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Alkhateeb T, Stollings JL, Sohn I, Liu D, Fleenor LM, Ely EW, Lahiri S. Tocilizumab is associated with reduced delirium and coma in critically ill patients with COVID-19. Sci Rep 2024; 14:11738. [PMID: 38778074 PMCID: PMC11111809 DOI: 10.1038/s41598-024-62505-1] [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] [Received: 11/29/2023] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Recent preclinical studies demonstrate a direct pathological role for the interleukin-6 (IL-6) pathway in mediating structural and functional delirium-like phenotypes in animal models of acute lung injury. Tocilizumab, an IL-6 pathway inhibitor, has shown reduced duration of ventilator dependency and mortality in critically ill patients with COVID-19. In this study, we test the hypothesis that tocilizumab is associated with reduced delirium/coma prevalence in critically ill patients with COVID-19. 253 patients were included in the study cohort, 69 in the tocilizumab group and 184 in the historical control group who did not receive tocilizumab. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) with a positive score indicating delirium. Coma was defined as a Richmond Agitation-Sedation Scale score of - 4 or - 5. Tocilizumab was associated with significantly greater number of days alive without delirium/coma (tocilizumab [7 days (IQR: 3-9 days)] vs control [3 days (IQR: 1-8 days)]; p < 0.001). These results remained significant after adjusting for age, sex, sepsis, Charlson Comorbidity Index, Sequential Organ Failure Assessment score, and median daily dose of analgesics/sedatives ( β ^ = 0.671, p = 0.010). There were no significant differences in mortality ( β ^ = - 0.204, p = 0.561), ventilator duration ( β ^ = 0.016, p = 0.956), and ICU or hospital length of stay ( β ^ = - 0.134, p = 0.603; β ^ = 0.003, p = 0.991, respectively). Tocilizumab use was associated with significantly increased number of days without delirium/coma. Confirmation of these findings in randomized prospective studies may inform a novel paradigm of pharmacological amelioration of delirium/coma during critical illness.
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Affiliation(s)
- Tuqa Alkhateeb
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ine Sohn
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Montana Fleenor
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- The Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Shouri Lahiri
- Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
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Mart MF, Boehm LM, Kiehl AL, Gong MN, Malhotra A, Owens RL, Khan BA, Pisani MA, Schmidt GA, Hite RD, Exline MC, Carson SS, Hough CL, Rock P, Douglas IS, Feinstein DJ, Hyzy RC, Schweickert WD, Bowton DL, Masica A, Orun OM, Raman R, Pun BT, Strength C, Rolfsen ML, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Ely EW, Jackson JC, Girard TD. Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00077-8. [PMID: 38701817 DOI: 10.1016/s2213-2600(24)00077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. METHODS This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete. FINDINGS Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. INTERPRETATION In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. FUNDING National Institutes of Health and the US Department of Veterans Affairs.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Leanne M Boehm
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA; Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Amy L Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Michelle N Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, New York, NY, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Margaret A Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory A Schmidt
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa, Iowa City, IA, USA
| | - R Duncan Hite
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David L Bowton
- Department of Anesthesiology, Section on Critical Care, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Onur M Orun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Rameela Raman
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Cayce Strength
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mark L Rolfsen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher G Hughes
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mayur B Patel
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Ng ESW. Treatment effects on functional outcomes in trials with severely ill patients. THE LANCET. RESPIRATORY MEDICINE 2024:S2213-2600(24)00087-0. [PMID: 38701816 DOI: 10.1016/s2213-2600(24)00087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Edmond S W Ng
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
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Abstract
Over 2.6 million adults over the age of 65 develop delirium each year in the United States (US). Delirium is associated with a significant increase in mortality and the US health care costs associated with delirium are estimated at over $164 billion annually. Despite the prevalence of the condition, the molecular pathophysiology of delirium remains unexplained, limiting the development of pharmacotherapies. Delirious patients can be identified by prominent impairments in attention and working memory (WM), two cognitive domains that localize to the dorsolateral prefrontal cortex (dlPFC). The dlPFC is also a key site for Alzheimer's disease (AD) pathology, and given the high risk of delirium in AD patients, suggests that efforts at understanding delirium might focus on the dlPFC as a final common endpoint for cognitive changes. Preclinical studies of the dlPFC reproduce many of the pharmacological observations made of delirious patients, including sensitivity to anticholinergics and an 'inverted U' pattern of dependence on monoaminergic input, with diminished performance outside a narrow range of signaling. Medications like guanfacine, which influence the dlPFC in the context of attention-deficit/hyperactivity disorder (ADHD), have emerged as therapies for delirium and motivate a detailed understanding of the influence of α-2 agonists on WM. In this review, I will discuss the neural circuitry and molecular mechanisms underlying WM and the function of the dlPFC. Localizing the cognitive deficits that are commonly seen in delirious patients may help identify new molecular targets for this highly prevalent disease.
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Affiliation(s)
- Kyle A. Lyman
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
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Spies C, Piazena H, Deja M, Wernecke KD, Willemeit T, Luetz A. Modification in ICU Design May Affect Delirium and Circadian Melatonin: A Proof of Concept Pilot Study. Crit Care Med 2024; 52:e182-e192. [PMID: 38112493 PMCID: PMC10930376 DOI: 10.1097/ccm.0000000000006152] [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: 12/21/2023]
Abstract
OBJECTIVES Nonpharmacologic delirium management is recommended by current guidelines, but studies on the impact of ICU design are still limited. The study's primary purpose was to determine if a multicomponent change in room design prevents ICU delirium. Second, the influence of lighting conditions on serum melatonin was assessed. DESIGN Prospective observational cohort pilot study. SETTING The new design concept was established in two two-bed ICU rooms of a university hospital. Besides modifications aimed at stress relief, it includes a new dynamic lighting system. PATIENTS Seventy-four adult critically ill patients on mechanical ventilation with an expected ICU length of stay of at least 48 hours, treated in modified or standard rooms. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The clinical examination included a prospective assessment for depth of sedation, delirium, and pain every 8 hours using validated scores. Blood samples for serum melatonin profiles were collected every 4 hours for a maximum of three 24-hour periods. Seventy-four patients were included in the analysis. Seventy-six percent ( n = 28) of patients in the standard rooms developed delirium compared with 46% of patients ( n = 17) in the modified rooms ( p = 0.017). Patients in standard rooms (vs. modified rooms) had a 2.3-fold higher delirium severity (odds ratio = 2.292; 95% CI, 1.582-3.321; p < 0.0001). Light intensity, calculated using the measure of circadian effective irradiance, significantly influenced the course of serum melatonin ( p < 0.0001). Significant interactions ( p < 0.001) revealed that differences in serum melatonin between patients in standard and modified rooms were not the same over time but varied in specific periods of time. CONCLUSIONS Modifications in ICU room design may influence the incidence and severity of delirium. Dedicated light therapy could potentially influence delirium outcomes by modulating circadian melatonin levels.
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Affiliation(s)
- Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Helmut Piazena
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Maria Deja
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Berlin, Lübeck, Germany
| | - Klaus-Dieter Wernecke
- Institute Department of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Willemeit
- Department of Architectural Research, GRAFT Architects Berlin, Berlin, Germany
| | - Alawi Luetz
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany
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Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
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Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Carayannopoulos KL, Alshamsi F, Chaudhuri D, Spatafora L, Piticaru J, Campbell K, Alhazzani W, Lewis K. Antipsychotics in the Treatment of Delirium in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024:00003246-990000000-00304. [PMID: 38488422 DOI: 10.1097/ccm.0000000000006251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis assessing whether the use of antipsychotic medications in critically ill adult patients with delirium impacts patient-important outcomes. DATA SOURCES A medical librarian searched Ovid MEDLINE, EMBASE, APA PsycInfo, and Wiley's Cochrane Library as well as clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2023. STUDY SELECTION Independently and in duplicate, reviewers screened abstracts and titles for eligibility, then full text of qualifying studies. We included parallel-group randomized controlled trials (RCTs) that included critically ill adult patients with delirium. The intervention group was required to receive antipsychotic medications at any dose, whereas the control group received usual care or placebo. DATA EXTRACTION Reviewers extracted data independently and in duplicate using a piloted abstraction form. Statistical analyses were conducted using RevMan software (version 5.4). DATA SYNTHESIS Five RCTs ( n = 1750) met eligibility criteria. The use of antipsychotic medications compared with placebo did not increase the number of delirium- or coma-free days (mean difference 0.90 d; 95% CI, -0.32 to 2.12; moderate certainty), nor did it result in a difference in mortality, duration of mechanical ventilation, ICU, or hospital length of stay. The use of antipsychotics did not result in an increased risk of adverse events (risk ratio 1.27; 95% CI, 0.71-2.30; high certainty). Subgroup analysis of typical versus atypical antipsychotics did not identify any subgroup effect for any outcome. CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in delirium- or coma-free days when delirious critically ill adults are treated with antipsychotic medications. Further studies in the subset of patients with hyperactive delirium may be of benefit.
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Affiliation(s)
- Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Critical Care, St. Joseph's Health Hospital, Syracuse, NY
| | | | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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9
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Madden K, Wolf M, Tasker RC, Figueroa J, McCracken C, Hall M, Kamat P. Antipsychotic Drug Prescription in Pediatric Intensive Care Units: A 10-Year U.S. Retrospective Database Study. J Pediatr Intensive Care 2024; 13:46-54. [PMID: 38571986 PMCID: PMC10987219 DOI: 10.1055/s-0041-1736523] [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: 07/10/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022] Open
Abstract
Delirium recognition during pediatric critical illness may result in the prescription of antipsychotic medication. These medications have unclear efficacy and safety. We sought to describe antipsychotic medication use in pediatric intensive care units (PICUs) contributing to a U.S. national database. This study is an analysis of the Pediatric Health Information System Database between 2008 and 2018, including children admitted to a PICU aged 0 to 18 years, without prior psychiatric diagnoses. Antipsychotics were given in 16,465 (2.3%) of 706,635 PICU admissions at 30 hospitals. Risperidone (39.6%), quetiapine (22.1%), and haloperidol (20.8%) were the most commonly used medications. Median duration of prescription was 4 days (interquartile range: 2-11 days) for atypical antipsychotics, and haloperidol was used a median of 1 day (1-3 days). Trend analysis showed quetiapine use increased over the study period, whereas use of haloperidol and chlorpromazine (typical antipsychotics) decreased ( p < 0.001). Compared with no antipsychotic administration, use of antipsychotics was associated with comorbidities (81 vs. 65%), mechanical ventilation (57 vs. 36%), longer PICU stay (6 vs. 3 days), and higher mortality (5.7 vs. 2.8%) in univariate analyses. In the multivariable model including demographic and clinical factors, antipsychotic prescription was associated with mortality (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.02-1.18). Use of atypical antipsychotics increased over the 10-year period, possibly reflecting increased comfort with their use in pediatric patients. Antipsychotics were more common in patients with comorbidities, mechanical ventilation, and longer PICU stay, and associated with higher mortality in an adjusted model which warrants further study.
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Affiliation(s)
- Kate Madden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Michael Wolf
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas, United States
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States
- Division of Critical Care, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, United States
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10
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Rambaud T, Hajage D, Dreyfuss D, Lebbah S, Martin-Lefevre L, Louis G, Moschietto S, Titeca-Beauport D, La Combe B, Pons B, De Prost N, Besset S, Combes A, Robine A, Beuzelin M, Badie J, Chevrel G, Bohe J, Coupez E, Chudeau N, Barbar S, Vinsonneau C, Forel JM, Thevenin D, Boulet E, Lakhal K, Aissaoui N, Grange S, Leone M, Lacave G, Nseir S, Poirson F, Mayaux J, Ashenoune K, Geri G, Klouche K, Thiery G, Argaud L, Rozec B, Cadoz C, Andreu P, Reignier J, Ricard JD, Quenot JP, Sonneville R, Gaudry S. Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial. Intensive Care Med 2024; 50:385-394. [PMID: 38407824 DOI: 10.1007/s00134-024-07339-1] [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] [Received: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI. METHODS We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS > + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization. RESULTS A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results. CONCLUSION In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.
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Affiliation(s)
- Thomas Rambaud
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
- Département de Médecine Intensive Réanimation Neuro, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - David Hajage
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Saïd Lebbah
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | | | - Guillaume Louis
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-à-Pitre/Abymes, Pointe-a-Pitre, France
| | | | - Sébastien Besset
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Adrien Robine
- Réanimation Soins Continus, CH de Bourg-en-Bresse - Fleyriat, 01012, Bourg-en-Bresse, France
| | | | - Julio Badie
- Réanimation Polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | - Guillaume Chevrel
- Réanimation Polyvalente, CH Sud Francilien, Corbeil Essonnes, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud Pierre Benite, Lyon, France
| | - Elisabeth Coupez
- Réanimation Polyvalente, Hôpital G. Montpied, Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation Médico-Chirurgicale, CH du Mans, Le Mans, France
| | | | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l'Oise, 95260, Beaumont Sur Oise, France
| | - Karim Lakhal
- Réanimation Chirurgicale Polyvalente, Hôpital Nord Laennec, Nantes, France
| | - Nadia Aissaoui
- Réanimation Médicale, Hôpital Georges Pompidou, Paris, France
| | | | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, Marseille, France
| | - Guillaume Lacave
- Réanimation Médico-Chirurgicale, Hôpital André Mignot, Versailles, France
| | - Saad Nseir
- Réanimation Médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France
| | - Florent Poirson
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation Médicale, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Guillaume Geri
- Réanimation Médico-Chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation,, Hôpital Lapeyronnie, Montpellier, France
| | - Guillaume Thiery
- Réanimation Médicale, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation Médicale, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyril Cadoz
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Médecine Intensive Réanimation, Hôtel Dieu, Nantes, France
| | | | - Jean-Damien Ricard
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- NSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP. Nord, Hôpital Bichat - Claude Bernard, Paris, France
- Université Paris Cité, INSERM UMR1137, IAME, 75018, Paris, France
| | - Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France.
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France.
- Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France.
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
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11
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Liu M, Su J, Wang B, Yu D, Li J, Cao X. The effect of haloperidol's perioperative application on postoperative delirium in elderly patients: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:49. [PMID: 38308229 PMCID: PMC10837937 DOI: 10.1186/s12871-024-02434-8] [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] [Received: 10/06/2023] [Accepted: 01/26/2024] [Indexed: 02/04/2024] Open
Abstract
OBJECTIVES To systematically review the evidence about the effect of haloperidol on postoperative delirium in elderly patients. METHODS PubMed, Embase, the Cochrane Library and China National Knowledge Infrastructure were used to find concerned studies for meta-analysis. The main outcome was the incidence of postoperative delirium, and the secondary outcomes were side effects of haloperidol and the length of hospital stay. The meta-analyses were conducted using the Review Manager Version 5.1. This study was conducted based on the PRISMA statement. RESULTS Eight RCTs (1569 patients) were included in the meta-analysis. There was a significant difference in the incidence of postoperative delirium between haloperidol and control groups (OR = 0.62, 95%CI 0.48-0.80, P = 0.0002, I2 = 20%). In addition, side effects of haloperidol and the duration of hospitalization were comparable (OR = 0.58, 95%CI 0.25-1.35, P = 0.21, I2 = 0%; MD =-0.01, 95%CI -0.16-0.15, P = 0.92, I2 = 28%). Subgroup analysis implied the effect of haloperidol on postoperative delirium might vary with the dose (5 mg daily: OR = 0.40, 95%CI 0.22-0.71, P = 0.002, I2 = 0%; <5 mg daily: OR = 0.72, 95%CI 0.42-1.23, P = 0.23, I2 = 0%). CONCLUSIONS The meta-analysis revealed perioperative application of haloperidol could decrease the occurrence of postoperative delirium without obvious side effects in elderly people, and high-dose haloperidol (5 mg daily) possessed a greater positive effect.
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Affiliation(s)
- Meinv Liu
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Jie Su
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Bei Wang
- Department of Gynaecology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Dongdong Yu
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
| | - Jianli Li
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China.
| | - Xinyu Cao
- Department of Anaesthesiology, Hebei General Hospital, Shijiazhuang, 050051, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei Province, 050011, China
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12
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Castro M, Butler M, Thompson AN, Gee S, Posporelis S. Effectiveness and Safety of Intravenous Medications for the Management of Acute Disturbance (Agitation and Other Escalating Behaviors): A Systematic Review of Prospective Interventional Studies. J Acad Consult Liaison Psychiatry 2024:S2667-2960(24)00012-0. [PMID: 38309683 DOI: 10.1016/j.jaclp.2024.01.004] [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: 08/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.
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Affiliation(s)
- Megan Castro
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom
| | - Matt Butler
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom.
| | | | - Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, KCL, London, United Kingdom
| | - Sotiris Posporelis
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
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13
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Frost SA, Brennan K, Sanchez D, Lynch J, Hedges S, Hou YC, El Sayfe M, Shunker SA, Bogdanovski T, Hunt L, Alexandrou E, Rolls K, Chroinin DN, Aneman A. Frailty in the prediction of delirium in the intensive care unit: A secondary analysis of the Deli study. Acta Anaesthesiol Scand 2024; 68:214-225. [PMID: 37903745 DOI: 10.1111/aas.14343] [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] [Received: 06/22/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Delirium is an acute disorder of attention and cognition with an incidence of up to 70% in the adult intensive care setting. Due to the association with significantly increased morbidity and mortality, it is important to identify who is at the greatest risk of an acute episode of delirium while being cared for in the intensive care. The objective of this study was to determine the ability of the cumulative deficit frailty index and clinical frailty scale to predict an acute episode of delirium among adults admitted to the intensive care. METHODS This study is a secondary analysis of the Deli intervention study, a hybrid stepped-wedge cluster randomized controlled trial to assess the effectiveness of a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adult intensive care units in the south-west of Sydney, Australia. Important predictors of delirium were identified using a bootstrap approach and the absolute risks, based on the cumulative deficit frailty index and the clinical frailty scale are presented. RESULTS During the 10-mth data collection period (May 2019 and February 2020) 2566 patients were included in the study. Both the cumulative deficit frailty index and the clinical frailty scale on admission, plus age, sex, and APACHE III (AP III) score were able to discriminate between patients who did and did not experience an acute episode of delirium while in the intensive care, with AUC of 0.701 and 0.703 (moderate discriminatory ability), respectively. The addition of a frailty index to a prediction model based on age, sex, and APACHE III score, resulted in net reclassified of risk. Nomograms to individualize the absolute risk of delirium using these predictors are also presented. CONCLUSION We have been able to show that both the cumulative deficits frailty index and clinical frailty scale predict an acute episode of delirium among adults admitted to intensive care.
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Affiliation(s)
- Steven A Frost
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- South Western Sydney Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Sydney, Australia
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Kathleen Brennan
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- Department of Intensive Care, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - David Sanchez
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Campbelltown-Camden Hospital, Sydney, Australia
| | - Joan Lynch
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Sonja Hedges
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Yu Chin Hou
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Masar El Sayfe
- Department of Intensive Care, Fairfield Hospital, Sydney, Australia
| | | | - Tony Bogdanovski
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
| | - Leanne Hunt
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Evan Alexandrou
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Kaye Rolls
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Danielle Ni Chroinin
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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14
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Devlin JW, Duprey MS, Girard TD. How does haloperidol influence the long-term outcomes of delirium? Intensive Care Med 2024; 50:269-271. [PMID: 38294525 DOI: 10.1007/s00134-024-07321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Affiliation(s)
- John W Devlin
- Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 140TF RD21602115, USA.
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | | | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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15
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Connell J, McCann B, Feng X, Shotwell MS, Hughes CG, Boncyk CS. The Association of Nonmodifiable Patient Factors on Antipsychotic Medication use in the Intensive Care Unit. J Intensive Care Med 2024; 39:176-182. [PMID: 37644873 PMCID: PMC10771026 DOI: 10.1177/08850666231198030] [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: 08/31/2023]
Abstract
PURPOSE We investigated the association of age, sex, race, and insurance status on antipsychotic medication use among intensive care unit (ICU) patients. MATERIALS AND METHODS Retrospective study of adults admitted to ICUs at a tertiary academic center. Patient characteristics, hospital course, and medication (olanzapine, quetiapine, and haloperidol) data were collected. Logistic regression models evaluated the independent association of age, sex, race, and insurance status on the use of each antipsychotic, adjusting for prespecified covariates. RESULTS Of 27,137 encounters identified, 6191 (22.8%) received antipsychotics. Age was significantly associated with the odds of receiving olanzapine (P < .001), quetiapine (P = .001), and haloperidol (P = .0046). Male sex and public insurance status were associated with increased odds of receiving antipsychotics olanzapine, quetiapine, and haloperidol (Male vs Female: OR 1.13, 95% CI [1.04, 1.24], P = .0005; OR 1.22, 95% CI [1.10, 1.34], P = .0001; OR 1.28, 95% CI [1.17, 1.40], P < .0001, respectively; public insurance vs private insurance: OR 1.32, 95% CI [1.20, 1.46], P < .0001; OR 1.21, 95% CI [1.09, 1.34], P = .0004; OR 1.15, 95% CI [1.04, 1.27], P = .0058, respectively). Black race was also associated with a decreased odds of receiving all antipsychotics (olanzapine (P = .0177), quetiapine (P = .004), haloperidol (P = .0041)). CONCLUSIONS Age, sex, race, and insurance status were associated with the use of all antipsychotic medications investigated, highlighting the importance of investigating the potential impact of these prescribing decisions on patient outcomes across diverse populations. Recognizing how nonmodifiable patient factors have the potential to influence prescribing practices may be considered an important factor toward optimizing medication regimens.
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Affiliation(s)
| | - Brittany McCann
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S. Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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16
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Swayngim R, Preslaski C, Dawson J. Use of Valproic Acid for the Management of Delirium and Agitation in the Intensive Care Unit. J Pharm Pract 2024; 37:118-122. [PMID: 36154329 DOI: 10.1177/08971900221128636] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Assess the efficacy and safety of valproic acid (VPA) for delirium and agitation in the intensive care unit (ICU) as compared to the use of other antipsychotics. Materials and Methods: This was a retrospective cohort study of patients treated for delirium and agitation in the ICU. Patients were included if they had a Richmond Agitation-Sedation Scale ≥2 and Confusion Assessment Method for the ICU positive. Patients were split into two groups based on their VPA exposure. The primary outcome was delirium free days. Secondary outcomes included agitation free days, ICU length of stay (LOS), mechanical ventilation duration, and mortality. Results: One hundred eight patients were included, 49 patients in the VPA group and 59 patients in the control group. Baseline characteristics were similar between groups. There was no significant difference in the primary outcome (difference -.15, 95% CI: 0.63-.93, P = .70). There were no significant differences in agitation-free days, mortality, mechanical ventilation duration, or ICU LOS. Conclusions: Our findings suggest that VPA is associated with similar delirium and agitation-free days compared to other non-VPA medications, with some adverse effects. Larger prospective studies are needed to validate the routine use of VPA in this setting.
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Affiliation(s)
- Rebecca Swayngim
- Department of Pharmacy, Denver Health Medical Center, Denver, CO, USA
| | - Candice Preslaski
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Jordan Dawson
- Department of Pharmacy, Denver Health Medical Center, Denver, CO, USA
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17
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Potter KM, Kennedy JN, Onyemekwu C, Prendergast NT, Pandharipande PP, Ely EW, Seymour C, Girard TD. Data-derived subtypes of delirium during critical illness. EBioMedicine 2024; 100:104942. [PMID: 38169220 PMCID: PMC10797145 DOI: 10.1016/j.ebiom.2023.104942] [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] [Received: 08/18/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND To understand delirium heterogeneity, prior work relied on psychomotor symptoms or risk factors to identify subtypes. Data-driven approaches have used machine learning to identify biologically plausible, treatment-responsive subtypes of other acute illnesses but have not been used to examine delirium. METHODS We conducted a secondary analysis of a large, multicenter prospective cohort study involving adults in medical or surgical ICUs with respiratory failure or shock who experienced delirium per the Confusion Assessment Method for the ICU. We used data collected before delirium diagnosis in an unsupervised latent class model to identify delirium subtypes and then compared demographics, clinical characteristics, and outcomes between subtypes in the final model. FINDINGS The 731 patients who developed delirium during critical illness had a median age of 63 [IQR, 54-72] years, a median Sequential Organ Failure Assessment score of 8.0 [6.0-11.0] and 613 [83.4%] were mechanically ventilated at delirium identification. A four-class model best fit the data with 50% of patients in subtype (ST) 1, 18% in subtype 2, 17% in subtype 3, and 14% in subtype 4. Subtype 2-which had more shock and kidney impairment-had the highest mortality (33% [ST2] vs. 17% [ST1], 25% [ST3], and 17% [ST4], p = 0.003). Subtype 4-which received more benzodiazepines and opioids-had the longest duration of delirium (6 days [ST4] vs. 3 [ST1], 4 [ST2], and 3 days [ST3], p < 0.001) and coma (4 days [ST4] vs. 2 [ST1], 1 [ST2], and 2 days [ST3], p < 0.001). Each of the four data-derived delirium subtypes was observed within previously identified psychomotor and risk factor-based delirium subtypes. Clinically significant cognitive impairment affected all subtypes at follow-up, but its severity did not differ by subtype (3-month, p = 0.26; 12-month, p = 0.80). INTERPRETATION The four data-derived delirium subtypes identified in this study should now be validated in independent cohorts, examined for differential treatment effects in trials, and inform mechanistic work evaluating treatment targets. FUNDING National Institutes of Health (T32HL007820, R01AG027472).
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Affiliation(s)
- Kelly M Potter
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Jason N Kennedy
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Chukwudi Onyemekwu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pratik P Pandharipande
- Division of Critical Care, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine in the Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Allergy, Pulmonary, and Critical Care Medicine in the Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Tennessee Valley Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States
| | - Christopher Seymour
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
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18
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Boncyk C, Rengel K, Stollings J, Marshall M, Feng X, Shotwell M, Pandharipande PP, Hughes CG. Recurrent delirium episodes within the intensive care unit: Incidence and associated factors. J Crit Care 2024; 79:154490. [PMID: 38000230 PMCID: PMC10842115 DOI: 10.1016/j.jcrc.2023.154490] [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] [Received: 03/27/2023] [Revised: 10/25/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE Describe the incidence and factors associated with recurrent delirium in the intensive care unit (ICU). MATERIALS AND METHODS Retrospective study of ICU patients diagnosed with delirium. Delirium clearance defined as 48 h of negative delirium assessments following initial episode and recurrent delirium as any positive delirium assessment following clearance. Multivariable logistic regression model assessed independent association of patient and hospital factors on development of recurrent delirium, adjusting for pre-defined covariates. RESULTS Among 8591 ICU admissions identified with delirium, 1067 (12.4%) had recurrent symptoms. Factors associated with increased odds of recurrent delirium were age (nonlinear; p = 0.02), shock (OR 1.45, 95% CI [1.20, 1.75]), admission to medical (OR 3.25, 95% CI [2.42, 4.37]), surgical (OR 3.00, 95% CI [2.21, 4.06]), or trauma (OR 2.17, 95% CI [1.58, 3.00]) ICU vs. cardiovascular ICU, increased duration of mechanical ventilation (OR 2.43, 95% CI [2.22, 2.65]), propofol use (OR 1.35, 95% CI [1.02, 1.80]), and antipsychotic medications (haloperidol OR 1.53, 95% CI [1.26, 1.86]; quetiapine OR 2.45, 95% CI [1.98, 3.02]; and olanzapine OR 1.54, 95% CI [1.25, 1.88]). CONCLUSIONS Over 10% of delirious ICU patients had recurrent symptoms. Factors associated with recurrence included age, duration of mechanical ventilation and medication exposure. CLINICAL TRIAL NUMBER Not applicable.
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Affiliation(s)
- Christina Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America.
| | - Kimberly Rengel
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
| | - Joanna Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America; Department of Pharmaceutical Services, Vanderbilt University Medical Center, United States of America
| | - Matt Marshall
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, United States of America
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Matthew Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, United States of America
| | - Pratik P Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, United States of America; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, University Medical Center, Vanderbilt, United States of America
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19
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Jose S, Cyriac MC, Dhandapani M. Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence. Indian J Crit Care Med 2024; 28:111-119. [PMID: 38323249 PMCID: PMC10839928 DOI: 10.5005/jp-journals-10071-24626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/10/2023] [Indexed: 02/08/2024] Open
Abstract
Background Delirium, a prevalent condition among elderly individuals admitted to hospitals, particularly in intensive care settings, necessitates specialized medical intervention. The present study assessed the proficiency of nurses in the management of delirium and their subjective experience of stress while providing care for patients with delirium in emergency rooms and critical care units. Materials and methods The study adopted a quantitative descriptive approach, utilizing standardized self-reporting measures that assessed the nurses' expertise and perceived burden of care. A cohort of 86 nurses from a tertiary care hospital in North India participated in the study. Additionally, the impact of the web-based instructional module in enhancing the nurses' knowledge in delirium management was assessed by one group pretest-posttest quasi-experimental study. Findings The research revealed that nurses exhibited significant deficiencies in their knowledge, particularly in relation to the symptoms and causes of delirium. The most significant source of subjective stress was attributed to hyperactive delirium-associated behaviors, characterized by uncooperative and aggressive conduct. The utilization of the web-based instructional program significantly enhanced the comprehension of nurses about the management of delirium. Conclusion This study revealed a significant knowledge gap among nurses in delirium management and emphasizes the considerable subjective stress, particularly in dealing with hyperactive delirium-associated behaviors. The positive impact of the web-based instructional program underscores its potential as a valuable tool for enhancing nurses' knowledge and addressing these challenges in healthcare settings. How to cite this article Jose S, Cyriac MC, Dhandapani M. Nurses' Knowledge and Subjective Strain in Delirium Care: Impact of a Web-based Instructional Module on Nurses Competence. Indian J Crit Care Med 2024;28(2):111-119.
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Affiliation(s)
- Sinu Jose
- Postgraduate Institute of Medical Education and Research, PGIMER, Chandigarh, India
| | | | - Manju Dhandapani
- National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, PGIMER, Chandigarh, India
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20
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Alghadeer S, Almesned RS, Alshehri EA, Alwhaibi A. Evaluation of the Efficacy and Safety of Quetiapine in the Treatment of Delirium in Adult ICU Patients: A Retrospective Comparative Study. J Clin Med 2024; 13:802. [PMID: 38337497 PMCID: PMC10856481 DOI: 10.3390/jcm13030802] [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: 11/28/2023] [Revised: 01/11/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Quetiapine is commonly prescribed off-label to manage delirium in intensive care unit (ICU) patients. However, limited studies comparing its efficacy and safety to those of other antipsychotics exist in the literature. Method: A retrospective, single-center chart review study was conducted on adults admitted to the ICU between January 2017 and August 2022, who were diagnosed with delirium and treated with a single antipsychotic and had no neurological medical conditions, active alcohol withdrawal, or prior use of antipsychotics. Data were analyzed using SPSS software version 28, with p-values of <0.05 indicating statistical significance. Results: In total, 47 patients were included, of whom 22 (46.8%), 19 (40.4%), 4 (8.5%), and 2 (4.3%) were on quetiapine, haloperidol, risperidone, and olanzapine, respectively. The median number of hours needed to resolve delirium were 12 (21.5), 23 (28), 13 (13.75), and 36 (10) (p = 0.115) for quetiapine, haloperidol, risperidone, and olanzapine, respectively, with haloperidol being used for a significantly shorter median number of days than quetiapine (3 (2.5) days vs. 7.5 (11.5) days; p = 0.007). Of the medication groups, only quetiapine-treated patients received a significantly higher median maintenance compared to the initiation dose (50 (50) mg vs. 50 (43.75) mg; p = 0.039). For the length of stay in the ICU and hospital, delirium-free days, % of ICU time spent in delirium, ventilator-free days, the difference between the highest and baseline QTc intervals, and ICU and hospital mortalities, no significant difference was observed between the groups. Conclusions: Overall, the use of quetiapine in our retrospective study seems to not be advantageous over the other drugs in terms of efficacy and safety outcomes.
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Affiliation(s)
- Sultan Alghadeer
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
| | - Rahaf S. Almesned
- Pharmacy Department, King Saud University Medical City (KSUMC), King Saud University, Riyadh 11411, Saudi Arabia;
| | - Emad A. Alshehri
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
| | - Abdulrahman Alwhaibi
- Department of Clinical Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (S.A.); (E.A.A.)
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21
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An G, Mi Z, Hong D, Ou D, Cao X, Liu Q, Xiong L, Li C. Nomogram to predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection. Front Psychiatry 2024; 14:1288948. [PMID: 38274422 PMCID: PMC10808537 DOI: 10.3389/fpsyt.2023.1288948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Objective To construct and validate nomogram models that predict the incidence of delirium in elderly patients with non-severe SARS-CoV-2 infection. Methods Elderly patients (≥65y) tested positive for SARS-CoV-2 infection at the hospital were included. We used the 3-min diagnostic Confusion Assessment Method for delirium diagnosis. Least absolute shrinkage and selection operator (LASSO) logistical regression analysis was performed to explore potential independent influencing factors of delirium. A predict model visualized by nomogram was constructed based on the confirmed variables. The predictive accuracy and clinical value of the model were evaluated using receiver operating characteristic (ROC) curves. Results The data of 311 elderly patients were analyzed, of whom 73 (23.47%) patients were diagnosed with delirium. Three independent influencing factors of delirium were confirmed: age (OR1.16,1.11-1.22), Glomerular filtration rate (OR 0.98,0.97-0.99), platelet-large cell ratio (1.06,1.02-1.10). These parameters were used to create a nomogram to predict the development of delirium, which showed good predictive accuracy confirmed by the ROC curves (AUC 0.82,0.76-0.88). Conclusion We construct a credible nomogram to predict the development of delirium in elderly patients with Non-severe SARS-CoV-2 infection. Our finding may be useful to physicians in early prevention and treatment of delirium.
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Affiliation(s)
| | | | | | | | | | - Qidong Liu
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lize Xiong
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
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22
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Stollings JL, Boncyk CS, Birdrow CI, Chen W, Raman R, Gupta DK, Roden DM, Rivera EL, Maiga AW, Rakhit S, Pandharipande PP, Ely EW, Girard TD, Patel MB. Antipsychotics and the QTc Interval During Delirium in the Intensive Care Unit: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2352034. [PMID: 38252439 PMCID: PMC10804270 DOI: 10.1001/jamanetworkopen.2023.52034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/28/2023] [Indexed: 01/23/2024] Open
Abstract
Importance Antipsychotic medications, often prescribed for delirium in intensive care units (ICUs), may contribute to QTc interval prolongation. Objective To determine whether antipsychotics increase the QTc interval in patients with delirium in the ICU. Design, Setting, and Participants An a priori analysis of a randomized clinical trial in medical/surgical ICUs within 16 centers across the US was conducted. Participants included adults with delirium in the ICU with baseline QTc interval less than 550 ms. The study was conducted from December 2011 to August 2017. Data analysis was performed from April 25 to August 18, 2021. Interventions Patients were randomized 1:1:1 to intravenous haloperidol, ziprasidone, or saline placebo administered twice daily until resolution of delirium, ICU discharge, or 14 days. Main Outcomes and Measures Twelve-lead electrocardiograms were used to measure baseline QTc before study drug initiation and telemetry was used to measure QTc before each subsequent dose of study drug. Unadjusted day-to-day changes in QTc were calculated and multivariable proportional odds regression was used to estimate the effects of antipsychotics vs placebo on next-day maximum QTc interval, adjusting for prespecified baseline covariates and potential interactions with sex. Safety end points, including the occurrence of torsade de pointes, were evaluated. All analyses were conducted based on the intention to treat principle. Results A total of 566 patients were randomized to haloperidol (n = 192), ziprasidone (n = 190), or placebo (n = 184). Median age was 60.1 (IQR, 51.4-68.7) years; 323 were men (57%). Baseline median QTc intervals across the groups were similar: haloperidol, 458.0 (IQR, 432.0-479.0) ms; ziprasidone, 451.0 (IQR, 424.0-472.0) ms; and placebo, 452.0 (IQR, 432.0-472.0) ms. From day 1 to day 2, median QTc changed minimally: haloperidol, -1.0 (IQR, -28.0 to 15.0) ms; ziprasidone, 0 (IQR, -23.0 to 20.0) ms; and placebo, -3.5 (IQR, -24.8 to 17.0) ms. Compared with placebo, neither haloperidol (odds ratio [OR], 0.95; 95% CI, 0.66-1.37; P = .78) nor ziprasidone (OR, 1.09; 95% CI, 0.75-1.57; P = .78) was associated with next-day QTc intervals. Effects were not significantly modified by sex (P = .41 for interaction). There were 2 occurrences of nonfatal torsade de pointes, both in the haloperidol group. Neither was associated with study drug administration. Conclusions and Relevance The findings of this trial suggest that daily QTc interval monitoring during antipsychotic use may have limited value in patients in the ICU with normal baseline QTc and few risk factors for QTc prolongation. Trial Registration ClinicalTrials.gov Identifier: NCT01211522.
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Affiliation(s)
- Joanna L. Stollings
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S. Boncyk
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caroline I. Birdrow
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wencong Chen
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deepak K. Gupta
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Heart Imaging Core Lab, Vanderbilt Translational and Clinical Cardiovascular Research Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dan M. Roden
- Department of Medicine, Departments of Pharmacology and Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Erika L. Rivera
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Amelia W. Maiga
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Anesthesia Service, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Timothy D. Girard
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Research, Investigation, and Systems Modeling of Acute Illness in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mayur B. Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Section of Surgical Sciences, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville
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Kaas-Hansen BS, Granholm A, Sivapalan P, Anthon CT, Schjørring OL, Maagaard M, Kjaer MBN, Mølgaard J, Ellekjaer KL, Fagerberg SK, Lange T, Møller MH, Perner A. Real-world causal evidence for planned predictive enrichment in critical care trials: A scoping review. Acta Anaesthesiol Scand 2024; 68:16-25. [PMID: 37649412 DOI: 10.1111/aas.14321] [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] [Received: 07/04/2023] [Revised: 08/01/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Randomised clinical trials in critical care are prone to inconclusiveness due, in part, to undue optimism about effect sizes and suboptimal accounting for heterogeneous treatment effects. Although causal evidence from rich real-world critical care can help overcome these challenges by informing predictive enrichment, no overview exists. METHODS We conducted a scoping review, systematically searching 10 general and speciality journals for reports published on or after 1 January 2018, of randomised clinical trials enrolling adult critically ill patients. We collected trial metadata on 22 variables including recruitment period, intervention type and early stopping (including reasons) as well as data on the use of causal evidence from secondary data for planned predictive enrichment. RESULTS We screened 9020 records and included 316 unique RCTs with a total of 268,563 randomised participants. One hundred seventy-three (55%) trials tested drug interventions, 101 (32%) management strategies and 42 (13%) devices. The median duration of enrolment was 2.2 (IQR: 1.3-3.4) years, and 83% of trials randomised less than 1000 participants. Thirty-six trials (11%) were restricted to COVID-19 patients. Of the 55 (17%) trials that stopped early, 23 (42%) used predefined rules; futility, slow enrolment and safety concerns were the commonest stopping reasons. None of the included RCTs had used causal evidence from secondary data for planned predictive enrichment. CONCLUSION Work is needed to harness the rich multiverse of critical care data and establish its utility in critical care RCTs. Such work will likely need to leverage methodology from interventional and analytical epidemiology as well as data science.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Praleene Sivapalan
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | | | - Jesper Mølgaard
- Department of Anesthesiology, Centre for Cancer and Organ Dysfunction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karen Louise Ellekjaer
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steen Kåre Fagerberg
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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24
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Frei AI, Wagner AS, Baumann SM, Grzonka P, Berger S, Hunziker S, Rüegg S, Marsch S, Sutter R. Concurrence of seizures and peri-ictal delirium in the critically ill - its frequency, associated characteristics, and outcomes. J Neurol 2024; 271:231-240. [PMID: 37676299 PMCID: PMC10769924 DOI: 10.1007/s00415-023-11944-3] [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] [Received: 06/10/2023] [Revised: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND To assess the frequency, clinical features, and outcome of peri-ictal delirium in adult patients experiencing seizures during intensive care. METHODS This observational study was conducted at a Swiss intensive care unit from 2015 to 2020. Patients aged ≥ 18 years with seizures were categorized as peri-ictal delirious (Intensive Care Delirium Screening Checklist [i.e., ICDSC] ≥ 4) or not (i.e., ICDSC < 4) within 24 h of seizures. The frequency of peri-ictal delirium and in-hospital death were defined as the primary endpoints. Illness severity and treatment characteristics between delirious and non-delirious patients were secondary endpoints. Logistic regression was used to compare in-hospital death and differences regarding clinical characteristics between delirious and non-delirious patients. RESULTS 48% of 200 patients had peri-ictal delirium for a median of 3 days. Delirious patients were older (median age 69 vs. 62 years, p = 0.002), had lower Simplified Acute Physiology Scores II (SAPS II; median 43 vs. 54, p = 0.013), received neuroleptics more frequently (31 vs. 5%, p < 0.001), were mechanically ventilated less often (56% vs. 73%, p = 0.013) and shorter (median 3 vs. 5 days, p = 0.011), and had decreased odds for in-hospital death with delirium (OR = 0.41, 95% CI 0.20-0.84) in multivariable analyses. CONCLUSIONS Delirium emerged in every second patient experiencing seizures and was associated with lower SAPS II, shorter mechanical ventilation, and better outcomes, contradicting assumptions that altered cerebral function, from seizures and delirium, are linked to unfavorable outcomes.
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Affiliation(s)
- Anja I Frei
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Anna S Wagner
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Sira M Baumann
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Sebastian Berger
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Intensive Care, University Hospital Basel, Basel, Switzerland.
- Department of Neurology, University Hospital Basel, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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Khan SH, Perkins AJ, Jawaid S, Wang S, Lindroth H, Schmitt RE, Doles J, True JD, Gao S, Caplan GA, Twigg HL, Kesler K, Khan BA. Serum proteomic analysis in esophagectomy patients with postoperative delirium: A case-control study. Heart Lung 2024; 63:35-41. [PMID: 37748302 PMCID: PMC10843392 DOI: 10.1016/j.hrtlng.2023.09.009] [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] [Received: 07/07/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Postoperative delirium occurs in up to 80% of patients undergoing esophagectomy. We performed an exploratory proteomic analysis to identify protein pathways that may be associated with delirium post-esophagectomy. OBJECTIVES Identify proteins associated with delirium and delirium severity in a younger and higher-risk surgical population. METHODS We performed a case-control study using blood samples collected from patients enrolled in a negative, randomized, double-blind clinical trial. English speaking adults aged 18 years or older, undergoing esophagectomy, who had blood samples obtained were included. Cases were defined by a positive delirium screen after surgery while controls were patients with negative delirium assessments. Delirium was assessed using Richmond Agitation Sedation Scale and Confusion Assessment Method for the Intensive Care Unit, and delirium severity was assessed by Delirium Rating Scale-Revised-98. Blood samples were collected pre-operatively and on post-operative day 1, and discovery proteomic analysis was performed. Between-group differences in median abundance ratios were reported using Wilcoxon-Mann-Whitney Odds (WMWodds1) test. RESULTS 52 (26 cases, 26 controls) patients were included in the study with a mean age of 64 (SD 9.6) years, 1.9% were females and 25% were African American. The median duration of delirium was 1 day (IQR: 1-2), and the median delirium/coma duration was 2.5 days (IQR: 2-4). Two proteins with greater relative abundance ratio in patients with delirium were: Coagulation factor IX (WMWodds: 1.89 95%CI: 1.0-4.2) and mannosyl-oligosaccharide 1,2-alpha-mannosidase (WMWodds: 2.4 95%CI: 1.03-9.9). Protein abundance ratios associated with mean delirium severity at postoperative day 1 were Complement C2 (Spearman rs = -0.31, 95%CI [-0.55, -0.02]) and Mannosyl-oligosaccharide 1,2-alpha-mannosidase (rs = 0.61, 95%CI = [0.29, 0.81]). CONCLUSIONS We identified changes in proteins associated with coagulation, inflammation, and protein handling; larger, follow-up studies are needed to confirm our hypothesis-generating findings.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA.
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samreen Jawaid
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heidi Lindroth
- Department of Nursing, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rebecca E Schmitt
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason Doles
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason D True
- Department of Biology, Ball State University, Muncie, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon A Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Homer L Twigg
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kenneth Kesler
- Department of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA
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26
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Mortensen CB, Andersen-Ranberg NC, Poulsen LM, Granholm A, Rasmussen BS, Kjær MBN, Lange T, Ebdrup BH, Collet MO, Andreasen AS, Bestle MH, Uslu B, Pedersen HS, Nielsen LG, Hästbacka J, Jensen TB, Damgaard K, Sommer T, Morgen M, Dey N, Citerio G, Estrup S, Egerod I, Samuelson K, Perner A, Mathiesen O. Long-term outcomes with haloperidol versus placebo in acutely admitted adult ICU patients with delirium. Intensive Care Med 2024; 50:103-113. [PMID: 38170227 PMCID: PMC10811094 DOI: 10.1007/s00134-023-07282-7] [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] [Received: 09/22/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE We assessed long-term outcomes in acutely admitted adult patients with delirium treated in intensive care unit (ICU) with haloperidol versus placebo. METHODS We conducted pre-planned analyses of 1-year outcomes in the Agents Intervening against Delirium in the ICU (AID-ICU) trial, including mortality and health-related quality of life (HRQoL) assessed by Euroqol (EQ) 5-dimension 5-level questionnaire (EQ-5D-5L) index values and EQ visual analogue scale (EQ VAS) (deceased patients were assigned the numeric value zero). Outcomes were analysed using logistic and linear regressions with bootstrapping and G-computation, all with adjustment for the stratification variables (site and delirium motor subtype) and multiple imputations for missing HRQoL values. RESULTS At 1-year follow-up, we obtained vital status for 96.2% and HRQoL data for 83.3% of the 1000 randomised patients. One-year mortality was 224/501 (44.7%) in the haloperidol group versus 251/486 (51.6%) in the placebo group, with an adjusted absolute risk difference of - 6.4%-points (95% confidence interval [CI] - 12.8%-points to - 0.2%-points; P = 0.045). These results were largely consistent across the secondary analyses. For HRQoL, the adjusted mean differences were 0.04 (95% CI - 0.03 to 0.11; P = 0.091) for EQ-5D-5L-5L index values, and 3.3 (95% CI - 9.3 to 17.5; P = 0.142) for EQ VAS. CONCLUSIONS In acutely admitted adult ICU patients with delirium, haloperidol treatment reduced mortality at 1-year follow-up, but did not statistically significantly improve HRQoL.
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Affiliation(s)
- Camilla Bekker Mortensen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark.
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.
| | - Nina Christine Andersen-Ranberg
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Lone Musaeus Poulsen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Maj-Brit Nørregaard Kjær
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Theis Lange
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, Copenhagen University Hospital, Mental Health Center Glostrup, Glostrup, Denmark
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Bjørn H Ebdrup
- Center for Neuropsychiatric Schizophrenia Research, Mental Health Center Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Oxenbøll Collet
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Anne Sofie Andreasen
- Department of Intensive Care, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Morten Heiberg Bestle
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Bülent Uslu
- Department of Anesthesiology and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Helle Scharling Pedersen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Department of Anesthesiology and Intensive Care, Nykøbing Falster Hospital, Nykøbing, Denmark
| | - Louise Gramstrup Nielsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
- Department of Perioperative and Intensive Care Medicine, Helsinki University Hospital and Helsinki University (Former Workplace), Helsinki, Finland
| | - Troels Bek Jensen
- Department of Anaesthesia and Intensive Care, Region Hospital Gødstrup, Herning, Denmark
| | - Kjeld Damgaard
- Department of Anaesthesia and Intensive Care, North Denmark Regional Hospital Hjoerring, Hjoerring, Denmark
| | - Trine Sommer
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Aabenraa, Denmark
| | | | - Nilanjan Dey
- Department of Anaesthesia and Intensive Care, Holstebro Hospital, Holstebro, Denmark
| | - Guiseppe Citerio
- Department of Medicine and Surgery, University Milan-Bicocca, Milan, Italy
| | - Stine Estrup
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Ingrid Egerod
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Karin Samuelson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Anders Perner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Koege, Lykkebækvej 1, 4600, Koege, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [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: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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28
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Liu Y, Cai X, Fang R, Peng S, Luo W, Du X. Future directions in ventilator-induced lung injury associated cognitive impairment: a new sight. Front Physiol 2023; 14:1308252. [PMID: 38164198 PMCID: PMC10757930 DOI: 10.3389/fphys.2023.1308252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Mechanical ventilation is a widely used short-term life support technique, but an accompanying adverse consequence can be pulmonary damage which is called ventilator-induced lung injury (VILI). Mechanical ventilation can potentially affect the central nervous system and lead to long-term cognitive impairment. In recent years, many studies revealed that VILI, as a common lung injury, may be involved in the central pathogenesis of cognitive impairment by inducing hypoxia, inflammation, and changes in neural pathways. In addition, VILI has received attention in affecting the treatment of cognitive impairment and provides new insights into individualized therapy. The combination of lung protective ventilation and drug therapy can overcome the inevitable problems of poor prognosis from a new perspective. In this review, we summarized VILI and non-VILI factors as risk factors for cognitive impairment and concluded the latest mechanisms. Moreover, we retrospectively explored the role of improving VILI in cognitive impairment treatment. This work contributes to a better understanding of the pathogenesis of VILI-induced cognitive impairment and may provide future direction for the treatment and prognosis of cognitive impairment.
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Affiliation(s)
- Yinuo Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Xintong Cai
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Ruiying Fang
- The Clinical Medical College of Nanchang University, Nanchang, China
| | - Shengliang Peng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wei Luo
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Du
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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29
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Andersen-Ranberg NC, Girard TD, Perner A. Haloperidol and delirium: what is next? Intensive Care Med 2023; 49:1535-1537. [PMID: 37792054 DOI: 10.1007/s00134-023-07232-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/09/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Nina C Andersen-Ranberg
- Department of Anaesthesiology and Intensive Care Medicine, Zealand University Hospital, Køge, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modelling of Acute Illness (CRISMA) Centre, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anders Perner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.
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Qian ET, Wang L, Stollings JL, Casey JD, Rice TW, Semler MW. Piperacillin-Tazobactam Versus Anti-Pseudomonal Cephalosporins and Renal and Neurologic Outcomes in Critically Ill Adults: A Secondary Analysis of the SMART Trial. J Intensive Care Med 2023; 38:1127-1135. [PMID: 37357717 PMCID: PMC10616997 DOI: 10.1177/08850666231184177] [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] [Received: 09/19/2022] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 06/27/2023]
Abstract
Background: Prior studies suggest associations between receipt of piperacillin-tazobactam and development of acute kidney injury and receipt of anti-pseudomonal cephalosporins and neurotoxicity. We compared clinically-relevant renal and neurologic outcomes in critically ill patients who received piperacillin-tazobactam versus anti-pseudomonal cephalosporins. Methods: We conducted a secondary analysis of data from the Isotonic Solutions and Major Adverse Renal Events Trial examining patients who received piperacillin-tazobactam or an anti-pseudomonal cephalosporin within 24 h of intensive care unit admission. We performed multivariable analysis using a proportional odds model to examine the association between the first antibiotic received and the outcomes of Major Adverse Kidney Events within 30 days (MAKE30) and days alive and free of delirium and coma to day 28. Results: 3199 were included in the study; 2375 (74%) receiving piperacillin-tazobactam and 824 (26%) receiving anti-pseudomonal cephalosporin. After adjustment for prespecified confounders, initial receipt of piperacillin-tazobactam, compared to anti-pseudomonal cephalosporins, was not associated with higher incidence of MAKE30 (adjusted odds ratio, 1.03; 95% CI, 0.83-1.27; P = .80) but was associated with a greater number of days alive and free of delirium and coma (adjusted odds ratio, 1.18; 95% CI, 1.00-1.38; P = .04). In a sensitivity analysis adjusting for baseline receipt of medications which may impact neuro function, this finding was not significant. Conclusion: Among critically ill adults, receipt of piperacillin-tazobactam was not associated with an increased incidence of death, renal replacement therapy, or persistent renal dysfunction or a greater number of days alive and free of delirium and coma. Randomized trials are needed to inform the choice of antibiotics for empiric treatment infection in critically ill adults.
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Affiliation(s)
- Edward T. Qian
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt University Medical Center, Critical Illness Brain Dysfunction Survivorship Center, Nashville, TN, USA
| | - Jonathan D. Casey
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Ward JA, Yerke J, Lumpkin M, Kapoor A, Lindenmeyer CC, Bass S. Evaluation of a protocol for rifaximin discontinuation in critically ill patients with liver disease receiving broad-spectrum antibiotic therapy. World J Hepatol 2023; 15:1226-1236. [DOI: 10.4254/wjh.v15.i11.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/05/2023] [Accepted: 10/23/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Rifaximin is frequently administered to critically ill patients with liver disease and hepatic encephalopathy, but patients currently or recently treated with antibiotics were frequently excluded from studies of rifaximin efficacy. Due to overlapping spectrums of activity, combination therapy with broad-spectrum antibiotics and rifaximin may be unnecessary. A pharmacist-driven protocol was piloted to reduce potentially overlapping therapy in critically ill patients with liver disease. It was hypothesized that withholding rifaximin during broad-spectrum antibiotic therapy would be safe and reduce healthcare costs.
AIM To determine the clinical, safety, and financial impact of discontinuing rifaximin during broad-spectrum antibiotic therapy in critically ill liver patients.
METHODS This was a single-center, quasi-experimental, pre-post study based on a pilot pharmacist-driven protocol. Patients in the protocol group were prospectively identified via the medical intensive care unit (ICU) (MICU) protocol to have rifaximin withheld during broad-spectrum antibiotic treatment. These were compared to a historical cohort who received combination therapy with broad-spectrum antibiotics and rifaximin. All data were collected retrospectively. The primary outcome was days alive and free of delirium and coma (DAFD) to 14 d. Safety outcomes included MICU length of stay, 48-h change in vasopressor dose, and ICU mortality. Secondary outcomes characterized rifaximin cost savings and protocol adherence. Multivariable analysis was utilized to evaluate the association between group assignment and the primary outcome while controlling for potential confounding factors.
RESULTS Each group included 32 patients. The median number of delirium- and coma-free days was similar in the control and protocol groups [3 interquartile range (IQR 0, 8) vs 2 (IQR 0, 9.5), P = 0.93]. In multivariable analysis, group assignment was not associated with a reduced ratio of days alive and free of delirium or coma at 14 d. The protocol resulted in a reduced median duration of rifaximin use during broad-spectrum antibiotic therapy [6 d control (IQR 3, 9.5) vs 1 d protocol (IQR 0, 1); P < 0.001]. Rates of other secondary clinical and safety outcomes were similar including ICU mortality and 48-h change in vasopressor requirements. Overall adherence to the protocol was 91.4%. The median estimated total cost of rifaximin therapy per patient was reduced from $758.40 (IQR $379.20, $1200.80) to $126.40 (IQR $0, $126.40), P < 0.01.
CONCLUSION The novel pharmacist-driven protocol for rifaximin discontinuation was associated with significant cost savings and no differences in safety outcomes including DAFD.
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Affiliation(s)
- Jessica A Ward
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Jason Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Mollie Lumpkin
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Christina C Lindenmeyer
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Stephanie Bass
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
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Young M, Holmes NE, Kishore K, Amjad S, Gaca M, Serpa Neto A, Reade MC, Bellomo R. Natural language processing diagnosed behavioural disturbance phenotypes in the intensive care unit: characteristics, prevalence, trajectory, treatment, and outcomes. Crit Care 2023; 27:425. [PMID: 37925406 PMCID: PMC10625294 DOI: 10.1186/s13054-023-04695-0] [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: 08/07/2023] [Accepted: 10/19/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Natural language processing (NLP) may help evaluate the characteristics, prevalence, trajectory, treatment, and outcomes of behavioural disturbance phenotypes in critically ill patients. METHODS We obtained electronic clinical notes, demographic information, outcomes, and treatment data from three medical-surgical ICUs. Using NLP, we screened for behavioural disturbance phenotypes based on words suggestive of an agitated state, a non-agitated state, or a combination of both. RESULTS We studied 2931 patients. Of these, 225 (7.7%) were NLP-Dx-BD positive for the agitated phenotype, 544 (18.6%) for the non-agitated phenotype and 667 (22.7%) for the combined phenotype. Patients with these phenotypes carried multiple clinical baseline differences. On time-dependent multivariable analysis to compensate for immortal time bias and after adjustment for key outcome predictors, agitated phenotype patients were more likely to receive antipsychotic medications (odds ratio [OR] 1.84, 1.35-2.51, p < 0.001) compared to non-agitated phenotype patients but not compared to combined phenotype patients (OR 1.27, 0.86-1.89, p = 0.229). Moreover, agitated phenotype patients were more likely to die than other phenotypes patients (OR 1.57, 1.10-2.25, p = 0.012 vs non-agitated phenotype; OR 4.61, 2.14-9.90, p < 0.001 vs. combined phenotype). This association was strongest in patients receiving mechanical ventilation when compared with the combined phenotype (OR 7.03, 2.07-23.79, p = 0.002). A similar increased risk was also seen for patients with the non-agitated phenotype compared with the combined phenotype (OR 6.10, 1.80-20.64, p = 0.004). CONCLUSIONS NLP-Dx-BD screening enabled identification of three behavioural disturbance phenotypes with different characteristics, prevalence, trajectory, treatment, and outcome. Such phenotype identification appears relevant to prognostication and trial design.
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Affiliation(s)
- Marcus Young
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Natasha E Holmes
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, 3000, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Sobia Amjad
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- School of Computing and Information Systems, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Michele Gaca
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
| | - Ary Serpa Neto
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael C Reade
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Joint Health Command, Australian Defence Force, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, Heidelberg, VIC, Australia.
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Melbourne, Australia.
- Department of Critical Care, School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia.
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.
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Turner E, Robinson DM, Roaten K. Psychological Issues. Phys Med Rehabil Clin N Am 2023; 34:849-866. [PMID: 37806702 DOI: 10.1016/j.pmr.2023.05.005] [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] [Indexed: 10/10/2023]
Abstract
Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.
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Affiliation(s)
- Emma Turner
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, USA.
| | - Diana M Robinson
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, USA.
| | - Kimberly Roaten
- The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Suite CS6.104B, Dallas, TX 75390, 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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Guo R, Zhang S, Yu S, Li X, Liu X, Shen Y, Wei J, Wu Y. Inclusion of frailty improved performance of delirium prediction for elderly patients in the cardiac intensive care unit (D-FRAIL): A prospective derivation and external validation study. Int J Nurs Stud 2023; 147:104582. [PMID: 37672971 DOI: 10.1016/j.ijnurstu.2023.104582] [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: 10/17/2022] [Revised: 07/29/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The elderly patients admitted to cardiac intensive care unit (CICU) are at relatively high risk for developing delirium. A simple and reliable predictive model can benefit them from early recognition of delirium followed by timely and appropriate preventive strategies. OBJECTIVE To explore the role of frailty in delirium prediction and develop and validate a delirium predictive model including frailty for elderly patients in CICU. DESIGN A prospective, observational cohort study. SETTINGS CICU at China-Japan Friendship Hospital from March 1, 2022 to August 25, 2022 (derivation cohort); CICU at Beijing Anzhen Hospital affiliated to Capital Medical University from March 14, 2023 to May 8, 2023 (external validation cohort). PARTICIPANTS A total of 236 and 90 participants were enrolled in the derivation and external validation cohorts, respectively. Participants in the derivation cohort were assigned into either the delirium (n = 70) or non-delirium group (n = 166) based on the occurrence of delirium. METHODS The simplified Chinese version of the Confusion Assessment Method for the Diagnosis of Delirium in the Intensive Care Unit was used to assess delirium twice a day at 8:00-10:00 and 18:00-20:00 until the onset of delirium or discharge from the CICU. Frailty was assessed using the FRAIL scale during the first 24 h in the CICU. Other possible risk factors were collected prospectively through patient interviews and medical records review. After processing missing data via multiple imputations, univariate analysis and bootstrapped forward stepwise logistic regression were performed to select optimal predictors and develop the models. The models were internally validated using bootstrapping and evaluated comprehensively via discrimination, calibration, and clinical utility in both the derivation and external validation cohorts. RESULTS The study developed D-FRAIL predictive model using FRAIL score, hearing impairment, Acute Physiology and Chronic Health Evaluation-II score, and fibrinogen. The area under the receiver operating characteristic curve (AUC) was 0.937 (95% confidence interval [CI]: 0.907-0.967) and 0.889 (95%CI: 0.840-0.938) even after bootstrapping in the derivation cohort. Inclusion of frailty was demonstrated to improve the model performance greatly with the AUC increased from 0.851 to 0.937 (p < 0.001). In the external validation cohort, the AUC of D-FRAIL model was 0.866 (95%CI: 0.782-0.907). Calibration plots and decision curve analysis suggested good calibration and clinical utility of the D-FRAIL model in both the derivation and external validation cohorts. CONCLUSIONS For elderly patients in the CICU, FRAIL score is an independent delirium predictor and the D-FRAIL model demonstrates superior performance in predicting delirium.
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Affiliation(s)
- Rongrong Guo
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Shan Zhang
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Saiying Yu
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Xiangyu Li
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Xinju Liu
- Cardiac Intensive Care Unit, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yanling Shen
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jinling Wei
- Cardiac Intensive Care Unit, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing 100029, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing 100069, China.
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Nicholas M, Wittmann J, Norena M, Ornowska M, Reynolds S. A randomized, clinical trial investigating the use of a digital intervention to reduce delirium-associated agitation. NPJ Digit Med 2023; 6:202. [PMID: 37903857 PMCID: PMC10616287 DOI: 10.1038/s41746-023-00950-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023] Open
Abstract
We aimed to determine if a novel digital therapeutic intervention could reduce agitation and unscheduled medication use in an adult delirious acute care population. Delirious participants were randomly allocated (1:1) to receive standard of care plus a single 4-hour exposure to the digital intervention "MindfulGarden", which uses a screen-based delivery to display a nature landscape with dynamic adjustment of screen content in response to movement and sound or standard of care only. Between March 2021 and January 2022, 73 participants were enrolled with 70 completing the trial protocol and included in the final analysis with a mean age of 61 years and 68% being male (35 intervention, 35 control). Mean RASS was significantly lower across the 4-hour study period in the intervention arm 0.3 (0.85) vs 0.9 (0.93), p = 0.01. Exposure to a nature-based dynamic digital intervention showed benefits in agitation reduction.
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Affiliation(s)
- Michelle Nicholas
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Jessica Wittmann
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, Vancouver, BC, V6Z 1Y6, Canada
| | - Marlena Ornowska
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| | - Steven Reynolds
- Intensive Care Unit, Fraser Health Authority C/O Royal Columbian Hospital, New Westminster, BC, V3L 3W7, Canada.
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada.
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Smit L, Slooter AJC, Devlin JW, Trogrlic Z, Hunfeld NGM, Osse RJ, Ponssen HH, Brouwers AJBW, Schoonderbeek JF, Simons KS, van den Boogaard M, Lens JA, Boer DP, Gommers DAMPJ, Rietdijk WJR, van der Jagt M. Efficacy of haloperidol to decrease the burden of delirium in adult critically ill patients: the EuRIDICE randomized clinical trial. Crit Care 2023; 27:413. [PMID: 37904241 PMCID: PMC10617114 DOI: 10.1186/s13054-023-04692-3] [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] [Received: 08/06/2023] [Accepted: 10/18/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND The role of haloperidol as treatment for ICU delirium and related symptoms remains controversial despite two recent large controlled trials evaluating its efficacy and safety. We sought to determine whether haloperidol when compared to placebo in critically ill adults with delirium reduces days with delirium and coma and improves delirium-related sequelae. METHODS This multi-center double-blind, placebo-controlled randomized trial at eight mixed medical-surgical Dutch ICUs included critically ill adults with delirium (Intensive Care Delirium Screening Checklist ≥ 4 or a positive Confusion Assessment Method for the ICU) admitted between February 2018 and January 2020. Patients were randomized to intravenous haloperidol 2.5 mg or placebo every 8 h, titrated up to 5 mg every 8 h if delirium persisted until ICU discharge or up to 14 days. The primary outcome was ICU delirium- and coma-free days (DCFDs) within 14 days after randomization. Predefined secondary outcomes included the protocolized use of sedatives for agitation and related behaviors, patient-initiated extubation and invasive device removal, adverse drug associated events, mechanical ventilation, ICU length of stay, 28-day mortality, and long-term outcomes up to 1-year after randomization. RESULTS The trial was terminated prematurely for primary endpoint futility on DSMB advice after enrolment of 132 (65 haloperidol; 67 placebo) patients [mean age 64 (15) years, APACHE IV score 73.1 (33.9), male 68%]. Haloperidol did not increase DCFDs (adjusted RR 0.98 [95% CI 0.73-1.31], p = 0.87). Patients treated with haloperidol (vs. placebo) were less likely to receive benzodiazepines (adjusted OR 0.41 [95% CI 0.18-0.89], p = 0.02). Effect measures of other secondary outcomes related to agitation (use of open label haloperidol [OR 0.43 (95% CI 0.12-1.56)] and other antipsychotics [OR 0.63 (95% CI 0.29-1.32)], self-extubation or invasive device removal [OR 0.70 (95% CI 0.22-2.18)]) appeared consistently more favorable with haloperidol, but the confidence interval also included harm. Adverse drug events were not different. Long-term secondary outcomes (e.g., ICU recall and quality of life) warrant further study. CONCLUSIONS Haloperidol does not reduce delirium in critically ill delirious adults. However, it may reduce rescue medication requirements and agitation-related events in delirious ICU patients warranting further evaluation. TRIAL REGISTRATION ClinicalTrials.gov (#NCT03628391), October 9, 2017.
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Affiliation(s)
- Lisa Smit
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Arjen J C Slooter
- Departments of Psychiatry, Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, USA
| | - Zoran Trogrlic
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Robert Jan Osse
- Department of Psychiatry, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Huibert H Ponssen
- Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Arjen J B W Brouwers
- Department of Intensive Care Adults, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith A Lens
- Department of Intensive Care, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Dirk P Boer
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands.
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Qian ET, Casey JD, Wright A, Wang L, Shotwell MS, Siemann JK, Dear ML, Stollings JL, Lloyd BD, Marvi TK, Seitz KP, Nelson GE, Wright PW, Siew ED, Dennis BM, Wrenn JO, Andereck JW, Han JH, Self WH, Semler MW, Rice TW. Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA 2023; 330:1557-1567. [PMID: 37837651 PMCID: PMC10576861 DOI: 10.1001/jama.2023.20583] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/21/2023] [Indexed: 10/16/2023]
Abstract
Importance Cefepime and piperacillin-tazobactam are commonly administered to hospitalized adults for empirical treatment of infection. Although piperacillin-tazobactam has been hypothesized to cause acute kidney injury and cefepime has been hypothesized to cause neurological dysfunction, their comparative safety has not been evaluated in a randomized clinical trial. Objective To determine whether the choice between cefepime and piperacillin-tazobactam affects the risks of acute kidney injury or neurological dysfunction. Design, Setting, and Participants The Antibiotic Choice on Renal Outcomes (ACORN) randomized clinical trial compared cefepime vs piperacillin-tazobactam in adults for whom a clinician initiated an order for antipseudomonal antibiotics within 12 hours of presentation to the hospital in the emergency department or medical intensive care unit at an academic medical center in the US between November 10, 2021, and October 7, 2022. The final date of follow-up was November 4, 2022. Interventions Patients were randomized in a 1:1 ratio to cefepime or piperacillin-tazobactam. Main Outcomes and Measures The primary outcome was the highest stage of acute kidney injury or death by day 14, measured on a 5-level ordinal scale ranging from no acute kidney injury to death. The 2 secondary outcomes were the incidence of major adverse kidney events at day 14 and the number of days alive and free of delirium and coma within 14 days. Results There were 2511 patients included in the primary analysis (median age, 58 years [IQR, 43-69 years]; 42.7% were female; 16.3% were Non-Hispanic Black; 5.4% were Hispanic; 94.7% were enrolled in the emergency department; and 77.2% were receiving vancomycin at enrollment). The highest stage of acute kidney injury or death was not significantly different between the cefepime group and the piperacillin-tazobactam group; there were 85 patients (n = 1214; 7.0%) in the cefepime group with stage 3 acute kidney injury and 92 (7.6%) who died vs 97 patients (n = 1297; 7.5%) in the piperacillin-tazobactam group with stage 3 acute kidney injury and 78 (6.0%) who died (odds ratio, 0.95 [95% CI, 0.80 to 1.13], P = .56). The incidence of major adverse kidney events at day 14 did not differ between groups (124 patients [10.2%] in the cefepime group vs 114 patients [8.8%] in the piperacillin-tazobactam group; absolute difference, 1.4% [95% CI, -1.0% to 3.8%]). Patients in the cefepime group experienced fewer days alive and free of delirium and coma within 14 days (mean [SD], 11.9 [4.6] days vs 12.2 [4.3] days in the piperacillin-tazobactam group; odds ratio, 0.79 [95% CI, 0.65 to 0.95]). Conclusions and Relevance Among hospitalized adults in this randomized clinical trial, treatment with piperacillin-tazobactam did not increase the incidence of acute kidney injury or death. Treatment with cefepime resulted in more neurological dysfunction. Trial Registration ClinicalTrials.gov Identifier: NCT05094154.
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Affiliation(s)
- Edward T. Qian
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam Wright
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Justin K. Siemann
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joanna L. Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brad D. Lloyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tanya K. Marvi
- Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin P. Seitz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - George E. Nelson
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patty W. Wright
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward D. Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M. Dennis
- Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse O. Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan W. Andereck
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jin H. Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville
| | - Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [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: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Zheng J, Wang L, Wang W, Zhang H, Yao F, Chen J, Wang Q. Association and prediction of subjective sleep quality and postoperative delirium during major non-cardiac surgery: a prospective observational study. BMC Anesthesiol 2023; 23:306. [PMID: 37697244 PMCID: PMC10494396 DOI: 10.1186/s12871-023-02267-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/02/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is an acute form of brain dysfunction that can result in serious adverse consequences. There has been a link between cognitive dysfunction and poor sleep. The present study aimed to determine the association and prediction of subjective sleep quality and postoperative delirium during major non-cardiac surgery. METHODS One hundred and thirty-four patients, aged 60 years or older, were scheduled for elective laparotomy or orthopaedic procedures. The Pittsburgh Sleep Quality Index (PSQI) and sleep log were used to assess perioperative subjective sleep quality in participants. Nursing Delirium Screening Checklist (NU-DESC) was used for screening, and the Confusion Assessment Method (CAM) was used to diagnose POD during the first seven days following surgery. The association between subjective sleep quality and POD was assessed using a multivariate logistic regression model. Thereafter, the prediction performance of subjective sleep quality was evaluated using a receiver operating characteristic (ROC) curve. RESULTS All assessments were completed on 119 patients who had an average PSQI score of 7.0 ± 2.4 before surgery. 23 patients (19.3%) suffered from POD. The multivariate logistic regression analysis showed that the occurrence of POD was closely related to age, BMI, PSQI and operation time. After adjusting for related factors, there was a statistically significant association between PSQI and POD occurrence (OR = 1.422, 95%CI 1.079-1.873, per 1-point increase in PSQI). The ROC curve analysis showed that the optimal PSQI cutoff value was 8.0 for predicting POD, and the area under the ROC (AUROC) value of PSQI was 0.741 (95%CI 0.635 to 0.817). The AUROC of the model developed by the multivariate logistic regression analysis was 0.870 (95%CI 0.797 to 0.925). CONCLUSIONS The study found that preoperative subjective sleep quality was strongly associated with POD during major non-cardiac surgery. Additionally, PSQI combined with age, BMI, and operation time improved POD prediction.
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Affiliation(s)
- Jinwei Zheng
- Department of anesthesiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
- Department of anesthesiology, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Lulu Wang
- Department of anesthesiology, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Wei Wang
- Department of anesthesiology, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Huafeng Zhang
- Department of anesthesiology, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Fangfang Yao
- Nursing department, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China
| | - Junping Chen
- Department of anesthesiology, Ningbo No.2 Hospital, Ningbo, 315000, Zhejiang, China.
| | - Qingxiu Wang
- Department of anesthesiology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China.
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Latuga NM, Grant PC, Levy K, Luczkiewicz DL. Author Reply to Comment on "Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management". Am J Hosp Palliat Care 2023; 40:1042-1043. [PMID: 36637401 DOI: 10.1177/10499091231152443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
| | - Pei C Grant
- Research Department, Hospice & Palliative Care Buffalo, Buffalo, NY, USA
| | - Kathryn Levy
- Research Department, Hospice & Palliative Care Buffalo, Buffalo, NY, USA
- Department of Planning and Research, Trocaire College, Buffalo, NY, USA
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Mart MF, Gardner-Gray JM, Ahmed S. Delirium and Long-Term Cognitive Impairment after Critical Illness. ATS Sch 2023; 4:387-388. [PMID: 37795122 PMCID: PMC10547026 DOI: 10.34197/ats-scholar.2022-0115ot] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/21/2023] [Indexed: 10/06/2023] Open
Affiliation(s)
- Matthew F. Mart
- Critical Illness, Brain Dysfunction, and Survivorship Center, Nashville, Tennessee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Jayna M. Gardner-Gray
- Division of Pulmonary and Critical Care Medicine, Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | - Shozab Ahmed
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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Flagg LK, Mauney JA. Updates and Clinical Implications of Pediatric Delirium. Crit Care Nurs Clin North Am 2023; 35:315-325. [PMID: 37532385 DOI: 10.1016/j.cnc.2023.04.006] [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: 08/04/2023]
Abstract
Delirium is a fluctuating level of awareness based on a physiologic disease process. Within pediatrics, delirium affects approximately 30% of patients admitted to critical care units and is associated with increased mortality, morbidity, length of stay, and care costs. Multiple pediatric critical care societies recommend the implementation of screening practices using validated delirium tools. Delirium remains underrecognized because of suboptimal screening and protocol implementation in pediatric critical care units nationally and internationally. The mainstay of delirium prevention and management is nonpharmacologic, focusing on normalizing a patient's environment, sleep/wake cycles, nutritional status, and activity levels.
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Affiliation(s)
- Lauren K Flagg
- Yale University School of Nursing, Orange, CT, USA; Yale New Haven Hospital, Pediatric Critical Care, New Haven, CT, USA.
| | - Jennifer A Mauney
- University of Florida College of Nursing, 1225 Center Drive, PO Box 100197, Gainesville, FL 32610, USA
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Martinez FE, Tee R, Poulter AL, Jordan L, Bell L, Balogh ZJ. Delirium Screening and Pharmacotherapy in the ICU: The Patients Are Not the Only Ones Confused. J Clin Med 2023; 12:5671. [PMID: 37685738 PMCID: PMC10488395 DOI: 10.3390/jcm12175671] [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: 08/04/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Delirium is difficult to measure in the Intensive Care Unit (ICU). It is possible that by considering the rate of screening, incidence, and rate of treatment with antipsychotic medications (APMs) for suspected delirium, a clearer picture can emerge. Methods: A retrospective, observational study was conducted at two ICUs in Australia, between April and June of 2020. All adult ICU patients were screened; those who spoke English and did not have previous neurocognitive pathology or intracranial pathology were included in the analysis. Data were collected from the hospitals' electronic medical records. The primary outcome was incidence of delirium based on the use of the Confusion Assessment Method for ICU (CAM-ICU). Secondary outcomes included measures of screening for delirium, treatment of suspected delirium with APMs, and identifying clinical factors associated with both delirium and the use of APMs. Results: From 736 patients that were screened, 665 were included in the analysis. The incidence of delirium was 11.3% (75/665); on average, the Richmond Agitation and Sedation Scale (RASS) was performed every 2.9 h and CAM-ICU every 40 h. RASS was not performed in 8.4% (56/665) of patients and CAM-ICU was not performed in 40.6% (270/665) of patients. A total of 17% (113/665) of patients were prescribed an APM, with quetiapine being the most used. ICU length of stay (LOS), APACHE-III score, and the use of alpha-2 agonists were associated with the presence of delirium, while ICU LOS, the use of alpha-2 agonists, and the presence of delirium were associated with patients receiving APMs. Conclusions: The incidence of delirium was lower than previously reported, at 11.3%. The rate of screening for delirium was low, while the use of APMs for delirium was higher than the incidence of delirium. It is possible that the true incidence is higher than what was measured. Critical prospective assessment is required to optimize APM indications in the ICU.
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Affiliation(s)
- F. Eduardo Martinez
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Rebecca Tee
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Amber-Louise Poulter
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Leah Jordan
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Liam Bell
- Intensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia; (F.E.M.); (R.T.); (A.-L.P.); (L.J.); (L.B.)
| | - Zsolt J. Balogh
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Traumatology, John Hunter Hospital, Lookout Road, New Lambton Heights, Newcastle, NSW 2305, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, NSW 2305, Australia
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Andersen-Ranberg NC, Barbateskovic M, Perner A, Oxenbøll Collet M, Musaeus Poulsen L, van der Jagt M, Smit L, Wetterslev J, Mathiesen O, Maagaard M. Haloperidol for the treatment of delirium in critically ill patients: an updated systematic review with meta-analysis and trial sequential analysis. Crit Care 2023; 27:329. [PMID: 37633991 PMCID: PMC10463604 DOI: 10.1186/s13054-023-04621-4] [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: 07/09/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Haloperidol is frequently used in critically ill patients with delirium, but evidence for its effects has been sparse and inconclusive. By including recent trials, we updated a systematic review assessing effects of haloperidol on mortality and serious adverse events in critically ill patients with delirium. METHODS This is an updated systematic review with meta-analysis and trial sequential analysis of randomised clinical trials investigating haloperidol versus placebo or any comparator in critically ill patients with delirium. We adhered to the Cochrane handbook, the PRISMA guidelines and the grading of recommendations assessment, development and evaluation statements. The primary outcomes were all-cause mortality and proportion of patients with one or more serious adverse events or reactions (SAEs/SARs). Secondary outcomes were days alive without delirium or coma, delirium severity, cognitive function and health-related quality of life. RESULTS We included 11 RCTs with 15 comparisons (n = 2200); five were placebo-controlled. The relative risk for mortality with haloperidol versus placebo was 0.89; 96.7% CI 0.77 to 1.03; I2 = 0% (moderate-certainty evidence) and for proportion of patients experiencing SAEs/SARs 0.94; 96.7% CI 0.81 to 1.10; I2 = 18% (low-certainty evidence). We found no difference in days alive without delirium or coma (moderate-certainty evidence). We found sparse data for other secondary outcomes and other comparators than placebo. CONCLUSIONS Haloperidol may reduce mortality and likely result in little to no change in the occurrence of SAEs/SARs compared with placebo in critically ill patients with delirium. However, the results were not statistically significant and more trial data are needed to provide higher certainty for the effects of haloperidol in these patients. TRIAL REGISTRATION CRD42017081133, date of registration 28 November 2017.
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Affiliation(s)
- Nina Christine Andersen-Ranberg
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark
| | - Anders Perner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Marie Oxenbøll Collet
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lone Musaeus Poulsen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC - University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Lisa Smit
- Department of Intensive Care, Erasmus MC - University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jørn Wetterslev
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Private Office, Tuborg Sundpark 3, 1. Th., 2900, Hellerup, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Mathias Maagaard
- Department of Anaesthesiology and Intensive Care, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark
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Kakar E, Ottens T, Stads S, Wesselius S, Gommers DAMPJ, Jeekel J, van der Jagt M. Effect of a music intervention on anxiety in adult critically ill patients: a multicenter randomized clinical trial. J Intensive Care 2023; 11:36. [PMID: 37592358 PMCID: PMC10433648 DOI: 10.1186/s40560-023-00684-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/28/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Previous studies show positive effect of music on reducing anxiety, pain, and medication requirement. Anxiety has become a more pertinent issue in the intensive care unit (ICU) since wakefulness is preferred according to recent guidelines. Nevertheless, evidence on the effect of music in ICU patients is scarce. Therefore, we studied the effect of music intervention on anxiety in ICU patients. METHODS A multicenter randomized clinical trial was conducted between August 2020 and December 2021 in ICU's at an academic medical centre and two regional hospitals. Adult critically ill patients were eligible when hemodynamically stable and able to communicate (Richmond agitation-sedation scale (RASS) of at least - 2). Patients in the intervention arm were offered music twice daily during three days for at least 30 min per session. Patients in the control group received standard care. The primary outcome was anxiety level assessed with the visual analogue scale for anxiety [VAS-A; range 0-10] twice daily (morning and evening). Secondary outcomes included; 6-item state-trait anxiety inventory (STAI-6), sleep quality, delirium, heart rate, mean arterial pressure, pain, RASS, medication, ICU length of stay, patients' memory and experience of ICU stay. RESULTS 94 patients were included in the primary analysis. Music did not significantly reduce anxiety (VAS-A in the intervention group; 2.5 (IQR 1.0-4.5), 1.8 (0.0-3.6), and 2.5 (0.0-3.6) on day 1, 2, and 3 vs. 3.0 (0.6-4.0), 1.5 (0.0-4.0), and 2.0 (0.0-4.0) in the control group; p > 0.92). Overall median daily VAS-A scores ranged from 1.5 to 3.0. Fewer patients required opioids (21 vs. 29, p = 0.03) and sleep quality was lower in the music group on study day one [5.0 (4.0-6.0) vs. 4.5 (3.0-5.0), p = 0.03]. Other outcomes were similar between groups. CONCLUSIONS Anxiety levels in this ICU population were low, and music during 3 days did not decrease anxiety. This study indicates that efficacy of music is context and intervention-dependent, given previous evidence showing decreased anxiety. Trial registration Netherlands Trial Register: NL8595, Registered, 1 April 2020. CLINICALTRIALS gov ID: NCT04796389, Registered retrospectively, 12 March 2021.
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Affiliation(s)
- Ellaha Kakar
- Department of Intensive Care, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, Room NA-2123, 3015 GD, Rotterdam, The Netherlands.
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Thomas Ottens
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Susanne Stads
- Department of Intensive Care, Ikazia Hospital, Rotterdam, The Netherlands
| | - Sanne Wesselius
- Department of Intensive Care, Haga Teaching Hospital, The Hague, The Netherlands
| | - Diederik A M P J Gommers
- Department of Intensive Care, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, Room NA-2123, 3015 GD, Rotterdam, The Netherlands
| | - Johannes Jeekel
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Neuroscience, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Center, Doctor Molewaterplein 40, Room NA-2123, 3015 GD, Rotterdam, The Netherlands
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Pandharipande P, Williams Roberson S, Harrison FE, Wilson JE, Bastarache JA, Ely EW. Mitigating neurological, cognitive, and psychiatric sequelae of COVID-19-related critical illness. THE LANCET. RESPIRATORY MEDICINE 2023; 11:726-738. [PMID: 37475124 PMCID: PMC10706757 DOI: 10.1016/s2213-2600(23)00238-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/22/2023]
Abstract
Despite advances in the treatment and mitigation of critical illness caused by infection with SARS-CoV-2, millions of survivors have a devastating, post-acute infection syndrome known as long COVID. A large proportion of patients with long COVID have nervous system dysfunction, which is also seen in the distinct but overlapping condition of post-intensive care syndrome (PICS), putting survivors of COVID-19-related critical illness at high risk of long-lasting morbidity affecting multiple organ systems and, as a result, engendering measurable deficits in quality of life and productivity. In this Series paper, we discuss neurological, cognitive, and psychiatric sequelae in patients who have survived critical illness due to COVID-19. We review current knowledge of the epidemiology and pathophysiology of persistent neuropsychological impairments, and outline potential preventive strategies based on safe, evidence-based approaches to the management of pain, agitation, delirium, anticoagulation, and ventilator weaning during critical illness. We highlight priorities for current and future research, including possible therapeutic approaches, and offer considerations for health services to address the escalating health burden of long COVID.
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Affiliation(s)
- Pratik Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Shawniqua Williams Roberson
- Departments of Neurology and Biomedical Engineering, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fiona E Harrison
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jo Ellen Wilson
- Department of Psychiatry and Behavioral Sciences, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Julie A Bastarache
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
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Jaworska N, Krewulak KD, Schalm E, Niven DJ, Ismail Z, Burry LD, Leigh JP, Fiest KM. Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study. J Gen Intern Med 2023; 38:2262-2271. [PMID: 37072535 PMCID: PMC10112822 DOI: 10.1007/s11606-023-08042-5] [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: 09/14/2022] [Accepted: 01/13/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate. OBJECTIVE The purpose of this study was to identify and describe relevant domains and constructs that influence antipsychotic medication prescribing and deprescribing practices among physicians, nurses, and pharmacists that care for critically ill adult patients during and following critical illness. DESIGN We conducted qualitative semi-structured interviews with critical care and ward healthcare professionals including physicians, nurses, and pharmacists to understand antipsychotic prescribing and deprescribing practices for critically ill adult patients during and following critical illness. PARTICIPANTS Twenty-one interviews were conducted with 11 physicians, five nurses, and five pharmacists from predominantly academic centres in Alberta, Canada, between July 6 and October 29, 2021. MAIN MEASURES We used deductive thematic analysis using the Theoretical Domains Framework (TDF) to identify and describe constructs within relevant domains. KEY RESULTS Seven TDF domains were identified as relevant from the analysis: Social/Professional role and identity; Beliefs about capabilities; Reinforcement; Motivations and goals; Memory, attention, and decision processes; Environmental context and resources; and Beliefs about consequences. Participants reported antipsychotic prescribing for multiple indications beyond delirium and agitation including patient and staff safety, sleep management, and environmental factors such as staff availability and workload. Participants identified potential antipsychotic deprescribing strategies to reduce ongoing antipsychotic medication prescriptions for critically ill patients including direct communication tools between prescribers at transitions of care. CONCLUSIONS Critical care and ward healthcare professionals report several factors influencing established antipsychotic medication prescribing practices. These factors aim to maintain patient and staff safety to facilitate the provision of care to patients with delirium and agitation limiting adherence to current guideline recommendations.
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Affiliation(s)
- Natalia Jaworska
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Health Services, Calgary, AB, Canada.
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Emma Schalm
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Lisa D Burry
- Departments of Pharmacy and Medicine, Sinai Health System, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Huang J, Zheng H, Zhu X, Zhang K, Ping X. The efficacy and safety of haloperidol for the treatment of delirium in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1200314. [PMID: 37575982 PMCID: PMC10414537 DOI: 10.3389/fmed.2023.1200314] [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: 04/04/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Purpose Delirium is common during critical illness and is associated with poor outcomes. Therefore, we conducted this meta-analysis to investigate the efficacy and safety of haloperidol for the treatment of delirium in critically ill patients. Methods Randomized controlled trials enrolling critically ill adult patients to compare haloperidol with placebo were searched from inception through to February 20th, 2023. The primary outcome were delirium-free days and overall mortality, secondary outcomes were length of intensive care unit stay, length of hospital stay, and adverse events. Results Nine trials were included in our meta-analysis, with a total of 3,916 critically ill patients. Overall, the pooled analyses showed no significant difference between critically ill patients treated with haloperidol and placebo for the delirium-free days (MD -0.01, 95%CI -0.36 to 0.34, p = 0.95, I2 = 30%), overall mortality (OR 0.89, 95%CI 0.76 to 1.04, p = 0.14, I2 = 0%), length of intensive care unit stay (MD -0.06, 95%CI -0.16 to 0.03, p = 0.19, I2 = 0%), length of hospital stay (MD -0.06, 95%CI -0.61 to 0.49, p = 0.83, I2 = 0%), and adverse events (OR 0.90, 95%CI 0.60 to 1.37, p = 0.63, I2 = 0%). Conclusion Among critically ill patients, the use of haloperidol as compared to placebo has no significant effect on delirium-free days, overall mortality, length of intensive care unit and/or hospital stay. Moreover, the use of haloperidol did not increase the risk of adverse events.
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Affiliation(s)
- Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xianfeng Zhu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Jaquet P, Couffignal C, Tardivon C, Godard V, Bellot R, Assouline B, Benghanem S, Da Silva D, Decavèle M, Dessajan J, Hermann B, Rambaud T, Voiriot G, Sonneville R. PupillOmetry for preDIction of DeliriUM in ICU (PODIUM): protocol for a prospective multicentre cohort study. BMJ Open 2023; 13:e072095. [PMID: 37438060 DOI: 10.1136/bmjopen-2023-072095] [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] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Delirium is a severe complication that is associated with short-term adverse events, prolonged hospital stay and neurological sequelae in survivors. Automated pupillometry is an easy-to-use device that allows for accurate objective assessment of the pupillary light responses in comatose patients in the intensive care unit (ICU). Whether automated pupillometry might predict delirium in critically ill patients is not known. We hypothesise that automated pupillometry could predict the occurrence of delirium in critically ill patients without primary brain injury, requiring more than 48 hours of invasive mechanical ventilation in the ICU. METHODS AND ANALYSIS The PupillOmetry for preDIction of DeliriUM in ICU (PODIUM) study is a prospective cohort study, which will be conducted in eight French ICUs in the Paris area. We aim to recruit 213 adult patients requiring invasive mechanical ventilation for more than 48 hours. Automated pupillometry (Neurological Pupil Index; NPi-200, Neuroptics) will be assessed two times per day for 7 days. Delirium will be assessed using the Confusion Assessment Method in ICU two times per day over 14 days in non-comatose patients (Richmond Agitation and Sedation Scale ≥-3).The predictive performances of the seven automated pupillometry parameters (ie, pupillary diameter, variation of the pupillary diameter, pupillary constriction speed, pupillary dilatation speed, photomotor reflex latency, NPi and symmetry of pupillary responses) measured to detect the delirium occurrence within 14 days will be the main outcomes. Secondary outcomes will be the predictive performances of the seven automated pupillometry parameters to detect complications related to delirium, ICU length of stay, mortality, functional and cognitive outcomes at 90 days. ETHICS AND DISSEMINATION The PODIUM study has been approved by an independent ethics committee, the Comité de Protection des Personnes (CPP) OUEST IV-NANTES (CPP21.02.15.45239 32/21_3) on 06 April 2021). Participant recruitment started on 15 April 2022. Results will be published in international peer-reviewed medical journals and presented at conferences. TRIAL REGISTRATION NUMBER NCT05248035; clinicaltrials.gov.
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Affiliation(s)
- Pierre Jaquet
- Intensive Care Unit, Delafontaine Hospital, Saint Denis, France
| | - Camille Couffignal
- Research Clinic, Epidemiology, Biostatistic Department Bichat hospital, DMU PRISME, Assistance Publique des Hôpitaux de Paris Nord, Groupe Hospitalier Universitaire Paris Cité, Paris, France
| | - Coralie Tardivon
- Research Clinic, Epidemiology, Biostatistic Department Bichat hospital, DMU PRISME, Assistance Publique des Hôpitaux de Paris Nord, Groupe Hospitalier Universitaire Paris Cité, Paris, France
| | - Virginie Godard
- Research Clinic, Epidemiology, Biostatistic Department Bichat hospital, DMU PRISME, Assistance Publique des Hôpitaux de Paris Nord, Groupe Hospitalier Universitaire Paris Cité, Paris, France
| | - Romane Bellot
- Research Clinic, Epidemiology, Biostatistic Department Bichat hospital, DMU PRISME, Assistance Publique des Hôpitaux de Paris Nord, Groupe Hospitalier Universitaire Paris Cité, Paris, France
| | - Benjamin Assouline
- Medical Intensive Care Unit, Département de Cardiologie, Assistance Publique - Hôpitaux de Paris, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Sarah Benghanem
- Medical Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Cochin University Hospital, Paris, France
- Sorbonne Paris Cité-Medical School, Paris Descartes University, Paris, France
| | - Daniel Da Silva
- Intensive Care Unit, Delafontaine Hospital, Saint Denis, France
| | - Maxens Decavèle
- INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Medical Intensive Care Unit, Département R3S, Assistance Publique - Hôpitaux de Paris, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Julien Dessajan
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris Nord, Bichat Claude Bernard Hospital, Paris, France
| | - Bertrand Hermann
- Medical Intensive Care Unit, Assistance Publique - Hôpitaux de Paris Centre, Université Paris Cité, Hôpital Européen Georges Pompidou, Paris, France
- INSERM UMR 1266 Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université de Paris, Paris, Île-de-France, France
| | - Thomas Rambaud
- Medical Intensive Care Unit, Assistance Publique - Hôpitaux de Paris, Avicenne Hospital, Bobigny, France
| | - Guillaume Voiriot
- Medical Intensive Care Unit, Assistance Publique-Hopitaux de Paris, Tenon Hospital, Paris, France
- INSERM UMRS938, Sorbonne université, Centre de recherche Saint-Antoine, Paris, France
| | - Romain Sonneville
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris Nord, Bichat Claude Bernard Hospital, Paris, France
- INSERM UMR 1137, IAME, Université Paris Cité, Paris, France
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