2%) had depression only, and 677 (68.3%) had neither. Delirium occurred in 406 of 991 total cohort (41.0%) patients; in the baseline anxiety and depression group, it occurred in 78 of 145 (53.8%), in the anxiety only group, 37 of 78 (47.4%), in the depression only group, 39 of 91 (42.9%), and in the group with neither in 252 of 677 (37.2%). Presence of both baseline anxiety and depression was associated with greater delirium occurrence (adjusted odds ratio, 1.99; 95% CI, 1.10–3.53; p = 0.02) and duration (adjusted risk ratio, 1.62; 95% CI, 1.17–2.23; p < 0.01). CONCLUSIONS: Baseline anxiety and depression are associated with increased ICU delirium occurrence and should be considered when delirium risk reduction strategies are being formulated.
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Stuff K, Kainz E, Kahl U, Pinnschmidt H, Beck S, von Breunig F, Nitzschke R, Funcke S, Zöllner C, Fischer M. Effect of sedative premedication with oral midazolam on postanesthesia care unit delirium in older adults: a secondary analysis following an uncontrolled before-after design. Perioper Med (Lond) 2022; 11:18. [PMID: 35585564 PMCID: PMC9118741 DOI: 10.1186/s13741-022-00253-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sedative premedication with benzodiazepines has been linked with prolonged recovery and inadequate emergence during the immediate postoperative period. We aimed to analyze the association between postanesthesia care unit (PACU) delirium and sedative premedication with oral midazolam. METHODS We performed a secondary analysis of prospectively collected data before (midazolam cohort) and after (non-midazolam cohort) implementation of a restrictive strategy for oral premedication with midazolam. From March 2015 until July 2018, we included patients 60 years and older, who underwent elective radical prostatectomy for prostate cancer. Exclusion criteria were contraindications to premedication with midazolam, preoperative anxiety, and a history of neurological disorders. Patients, who were scheduled for postoperative admission to the intensive care unit, were excluded. Between 2015 and 2016, patients received 7.5 mg oral midazolam preoperatively (midazolam cohort). Patients included between 2017 and 2018 did not receive any sedative medication preoperatively (non-midazolam cohort). The primary endpoint was the incidence of PACU delirium. RESULTS PACU delirium rates were 49% in the midazolam cohort (n = 214) and 33% in the non-midazolam cohort (n = 218). This difference was not statistically significant on multivariable logistic regression analysis (OR 0.847 [95% CI 0.164; 4.367]; P = 0.842). Age (OR 1.102 [95% CI 1.050; 1.156]; P < 0.001), the cumulative dose of sufentanil (OR 1.014 [95% CI 1.005; 1.024]; P = 0.005), and propofol-sufentanil for anesthesia maintenance (OR 2.805 [95% CI 1.497; 5.256]; P = 0.001) were significantly associated with PACU delirium. CONCLUSION Midazolam for sedative premedication was not significantly associated with PACU delirium. The reduction in the incidence of PACU delirium throughout the study period may be attributable to improvements in perioperative management other than a more restrictive preoperative benzodiazepine administration.
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Affiliation(s)
- Karin Stuff
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elena Kainz
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ursula Kahl
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefanie Beck
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska von Breunig
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Nitzschke
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Funcke
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Shi HJ, Yuan RX, Zhang JZ, Chen JH, Hu AM. Effect of midazolam on delirium in critically ill patients: a propensity score analysis. J Int Med Res 2022; 50:3000605221088695. [PMID: 35466751 PMCID: PMC9044793 DOI: 10.1177/03000605221088695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To observe the association between exposure to midazolam within 24 hours prior to delirium assessment and the risk of delirium. Methods We performed a systematic cohort study with two sets of cohorts to estimate the relative risks of outcomes among patients administered midazolam within 24 hours prior to delirium assessment. Propensity score matching was performed to generate a balanced 1:1 matched cohort and identify potential prognostic factors. The outcomes included the odds of delirium, mortality, length of intensive care unit stay, length of hospitalization, and odds of being discharged home. Results A total of 78,364 patients were included in this study, of whom 22,159 (28.28%) had positive records. Propensity matching successfully balanced covariates for 9348 patients (4674 per group). Compared with no administration of midazolam, midazolam administration was associated with a significantly higher risk of delirium, higher mortality, and a longer intensive care unit stay. Patients treated with midazolam were relatively less likely to be discharged home. There was no significant difference in hospitalization duration. Conclusions Midazolam may be an independent risk factor for delirium in critically ill patients.
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Affiliation(s)
- He-Jie Shi
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Rui-Xia Yuan
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Jun-Zhi Zhang
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Jia-Hui Chen
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - An-Min Hu
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
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30
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Suarez Montero JC, Caballero Gonzalez AC, Martín Aguilar L, Mancebo Cortés J. Immune effector cell-associated neurotoxicity syndrome: A therapeutic approach in the critically ill. Med Intensiva 2022; 46:201-212. [PMID: 35216966 DOI: 10.1016/j.medine.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/08/2020] [Accepted: 06/14/2020] [Indexed: 06/14/2023]
Abstract
Immunotherapy with chimeric antigen-specific receptor modified T cells, known as CAR-T, is emerging as a promising approach to hematological malignancies. In this regard, CAR-T against human cluster of differentiation (CD) 19 has demonstrated antitumor efficacy in application to B cell neoplasms resistant to conventional therapy. However, activation of the immune system induces severe and specific complications which can prove life-threatening. These include cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (known as ICANS) - the latter being the subject of the present review. Although the physiopathological mechanisms underlying ICANS are not well known, a number of clinical and biological factors increase the risk of developing neurotoxicity associated to CAR-T therapy. Treatment is based on close monitoring, measures of support, anticonvulsivants, corticosteroids, and early admission to intensive care. The present study offers a comprehensive review of the available literature from a multidisciplinary perspective, including recommendations from intensivists, neurologists and hematologists dedicated to the care of critically ill adults.
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Affiliation(s)
- J C Suarez Montero
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - A C Caballero Gonzalez
- Servicio de Hematología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - L Martín Aguilar
- Servicio de Neurología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Mancebo Cortés
- Servicio de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Tian Y, Qin Z, Han Y. Suvorexant with or without ramelteon to prevent delirium: a systematic review and meta-analysis. Psychogeriatrics 2022; 22:259-268. [PMID: 34881812 DOI: 10.1111/psyg.12792] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/01/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
Delirium is a common and serious neurobehavioral syndrome, associated with prolonged hospital stays, and increased morbidity and mortality. As it remains unclear whether suvorexant with or without ramelteon prevents delirium in elderly hospitalized patients, we conducted a systematic review and meta-analysis to evaluate, searching the PubMed, Cochrane Library, Web of Science, EMBASE, and EBSCOhost databases for all randomized controlled trials (RCTs), case-control studies, and cohort studies that investigated the effects of suvorexant with or without ramelteon on delirium in adult hospitalized patients. The primary outcome was the incidence of delirium. Two randomized controlled trials, 7 cohort studies and 2 case-control studies involving 2594 patients were included in this meta-analysis. The results showed that both suvorexant alone (odds ratio (OR) = 0.30, 95% confidence interval (CI): 0.14-0.65, P = 0.002) and suvorexant with ramelteon (OR = 0.39, 95% CI 0.23-0.65, P = 0.0003) reduced the incidence of delirium in adult hospitalized patients. Six studies involved the use of benzodiazepines; subgroup analysis performed separately in the suvorexant alone and suvorexant with ramelteon groups indicated that when benzodiazepine was administered, suvorexant with ramelteon was effective at reducing the incidence of delirium (OR = 0.53, 95% CI 0.37-0.74, P = 0.0002), but no significant difference was observed for suvorexant alone (OR = 0.40, 95% CI 0.11-1.53, P = 0.18). The current literature thus supports the effectiveness of suvorexant with or without ramelteon for delirium prevention, although suvorexant alone failed to significantly reduce the incidence of delirium when benzodiazepine was administered. The present study was limited by the significant heterogeneity among the included studies, and caution should be exercised when interpreting the results. This study was registered in the PROSPERO database (CRD4202017964).
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Affiliation(s)
- Yu Tian
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zaisheng Qin
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yunyang Han
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Differential Effects of Gamma-Aminobutyric Acidergic Sedatives on Risk of Post-Extubation Delirium in the ICU: A Retrospective Cohort Study From a New England Health Care Network. Crit Care Med 2022; 50:e434-e444. [PMID: 34982739 DOI: 10.1097/ccm.0000000000005425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether different gamma-aminobutyric acidergic (GABAergic) sedatives such as propofol and benzodiazepines carry differential risks of post-extubation delirium in the ICU. DESIGN Retrospective cohort study. SETTING Seven ICUs in an academic hospital network, Beth Israel Deaconess Medical Center (Boston, MA). PATIENTS Ten thousand five hundred and one adult patients mechanically ventilated for over 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tested the hypothesis that benzodiazepine versus propofol-based sedation is associated with fewer delirium-free days within 14 days after extubation. Further, we hypothesized that the measured sedation level evoked by GABAergic drugs is a better predictor of delirium than the drug dose administered. The proportion of GABAergic drug-induced deep sedation was defined as the ratio of days with a mean Richmond Agitation-Sedation Scale of less than or equal to -3 during mechanical ventilation. Multivariable regression and effect modification analyses were used. Delirium-free days were lower in patients who received a high proportion of deep sedation using benzodiazepine compared with propofol-based sedation (adjusted absolute difference, -1.17 d; 95% CI, -0.64 to -1.69; p < 0.001). This differential effect was magnified in elderly patients (age > 65) and in patients with liver or kidney failure (p-for-interaction < 0.001) but not observed in patients who received a low proportion of deep sedation (p = 0.95). GABAergic-induced deep sedation days during mechanical ventilation was a better predictor of post-extubation delirium than the GABAergic daily average effective dose (area under the curve 0.76 vs 0.69; p < 0.001). CONCLUSIONS Deep sedation during mechanical ventilation with benzodiazepines compared with propofol is associated with increased risk of post-extubation delirium. Our data do not support the view that benzodiazepine-based compared with propofol-based sedation in the ICU is an independent risk factor of delirium, as long as deep sedation can be avoided in these patients.
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Kim MK, Oh J, Kim JJ, Park JY. Development and Validation of Simplified Delirium Prediction Model in Intensive Care Unit. Front Psychiatry 2022; 13:886186. [PMID: 35845446 PMCID: PMC9277122 DOI: 10.3389/fpsyt.2022.886186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The intensive care unit (ICU) is where various medical staffs and patients with diverse diseases convene. Regardless of complexity, a delirium prediction model that can be applied conveniently would help manage delirium in the ICU. OBJECTIVE This study aimed to develop and validate a generally applicable delirium prediction model in the ICU based on simple information. METHODS A retrospective study was conducted at a single hospital. The outcome variable was defined as the occurrence of delirium within 30 days of ICU admission, and the predictors consisted of a 12 simple variables. Two models were developed through logistic regression (LR) and random forest (RF). A model with higher discriminative power based on the area under the receiver operating characteristics curve (AUROC) was selected as the final model in the validation process. RESULTS The model was developed using 2,588 observations (training dataset) and validated temporally with 1,109 observations (test dataset) of ICU patients. The top three influential predictors of the LR and RF models were the restraint, hospitalization through emergency room, and drainage tube. The AUROC of the LR model was 0.820 (CI 0.801-0.840) and 0.779 (CI 0.748-0.811) in the training and test datasets, respectively, and that of the RF model was 0.762 (CI 0.732-0.792) and 0.698 (0.659-0.738), respectively. The LR model showed better discriminative power (z = 4.826; P < 0.001). CONCLUSION The LR model developed with brief variables showed good performance. This simplified prediction model will help screening become more accessible.
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Affiliation(s)
- Min-Kyeong Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jooyoung Oh
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Young Park
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea.,Center for Digital Health, Yongin Severance Hospital, Yongin, South Korea
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Shin HJ, Yoon J, Na HS. 5-HT 3 receptor antagonists decrease the prevalence of postoperative delirium in older patients undergoing orthopedic lower limb surgery. Perioper Med (Lond) 2021; 10:51. [PMID: 34876219 PMCID: PMC8653581 DOI: 10.1186/s13741-021-00222-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delirium is an important postoperative complication. Recent research suggested that 5-hydroxytryptamine 3 (5-HT3) receptor antagonists may have clinical effect in the treatment and prevention of delirium. We investigated the association between 5-HT3 receptor antagonists and the occurrence of postoperative delirium (POD). METHODS Retrospectively, the electronic medical records were reviewed in patients aged ≥ 65 years who underwent orthopedic lower limb surgery under regional anesthesia (spinal or combined spinal-epidural anesthesia) and administered intravenous 0.075 mg palonosetron or 0.3 mg ramosetron prior to the end of surgery between July 2012 and September 2015. POD incidence and anesthesia-, surgery-, and patient-related factors were evaluated. To investigate the association between 5-HT3 receptor antagonists and the occurrence of POD, multivariable logistic regression analysis was performed. RESULTS Of the 855 patients included, 710 (83%) were administered 5-HT3 receptor antagonists. POD was confirmed in 46 (5.4%) patients. 5-HT3 receptor antagonists reduced the POD incidence by 63% (odds ratio [OR] 0.37; 95% confidence interval [CI], 0.15-0.94; P = 0.04). Moreover, the POD incidence decreased by 72% (OR 0.28, 95% CI 0.10-0.77, P = 0.01) when palonosetron was administered. Other identified risk factors for POD were emergency surgery, older age, hip surgery, lower body mass index, and intraoperative propofol sedation. CONCLUSION 5-HT3 receptor antagonists may be related with a significantly reduced risk for POD in older patients undergoing orthopedic lower limb surgery. Notably, palonosetron was more effective for POD prevention.
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Affiliation(s)
- Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang, Seongnam, 13620, South Korea
| | - Jiwon Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang, Seongnam, 13620, South Korea
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang, Seongnam, 13620, South Korea.
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Geen O, Rochwerg B, Wang XM. Optimisation des soins chez les personnes âgées gravement malades. CMAJ 2021; 193:E1850-1859. [PMID: 34872961 PMCID: PMC8648358 DOI: 10.1503/cmaj.210652-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Olivia Geen
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont.
| | - Bram Rochwerg
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont
| | - Xuyi Mimi Wang
- Division de médecine gériatrique (Geen, Wang) et de médecine de soins intensifs (Rochwerg), Départements de médecine et des méthodes, impacts et données probantes de la recherche en santé (Rochwerg), Université McMaster, Hamilton, Ont
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Ghasemiyeh P, Mohammadi-Samani S, Firouzabadi N, Vazin A, Zand F. A brief ICU residents’ guide: Pharmacotherapy, pharmacokinetic aspects and dose adjustments in critically ill adult patients admitted to ICU. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Remimazolam reduces sepsis-associated acute liver injury by activation of peripheral benzodiazepine receptors and p38 inhibition of macrophages. Int Immunopharmacol 2021; 101:108331. [PMID: 34810122 DOI: 10.1016/j.intimp.2021.108331] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Remimazolam is a novel ester-type benzodiazepine with ultrafast onset of sedation effect and fast recovery of consciousness. It has potential advantages in the sedation of sepsis-associated acute liver injury (SALI) patients. However, the effect and mechanism of remimazo lam on inflammation in the liver have not yet been elucidated. This study investigated the anti-inflammatory effects and mechanisms of remimazolam on SALI both in vivo and in vitro. METHODS Lipopolysaccharide (LPS) plus galactosamine treated rat model and LPS-challenged RAW264.7 cells model were constructed to simulate SALI. Next, the models were used to explore the efficacy of remimazolam treatment on SALI. Benzodiazepine receptor inhibitor, PK11195, was also employed. Hepatic injury was assessed by quantifying levels of transaminases, examining liver pathology, and calculating the number of inflammatory cells in the liver. Inflammatory response was evaluated by determining levels of pro-inflammatory cytokines and chemokines in blood, as well as p38 phosphorylation (p-p38) in the liver. RESULTS SALIrat models showed significant liver damage as manifested by increased levels of transaminases, proinflammatory cytokines, chemokines, and p-38. Remimazolam treatment reduced the liver injury and pathological changes, suppressed pro-inflammatory reactions, and elevated p-p38. The protective effect of remimazolam on liver injury was significantly blocked by PK11195. In LPS-stimulated RAW264.7 cells, it was found that treatment with remimazolam reduced the inflammatory response in LPS-treated cells in a time-dependent manner and decreased the level of p-p38. These results suggest that PK11195 can block remimazolam-induced inhibition of proinflammatory cytokine release and p-38 phosphorylation. CONCLUSIONS This study shows that remimazolam can attenuate inflammatory response in SALI, which may be associated with activation of peripheral benzodiazepine receptors and inhibition of p38 phosphorylation in macrophages.
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Browder K, Wanek M, Wang L, Hohlfelder B. Opioid and sedative requirements in extracorporeal membrane oxygenation patients on hydromorphone versus fentanyl. Artif Organs 2021; 46:878-886. [PMID: 34813116 DOI: 10.1111/aor.14125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/07/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extracorporeal membrane oxygenation (ECMO) circuit causes pharmacokinetic alterations of medications which impact drug selection and dosing. Although hydromorphone has a favorable pharmacokinetic profile, it is unclear whether hydromorphone provides better patient-centered benefits compared to fentanyl. The objective of this study is to compare opioid and sedative requirements in ECMO patients started on a fentanyl- versus hydromorphone-based analgesia regimen. METHODS This was a non-interventional retrospective cohort study. It was conducted at a single center in the cardiovascular intensive care units and cardiac intensive care units. We included venovenous (VV) or venoarterial ECMO patients. Patients who were started on a fentanyl continuous infusion within 24 h of cannulation were compared to patients started on a hydromorphone continuous infusion. RESULTS A linear mixed effects model was performed to compare doses of opioid, sedative, and propofol between groups over time. We included 28 hydromorphone patients and 53 fentanyl patients, with 85% on VV ECMO. There were no differences between hydromorphone and fentanyl groups in opioid or sedative (including propofol and benzodiazepine) doses for any ECMO day (p value for interaction .63 and .83, respectively). Propofol doses alone, however, were significantly higher in the fentanyl group on ECMO days three, four, and five. CONCLUSIONS There appear to be no major differences in opioid or sedative requirements whether ECMO patients are initiated on a hydromorphone- or fentanyl-based regimen.
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Affiliation(s)
- Kelsey Browder
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew Wanek
- Department of Pharmacy, Mayo Clinic, Pheonix, Arizona, USA
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
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Jäckel M, Zotzmann V, Wengenmayer T, Duerschmied D, Biever PM, Spieler D, von Zur Mühlen C, Stachon P, Bode C, Staudacher DL. Incidence and predictors of delirium on the intensive care unit after acute myocardial infarction, insight from a retrospective registry. Catheter Cardiovasc Interv 2021; 98:1072-1081. [PMID: 32926556 DOI: 10.1002/ccd.29275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study aimed to identify the incidence and potential risk factors for delirium after myocardial infarction (MI). BACKGROUND Delirium is a common complication on intensive care units. Data on incidence and especially on predictors of delirium in patients after acute MI are rare. METHODS In this retrospective study, all patients hospitalized for MI treated with coronary angiography in an university hospital in 2018 were included and analyzed. Onset of delirium within the first 5 days after MI was attributed to the MI and was defined by a Nursing Delirium screening scale (NuDesc) ≥2. This score is taken as part of daily care in every patient on intensive care unit three times a day by especially trained nurses. RESULTS A total of 624 patients with MI (age 68.5 ± 13.2 years, ST-elevation MI 41.6%, hospital mortality 3.2%) were included in the study. Delirium was detected in 10.9% of all patients. In the subgroup of patients with a stay on the intensive care unit (ICU) for more than 24 hr (n = 229), delirium was detected in 29.7%. Hospital and ICU stay were significantly longer in patients with delirium (p < .001). Delirium was an independent predictor of prolonged ICU-stay. Independent predictors of delirium were age, dementia, alcohol abuse, cardiac arrest, hypotension, and leucocytosis. Infarct size or presentation with ST-elevation were not associated with incidence of delirium. CONCLUSION Development of delirium is frequent after acute MI and prolongs hospitalization. Incidence of delirium is associated with clinical instability, preexisting comorbidity, and age rather than MI type or size.
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Affiliation(s)
- Markus Jäckel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M Biever
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Derek Spieler
- Department of Psychosomatic Medicine and Psychotherapy, Center for Mental Health, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Krowsoski L, Medina BD, DiMaggio C, Hong C, Moore S, Straznitskas A, Rogers C, Mukherjee V, Uppal A, Frangos S, Bukur M. Percutaneous Dilational Tracheostomy at the Epicenter of the SARS-CoV-2 Pandemic: Impact on Critical Care Resource Utilization and Early Outcomes. Am Surg 2021; 87:1775-1782. [PMID: 34766508 DOI: 10.1177/00031348211058644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.
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Affiliation(s)
- Leandra Krowsoski
- Department of Surgery, Division of Trauma and Acute Care Surgery, 25056NYU Grossman School of Medicine/New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Benjamin D Medina
- Department of Surgery, 12296NYU Grossman School of Medicine, New York, NY, United States
| | - Charles DiMaggio
- Department of Surgery, 12296NYU Grossman School of Medicine, New York, NY, United States
| | - Charles Hong
- Department of Surgery, 12296NYU Grossman School of Medicine, New York, NY, United States
| | - Samantha Moore
- Department of Pharmacy, 12296New York City Health and Hospitals/Bellevue, New York, NY, United States.,12296St John's University College of Pharmacy and Health Sciences, New York, NY, United States
| | - Andrew Straznitskas
- Department of Pharmacy, 12296New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Charmel Rogers
- Department of Respiratory Therapy, 12296New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Vikramjit Mukherjee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, 12296NYU Grossman School of Medicine/New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Amit Uppal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, 12296NYU Grossman School of Medicine/New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Spiros Frangos
- Department of Surgery, Division of Trauma and Acute Care Surgery, 25056NYU Grossman School of Medicine/New York City Health and Hospitals/Bellevue, New York, NY, United States
| | - Marko Bukur
- Department of Surgery, Division of Trauma and Acute Care Surgery, 25056NYU Grossman School of Medicine/New York City Health and Hospitals/Bellevue, New York, NY, United States
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The Risk of Preoperative Central Nervous System-Acting Medications on Delirium Following Hip or Knee Surgery: A Matched Case-Control Study. Drug Saf 2021; 45:75-82. [PMID: 34748199 DOI: 10.1007/s40264-021-01136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear. OBJECTIVES We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery. METHODS A matched case-control study was conducted using data from the Australian Government Department of Veterans' Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls. RESULTS A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24-2.64), sertraline (OR = 1.50, 95% CI 1.20-1.87), mirtazapine (OR = 1.38, 95% CI 1.11-1.74), venlafaxine (OR = 1.42, 95% CI 1.02-1.98), citalopram (OR = 1.54, 95% CI 1.19-1.99), escitalopram (OR = 1.42, 95% CI 1.06-1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15-11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05-1.37) and antidepressants (OR = 1.64, 95% CI 1.47-1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances. CONCLUSIONS People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium.
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and its Pharmacological Causes in Older People, Part Two. Sr Care Pharm 2021; 36:534-547. [PMID: 34717785 DOI: 10.4140/tcp.n.2021.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes. Part two of this series continues to review drugs and drug classes that can cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Demirer Aydemir F, Oncu S, Yakar NM, Utkugun GA, Gokmen N, Comert B, Ucku R, Gelal A. Potentially inappropriate medication use in elderly patients treated in intensive care units: A cross-sectional study using 2019 Beers, STOPP/v2 Criteria and EU(7)-PIM List. Int J Clin Pract 2021; 75:e14802. [PMID: 34482620 DOI: 10.1111/ijcp.14802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/03/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To determine the prevalence of and the risk factors for Potentially Inappropriate Medication (PIM), the drug groups most commonly evaluated as PIMs in elderly patients in the ICUs by using 2019 Beers Criteria, STOPP version 2 (v2) Criteria and EU(7)-PIM List. The relation between mortality rate and length of ICU stay with PIMs was also examined. METHODS This was a cross sectional study conducted on patients aged ≥65 years, treated in ICUs (n = 139) between June 8, 2020, and January 11, 2021. Patients' demographic characteristics, clinical data and laboratory findings about the drugs used were collected prospectively. PIMs were evaluated according to each of the criteria applied. Relationship of dependent and independent variables was evaluated using chi-square analysis, t-test and logistic regression analysis. P < .05 was considered statistically significant. RESULTS The number of patients with at least 1 PIM according to three criteria was 118 (84.9%) (80.6%, 59.7%, 48.2%, Beers, STOPP/v2 and EU(7)-PIM List, respectively). In the univariate analysis, receiving renal replacement therapy and high number of drugs were the covariates that significantly affected the presence of PIM according to all three criteria (P < .05). Combined use of anxiolytics and opioids in Beers Criteria (58.3%), antipsychotics (26.6%) in STOPP/v2 Criteria, and antiarrhythmics (23.7%) in EU(7)-PIM List were the drugs that caused PIM at most. No relationship was found between the presence of PIM and mortality. The length of ICU stay was determined significantly longer in the presence of PIM according to Beers Criteria (P = .028). CONCLUSIONS In this study, the prevalence of PIM was determined higher in elderly patients in ICU. Our results supported that 2019 Beers Criteria for ICU patients seems to be more directive in detecting PIMs and determining the prognosis. Reducing the number of drugs administered may be the first step to decrease PIMs in elderly patients in ICU and to maintain the treatment safely.
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Affiliation(s)
- Ferhan Demirer Aydemir
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Seyma Oncu
- Department of Pharmacology, Faculty of Medicine, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Nuri M Yakar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Gokalp A Utkugun
- Department of Pharmacology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Necati Gokmen
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Bilgin Comert
- Division of Intensive Care Medicine, Department of Internal Medicine, Izmir Medicana International Hospital, Izmir, Turkey
| | - Reyhan Ucku
- Department of Public Health, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Ayse Gelal
- Department of Pharmacology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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Kakar E, Ista E, Klimek M, Jeekel J. Implementation of music in the perioperative standard care of colorectal surgery: study protocol of the IMPROVE Study. BMJ Open 2021; 11:e051878. [PMID: 34711596 PMCID: PMC8557300 DOI: 10.1136/bmjopen-2021-051878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Perioperative music intervention has been proven effective in reducing anxiety, pain, neurohormonal stress response and medication requirement. Unfortunately, there is a gap between new effective interventions and their (interventions) integration in standard care protocols. The aim of this preimplementation and postimplementation study is to investigate the adherence to a music intervention in a tailored, multilevel, systematic implementation strategy and the initial impact of the implementation on postoperative pain in patients undergoing colorectal surgery. METHODS AND DESIGN A monocentre prospective preimplementation and postimplementation study was set up using The Consolidated Framework for Implementation Research to conduct a systematic implementation of music intervention in three phases. Primary outcomes are adherence to the music intervention and the initial impact of the music intervention implementation on postoperative pain scores on the first postoperative day. At least 100 patients will be included in the study. Secondary outcomes include adherence to the implementation strategy, penetration of music intervention in the standard care, assessment of the determinants for implementation, impact of the implemented music intervention on pain during the entire admission, anxiety, medication usage, complications, hospital and intensive care unit (ICU) length of stay. ETHICS AND DISSEMINATION The Medical Ethics Review Board of Erasmus MC University Medical Centre Rotterdam, The Netherlands, has approved this protocol. The study is being conducted in accordance with the Declaration of Helsinki. Results of this trial will be published in peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION Dutch Trial Register NL8071.
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Affiliation(s)
- Ellaha Kakar
- General Surgery and Intensive Care Unit, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Intensive Care Unit, Erasmus MC, Rotterdam, Netherlands
| | - Erwin Ista
- Intensive Care Unit, Erasmus MC, Rotterdam, Netherlands
- Pediatric surgery, Intensive Care Unit, Internal Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - M Klimek
- Anesthesiology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Johannes Jeekel
- General Surgery and Intensive Care Unit, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Neuroscience, Erasmus MC, Rotterdam, Netherlands
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Lee HJ, Bae E, Lee HY, Lee SM, Lee J. Association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit. Acute Crit Care 2021; 36:332-341. [PMID: 34696555 PMCID: PMC8907453 DOI: 10.4266/acc.2021.00556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients in the intensive care unit (ICU) have increased risks of delirium, which is associated with worse outcomes. As pharmacologic treatments for delirium are ineffective, prevention is important. Nonpharmacologic preventive strategies include exposure to natural light and restoring circadian rhythm. We investigated the effect of exposure to natural light through windows on delirium in the ICU. Methods This retrospective cohort study assessed all patients admitted to the medical ICU of a university-affiliated hospital between January and June 2020 for eligibility. The ICU included 12 isolation rooms, six with and six without windows. Patients with ICU stays of >48 hours were included and were divided into groups based on their admission to a single room with (window group) or without windows (windowless group). The primary outcome was the cumulative incidence of delirium. The secondary outcomes were the numbers of delirium- and mechanical ventilation-free days, ICU and hospital length of stay, and in-ICU and 28-day mortalities. Results Of the 150 included patients (window group: 83 [55.3%]; windowless group: 67 [44.7%]), the cumulative incidence of delirium was significantly lower in the window group than in the windowless group (21.7% vs. 43.3%; relative risk, 1.996; 95% confidence interval [CI], 1.220–3.265). Other secondary outcomes did not differ between groups. Admission to a room with a window was independently associated with a decreased risk of delirium (adjusted odds ratio, 0.318; 95% CI, 0.125–0.805). Conclusions Exposure to natural light through windows was associated with a lower incidence of delirium in the ICU.
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Affiliation(s)
- Hyo Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunhye Bae
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Louzon PR, Heavner MS, Herod K, Wu TT, Devlin JW. Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists. Ann Pharmacother 2021; 56:839-849. [PMID: 34612725 DOI: 10.1177/10600280211048494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. DATA SOURCES Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. STUDY SELECTION AND DATA EXTRACTION Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. DATA SYNTHESIS Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. CONCLUSIONS Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.
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Affiliation(s)
| | | | - Kyle Herod
- Portsmouth Regional Hospital, Portsmouth NH, USA
| | - Ting Ting Wu
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - John W Devlin
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Abstract
Ketamine is increasingly being used for analgosedation, but its effect on delirium remains unclear. We compared delirium risk variables and ketamine analgosedation use between adults who developed incident delirium and those who did not, evaluated whether ketamine analgosedation increases delirium risk, and compared ICU delirium characteristics, treatments, and outcomes between ketamine and nonketamine patients with delirium. DESIGN Secondary, subgroup analysis of a cohort study. SETTING Single, 36-bed mixed medical-surgical ICU in the Netherlands from July 2016 to February 2020. PATIENTS Consecutive adults were included. Patients admitted after elective surgery, not expected to survive greater than or equal to 48 hours, admitted with delirium, or where delirium occurred prior to ketamine use were excluded. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Trained ICU nurses evaluated patients without coma (Richmond Agitation Sedation Scale. -4/-5) every 8 hours with the Confusion Assessment Method ICU; a delirium day was defined by greater than or equal to1 + Confusion Assessment Method ICU and/or scheduled antipsychotic use. Among 11 variables compared between the delirium and nondelirium groups (Baseline: age, Charlson Comorbidity score, cognitive impairment, admission type, and Acute Physiology and Chronic Health Evaluation-IV score, daily ICU [until delirium occurrence or discharge]: Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) and total ICU days, 7 (age, Charlson score, Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) were significantly different and were entered, along with delirium occurrence, in a logistic regression model. A total of 332 of 925 of patients (36%) developed delirium. Ketamine use was greater in patients with delirium (54 [16%] vs 4 [0.7%]; p < 0.01). Ketamine use (adjusted odds ratio, 5.60; 95% CI, 1.09-29.15), age (adjusted odds ratio, 1.03; 95% CI, 1.01-1.06), coma (adjusted odds ratio, 2.10; 95% CI, 1.15-3.78), opioid use (adjusted odds ratio, 171.17; 95% CI, 66.45-553.68), and benzodiazepine use (adjusted odds ratio, 34.07; 95% CI, 8.12-235.34) were each independently and significantly associated with increased delirium. Delirium duration, motoric subtype, delirium treatments, and outcomes were not different between the ketamine and nonketamine groups. CONCLUSIONS Ketamine analgosedation may contribute to increased ICU delirium. The characteristics of ketamine and nonketamine delirium are similar. Further prospective research is required to evaluate the magnitude of risk for delirium with ketamine use.
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Affiliation(s)
- Olivia Geen
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont.
| | - Bram Rochwerg
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont
| | - Xuyi Mimi Wang
- Divisions of Geriatric Medicine (Geen, Wang) and Critical Care Medicine (Rochwerg), Department of Medicine, and Department of Health Research Methods, Impact and Evidence (Rochwerg), McMaster University, Hamilton, Ont
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Palakshappa JA, Hough CL. How We Prevent and Treat Delirium in the ICU. Chest 2021; 160:1326-1334. [PMID: 34102141 PMCID: PMC8727852 DOI: 10.1016/j.chest.2021.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.
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Ragheb J, McKinney A, Zierau M, Brooks J, Hill-Caruthers M, Iskander M, Ahmed Y, Lobo R, Mentz G, Vlisides PE. Delirium and neuropsychological outcomes in critically Ill patients with COVID-19: a cohort study. BMJ Open 2021; 11:e050045. [PMID: 34535480 PMCID: PMC8450964 DOI: 10.1136/bmjopen-2021-050045] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To characterise the clinical course of delirium for patients with COVID-19 in the intensive care unit, including postdischarge neuropsychological outcomes. DESIGN Retrospective chart review and prospective survey study. SETTING Intensive care units, large academic tertiary-care centre (USA). PARTICIPANTS Patients (n=148) with COVID-19 admitted to an intensive care unit at Michigan Medicine between 1 March 2020 and 31 May 2020 were eligible for inclusion. PRIMARY AND SECONDARY OUTCOME MEASURES Delirium was the primary outcome, assessed via validated chart review method. Secondary outcomes included measures related to delirium, such as delirium duration, antipsychotic use, length of hospital and intensive care unit stay, inflammatory markers and final disposition. Neuroimaging data were also collected. Finally, a telephone survey was conducted between 1 and 2 months after discharge to determine neuropsychological function via the following tests: Family Confusion Assessment Method, Short Blessed Test, Patient-Reported Outcomes Measurement Information System Cognitive Abilities 4a and Patient-Health Questionnaire-9. RESULTS Delirium was identified in 108/148 (73%) patients, with median (IQR) duration lasting 10 (4-17) days. In the delirium cohort, 50% (54/108) of patients were African American and delirious patients were more likely to be female (76/108, 70%) (absolute standardised differences >0.30). Sedation regimens, inflammation, delirium prevention protocol deviations and hypoxic-ischaemic injury were likely contributing factors, and the most common disposition for delirious patients was a skilled care facility (41/108, 38%). Among patients who were delirious during hospitalisation, 4/17 (24%) later screened positive for delirium at home based on caretaker assessment, 5/22 (23%) demonstrated signs of questionable cognitive impairment or cognitive impairment consistent with dementia and 3/25 (12%) screened positive for depression within 2 months after discharge. CONCLUSION Patients with COVID-19 commonly experience a prolonged course of delirium in the intensive care unit, likely with multiple contributing factors. Furthermore, neuropsychological impairment may persist after discharge.
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Affiliation(s)
| | - Amy McKinney
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | - Joseph Brooks
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | | | | | - Yusuf Ahmed
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Remy Lobo
- Radiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Graciela Mentz
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Phillip E Vlisides
- Anesthesiology, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, Michigan, USA
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