Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306. [PMID: 23269131 DOI: 10.1097/ccm.0b013e3182783b72]

Incidence and Risk Factors for Accidental Removal of Medical Devices in an Intensive Care Unit: A Retrospective Cohort

BACKGROUND

Accidental removal of medical devices (ARMD) is an important safety risk for critically ill patients admitted to an intensive care unit (ICU), and little is known about the risk factors for its occurrence.

OBJECTIVE

To estimate the incidence and investigate risk factors for ARMD among adult patients admitted to the ICU.

METHODS

This is a retrospective cohort study including data from adult patients admitted to the ICU between 2018 and 2021. The study was carried out in the adult ICU of a hospital accredited by the Joint Commission International, consisting of 54 beds.

RESULTS

A total of 5880 medical records of patients admitted to the ICU were included. Of these, 376 (6.4%) were affected by ARMD; the majority were male (256 [68.1%]), with a mean age of 68.2 (18.9) years. The nasoenteral catheter was the most frequently removed device (44.4%), followed by the central venous catheter (11.4%), the indwelling bladder catheter (9.0%), and the peripheral venous catheter (6.9%). The logistic regression model showed that the diagnosis of kidney disease (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.34-12.44), occurrence of delirium (OR, 2.02; 95% CI, 1.35-3.03), and length of stay in the ICU (OR, 1.02; 95% CI, 1.01-1.02) increased the chance of ARMD occurrence. Patients requiring vasopressor medications had a lower chance of ARMD (OR, 0.32; 95% CI, 0.22-0.46).

CONCLUSIONS

The incidence rate of ARMD is similar to those reported in previous studies. However, the results pointed to new risk factors for the occurrence of ARMD, such as chronic kidney disease and length of stay in the ICU.

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.

Effects of Esketamine Versus Remifentanil on Hemodynamics and Prognosis in Patients with Septic Shock Receiving Invasive Mechanical Ventilation: A Randomized Controlled Trial

Background

Analgesics and sedatives may affect the hemodynamics of patients with septic shock and produce adverse reactions. The purpose of this study is to compare the hemodynamic effects and prognosis of esketamine and remifentanil in combination with propofol in patients with septic shock receiving invasive mechanical ventilation.

Methods

In this single-center, prospective, randomized, controlled pilot study, patients with septic shock in the intensive care unit (ICU) receiving invasive mechanical ventilation were randomized to receive esketamine or remifentanil in combination with propofol intravenously. The target Critical-Care Pain Observation Tool (CPOT) score was <3 points and Richmond Agitation and Sedation Scale (RASS) score was -2~0 points. The primary outcome was dosage of norepinephrine (mg/kg). Secondary outcomes included mechanical ventilation time(hours), dosage of propofol (mg/kg), intestinal dysfunction rate, ICU length of stay(days), hospital length of stay(days), hospital mortality and 28-day survival rate. We registered the study at ClinicalTrials.gov on 23/09/2022 (https://clinicaltrials.gov/study/NCT05551910).

Results

A total of 120 patients were enrolled in the study. Sixty patients were assigned to each group. The median dosage of norepinephrine of remifentanil group was 4.09(1.52,8.85) mg/kg while that of esketamine group was 1.72(1.01,3.97) mg/kg. The dosage of norepinephrine of esketamine group was less than that of remifentanil group(P=0.007). There were no significant differences between the two groups with respect to adverse event rate, intestinal dysfunction rate, dosage of propofol, mechanical ventilation time, ICU length of stay, hospital length of stay and hospital mortality(P>0.05). Kaplan-Meier survival analysis showed that there was no significant difference in 28-day survival rate between the two groups(P=0.225).

Conclusion

Esketamine may decrease the dosage of norepinephrine in patients with septic shock receiving invasive mechanical ventilation. It is beneficial for stabilizing hemodynamics and appears to be an effective and safe agent for patients with septic shock requiring invasive mechanical ventilation.

Agitation-sedation models for critical care: Insights into endogenous agitation reduction and stimulus

BACKGROUND

Sedation and agitation management are core treatments in the intensive care unit. This study uses pharmacokinetic-pharmacodynamic (PKPD) models to capture the endogenous agitation response. The identification and validation of these models allow for a better understanding of agitation-sedation dynamics and improves the clinical implementation.

METHODS

A cohort of healthy volunteers (N=25) was exposed to a controlled psychological stimulus, with agitation levels quantitatively measured using heart rate-derived metrics. Endogenous agitation reduction (EAR) coefficients were determined from the post-stimulus decay. Using these parameters and a priori information about the experienced stimulus, the model was validated against the measured agitation data.

RESULTS

The model demonstrated a good fit between measured and modelled agitation. EAR parameters were identified with 45% of the cohort ranging between 0.003-0.004 s-1. Using a population value for EAR still resulted in a good fit to measured data. Minimal differences were observed between female and male participants.

CONCLUSION

This study provides further development of PKPD models of agitation-sedation dynamics. The identified EAR parameter can be used in future studies and in the clinical application of these models.

Contemporary Prevention and Management of Postoperative Delirium in Cardiac Surgery Patients

OBJECTIVE

This review examines the prevention and management of postoperative delirium in cardiac surgery patients, a frequent complication linked with significant mortality, morbidity, prolonged hospitalization, and cognitive decline. The aim was to consolidate current evidence on postoperative delirium pathophysiology, risk factors, diagnostic approaches, and pharmacologic and non-pharmacologic interventions.

METHODS

A PubMed/MEDLINE database review was conducted through October 2024, identifying studies that evaluated the relationship between cardiac surgery and the occurrence of postoperative delirium.

RESULTS

The pathogenesis of postoperative delirium is complex, involving neuroinflammation, neurotransmitter imbalance, and endothelial dysfunction, compounded by baseline vulnerabilities and perioperative stressors. Early screening using tools like the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) aids in timely detection. Prevention emphasizes non-pharmacologic interventions, such as the Hospital Elder Life Program and the ABCDEF bundle, alongside pharmacologic strategies to minimize high-risk sedatives. Emerging technologies, including intraoperative neurophysiologic monitoring modalities and machine learning models, enhance postoperative delirium risk assessment and enable targeted interventions.

CONCLUSION

Effective postoperative delirium management in cardiac surgery requires a balanced approach incorporating non-pharmacologic and pharmacologic methods. Integration of evidence-based practices and innovative technologies into routine care holds promise for improving patient outcomes. Ongoing research is essential to optimize postoperative delirium management and standardize practices in high-risk populations.

Connective Tissue Disorder-Induced Diffuse Alveolar Hemorrhage: A Comprehensive Review with an Emphasis on Airway and Respiratory Management

Diffuse alveolar hemorrhage (DAH), a catastrophic complication of connective tissue disorders (CTDs), manifests as rapid-onset hypoxemia, alveolar infiltrates, and progressive bleeding into the airways. While immune-mediated alveolar-endothelial injury primarily drives its pathophysiology, diagnosis is based on bronchoscopy and chest imaging. The clinical urgency lies in securing the compromised airway and stabilizing respiratory failure, a challenge increased by CTD-specific anatomical alterations such as cervical spine instability, cricoarytenoid arthritis, and subglottic stenosis. High-dose corticosteroids and immunosuppression are essential, while severe cases require extracorporeal membrane oxygenation or plasmapheresis. This comprehensive review introduces two novel approaches to address fundamental gaps in the management of CTD-induced DAH: a structured algorithm for a CTD-specific airway risk stratification tool, integrating anatomical screening and the application of lung ultrasounds (LUSs) for post-intubation CTD-induced DAH ventilation management. The need for a multidisciplinary team approach is also discussed. Despite aggressive care, mortality remains high (25-50%), underscoring the necessity for improved early recognition and intervention strategies for these high-risk patients.

A Comparison of Monotherapy and Combination Therapy With Antipsychotic Medications for Intensive Care Unit Delirium: A Retrospective Cohort Study

BACKGROUND

Antipsychotic medications continue to be frequently prescribed by clinicians in the intensive care unit (ICU) for delirium, despite inconclusive data.

OBJECTIVE

To determine if using a combination of antipsychotics reduces the time patients spend in delirium compared with monotherapy.

METHODS

This was a single-center, retrospective, cohort medical record review of patients who scored positive on Confusion Assessment Method for the ICU (CAM-ICU) and received antipsychotic therapy. Patients were excluded if they received any antipsychotics prior to hospital admission or had a Richmond Agitation-Sedation Scale (RASS) scores of -4 or -5 at the time of CAM-ICU assessment. The primary outcome was duration of delirium. The secondary outcomes included ICU length of stay (LOS), hospital LOS, overall mortality, occurrence of adverse events (AEs), and whether antipsychotics were continued at hospital discharge.

RESULTS

A total of 84 patients were included, of these 45 and 39 received monotherapy and combination therapy, respectively. Median Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were significantly higher in the monotherapy group (18 vs 13, P = 0.006). Median duration of delirium was not significantly different between the monotherapy and combination therapy groups (8 vs 8 days, P = 0.932). Median ICU and hospital LOS, and occurrence of AEs were not significantly different. A significant difference in mortality was found between monotherapy and combination therapy (31% vs 10%, P = 0.02). Antipsychotics were continued at hospital discharge in 64% of the monotherapy and in 44% of the combination therapy group.

CONCLUSION AND RELEVANCE

In patients with ICU delirium, there was no difference in duration of delirium among patients receiving monotherapy compared with combination therapy with antipsychotics, though they may be sicker and have a higher mortality. Patients commonly remain on antipsychotics at hospital discharge, the implications of which warrant further study.

Impact of Benzodiazepines on Outcomes of Mechanically Ventilated Pediatric Intensive Care Patients: A Retrospective Cohort Study

IMPORTANCE

Benzodiazepines are the most frequently used sedatives in PICUs, but they are increasingly associated with negative outcomes. Understanding their impact on patient outcomes is critical to provide better sedative management for patients.

OBJECTIVE

Our objective was to determine the impact of midazolam and lorazepam on clinical outcomes among subjects requiring mechanical ventilation in the PICU. We hypothesized that subjects receiving benzodiazepines for tolerance of mechanical ventilation will demonstrate worse clinical outcomes when compared with those not receiving benzodiazepines.

DESIGN

Single-center, retrospective cohort study.

SETTING AND PARTICIPANTS

PICU of a tertiary-care medical center. One thousand fifty-four pediatric participants requiring invasive mechanical ventilation between June 2018 and December 2022. Participants were categorized into those who received benzodiazepine-inclusive sedation regimens (n = 747) and those who received nonbenzodiazepine regimens (n = 307).

INTERVENTIONS

None.

MAIN OUTCOMES AND MEASURES

Subjects were sorted into groups of benzodiazepine-sedative regimens (midazolam and lorazepam, only lorazepam) or nonbenzodiazepine-sedation regimens. The primary outcome was ventilator-free days (VFDs). Statistical analysis was performed using multivariable linear regression and propensity-score matching.

RESULTS

Subjects receiving continuous and/or intermittent benzodiazepines had fewer VFDs compared with the nonbenzodiazepine group (median 21.0 vs. 26.7; p < 0.001). The benzodiazepine group had fewer ICU-free and hospital-free days, higher delirium scores, and a greater need for withdrawal-tapering medications. This was redemonstrated in subjects only receiving intermittent benzodiazepines as well. Younger subjects were more likely to receive benzodiazepines.

CONCLUSIONS AND RELEVANCE

Our study demonstrates an association between children receiving both continuous and intermittent benzodiazepine sedation and worse clinical outcomes. These patients have fewer VFDs and longer length of stay, higher doses of nonbenzodiazepine sedatives, and increased need for withdrawal tapering medications and antipsychotics. It is unclear in this retrospective study if the outcomes were worse because the subjects received benzodiazepines or because subjects receiving benzodiazepines were sicker and thus required benzodiazepines in their analgosedative regimen. Further investigation is warranted into the impact of benzodiazepines on patient outcomes, nonpharmacologic management of sedation, improvement in bedside assessment of analgosedation, and optimal balance between over- and under-sedation.

Regular use of opioids and dementia, cognitive measures, and neuroimaging outcomes among UK Biobank participants with chronic non-cancer pain

INTRODUCTION

We investigated the association between regular opioid use and incident dementia, neuroimaging outcomes, and cognitive measures.

METHODS

Cox regression was used to assess the association between opioid use and incident dementia among197,673 UK Biobank participants with chronic non-cancer pain. Linear and logistic regression were applied to explore the associations between opioid use and dementia-related neuroimaging and cognitive function outcomes.

RESULTS

Regular opioid use was associated with a 20% higher risk of all-cause dementia and a 49% higher risk of vascular dementia (VD) compared with those not using analgesics. Moreover, those using strong opioids had a 72% higher risk of all-cause dementia and a 155% higher risk of VD. Strong opioid use was also linked to reductions in hippocampal, white matter, and total brain volumes. Lastly, regular opioid use was associated with lower fluid intelligence.

DISCUSSION

A higher risk of dementia was observed among participants regularly using opioids, escalating with opioid strength.

HIGHLIGHTS

Regular opioid use was associated with an increased risk of all-cause dementia and VD. Those using strong opioids had a much higher risk of all-cause dementia and VD. Strong opioid use was also associated with worse neuroimaging outcomes. Regular opioid use was also associated with lower fluid intelligence.

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.

Nociceptive and non-nociceptive pain in critical care patients after cardiac surgery

AIM

To assess pain intensity during nociceptive (endotracheal suctioning) and non-nociceptive (body temperature measurement) procedures in critically ill patients after cardiac surgery.

METHODS

A descriptive and cross-sectional design was carried out. The study sample consisted of 60 critically ill patients. The study used the Critical Care Pain Observation Scale, the Behavioural Pain Scale, the Ramsey Sedation Scale and Physiological Parameter Form for data collection. Pain was assessed before, during, and 20 min after endotracheal suctioning and body temperature measurement in the study.

RESULTS

The pain scores were found to be statistically significant differences during endotracheal suctioning and body temperature measurement (p < 0.001). Pain scores were found to be higher during endotracheal suctioning, which is a nociceptive procedure (p < 0.05). Systolic and diastolic blood pressure, heart rate scores were also determined to be statistically higher during endotracheal suctioning (p < 0.05).

CONCLUSION

Pain scores and physiological parameters were found to be higher during endotracheal suctioning, a procedure known to be nociceptive. Critical care nurses are recommended to follow pain assessment protocols.

Adjuvant nefopam versus standard of care in mechanically ventilated surgical critically ill patients: A randomized, double-blind controlled study

BACKGROUND

Multimodal analgesia, through combining different classes of analgesia that target pain pathways with different mechanisms reduces opioid consumption. This study aimed to determine the impact of adjunct nefopam infusion on opiate consumption when added to standard-of-care analgesia and sedation in mechanically ventilated critically ill patients.

METHODS

This was a prospective, randomized, active control, double-blind study. Patients admitted to the ICU, being mechanically ventilated and candidates for analgesia and sedation protocols were randomized to the intervention group (n = 30) or to the control group (n = 30). The primary outcome was the cumulative dose of fentanyl in the first 24 h after inclusion. The secondary outcomes were the proportion of patients with positive pain scores, change in mean arterial pressure (MAP), heart rate (HR), ICU mortality, and others.

RESULTS

A total of 60 patients were included in the final analysis; median (Q1, Q3) cumulative fentanyl consumption mcg/24 h was significantly (p = 0.001) lower in the intervention group compared to the control group 1300 (575, 2087.5) vs. 2400 (1612.5, 2665) mcg/24 h respectively. Pain and sedation scores were comparable between the two study groups. ICU mortality was 25 (83.3%) in the intervention group vs. 20 (66.7%) in the control group (P = 0.136).

CONCLUSIONS

Nefopam was found to be an effective non-opioid option for analgesia in mechanically ventilated surgical and trauma critically ill patients, and more studies are needed to evaluate its safety.

CLINICAL TRIAL REGISTRY AND NUMBER

ClinicalTrials.gov (identifier: NCT05071352).

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.

Disempowered Warriors: Insights on Psychological Responses of ICU Patients Through a Meta-Ethnography

Objectives: to systematically examine and synthesize qualitative evidence on adult patients' psychological distress during an intensive care unit stay to inform development of interventions tailored to their needs. Method: We conducted systematic literature searches in CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Dissertations and Theses Global, and Google Scholar databases using predefined eligibility criteria. We synthesized primary qualitative research evidence using Noblit and Hare's meta-ethnographic approach. Reporting was based on the eMERGe framework. The quality of included articles was assessed by the Critical Appraisal Skills Program tool. Findings: We identified 31 primary studies from 19 countries. The studies were of moderate to high quality. Data analysis revealed five themes: "disempowerment", "altered self-identity" "fighting", "torment", and "hostile environment". One overarching theme, "the disempowered warrior", captured the perpetual tension between the need to fight for their lives and the need to succumb to the care process. Our synthesis discloses that critically ill patients perceive themselves to be in a battle for their lives; while at the same time they may feel helpless and disempowered. Conclusions: Our review revealed the tension between the need to fight for one's life and the sense of powerlessness in the intensive care unit environment. Although participants recognize the important role of healthcare workers, they desired more involvement, collaboration, control, empathy, and empowerment in the care process. These findings can inform approaches to empowering critically ill patients and managing their psychological responses. Care standards must include distress assessment and management that maximize patients' empowerment and emotional safety with the care process.

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.

Implementing Early Mobility Practices in a Respiratory Care Unit: A Quality Improvement Project

BACKGROUND

Early mobility (EM) is beneficial for critically ill patients, but adoption in intermediate care units remains limited.

LOCAL PROBLEM

At the project site, fewer than 10% of patients admitted to the respiratory care unit (RCU) engaged in EM due to clinical severity, lack of staff confidence, and limited collaboration with physical therapy.

METHODS

A pre- postimplementation quality improvement design was used to assess mobility outcomes.

INTERVENTIONS

A nurse-driven EM program was implemented in a 10-bed RCU at a tertiary center. A multidisciplinary team delivered staff education, introduced an evidence-based protocol, and addressed barriers.

RESULTS

Forty-eight patients were included in the project (22 preimplementation and 26 postimplementation). The number of physical therapy consultations increased from 36% to 73% (P= .01), with 69% of patients achieving higher discharge mobility postimplementation versus 59% preimplementation. Length of stay and mortality were unchanged.

CONCLUSIONS

EM practices improve mobility in intermediate care through education and collaboration.

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.

Evaluation of pressure-induced pain in patients with disorders of consciousness based on functional near infrared spectroscopy

Objective

This study aimed to investigate the brain's hemodynamic responses (HRO) and functional connectivity in patients with disorders of consciousness (DoC) in response to acute pressure pain stimulation using near-infrared spectroscopy (NIRS).

Methods

Patients diagnosed with DoC underwent pressure stimulation while brain activity was measured using NIRS. Changes in oxygenated hemoglobin (HbO) and deoxygenated hemoglobin (HbR) concentrations were monitored across several regions of interest (ROIs), including the primary somatosensory cortex (PSC), primary motor cortex (PMC), dorsolateral prefrontal cortex (dPFC), somatosensory association cortex (SAC), temporal gyrus (TG), and frontopolar area (FPA). Functional connectivity was assessed during pre-stimulation, stimulation, and post-stimulation phases.

Results

No significant changes in HbO or HbR concentrations were observed during the stimulation vs. baseline or stimulation vs. post-stimulation comparisons, indicating minimal activation of the targeted brain regions in response to the pressure stimulus. However, functional connectivity between key regions, particularly the PSC, PMC, and dPFC, showed significant enhancement during the stimulation phase (r > 0.9, p < 0.001), suggesting greater coordination among sensory, motor, and cognitive regions. These changes in connectivity were not accompanied by significant activation in pain-related brain areas.

Conclusion

Although pain-induced brain activation was minimal in patients with DoC, enhanced functional connectivity during pain stimulation suggests that the brain continues to process pain information through coordinated activity between regions. The findings highlight the importance of assessing functional connectivity as a potential method for evaluating pain processing in patients with DoC.

Guanfacine Use in the ICU for Management of Sedation Weaning

Recent evidence highlights the increasing utilization of guanfacine in the intensive care unit. While dexmedetomidine is a widely used sedative and anti-anxiety agent in the intensive care unit, prolonged use can lead to withdrawal effects when attempting to reduce the dosage. This has generated interest in using guanfacine to manage agitation in patients being weaned off dexmedetomidine. Clonidine has been used for dexmedetomidine weaning, but its use has been associated with adverse cardiovascular events. Some observational studies and case reports have explored the use of guanfacine and have shown its benefits and tolerability for patients taking dexmedetomidine experiencing adverse effects. Guanfacine is increasingly being used in the intensive care unit instead of clonidine and is commonly prescribed for the management of withdrawal effects. While there are limited data from observational studies, it holds promise for future clinical research and broader adoption of guanfacine in the intensive care unit.

Dexmedetomidine improves prognosis in septic patients with myocardial injury and lower APACHE IV scores: a retrospective cohort study

BACKGROUND AND OBJECTIVE

Sepsis is a major cause of mortality, particularly in patients with myocardial injury. The objective of this study was to evaluate the impact of dexmedetomidine, propofol, and midazolam on mortality and various outcomes in this population.

METHODS

A retrospective cohort study was performed using the eICU database, encompassing 2,171 septic patients with myocardial injury. Patients were categorized into single- and multiple-sedative groups. The primary endpoint was 100-day mortality, with secondary endpoints encompassing hospital stay, intensive care unit (ICU) stay, mechanical ventilation (MV), and dialysis. Statistical analysis was conducted using Cox regression, Kaplan-Meier curves, and propensity score matching.

RESULTS

Among 2,171 patients, dexmedetomidine was associated with lower 100-day mortality in patients with APACHE IV scores < 78.9, particularly in specific subgroups. In patients with APACHE IV scores ≥ 78.9, dexmedetomidine provided no mortality advantage over propofol. Midazolam was linked to higher mortality across all score ranges, and its combination with propofol resulted in worse outcomes compared to dexmedetomidine-propofol. No significant differences were found in hospital stay, ICU stay, or MV rates between the groups.

CONCLUSION

Dexmedetomidine improves prognosis in septic patients with myocardial injury, particularly in those with lower severity of illness, highlighting its potential as a preferred sedative choice in this population.

Utilization of NIRS Monitor to Compare the Regional Cerebral Oxygen Saturation Between Dexmedetomidine and Propofol Sedation in Mechanically Ventilated Critically ill Patients with Sepsis- A Prospective Randomized Control Trial

Aim & Background: Delirium frequently occurs in the acute phase of sepsis and is associated with increased ICU and hospital length of stay, duration of mechanical ventilation, and higher mortality rates. We utilized the Near-Infrared Spectroscopy monitor to measure and compare the regional cerebral oxygen saturation in mechanically ventilated patients of sepsis receiving either dexmedetomidine or propofol sedation and assessed the association between delirium and regional cerebral oxygen saturation. Methods: A single center prospective randomized control trial conducted over a period of two years, 54 patients were included, equally divided between propofol and dexmedetomidine groups. Patients received a blinded study drug, propofol (10 mg/mL) or dexmedetomidine (5 mcg/mL) via infusion pump according to randomization. Infusion rates were adjusted every 10 min based on weight-based titration tables, aiming for target sedation (RASS -2 to 0). Management components included pain monitoring using the CPOT score and delirium assessment using CAM-ICU score. Results: Dexmedetomidine group showed higher mean regional cerebral oxygen saturation as compared to propofol group (P = .036). No significant differences were found in mechanical ventilation or ICU stay durations, delirium-free days, or sedation cessation reasons. Delirium occurred in 36 patients, with lower mean regional cerebral oxygen saturation as compared to non-delirious patients. Conclusion: The dexmedetomidine group had higher regional cerebral oxygen saturation compared to the propofol group. Delirious patients showed lower cerebral oxygen saturation than non-delirious patients, suggesting a link between sedation type, cerebral oxygenation, and delirium. CTRI registration: REF/2021/11/048655 N.

Sedation Intensity in Patients with Moderate to Severe Traumatic Brain Injury in the Intensive Care Unit: A TRACK-TBI Cohort Study

BACKGROUND

Interventions to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) are multimodal but variable, including sedation-dosing strategies. This article quantifies the different sedation intensities administered in patients with moderate to severe TBI (msTBI) using the therapy intensity level (TIL) across different intensive care units (ICUs), including the use of additional ICP-lowering therapies.

METHODS

Within the prospective Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study, we performed a retrospective analysis of adult patients with msTBI admitted to an ICU for a least 5 days from seven US level 1 trauma centers who received invasive ICP monitoring and intravenous sedation. Sedation intensity was classified prospectively as one of three ordinal levels as part of the validated TIL score, which were collected at least once a day.

RESULTS

A total of 127 patients met inclusion criteria (mean age 41.6 ± 17.7 years; 20% female). The median Injury Severity Score was 27 (interquartile range 17-33), with a median admission Glasgow Coma Score of 3 (interquartile range 3-7); 104 patients had severe TBI (82%), and 23 patients had moderate TBI (18%). The sedation intensity score was highest on the first ICU day (2.69 ± 1.78), independent of patient severity. Time to reaching each sedation intensity level varied by site. Sedation level I was reached within 24 h for all sites, but sedation levels II and III were reached variably between days 1 and 3. Sedation level III was never reached by two of seven sites. The total TIL score was highest on the first ICU day, with a modest decrease for each subsequent ICU day, but there was high site-specific practice-pattern variation.

CONCLUSIONS

Intensity of sedation and other therapies for elevated ICP for patients with msTBI demonstrate large practice-pattern variation across level 1 trauma centers within the TRACK-TBI cohort study, independent of patient severity. Optimizing sedation strategies using patient-specific physiologic and pathoanatomic information may optimize patient outcomes.

The Role of Anesthesia in Sedation and Weaning From Mechanical Ventilation: A Systematic Review

Mechanical ventilation is a critical component of care in ICUs, yet its prolonged use can result in significant complications. Effective sedation strategies play a pivotal role in facilitating the discontinuation of mechanical ventilation and minimizing associated adverse outcomes. This systematic review evaluates the impact of anesthetic-based sedation methods on optimizing the process of weaning adult patients from mechanical ventilation in intensive care settings. A comprehensive literature search was conducted across major databases, including PubMed, Web of Science, Scopus, the Virtual Health Library, and Cochrane CENTRAL, up to March 10, 2024, following established systematic review guidelines. Eligible studies included randomized controlled trials and observational research comparing anesthetic agents with conventional sedation techniques, with outcomes such as weaning duration, extubation success, length of stay in the ICU, incidence of delirium, sedation quality, adverse events, and mortality. Study quality was assessed using a validated methodological checklist. Out of 1,649 records screened, five studies met the inclusion criteria. Results indicated that dexmedetomidine was associated with shorter weaning times and reduced anxiety, agitation, and delirium compared to traditional sedation. Sequential sedation protocols, particularly transitions from midazolam to dexmedetomidine, yielded improved clinical outcomes, while enteral methadone significantly reduced weaning duration compared to fentanyl. Despite higher daily costs, anesthetic agents demonstrated favorable economic outcomes due to shorter intensive care stays. These findings suggest that targeted anesthetic sedation strategies may enhance the weaning process and improve overall patient outcomes, underscoring the need for further large-scale studies to validate and standardize these approaches.

Ketamine for Critically Ill Patients with Severe Acute Brain Injury: A Systematic Review with Meta-analysis and Trial Sequential Analysis of Randomized Clinical Trials

BACKGROUND

Patients with severe acute brain injury have a high risk of a poor clinical outcome due to primary and secondary brain injury. Ketamine reportedly inhibits cortical spreading depolarization, an electrophysiological phenomenon that has been associated with secondary brain injury, making ketamine potentially attractive for patients with severe acute brain injury. The aim of this systematic review is to explore the current literature regarding ketamine for patients with severe acute brain injury.

METHODS

We systematically searched international databases for randomized clinical trials comparing ketamine by any regimen versus placebo, no intervention, or any control drug for patients with severe acute brain injury. Two authors independently reviewed and selected trials for inclusion, extracted data, assessed risk of bias, and performed analysis using Review Manager and Trial Sequential Analysis. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcomes were the proportion of participants with an unfavorable functional outcome, the proportion of participants with one or more serious adverse events, and quality of life.

RESULTS

We identified five randomized trials comparing ketamine versus sufentanil, fentanyl, other sedatives, or saline (total N = 149 participants). All outcomes were at overall high risk of bias. The proportions of participants with one or more serious adverse events did not differ between ketamine and sufentanil or fentanyl (relative risk 1.45, 95% confidence interval 0.81-2.58; very low certainty). Trial sequential analysis showed that further trials are needed.

CONCLUSIONS

The level of evidence regarding the effects of ketamine on functional outcome and serious adverse events in patients with severe acute brain injury is very low. Ketamine may markedly, modestly, or not at all affect these outcomes. Large randomized clinical trials at low risk of bias are needed.

Protocol and design of the REPOSE study: a double-blinded, randomised, placebo-controlled trial to evaluate the efficacy of suvorexant to improve postoperative sleep and reduce delirium severity in older patients undergoing non-cardiac surgery

INTRODUCTION

Postoperative delirium occurs in up to 40% of older surgical patients and has been associated with prolonged hospital stays, long-term cognitive impairment and increased 1-year postoperative mortality. Postoperative sleep disturbances may increase the risk of delirium, but studies investigating pharmacotherapies to improve postoperative sleep to prevent delirium remain limited. Suvorexant is a selective antagonist of orexin 1 and 2 receptors and is approved for insomnia pharmacotherapy by the Food and Drug Administration. It has the potential to improve postoperative sleep and reduce postoperative delirium rates, but randomised controlled trials (RCTs) are needed to determine the efficacy of postoperative suvorexant administration. The REPOSE study (reducing delirium by enhancing postoperative sleep with suvorexant) is a single-centre, randomised, double-blinded RCT that aims to evaluate the efficacy of suvorexant in increasing total sleep time (TST) and decreasing delirium severity in older patients undergoing non-cardiac surgery.

METHODS AND ANALYSIS

REPOSE will enroll 130 patients (aged ≥65 years) undergoing non-cardiac surgery with a planned postoperative inpatient stay. Participants will be randomised to receive 20 mg oral suvorexant or placebo nightly on postoperative nights 0, 1 and 2. The primary endpoint is TST on the first postoperative night, as measured using an electroencephalography headband. The secondary endpoint is peak postoperative delirium severity as measured by the 3-minute diagnostic interview for the confusion assessment method severity scores. Primary endpoint data will be analysed with a two-sample t-test using an intent-to-treat approach to compare TST on the first night that a patient received a study drug dose. Secondary and exploratory endpoint data will be analysed using two-sample t-tests between groups.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Duke Institutional Review Board (protocol #00111869). Results of the REPOSE study will be published in a peer-reviewed journal and presented at academic conferences. Trial data will be deposited in ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05733286.

The measurement properties of patient experience scales in the intensive care unit: A systematic review

BACKGROUND

As health care recipients, patients play an essential role in evaluating health care quality. Critical care patients have specific experiences that differ from those of regular patients. Existing instruments of patient experience to improve intensive care quality and their measurement properties should be defined.

AIM

To review the existing tools for measuring patient experience in the intensive care unit (ICU) and evaluate their measurement properties.

STUDY DESIGN

This is a systematic review. The PubMed, CINAHL complete, Ovid: Embase, ProQuest Health and Medical complete and Cochrane Library databases were systematically screened from their inception to 9 November 2022. All the research that reported the development and measurement properties of instruments for ICU patient-perceived care was included. The COnsensus-based Standards for the selection of health Measurement Instruments risk of bias checklist (COSMIN-RoB-Checklist) was applied to assess the psychometric indicators of the included studies.

RESULTS

The search yielded 565 documents, of which 15 scales described in 17 studies met the inclusion requirements. Of the 15 scales, seven assessed ICU patient satisfaction and eight assessed patient experience. We categorized the items from existing scales into different elements based on the National Health Service (NHS) framework. The most frequently assessed elements are 'Respect for patient-centred values, preferences and expressed needs', 'Information, communication and education' and 'Physical comfort' (93.33%, 14/15), while 'Transition and continuity' (33.33%, 5/15) is the least frequently measured. There are no studies presenting all the criteria of measurement properties outlined by the COSMIN. In the scale development part, only eight of the items met the requirements of the pilot test. Among all the measurement properties, internal consistency (80%, 12/15) and structural validity (80%, 12/15) were the two most frequently measured attributes. The three most uncommon measurement properties were retest reliability (five, 33.33%), responsiveness (four, 26.67%) and measurement error (three, 20%).

CONCLUSIONS

To enhance the quality of intensive care, it is essential to use professional scales to gather feedback from ICU patients. This systematic review examines existing tools and evaluates their measurement properties using the COSMIN-RoB-Checklist. Further research is needed to develop a strong patient experience framework and reliable psychometric properties.

RELEVANCE TO CLINICAL PRACTICE

Given the insufficient attention to critical care patients' experience, this review summarizes current patient experience scales in the intensive care unit and presents their measurement properties. This helps clinicians select more appropriate tools, develop better intensive care patient experience scales, enhance the understanding of intensive care quality and ultimately improve the excellence of work in ICUs.

Reliability and validity of the Chinese version of the functional status score for the ICU (FSS-ICU) after translation and cross-cultural adaptation

PURPOSE

The Functional Status Score for the Intensive Care Unit (FSS-ICU) is designed to assess the physical functional status of patients in ICU settings. This study aimed to translate and culturally adapt the FSS-ICU for the Chinese context and to evaluate its reliability and validity.

METHODS

Following Beaton's translation model, the original FSS-ICU was subjected to forward translation, back-translation, and synthesis. After cultural adaptation and preliminary testing, the Chinese version of the FSS-ICU was established, and then two rehabilitation therapists assessed the functional status of 51 ICU patients using this scale, evaluating its reliability and validity.

RESULTS

The Chinese version of the FSS-ICU exhibits excellent internal consistency with a Cronbach's alpha coefficient of 0.934. The inter-rater and intra-rater correlation coefficients are 0.995 and 0.997, respectively. Both item-level and scale-level content validity indices are 1.00. The FSS-ICU demonstrates good convergent validity with other physical function assessment tools (Medical Research Council Sum-Score, grip strength, the Intensive Care Unit Mobility Scale), with |rs| values all above 0.5, and satisfactory discriminant validity with non-physical function assessment indicators (body mass index, blood glucose), with |rs| values all below 0.2. Additionally, it demonstrated no ceiling or floor effects.

CONCLUSION

The Chinese FSS-ICU, demonstrating strong reliability and validity, can serve as an effective assessment tool for physical function in ICU patients.

Pharmacotherapy adjuncts for traumatic brain injury: A narrative review of evidence and considerations in the emergency department

Traumatic Brain Injury (TBI) remains a significant global health concern with significant impact on morbidity and mortality. This narrative review explores adjunctive pharmacologic agents to be employed by emergency medicine clinicians during Advanced Trauma Life Support (ATLS) in patients presenting with a TBI. Pharmacologic agents are commonly employed for the management of rapid sequence intubation and post-intubation analgosedation, hemodynamics, intracranial pressure, coagulopathy, seizure prophylaxis, and infection. This narrative review discusses current evidence and controversies to optimize adjunct pharmacotherapies during the acute management of TBI within the emergency department.

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

RATIONALE

Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes.

OBJECTIVES

The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

PANEL DESIGN

The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting.

METHODS

The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations.

RESULTS

The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium.

CONCLUSIONS

The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

Patients' and family members' dyadic experience of post-operative delirium in the intensive care unit: A qualitative study

BACKGROUND

Post-operative delirium is a complication with long-lasting consequences for both patients and their families. This is particularly true for those transferred to the intensive care unit after surgery, where the incidence of post-operative delirium is high, and patient outcomes are often poor. Despite the acknowledged role of family engagement in delirium management, previous research has mainly focused on patients, with limited exploration of the shared experiences between patients and family members.

AIM

This study aims to explore the experiences of patients and family members during episodes of post-operative delirium in the intensive care unit to better understand their unmet needs.

STUDY DESIGN

A qualitative descriptive study was conducted at a tertiary general hospital. Eighteen pairs of patients, their family members and two other family members were interviewed. Data were collected through face-to-face semi-structured interviews within the first week after patients' discharge from the intensive care unit and analysed using thematic analysis.

RESULTS

Four major themes emerged: (1) the dyadic relationship between patients and family members must be understood in the context of their shared emotional and behavioural experiences; (2) family's history may predispose patients to post-operative delirium; (3) family engagement may prevent the development of post-operative delirium; and (4) inadequate communication between health care providers and patients or families may negatively affect post-operative delirium outcomes.

CONCLUSIONS

Post-operative delirium presents significant emotional and physical challenges for both patients and their families. Addressing these challenges requires improved communication between health care providers and families, as well as strategies that emphasize early family support and collaboration in care.

RELEVANCE TO CLINICAL PRACTICE

Patients and their families should be considered a unit during post-operative delirium management, and earlier family engagement is essential. Health care systems should adapt intensive care unit practices to meet the dynamic needs of families, promoting more comprehensive support during critical care.

Incidence, characteristics and influencing factors of medical adhesive-related skin injury in the indwelling urinary catheter attachment region in critically ill patients: A longitudinal study

BACKGROUND

Medical adhesives are potentially harmful to the skin, depending on the patient's condition, the adhesive agent and the adhesive application and removal technique.

AIM

The objective of the study was to determine the incidence, characteristics and influencing factors of medical adhesive-related skin injury from the indwelling urinary catheter attachment in critically ill patients.

STUDY DESIGN

This is a longitudinal study. Data were collected in an adult intensive care unit of a university hospital, a sample size of 132. The socio-demographic and clinical data were obtained from the medical records. Skin exposed to indwelling urinary catheter adhesive tapes was examined daily by trained field researchers. The association between independent variables and medical adhesive-related skin injury was investigated by bivariate statistical analysis and multiple logistic regression.

RESULTS

The medical adhesive-related skin injury incidence was 28%. The association between independent variables and medical adhesive-related skin injury was mechanical (91.8%): skin peeling (56.7%), skin breakdown (18.9%) and tension injury or blister (16.2%); followed by irritant contact dermatitis (21.6%), with no statistical difference between the groups. More than one type of medical adhesive-related skin injury was concomitantly located in 16% of patients, with skin peeling present in all of these cases. The length of stay in the intensive care unit was an independent risk factor for medical adhesive-related skin injury (odds ratio [OR]: 1.072; 95% confidence interval [2.1-12.5]) and the Braden Scale score was a predictive factor (OR: 0.711; 95% CI: 0.3-49.3), with higher scores indicating lower risk.

CONCLUSIONS

Medical adhesive-related skin injury at the indwelling urinary catheter fixation site is a relevant problem, its mechanical aetiology is predominant and most of the risk factors are modifiable.

RELEVANCE TO CLINICAL PRACTICE

This evidence contributes to the epidemiological and clinical knowledge of medical adhesive-related skin injury at the indwelling urinary catheter attachment site, as well as to recognizing the problem as relevant and implementing preventive care.

Association of Number of Oral bacteria with Ventilator-Associated Pneumonia and Delirium in Patients in the Intensive Care Unit

OBJECTIVES

Ventilator-associated pneumonia (VAP) and delirium are major complications among patients in the intensive care unit (ICU). The impact of oral bacterial count on these conditions is not well understood. This study aimed to explore the association between oral bacterial load and the incidence of VAP and delirium in ICU patients.

METHODS

In this single-center longitudinal study, 130 patients admitted to the ICU from September 2022 to May 2023 were included. Oral bacteria counts on the tongue were quantified, and assessments of oral health using the Oral Health Assessment Tool (OHAT) and oral moisture levels were also conducted. We examined the associations between oral bacterial count, OHAT scores, and oral moisture with the incidence of VAP and delirium.

RESULTS

The incidence rates of VAP and delirium were 31.4% and 35.4%, respectively. Patients with a high oral bacterial load (≥5.0 × 107 CFU/mL) at ICU admission had a higher likelihood of developing VAP (odds ratio [OR] 7.43, 95% confidence interval [CI] 1.68-32.87) and delirium (OR 3.30, 95% CI 1.04-10.44) compared with those with lower bacterial counts (<1.0 × 107 CFU/mL). No significant associations were found between OHAT scores and oral moisture and the occurrence of VAP or delirium.

CONCLUSION

A higher oral bacterial count at ICU admission was associated with increased incidences of VAP and delirium.

A type-5 metabotropic glutamate receptor-perineuronal net axis shapes the function of cortical GABAergic interneurons in chronic pain

Parvalbumin-positive (PV+) interneurons (basket and chandelier cells) regulate the firing rate of pyramidal neurons in the cerebral cortex and play a key role in the generation of network oscillations in the cerebral cortex. A growing body of evidence suggest that cortical PV+ interneurons become overactive in chronic pain and contribute to nociceptive sensitization by inhibiting a top-down analgesic pathway. Here, we provide further support to this hypothesis showing that intracortical infusion of the GABAA receptor antagonist, bicuculline, caused analgesia in a mouse model of chronic inflammatory pain, although it reduced pain thresholds in healthy mice. We propose that mGlu5 metabotropic glutamate receptors and perineuronal nets (PNNs) shape the activity of PV+ interneurons in chronic pain, generating a form of maladaptive plasticity that enhances behavioural pain responses. mGlu5 receptors might be locally targeted by drugs activated by light delivered in cortical regions of the pain matrix, whereas the density of PNNs enwrapping PV+ interneurons might be reduced by local activation of PNN-degrading enzyme, such as type-9 matrix metalloproteinase. These strategies, which may require invasive treatments, might be beneficial in the management of severe pain which is refractory to conventional pharmacological and non-pharmacological interventions.

A bibliometric analysis on delirium in intensive care unit from 2013-2023

Background

Delirium is a common manifestation of acute brain dysfunction among patients in the Intensive Care Unit (ICU), afflicting an estimated 30-35% of this vulnerable population. The prevalence of delirium in ICU settings has catalyzed a surge in academic interest, as evidenced by a growing body of literature on the subject. This study seeks to synthesize the progress in understanding ICU delirium through a bibliometric analysis.

Methods

We conducted a comprehensive search of the Web of Science Core (WOS) Collection database for literature on ICU delirium, focusing on studies published between 2013 and 2023. Our analysis utilized two bibliometric software tools, Citespace and VOSviewer, to scrutinize the data across various dimensions, including country contributions, authorship patterns, publishing journals, key thematic terms, and other pertinent metrics, with the aim of identifying emerging trends in the field.

Results

Our search yielded a total of 1,178 publications on ICU delirium within the WOS database from January 2013 to June 2023. The United States emerged as the leading contributor in terms of published articles, with Ely, E. Wesley being the most prolific author, having published 85 articles, and "Critical Care Medicine" as the journal with the highest number of publications, totaling 105. The application of literature clustering and keyword analysis revealed that future research is poised to delve deeper into areas such as pediatric delirium, risk factors, and the development of preventive and therapeutic strategies.

Conclusion

This study employs bibliometric analysis to provide a multifaceted overview of the ICU delirium research landscape over the past decade. By examining the topic from various perspectives, we have not only mapped the current state of ICU delirium research but also illuminated potential avenues for future inquiry and areas of emphasis.

Exploring Cognitive Stimulation as a Therapy for the Prevention of Delirium in a Hospital Setting: A Narrative Review

Delirium is a highly prevalent and costly neuropsychiatric condition that affects up to 87% of critically ill hospitalized patients. It impacts various cognitive domains, including attention, memory, perception, and motor functions, with symptoms such as behavioral changes, hallucinations, slurred speech, visual impairments, and fatigue. Non-pharmacological interventions have been shown to reduce the incidence and duration of delirium, with strategies like reality orientation, cognitive stimulation, family support, and physical support. However, the scalability of these interventions in hospital settings is limited by resource constraints, low patient engagement, and the complexity of delivery. Digital technology-based cognitive stimulation offers a potential solution to these barriers, though evidence supporting its effectiveness is currently insufficient. This narrative literature review explores both traditional and novel digital technology-based cognitive stimulation techniques for the prevention and management of delirium in acute hospital settings.

Factors influencing thirst in ICU patients: A mixed methods systematic review

OBJECTIVE

To systematically review the factors influencing thirst in ICU patients, providing a reference for effective management of thirst in ICU patients and the formulation of intervention measures.

METHODS

A total of 12 electronic databases were searched from inception to July 2023. The synthesis method of JBI mixed methods research systematic review was used. The quantitative studies were analyzed by Stata17.0 and RevMan 5.3 software, and the qualitative studies by meta-aggregation.

RESULTS

A total of 13 studies were included, including 2 qualitative studies and 11 quantitative studies. The quantitative study was carried out by meta-aggregation, extracting seven categories to form two synthesized findings. Quantitative meta-analysis revealed that 11 factors, including marital status, whether to use mechanical ventilation for the first time, air leakage, mechanical ventilation mode, simplified acute physiology score, respiratory rate, mask comfort, serum sodium concentration, breathing pattern, diuretics, and vasoactive drugs, were all associated with the occurrence of thirst in ICU patients. The qualitative and quantitative results were integrated into 5 categories, namely personal characteristics and lifestyle, disease factors, treatment factors, psychological factors, and nurse factors.

CONCLUSIONS

Thirst is a prevalent and severe issue among ICU patients, and effective interventions are required to address it. Considering its various causes, managing thirst in ICU patients should involve multiple levels of intervention. Treatment-related factors contribute significantly to thirst, and these factors should be taken into consideration when developing a thirst management strategy. Personal characteristics and lifestyle, psychological factors, drug-related factors, and nursing factors should be identified and optimized as soon as possible.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals should pay attention to thirst symptoms in ICU patients and promptly take effective preventive or intervention measures based on the influencing factors.

Dexmedetomidine Improves Microcirculatory Alterations in Patients With Initial Resuscitated Septic Shock

Trial registration: Clinicaltrials.gov NCT02270281. Registered October 16, 2014.

The association between pain, analgesia, and delirium among critically ill adults: a systematic review and meta-analysis

PURPOSE

We performed a systematic review with meta-analysis examining the relationship between pain or pain medications and delirium occurence, duration, and severity.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials from inception to May 15, 2023. We included randomised or observational studies among critically ill adults, that reported data on pain or exposure to analgesics, and reported delirium presence, duration, or severity with no language or region restrictions.

PROSPERO ID

CRD42022367715. Two authors independently screened records and extracted data. Risk of bias was evaluated using Risk of Bias 2 or the Risk of Bias In Non-randomized Studies of Interventions. We pooled data using the Hartung-Knapp Sidik-Jonkmann random effects model. PRISMA was followed.

RESULTS

From 8,054 citations, 90 studies (119,230 patients) published between 2001 and 2023 were included in the systematic review. 41 studies were included in the primary meta-analysis examining prevalent delirium: seven studies evaluated pain; 12 studies evaluated fentanyl; and five studies evaluated morphine. There was a trend to association between pain and delirium occurrence (OR 2.49, 95% CI 0.98-6.30), and a significant association between pain and incident delirium (OR 3.70, 95% CI 1.73-7.93). Fentanyl (OR 2.49, 95% CI 1.45-4.27) and morphine (OR 2.13, 95% CI 1.21-3.75) were associated with delirium occurrence. Risk of bias was critical for many studies.

CONCLUSIONS

We observed an association between pain and incident delirium among critically ill adults. Exposure to morphine or fentanyl (but no other pain medications) was associated with increased risk of delirium occurrence.

Delirium due to any cause is associated with higher resource utilization in patients undergoing liver transplantation: analysis of the National Inpatient Sample

OBJECTIVE

The only curative treatment for patients with end-stage liver disease (ESLD) is liver transplantation (LT). Patients with ESLD can develop delirium due to multiple etiologies. In this study, we aimed to assess the prevalence and impact of delirium on outcomes and resource utilization among hospitalized patients undergoing LT.

METHODS

We used the National Inpatient Sample Database 2016-2020 to identify adult patients undergoing LT. Patients were stratified into two groups based on the presence of delirium. The outcomes studied were in-hospital mortality, perioperative adverse events, and resource utilization. Multivariate logistic and linear regression analysis was used to identify the relationship between delirium and outcomes.

RESULTS

Of 34 405 included patients, 4930 (14.3%) patients had delirium. Patients with delirium had a higher need for renal replacement therapy (31.7% vs. 17.6%, P  < 0.001), vasopressor support (16.8% vs. 11.1%, P  < 0.001), and mechanical ventilation (34.1% vs. 15.3%, P  < 0.001). They also had higher total perioperative complications (77.3% vs. 60.4%, P  < 0.001), longer length of stay (34.8 vs. 17. 7, P  < 0.001), and total hospitalization charges ($927 200 vs. $565 486 P  < 0.001). After multivariable analysis, patients with delirium had higher odds of perioperative complications (adjusted odds ratio: 1.54, 95% confidence interval: 1.24-1.92, P  < 0.001) and resource utilization.

CONCLUSION

Our finding suggests the need for physicians to identify and reverse delirium as soon as possible.

Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design

BACKGROUND

Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores.

METHODS

BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase.

RESULTS

Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection).

CONCLUSIONS

The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Optimizing Sedation Strategies in the Cardiac ICU: Induction, Maintenance and Weaning

PURPOSE OF REVIEW

We aim to summarize the available literature guiding tailored sedation practices for specific conditions encountered in the Cardiovascular Intensive Care Unit (CICU).

RECENT FINDINGS

Data specific for the CICU population is lacking. Preclinical data and observational studies guide sedation approaches for specific pathologies that we have used to generate a guideline for sedative choice for various scenarios. We discuss the challenges associated with extubation and highlight the importance of spontaneous breathing trials and role of non invasive ventilation. Understanding the underlying pathology and the effects of sedation and positive pressure ventilation is the base to guide induction and sedation management for patients in the CICU. There is a pressing need for further research to generate high quality clinical data to improve sedation techniques in the CICU.

Barriers to nurse-led delirium management in intensive care units: an integrative systematic review using COM-B model

BACKGROUND

Development of effective guideline for delirium management is still seeking nowadays. As nurses are in the first confrontation line for delirium, their prospective in identifying barriers are essential in developing integrated strategies and clinical guidelines.

OBJECTIVE

To explore the barriers focusing on intensive care unit (ICU) nurses' point of views to provide an evidence-based support for effective nurse-led delirium management in ICU settings.

METHODS

Whittemore and Knafl framework was recruited to build up this integrative review. PRISMA guidelines were followed to search about barriers of nurse-led delirium management. Articles published up to June 2024 in five databases; Web of Science, Scopus, PubMed, CINAHL and EMBASE using related keywords were involved. Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of articles included in this review and then reported nurse-led delirium barriers were mapped according to COM-B model.

RESULTS

Twenty-three articles out of 1,020 research articles were included in this review after carefully checked according to the exclusion and inclusion criteria. based on MMAT, 7 articles achieved 100%, 11 articles were achieved 80%, and 5 articles achieved 60%. Nurses' knowledge deficit is the most common psychological capability barriers of nurse-led delirium management, while complexity of delirium screening tools was found to be a physical capability barriers. High workload, lack of staff, lack of time, lack of documentation and lack/ shortage of guidelines were barriers mapped to physical opportunity, while communication barriers in particular patient's intubation and sedation were mapped to social opportunity barriers. Motivation was represented by addressing delirium as a major problem, self-confidence, psychological support and considering nurse's views.

CONCLUSIONS

Nurse's knowledge deficit, complexity of delirium screening tools, high workload, lack of time, lack of documentation, lack/ shortage of guideline, and impaired communication were barriers of nurse led delirium management. This study is promising in ease of application in clinical practice since delirium barriers in ICU settings were well-presented in a COM-B framework that may facilitate therapeutic strategies and related decision making.

A pharmacist's guide to mitigating sleep dysfunction and promoting good sleep in the intensive care unit

PURPOSE

To review causes, risk factors, and consequences of sleep disruption in critically ill patients; evaluate the role of nonpharmacological and pharmacological therapies for management of sleep in the intensive care unit (ICU); and discuss the role of pharmacists in implementation of sleep bundles.

SUMMARY

Critically ill patients often have disrupted sleep and circadian rhythm alterations that cause anxiety, stress, and traumatic memories. This can be caused by factors such as critical illness, environmental factors, mechanical ventilation, and medications. Methods to evaluate sleep, including polysomnography and questionnaires, have limitations that should be considered. Multicomponent sleep bundles with a focus on nonpharmacological therapy aiming to reduce nocturnal noise, light, and unnecessary patient care may improve sleep disorders in critically ill patients. While pharmacological agents are often used to facilitate sleep in critically ill patients, evidence supporting their use is often of low quality, which limits use to patients who have sleep disruption refractory to nonpharmacological therapy. Dedicated interprofessional teams are needed for implementation of sleep bundles in the ICU. Extensive pharmacotherapeutic training and participation in daily patient care rounds make pharmacists vital members of the team who can help with all components of the bundle. This narrative review discusses evidence for elements of the multicomponent sleep bundle and provides guidance on how pharmacists can help with implementation of nonpharmacological therapies and management of neuroactive medications to facilitate sleep.

CONCLUSION

Sleep bundles are necessary for patients in the ICU, and dedicated interprofessional teams that include pharmacists are vital for successful creation and implementation.

Metal Oxide Nanocatalysts for the Electrochemical Detection of Propofol

Propofol is one of the most widely used intravenous drugs for anaesthesia and sedation and is one of the most commonly used drugs in intensive care units for the sedation of mechanically ventilated patients. The correct dosage of propofol is of high importance, but there is currently a lack of suitable point-of-care techniques for determining blood propofol concentrations. Here, we present a cytochrome P450 2B6/carbon nanotube/graphene oxide/metal oxide nanocomposite sensor for discrete measurement of propofol concentration. Propofol is converted into a quinol/quinone redox couple by the enzyme and the nanocomposite enables sensitive and rapid detection. The metal oxide nanoparticles are synthesised via green synthesis and a variety of metal oxides and mixed metal oxides are investigated to determine the optimal nanocatalyst. Converting propofol into the redox couple allows for the measurement to take place over different potential ranges, enabling interference from common sources such as paracetamol and uric acid to be avoided. It was found that nanocomposites containing copper titanium oxide nanoparticles offered the best overall performance and electrodes functionalised with such nanocomposites demonstrated a limit of detection in bovine serum of 0.5 µg/mL and demonstrated a linear response over the therapeutic range of propofol with a sensitivity of 4.58 nA/μg/mL/mm2.

Dexmedetomidine-associated hypothermia in critical trauma: A case report and literature analysis

RATIONALE

Hypothermia, defined as a core body temperature below 35°C, is a common and serious complication in severe trauma patients, often worsened by hemorrhage and medical interventions. Dexmedetomidine, an α2-adrenergic agonist used for sedation in intensive care units, has known thermoregulatory effects; however, its association with hypothermia in trauma patients remains insufficiently explored.

PATIENT CONCERNS

A 40-year-old male with severe polytrauma from a motor vehicle accident presented in distress, with hypotension, tachycardia, and a baseline temperature of 35.8°C. Despite effective management, he developed profound hypothermia, with a recorded temperature dropping below 34.0°C after switching from midazolam to dexmedetomidine for sedation.

DIAGNOSES

The patient had multiple bilateral rib fractures, a right-sided pneumothorax, and grade 3 liver and grade 5 splenic injuries, along with orthopedic fractures. His Injury Severity Score signified critical trauma, increasing the risk of complications like hypothermia.

INTERVENTIONS

Following stabilization, dexmedetomidine was administered for sedation. Continuous warming interventions were initiated to address hypothermia; however, the temperature continued to decline. Suspecting dexmedetomidine's contribution, its administration was discontinued.

OUTCOMES

After stopping dexmedetomidine, the patient's temperature gradually recovered to 36.8°C within 5 hours. He demonstrated improved consciousness and stable vital signs, subsequently undergoing 2 successful orthopedic surgeries and discharging without further hypothermia-related issues.

LESSONS

This case highlights dexmedetomidine's potential to induce hypothermia in critically ill trauma patients. It stresses the importance of careful temperature monitoring and proactive thermoregulation during sedative administration in intensive care. Further research is needed to explore the prevalence and mechanisms of dexmedetomidine-associated hypothermia in trauma populations.

Current trends in pain management: A bibliometric analysis for the 1980-to-2023 period

There is currently no bibliometric analysis available regarding pain management (PM). The aim of this study was to monitor the advancement of the PM research field, demonstrate global productivity, identify the most highly cited studies, delineate collaborations between research areas and countries, and uncover new research topics and intriguing trends. A total of 16,216 articles on the subject of PM published between 1980 and 2023 were downloaded from the Web of Science database and analyzed using various bibliometric analysis methods. Trend keyword analysis, thematic evolution analysis, conceptual structure analysis, factor analysis, citation and co-citation analyses, and international collaboration analyses were conducted. The top 3 most active countries were the United States of America (n = 4021), the United Kingdom (n = 791), and Canada (n = 602). The most prolific author was Christine Miaskowski (n = 47). The most researched topics from the past to the present were chronic pain, opioids, analgesia/analgesics, cancer pain, postoperative pain, low back pain, opioid, cancer, acute pain, and self-management. Factor analysis identified key topics such as analgesia and various types of pain in the central factor, with additional subfactors including low back pain and physiotherapy, nursing, and postoperative anxiety and depression. In recent years, starting in 2020, trending research topics have shifted towards e-health, telemedicine, virtual reality, digital health, mental health, peripheral nerve blocks, erector spinae plane blocks, quadratus lumborum blocks, opioid use disorder, buprenorphine, musculoskeletal pain, COVID-19, cervicalgia, and interprofessional collaboration. In addition to Western countries with major economies in the field of PM (USA, Canada, Australia, and European countries), we identified China, India, and Turkey as research leaders. Our bibliometric analysis of 10,566 articles on PM reveals a significant growth in research, with recent trends focusing on e-health, telemedicine, virtual reality, and peripheral nerve blocks. These emerging technologies and personalized treatment approaches are shaping the future of PM.

Protective effect and mechanism of Sufentanil on acute lung injury in septic mice

This study was designed to investigate the protective effect and mechanism of Sufentanil on acute lung injury in septic mice based on network pharmacology and animal experiments, and to provide new ideas for clinical treatment. To this end, a protein-protein interaction (PPI) network for common targets was first constructed with Swiss Target Prediction Database, GeneCards Database, Draw Venn Diagram Software, STRING 11.5 Database, Cytoscape 3.10.0 Software and Metascape Database, and then key targets were subject to enrichment analysis by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) to obtain the key targets of Sufentanil for the treatment of pulmonary sepsis, and then verified by animal experiments. A sepsis model was constructed by cecal ligation and puncture (CLP) in this study, and lung tissues and bronchoalveolar lavage fluid (BALF) were taken from each group of mice. The morphological changes of lung tissues and apoptosis were observed by HE and TUNEL staining, the content of inflammatory factors in the lung tissues was detected by ELISA, and the expression of proteins, such as p-JAK2 and p-STAT3, was detected in the lung tissues by Western blotting. According to the results of network pharmacology, a total of 40 common targets of were screened out for Sufentanil and pulmonary sepsis, and GO enrichment analysis involved 1,483 biological processes (BPs), 84 cellular components (CCs) and 125 molecular functions (MFs); KEGG enrichment analysis identified 137 signaling pathways with p < 0.05 such as JAK-STAT. According to the results of animal experiments, compared with the control group, mice in the model group had severe lung tissue injury and elevated expression of relevant inflammatory factors in lung tissue. Compared with the model group, CLP + Sufentanil group showed reduced pathomorphologic lesions, lower expression of inflammatory factors and apoptosis level, as well as lower expression of p-JAK2 and p-STAT3 proteins in lung tissue. The results of animal experiments were consistent with network pharmacology. In summary, Sufentanil may improve lung injury in septic mice by inhibiting the JAK2-STAT3 signaling pathway, which provides a basis for research on the mechanism of Sufentanil on pulmonary sepsis and clinical treatment.