Adverse drug events associated with the use of analgesics, sedatives, and antipsychotics in the intensive care unit

The Sedative and Haemodynamic effects Of Continuous Ketamine infusions on Intensive Care Unit patients (SHOCK-ICU): Investigating key outcomes, resource utilisation and staff decision-making: Clinical feasibility study protocol

Background

Between April 2022 and March 2023, 43.8% (88,259) patients admitted to Intensive Care Units (ICU) in the United Kingdom (UK) required breathing support through a ventilator, the majority require sedation. Unfortunately, mechanical ventilation is associated with high mortality and morbidity, and sedative agents currently used have significant side effects including hypotension and delirium. They are also implicated in long-term psychological sequelae such as major depression and posttraumatic stress disorder. Ketamine has been utilised in anaesthesia for over 50 years and has an excellent safety profile. The diverse properties of ketamine are the focus of much research currently, including its properties as a potent antidepressant. Ketamine has not been fully investigated in the context of ICU, and there are gaps in the evidence that warrant further investigation through a large randomised controlled trial. Preparatory work for such a study includes refining study designs, identifying key clinical and patient centred outcomes and exploring barriers to implementation, which is the focus of this work.

Methods

SHOCK-ICU is a single centre, non-randomised, feasibility study assessing the feasibility of continuous ketamine infusions for the provision of sedation for 30 patients undergoing mechanical ventilation on the ICU.Data will be collected at baseline, daily until >48 h without mechanical ventilation, ICU discharge, and 90-days from enrolment. Data collection will include trial aspects such as expected recruitment, refusal, and follow-up rates, ability to collect data, and exploratory assessment of clinical efficacy markers.

Primary outcome

The primary outcome is study feasibility; this will be assessed using pre-defined progression criteria that will aid design of future ketamine sedation studies.

Pharmacokinetics of Opioid Infusions in the Adult Intensive Care Unit Setting-A Systematic Review

INTRODUCTION

Pharmacokinetics (PKs) of drugs are often altered in the intensive care unit (ICU). Opioids are often used in the ICU, particularly as continuous infusions, and their characteristics lead them to undergo PK alterations. We conducted a systematic review to assess the PK of opioid infusions in the ICU.

METHODS

Embase, MEDLINE, PubMed, CINAHL, and Evidence-Based Medicine Reviews (EBMR) were searched from inception to March 2024. Studies were included if they evaluated PKs of opioid infusions in adult patients in the ICU. Two reviewers independently selected and extracted data.

RESULTS

Out of the 1040 records screened, 17 studies were included. Five studies were conducted on fentanyl, seven on morphine, one on hydromorphone, two on remifentanil, two on alfentanil, and one on sufentanil. Most studies where observational studies or case series. The mean age was 56 years old. Duration of the infusion varied between 3 h and 20 days. PKs of fentanyl, sufentanil, and hydromorphone were significantly impaired, whereas the PKs of morphine, alfentanil, and remifentanil were impaired to a lesser degree. The PK parameter that was most affected by critical illness was the half-life (T½).

CONCLUSIONS

To counter these PK alterations, new therapeutic avenues must be further explored in the ICU to individualize opioid infusions.

Management of pain and sedation in the intensive care unit

Advances in our approach to treating pain and sedation when caring for patients in the intensive care unit (ICU) have been propelled by decades of robust trial data, knowledge gained from patient experiences, and our evolving understanding of how pain and sedation strategies affect patient survival and long term outcomes. These data contribute to current practice guidelines prioritizing analgesia-first sedation strategies (analgosedation) that target light sedation when possible, use of short acting sedatives, and avoidance of benzodiazepines. Together, these strategies allow the patient to be more awake and able to participate in early mobilization and family interactions. The covid-19 pandemic introduced unique challenges in the ICU that affected delivery of best practices and patient outcomes. Compliance with best practices has not returned to pre-covid levels. After emerging from the pandemic and refocusing our attention on optimal pain and sedation management in the ICU, it is imperative to revisit the data that contributed to our current recommendations, review the importance of best practices on patient outcomes, and consider new strategies when advancing patient care.

Adverse events leading to intensive care unit admission in a low-and-middle-income-country: A prospective cohort study and a systematic review

INTRODUCTION

Adverse events (AE) are frequent in critical care and could be even more prevalent in LMIC due to a shortage of ICU beds and Human resources. There is limited data on how relevant AE are among the reasons for ICU admission, being all of which published by High-Income-Countries services. Our main goal is to describe the rate of adverse events-related ICU admissions and their preventability in a LMIC scenario, comparing our results with previous data.

METHODS

This was a prospective cohort study, during a one-year period, in two general ICUs from a tertiary public academic hospital. Our exposure of interest was ICU admission related to an AE in adult patients, we further characterized their preventability and clinical outcomes. We also performed a systematic review to identify and compare previous published data on ICU admissions due to AE.

RESULTS

Among all ICU admissions, 12.1% were related to an AE (9.8% caused by an AE, 2.3% related but not directly caused by an AE). These ICU admissions were not associated with a higher risk of death, but most of them were potentially preventable (70.9% of preventability rate, representing 8.6% of all ICU admissions). The meta-analysis resulted in a proportion of ICU admissions due to AE of 11% (95% CI 6%-16%), with a preventability rate of 54% (95% CI 42%-66%).

CONCLUSIONS

In this prospective cohort, adverse events were a relevant reason for ICU admission. This result is consistent with data retrieved from non-LMIC as shown in our meta-analysis. The high preventability rate described reinforces that quality and safety programs could work as a tool to optimize scarce resources.

Continuous infusion ketamine for sedation of mechanically ventilated adults in the intensive care unit: A scoping review

Introduction

Mechanical ventilation (MV) is a common and often live-saving intervention on the Intensive Care Unit (ICU). The optimisation of sedation to mechanical ventilation is fundamental, and inappropriate sedation has been associated with worse outcomes. This scoping review has been designed to answer the question 'What is known about the use of ketamine as a continuous infusion to provide sedation in mechanically ventilated adults in the intensive care unit, and what are the gaps in the evidence?'

Methods

The protocol was designed using the PRISMA-ScR checklist and the JBI manual for evidence synthesis. Data were extracted and reviewed by a minimum of two reviewers.

Results

Searches of electronic databases (PubMed, OVID, Scopus, Web of Science) produced 726 results; 45 citations were identified for further eligibility assessment, an additional five studies were identified through keyword searches, and 12 through searching reference lists. Of these 62 studies, 27 studies were included in the final review: 6 case reports/case series, 11 retrospective cohort/observational studies, 1 prospective cohort study, 9 prospective randomised studies.

Conclusion

We found a lack of high-quality well-designed studies investigating the use of continuous ketamine sedation on ICU. The available data suggests this intervention is safe and well tolerated, however this is of very low certainty given the poor quality of evidence.

Machine learning as a tool to identify inpatients who are not at risk of adverse drug events in a large dataset of a tertiary care hospital in the USA

AIMS

Adverse drug events (ADEs) are a major threat to inpatients in the United States of America (USA). It is unknown how well machine learning (ML) is able to predict whether or not a patient will suffer from an ADE during hospital stay based on data available at hospital admission for emergency department patients of all ages (binary classification task). It is further unknown whether ML is able to outperform logistic regression (LR) in doing so, and which variables are the most important predictors.

METHODS

In this study, 5 ML models- namely a random forest, gradient boosting machine (GBM), ridge regression, least absolute shrinkage and selection operator (LASSO) regression, and elastic net regression-as well as a LR were trained and tested for the prediction of inpatient ADEs identified using ICD-10-CM codes based on comprehensive previous work in a diverse population. In total, 210 181 observations from patients who were admitted to a large tertiary care hospital after emergency department stay between 2011 and 2019 were included. The area under the receiver operating characteristics curve (AUC) and AUC-precision-recall (AUC-PR) were used as primary performance indicators.

RESULTS

Tree-based models performed best with respect to AUC and AUC-PR. The gradient boosting machine (GBM) reached an AUC of 0.747 (95% confidence interval (CI): 0.735 to 0.759) and an AUC-PR of 0.134 (95% CI: 0.131 to 0.137) on unforeseen test data, while the random forest reached an AUC of 0.743 (95% CI: 0.731 to 0.755) and an AUC-PR of 0.139 (95% CI: 0.135 to 0.142), respectively. ML statistically significantly outperformed LR both on AUC and AUC-PR. Nonetheless, overall, models did not differ much with respect to their performance. Most important predictors were admission type, temperature and chief complaint for the best performing model (GBM).

CONCLUSIONS

The study demonstrated a first application of ML to predict inpatient ADEs based on ICD-10-CM codes, and a comparison with LR. Future research should address concerns arising from low precision and related problems.

A pharmacogenetic precision medicine approach to analgesia and sedation optimization in critically ill adults

Precision medicine is a growing field in critical care. Research increasingly demonstrated pharmacogenomic variability to be an important determinant of analgesic and sedative drug response in the intensive care unit (ICU). Genome-wide association and candidate gene finding studies suggest analgesic and sedatives tailored to an individual's genetic makeup, environmental adaptations, in addition to several other patient- and drug-related factors, will maximize effectiveness and help mitigate harm. However, the number of pharmacogenetic studies in ICU patients remains small and no prospective studies have been published using pharmacogenomic data to optimize analgesic or sedative therapy in critically ill patients. Current recommendations for treating ICU pain and agitation are based on controlled studies having low external validity, including the failure to consider pharmacogenomic factors affecting response. Use of a precision medicine approach to individualize pharmacotherapy focused on optimizing ICU patient comfort and safety may improve the outcomes of critically ill adults. Additionally, benefits and risks of analgesic and/or sedative therapy in an individual may be informed with large, standardized datasets. The purpose of this review was to describe a precision medicine approach focused on optimizing analgesic and sedative therapy in individual ICU patients to optimize clinical outcomes and reduce safety concerns.

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist

OBJECTIVES

To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist.

DATA SOURCES

Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer.

STUDY SELECTION

Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication.

DATA EXTRACTION

Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice.

DATA SYNTHESIS

Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer.

CONCLUSIONS

Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.

Evaluation of the Relationship between Baseline Autonomic Tone and Haemodynamic Effects of Dexmedetomidine

Dexmedetomidine, a central α-2 agonist, is used for procedural sedation and for conscious sedation influences on heart rate and blood pressure. Authors verified whether it is possible to predict bradycardia and hypotension with the use of heart rate variability (HRV) analysis for an autonomic nervous system (ANS) activity assessment. The study included adult patients of both sexes with an ASA score of I or II scheduled for ophthalmic surgery to be performed under sedation. The loading dose of dexmedetomidine was followed by a 15 min infusion of the maintenance dose. The frequency domain heart rate variability parameters from the 5-min Holter electrocardiogram recordings before dexmedetomidine administration were used for the analysis. The statistical analysis also included pre-drug heart rate and blood pressure as well as patient age and sex. The data from 62 patients were analysed. There was no relationship between the decrease in heart rate (42% of cases) and initial HRV parameters, haemodynamic parameters or sex and age of patients. In multivariate analysis, the only risk factor for a decrease in mean arterial pressure (MAP) > 15% from the pre-drug value (39% of cases) was the systolic blood pressure before dexmedetomidine administration as well as for a >15% decrease in MAP sustained at more than one consecutive time point (27% of cases). The initial condition of the ANS did not correlate with the incidence of bradycardia or hypotension; HRV analysis was not helpful in predicting the abovementioned side effects of dexmedetomidine.

Comparison of clinical safety and efficacy of dexmedetomidine, remifentanil, and propofol in patients who cannot tolerate non-invasive mechanical ventilation: A prospective, randomized, cohort study

Background and objectives

Non-invasive ventilation (NIV) is used in intensive care units (ICUs) to treat of respiratory failure. Sedation and analgesia are effective and safe for improving compliance in patients intolerant to NIV. Our study aimed to evaluate the effects of dexmedetomidine, remifentanil, and propofol on the clinical outcomes in NIV intolerant patients.

Methods

This prospective randomized cohort study was conducted in a tertiary ICU, between December 2018 and December 2019. We divided a total of 120 patients into five groups (DEXL, DEXH, REML, REMH, PRO). IBM SPSS Statistics 20 (IBM Corporation, Armonk, New York, USA) was used to conduct the statistical analyses.

Results

The DEXL, DEXH, REML, and REMH groups consisted of 23 patients each while the PRO group consisted of 28 patients. Seventy-five patients (62.5%) became tolerant of NIV after starting the drugs. The NIV time, IMV time, ICU LOS, hospital LOS, intubation rate, side effects, and mortality were significantly different among the five groups (P = 0.05). In the groups that were given dexmedetomidine (DEXL, and DEXH), NIV failure, mortality, ICU LOS, and hospital LOS were lower than in the other groups.

Conclusion

In this prospective study, we compared the results of three drugs (propofol, dexmedetomidine, and remifentanil) in patients with NIV intolerance. The use of sedation increased NIV success in patients with NIV intolerance. NIV failure, mortality, ICU LOS, IMV time, and hospital LOS were found to be lower with dexmedetomidine.

The effectiveness of music interventions on stress response in intensive care patients: A systematic review and meta-analysis

AIM AND OBJECTIVE

To investigate the effectiveness of music interventions on physiological and psychological stress response in intensive care unit (ICU) patients.

BACKGROUND

ICU patients are exposed to several physiological and psychological stressors during their treatments. Music interventions can be implemented to control these negative effects.

DESIGN

Systematic review and meta-analysis conducted according to PRISMA Guidelines.

METHOD

This meta-analysis was conducted per PRISMA guidelines. Seven electronic literature databases, reference lists of similar reviews, grey literature and the Clinical Trials Registry were searched for potential studies up to 30 September 2021. Studies were expected to meet PICOS inclusion criteria. Two reviewers independently assessed the risk of bias of the included studies by using the Cochrane Collaboration tool. Overall, meta-analysis and subgroup analyses (comparator group and music session frequency) were performed using RevMan 5.4. Meta-analysis was conducted when data were available; otherwise, a narrative description was provided.

RESULTS

Twenty-five articles were included in this review. Music intervention was found to provide reductions in anxiety levels concerning psychological stress. However, it was found that music had an effect only on the systolic blood pressure level concerning the physiological stress and had no effect on the diastolic blood pressure, respiration rate or heart rate. In the subgroup analysis performed against the comparator groups, it was found that music decreased the anxiety level compared to the standard care group but was not effective compared to the noise reduction group. It was found that multiple music sessions reduced the anxiety level better than a single music session.

CONCLUSIONS

Music interventions involving multiple sessions can be used as a nursing intervention to control the anxiety levels of ICU patients.

RELEVANCE TO THE CLINICAL PRACTICE

Using music to reduce anxiety and stress levels may reduce the pharmacological need (for sedative or antipsychotic medications) and the risk of associated side effects in ICU patients.

The Withdrawal Assessment Tool to identify iatrogenic withdrawal symptoms in critically ill paediatric patients: A COSMIN systematic review of measurement properties

RATIONALE, AIMS AND OBJECTIVES

The Withdrawal Assessment Tool (WAT-1) is one of the most widely used clinician-reported outcome measures to evaluate iatrogenic withdrawal symptoms (IWS) in critically ill children. However, the WAT-1's measurement properties have not been aggregated. Aggregating psychometric research on the WAT-1 will enhance appropriate use, and outline gaps for future empirical research. The aim of this systematic review is to critically appraise, compare, and summarize the measurement properties and evidence quality, and describe the interpretability and feasibility of the WAT-1 for identifying IWS symptoms in critically ill children.

METHODS

A systematic search of Medline, Embase and CINAHL was conducted from inception to 15 April 2020. Study inclusion/exclusion, data extraction, and measurement property evidence and the modified GRADE quality scoring were applied according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

Six studies were included in the review. There was sufficient, high-quality evidence for reliability, structural validity, criterion validity, measurement error, construct validity, and feasibility. More information is required to support the WAT-1's content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability according to COSMIN guidelines.

CONCLUSION

The results of this review indicate that the WAT-1 is a precise, easy to use measure of IWS in critically ill children despite some measurement property inconsistencies and gaps in the publication record. More information is required to support its content validity, responsiveness, internal consistency, cross-cultural validity, and interpretability.

A Clinician's Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy

Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is a common complication in critical illness and has a significant impact on pharmacokinetic factors determining drug exposure, including absorption, distribution, transport, metabolism, and clearance. In this review, we provide a practical guide to drug dosing considerations in critically ill patients undergoing CRRT, focusing on the most commonly used analgesic, anticonvulsant, and psychotropic medications in the clinical care of critically ill patients. A literature search was conducted to identify articles in which drug dosing was evaluated in adult patients receiving CRRT between the years 1980 and 2020. We included articles with pharmacokinetic/pharmacodynamic analyses and those that described medication clearance via CRRT. A summary of the data focused on practical pharmacokinetic and pharmacodynamic principles is presented, with recommendations for drug dosing of analgesics, anticonvulsants, and psychotropic medications. Pharmacokinetic and pharmacodynamic studies to guide drug dosing of analgesics, anticonvulsants, and psychotropic medications in critically ill patients receiving CRRT are sparse. Considering the widespread use of these medications, narrow therapeutic index of these drug classes, and risks of over- and underdosing, additional studies in patients receiving CRRT are needed to inform drug dosing.

A cost-effectiveness analysis of propofol versus midazolam for the sedation of adult patients admitted to the intensive care unit

Objetivo

Construir um modelo de custo-efetividade para comparar o uso de propofol com o de midazolam em pacientes críticos adultos sob uso de ventilação mecânica.

Métodos

Foi construído um modelo de árvore decisória para pacientes críticos submetidos à ventilação mecânica, o qual foi analisado sob a perspectiva do sistema privado de saúde no Brasil. O horizonte temporal foi o da internação na unidade de terapia intensiva. Os desfechos foram custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e custo-efetividade por hora de ventilação mecânica evitada. Foram obtidos os dados do modelo a partir de metanálise prévia. Assumiu-se que o custo da medicação estava incluído nos custos da unidade de terapia intensiva. Conduziram-se análises univariada e de sensibilidade probabilística.

Resultados

Pacientes mecanicamente ventilados em uso de propofol tiveram diminuição de sua permanência na unidade de terapia intensiva e na duração da ventilação mecânica, respectivamente, em 47,97 horas e 21,65 horas. Com o uso de propofol, ocorreu redução média do custo de U$2.998,971 em comparação ao uso do midazolam. A custo-efetividade por hora de permanência na unidade de terapia intensiva evitada e por hora de ventilação mecânica evitada foi dominante, respectivamente, em 94,40% e 80,8% do tempo.

Conclusão

Ocorreu diminuição significante do custo associado ao uso de propofol, no que se refere à permanência na unidade de terapia intensiva e à duração da ventilação mecânica para pacientes críticos adultos.

Morbidity and Mortality in Critically Ill Children. I. Pathophysiologies and Potential Therapeutic Solutions

OBJECTIVES

Developing effective therapies to reduce morbidity and mortality requires knowing the responsible pathophysiologies and the therapeutic advances that are likely to be impactful. Our objective was to determine at the individual patient level the important pathophysiological processes and needed therapeutic additions and advances that could prevent or ameliorate morbidities and mortalities.

DESIGN

Structured chart review by pediatric intensivists of PICU children discharged with significant new morbidity or mortality to determine the pathophysiologies responsible for poor outcomes and needed therapeutic advances.

SETTING

Multicenter study (eight sites) from the Collaborative Pediatric Critical Care Research Network of general and cardiac PICUs.

PATIENTS

First PICU admission of patients from December 2011 to April 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two-hundred ninety-two patients were randomly selected from 681 patients discharged with significant new morbidity or mortality. The median age was 2.4 years, 233 (79.8%) were in medical/surgical ICUs, 59 (20.2%) were in cardiac ICUs. Sixty-five (22.3%) were surgical admissions. The outcomes included 117 deaths and 175 significant new morbidities. The most common pathophysiologies contributing to the poor outcomes were impaired substrate delivery (n = 158, 54.1%) and inflammation (n = 104, 35.6%). There were no strong correlations between the pathophysiologies and no remarkable clusters among them. The most common therapeutic needs involved new drugs (n = 149, 51.0%), cell regeneration (n = 115, 39.4%), and immune and inflammatory modulation (n = 79, 27.1%). As with the pathophysiologies, there was a lack of strong correlations or meaningful clusters in the suggested therapeutic needs.

CONCLUSIONS

There was no single dominant pathophysiology or cluster of pathophysiologies responsible for poor pediatric critical care outcomes. Therapeutic needs often involved therapies that are not close to implementation such as cell regeneration, improved organ transplant, improved extracorporeal support and artificial organs, and improved drugs.

Butorphanol versus Propofol in Patients Undergoing Noninvasive Ventilation: A Prospective Observational Study

Background

The present study aimed to explore sedation management in agitated patients who suffered from acute respiratory failure (ARF) and were treated with noninvasive ventilation (NIV).

Patients and Methods

We divided 118 patients undergoing NIV treatment with butorphanol or propofol into two groups: group B (n = 57, butorphanol was initiated at the rate of 0.12 µg/kg/min as a continuous intravenous infusion and then titrated by 0.06 µg/kg/min every half an hour, group P (n = 61, propofol was initiated at the rate of 5 µg/kg/min as a continuous intravenous infusion and then titrated by 1.5 µg/kg/min every half an hour). Score of Sedation Agitation Scale (SAS) in the two groups was maintained between 3 and 4. Medications including sedative, analgesic, and antipsychotic, NIV intolerance score, SAS score, visual analog scale (VAS), medication use and adverse events were recorded repeatedly.

Results

Patients receiving butorphanol required significantly less total amount of fentanyl than patients receiving propofol during NIV to maintain the target VAS [0 (0–0) µg vs 150 (50–200) µg, P< 0.005]. Hemodynamic stability during NIV showed it was better kept in patients treated with butorphanol.

Conclusion

Butorphanol not only decreased the requirements of fentanyl but also enhanced hemodynamic stability in agitated patients suffering from ARF receiving NIV.

Trial Registration

Registered at http://www.chictr.org.cn/ (ChiCTR1800015534).

Management of delirium in a medical and surgical intensive care unit

WHAT IS KNOWN AND OBJECTIVE

Delirium has been associated with increased mortality and prolonged hospital length of stay among critical care patients. Furthermore, treatment of delirium remains variable amongst clinicians due to limited evidence. The objective of this study was to determine the local incidence of delirium and to characterize the effectiveness and safety of pharmacological therapy used to treat delirium.

METHODS

A retrospective chart review evaluated patients diagnosed with delirium (Intensive Care Delirium Screening Checklist score ≥4) and requiring mechanical ventilation for ≥48 hours from January 2016 to June 2017. The primary outcomes included comparison of resolution, the time to first resolution and recurrence of delirium in patients prescribed pharmacological and/or pre-emptive therapy versus those who did not. Secondary outcomes included incidence of adverse effects of drug therapy and delirium attributable adverse events.

RESULTS AND DISCUSSION

The incidence of delirium during our defined study period was 49%. Of the 178 patients included in the study, 136 (76%) received drug therapy for delirium. Agents used for treatment of delirium included dexmedetomidine (n = 90 [66%]), haloperidol (n = 77 [57%]), and quetiapine (n = 74 [54%]). Resolution of delirium occurred in 94 (52%) of patients and the difference was statistically significant favoring patients who did not receive pharmacological therapy. There was no difference in the median time to resolution of delirium (3 days) for patients who received pharmacological and/or pre-emptive therapy versus those who did not. Bradycardia and hypotension were the most frequently documented medication-related adverse events. Self-removal of an invasive line/catheter, was reported in 36 (26%) patients despite receiving pharmacological treatment.

WHAT IS NEW AND CONCLUSION

Despite unclear evidence that pharmacological interventions help with delirium management, the majority of our patients received such interventions. To improve patient outcomes, we should shift focus towards non-pharmacological interventions for delirium.

Blood Pressure During Endovascular Treatment Under Conscious Sedation or Local Anesthesia

Objective

To evaluate the role of blood pressure (BP) as mediator of the effect of conscious sedation (CS) compared to local anesthesia (LA) on functional outcome after endovascular treatment (EVT).

Methods

Patients treated in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry centers with CS or LA as preferred anesthetic approach during EVT for ischemic stroke were analyzed. First, we evaluated the effect of CS on area under the threshold (AUT), relative difference between baseline and lowest procedural mean arterial pressure (∆LMAP), and procedural BP trend, compared to LA. Second, we assessed the association between BP and functional outcome (modified Rankin Scale [mRS]) with multivariable regression. Lastly, we evaluated whether BP explained the effect of CS on mRS.

Results

In 440 patients with available BP data, patients treated under CS (n = 262) had larger AUTs (median 228 vs 23 mm Hg*min), larger ∆LMAP (median 16% vs 6%), and a more negative BP trend (−0.22 vs −0.08 mm Hg/min) compared to LA (n = 178). Larger ∆LMAP and AUTs were associated with worse mRS (adjusted common odds ratio [acOR] per 10% drop 0.87, 95% confidence interval [CI] 0.78–0.97, and acOR per 300 mm Hg*min 0.89, 95% CI 0.82–0.97). Patients treated under CS had worse mRS compared to LA (acOR 0.59, 95% CI 0.40–0.87) and this association remained when adjusting for ∆LMAP and AUT (acOR 0.62, 95% CI 0.42–0.92).

Conclusions

Large BP drops are associated with worse functional outcome. However, BP drops do not explain the worse outcomes in the CS group.

Effectiveness of Quetiapine as a Sedative Adjunct in Mechanically Ventilated Adults Without Delirium

BACKGROUND

Quetiapine is an atypical antipsychotic that is commonly used in the Intensive Care Unit (ICU). The utility of quetiapine as a sedative adjunct has not yet been evaluated, but has been described previously in studies evaluating quetiapine for delirium or delirium prophylaxis.

OBJECTIVE

To determine if adjunctive use of quetiapine reduces sedative dosage requirements among mechanically ventilated adults without delirium.

METHODS

This retrospective intrapatient comparator study included all mechanically ventilated adults admitted to a medical ICU who received quetiapine between July 1, 2013, and July 1, 2018. The primary outcome was the change in sedative dosage requirements over 24 hours following quetiapine initiation. Secondary outcomes included change in sedative dosage requirements 48 hours postquetiapine initiation, opioid dosage requirements 24 hours postquetiapine initiation, percent time at goal for both pain and sedation scores, depth of sedation, and QTc.

RESULTS

A total of 57 patients were included in the study cohort. There was no significant difference in 24-hour cumulative doses of propofol (P = 0.10), dexmedetomidine (P = 0.14), or benzodiazepines (P = 0.14). During the 48-hour treatment period, there was a significant increase in dexmedetomidine requirements (P = 0.03). There were no differences in 24-hour opioid dosage requirements, percent time at goal pain or sedation scores, depth of sedation, or QTc following quetiapine initiation.

CONCLUSION AND RELEVANCE

Adjunctive use of quetiapine was not associated with a significant reduction in sedative dosage requirements 24 or 48 hours following initiation among mechanically ventilated adults without delirium.

Cardiovascular Safety of Clonidine and Dexmedetomidine in Critically Ill Patients after Cardiac Surgery

Purpose

The aim of this retrospective study was to assess the haemodynamic adverse effects of clonidine and dexmedetomidine in critically ill patients after cardiac surgery.

Methods

2769 patients were screened during the 30-month study period. Heart rate (HR), mean arterial pressure (MAP), and norepinephrine requirements were assessed 3-hourly during the first 12 hours of the continuous drug infusion. Results are given as median (interquartile range) or numbers (percentages).

Results

Patients receiving clonidine (n = 193) were younger (66 (57-73) vs 70 (63-77) years, p=0.003) and had a lower SAPS II (35 (27-48) vs 41 (31-54), p=0.008) compared with patients receiving dexmedetomidine (n = 141). At the start of the drug infusion, HR (90 (75-100) vs 90 (80-105) bpm, p=0.028), MAP (70 (65-80) vs 70 (65-75) mmHg, p=0.093), and norepinephrine (0.05 (0.00-0.11) vs 0.12 (0.03-0.19) mcg/kg/min, p < 0.001) were recorded in patients with clonidine and dexmedetomidine. Bradycardia (HR < 60 bpm) developed in 7.8% with clonidine and 5.7% with dexmedetomidine (p=0.51). Between baseline and 12 hours, norepinephrine remained stable in the clonidine group (0.00 (-0.04-0.02) mcg/kg/min) and decreased in the dexmedetomidine group (-0.03 (-0.10-0.02) mcg/kg/min, p=0.007).

Conclusions

Dexmedetomidine and the low-cost drug clonidine can both be used safely in selected patients after cardiac surgery.

Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: A Prospective Exploratory Study

Supplemental Digital Content is available in the text.

Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome.

Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

Serious Cardiovascular Adverse Events Reported with Intravenous Sedatives: A Retrospective Analysis of the MedWatch Adverse Event Reporting System

BACKGROUND

Serious cardiovascular adverse events (SCAEs) associated with intravenous sedatives remain poorly characterized.

OBJECTIVE

The objective of this study was to compare SCAE incidence, types, and mortality between intravenous benzodiazepines (i.e., diazepam, lorazepam, and midazolam), dexmedetomidine, and propofol in the USA over 8 years regardless of the clinical setting where it was administered.

METHODS

The Food and Drug Administration's MedWatch Adverse Event Reporting System was searched between 2004 and 2011 using the Evidex^® platform from Advera Health Analytics, Inc. to identify all reports that included one or more of ten different SCAEs (package insert incidence ≥ 1%) and where an intravenous benzodiazepine, dexmedetomidine, or propofol was the primary suspected drug.

RESULTS

Among the 2326 Food and Drug Administration's MedWatch Adverse Event Reporting System cases reported, 394 (16.9%) were related to a SCAE. The presence of a SCAE (vs. a non-SCAE) is associated with higher mortality (34 vs. 8%, p < 0.001). The percentage of cases with one or more SCAE, the case mortality rate (%), and the incidence of each SCAE (per 10⁶ days of sedative exposure), respectively, were benzodiazepines (14, 26, 13) [diazepam (13, 23, 31); lorazepam (15, 43, 14); midazolam (14, 20, 11)]; dexmedetomidine (40, 15, 13); and propofol (17, 39, 7). Propofol (vs. either a benzodiazepine or dexmedetomidine) was associated with more total SCAEs (268 vs. 126, p < 0.001) but a lower incidence (per 10⁶ days of sedative exposure) of SCAE (7 vs. 13, p = 0.0001) and cardiac arrest [6.3 (benzodiazepine) vs. 6.7 (dexmedetomidine) vs. 1.4 (propofol), p < 0.0001].

CONCLUSIONS

Serious cardiac adverse events account for nearly one-fifth of intravenous sedative Food and Drug Administration's MedWatch Adverse Event Reporting System reports. These SCAEs appear to be associated with greater mortality than non-cardiac serious adverse events. Serious cardiac events may be more prevalent with either benzodiazepines or dexmedetomidine than propofol.

The KEEP SIMPLEST Study: Improving In-House Delays and Periinterventional Management in Stroke Thrombectomy-A Matched Pair Analysis

BACKGROUND AND PURPOSE

Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT.

METHODS

KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months.

RESULTS

Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups.

CONCLUSION

An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.

Drug Interactions of Chronic Neuropsychiatric Drugs in Neuro-critical Care

Neuro psychiatric illnesses are commonly recognised these days in the intensive care especially with the increasing aging population and more intensive care admissions. However they are still inadequately diagnosed and treated disease entities as a majority of these patients do not seek the help of specialists psychiatrists Of course the number of drugs used in psychiatry has explosively increased in recent years. As a corollary to this, the phenomenon of drug- drug interaction between psychiatric drugs and other drugs has come to the forefront. Drug- drug interaction (DDI)) is the response (pharmacological or clinical) of altered drug effects or increase in adverse effects when two or more drugs are used simultaneously^1,2 This effect may be different from the usual action of the individual drugs when used alone. Potential drug- drug interaction (PDDI) are those where theoretically there may be an interaction between the drugs but have not clinically occurred.^1,2

Prolonged hospitalization is a risk factor for delirium onset: one-day prevalence study in Slovenian INTENSIVE CARE UNITS

Delirium is a clinical syndrome often underestimated in the intensive care units (ICU). The aim of this study was to determine the prevalence and factors that influence the onset of delirium. A questionnaire was sent to intensivists in Slovenian ICUs, who estimated the prevalence of delirious patients. The questionnaire consisted of demographic data, type of ICU, diagnosis, reason for admission to the ICU, type of anesthesia and surgery, clinical condition, type of supportive therapy, presence of delirium, data on discharge, transfers between departments or patient outcome on day 30. Patient consciousness was assessed by the Richmond Agitation-Sedation Scale (RASS) and the presence of delirium by the validated delirium-screening Confusion Assessment Method for the ICU (CAM-ICU). Replies received from intensivists included data on 103 patients. According to RASS ≥-3, the prevalence of delirium was 9.5% (7 out of 74 patients). There was no difference in the prevalence of delirium between surgical and medical ICU patients (p=0.388). Delirious patients had longer hospital stay (p=0.002) and ICU stay (p=0.032) compared to patients without delirium. All delirious patients survived until day 30, whereas 19 patients without delirium died (p=0.092). Logistic regression analysis dismissed any association of delirium with patient mortality (p=0.998). Age, gender, anesthesia, mechanical ventilation, and type of surgical procedure could not be evaluated as risk factors for delirium. In Slovenian ICUs, a lower proportion of delirium was observed, as reported from similar studies. Risk factors such as gender, age, mechanical ventilation, sedation, anesthesia, or department could not predict delirium. However, prolonged hospitalization of ICU patients could predict the onset of delirium, but the presence of delirium did not increase patient mortality.

The Effect of Concomitant Sirolimus and Propofol Therapy on Triglyceride Concentrations in Critically Ill Patients

BACKGROUND

Sirolimus and propofol are both independently associated with the development of hypertriglyceridemia (HTG) during therapy. To date, there are no published reports describing synergistic or additive drug interaction resulting in HTG with concomitant use of these medications.

STUDY QUESTION

To identify the occurrence of HTG in patients receiving concomitant sirolimus and propofol infusion therapy.

METHODS

Adult patients receiving sirolimus and a continuous propofol infusion for at least 12 hours from January 2005 to August 2009 were retrospectively evaluated. Data included Acute Physiology and Chronic Health Evaluation II score, weight, length of propofol therapy, and baseline triglyceride (TG) concentrations. The major outcome was incidence of HTG (TGs ≥500 mg/dL). Minor outcomes included the change in TG concentration from therapy initiation and manifestations of propofol-related infusion syndrome (PRIS).

RESULTS

Sixteen patients were included in the analysis, with 8 (50%) of the patients developing HTG. The patients in this case series had the following mean values: Acute Physiology and Chronic Health Evaluation II score of 20.2 ± 5.3, weight of 76.3 ± 21.2 kg, and baseline TG concentrations of 181.3 ± 89.7 mg/dL. Indications for sirolimus therapy included hematopoietic stem-cell transplantation (n = 15) and heart transplantation (n = 1). Mean length of propofol infusion was 99.8 ± 88.5 hours. The mean TG concentration during infusion was 515.6 ± 468.1 mg/dL. Fourteen (87.5%) patients had an increase of ≥100 mg/dL, 12 (75%) patients had an increase of ≥200 mg/dL, and 6 (37.5%) patients had an increase of ≥300 mg/dL in TG concentrations during therapy. Eleven patients developed one manifestation of PRIS, excluding HTG, and one patient had more than 2 new onset PRIS manifestations during propofol therapy.

CONCLUSIONS

Coadministration of propofol and sirolimus can potentially result in HTG, which may warrant more frequent monitoring. Further analysis is needed to examine the mechanism and clinical impact of this interaction.

A Systematic Review of Alpha-2 Agonists for Sedation in Mechanically Ventilated Neurocritical Care Patients

The use of sedative medications is commonplace in intensive care units (ICUs) and an invaluable clinical tool for the intensive care physician. Sedation for critically ill, mechanically ventilated patients provides an opportunity to reduce anxiety, discomfort as well as ventilator intolerance and dyssynchrony. Alpha-2 agonists in particular have become increasingly popular for use in the neurocritical care population due to their proposed effectiveness in facilitating examinations and procedures as well as reducing the need for adjunctive agents. However, there is a paucity of literature to assess the safety of their use in the neurocritically ill patients, a population that presents unique sensitivities and considerations for management of global and cerebral hemodynamics, agitation and facilitation of neurological assessments. This review assesses the safety and efficacy of alpha-2 agonists for non-procedural sedation in critically ill brain-injured patients on mechanical ventilation. In June 2016, we searched the EMBASE, MEDLINE and CENTRAL Cochrane Databases for randomized controlled trials, prospective and retrospective cohort studies examining neurocritically ill adult patients aged 18 years and older who are on mechanical ventilation and receiving alpha-2 agonists for non-procedural sedation. Primary outcomes of interest include mean arterial pressure (MAP), intracranial pressure (ICP), and cerebral perfusion pressure (CPP). Secondary outcomes include adverse events, duration of mechanical ventilation, 30-day mortality, ICU length of stay, incidence of delirium, and quality of sedation. We identified 17 studies for inclusion, all reporting on dexmedetomidine use, only 7 of which reported on our primary outcomes of interest. We found mixed results with regard to statistically significant changes in ICP, CPP, and MAP but did not find evidence of severe hemodynamic disturbances. However, the studies are notably limited by lack of reporting on sedative and hemodynamic adjuncts. Based on the limited available data, dexmedetomidine does not appear to result in severe, uncompensated hemodynamic disturbances (cerebral or systemic). The validation of an effective and safe agent with reporting of dosing strategy, sedation protocol use, co-interventions administered, and a priori defined adverse events is recommended.

In vitro and in vivo evaluation of hypothermia on pharmacokinetics and pharmacodynamics of nimodipine in rabbits

Objective To investigate the effect of hypothermia on the pharmacokinetics and pharmacodynamics of nimodipine in rabbits using in vivo and in vitro methods. Methods Five healthy New Zealand rabbits received a single dose of nimodipine (0.5 mg/kg) intravenously under normothermic and hypothermic conditions. Doppler ultrasound was used to monitor cerebral blood flow, vascular resistance, and heart rate. In vitro evaluations of protein binding, hepatocyte uptake and intrinsic clearance of liver microsomes at different temperatures were also conducted. Results Plasma concentrations of nimodipine were significantly higher in hypothermia than in normothermia. Nimodipine improved cerebral blood flow under both conditions, but had a longer effective duration during the hypothermic period. Low temperature decreased the intrinsic clearance of liver microsomes, with no change in protein binding or hepatocyte uptake of nimodipine. Conclusion Nimodipine is eliminated at a slower rate during hypothermia than during normothermia, mainly due to the decreased activity of cytochrome P450 enzymes. This results in elevated system exposure with little enhancement in pharmacological effect.

Opioid-associated iatrogenic withdrawal in critically ill adult patients: a multicenter prospective observational study

Background

Opioids and benzodiazepines are frequently used in the intensive care unit (ICU). Regular use and prolonged exposure to opioids in ICU patients followed by abrupt tapering or cessation may lead to iatrogenic withdrawal syndrome (IWS). IWS is well described in pediatrics, but no prospective study has evaluated this syndrome in adult ICU patients. The objective of this study was to determine the incidence of IWS caused by opioids in a critically ill adult population. This multicenter prospective cohort study was conducted at two level-1 trauma ICUs between February 2015 and September 2015 and included 54 critically ill patients. Participants were eligible if they were 18 years and older, mechanically ventilated and had received more than 72 h of regular intermittent or continuous intravenous infusion of opioids. For each enrolled patient and per each opioid weaning episode, presence of IWS was assessed by a qualified ICU physician or senior resident according to the 5th edition of Diagnostic and Statistical Manual of Mental Disorders criteria for opioid withdrawal.

Results

The population consisted mostly of males (74.1%) with a median age of 50 years (25th–75th percentile 38.2–64.5). The median ICU admission APACHE II score was 22 (25th–75th percentile 12.0–28.2). The overall incidence of IWS was 16.7% (95% CI 6–27). The median cumulative opioid dose prior to weaning was higher in patients with IWS (245.7 vs. 169.4 mcg/kg, fentanyl equivalent). Patients with IWS were also exposed to opioids for a longer period of time as compared to patients without IWS (median 151 vs. 125 h). However, these results were not statistically significant.

Conclusions

IWS was occasionally observed in this very specific population of mechanically ventilated, critically ill ICU patients. Further studies are needed to confirm these preliminary results and identify risk factors.

Impact of restarting home neuropsychiatric medications on sedation outcomes in medical intensive care unit patients

PURPOSE

This single-center, retrospective cohort study investigated the effects of timing of initiating home neuropsychiatric medications (NPMs) on sedation-related outcomes.

MATERIALS AND METHODS

Subjects included adult medical intensive care unit (MICU) patients who had an NPM on their admission medication list; intubated before or on arrival to the intensive care unit (ICU); and were on benzodiazepine-based sedation. The intervention assessed was the timing of the initiation of home NPMs: early (≤5days) vs. late (>5days) into the ICU stay.

RESULTS

There were 56 and 53 patients in the early and late restart groups, respectively. Early cohort patients maintained a median daily RASS of -1.5, while late cohort patients had a median daily RASS of -2.0 (p=0.02). The effect was driven by the subgroup of patients on home anti-depressant therapy who were restarted early on these agents. The early restart group had a higher percentage of days with RASS scores within goal (p=0.01) and less delirium (p=0.02). Early restarting of home NPMs was associated with a non-significant decrease in ventilator days compared with late restarting (p=0.11).

CONCLUSIONS

Restarting home NPMs was associated with lighter sedation levels and less delirium.

Alpha-2 agonists for sedation in mechanically ventilated neurocritical care patients: a systematic review protocol

BACKGROUND

Sedation is an important consideration in the care of the neurocritically ill patient. It provides anxiety and relief, facilitates procedures and nursing tasks, and minimizes intolerance of mechanical ventilation. Alpha-2 agonists such as dexmedetomidine and clonidine have been shown to be an effective alternative in the general critical care population by reducing duration of mechanical ventilation and length of stay in the intensive care unit (ICU), as compared to traditional sedative agents such as propofol or benzodiazepines. However, there is a paucity of literature detailing their utility and safety in neurocritical care, a population that presents unique considerations for management of global and cerebral hemodynamics, agitation, and facilitation of neurological assessments. The objective of this review is to assess the efficacy and safety of alpha-2 agonists for non-procedural sedation in mechanically ventilated brain-injured patients.

METHODS

We will search the Embase and MEDLINE databases for all randomized controlled trials, prospective and retrospective cohort studies examining neurocritically ill adult patients aged 18 years and older who are on mechanical ventilation and receiving alpha-2 agonists for non-procedural sedation. Primary outcomes of interest include effect on mean arterial pressure (MAP), intracranial pressure (ICP), and cerebral perfusion pressure (CPP). Secondary outcomes include adverse events, duration of mechanical ventilation, 30-day mortality, ICU length of stay, incidence of delirium, and quality of sedation. Continuous outcomes will be presented as means and mean differences and discrete counting events will be presented as event rates. Pre-defined criteria for heterogeneity are provided for determination of pooling eligibility. Where appropriate, we will pool estimates for individual outcomes. Planned subgroup analyses include specific alpha-2 agonist agent, study design, clinical diagnosis, dosing regimen, and use of adjunctive agents. Quality of evidence for the recommendation will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach where appropriate.

DISCUSSION

This systematic review will summarize the evidence on the efficacy and safety for the use of alpha-2 agonists as sedative agents in the neurocritical care population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016037045.

Cardiovascular side effects of psychopharmacologic therapy

WHO defined in 1976 psychopharmaca as drugs affecting psychological functions, behaviour and self-perception. Psychopharmacology is the study of pharmacological agents that affect mental and emotional functions. Creative approach to psychopharmacotherapy reflects a transdisciplinary, integrative and person-centered psychiatry. Psychiatric disorders often occur in cardiac patients and can affect the clinical presentation and morbidity. Cardiovascular (CV) side effects (SE) caused by psychopharmaceutic agents require comprehensive attention. Therapeutic approach can increase placebo and decrease nocebo reactions. The main purpose of this review is to comprehend CV SE of psychotropic drugs (PD). Critical overview of CV SE of PD will be presented in this review. Search was directed but not limited to CV effects of psychopharmacological substances, namely antipsychotics, anxiolytics, hypnotics, sedatives, antidepressants and stimulants. Literature review was performed and data identified by searches of Medline and PubMed for period from 2004 to 2015. Only full articles and abstracts published in English were included. SE of PD are organized according to the following types of CV effects: cardiac and circulatory effects, abnormalities of cardiac repolarisation and arrhythmias and heart muscle disease. There is wide spectrum and various CV effects of PD. Results of this review are based on literature research. The reviewed data came largely from prevalence studies, case reports, and cross-sectional studies. Psychopharmacotherapy of psychiatric disorders is complex and when concomitantly present with CV disease, presentation of drug SEs can significantly contribute to illness course. Further development of creative psychopharmacotherapy is required to deal with CV effects of PD.

Tolerance and Withdrawal Issues with Sedatives in the Intensive Care Unit

Prolonged use of sedative medications continues to be a concern for critical care practitioners, with potential adverse effects including tolerance and withdrawal. The amount of sedatives required in critically ill patients can be lessened and tolerance delayed with the use of pain and/or sedation scales to reach the desired effect. The current recommendation for prolonged sedation is to wean patients from the medications over several days to reduce the risk of drug withdrawal. It is important to identify patients at risk for iatrogenic withdrawal and create a treatment strategy.

Treatment of Convulsive Status Epilepticus

OPINION STATEMENT

Convulsive status epilepticus (CSE) is a medical emergency with an associated high mortality and morbidity. It is defined as a convulsive seizure lasting more than 5 min or consecutive seizures without recovery of consciousness. Successful management of CSE depends on rapid administration of adequate doses of anti-epileptic drugs (AEDs). The exact choice of AED is less important than rapid treatment and early consideration of reversible etiologies. Current guidelines recommend the use of benzodiazepines (BNZ) as first-line treatment in CSE. Midazolam is effective and safe in the pre-hospital or home setting when administered intramuscularly (best evidence), buccally, or nasally (the latter two possibly faster acting than intramuscular (IM) but with lower levels of evidence). Regular use of home rescue medications such as nasal/buccal midazolam by patients and caregivers for prolonged seizures and seizure clusters may prevent SE, prevent emergency room visits, improve quality of life, and lower health care costs. Traditionally, phenytoin is the preferred second-line agent in treating CSE, but it is limited by hypotension, potential arrhythmias, allergies, drug interactions, and problems from extravasation. Intravenous valproate is an effective and safe alternative to phenytoin. Valproate is loaded intravenously rapidly and more safely than phenytoin, has broad-spectrum efficacy, and fewer acute side effects. Levetiracetam and lacosamide are well tolerated intravenous (IV) AEDs with fewer interactions, allergies, and contraindications, making them potentially attractive as second- or third-line agents in treating CSE. However, data are limited on their efficacy in CSE. Ketamine is probably effective in treating refractory CSE (RCSE), and may warrant earlier use; this requires further study. CSE should be treated aggressively and quickly, with confirmation of treatment success with epileptiform electroencephalographic (EEG), as a transition to non-convulsive status epilepticus is common. If the patient is not fully awake, EEG should be continued for at least 24 h. How aggressively to treat refractory non-convulsive SE (NCSE) or intermittent non-convulsive seizures is less clear and requires additional study. Refractory SE (RSE) usually requires anesthetic doses of anti-seizure medications. If an auto-immune or paraneoplastic etiology is suspected or no etiology can be identified (as with cryptogenic new onset refractory status epilepticus, known as NORSE), early treatment with immuno-modulatory agents is now recommended by many experts.

Intravenous Artesunate for the Treatment of Severe and Complicated Malaria in the United States: Clinical Use Under an Investigational New Drug Protocol

BACKGROUND

Quinidine gluconate, the only U.S. Food and Drug Administration-approved treatment for life-threatening malaria in the United States, has a problematic safety profile and is often unavailable in hospitals.

OBJECTIVE

To assess the safety and clinical benefit of intravenous artesunate as an alternative to quinidine.

DESIGN

Retrospective case series.

SETTING

U.S. hospitals.

PATIENTS

102 patients aged 1 to 72 years (90% adults; 61% men) with severe and complicated malaria. Patients received 4 weight-based doses of intravenous artesunate (2.4 mg/kg) under a treatment protocol implemented by the Centers for Disease Control and Prevention between January 2007 and December 2010. At baseline, 35% had evidence of cerebral malaria, and 17% had severe hepatic impairment. Eligibility required the presence of microscopically confirmed malaria, need for intravenous treatment, and an impediment to quinidine.

MEASUREMENTS

Clinical and laboratory data from each patient's hospital records were abstracted retrospectively, including information from baseline through a maximum 7-day follow-up, and presented before a physician committee to evaluate safety and clinical benefit outcomes.

RESULTS

7 patients died (mortality rate, 6.9%). The most frequent adverse events were anemia (65%) and elevated hepatic enzyme levels (49%). All deaths and most adverse events were attributed to the severity of malaria. Patients' symptoms generally improved or resolved within 3 days, and the median time to discharge from the intensive care unit was 4 days, even for patients with severe liver disease or cerebral malaria. More than 100 concomitant medications were used, with no documented drug-drug interactions.

LIMITATION

Potential late-presenting safety issues might occur outside the 7-day follow-up.

CONCLUSION

Artesunate was a safe and clinically beneficial alternative to quinidine.

Detrimental effects of postnatal exposure to propofol on memory and hippocampal LTP in mice

Acute effects of propofol on memory and hippocampal long-term potentiation (LTP) in adult animals were reported. However, long-term effect of early postnatal application of propofol on memory was not totally disclosed. In this study, experiments were designed to verify the mechanisms underlying the long-term detrimental effects of propofol on memory and hippocampal synaptic plasticity. A consecutive propofol protocol from postnatal day 7 was applied to model anesthesia, long term memory and hippocampal synaptic plasticity were detected 2 months later. Our results showed that repeated propofol exposure in early phase affect the memory in the adult phase. Through recording the field excitatory postsynaptic potentials (fEPSPs) at Schaffer colletaral-CA1 synapses, both of basal synaptic transmission and hippocampal LTP were decreased after propofol application. While LTD induced by low frequency stimulation and 3,5-dihydroxyphenylglycine (3,5-DHPG) were not affected. Through analyzing the ultrastructure of dendrite in CA1 region, we found that propofol application decreased the spine density, which was consistent with the decrease of PSD-95 expression. In addition, p-AKT level was reduced after first propofol application. Intracerebroventricular injection of Akt inhibitor could mimic the propofol effects on basal synaptic transmission, hippocampal LTP and memory. Taken together, these results suggested that propofol possibly decreased AKT signaling pathway to restrict the spine development, finally leading to hippocampal LTP impairment and memory deficit.

Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebo-controlled pilot study

BACKGROUND

Successful application of noninvasive ventilation (NIV) for acute respiratory failure (ARF) requires patient cooperation and comfort. The efficacy and safety of early IV dexmedetomidine when added to protocolized, as-needed IV midazolam and fentanyl remain unclear.

METHODS

Adults with ARF and within 8 h of starting NIV were randomized to receive IV dexmedetomidine (0.2 μg/kg/h titrated every 30 min to 0.7 μg/kg/h to maintain a Sedation-Agitation Scale [SAS] score of 3 to 4) or placebo in a double-blind fashion up to 72 h, until NIV was stopped for ≥ 2 h, or until intubation. Patients with agitation (SAS ≥ 5) or pain (visual analog scale ≥ 5 of 10 cm) 15 min after each dexmedetomidine and placebo increase could receive IV midazolam 0.5 to 1.0 mg or IV fentanyl 25 to 50 μg, respectively, at a minimum interval of every 3 h.

RESULTS

The dexmedetomidine (n = 16) and placebo (n = 17) groups were similar at baseline. Use of early dexmedetomidine did not improve NIV tolerance (score, 1 of 4; OR, 1.44; 95% CI, 0.44-4.70; P = .54) nor, vs. placebo, led to a greater median (interquartile range) percent time either tolerating NIV (99% [61%-100%] vs. 67% [40%-100%], P = .56) or remaining at the desired sedation level (SAS score = 3 or 4, 100% [86%-100%] vs. 100% [100%-100%], P = .28], or fewer intubations (P = .79). Although use of dexmedetomidine was associated with a greater duration of NIV vs placebo (37 [16-72] vs. 12 [4-22] h, P = .03), the total ventilation duration (NIV + invasive) was similar (3.3 [2-4] days vs. 3.8 [2-5] days, P = .52). More patients receiving dexmedetomidine had one or more episodes of deep sedation vs placebo (SAS ≤ 2, 25% vs. 0%, P = .04). Use of midazolam (P = .40) and episodes of either severe bradycardia (heart rate ≤ 50 beats/min, P = .18) or hypotension (systolic BP ≤ 90 mm Hg, P = .64) were similar.

CONCLUSIONS

Initiating dexmedetomidine soon after NIV initiation in patients with ARF neither improves NIV tolerance nor helps to maintain sedation at a desired goal. Randomized, multicenter trials targeting patients with initial intolerance are needed to further elucidate the role for dexmedetomidine in this population.

Adverse neurologic effects of medications commonly used in the intensive care unit

Adverse drug effects often complicate the care of critically ill patients. Therefore, each patient's medical history, maintenance medication, and new therapies administered in the intensive care unit must be evaluated to prevent unwanted neurologic adverse effects. Optimization of pharmacotherapy in critically ill patients can be achieved by considering the need to reinitiate home medications, and avoiding drugs that can decrease the seizure threshold, increase sedation and cognitive deficits, induce delirium, increase intracranial pressure, or induce fever. Avoiding medication-induced neurologic adverse effects is essential in critically ill patients, especially those with neurologic injury.

Drug-induced cardiovascular adverse events in the intensive care unit

Critically ill patients are at high risk of adverse drug events during their intensive care unit stay. Of the potential adverse drug events, those related to the cardiovascular system are particularly concerning. Common cardiovascular adverse drug events include drug-induced arrhythmias, drug-induced blood pressure abnormalities, and drug-induced heart failure. The specific drug-induced events to be reviewed include bradycardia, tachycardia, corrected QT interval prolongation, hypertension, hypotension, and heart failure exacerbation.

Cost effectiveness of a benzodiazepine vs a nonbenzodiazepine-based sedation regimen for mechanically ventilated, critically ill adults

PURPOSE

Nonbenzodiazepine sedation (eg, dexmedetomidine or propofol) may be more cost effective than benzodiazepine (BZ) sedation despite its higher acquisition cost.

MATERIALS AND METHODS

A cost effectiveness (CE) analysis of noncardiac surgery, critically ill adults requiring at least 1 day of mechanical ventilation (MV) and administered either BZ or non-BZ sedation, that cycled health states and costs daily using a Markov model accounting for daily MV use until intensive care unit (ICU) discharge, was conducted from a third-party perspective. Transition probabilities were obtained from a published meta-analysis, and costs were estimated from best evidence. Sensitivity analyses were run for all extubation and discharge probabilities, for different cost estimates and for the specific non-BZ administered.

RESULTS

When non-BZ rather than BZ sedation was used, the incremental cost-effectiveness ratio to avert 1 ICU day while MV or while either MV or non-MV was $3406 and $3136, respectively. The base-case analysis revealed that non-BZ sedation (vs BZ sedation) resulted in higher drug costs ($1327 vs $65) but lower total ICU costs (percent accounted for MV need): $35380 (71.0%) vs $45394 (70.6%). Sensitivity analysis revealed that BZ sedation would only be less costly if the daily rate of extubation was at least 16%, and the daily rate of ICU discharge without MV was at least 77%. The incremental CE ratio to avert 1 ICU day while MV or non-MV was similar between the dexmedetomidine and propofol non-BZ options.

CONCLUSIONS

Among MV adults, non-BZ sedation has a more favorable CE ratio than BZ sedation over most cost estimates.

Norepinephrine infusion increases urine output in children under sedative and analgesic infusion

Objective: to evaluate the effects of early norepinephrine (NE) infusion in children submitted to mechanical ventilation (MV) requiring continuous sedative and analgesic infusion. Methods: double-blinded, randomized, placebo-controlled trial enrolling children (1 month to 12 years of age) admitted to a Brazilian PICU and expected to require MV and continuous sedative and analgesic drug infusions for at least five days. Children were randomized to receive either norepinephrine (NE) (0.15 mcg/kg/min) or normal saline infusion, started in the first 24 hours of MV, and maintained for 72 hours. We compared hemodynamic variables, fluid intake, renal function and urine output between groups. Results: forty children were equally allocated to the NE or placebo groups, with no differences in baseline characteristics, laboratorial findings, PRISM II score, length of MV, or mortality between groups. The average norepinephrine infusion was 0.143 mcg/kg/min. The NE group showed higher urine output (p = 0.016) and continuous increment in the mean arterial pressure compared to the baseline (p = 0.043). There were no differences in the remaining hemodynamic variables, fluid requirements, or furosemide administration. Conclusion: early norepinephrine infusion in children submitted to MV improves mean arterial pressure and increases urine output. These effects were attributed to reversion of vasoplegia induced by the sedative and analgesic drugs.