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

The effects of hypnosis and music intervention on comfort and anxiety during weaning from mechanical ventilation: A pilot study

OBJECTIVE

To compare the efficacy of hypnosis or music intervention in alleviating distressing symptoms in critically ill patients facing extended or challenging liberation from mechanical ventilation (MV).

STUDY DESIGN

Single-center, prospective interventional trial.

METHODS

Critically ill patients experiencing extended or challenging MV weaning were assigned to either a hypnosis group or a music intervention group where participants chose calming music from a provided list for a 30-min session. Inclusion criteria encompassed periods during pressure support ventilation, spontaneous breathing trials with tracheostomy or immediately after MV weaning. Hemodynamic, respiratory and electroencephalogram (EEG) parameters were collected before, during and after the intervention. Cortisol blood levels were also assessed. The primary outcome was the patient comfort and anxiety levels assessed using a Visual Analog Scale (VAS).

RESULTS

Twenty-nine patients out of 75 eligible patients were enrolled in the study (15 in the hypnosis group and 14 in the music intervention group). The comfort level increased from 4 [2-6] to 8 [7-9] (p < 0.01) and from 5 [4-6] to 7 [5-8] (p < 0.01) for the hypnosis and music intervention groups, respectively (both p < 0.01). The anxiety level decreased from 5 [5-7] to 3 [2-5] (p < 0.01) and from 6 [5-8] to 4 [3-6] (p < 0.01) for the hypnosis and music intervention groups, respectively (both p < 0.01). No differences were observed between the study groups. Respiratory rate decreased after hypnosis from 28 [25-37] to 24 [23-35] (p < 0.01), but was unchanged with music intervention. Heart rate showed a significant decline from baseline values after both interventions, but reverted to initial values subsequently. Mean arterial pressure exhibited an elevation from 94 (86-110) to 99 (80-108) mmHg after hypnosis (p = 0.01), while a reduction from 87 (75-101) to 82 (74-88) mmHg after music intervention (p = 0.01). Cortisol concentrations significantly decreased from 249 [175-291] to 207 [145-242] μg/L after music intervention (p = 0.02), but was unchanged after hypnosis (both p = 0.04). Both interventions led to a significant decrease in slow delta power and an increase in theta and alpha power on EEG, indicative of a hypnosis-like state.

CONCLUSIONS

In this pilot study, a single session of either hypnosis or music intervention was demonstrated to effectively reduce anxiety and enhance comfort, in critically ill patients facing extended or challenging MV weaning.

Occurrence rate and risk factors for rest and procedural pain in critically ill patients: A systematic review and meta-analysis

OBJECTIVES

To summarize the occurrence rates and identified the risk factors for pain at rest and during procedures in critically ill patients.

METHODS

This study conducted a systematic review and meta-analysis. The Embase, PubMed, CINAHL Plus, Web of Science Core Collection and ProQuest Dissertations & Theses A&I databases were searched from inception to January 10, 2025, for relevant studies. Two independent researchers screened the articles, reviewed them, and extracted data. The data were analyzed using a random-effects model.

RESULTS

This meta-analysis included 23 observational studies with prospective, retrospective, and cross-sectional study designs encompassing 8,073 adult participants. The pooled occurrence rate of pain at rest among critically ill patients was 41 % (95 % confidence interval [CI] = 0.27 to 0.57), whereas that of pain during procedures was 68.4 % (95 % CI = 0.58 to 0.77). Most studies on intensive care unit (ICU)-related pain were conducted in the Asia Pacific region, the Americas, and Western Europe. Age was determined to be negatively associated with pain at rest, whereas opioid use percentage and percentage of male were positively associated with the occurrence of pain during procedures.

CONCLUSIONS

Pain at rest and during procedures is highly prevalent and often undertreated in ICU patients. Health-care providers should develop and implement effective pain management strategies to mitigate both pain at rest and procedural pain in critically ill patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Pain is a frequent and troubling experience for patients in the ICU, so healthcare providers need to assess and address it regularly. This study also pinpointed specific factors linked to pain at rest and during procedures, some of which can be changed or managed. These results offer ICU medical team valuable insights for identifying high-risk patients and delivering personalized interventions to minimize pain.

The 2023 World delirium awareness and quality Survey: A Canadian substudy

OBJECTIVE

This study aimed to evaluate the proportion of screened patients with delirium and the strategies used for its management in Canadian hospitals caring for critically ill children or adults.

METHODS

This is a secondary analysis of a cross-sectional study completed on World Delirium Awareness Day (March 15, 2023). Respondents completed a 35-question survey on the proportion of screened patients with delirium (at 8:00 am and 8:00 pm), treatment, and management strategies employed.

RESULTS

A total of 27 ICUs (22 adult and 5 pediatric) participated. Among adult ICU patients assessed for delirium, 18 % (n = 34/194) had delirium at 8:00 am and 18 % (32/181) had delirium at 8:00 pm. In pediatric ICUs, the proportion of screened patients with delirium was higher, with 50 % (n = 8/16) at 8:00 am and 44 % (n = 7/16) at 8:00 pm. Delirium management strategies varied: with non-pharmacological approaches such as multi-professional rounds (100 %), pain management (96 %), and mobilization (85 %) being most common. The most reported written delirium management protocols included spontaneous breathing trials in adult ICUs and physical restraint and sedation management in PICUs. Few ICUs reported written protocols for family engagement and empowerment.

CONCLUSIONS

Delirium remains a prevalent issue in Canadian ICUs, with variability in assessment and management strategies. Gaps in family engagement and pediatric-specific protocols persist. Addressing barriers like staff shortages and lack of training is critical to improving care.

IMPLICATIONS FOR CLINICAL PRACTICE

Improving delirium management requires standardized protocols, especially in PICUs, and better integration of family engagement in care. Addressing workforce challenges (e.g., staff shortages and educating new staff on delirium) will be crucial for enhancing delirium prevention and treatment in Canadian ICUs. Further research should focus on pediatric-specific interventions and pharmacological management.

The comparison of pupillometry to standard clinical practice for pain and preemptive analgesia before endotracheal suctioning: A randomized controlled trial

BACKGROUND

Pain during endotracheal aspiration (ETA) is frequent in critically ill patients. Managing pre-emptive analgesia before procedures remains a crucial aspect of care. We compared pupillometry to standard clinical practice for assessing preemptive-analgesia administration and pain before ETA according to Behavioural Pain Scale (BPS), the Behavioural Pain Indicator Scale (ESCID), and the Pupillary Dilation Reflex (PDR).

TRIAL DESIGN

A multicentre parallel-group, controlled trial with balanced (1:1) randomization.

METHODS

Sedated, mechanically ventilated patients aged ≥ 18 with baseline BPS = 3, ESCID = 1, and RASS scores between -1 and -4 were included.

CONTROL GROUP

preemptive-analgesia was administered according to nurse criteria. In the experimental group, preemptive analgesia was administered in patients with PDR ≥ 11.5 % after a 20 mA stimulus measured using AlgiScan®. The preemptive analgesia was fentanyl one µg/kg iv bolus. We used the Chi-square statistic to compare post-intervention pain according to BPS, ESCID, and PDR pain values. A multivariate logistic regression study adjusting for sex, BIS, RASS, APACHE II, remifentanil, and preemptive analgesia was conducted.

RESULTS

Ninety-two patients were studied, 51 in control groups and 41 in intervention groups. Pain incidence was lower in the experimental group. Significantly, 43.9 % of patients in the experimental group were prescribed preemptive analgesia before ETA compared to 19.6 % in the control group (p = 0.03). Multivariate analysis showed significant reductions in pain in the group that received preemptive-analgesia before ETA guided by pupillometry across BPS [OR = 0.34 (95 % CI: 0.12-0.99), p = 0.048], ESCID [OR = 0.29 (95 % CI: 0.09-0.88), p = 0.030] and PDR [OR = 0.27 (95 % IC: 0.08-0.86), p = 0.027] compared to standard clinical practice.

CONCLUSIONS

Preemptive analgesia monitored with pupillometry group had a lower percentage of patients with pain than those who received analgesia based on standard clinical practice. This effect was independent of the sex, patient severity, BIS score, remifentanil use, or preemptive- analgesia.

IMPLICATIONS FOR CLINICAL PRACTICE

The requirement for preemptive analgesia before aspiration, evaluated through routine clinical practice, was lower than detected by pupillometric monitoring of patients. The use of pupillometry to monitor preemptive analgesia reduced pain after secretion aspiration. Pupillometry would be an effective tool to individualize the need for preemptive analgesia before potentially painful interventions, applicable to all patients regardless of sex, severity, or sedation level.

ICU nurses' perceptions on family involvement in delirium care for postoperative cardiac surgery patients: A qualitative study

AIMS

Delirium is common among adults recovering from cardiac surgery in the intensive care unit (ICU), prompting increased family involvement in their care. This study aimed to describe ICU nurses' perceptions of factors that support or impede family involvement in preventing, assessing, and managing delirium in the postoperative period following cardiac surgery.

METHODS

A convenience sample of 18 nurses with a mean age 36 years (24-49), 89 % female) was recruited from two university-affiliated ICUs in Canada. After providing written informed consent, participants engaged in a semi-structured individual interview. Descriptive thematic analysis was performed using an established method.

FINDINGS

The analysis identified six key themes: 1) Choosing the right time to involve the family, 2) The importance of sharing information, 3) Influence of family characteristics, 4) Influence of organizational characteristics, 5) Family input helps detect delirium, and 6) Families can take concrete actions when delirium occurs. Notably, while information sharing during delirium episodes was highly valued, discussions on delirium prevention were absent among all nurse participants.

CONCLUSIONS

Overall, ICU nurses perceive family involvement in delirium care as beneficial, depending on factors such as patient condition, nurse attitudes and preferences, family characteristics, and organizational support. This qualitative study provides valuable insights on nurses' perceptions regarding family involvement in ICU settings.

IMPLICATIONS FOR CLINICAL PRACTICE

ICU nurses, healthcare administrators and educators can use these findings to support family involvement in ICU delirium care after cardiac surgery. Overcoming barriers, particularly around delirium prevention, requires further investigation into nurses' education, resource allocation, and organizational support.

Exploring differences in reported mental health outcomes and quality of life between physically restrained and non-physically restrained ICU patients; a prospective cohort study

BACKGROUND

Physical restraints are frequently used in ICU patients, while their effects are unclear.

OBJECTIVE

To explore differences in patient reported mental health outcomes and quality of life between physical restrained and non-physical restrained ICU patients at 3- and 12-months post ICU admission, compared to pre-ICU health status.

RESEARCH METHODOLOGY/DESIGN

Prospective cohort study. Patients were included when 16 years or older, admitted for at least 12 h and provided informed consent. Differences between groups were analysed using linear mixed model analyses.

SETTING

Two ICUs, a 35 bed academic ICU and a 12 bed ICU in a teaching hospital in the Netherlands.

MAIN OUTCOME MEASURES

Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale, post-traumatic stress disorder using the Impact of Event Scale-Revised, and Quality of life using the Short Form-36 scores.

RESULTS

2,764 patients were included, of which 486 (17.6 %) were physically restrained for median 2 [IQR 1-6] days. Significantly worse outcomes were reported at 3-months by physically restrained patients (symptoms of depression 0.89, 95 %CI 0.37 to 1.41, p < 0.001; PCS -2.82, 95 %CI -4.47 to -1,17p < 0.001; MCS -2.67, 95 %CI -4.39 to -0.96, p < 0.01). At 12-months, only the PCS scores remained significantly lower (-1.71, 95 %CI -3.42 to -0.004, p < 0.05).

CONCLUSION

Use of physical restraints is associated with worse self-reported symptoms of depression and decreased quality of life 3-months post ICU, and lower physical quality of life after 12-months.

IMPLICATIONS FOR CLINICAL PRACTICE

Use of physical restraints is associated with statistical significant worse mental and physical outcomes.

Nurse-led evidence-based quality improvement programme to improve intensive care unit patient sleep quality

BACKGROUND

Patients in the intensive care unit (ICU) suffer from significant sleep disturbances, which can negatively impact their healing and overall health. Nurses, as the primary caregivers, need to have expertise in sleep management to ensure better patient outcomes. Implementing nurse-led, evidence-based sleep protocols in ICUs is crucial.

AIM

This study aimed to improve ICU patients' sleep quality by developing and implementing a nurse-led, evidence-based SLEEP Bundle, including Sleep initiative, Light control, Eye mask and earplugs usage, Environment noise cancellation and Provision of non-pharmacological (aromatherapy and music therapy) and pharmacological (dexmedetomidine and painkillers) support.

METHODS

The Framework of Evidence-based Continuous Quality Improvement and the Ottawa Model of Research Use framework were used to guide the development, implementation and assessment of the SLEEP Bundle. A quasi-experimental study was conducted in a 12-bed surgical intensive care unit (SICU), assessing patient-perceived sleep quality, nurses' self-report knowledge, attitudes and actions regarding patient sleep conditions and nurses' adherence to the interventions.

INTERVENTIONS

In order to successfully translate evidence into clinical practice, the protocol was crafted with significant nurse involvement, input in sleep promotion materials and a flexible continuing education component, which provided credits to encourage nurse participation. A sleep-aid kit, complete with non-pharmacological tools, and a system of regular quality control and feedback were integral to the clinical application of the protocol.

RESULTS

The intervention significantly enhanced ICU patients' sleep quality, as evidenced by a significant increase in Richards-Campbell Sleep Questionnaire scores from 62 (IQR = 48-72) to 70 (IQR = 62-76) (95% CI [-10.000, -6.000], Z = -6.100, p < .001). Nurses demonstrated a 100% agreement in knowledge items and a significant upsurge in action items following the intervention. Concurrently, adherence to practice standards showed notable improvements in sleep management practices, including enhanced sleep quality assessment, daytime functional exercise support and compliance with environmental regulations, along with increased use of earplugs, eye masks and aromatherapy/music therapy.

CONCLUSIONS

The study highlights the effectiveness and feasibility of a nurse-led sleep management strategy, as demonstrated by improved patient outcomes and increased nurse adherence to sleep promotion interventions.

RELEVANCE TO CLINICAL PRACTICE

The significant improvements in sleep quality as well as the increased adherence to evidence-based interventions by nurses suggest that this SLEEP Bundle could be effectively translated to other clinical settings.

Nonpharmacological interventions to promote sleep in the adult critical patients unit: A scoping review

BACKGROUND

Sleep and circadian rhythms are markedly altered in intensive care unit (ICU) patients. Numerous factors related to the patient and the ICU environment affect the ability to initiate and maintain sleep. Therefore, nonpharmacological interventions could play an essential role in improving sleep and circadian rhythm.

OBJECTIVE

The aim of this study was to examine nonpharmacological interventions evaluated for promoting sleep in adult ICUs.

METHODS

A scoping review was conducted, including randomised controlled trials, nonrandomised controlled trials, quasi-experimental trials, and other controlled studies investigating the effects of nonpharmacological interventions promoting sleep in adult ICU patients.

RESULTS

A total of 57 articles and 14 ongoing trials were included in the review, of which 38 were randomised clinical trials. Nine nonpharmacological interventions to improve sleep in critically ill patients were evaluated: earplugs and/or eye masks, aromatherapy, bundles, music intervention, massage or acupressure, noise masking, bright light, and dynamic light. Most included trials simultaneously assessed the effect of more than one intervention on perceived sleep quality using questionnaires. The association between the interventions and improved sleep varied. In the case of multicomponent interventions, it is difficult to identify which components might have influenced sleep improvement.

CONCLUSIONS

Numerous studies have evaluated various nonpharmacological interventions to promote sleep in critically ill patients, several of which improved perceived sleep quality. However, the substantial variability of the assessed interventions and their implementation complicates drawing reliable conclusions.

REGISTRATION

The protocol for this scoping review was registered with the Open Science Framework under the identifier https://doi.org/10.17605/OSF.IO/MPEQ5.

Continuous deep sedation versus minimal sedation after cardiac arrest and resuscitation (SED-CARE): A protocol for a randomized clinical trial

BACKGROUND

Sedation is often provided to resuscitated out-of-hospital cardiac arrest (OHCA) patients to tolerate post-cardiac arrest care, including temperature management. However, the evidence of benefit or harm from routinely administered deep sedation after cardiac arrest is limited. The aim of this trial is to investigate the effects of continuous deep sedation compared to minimal sedation on patient-important outcomes in resuscitated OHCA patients in a large clinical trial.

METHODS

The SED-CARE trial is part of the 2 × 2 × 2 factorial Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, a randomized international, multicentre, parallel-group, investigator-initiated, superiority trial with three simultaneous intervention arms. In the SED-CARE trial, adults with sustained return of spontaneous circulation (ROSC) who are comatose following resuscitation from OHCA will be randomized within 4 hours to continuous deep sedation (Richmond agitation and sedation scale (RASS) -4/-5) (intervention) or minimal sedation (RASS 0 to -2) (comparator), for 36 h after ROSC. The primary outcome will be all-cause mortality at 6 months after randomization. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to the allocation group. To detect an absolute risk reduction of 5.6% with an alpha of 0.05, 90% power, 3500 participants will be enrolled. The secondary outcomes will be the proportion of participants with poor functional outcomes 6 months after randomization, serious adverse events in the intensive care unit, and patient-reported overall health status 6 months after randomization.

CONCLUSION

The SED-CARE trial will investigate if continuous deep sedation (RASS -4/-5) for 36 h confers a mortality benefit compared to minimal sedation (RASS 0 to -2) after cardiac arrest.

Critical care nurses' prioritisation of patient care, including delirium prevention and management strategies: A mixed-method study

BACKGROUND

Delirium is a common issue in critical care, yet its prevention and management strategies are often inconsistent. Understanding the factors that lead to the omission or delay in delirium-related care by critical care nurses is essential for enhancing patient outcomes.

OBJECTIVES

This study aimed to identify the specific delirium-related prevention and management strategies that are frequently missed or delayed by critical care nurses. It also explored factors influencing nurses' prioritisation of care, including delirium-related strategies.

METHODS

A mixed-method approach was utilised, combining quantitative data from online surveys and qualitative insights from interviews with critical care nurses in a Canadian health authority. The Missed Nursing Care Survey identified instances of missed or delayed care, while interviews provided deeper insights into care prioritisation decisions.

RESULTS

Quantitative findings indicated frequent delays in patient mobilisation and physical care that were attributed to staffing shortages, high patient volume, and increased admissions and discharges. Qualitative findings revealed that factors such as patient acuity, structured routines, knowledge gaps, limited support, unit culture, and resource inadequacies influenced the prioritisation of delirium-related care, often leading to its inadvertent deprioritisation.

CONCLUSION

This study underscores the need to integrate delirium care into patient acuity assessments and establish sustainable education programs to enhance the recognition and prioritisation of delirium by critical care nurses. Addressing these factors is critical for improving patient outcomes in critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

Strengthening critical care nurses' capacity to consistently recognise and prioritise delirium-related care through targeted education and system-level support could potentially contribute to better patient outcomes.

Prehabilitation to mitigate postintensive care syndrome in surgical patients: The rationale for a peri-critical illness pathway involving anaesthesiologists and intensive care physicians

The post-intensive care syndrome (PICS) refers to the long-term physical, psychological and cognitive impairments experienced by intensive care unit (ICU) survivors, while PICS-Family (PICS-F) affects their family members. Despite preventive strategies during the ICU stay, PICS remains a significant concern impacting survivors' quality of life, increasing the healthcare costs, and complicating recovery. Prehabilitation offers a promising approach to mitigating PICS and PICS-F, especially when the ICU stay can be anticipated, such as in the case of major surgery. Recent literature indicates that prehabilitation - interventions designed to enhance patients' functional capacity before critical illness - may mitigate the risk and severity of PICS. Studies have demonstrated that prehabilitation programs can improve muscle strength, reduce anxiety levels and enhance overall quality of life in ICU survivors. Family prehabilitation (prehabilitation-F) is also introduced as a potential intervention to help families to cope with the stress of critical illness. This article aims to explore the role of multimodal prehabilitation and post-ICU follow-up in preventing and managing PICS and PICS-F, focusing on improving patient outcomes, supporting families and optimising healthcare resources. Combining prehabilitation with post-ICU follow-up in peri-critical care clinics could streamline resources and improve outcomes, creating a holistic care pathway. These clinics, focused on both pre-ICU and post-ICU care, would thus address PICS from multiple angles. However, the heterogeneity of patient populations and prehabilitation protocols present challenges in standardising the interventions. Further research is necessary to establish optimal prehabilitation strategies tailored to individual patient needs and to demonstrate their utility in terms of patient outcome.

Feasibility and Acceptability of Using Wireless Limited Polysomnography to Capture Sleep Before, During, and After Hospitalization for Patients With Planned Cardiothoracic Surgery

BACKGROUND

Sleep disruption, a common symptom among patients requiring cardiovascular surgery, is a potential risk factor for the development of postoperative delirium. Postoperative delirium is a disorder of acute disturbances in cognition associated with prolonged hospitalization, cognitive decline, and mortality.

OBJECTIVE

The aim of this study was to evaluate the feasibility and acceptability of using polysomnography (PSG) to capture sleep in patients with scheduled cardiothoracic surgery.

METHODS

Wireless limited PSG assessed sleep at baseline (presurgery at home), postoperatively in the intensive care unit, and at home post hospital discharge. Primary outcomes were quality and completeness of PSG signals, and acceptability by participants and nursing staff.

RESULTS

Among 15 patients, PSG data were of high quality, and mean percentage of unscorable data was 5.5% ± 11.1%, 3.7% ± 5.4%, and 3.7% ± 8.4% for baseline, intensive care unit, and posthospitalization measurements, respectively. Nurses and patients found the PSG monitor acceptable.

CONCLUSIONS

Wireless, limited PSG to capture sleep across the surgical continuum was feasible, and data were of high quality. Authors of future studies will evaluate associations of sleep indices and development of postoperative delirium in this high-risk population.

Prevalence and variability in use of physical restraints in intensive care units: A systematic review and meta-analysis

BACKGROUND

Given the varying perspectives on the use of physical restraint (PR) over the past decades and the provided protocols to minimise its occurrence in intensive care units (ICUs), a comprehensive study was deemed necessary to examine the prevalence and variation of PR use in ICUs.

OBJECTIVE

The aim of this study was to estimate the overall proportions of PR utilised in adult ICUs whilst examining the various factors contributing to the variability of these estimates.

METHODS

A search of five databases (PubMed, Cochrane Library, Scopus, Embase, and Web of Science) was performed. Studies published in English and available online from inception to December 18, 2024, were included. A pooled estimate with a 95% confidence interval was calculated, and the data were represented by the random-effect model. Analysis was performed using the STATA statistical software (version 17).

RESULTS

The meta-analysis included 39 studies, with a sample size of 21 665 patients. The overall prevalence of patients exposed to PRs was 41.6% (95% confidence interval: 33.8%-49.5%). The heterogeneity was significantly high (I2 = 99.61%), and the Q Cochrane test for homogeneity was significant (p value < 0.001), indicating substantial variability between studies. Subgroup analysis regarding the continent and restraint method contributed to a lowered heterogeneity.

CONCLUSIONS

There was considerable variation in reported estimates of PR prevalence in adult ICUs. Despite valid guidelines and recommendations supporting the reduction of PR, the results of our study show its significant prevalence. Additionally, our study demonstrated a relationship between PR use and delirium, sedation use, and mechanical ventilation. This study emphasises the importance of managing and focussing on PRs in ICUs. Also, it is crucial to evaluate barriers to guideline implementation.

REGISTRATION

The systematic review protocol has been prospectively registered in the International Prospective Register of Systematic Reviews: CRD42024566480.

Factors associated with Intensive care nurses' use of non-pharmacological methods of pain management: A multinomial logistic regression analysis

BACKGROUND

Although there are numerous studies in the literature on the roles, methods used and attitudes of nurses in pain management, the factors related to the use of non-pharmacological methods (NPMs) are not well-documented.

AIM

This research aims to determine the factors related to the use of NPMs by intensive care nurses in Turkey.

STUDY DESIGN

This descriptive and cross-sectional study was conducted with the participation of 385 intensive care unit nurses. Data were collected by using the 'Sociodemographic Data Form', 'Non-Pharmacological Methods Form' and 'Pain Beliefs Questionnaire' (PBQ) between January-December 2022. Multiple multinomial logistic regression analysis was used to identify factors associated with non-pharmacological methods. Pain management was categorized as pharmacological, non-pharmacological and both. The use of pharmacological methods (PMs) was taken as the reference category. The STROBE checklist was adhered to in this study.

RESULTS

It was found that in pain management in the ICU, 33% used pharmacological methods, and 62.1% used both methods. The most frequent barriers experienced in the use of NPMs were 'heavy workload' (82.9%), 'inadequate time' (82.9%) and 'patients being unstable' (69.6%). Receiving pain management training increased the nurses' use of NPMs by 237% compared to pharmacological methods (RRR = 2.377, 95% CI = 1.200-4.707; p = .013). Regarding the barriers to the use of NPMs, 'the lower priority of NPMs compared to emergency practices (RRR=0.333, 95% CI=0.191-0.579; p=.000) and Deficiency in resources (materials and equipment)' (RRR = 0.454, 95% CI = 0.244-0.846; p = .013) decreased the use of NPMs. The Psychological Beliefs subscale of the PBQ increased the use of NPMs (RRR = 2.094, 95% CI = 1.152-3.803; p = .015).

CONCLUSION

Nurses should be provided with training on non-pharmacological methods as well as pharmacological methods in pain management, barriers to the use of non-pharmacological methods should be eliminated and psychological beliefs regarding pain should also be addressed.

RELEVANCE TO CLINICAL PRACTICE

There is a need to solve the problems of lack of education, legal barriers and lack of resources in increasing the use of non-pharmacological pain methods by nurses in intensive care units.

Communication difficulties in mechanically ventilated voiceless patients in intensive care units: A qualitative study

BACKGROUND

Mechanically ventilated patients are unable to verbally communicate due to the endotracheal tube or tracheostomy, rendering them temporarily 'voiceless'. More and more patients are conscious during mechanical ventilation because of a new paradigm based on mild/no sedation. Communicating with conscious voiceless patients can be complex and frustrating, leading to negative outcomes and experiences for patients, family members and health care professionals.

AIM

To explore the negative effects of the inability to communicate verbally among voiceless patients in intensive care units (ICUs), considering the perspectives of voiceless patients, health care professionals and family members.

STUDY DESIGN

This qualitative study uses Interpretive Description methodology. Semi-structured interviews were conducted with patients, family members and health care professionals. Data were collected at three ICUs in Italy over 3 months. Data were analysed using the Rapid and Rigorous qualitative data analysis.

RESULTS

Forty-three people were interviewed (10 patients, 13 caregivers, 13 nurses and 7 physicians). Three major themes were identified: perception of communication difficulties, negative impacts on relationships and emotions, and negative effects on care. These findings indicate that communication difficulties in ICU have negative emotional and psychological consequences for all participants and the health care provided.

CONCLUSIONS

Effective communication with voiceless patients is essential for their well-being and quality of care. Future research should focus on identifying and evaluating tailored communication methods for voiceless patients.

RELEVANCE TO CLINICAL PRACTICE

This study emphasizes the importance of interventions improving voiceless communication, including training health care professionals and critical care nurses in alternative communication strategies, providing psychological support to voiceless patients, and encouraging extended family presence.

Patient Agitation in the Intensive Care Unit: A Concept Analysis

AIM

Exploring the concept of patient agitation in the intensive care unit.

BACKGROUND

Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management.

DESIGN

Concept Analysis.

METHOD

Walker and Avant's eight-step concept analysis approach.

DATA SOURCES

A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation.

RESULTS

Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff.

CONCLUSION

Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours.

IMPLICATIONS

A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research.

PATIENT OR PUBLIC CONTRIBUTION

This concept analysis was developed with input from a patient representative.

The use of audio-visual aids to reduce delirium after cardiac surgery in intensive care units (DaCSi-ICU): A feasibility study protocol

INTRODUCTION

Delirium can affect over 50% of patients following cardiac surgery in intensive care units (ICU), leading to an increased risk of long-term cognitive impairment, prolonged hospital stays and increased costs. Nurse-led auditory-visual stimulation to help prevent and manage ICU delirium is a novel, unexplored strategy in postoperative cardiac surgical patients but proven to be effective in other long-term conditions. The Delirium after Cardiac Surgery in the Intensive Care Unit (DaCSi-ICU) study aims to assess the feasibility and acceptability of implementing an innovative, family-focused auditory-visual intervention to reduce delirium in ICU patients following major cardiac surgery.

METHODS AND ANALYSIS

This is a pilot, mixed-methods, non-randomised feasibility study to be delivered in a university hospital cardiac ICU. The primary outcome is to explore the feasibility and acceptability of an innovative family-focused intervention to reduce ICU delirium rates in patients following cardiac surgery. Secondary outcomes are to: explore short-term post-surgical outcomes up to three months of hospital discharge; and investigate participants' perspectives of taking part in the study. A total of 12 patients, alongside 12 family members or significant others and 6 ICU nurses will be recruited. Demographic data will be reported descriptively, and clinical data will be managed statistically through SPSS. Data collected from interviews will be transcribed full verbatim and analysed on NVIVO using framework analysis. This study has received Health Research Authority (HRA) approval (24/YH/0011). Imperial College Healthcare NHS Trust is the sponsor for research governance purposes. This trial is registered at ClinicalTrials.gov (NCT06355570). Findings will be disseminated through peer-reviewed open-access journals and presented in national and international scientific meetings. Findings will also be shared with patients and the clinical team. Study results will determine the feasibility and acceptability of the intervention, facilitating the progression to a future controlled effectiveness trial.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

Development and psychometric validation of the Behavioral Indicators of Pain Scale-Brain Injury (ESCID-DC) for pain assessment in critically ill patients with acquired brain injury, unable to self-report and with artificial airway

INTRODUCTION

The aim of this study was to develop and validate the adaptation of the behavioural indicators of pain scale (ESCID) for patients with acquired brain injury (ESCID-DC), unable to self-report and with artificial airway.

METHODS

Multicenter study conducted in 2 phases: scale development and evaluation of psychometric properties. Two blinded observers simultaneously assessed pain behaviours with two scales: ESCID-DC and Nociception Coma Scale-Revised version-adapted for Intubated patients (NCS-R-I). Assessments were performed at 3 time points: 5 min before, during and 15 min after the application of the painfull procedures (tracheal suction and application of pressure to the right and left nail bed) and a non-painful procedure (rubbing with gauze). On the day of measurement, the Glasgow Coma Score (GCS) and the Richmond Agitation Sedation Scale (RASS) were evaluated. A descriptive and psychometric analysis was performed.

RESULTS

A total of 4152 pain evaluations were performed in 346 patients, 70% men with a mean age of 56 years (SD = 16.4). The most frequent etiologies of brain damage were vascular 155 (44.8%) and traumatic 144 (41.6%). The median GCS and RASS on the day of evaluation were 8.50 (IQR = 7 to 9) and -2 (RIQ = -3 to -2) respectively. In ESCID-DC the median score was 6 (IQR = 4 to 7) during suction, 3 (RIQ = 1 to 4) for right pressure and 3 (RIQ = 1 to 5) for left pressure. During the non-painful procedure it was 0. The ESCID-DC showed a high discrimination capacity between painful and non-painful procedures (AUC > 0.83) and is sensitive to change depending on the time of application of the scale. High interobserver agreement (Kappa > 0.87), good internal consistency during procedures (α-Cronbach≥0.80) and a high correlation between the ESCID-DC and the NCS-R-I (r ≥ 0.75) were obtained.

CONCLUSIONS

The results of this study demonstrate that the ESCID-DC is a valid and reliable tool for assessing pain in patients with acquired brain injury, unable to self-report and with artificial airway.

Dyspnea Among Mechanically Ventilated Patients: A Systematic Review

OBJECTIVES

Dyspnea is a common and distressing symptom; yet, how frequently and intensely mechanically ventilated patients experience dyspnea remains unclear. We performed a systematic review to identify the prevalence and severity of dyspnea in communicative, mechanically ventilated critically ill adults. We also identified factors associated with dyspnea in the short-term and long-term and potential management strategies.

DATA SOURCES

We performed a systematic search of the following databases: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, PsycInfo, and CINAHL.

DATA EXTRACTION

Our search strategy used variations of these terms: dyspnea, mechanical ventilation, and critical care. We included prospective observational studies and randomized controlled trials. Two independent reviewers screened citations and extracted data using a predrafted report form to examine dyspnea prevalence and severity, association with short-term and long-term outcomes, and interventions to mitigate dyspnea.

DATA SYNTHESIS

Of 6290 records screened, we included 21 observational studies and 3 randomized controlled trials. We calculated percentages and 95% CIs for prevalence using Stata 17 se. Dyspnea was present in 475 of 1169 communicative, mechanically ventilated patients (40.6%, 95% CI, 37.8-43.5) and was found to be moderate to severe. In the lone study to examine long-term outcomes, dyspnea was associated with posttraumatic stress disorder (PTSD) at 90 days. Interventions to reduce dyspnea included: mechanical threshold inspiratory muscle training, ventilation adjustments, supplemental high-flow nasal cannula, opioids, hyperoxemia, and nonpharmacologic interventions, including music and fan therapy.

CONCLUSIONS

In this systematic review, we found that dyspnea among mechanically ventilated patients is common and moderate to severe in its intensity. Dyspnea is associated with adverse long-term outcomes, including probable PTSD. Strategies to manage, or palliate, dyspnea were identified. Future study is warranted to examine how this information can be incorporated into clinical practice to improve short-term and long-term outcomes.

Analgosedation practice during noninvasive respiratory supports: Results from an Italian survey

PURPOSE

There are currently no established guidelines pertaining the application of analgosedation strategies for patients undergoing Noninvasive Respiratory Supports (NRSs) for acute respiratory failure treatment. The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) conducted a nation-wide survey to describe the current clinical practice in the management of analgosedation during NRSs.

METHODS

This is a nationwide online survey, involving Italian anesthesiologist-intensivists, developed by experts affiliated with SIAARTI. Invitations to participate were distributed via emails and social networks. Data were collected over a period of three months (March 16 to May 10, 2024).

RESULTS

Two hundred and seventy-seven full responses were collected. Most respondents were attending physician (83 %), with <10 years of ICU experience (56 %) and work in ICU medical department (75 %). In terms of optimizing the NRS success, 80 % of respondents used a pharmacological strategy and 50 % of respondents did not use a non-pharmacological strategy. Dexmedetomidine was the most commonly administered drug (82 %), followed by morphine and remifentanil. Additionally, 33 % of respondents reported using a combination of dexmedetomidine and remifentanil as part of their pharmacological strategy during NRSs. Concerning the motivations for analgosedation use during NRSs, over 80 % of respondents aimed to improve patient-ventilator interaction, more than 60 % focused on reducing patient anxiety and dyspnea, 59 % sought for having a lower respiratory rate, and only 40 % prioritized pain reduction.

CONCLUSION

Sedation is frequently used in patients with acute respiratory failure undergoing NRSs. Current analgesic practices are becoming more standardized, with analgosedation strategies increasingly tailored to individual patient characteristics.

Fospropofol disodium versus Propofol for deep sedation in critically ill patients: a randomized pilot study

BACKGROUND

Fospropofol disodium is comparable to propofol in maintaining mild-to-moderate sedation for mechanically ventilated patients in intensive care unit (ICU). However, its efficacy for deep sedation remains unclear. Therefore, we conducted a randomized-controlled trial comparing the efficacy and safety of fospropofol disodium with propofol for deep sedation of mechanically ventilated patients in ICU.

METHODS

In this randomized pilot study, critically ill adult patients requiring deep sedation were randomized to receive fospropofol disodium or propofol. The study drug was titrated to maintain a Richmond Agitation-Sedation Scale score (RASS) of-5 or-4. Narcotrend Index (NI) value was monitored during the whole study period. The primary outcome was the percentage of time in the target sedation range without rescue sedation. The secondary outcomes were successful extubation, ventilator-free days at day 7, ventilator-free days at day 28, 28-day all-cause mortality and adverse events.

RESULTS

Thirty patients were included in each group. The fospropofol disodium infusion lasted for 47.50 (IQR 31.75 to 48.00) hours at a dose of 8.19 ± 2.36 mg/kg/h, while propofol infusion for 48.00 (IQR 30.88 to 48.00) hours at 2.73 ± 0.83 mg/kg/h. The proportion of time within the target RASS range without rescue sedation was 96.78%±0.07% in the fospropofol group and 98.43%±0.04% in the propofol group (p = 0.273). A total of 39 patients experienced adverse events, with 19 in the fospropofol group and 20 in the propofol group. The most common adverse event was hypotension, with 18 patients (60.0%) in each group. No significant differences were observed in successful extubation, ventilator-free days at day 7, ventilator-free days at day 28, or 28-day all-cause mortality.

CONCLUSIONS

In this open-label trial, fospropofol disodium achieved deep sedation at a rate comparable to propofol. For mechanically ventilated ICU patients, fospropofol disodium may offer a safe and effective sedation option. Larger multicenter trials are needed to confirm these findings.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov on May 12, 2023, with the identifer NCT05870514.

Clinicians' opinion on massage in the intensive care unit patients

Introduction

Physiotherapy in the Intensive Care Unit (ICU) is a common medical procedure involving mainly elements of mobilisation, electrotherapy and also, in various forms and to a lesser extent, elements of massage. Massage can positively influence the physical and psychological outcomes of the ICU) patients.

Aim

The study aimed to assess the perception of physiotherapists (PTs), physicians (PHs), and registered nurses (RNs) working in ICU about the possibilities and safety of implementing massage in the process of rehabilitation of ICU patients.

Methods

This multicentre survey was conducted in Poland in three ICUs (Gdansk, Koscierzyna, Krakow). A total of 135 people participated in the study. Of these, 25.9% (35/135) were PTs, 21.5% (29/135) were PHs, and 52.6% (71/135) were RNs. The questionnaires were distributed and collected online (directly by respondents to Google Form system) and in written form.

Results

Most PTs-71% (25/35)-perceive massage as a beneficial and safe treatment while working with ICU patients. PHs 96% (28/29) and RNs 92% (65/71) also recommend using massage by physiotherapists to rehabilitate ICU patients. In the respondents' opinion, the possibilities for the use of massage by PHs and RNs are lower (between 20% and 55%).

Conclusions

According to the surveyed clinicians working in the ICU, massage is a safe form of treatment, especially when performed by PTs and it could be a permanent element of rehabilitation among ICU patients, especially for reducing pain, anxiety and restlessness and also improving sleep quality and bowel movement.

Ciprofol versus propofol for long-term sedation in mechanically ventilated patients with sepsis: a randomized controlled trial

BACKGROUND

Sedatives are often used to facilitate mechanical ventilation in patients with sepsis. Ciprofol is a new promising sedated candidate with a higher binding activity to the gamma-aminobutyric acid-A receptor than propofol. This study aimed to compare the efficacy and safety of ciprofol and propofol for long-term sedation in mechanically ventilated patients with sepsis.

METHODS

In this single-center randomized clinical trial, mechanically ventilated adults with sepsis in the intensive care unit (ICU) who anticipated to require long-term sedation ≥ 24 h were randomly assigned to receive intravenous ciprofol or propofol. The target sedation goal was - 3 to 0 according to the Richmond Agitation-Sedation Scale. The primary outcome was weaning time. Secondary outcomes included the percentage of time within the target sedation range, successful sedation (the percentage of time within the target sedation range ≥ 70% without rescue sedation), ICU and in-hospital mortality, length of ICU and hospital stay, hypotension, and bradycardia.

RESULTS

A total of 60 patients were randomized, 4 were excluded because of withdrawing treatment, 28 were assigned to ciprofol group and 28 to propofol group. Weaning time in ciprofol group was shorter than propofol group (median [interquartile range (IQR)], 104.0 [40.8-147.3] hours vs 132.5 [69.8-207.8] hours), but not reached significant difference between groups (P = 0.123). Ciprofol had significantly higher percentage of time within the target sedation range (median [IQR], 72.2% [14.3-92.7%] vs 22.6% [0.0-45.4%]) and successful sedation (53.6% [15/28] vs 14.3% [4/28]) than propofol. No significant differences were observed in ICU mortality, in-hospital mortality, length of ICU stay, length of hospital stay, hypotension, and bradycardia between groups.

CONCLUSIONS

Ciprofol is an effective and safe agent among mechanically ventilated patients with sepsis who anticipated to require long-term sedation.

TRIAL REGISTRATION NUMBER

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200066835) on December 19, 2022.

Psychometric properties of the Chinese version of difficulty scale for nurses who care for patients with delirium in the intensive care unit

BACKGROUND

Intensive Care Unit (ICU) nurses experience many difficulties and challenges in caring for delirium patients. Identifying and measuring these difficulties experienced by nurses is critical for implementing precise interventions. We currently lack a standard tool for assessing the level of difficulty faced by ICU nurses in caring for delirium patients that fits the nursing context in China. This study aimed to translate the Difficulty Scale for Nurses who Care for Patients with Delirium in the Intensive Care Unit (DSNCPD-ICU) into Chinese (C-DSNCPD-ICU) and psychometrically validate the translated scale.

METHODS

The English version of DSNCPD-ICU consisted of a main scale with eight factors and an additional scale of one factor. It was translated in strict accordance with Brislin's translation model to yield the Chinese versions. Using a convenience sampling method, 477 ICU nurses from ten general hospitals were recruited for online survey, which collected sociodemographic information, scores on C-DSNCPD-ICU and the Strain of Care for Delirium Index. Subsequent psychometric attributes of the C-DSNCPD-ICU were also tested by the validity and reliability.

RESULTS

There were 437 valid responses. The content validity index was calculated as 0.96. Cronbach's alpha for the total scale and each factor were 0.919 and 0.705-0.878, respectively. Exploratory factor analysis verified an eight-factor scale and an additional scale structure with cumulative variance contributions of the factors of 63.78% and 57.62%, respectively. Confirmatory factor analysis showed that all data-model fits were acceptable.

CONCLUSIONS

The C-DSNCPD-ICU validated in this study showed satisfactory psychometric properties. This will help Chinese nurse managers to accurately assess the degree of difficulty and identify the causes of precise barriers in caring for patients with delirium. Using the scale, nurse managers can determine what kind of measures should be taken, including formulating effective and tailored educational programs and providing more resources to support nurses.

Effects of Virtual Reality Meditation on Sleep and Delirium in ICU Patients: A Randomized Controlled Trial

The purpose of this study was to evaluate the effectiveness of virtual reality meditation compared with standard care on sleep quality and delirium incidence in patients admitted to the ICU. We conducted a randomized controlled trial with 96 patients in an 11-bed surgical ICU at a South Korean university hospital. The control group received usual sleep care, whereas the intervention group received an additional 20-minute virtual reality-based mindfulness and relaxation meditation before bedtime. Using the Verran and Snyder-Halpern Sleep Scale, we found significantly improved subjective sleep quality in the intervention group compared with controls during both the first (47.82 vs 39.75, P = .015) and second nights (50.26 vs 43.65, P = .025) of ICU admission. However, objective sleep measurements using Fitbit devices showed no significant differences in total sleep time between groups for either the first (384.59 vs 358.19 minutes, P = .450) or second night (319.94 vs 310.77 minutes, P = .807). Delirium incidence was similar between groups (12.2% vs 12.8%, P = .938). These findings suggest the need for larger-scale studies with robust experimental designs to definitively establish the impact of virtual reality meditation on sleep quality and delirium in ICU patients.

Effect size estimates of risk factors for post-intensive care syndrome: A systematic review and meta-analysis

OBJECTIVE

To provide updated evidence on the risk factors and accurately quantify the effect size of the risk factors associated with post-intensive care syndrome (PICS), encompassing cognitive, mental, physical and socio-economic domains.

RESEARCH METHODOLOGY

We conducted a systematic review of literature from January 2010 to October 2023. The meta-analysis was conducted to calculate an effect size for every risk factor, and odds ratio and 95% confidence intervals were used as summary statistics.

RESULTS

Of 67,468 retrieved studies, 160 were included in qualitative synthesis, 102 were included in quantitative synthesis. A total of 60 factors were identified, categorized into 17 person-related, 23 disease-related and 20 ICU-related categories. The strongest correlations with cognitive health were observed for previous cognitive problems, sedatives and delirium. Factors most strongly correlated with mental health included previous mental problems, delirium, lack of social support, illicit drug and bad experience in ICU. The strongest correlations with physical health involved previous mental problem, delirium, organ dysfunction of neurologic and respiratory support. For socio-economic domains, older age and female were identified as significant risk factors.

CONCLUSIONS

This systematic review and meta-analysis identified and quantified the person, disease, and ICU-related risk factors associated with PICS. These findings may enable clinicians to better recognize the patient at high risk for PICS at an early stage during their stay in ICU.

IMPLICATIONS FOR CLINICAL PRACTICE

A thorough investigation of risk factors across the four domains of PICS is necessary to gain a holistic understanding. The identification and integration of risk factors associated with PICS empower critical care multidisciplinary teams to optimize management strategies, thereby assisting ICU survivors a better recovery. Since multiple risk factors may be simultaneously associated with the four domains of post-intensive care syndrome, it is imperative to develop a comprehensive prediction algorithm.

Awake Venovenous Extracorporeal Membrane Oxygenation in the Intensive Care Unit: Challenges and Emerging Concepts

Extracorporeal membrane oxygenation (ECMO) is an advanced treatment for severe respiratory failure. Implantation of ECMO before invasive ventilation or extubation during ECMO has been reported and is becoming increasingly popular. Avoidance of sedation and invasive ventilation during ECMO (commonly referred to as "awake ECMO") may have potential advantages, including a lower rate of delirium, shorter mechanical ventilation time, and the possibility of undergoing early rehabilitation and/or physiotherapy. However, awake ECMO is also associated with several risks, such as self-inflicted lung injury and cannula displacement or self-removal. Accordingly, invasive ventilation before ECMO, as well as weaning from ECMO before weaning from mechanical ventilation, remain the most common approaches. In this review, the authors describe indications, contraindications, advantages, disadvantages, and current evidence on the use of ECMO without invasive ventilation in patients with respiratory failure.

The frequency of sepsis-associated delirium in intensive care unit and its effect on nurse workload

AIM

To determine the frequency of sepsis-associated delirium (SAD) in the intensive care unit and its effect on nurse workload.

DESIGN

A cross-sectional and correlational design was used.

METHODS

The study was conducted with 158 patients in the adult intensive care unit of a hospital between October 28 and July 28, 2022. Data analysis included frequency, chi-squared/fisher's exact test, independent samples t-test, correlation analysis, simple and multiple linear regression analyses. The study adhered to the STROBE guidelines.

RESULTS

Sepsis was detected in 12.7% of the patients, delirium in 39.9%, and SAD in 10.1%. SAD was more common in males (19%) and 56.3% of the patients were admitted to the unit from the emergency department. Patients developing SAD had significantly higher age and mean sequential organ failure evaluation, acute physiology and chronic health evaluation II, and C-reactive protein and lactate scores, but their Glasgow Coma Scale scores were significantly low. There was a moderate positive relationship between the patients' Sequential Organ Failure Assessment score and the presence of SAD. The most common source of infection in patients diagnosed with SAD was bloodstream infection (44.4%). SAD significantly increased nurse workload and average care time (1.8 h) and it explained 22.8% of the total variance in nurse workload. Additionally, the use of antibiotics, vasopressors and invasive mechanical ventilation significantly increased nurse workload.

CONCLUSION

In the study, in patients who developed SAD increased nurse workload and average care time significantly. Preventive nursing approaches and effective management of SAD can reduce the rate of development of SAD and nurse workload.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

It is important to work with routine screening, prevention and patient-nurse ratio appropriate to the workload for SAD.

Prioritization Patterns of Nurses in the Management of a Patient With Delirium: Results of a Q-Methodology Study

Nurses are required to decide on priorities; however, how they prioritize the interventions toward patients with delirium is still unclear. Therefore, expanding the knowledge on (a) how nurses prioritize interventions to manage episodes of delirium and (b) the underlying prioritization patterns were the aims of this study. The Q-methodology was applied in 2021. A systematic review to identify the recommended interventions for patients with delirium was performed, and a nominal group technique was used to select those interventions that are applicable in daily practice (35 out of 96 identified). Then, using a specific scenario, 56 clinical nurses working in hospital medical (n = 31), geriatric (n = 15), and postacute (n = 10) units were asked to order the 35 interventions (from -4 the lowest to +4 the highest priority) using a Q-sort table. Averages (confidence interval at 95%) were calculated at the group level, and a by-person factor analysis was applied to discover underlying patterns of prioritization at the overall and at the individual levels. At the group level, "Ensuring a safe environment (e.g., reducing bed height)" was ranked as the highest priority (2.29 out of four); at the individual level, three prioritization patterns accounting for a total variance of 50.21% have emerged: "Individual needs-oriented" (33.82% variance explained; 41 nurses); "Prevention-oriented" (8.47%; five nurses); and "Cognitive-oriented" (7.92%; six nurses). At the group level, nurses prioritize safety while caring for patients with delirium; however, at the individual level, they follow three different patterns of prioritization oriented toward diverse aspects, suggesting uncertainty in the actions to be taken-with potential implications for patients.

Development and usability evaluation of a nurse-led clinical decision support system (AI-AntiDelirium) for management of intensive care unit delirium: A mixed methods study

BACKGROUND

Clinical decision support systems (CDSS) have been identified to aid clinical decision-making, but few studies focus on the application of CDSS in intensive care unit (ICU) delirium, and particularly usability testing is not employed. We aimed to develop and conduct usability testing of Artificial Intelligence Assisted Prevention and Management for Delirium (AI-AntiDelirium), a CDSS designed to identify delirium and modifiable risk factors and prevent and manage delirium in the ICU.

METHODS

Between January and April 2021, a cross-sectional study including 117 ICU nurses recruited for usability testing from four ICUs in two university-affiliated hospitals was conducted. The development of AI-AntiDelirium included needs assessment, function design, iterative design, agile development, and usability testing using the Delirium System Usability Evaluation Scale (Delirium-SUES).

RESULTS

Based on the needs assessment, AI-AntiDelirium was developed to contain four main modules-delirium assessment tools, risk-factor assessment, nursing care plan, and care activity list-and was designed to provide individualized interventions based on patient risk factors. The mean Delirium-SUES score was 184.64 (full score: 210), indicating that AI-AntiDelirium was acceptable in terms of usefulness, ease of use, attitude, use tendency, and long-term effects.

CONCLUSIONS

Our study developed AI-AntiDelirium, a CDSS perceived as useful and easy to use. Incorporating usability evaluation when designing AI-AntiDelirium may be effective in and enhancing clinical staff use.

Impact of patient safety on outcomes. From prevention to the treatment of post-intensive care syndrome

Survivors of critical illness may present physical, psychological, or cognitive symptoms after hospital discharge, encompassed within what is known as post-intensive care syndrome. These alterations result from both the critical illness itself and the medical interventions surrounding it. For its prevention, the implementation of the ABCDEF bundle (Assess/treat pain, Breathing/awakening trials, Choice of sedatives, Delirium reduction, Early mobility and exercise, Family) has been proposed, along with additional strategies grouped under the acronym GHIRN (Good communication, Handout materials, Redefined ICU architectural design, Respirator, Nutrition). In addition to these preventive measures during the ICU stay, high-risk patients should be identified for subsequent follow-up through multidisciplinary teams coordinated by Intensive Care Medicine Departments.

Physical restraint intervention in the intensive care unit: An observational pilot study

PURPOSE

Physical restraint (PR) is applied for patients' safety and to prevent the removal of inserted devices. No matter how well applied, PR causes undesired effects and discomfort to patients. Because PR-Guidelines are not yet implemented in Turkey, an observational study was performed to get baseline data on the type and number of PR-activities and on patients' complications in intensive care unit (ICU) patients.

METHODS

An observational pilot study was conducted in anesthesia and reanimation adult ICUs in a midsized general hospital in Turkey. Included were 31 patients and two data collection tools: a basic form (patient demographics, medical information, and complications) and a PR observation guide on nurses' PR-activities. Descriptive statistics (frequencies, percentages, and mean and standard deviation) were used for data evaluation.

FINDINGS

Most patients (61.3%) were male, and 74.2% were aged 60-79 years. Almost a third was unconscious (Glasgow Coma Scale <9) and at risk for falling. Of the total 33 activities of the Nursing Interventions Classification (NIC), 13 were never applied in 33% of patients. The most applied activity was "provide sufficient staff to assist with the safe application of physical restraining devices or manual restraints" (96.8%). Least applied were "explain inpatient and significant others the behaviors necessary for the termination of the intervention," "Provide the dependent patient with a means of summoning help" (6.5%), and "Teach family the risks and benefits of restraint reduction" (3.2%). Overall, 58.1% of patients had PR complications.

CONCLUSIONS

For the first time, PR NIC activities were evaluated in a Turkish ICU. Findings show low performance of NIC activities and a high complication rate.

IMPLICATIONS FOR NURSING PRACTICE

The findings provide the basis to implement a PR-Guideline in Turkish ICUs to enhance patients' safety and comfort.

Airway Safety During Mechanical Ventilation: Survey of ICU Clinicians Practices and Perceptions

We report results from a survey of members of the Society of Critical Care Medicine to assess ICU clinicians' perceptions of artificial airway safety practices and unplanned extubation (UE) prevention. The survey was distributed between January and February 2024 and received 518 responses (68.5% response rate), with 87.5% from adult ICUs and 12.5% from Pediatric ICUs. Only 48% of adult ICU respondents tracked UE, compared with 73% tracking pressure injuries. Most respondents did not consider UE a "never event," with over half viewing it as unavoidable. In adult ICUs, delirium was ranked as the highest UE risk factor, and commercial securement devices were the primary endotracheal tube securement method (75.2%). Significant variations were observed in artificial airway management practices and responsibility assignments across ICU settings. The results highlight substantial disparities in airway safety management beliefs and practices, underscoring the need for standardized, evidence-based guidelines.

Early mobilisation in patients with shock and receiving vasoactive drugs in the intensive care unit: A systematic review and meta-analysis of observational studies

OBJECTIVE

The aim of the study was to assess the feasibility and safety of early mobilisation in patients with shock requiring vasoactive drugs in the intensive care unit (ICU).

DESIGN

Systematic review and meta-analysis.

SETTING

Intensive care unit (ICU).

PATIENTS OR PARTICIPANTS

Adult patients requiring vasoactive drugs who received early mobilisation in the intensive care unit.

INTERVENTIONS

A systematic search was conducted using the databases PubMed, Cochrane Library, Scopus, Medline Ovid, Science Direct, and CINAHL, including observational studies involving adult patients requiring vasoactive drugs who received early mobilisation. A meta-analysis was performed on the proportion of safety events and the proportion of early mobilisation in patients with high, moderate, and low doses of vasoactive drugs.

MAIN VARIABLES OF INTEREST

Feasibility, safety events, and the maximum level of activity achieved during early mobilisation.

RESULTS

The search yielded 1875 studies, of which 8 were included in the systematic review and 5 in the meta-analysis. The results showed that 64% (95% CI: 34%-95%, p<0.05) of patients were mobilised with low doses of vasoactive drugs, 30% (95% CI: 7%-53%, p<0.05) with moderate doses, and 7% (95% CI: 3%-16%, p 0.17) with high doses. The proportion of adverse events was low, at 2% (95% CI: 1%-4%, p<0.05).

CONCLUSIONS

Early mobilisation in patients with shock and the need for vasoactive drugs is feasible and generally safe. However, there is an emphasis on the need for further high-quality research to confirm these findings.

Postintubation Sedation of Pediatric Patients in the Emergency Department: A Systematic Review and Meta-Analysis

CONTEXT

Postintubation sedation is a critical intervention for patients undergoing mechanical ventilation. Research in the intensive care unit (ICU) and adult emergency department (ED) demonstrates that appropriate postintubation sedation has a significant impact on patient outcomes. There are minimal published data regarding postintubation sedation for pediatric ED patients.

OBJECTIVE

To identify, describe, and critique published literature on postintubation sedation in pediatric ED patients.

DATA SOURCES

Embase, Ovid Medline, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.Gov.

STUDY SELECTION

Studies describing postintubation sedation in the ED for pediatric patients (<18 years of age) intubated in the ED via rapid sequence intubation (RSI) were included. Studies reporting intubation outside the ED, intubation not by RSI, or nonpediatric patients were excluded, as were studies not reporting novel human clinical research.

DATA EXTRACTION

Data were abstracted by 2 authors using a standardized worksheet. Data included study design & setting, demographics, medications for RSI and postintubation sedation, administration of any or appropriately timed postintubation sedation, and predictive factors for postintubation sedation-related outcomes.

RESULTS

A total of 10 studies were included, all of which were nonrandomized; there was significant heterogeneity and many key variables and outcomes were not consistently reported. Meta-analysis of eligible studies demonstrated pooled estimates of 77.3% (95% confidence interval [CI]: 62.5-92.0) for proportion of patients receiving any postintubation sedation, 43.5% (95% CI: 29.3-57.6) for proportion of patients receiving appropriately timed postintubation sedation, and 18.6 minutes (95% CI: 12.5-24.7) for median time to postintubation sedation, all with significant heterogeneity.

CONCLUSIONS

Data on postintubation sedation in pediatric ED patients are limited. Administration of postintubation sedation is inconsistent and may be substantially delayed. Further high-quality research into the use of postintubation sedation in this setting is needed, and appropriate postintubation sedation should be a target for quality improvement.

The Impact of Non-Pharmacological Sleep Interventions on Delirium Prevention and Sleep Improvement in Postoperative ICU Patients: A Systematic Review and Network Meta-Analysis

OBJECTIVES

Analyze the effectiveness of different non-pharmacological sleep interventions in preventing delirium among postoperative ICU patients.

RESEARCH METHODOLOGY

We conducted a comprehensive search on PubMed, Cochrane Library, Web of Science, Embase, CINAHL, OpenGrey and reference lists up to May 2024.

SETTING

We systematically searched all randomized controlled trials related to non-pharmacological sleep interventions for the prevention of delirium.

RESULTS

The results of the network meta-analysis showed that, compared to Usual Care, multicomponent interventions are the most effective measures for preventing delirium in postoperative ICU patients (RR = 0.32, 95 % CI = 0.20 to 0.51). This is followed by non-pharmacological sleep interventions aimed at stress relief (RR = 0.60, 95 % CI = 0.41 to 0.89) and circadian rhythm (RR = 0.61, 95 % CI = 0.39 to 0.96). Additionally, non-pharmacological sleep interventions focusing on circadian rhythm demonstrated an improvement in sleep quality among postoperative ICU patients (SMD = -0.99, 95 % CI = -1.88 to -0.11).

CONCLUSIONS

Our study found that multicomponent non-pharmacological sleep interventions are effective in reducing the incidence of delirium in postoperative ICU patients. Furthermore, non-pharmacological interventions focused on circadian rhythm regulation significantly enhance sleep quality among these patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Based on this study, intensive care units and nursing staff have an opportunity to implement the most effective non-pharmacological sleep interventions to prevent delirium and improve sleep quality in postoperative ICU patients. This could contribute to a reduction in the incidence of delirium in postoperative ICU patients.

Intensive Care Nurses' Pain Management Experiences within the Framework of the Biopsychosocial-Spiritual Model in Türkiye: A Qualitative Approach

Pain, which includes biological, psychological, social and spiritual factors, is a common symptom experienced by patients in intensive care. This study aimed to uncover intensive care nurses' perspectives on pain management strategies, employing the biopsychosocial-spiritual model as the guiding framework. This research employed a descriptive qualitative method, engaging participants from diverse locations across five provinces and eight different institutions. The study involved 16 intensive care nurses and utilized semi-structured online Zoom interviews. Data analysis was conducted using Braun and Clarke's six stages, and reporting followed the consolidated criteria for qualitative studies. The answers of the nurses were grouped under four themes and six subthemes: (1) biological interventions, (2) psychological interventions, (3) social interventions: involving families in the process and (4) spiritual interventions: support religious activities. This study shows that intensive care nurses benefit from many practices in pain management. These interventions included medication management and ensuring physical comfort in the biological factor, distracting activities and being with the patient in the psychological factor, involving the family in care in the social factor and providing an environment that supports the patient's religious needs under the spiritual factor.

Impact of a Sleep-Promoting Schedule on Sleep Quality in the Intensive Care Unit

BACKGROUND

Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of illness and is especially high in intensive care unit patients. Sleep deprivation can prolong the intensive care unit stay, contribute to emotional and physiological distress, and even increase the patient's risk of death.

LOCAL PROBLEM

Critical care nurses in a 28-bed medical intensive care unit reported that patients often complained of sleep disruption or exhibited emotional and physical distress resulting from sleep deprivation. An analysis of the gap between recommended evidence-based best practice and current practices in the unit revealed numerous opportunities to improve patients' sleep. The aim of this evidence-based quality improvement project was to increase interprofessional adherence to an existing sleep-promoting schedule to reduce avoidable interruptions and improve patient sleep quality.

METHODS

To promote sleep, staff member interactions with patients between midnight and 4 am were minimized, if appropriate. Documented patient encounters and call bell initiation were evaluated as process measures. Patients' self-perceived sleep quality, an outcome measure, was evaluated using the Richards-Campbell Sleep Questionnaire.

RESULTS

Adherence to a sleep-promoting schedule reduced patient sleep interruptions between midnight and 4 am by as much as two-thirds while increasing patients' overall self-perceived sleep quality by 6.7 percentage points.

CONCLUSION

An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.

Videodistraction to reduce agitation in elderly patients in the emergency department: an open label parallel group randomized controlled trial

BACKGROUND AND IMPORTANCE

Agitation of elderly patients in the emergency department (ED) often complicates workup and therapy.

OBJECTIVE

In this study, we investigated if agitation in the ED can be reduced by showing calming video sequences in elderly agitated patients.

DESIGNS

Prospective randomized intervention study.

SETTINGS AND PARTICIPANTS

ED patients aged ≥65 years were screened for the risk of agitation/delirium using the 4-A's test (4-AT) test. In case of ≥4 4-AT points, patients were scored using the Richmond Agitation-Sedation Scale (RASS) and the Nursing Delirium Screening Scale (Nu-DESC). They were included in the study if RASS was ≥+2 and Nu-DESC ≥ 4 after informed consent of the legal representative. Patients were then randomized to the intervention or control group. A total of n  = 57 patients were included in the study.

INTERVENTION

Patients in the intervention group were exposed to projections of calming video sequences for 60 min. Patients in the control group received standard care.

OUTCOME MEASURES AND ANALYSIS

Changes in RASS and Nu-DESC were assessed 30 and 60 min after the intervention was started.

MAIN RESULTS

A total of 57 patients were included in the study, with 30 patients in the intervention group and 27 patients in the control group. Before the intervention, the median (interquartile range) RASS scores were comparable between the intervention group [3 (2-3)] and the control group [3 (2-3)]. After 30 min of exposure to calming video sequences, patients in the intervention group showed significantly lower RASS and Nu-DESC scores compared to the control group [RASS: 1 (0-1) vs. 2 (1.5-3), P  < 0.001; Nu-DESC: 3 (2-4) vs. 5 (4-6), P  < 0.001]. This difference persisted at 60 min [RASS: 0 (0-1) vs. 2 (1-2.5), P  < 0.001; Nu-DESC: 2 (2-3) vs. 5 (4-6), P  < 0.001]. Additionally, fewer patients in the intervention group required additional sedating or antipsychotic medication (1/30) compared to the control group (9/27), with this difference being statistically significant ( P  = 0.004).

CONCLUSION

In this randomized controlled trial, the use of calming video sequences in elderly patients with agitation in the ED resulted in significant reductions in agitation and the need for additional sedative or antipsychotic medication.

Sleep and Circadian-Related Outcomes after Critical Illness

Sleep and circadian disruptions are frequently reported in studies of critically ill patients. Less is known about sleep and circadian disruptions after an intensive care unit (ICU) admission. It is recognized now that survivors of critical illness may develop what is termed post-intensive care syndrome (PICS) which is a constellation of symptoms of which two of the most prominent features are fatigue and sleep complaints. Clinicians and researchers are now recognizing the importance of examining symptoms in survivors which impact their quality of life. Although current data are limited this review addresses what is now known about sleep and circadian disruptions post-ICU. Current ongoing research and future studies should continue to inform our understanding of how critical illness and the ICU environment both influence long-term outcomes in critically ill patients.

Comparison of retroperitoneal laparoscopic radical nephroureterectomy outcomes in elderly patients based on the Geriatric 8 (G8) screening tool

AIM

The Geriatric 8 (G8) screening tool consists of eight questions and is widely used to assess geriatric frailty. This study aimed to compare laparoscopic radical nephroureterectomy outcomes in patients aged >70 years with high and low G8 scores.

MATERIALS AND METHODS

Patients who underwent laparoscopic radical nephroureterectomy at a single center between 2017 and 2022 were included in this study. Patient background and perioperative outcomes were evaluated in two groups: low G8 (<14) and high G8 (≥14). The effects of age and body mass index (BMI) were assessed using logistic regression models adjusted for inverse-probability treatment weighting in the low G8 and high G8, respectively.

RESULTS

In total, 37 cases were categorized as low G8 and 30 cases as high G8. Significant differences in patient background were found in terms of age, BMI, American Society of Anesthesiologists physical status, presence of dementia, and estimated glomerular filtration rate (eGFR). Significant differences in perioperative outcomes were observed in the operative time and number of lymph node dissections. Postoperative delirium and eGFR were significantly higher in the low G8 group. The high G8 group showed significantly higher recurrence-free survival and overall survival rates than the low G8 group. After adjustment using the inverse-probability treatment weighting method, postoperative delirium and eGFR were significantly higher in the low G8 group but there were no significant differences in recurrence-free survival rates, cancer-specific survival, or overall survival.

CONCLUSION

After adjusting for age and BMI, preoperative G8 had a different frequency of postoperative delirium but had no effect on prognosis. Geriatr Gerontol Int 2025; ••: ••-••.

Evaluation of postoperative delirium in cardiac surgery patients with the SDACS screening tool: a multicenter-multiphase study

OBJECTIVE

Postoperative delirium is a prevalent complication in cardiac surgery patients, highlighting the importance of early risk factor identification for optimal management. This study aimed to pinpoint risk factors and devise a novel screening tool, the Screening Tool for Delirium After Cardiac Surgery (SDACS), to predict postoperative delirium in cardiac surgery patients after the first day.

MATERIALS AND METHODS

This study employed a multiphase design consisting of three phases. In the first phase, through a scoping review of 38 finally selected published papers, 136 potential risk factors for identifying delirium after cardiac surgery were identified. These risk factors were then incorporated into three Delphi rounds of expert panels to develop a screening tool for postoperative delirium. Finally, 76 potential risk factors were examined on 920 cardiac surgery patients at three academic institutions between 2020 and 2023 (third phase of the study). All predictors were included into a screening instrument (SDACS), and the regression coefficient of each predictor was transformed into a risk score.

RESULTS

Delirium was diagnosed in 53% (n = 488) of 920 patients. Four independent predictors of delirium were identified: chronic opioid use (OR: 4.605, 95% CI: 2.163-9.804), hearing impairment (OR: 6.926, 95% CI: 3.630-12.215), benzodiazepine history (OR: 8.506, 95% CI: 5.651-11.805), and poor sleep quality on the first night after cardiac surgery (OR: 9.081, 95% CI: 6.225-12.248). The cross-validated area under receiver operating characteristics curve (AUC) for the screening instrument was 0.897 (95% CI: 0.876-0.916; P < 0.001).

CONCLUSION

Chronic opioid use, hearing impairment, benzodiazepine history, and poor sleep quality post-surgery are linked to postoperative delirium in cardiac surgery patients. The SDACS screening tool effectively forecasts this syndrome early, offering bedside nurses a valuable tool for prompt intervention and improved patient outcomes. The SDACS screening tool aids in early delirium risk assessment, enabling timely interventions and better patient outcomes. By predicting postoperative delirium accurately, nurses can address risk factors proactively, potentially reducing its incidence and severity, leading to improved postoperative outcomes for patients.

A target trial emulation of dexmedetomidine to treat agitation in the intensive care unit

OBJECTIVE

Agitation is a major problem in the intensive care unit. However, no treatment has clearly emerged as effective and safe. Using target trial emulation, we aimed to test the hypothesis that early intervention with dexmedetomidine would accelerate agitation resolution.

METHODS

We read clinical notes in an electronic medical records system with natural language processing to identify patients with agitation. We obtained their demographics, trajectories, associations, and outcomes. We used g-formulas to study the possible effects of dexmedetomidine on agitation resolution and key outcomes.

RESULTS

We screened 7525 patients. Overall, 2242 patients (29.8%) developed within-intensive care unit agitation, and 2052 (27.3%) were eligible for inclusion in the target trial emulation, with 314 treated with dexmedetomidine. Dexmedetomidine-treated patients had more severe illness and were more likely to have unplanned emergency admissions with medical diagnoses. However, they achieved higher rates of resolution of within-intensive care unit agitation (94% versus 72%; p < 0.001) and lower 30-day mortality (5% versus 9%; p = 0.033). Early initiation of dexmedetomidine accelerated the resolution of agitation (risk ratio [RR] 1.13 [95%CI 1.03 - 1.21]; risk difference [RD] 9.8% [95%CI 2.6% - 15.4%]); extubation by Day 30 (RR 1.03 [95%CI 1.02 - 1.04]; RD 3.1% [95%CI 2.2% - 4.2%]); and reduced the chance of having a tracheostomy by Day 30 (RR 0.67 [95%CI 0.34 - 0.99]; RD -3.5% [95%CI -7.0% - -0.0%]).

CONCLUSION

Through target trial emulation analysis, early dexmedetomidine was associated with an increased rate of resolution of agitation and extubation and decreased tracheostomy risk.

Inhaled Sedation in Acute Respiratory Distress Syndrome: The SESAR Randomized Clinical Trial

Importance

Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown.

Objective

To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS.

Design, Setting, and Participants

Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units.

Interventions

Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days.

Main Outcomes and Measures

The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival.

Results

Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, -2.1 [95% CI, -3.6 to -0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit-free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, -2.5 [95% CI, -3.7 to -1.4]) compared with propofol.

Conclusions and Relevance

Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol.

Trial Registration

ClinicalTrials.gov Identifier: NCT04235608.

Two in one: a randomized controlled trial on an internet-based intervention (Lenio) for management of both chronic pain and depressive symptoms

The high prevalence of chronic pain and comorbid depression, along with their negative impacts on individuals and society, highlights the need for accessible and effective interventions. This study examined the feasibility, efficacy, and acceptability of Lenio, an Internet-based self-help intervention, combined with the COGITO smartphone application for managing these conditions. The randomized controlled trial involved an intervention group (IG) using Lenio and COGITO, an active control group (ACG) using a transdiagnostic app, and a wait-list control group (WCG) receiving usual treatment. Lenio incorporates cognitive behavioral therapy and third-wave techniques, supported by COGITO's gamified daily exercises to enhance adherence. Across 263 participants assessed at three intervals over 16 weeks, the IG showed significant improvement in somatic-affective depressive symptoms compared to the WCG post-intervention and both control groups at follow-up. However, the ACG outperformed the IG in managing pain at post-intervention though these effects did not persist until follow-up. The interventions were well-received and feasible, with older participants benefiting more from the Lenio/COGITO combination. Lenio and COGITO could bridge gaps to conventional therapy, potentially easing pain by enhancing psychological well-being and coping strategies. Future studies should investigate tailored interventions for chronic pain and their long-term effectiveness.

Protocol

Full trial protocol can be accessed via DOI: 10.1186/s13063-023-07440-8.

Clinical trial registration

https://drks.de/register/de/trial/DRKS00026722/preview, identifier DRKS-IDDRKS00026722.