Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo

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

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

Efficacy and Impact of a Cleaning and Disinfection Protocol for Musical Instruments Used in Music Therapy Services in ICUs: A Prospective Cohort Study

BACKGROUND

Health care-associated infections (HAIs) can affect patient safety and recovery. Musical instruments used by music therapy services may carry pathogens, particularly in ICUs. The aim of this study was to determine the efficacy of the cleaning and disinfection protocol by the music therapy service of the University Hospital Fundación Santa Fe de Bogotá.

METHODS

This prospective cohort study included all ICU music therapy patients from July to August 2023. Adenosine triphosphate (ATP) bioluminescence tests and microbiological cultures were taken before and after cleaning the musical instruments for nine patients in the adult and pediatric ICUs. ATPs were taken before starting music therapy, after finishing music therapy, and after cleaning the instruments. Cultures were taken if an ATP test was above the established cutoff of ≤ 200 relative light units (RLUs). If no ATP value was above the cutoff, cultures were taken randomly.

RESULTS

A total of 63 ATPs and 10 random microbiological cultures were taken. After applying the cleaning and disinfection protocol, all ATP values were ≤ 200 RLUs. Of the 10 microbiological cultures, 1 screened positive for Streptococcus sp., yeast, and Micrococcus. One hundred ICU music therapy patients were followed up, and positive associations with HAIs were found for age (p = 0.01), type of unit (p = 0.001), tracheostomy (p < 0.001), arterial line (p = 0.005), hemodialysis catheter (p = 0.05), bladder catheter (p = 0.02), number of invasive devices (p = 0.02), duration use of invasive devices (p = 0.01), and days of hospitalization (p = 0.01). Number of music therapy sessions/patient was not associated with HAIs (p = 0.86).

CONCLUSION

The results indicate that the current cleaning and disinfection protocol can be considered safe and effective. To the authors' knowledge, this is one of the first studies investigating biosafety of musical instruments in a hospital-based music therapy service. Patient safety is of the utmost importance in hospital settings, and awareness about proper cleaning of their work tools among music therapists is paramount.

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews

BACKGROUND

Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.

OBJECTIVES

The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.

METHODS

A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.

RESULTS

Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.

CONCLUSIONS

Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.

Dexmedetomidine versus haloperidol for sedation of non-intubated patients with hyperactive delirium during the night in a high dependency unit: study protocol for an open-label, parallel-group, randomized controlled trial (DEX-HD trial)

BACKGROUND

Delirium is common in critically ill patients. Haloperidol has long been used for the treatment of delirium. Dexmedetomidine has recently been used to treat delirium among intubated critically ill patients. However, the efficacy of dexmedetomidine for delirium in non-intubated critically ill patients remains unknown. We hypothesize that dexmedetomidine is superior to haloperidol for sedation of patients with hyperactive delirium, and would reduce the prevalence of delirium among non-intubated patients after administration. We will conduct a randomized controlled trial to compare dexmedetomidine and haloperidol for the treatment of nocturnal hyperactive delirium in non-intubated patients in high dependency units (HDUs).

METHODS

This is an open-label, parallel-group, randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for nocturnal hyperactive delirium in non-intubated patients at two HDUs of a tertiary hospital. We will recruit consecutive non-intubated patients who are admitted to the HDU from the emergency room, and allocate them in a 1:1 ratio to the dexmedetomidine or haloperidol group in advance. The allocated investigational drug will be administered only when participants develop hyperactive delirium (Richmond Agitation-Sedation Scale [RASS] score ≥1 and a positive score on the Confusion Assessment Method for the ICU between 19:00 and 6:00 the next day) during the night at an HDU. Dexmedetomidine is administered continuously, while haloperidol is administered intermittently. The primary outcome is the proportion of participants who achieve the targeted sedation level (RASS score of between -3 and 0) 2h after the administration of the investigational drug. Secondary outcomes include the sedation level and prevalence of delirium on the day following the administration of the investigational drugs, and safety. We plan to enroll 100 participants who develop nocturnal hyperactive delirium and receive one of the two investigational drugs.

DISCUSSION

This is the first randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for sedation of non-intubated critically ill patients with hyperactive delirium in HDUs. The results of this study may confirm whether dexmedetomidine could be another option to sedate patients with hyperactive delirium.

TRIAL REGISTRATION

Japan Registry of Clinical Trials, jRCT1051220015, registered on 21 April 2022.

Sedation level with midazolam: a pediatric surgery approach

Midazolam (MDZ) is a short-acting benzodiazepine that is widely used to induce and maintain general anesthesia during diagnostic and therapeutic procedures in pediatric patients due to its sedative properties. The aim of this study was to perform a systematic review without a meta-analysis to identify scientific articles and clinical assays concerning MDZ-induced sedation for a pediatric surgery approach. One hundred and twenty-eight results were obtained. After critical reading, 37 articles were eliminated, yielding 91 publications. Additional items were identified, and the final review was performed with a total of 106 publications.

In conclusion, to use MDZ accurately, individual patient characteristics, the base disease state, comorbidities, the treatment burden and other drugs with possible pharmacological interactions or adverse reactions must be considered to avoid direct alterations in the pharmacokinetics and pharmacodynamics of MDZ to obtain the desired effects and avoid overdosing in the pediatric population.

Can ultrasound-guided infraclavicular block be an alternative option for forearm reduction in the emergency department? A prospective randomized study

Objective

Ultrasound-guided infraclavicular nerve block (IB) has become a well-established method in several outpatient procedures; however, its use in emergency departments (EDs) remains limited. The aim of this study was to compare procedural sedation and anlagesia (PSA) and IB in the pain management for patients who underwent forearm fracture reduction in the ED.

Methods

This prospective randomized study included 60 patients aged 18 to 65 years, who visited the ED with forearm fractures. They were randomly divided into two groups: Group PSA (n=30) and Group IB (n=30). The pain scores of patients were evaluated before and during the procedure with the visual analog scale. Complications and patient and operator satisfaction levels were recorded.

Results

There was no difference between the two groups in terms of demographic characteristics. The median (interquartile range) pain scores observed during the procedures were significantly higher in Group PSA than in Group IB (4 [4–6] vs. 2 [0–2], respectively; P<0.001). Patient and operator satisfaction levels were significantly higher in Group IB (P<0.001). Oxygen desaturation was statistically higher in Group PSA than in Group IB (40.00% vs. 3.33%, respectively; P=0.002).

Conclusion

IB was an effective alternative for reducing pain and increasing patient satisfaction in ED patients undergoing forearm fracture reduction.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

Comparison of isoflurane and propofol sedation in critically ill COVID-19 patients-a retrospective chart review

Purpose

In this retrospective study, we compared inhaled sedation with isoflurane to intravenous propofol in invasively ventilated COVID-19 patients with ARDS (Acute Respiratory Distress Syndrome).

Methods

Charts of all 20 patients with COVID-19 ARDS admitted to the ICU of a German University Hospital during the first wave of the pandemic between 22/03/2020 and 21/04/2020 were reviewed. Among screened 333 days, isoflurane was used in 97 days, while in 187 days, propofol was used for 12 h or more. The effect and dose of these two sedatives were compared. Mixed sedation days were excluded.

Results

Patients’ age (median [interquartile range]) was 64 (60–68) years. They were invasively ventilated for 36 [21–50] days. End-tidal isoflurane concentrations were high (0.96 ± 0.41 Vol %); multiple linear regression yielded the ratio (isoflurane infusion rate)/(minute ventilation) as the single best predictor. Infusion rates were decreased under ECMO (3.5 ± 1.4 versus 7.1 ± 3.2 ml∙h⁻¹; p < 0.001). In five patients, the maximum recommended dose of propofol of 4 mg∙hour⁻¹∙kg⁻¹ABW was exceeded on several days. On isoflurane compared to propofol days, neuro-muscular blocking agents (NMBAs) were used less frequently (11% versus 21%; p < 0.05), as were co-sedatives (7% versus 31%, p < 0.001); daily opioid doses were lower (720 [720–960] versus 1080 [720–1620] mg morphine equivalents, p < 0.001); and RASS scores indicated deeper levels of sedation (− 4.0 [− 4.0 to − 3.0] versus − 3.0 [− 3.6 to − 2.5]; p < 0.01).

Conclusion

Isoflurane provided sufficient sedation with less NMBAs, less polypharmacy and lower opioid doses compared to propofol. High doses of both drugs were needed in severely ill COVID-19 patients.

Reflection Versus Rebreathing for Administration of Sevoflurane During Minor Gynecological Surgery

BACKGROUND

Contemporary anesthetic circle systems, when used at low fresh gas flows (FGF) to allow rebreathing of anesthetic, lack the ability for rapid dose titration. The small-scale anesthetic reflection device Anaesthetic Conserving Device (50mL Version; AnaConDa-S) permits administration of volatile anesthetics with high-flow ventilators. We compared washin, washout, and sevoflurane consumption using AnaConDa-S versus a circle system with low and minimal FGF.

METHODS

Forty patients undergoing breast surgery were randomized to receive 0.5 minimal alveolar concentration (MAC) sevoflurane with AnaConDa-S (21 patients, reflection group) or with a circle system (low flow: FGF = 0.2 minute ventilation [V'E], 9 patients; or minimal flow: 0.1 V'E, 10 patients). In the reflection group, syringe pump boluses were given for priming and washin; to simulate an open system, the FGF of the anesthesia ventilator was set to 18 L·min-1 with the soda lime removed. In the other groups, the FGF was increased for washin (1 V'E for 8 minutes) and washout (3 V'E). For all patients, tidal volume was 7 mL·kg-1 and the respiratory rate adjusted to ensure normoventilation. Analgesia was attained with remifentanil 0.3 µg·kg-1·min-1. Sevoflurane consumption was compared between the reflection group and the low- and minimal-flow groups, respectively, using a post hoc test (Fisher Least Significant Difference). To compare washin and washout (half-life), the low- and minimal-flow groups were combined.

RESULTS

Sevoflurane consumption was reduced in the reflection group (9.4 ± 2.0 vs 15.0 ± 3.5 [low flow, P < .001] vs 11.6 ± 2.3 mL·MAC h-1 [minimal flow, P = .02]); washin (33 ± 15 vs 49 ± 12 seconds, P = .001) and washout (28 ± 15 vs 55 ± 19 seconds, P < .001) times were also significantly shorter.

CONCLUSIONS

In this clinical setting with short procedures, low anesthetic requirements, and low tidal volumes, AnaConDa-S decreased anesthetic consumption, washin, and washout times compared to a circle system.

[Treatment of extreme anemia with polymerized bovine hemoglobin : Case report and review of the literature]

This article reports the case of a 29-year-old female Jehovah's Witness with severe anemia after intrauterine fetal death in the 25th week of gestation, complicated by vaginal bleeding, acute renal failure and hemolysis. Due to her religious beliefs the patient categorically refused blood transfusions. Despite adhering to the recommendations for patient blood management, the hemoglobin (Hb) level gradually decreased to 1.9 g/dl on day 10, when she fainted and had to be sedated and invasively ventilated. Inhalative isoflurane was chosen for sedation because of its potential organ-protective effects and because it provides deep sedation with reduced oxygen requirements, while enabling rapid neurological examination during the sedation windows as well as regular and calm spontaneous breathing. Posthypoxic encephalopathy was demonstrated clinically and electroencephalographically by seizure activity during the sedation windows. Anticonvulsive treatment was started. At a hemoglobin of 1.8 g/dl, she received 2 units of polymerized bovine hemoglobin (Hemopure®, Hemoglogin Oxygen Therapeutics LLC, Souderton, PA, USA), repeated several times on subsequent days because of its short half-life. Considerable methemoglobinemia was noted. After subtracting methemoglobin, the hemoglobin rose by 0.4-0.8 g/dl after each 2 units, initially increasing the oxygen binding capacity of the blood by 33%. After a full neurological recovery and weaning from the ventilator but still on hemodialysis, the patient was transferred to another hospital after 38 days.If allogeneic blood transfusion is not an option, administration of polymerized bovine hemoglobin can temporarily increase the oxygen transport capacity as a last resort treatment. Reduction of oxygen requirements by deep inhaled sedation with isoflurane also seems beneficial and provides advantages.

Washout and Awakening Times after Inhaled Sedation of Critically Ill Patients: Desflurane Versus Isoflurane

In recent years, inhaled sedation has been increasingly used in the intensive care unit (ICU). The aim of this prospective, controlled trial was to compare washout and awakening times after long term sedation with desflurane and isoflurane both administered with the Mirus™ system (TIM GmbH, Koblenz, Germany). Twenty-one consecutive critically ill patients were alternately allocated to the two study groups, obtaining inhaled sedation with either desflurane or isoflurane. After 24 h study sedation, anesthetic washout curves were recorded, and a standardized wake-up test was performed. The primary outcome measure was the time required to decrease the endtidal concentration to 50% (T50%). Secondary outcome measures were T80% and awakening times (all extremities moved, RASS -2). Decrement times (min) (desflurane versus isoflurane, median (1st quartile-3rd quartile)) (T50%: 0.3 (0.3-0.4) vs. 1.3 (0.4-2.3), log-rank test P = 0.002; P80%: 2.5 (2-5.9) vs. 12.1 (5.1-20.2), P = 0.022) and awakening times (to RASS -2: 7.5 (5.5-8.8) vs. 41.0 (24.5-43.0), P = 0.007; all extremities moved: 5.0 (4.0-8.5) vs. 13.0 (8.0-41.25), P = 0.037) were significantly shorter after desflurane compared to isoflurane. The use of desflurane with the Mirus™ system significantly shortens the washout times and leads to faster awakening after sedation of critically ill patients.

Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

OBJECTIVE

To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources.

METHODS

A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva.

RESULTS

Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19.

DISCUSSION

Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.

An overview of management of intracranial hypertension in the intensive care unit

Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.

Halving the Volume of AnaConDa: Evaluation of a New Small-Volume Anesthetic Reflector in a Test Lung Model

BACKGROUND

Volatile anesthetics are increasingly used for sedation in intensive care units. The most common administration system is AnaConDa-100 mL (ACD-100; Sedana Medical, Uppsala, Sweden), which reflects volatile anesthetics in open ventilation circuits. AnaConDa-50 mL (ACD-50) is a new device with half the volumetric dead space. Carbon dioxide (CO2) can be retained with both devices. We therefore compared the CO2 elimination and isoflurane reflection efficiency of both devices.

METHODS

A test lung constantly insufflated with CO2 was ventilated with a tidal volume of 500 mL at 10 breaths/min. End-tidal CO2 (EtCO2) partial pressure was measured using 3 different devices: a heat-and-moisture exchanger (HME, 35 mL), ACD-100, and ACD-50 under 4 different experimental conditions: ambient temperature pressure (ATP), body temperature pressure saturated (BTPS) conditions, BTPS with 0.4 Vol% isoflurane (ISO-0.4), and BTPS with 1.2 Vol% isoflurane. Fifty breaths were recorded at 3 time points (n = 150) for each device and each condition. To determine device dead space, we adjusted the tidal volume to maintain normocapnia (n = 3), for each device. Thereafter, we determined reflection efficiency by measuring isoflurane concentrations at infusion rates varying from 0.5 to 20 mL/h (n = 3), for each device.

RESULTS

EtCO2 was consistently greater with ACD-100 than with ACD-50 and HME (ISO-0.4, mean ± standard deviations: ACD-100, 52.4 ± 0.8; ACD-50, 44.4 ± 0.8; HME, 40.1 ± 0.4 mm Hg; differences of means of EtCO2 [respective 95% confidence intervals]: ACD-100 - ACD-50, 8.0 [7.9-8.1] mm Hg, P < .001; ACD-100 - HME, 12.3 [12.2-12.4] mm Hg, P < .001; ACD-50 - HME, 4.3 [4.2-4.3] mm Hg, P < .001). It was greatest under ATP, less under BTPS, and least with ISO-0.4 and BTPS with 1.2 Vol% isoflurane. In addition to the 100 or 50 mL "volumetric dead space" of each AnaConDa, "reflective dead space" was 40 mL with ACD-100 and 25 mL with ACD-50 when using isoflurane. Isoflurane reflection was highest under ATP. Under BTPS with CO2 insufflation and isoflurane concentrations around 0.4 Vol%, reflection efficiency was 93% with ACD-100 and 80% with ACD-50.

CONCLUSIONS

Isoflurane reflection remained sufficient with the ACD-50 at clinical anesthetic concentrations, while CO2 elimination was improved. The ACD-50 should be practical for tidal volumes as low as 200 mL, allowing lung-protective ventilation even in small patients.

Oversedation Zero as a tool for comfort, safety and intensive care unit management

Sedation is necessary in the management of critically ill patients, both to alleviate suffering and to cure patients with diseases that require admission to the intensive care unit. Such sedation should be appropriate to the patient needs at each timepoint during clinical evolution, and neither too low (undersedation) nor too high (oversedation). Adequate sedation influences patient comfort, safety, survival, subsequent quality of life, bed rotation of critical care units and costs. Undersedation is detected and quickly corrected. In contrast, oversedation is silent and difficult to prevent in the absence of management guidelines, collective awareness and teamwork. The Zero Oversedation Project of the Sedation, Analgesia and Delirium Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units aims to offer a practical teaching and collective awareness tool for ensuring patient comfort, safety and management with a view to optimizing the clinical outcomes and minimizing the deleterious effects of excessive sedation. The tool is based on a package of measures that include monitoring pain, analgesia, agitation, sedation, delirium and neuromuscular block, keeping patients pain-free, performing dynamic sedation according to clinical objectives, agreeing upon the multidisciplinary protocol to be followed, and avoiding deep sedation where not clinically indicated.

Dexmedetomidine implementation in pain management in the immediate postoperative period of cardiac surgery

BACKGROUND

This study arose from the need to improve all tasks related to monitoring pain in post cardiac surgery patients.

OBJECTIVES

Checking and quantifying the pain suffered by patients undergoing cardiac surgery in the first 24hours of their stay in the intensive care unit (ICU), treated with Dexmedetomidine (Dex) as analgesic adjuvant, as well as their degree of sedation and the need for opiates such as rescue analgesia.

MATERIAL AND METHODS

Unicentric study, observational, descriptive, from April 2016 to September 2017. Both genders, all adult, undergoing cardiac surgery, operating theatre-extubated and Dex continuous infusion carriers. Pain degree level was evaluated by the Visual analogue Scale of Pain (VAS), from immediately post-surgery until 24hours from ICU entry and sedation degree, by the Richmond Sedation Agitation Scale (RASS), only while the Dex infusion lasted.

RESULTS

109 patients were included. The results obtained showed that the average pain suffered by patients during the first 24hours was .47 with standard deviation (SD) of 1.25; the average maximum pain experienced was 3.58 with a range of 0 to 8 and the RASS average was -.68 (SD: 0,80). In addition, 44.04% of the patients needed rescue opiates, although only 7.32% showed severe pain greater than 6.

CONCLUSIONS

The Dex infusion patients showed mild levels of pain, however, a small percentage, who must be taken into account, suffered severe pain.

ICU Physicians' Perception of Patients' Tolerance Levels in Light Sedation Impacts Sedation Practice for Mechanically Ventilated Patients

Purpose: To investigate physicians' perception of patients' tolerance levels regarding sedation, which could affect sedation practice for mechanically ventilated (MV) patients.

Methods: This is a questionnaire survey combined with a 24 h cross-sectional study. The physician's propensity score for light sedation (PS-_LS) was estimated by his/her response to the given answers for each item of the questionnaire, which tested the levels of interviewee's desire to manage MV patient with light sedation. Thereby, the mean physicians' PS-_LS of each participating ICU (ICU-_meanPS-_LS) was calculated. The practical measurements of all variables listed on the questionnaire were used to semi-quantitatively assess stimulus intensity of what the recruited patients suffered (i.e., semi-quantitative stimulus intensity, SSI). Sedation depth was assessed by Richmond Agitation Sedation Scale (RASS).

Results: 555 of 558 (99.5%) physicians from 102 ICUs were concerned with patients' tolerance levels regarding sedation while titrating sedation depth. The physician's PS-_LS was non-normally distributed with median (IQR) of 3 (0–5). ICU-_meanPS-_LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from −5 to 7 with a median (IQR) of 2.37 (0.16–4.33). A significant increasing trend in prevalence of light sedation was observed over increasing ICU-_meanPS-_LS quartiles (from Q1 to Q4, χ²-test for trend, p = 0.002). Moreover, odds ratio for probability of light sedation remained significant in MV patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE II score (OR, 2.332; 95% CI: 1.463–3.717; p < 0.001) or SSI score (OR, 2.445; 95% CI: 1.468–4.074; p = 0.001). Notably, adjusted OR for mortality was significant in deeply sedated MV patients (OR, 2.034; 95% CI: 1.435–2.884; p < 0.001).

Conclusions: ICU physician's individualized perception for patients' tolerance levels regarding sedation, in light sedation affected sedation practice for MV patients.

Intravenous Oxycodone Versus Other Intravenous Strong Opioids for Acute Postoperative Pain Control: A Systematic Review of Randomized Controlled Trials

Introduction

Optimal pain management is crucial to the postoperative recovery process. We aimed to evaluate the efficacy and safety of intravenous oxycodone with intravenous fentanyl, morphine, sufentanil, pethidine, and hydromorphone for acute postoperative pain.

Methods

A systematic literature search of PubMed, Cochrane Library, and EMBASE databases was performed for randomized controlled trials published from 2008 through 2017 (inclusive) that evaluated the acute postoperative analgesic efficacy of intravenous oxycodone against fentanyl, morphine, sufentanil, pethidine, and hydromorphone in adult patients (age ≥ 18 years). Outcomes examined included analgesic consumption, pain intensity levels, side effects, and patient satisfaction.

Results

Eleven studies were included in the review; six compared oxycodone with fentanyl, two compared oxycodone with morphine, and three compared oxycodone with sufentanil. There were no eligible studies comparing oxycodone with pethidine or hydromorphone. Overall, analgesic consumption was lower with oxycodone than with fentanyl or sufentanil. Oxycodone exhibited better analgesic efficacy than fentanyl and sufentanil, and comparable analgesic efficacy to morphine. In terms of safety, there was a tendency towards more side effects with oxycodone than with fentanyl, but the incidence of side effects with oxycodone was comparable to morphine and sufentanil. Where patient satisfaction was evaluated, higher satisfaction levels were observed with oxycodone than with sufentanil and comparable satisfaction was noted when comparing oxycodone with fentanyl. Patient satisfaction was not evaluated in the studies comparing oxycodone with morphine.

Conclusions

Our findings suggest that intravenous oxycodone provides better analgesic efficacy than fentanyl and sufentanil, and comparable efficacy to morphine with less adverse events such as sedation. No studies comparing intravenous oxycodone with pethidine or hydromorphone were identified in this review. Better alignment of study methodologies for future research in this area is recommended to provide the best evidence base for a meta-analysis.

Funding

Mundipharma Singapore Holding Pte Ltd, Singapore.

Electronic supplementary material

The online version of this article (10.1007/s40122-019-0122-4) contains supplementary material, which is available to authorized users.

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Enteral versus intravenous approach for the sedation of critically ill patients: a randomized and controlled trial

Background

ICU patients must be kept conscious, calm, and cooperative even during the critical phases of illness. Enteral administration of sedative drugs might avoid over sedation, and would be as adequate as intravenous administration in patients who are awake, with fewer side effects and lower costs. This study compares two sedation strategies, for early achievement and maintenance of the target light sedation.

Methods

This was a multicenter, single-blind, randomized and controlled trial carried out in 12 Italian ICUs, involving patients with expected mechanical ventilation duration > 72 h at ICU admission and predicted mortality > 12% (Simplified Acute Physiology Score II > 32 points) during the first 24 h on ICU. Patients were randomly assigned to receive intravenous (midazolam, propofol) or enteral (hydroxyzine, lorazepam, and melatonin) sedation. The primary outcome was percentage of work shifts with the patient having an observed Richmond Agitation-Sedation Scale (RASS) = target RASS ±1. Secondary outcomes were feasibility, delirium-free and coma-free days, costs of drugs, length of ICU and hospital stay, and ICU, hospital, and one-year mortality.

Results

There were 348 patients enrolled. There were no differences in the primary outcome: enteral 89.8% (74.1–100), intravenous 94.4% (78–100), p = 0.20. Enteral-treated patients had more protocol violations: n = 81 (46.6%) vs 7 (4.2%), p < 0.01; more self-extubations: n = 14 (8.1%) vs 4 (2.4%), p = 0.03; a lighter sedative target (RASS = 0): 93% (71–100) vs 83% (61–100), p < 0.01; and lower total drug costs: 2.39 (0.75–9.78) vs 4.15 (1.20–20.19) €/day with mechanical ventilation (p = 0.01).

Conclusions

Although enteral sedation of critically ill patients is cheaper and permits a lighter sedation target, it is not superior to intravenous sedation for reaching the RASS target.

Trial registration

ClinicalTrials.gov, NCT01360346. Registered on 25 March 2011.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2280-x) contains supplementary material, which is available to authorized users.

Volumetric and reflective device dead space of anaesthetic reflectors under different conditions

Inhalation sedation is increasingly performed in intensive care units. For this purpose, two anaesthetic reflectors, AnaConDa™ and Mirus™ are commercially available. However, their internal volume (100 ml) and possible carbon dioxide reflection raised concerns. Therefore, we compared carbon dioxide elimination of both with a heat moisture exchanger (HME, 35 ml) in a test lung model. A constant flow of carbon dioxide was insufflated into the test lung, ventilated with 500 ml, 10 breaths per minute. HME, MIRUS and AnaConDa were connected successively. Inspired (insp-CO2) and end-tidal carbon dioxide concentrations (et-CO2) were measured under four conditions: ambient temperature pressure (ATP), body temperature pressure saturated (BTPS), BTPS with 0.4 Vol% (ISO-0.4), and 1.2 Vol% isoflurane (ISO-1.2). Tidal volume increase to maintain normocapnia was also determined. Insp-CO2 was higher with AnaConDa compared to MIRUS and higher under ATP compared to BTPS. Isoflurane further decreased insp-CO2 and abolished the difference between AnaConDa and MIRUS. Et-CO2 showed similar effects. In addition to volumetric dead space, reflective dead space was determined as 198 ± 6/58 ± 6/35 ± 0/25 ± 0 ml under ATP/BTPS/ISO-0.4/ISO-1.2 conditions for AnaConDa, and 92 ± 6/25 ± 0/25 ± 0/25 ± 0 ml under the same conditions for MIRUS, respectively. Under BTPS conditions and with the use of moderate inhaled agent concentrations, reflective dead space is small and similar between the two devices.

Impact of a remifentanil supply shortage on mechanical ventilation in a tertiary care hospital: a retrospective comparison

Background

The continuous administration of opioids in critical care patients is a common therapy for the tolerance of mechanical ventilation. Opioid choice has a crucial impact on the length of mechanical ventilation. Owing to its very short context-sensitive half-life, remifentanil widens the available options for sedoanalgetic strategies. Supply disruption of such established intensive care medication has been reported to worsen clinical outcomes.

Methods

This retrospective study investigated the influence of a nationwide supply shortage of remifentanil on mechanical ventilation and ventilation-associated outcomes at three perioperative intensive care units (ICUs) in a tertiary care hospital in Vienna. Two groups were followed: patients admitted to the ICU during the remifentanil shortage (July 1, 2016 to September 30, 2016) and a control group one year after the remifentanil shortage (July 1, 2017 to September 30, 2017). Included patients were adults, received mechanical ventilation for at least 6 h, were admitted less than 90 days in the respective ICU, and survived their admission.

Results

For comparison, Poisson count regression models and logistic regression models were computed. To compensate for multiple testing, the significance level was split (0.02 for the primary and 0.006 for secondary outcome parameters). Patients in the remifentanil shortage group received significantly longer mechanical ventilation (risk ratio 2.19, 95% confidence interval 2.14–2.24, P <0.001) with significantly prolonged ICU stay (P <0.001), days with non-invasive ventilation (P <0.001), and length of hospital stay (P <0.001). No significant difference was found in the occurrence of pneumonia (P = 0.040) and sepsis (P = 0.061). A greater proportion of patients in the shortage group underwent secondary tracheostomy (P <0.001).

Conclusions

The remifentanil shortage caused a significant impairment of essential outcome parameters in the ICU.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2198-3) contains supplementary material, which is available to authorized users.

Pain Assessment in Mechanically Ventilated, Noncommunicative Severe Trauma Patients

The aim of this study was to measure pain levels in noncommunicative patients with severe trauma who required tracheal suctioning and mobilization and to determine the utility of the Behavioral Indicators of Pain Scale (ESCID) in these cases. The pain scores for the procedures were recorded on Days 1, 3, and 6 of the patients' stay in the intensive care unit. These assessments were performed at 3 moments: before, during, and after the application of the procedures. Because of the longitudinal character of the study, data were fitted into a multivariate model using the Generalized Estimating Equations method. The sample of 124 patients comprised 77.4% males and 22.6% females with an average age of 45.93 (SD = 16.43) years. A significant increase (p < .01) in the ESCID score was observed during the application of the procedures that produced similar pain levels. Kappa coefficient value obtained for interobserver agreement of ESCID scale scores during the application of care procedures at the intervals being evaluated was greater than 0.84, which should be interpreted as almost perfect. The ESCID scores increased during 2 care procedures that are frequently carried out in intensive care units and indicated that they produced similar pain levels.

Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach

Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.

Halving the volume of AnaConDa: initial clinical experience with a new small-volume anaesthetic reflector in critically ill patients-a quality improvement project

AnaConDa-100 ml (ACD-100, Sedana Medical, Uppsala, Sweden) is well established for inhalation sedation in the intensive care unit. But because of its large dead space, the system can retain carbon dioxide (CO2) and increase ventilatory demands. We therefore evaluated whether AnaConDa-50 ml (ACD-50), a device with half the internal volume, reduces CO2 retention and ventilatory demands during sedation of invasively ventilated, critically ill patients. Ten patients participated in this cross-over protocol. After sedation with isoflurane via ACD-100 for 24 h, the 5-h observation period started. During the first hour, ACD-100 was used; for the next 2 h, ACD-50; and for the last 2 h, ACD-100 was used again. Sedation was titrated to Richmond Agitation and Sedation Scale (RASS) score - 3 to - 4 and a processed electroencephalogram (Narcotrend Index, Narcotrend-Gruppe, Hannover, Germany) was recorded. Minute ventilation, CO2 elimination, and isoflurane consumption were compared. All patients were deeply sedated (Narcotrend Index, mean ± SD: 38 ± 10; RASS scores - 3 to - 5) and breathed spontaneously with pressure support throughout the observation period. Infusion rates of isoflurane and opioid, either remifentanil or sufentanil, as well as ventilator settings were unchanged. Minute ventilation and end-tidal CO2 were significantly reduced with the ACD-50, respiratory rate remained unchanged, and tidal volume decreased by 66 ± 43 ml. End-tidal isoflurane concentrations were also slightly reduced while haemodynamic measures remained constant. The ACD-50 reduces the tidal volume needed to eliminate carbon dioxide without augmenting isoflurane consumption.

Factors associated with delirium in critical patients in a health institution in Bucaramanga, Colombia

OBJECTIVE

To determine the incidence and the factors associated with delirium in intensive care unit patients.

METHODS

A cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia., who were recruited in the first 24hours following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU.

RESULTS

The incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk(RR) 2.4, 95% confidence interval (95% CI) = 1.2-4.5), infection (RR = 2. 8, 95% CI=1.3-5.9), metabolic acidosis (RR = 4 3, 95% CI=2.3-8.0), mechanical ventilation (RR = 4 6, 95% CI=2.0-10.6), aged over 60 years (RR = 2 3, 95% CI=1.09-5.3) and APACHE score greater than 14 (RR = 3. 0) (95% CI=1.1-8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR = 3 8, 95% CI=1.6-9.1) and being aged over 60 years (RR = 3 2, 95% CI 1.2-8.3).

CONCLUSIONS

delirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients.

"Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.

Comodidad del paciente en una unidad de cuidado intensivo cardiovascular

Los pacientes con enfermedad cardiovascular pueden requerir hospitalización en Unidad de Cuidado Intensivo cardiovascular (UCIC), generando incomodidad a múltiples niveles. Enfermería como disciplina brinda cuidado para recuperar la comodidad. Es necesario reconocer la comodidad como compleja y multidimensional, requiere ser estudiada desde una postura epistémica interpretativa con el complemento objetivo que ofrece la indagación cuantitativa.Objetivo: Describir la comodidad y los factores que la afectan en el paciente adulto hospitalizado en una UCIC.Metodología: Enfoque mixto que implicó un estudio cualitativo y la recolección de datos cuantitativos de manera paralela para realizar un análisis independiente y mayor. Muestra correspondiente a 45 personas participaciones, hospitalizadas en los meses de diciembre de 2015 y enero de 2016 en un hospital de cuarto nivel en Bogotá. Se aplicó una entrevista semiestructurada y el instrumento de comodidad (GCQ) de Kolcaba.Resultados: Se obtuvieron seis categorías y dieciséis códigos, los factores que alteraron la comodidad fueron percepción de no poder realizar actividades; sentirse encerrado, percepción de mucho ruido o el tener que hacer sus funciones corporales ante personas desconocidas. Los factores que mejoran la comodidad están: poder contar con el apoyo de otra persona y el apoyo espiritual. Según el cuestionario GCQ las necesidades de comodidad están a un nivel medio-alto y alto.Conclusiones: El nivel de comodidad fue alto, el ámbito más comprometido fue el físico. La metodología mixta permitió describir de manera completa la comodidad de las personas en la UCIC.

Comparison of clinical practice guidelines for the management of pain, agitation, and delirium in critically ill adult patients

Guideline‐based management approaches for pain, agitation, and delirium (PAD) in critically ill adult patients are widely believed to result in good outcomes. However, there are some differences in the recommendations and evidence levels among the management guidelines established for PAD. To identify and compare the current management guidelines, we used the PubMed database. The PAD guidelines and Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva (FEPIMCTI) guidelines were identified from our search. We compared the main aspects of these two guidelines as well as the Japanese guidelines for the management of PAD (J‐PAD guidelines). The PAD, FEPIMCTI, and J‐PAD guidelines contained a total of 4, 12, and 5 sections, having 32, 138, and 37 recommendations, respectively, pertaining to routine monitoring of pain in adult patients in the intensive care unit. Intravenous opioids were recommended as the first‐line drug of choice for treating pain. Sedative titrated to maintain a light, rather than deep, level of sedation can be given unless clinically contraindicated. Although neither the PAD nor J‐PAD guidelines recommend use of a pharmacologic delirium prevention protocol or treatment with any pharmacological agent to reduce the duration of delirium, the FEPIMCTI guidelines provide such recommendations. The FEPIMCTI guidelines provide suggestions on which analgesics to use for several different cases and present algorithms for sedation and analgesia. The outlines of the three guidelines are similar, and all reinforce the management of PAD to improve patient outcomes.

Ethics research in critically ill patients

Research in critical care patients is an ethical obligation. The ethical conflicts of intensive care research arise from patient vulnerability, since during ICU admission these individuals sometimes lose all or part of their decision making capacity and autonomy. We therefore must dedicate effort to ensure that neither treatment (sedation or mechanical ventilation) nor the disease itself can affect the right to individual freedom of the participants in research, improving the conditions under which informed consent must be obtained. Fragility, understood as a decrease in the capacity to tolerate adverse effects derived from research must be taken into account in selecting the participants. Research should be relevant, not possible to carry out in non-critical patients, and a priori should offer potential benefits that outweigh the risks that must be known and assumable, based on principles of responsibility.

The early diagnosis and management of mixed delirium in a patient placed on ECMO and with difficult sedation: A case report

Delirium represents a serious problem that impacts the physical and cognitive prognosis of patients admitted to intensive care units and requires prompt diagnosis and management. This article describes the case and progress of a patient placed on Extracorporeal Membrane Oxygenation with difficult sedation criteria and an early diagnosis of mixed delirium. During the case report, we reflect on the pharmacological and non-pharmacological strategies employed to cope with delirium paying special attention to the non-use of physical restraint measures in order to preserve vital support devices (endotracheal tube or Extracorporeal Membrane Oxygenation cannula). The multimodal and multidisciplinary approach, focused on nursing interventions, strict Pain/Agitation/Delirium monitoring and pharmacological measures, as well as the implementation of measures according to the eCASH (early Comfort using Analgesia, minimal Sedatives and maximal Human Care) concept, were effective, resulting in a relatively short admission considering the severity of the patient's condition and the associated complications. Early independent ambulation was achieved prior to transfer to a hospitalisation unit.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Modifiable Risk Factors for Delirium in Critically Ill Trauma Patients: A Multicenter Prospective Study

OBJECTIVE:

Intensive care unit (ICU)-acquired delirium has been associated with increased morbidity and mortality. Prevention strategies including modification of delirium risk factors are emphasized by practice guidelines. No study has specifically evaluated modifiable delirium risk factors in trauma ICU patients. Our goal was to evaluate modifiable risk factors for delirium among trauma patients admitted to the ICU.

DESIGN:

Prospective observational study.

SETTING:

Two level 1 trauma ICU centers.

PATIENTS:

Patients 18 years of age or older admitted for trauma including mild to moderate traumatic brain injury were eligible for the study.

INTERVENTIONS AND MEASUREMENTS:

Delirium was assessed daily using the confusion assessment method for the ICU (CAM-ICU). The effect of modifiable risk factors was assessed using multivariate Cox regression analysis adjusting for severity of illness and significant nonmodifiable risk factors.

MAIN RESULTS:

A total of 58 of 150 recruited patients (38.7%; 95% confidence interval [CI] 30.9-46.5) screened positive for delirium during ICU stay. When adjusting for significant nonmodifiable risk factors, physical restraints (hazard ratio [HR]: 2.13; 95% CI: 1.07-4.24) and active infection or sepsis (HR: 2.12; 95% CI: 1.18-3.81) significantly increased the risk of delirium, whereas opioids (HR: 0.35; 95% CI: 0.13-0.98), episodes of hypoxia (HR: 0.55; 95% CI: 0.31-0.95), access to a television/radio in the room (HR: 0.26; 95% CI: 0.11-0.62), and number of hours mobilized per day (HR: 0.77; 95% CI: 0.68-0.88) were associated with significantly less risk of delirium.

CONCLUSION:

We have identified modifiable risk factors for delirium. Future studies should aim at implementing strategies to modify these risk factors and evaluate their impact on the risk of delirium.

Characterization of Guideline Evidence for Off-label Medication Use in the Intensive Care Unit

BACKGROUND

Non-Food and Drug Administration (FDA) or off-label medication prescribing occurs commonly in the intensive care unit (ICU). Off-label medication use creates a concern for untoward adverse effects; however, this worry may be alleviated by supportive literature.

OBJECTIVE

To evaluate the evidence behind off-label medication use by determining the presence of guideline support and compare graded recommendations to an online tertiary resource, DRUGDEX.

METHODS

Off-label medication use was identified prospectively over 3 months in medical ICUs in 3 academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website to determine the presence of guideline support. DRUGDEX was also searched for strength-of-evidence ratings to serve as a comparator.

RESULTS

A total of 287 off-label medication indication searches resulted in 44% (126/287) without identified evidence; 253 guidelines were identified for 56% (161/287) of indications. Of the published guidelines, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, whereas 33% (47/144) of the gradings matched the online database.

CONCLUSION

Because more than half of off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines to inform off-label medication use in the ICU. Still, there is a considerable amount of off-label medication use in the ICU that lacks supporting evidence, and use remains concerning because it may lead to inappropriate treatment and adverse events.

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients

OBJECTIVE

To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients.

DESIGN

A multicentre, prospective observational study was designed to validate a scale measuring instrument.

SETTING

Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System.

PARTICIPANTS

A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients.

PROCEDURE

Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure.

MAIN VARIABLES

ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS.

RESULTS

A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88).

CONCLUSION

ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.