The Long-term Psychological Effects of Daily Sedative Interruption on Critically Ill Patients

Where the Postanesthesia Care Unit and Intensive Care Unit Meet

The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many similarities and many of the same care, technology, and care protocols apply to patients in both units. As shown by the COVID-19 pandemic, there is immense value in maintaining protocols, processes, and staffing models for the safe care of ICU patients in the PACU when ICU demands exceed capacity.

Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis

Background

Sedation is routinely administered to critically ill patients to alleviate anxiety, discomfort, and patient-ventilator asynchrony. However, it must be balanced against risks such as delirium and prolonged intensive care stays. This study aimed to investigate the effects of different levels of sedation in critically ill adults.

Methods

Systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials including critically ill adults admitted to the intensive care unit. CENTRAL, MEDLINE, Embase, LILACS, and Web of Science were searched from their inception to 13 June 2023. Risks of bias were assessed using the Cochrane risk of bias tool. Primary outcome was all-cause mortality. Aggregate data were synthesised with meta-analyses and TSA, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO: CRD42023386960.

Findings

Fifteen trials randomising 4352 patients were included, of which 13 were assessed high risk of bias. Meta-analyses comparing lighter to deeper sedation showed no evidence of a difference in all-cause mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.83-1.06; p = 0.28; 15 trials; moderate certainty evidence), serious adverse events (RR 0.99, CI 0.92-1.06; p = 0.80; 15 trials; moderate certainty evidence), or delirium (RR 1.01, 95% CI 0.94-1.09; p = 0.78; 11 trials; moderate certainty evidence). TSA showed that when assessing mortality, a relative risk reduction of 16% or more between the compared interventions could be rejected.

Interpretation

The level of sedation has not been shown to affect the risks of death, delirium, and other serious adverse events in critically ill adult patients. While TSA suggests that additional trials are unlikely to significantly change the conclusion of the meta-analyses, the certainty of evidence was moderate. This suggests a need for future high-quality studies with higher methodological rigor.

Funding

None.

Anticipating ICU discharge and long-term follow-up

PURPOSE OF REVIEW

This review aims to summarize recent literature findings on long-term outcomes following critical illness and to highlight potential strategies for preventing and managing health deterioration in survivors of critical care.

RECENT FINDINGS

A substantial number of critical care survivors experience new or exacerbated impairments in their physical, cognitive or mental health, commonly named as postintensive care syndrome (PICS). Furthermore, those who survive critical illness often face an elevated risk of adverse outcomes in the months following their hospital stay, including infections, cardiovascular events, rehospitalizations and increased mortality. These findings underscore the need for effective prevention and management of long-term health deterioration in the critical care setting. While robust evidence from well designed randomized clinical trials is limited, potential interventions encompass sedation limitation, early mobilization, delirium prevention and family presence during intensive care unit (ICU) stay, as well as multicomponent transition programs (from ICU to ward, and from hospital to home) and specialized posthospital discharge follow-up.

SUMMARY

In this review, we offer a concise overview of recent insights into the long-term outcomes of critical care survivors and advancements in the prevention and management of health deterioration after critical illness.

Verifying the Japanese version of the Healthy Aging Brain Care Monitor self-report tool for evaluating post-intensive care syndrome

BACKGROUND

Post-intensive care syndrome (PICS) requires the use of multiple assessment tools because it affects multiple domains: Cognitive, Functional, and Behavioural/Psychological. Therefore, this study translated the self-report (SR) version of the Healthy Aging Brain Care Monitor (HABC-M), spanning multiple domains, into Japanese and analysed its reliability and validity in a post-intensive care setting.

METHODS

Patients aged 20 years or older and admitted to the adult intensive care unit from August 2019 to January 2021 were included and surveyed by questionnaire. The 21-item Dementia Assessment Sheet for the Regional Comprehensive Care System was used to validate cognitive and physical aspects, and the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition were used to validate emotional aspects. Reliability was assessed by Cronbach's alpha, and congruent validity by correlation analysis. Multivariate linear regression models were used to identify potential factors for PICS.

RESULTS

A total of 104 patients (mean age: 64 ± 14 years) with 3 median mechanical ventilation days (interquartile range: 2-5) were enrolled. The Cognitive domain of the HABC-M SR was highly correlated with memory and disorientation (r = 0.77 for each), while the Functional domain was highly correlated with Instrumental Activities of Daily Living Scale (r = 0.75-0.79). The Behavioural/Psychological domain highly correlated with the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition (r = 0.75-0.76). Multivariate analysis revealed longer ICU stays associated with lower Cognitive and Functional (p = 0.03 for each) domains and longer mechanical ventilation days with a lower Behavioural/Psychological domain (p < 0.01).

CONCLUSION

The translated Japanese HABC-M SR showed high validity for assessment of the Cognitive, Functional, and Behavioural/Psychological domains of PICS. Therefore, we recommend that the Japanese version of the HABC-M SR be routinely used in the assessment of PICS.

Hospital Memories and Six-Month Psychological Outcome: A Prospective Study in Critical Ill Patients with COVID-19 Respiratory Failure

ICU survivors suffer from various long-term physical and psychological impairments. Memories from the critical illness may influence long-term psychological outcome. In particular, the role of ICU memories in COVID-19 critically ill patients is unknown. In a prospective observational study, we aimed to investigate patients' memories from the experience of critical illness and their association with a six-month psychological outcome involving quality of life evaluation. Patients' memories were investigated with ICU Memory tool, while psychological outcome and quality of life were evaluated by means of a battery of validated questionnaires during an in-person interview at the follow-up clinic. 149 adult patients were enrolled. 60% retained memories from pre-ICU days spent on a general ward, while 70% reported memories from the in-ICU period. Delusional memories (i.e., memories of facts that never happened) were reported by 69% of patients. According to a multivariable analysis, the lack of pre-ICU memories was an independent predictor of worse psychological outcomes in terms of anxiety, depression and Post-traumatic Stress Disorder (PTDS). Factors associated with long-term outcome in ICU survivors are not still fully understood and patients' experience during the day spent before ICU admission may be associated with psychological sequelae.

Electroanalysis of Ibuprofen and Its Interaction with Bovine Serum Albumin

The current work presents a sensitive, selective, cost-effective, and environmentally benign protocol for the detection of ibuprofen (IBP) by an electrochemical probe made of a glassy carbon electrode modified with Ag-ZnO and MWCNTs. Under optimized conditions, the designed sensing platform was found to sense IBP up to a 28 nM limit of detection. The interaction of IBP with bovine serum albumin (BSA) was investigated by differential pulse voltammetry. IBP-BSA binding parameters such as the binding constant and the stoichiometry of complexation were calculated. The results revealed that IBP and BSA form a single strong complex with a binding constant value of 8.7 × 10¹³. To the best of our knowledge, this is the first example that reports not only IBP detection but also its BSA complexation.

Inflammation and cardiovascular status impact midazolam pharmacokinetics in critically ill children: An observational, prospective, controlled study

Altered physiology caused by critical illness may change midazolam pharmacokinetics and thereby result in adverse reactions and outcomes in this vulnerable patient population. This study set out to determine which critical illness-related factors impact midazolam pharmacokinetics in children using population modeling. This was an observational, prospective, controlled study of children receiving IV midazolam as part of routine care. Children recruited into the study were either critically-ill receiving continuous infusions of midazolam or otherwise well, admitted for elective day-case surgery (control) who received a single IV bolus dose of midazolam. The primary outcome was to determine the population pharmacokinetics and identify covariates that influence midazolam disposition during critical illness. Thirty-five patients were recruited into the critically ill arm of the study, and 54 children into the control arm. Blood samples for assessing midazolam and 1-OH-midazolam concentrations were collected opportunistically (critically ill arm) and in pre-set time windows (control arm). Pharmacokinetic modeling demonstrated a significant change in midazolam clearance with acute inflammation (measured using C-Reactive Protein), cardio-vascular status, and weight. Simulations predict that elevated C-Reactive Protein and compromised cardiovascular function in critically ill children result in midazolam concentrations up to 10-fold higher than in healthy children. The extremely high concentrations of midazolam observed in some critically-ill children indicate that the current therapeutic dosing regimen for midazolam can lead to over-dosing. Clinicians should be aware of this risk and intensify monitoring for oversedation in such patients.

Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients.

METHODS AND ANALYSES

We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.

Quantifying the burden of the post-ICU syndrome in South Africa: A scoping review of evidence from the public health sector

BACKGROUND

The post-ICU syndrome (PICS) comprises unexpected impairments in physical, cognitive, and mental health after intensive care unit (ICU) discharge, and is associated with a diminished health-related quality of life (HRQOL). A Cochrane review recommended more research in this field from low- and middle-income countries.

OBJECTIVES

This review aims to examine the extent and nature of publications in the field of PICS in the South African (SA) public health sector. Findings of available local research are contextualised through comparison with international data.

METHODS

A comprehensive literature search strategy was employed. Inclusion criteria comprised publications enrolling adult patients following admission to SA public hospital ICUs, with the aim to study the main elements of PICS (ICU-acquired neuromuscular weakness, neurocognitive impairment, psychopathology and HRQOL).

RESULTS

Three studies investigated physical impairment, 1 study psychopathology, and 2 studies HRQOL. Recommended assessment tools were utilised. High rates of attrition were reported. Neuromuscular weakness in shorter-stay patients had recovered at 3 months. Patients who were ventilated for ≥5 days were more likely to be impaired at 6 months. The study on psychopathology reported high morbidity. The HRQOL of survivors was diminished, particularly in patients ventilated for ≥5 days.

CONCLUSION

This review found a paucity of literature evaluating PICS in the SA public health sector. The findings mirror those from international studies. Knowledge gaps pertaining to PICS in medical, surgical and HIV-positive patients in SA are evident. No publications on neurocognitive impairment or the co-occurrence of PICS elements were identified. There is considerable scope for further research in this field in SA.

CONTRIBUTIONS OF THE STUDY

This review identified the available publications investigating the post ICU syndrome (PICS) in the South African public healthcare setting. A small number of ground-breaking studies were found. Knowledge gaps in this field were identified.

Seeking the Light in Intensive Care Unit Sedation: The Optimal Sedation Strategy for Critically Ill Patients

The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep sedation (DS) may still be necessary for certain clinical scenarios, it should be limited to strict indications, such as mechanically ventilated patients with Acute Respiratory Distress Syndrome (ARDS), status epilepticus, intracranial hypertension, or those requiring target temperature management. DS, if not indicated, is associated with prolonged duration of mechanical ventilation and ICU stay, and increased mortality. Therefore, continuous monitoring of the level of sedation, especially when associated with the raw EEG data, is important to avoid unnecessary oversedation and to convert a DS strategy to light sedation as soon as possible. The approach to the management of critically ill patients is multidimensional, so targeted sedation should be considered in the context of the ABCDEF bundle, a holistic patient approach. Sedation may interfere with early mobilization and family engagement and may have an impact on delirium assessment and risk. If adequately applied, the ABCDEF bundle allows for a patient-centered, multidimensional, and multi-professional ICU care model to be achieved, with a positive impact on appropriate sedation and patient comfort, along with other important determinants of long-term patient outcomes.

Tracheostomy decreases continuous analgesia and sedation requirements

BACKGROUND

The goals of sedation in the critically ill surgical patient are to minimize pain, anxiety, and agitation without hindering cardiopulmonary function. One potential benefit of tracheostomy over endotracheal intubation is the reduction of sedation and analgesia, however, there is little data to support this supposition. We hypothesized that patients undergoing tracheostomy would have a rapid reduction in sedation and analgesia following tracheostomy.

METHODS

A retrospective review of tracheostomies performed at a single level 1 trauma center from January 2013- June 2018 was completed. An evaluation of Glasgow Coma Score (GCS), Richmond Agitation-Sedation Score (RASS), and Confusion Assessment Method for the ICU (CAM-ICU) 72 hours pre- to 72 hours post-tracheostomy was performed. The total daily dose of sedation, anxiolytic, and analgesic medications administered were recorded. Mixed-effects models were used to evaluate longitudinal drug does over time (hours).

RESULTS

468 patients included for analysis with a mean age of 58.8 ± 18.3 years. There was a significant decrease in propofol and fentanyl utilization from 24-hours pre to 24-hours post-tracheostomy in both dose and number of patients receiving these continuous intravenous medications. Similarly, total morphine milligram equivalents (MME) use and continuous midazolam significantly decreased from 24-hours pre- to 24-hours post-tracheostomy. By contrast, intermittent enteral quetiapine and methadone administration increased after tracheostomy. Importantly, RASS, GCS, and CAM scoring were also significantly improved as early as 24 hours post-tracheostomy. Total MME use was significantly elevated in patients less than 65 years of age and in male patients pre-tracheostomy compared to female patients. Patients admitted to the MICU had significantly higher MME use compared to those in the SICU pre-tracheostomy.

CONCLUSIONS

Tracheostomy allows for a rapid and significant reduction in intravenous sedation and analgesia medication utilization. Post-tracheostomy sedation can transition to intermittent enteral medications, potentially contributing to the observed improvements in postoperative mental status and agitation.

LEVEL OF EVIDENCE

Level 3, therapeutic.

Implementation of a Nurse-Driven Spontaneous Awakening Trial Protocol in a Cardiac Intensive Care Unit

BACKGROUND

In patients receiving mechanical ventilation, spontaneous awakening trials reduce morbidity and mortality when paired with spontaneous breathing trials. However, spontaneous awakening trials are not performed every day they are indicated and little is known about spontaneous awakening trial protocol use in cardiac intensive care units.

LOCAL PROBLEM

Spontaneous awakening trial completion rate at the study institution was low and no trial protocol was regularly used.

METHODS

A preintervention-postintervention retrospective cohort study was performed in adult patients with at least 24 hours of invasive mechanical ventilation in Michigan Medicine's cardiac intensive care unit. Patients with SARS-CoV-2 infection were excluded. Data included demographics, sedation, mechanical ventilation duration, and in-hospital mortality. A nurse-driven spontaneous awakening trial protocol modified for the cardiac intensive care unit was implemented in October 2020.

RESULTS

Compared with the preintervention cohort (n = 29, May through July 2020), the postintervention cohort (n = 27, October 2020 through February 2021) had a higher ratio of number of trials performed to number of days eligible for trial (0.91 vs 0.52; P < .01). Median continuous sedative infusion duration was shorter after intervention (2.3 vs 3.6 days; P = .02). Median mechanical ventilation duration (3.8 vs 4.7 days; P = .18) and mortality (41% vs 41%; P = .95) were similar between groups.

CONCLUSIONS

Spontaneous awakening trial protocol implementation led to a higher trial completion rate and a shorter duration of continuous sedative infusion. Larger studies are needed to assess the impact of protocolized spontaneous awakening trials on cardiac intensive care unit patient outcomes.

Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies

INTRODUCTION

Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery.

AREAS COVERED

First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families.

EXPERT OPINION

PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.

Early Mobilization during ECMO for Cardiopulmonary Failure in Adults: Factors Associated with Intensity of Treatment

RATIONALE

Early mobilization of ECMO-supported patients is increasingly common, but it remains unknown whether there are factors predictive of achieving higher intensity mobilization among those able to participate in physical therapy. Additionally, data regarding the safety and feasibility of early mobilization with femoral cannulation, particularly ambulation, are sparse.

OBJECTIVES

To determine whether there are factors associated with achieving out-of-bed versus in-bed physical therapy in ECMO-supported patients participating in physical therapy, and whether mobilization with femoral cannulation is safe and feasible.

METHODS

This large, single-center, retrospective study evaluated adult patients who performed active physical therapy while receiving ECMO. Mixed effects modeling was used to identify predictors of out-of-bed versus in-bed activity. Rates of mobilization with femoral cannulation and adverse events were also reported.

RESULTS

Between April 2009 and January 2020, 511 patients were supported with ECMO in a single medical intensive care unit, of whom 177 (35%) underwent active physical therapy and were included in the analysis, including 124 of 141 (88%) bridge-to-lung transplantation and 53 of 370 (14%) bridge-to-recovery. These 177 patients accounted for 2706 active physical therapy sessions, with 138 patients (78%) achieving out-of-bed activity. One hundred eight (61%) patients ambulated (1284 sessions), 34 of whom had femoral cannulae (250 sessions). Bridge-to-transplant (OR 17.2, 95% CI [4.12-72.1]), venovenous ECMO (OR 2.83, 95% CI [1.29-6.22]), later cannulation year (OR 1.65, 95% CI [1.37-1.98]) and higher Charlson Comorbidity Index (OR 1.53, 95% CI [1.07-2.19]) were associated with increased odds of achieving out-of-bed versus in-bed physical therapy, whereas invasive mechanical ventilation (OR 0.11, 95% CI [0.05-0.25]) and femoral cannulation (OR 0.19, 95% CI [0.04-0.92) were associated with decreased odds of performing out-of-bed activities. Adverse events occurred in 2% of sessions.

CONCLUSIONS

Several patient- and ECMO-related factors were associated with achieving higher intensity of early mobilization in those participating in rehabilitation. Physical therapy with femoral cannulation was safe and feasible, and complications related to mobilization were uncommon.

Long-term outcomes after critical illness: recent insights

Intensive care survivors often experience post-intensive care sequelae, which are frequently gathered together under the term “post-intensive care syndrome” (PICS). The consequences of PICS on quality of life, health-related costs and hospital readmissions are real public health problems. In the present Viewpoint, we summarize current knowledge and gaps in our understanding of PICS and approaches to management.

Prevalence and experience of fatigue in survivors of critical illness: a mixed-methods systematic review

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the extracted data into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92-59.97). They improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors' quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Impact of Sleep Deprivation in the Neurological Intensive Care Unit: A Narrative Review

Sleep is fundamental for everyday functioning, yet it is often negatively impacted in critically ill patients by the intensive care setting. With a focus on the neurological intensive care unit (NeuroICU), this narrative review summarizes methods of measuring sleep and addresses common causes of sleep disturbance in the hospital including environmental, pharmacological, and patient-related factors. The effects of sleep deprivation on the cardiovascular, pulmonary, immune, endocrine, and neuropsychological systems are discussed, with a focus on short-term deprivation in critically ill populations. Where evidence is lacking in the literature, long-term sleep deprivation studies and the effects of sleep deprivation in healthy individuals are also referenced. Lastly, strategies for the promotion of sleep in the NeuroICU are presented.

Evolving targets for sedation during mechanical ventilation

PURPOSES OF REVIEW

Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS).

RECENT FINDINGS

The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS.

SUMMARY

Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.

Exploring the pathophysiology of post-sepsis syndrome to identify therapeutic opportunities

Sepsis is a major health problem worldwide. As the number of sepsis cases increases, so does the number of sepsis survivors who suffer from “post-sepsis syndrome” after hospital discharge. This syndrome involves deficits in multiple systems, including the immune, cognitive, psychiatric, cardiovascular, and renal systems. Combined, these detrimental consequences lead to rehospitalizations, poorer quality of life, and increased mortality. Understanding the pathophysiology of these issues is crucial to develop new therapeutic opportunities to improve survival rate and quality of life of sepsis survivors. Such novel strategies include modulating the immune system and addressing mitochondrial dysfunction. A sepsis follow-up clinic may be useful to identify long-term health issues associated with post-sepsis syndrome and evaluate existing and novel strategies to improve the lives of sepsis survivors.

Dyspnea, Acute Respiratory Failure, Psychological Trauma, and Post-ICU Mental Health: A Caution and a Call for Research

Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.

The effects of sedation cessation within the first four hours of intensive care unit admission in mechanically ventilated critically ill patients - a quality improvement study

BACKGROUND

Early deep sedation in mechanically ventilated patients during the first 48 h of intensive care unit (ICU) admission can be associated with adverse outcomes. We hypothesised that moving the 'daily sedation break' process forwards, might allow earlier titration of sedation to target levels - an 'early sedation cessation' (ESC).

METHODS

We commenced a quality improvement project with the primary outcome being to stop sedation completely, within 4 h of ICU admission, in 95% of eligible patients. This was done by small, step-wise tests of change. No ethical approval was required.

FINDINGS

Between 1 February 2014 and 31 January 2018, 1787 intubated patients were included. 1052 received an 'ESC' within 4 h ('Yes'), 545 were excluded ('Excluded'), and 190 were inadvertently omitted from 'ESC' ('No'). The primary aim was achieved for the first time after 12 months. Compared to the 'Yes' group, the 'Excluded' group received 38% more propofol in the first 48 h of admission (IRR 1.38 (1.31-1.47), p<0.001), while the 'No' group received 32% more (IRR 1.32 (1.22-1.43), p<0.001). At four hours, 19·6% (12·9-27·9) of the 'Yes' group had attained a target RASS of -1, 0 or 1, compared to 13·6% (8·0-21·0) of those in the 'No' group. This proportion increased to 55·6% (46·1-64·9) at 24 h compared with 44·9% (35·6-54·4) in the 'No' group.

INTERPRETATION

Ceasing sedative infusions as soon as possible, is safe and feasible, in both medical and surgical patients, and can be implemented into 'real life' with no additional staffing.

Effect of non-sedation on post-traumatic stress and psychological health in survivors of critical illness-A substudy of the NONSEDA randomized trial

BACKGROUND

Critical illness can cause post-traumatic stress and impaired mental health. The NONSEDA trial was a Scandinavian multicenter RCT, assessing non-sedation versus sedation with a daily wake-up call during mechanical ventilation in critically ill adults. The aim of this substudy was to assess the effect of non-sedation on post-traumatic stress and mental health.

METHODS

This substudy is based on all participating patients from a single NONSEDA trial site (Kolding, Denmark). Patients were randomized to sedation or non-sedation within the first 24 hours of mechanical ventilation. Three months after ICU discharge survivors were examined by a neuropsychologist for post-traumatic stress, anxiety and depression, and filled out the SF-36 questionnaire regarding quality of life.

RESULTS

The two groups of survivors were similar with regard to baseline characteristics, length of admission and mechanical ventilation. Sedated patients received more propofol and midazolam. Doses of morphine and haloperidole were equal.

PRIMARY OUTCOME

the number of patients with post-traumatic stress disorder did not differ between groups (non-sedated: 2 patients vs sedated: 0, P = .23).

SECONDARY OUTCOMES

there were no differences between groups in Beck Anxiety Index (median, non-sedated: 0 vs sedated: 0, P = .62), Beck Depression Index (median, non-sedated: 7 vs sedated: 4, P = .24), SF-36 mental component score (mean, non-sedated: 46.7 vs sedated: 47.5, P = .73) or number of patients with symptoms of post-traumatic stress (8 in both groups, P = .89).

CONCLUSION

Levels of PTSD, anxiety and depression and quality of life regarding mental health were similar between the non-sedated and sedated group.

Physical Function Trajectories in Survivors of Acute Respiratory Failure

RATIONALE

Survivorship from critical illness has improved; however, factors mediating the functional recovery of persons experiencing a critical illness remain incompletely understood.

OBJECTIVES

To identify groups of acute respiratory failure (ARF) survivors with similar patterns of physical function recovery after discharge and to determine the characteristics associated with group membership in each physical function trajectory group.

METHODS

We performed a secondary analysis of a randomized controlled trial, using group-based trajectory modeling to identify distinct subgroups of patients with similar physical function recovery patterns after ARF. Chi-square tests and one-way analysis of variance were used to determine which variables were associated with trajectory membership. A multinomial logistic regression analysis was performed to identify variables jointly associated with trajectory group membership.

RESULTS

A total of 260 patients enrolled in a trial evaluating standardized rehabilitation therapy in patients with ARF and discharged alive (NCT00976833) were included in this analysis. Physical function was quantified using the Short Physical Performance Battery at hospital discharge and 2, 4, and 6 months after enrollment. Latent class analysis of the Short Physical Performance Battery scores identified four trajectory groups. These groups differ in both the degree and rate of physical function recovery. A multinomial logistic regression analysis was performed using covariates that have been previously identified in the literature as influencing recovery after critical illness. By multinomial logistic regression, age (P < 0.001), female sex (P = 0.001), intensive care unit (ICU) length of stay (LOS) (P = 0.003), and continuous intravenous sedation days (P = 0.004) were the variables that jointly influenced trajectory group membership. Participants in the trajectory demonstrating most rapid and complete functional recovery consisted of younger females with fewer continuous sedation days and a shorter LOS. The participant trajectory that failed to functionally recover consisted of older patients with greater sedation time and the longest LOS.

CONCLUSIONS

We identified distinct trajectories of physical function recovery after critical illness. Age, sex, continuous sedation time, and ICU length of stay impact the trajectory of functional recovery after critical illness. Further examination of these groups may assist in clinical trial design to tailor interventions to specific subgroups.

Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD following ICU.

KEY LEARNING AIMS

To recognise PTSD following admissions to intensive care units (ICUs).To understand how the ICU experience can lead to PTSD development.To understand how Ehlers and Clark's (2000) cognitive model of PTSD can be applied to post-ICU PTSD.To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.

Building Resiliency in Dyads of Patients Admitted to the Neuroscience Intensive Care Unit and Their Family Caregivers: Lessons Learned From William and Laura

Sustaining a stroke, regardless of its severity, is a life-changing and often traumatizing event that can lead to chronic depression, anxiety, and posttraumatic stress in both survivors and their family caregivers. Psychosocial interventions for emotional distress after stroke are limited, have emphasized psychoeducation rather than skills, treatment of chronic emotional distress rather than prevention, and have targeted either the patient or their caregiver without accounting for the context of their interpersonal relationship. Here we discuss "Recovering Together," a novel program for dyads of patients with stroke and their family caregivers aimed at preventing chronic emotional distress by using cognitive behavioral principles to teach resiliency and interpersonal communication skills beginning during hospitalization in a neuroscience intensive care unit and continuing after discharge via telehealth. We illustrate the case of a pilot dyad enrolled in the Recovering Together program, to showcase how patients and caregivers can engage with and benefit from it. This dyad's experience suggests that Recovering Together is credible, feasible, and useful. The potential dyadic benefit of this intervention lies not only in providing the opportunity to optimize recovery and prevent long-term emotional distress, but also in creating the space to come together as a pair and make meaning from critical illness.

The neural correlates of mindfulness-induced depression reduction in adults with autism spectrum disorder: A pilot study

Adults with autism spectrum disorder (ASD) experience high rates of depression and anxiety, and some evidence suggests mindfulness-based stress reduction (MBSR) is effective in reducing these symptoms. However, the neural mechanisms of symptom alleviation, and benefit of MBSR beyond education/support groups are unknown. Maladaptive forms of self-reflection are linked to ASD, depression, and anxiety. In this pilot study, we hypothesized (a) MBSR would reduce depression and anxiety in adults with ASD and (b) a mechanism of symptom alleviation would be increased blood oxygen level-dependent signal in neural self-reflection hubs. Twenty-eight adults were randomly assigned to an 8-week MBSR group (n = 15) or a support group (n = 13) that met for the same amount of time with relaxation education materials. Based on previous self-reflection literature in ASD, regions of interest (ROIs) were middle cingulate cortex (MCC) and ventromedial prefrontal cortex (vmPFC). Only the MBSR group demonstrated significant reductions in depression, and neither group significantly changed in anxiety. Only the MBSR group increased activity of right MCC during self-reflection, and the increase correlated with depression alleviation. There were no changes in vmPFC for the MBSR group or either ROI for the support/education group. Seed-to-voxel connectivity analysis revealed that only the MBSR group increased functional connectivity between right MCC and pre/postcentral gyrus, suggesting MBSR may increase primary sensorimotor input to higher order cognitive brain regions. Taken together, MBSR may be effective for reducing depression in adults with ASD, and the neural mechanism may be increasing frontal circuit involvement during self-directed thought.

Paralytics, Sedation, and Steroids in Acute Respiratory Distress Syndrome

In this article, we discuss the literature behind the use of paralytics, sedation, and steroids in acute respiratory distress syndrome. We explore the controversies and discuss the recommendations for the use of these agents.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

The ABCDEF Bundle for the Respiratory Therapist

The clinical approach to the critically ill patient has changed dramatically over the last several decades from one of deep sedation to that of mobilizing patients on mechanical ventilation and limiting sedation. The ABCDEF bundle is a multidisciplinary, evidence-based approach to the holistic management of critically ill patients that aims to optimize patient recovery, minimize iatrogenesis, and engage and empower the patient and family during their hospitalization. To achieve this goal, the bundle includes assessments for pain, delirium, and readiness to stop sedation and to start spontaneous breathing trials. It also encourages early mobilization of the patient, avoidance of restraints, and engagement with the family in bedside rounds to improve communication. Performance of this bundle reduces mortality, ventilator days, intensive care readmissions, delirium, coma, restraint use, and discharge to facilities in a dose-dependent manner. The respiratory therapist, as a key member of the critical care team, is essential to the implementation, performance, and success of the ABCDEF bundle. This review aims to describe each component of the ABCDEF bundle, provide evidence for both the impact of individual interventions as well as the entire bundle, and detail the importance of this multidisciplinary approach to the care of the critically ill patient.

Implementation of strategies to liberate patients from mechanical ventilation in a tertiary-level medical center

BACKGROUND

Considerable discrepancies have been observed in the implementation of strategies to liberate patients from mechanical ventilation. The aim of this study was to describe critical care nurses' knowledge of and self-reported and documented adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate and evaluate how these practices differ between patients with and without ventilator-associated pneumonia and between survivors and nonsurvivors.

METHODS

The survey was conducted in a tertiary-level hospital in Finland from October 2014 to June 2015. Actual adherence was evaluated based on documentation of performed practices.

RESULTS

A total of 86 critical care nurses responded to the survey, and 85 patients were followed. The levels of knowledge of and self-reported adherence to low tidal ventilation were 84.5% and 90.2%, respectively, and the median tidal volume was at a target level in 74.4% of patients. Regarding daily sedation interruption, the level of knowledge was 85.7%, the level of self-reported adherence was 77.3%, and documented adherence was 33.3%. The levels of knowledge and self-reported adherence regarding spontaneous breathing trials were 61.9% and 71.6%, respectively. Adherence to lung-protective ventilation, daily sedation interruption, and daily assessment of readiness to extubate did not differ between patients with (n = 20) and without (n = 65) ventilator-associated pneumonia and between survivors (n = 55) and nonsurvivors (n = 30).

CONCLUSIONS

Lung-protective ventilation, including low-tidal ventilation and avoidance of high inspiratory plateau pressures, was well implemented and adhered to. The levels of knowledge and self-reported adherence versus documented adherence regarding daily sedation interruption and spontaneous breathing trial demonstrated insufficient implementation of local guidelines. There was no effect on the outcome.

The Effect of Sedation on Long-Term Psychological Impairment After Extracorporeal Life Support

OBJECTIVE

This retrospective study aimed to identify the association between long-term psychological impairment and total sedation received during venovenous extracorporeal life support (VV-ECLS) for acute respiratory failure (ARF).

DESIGN

This observational retrospective study compared characteristics between patients with and without long-term psychological morbidity at long-term follow-up after VV-ECLS for ARF.

SETTING

A single institutional experience in a quaternary referral academic medical center in the United States.

PATIENTS

Patients who received VV-ECLS for ARF between January 1, 2015, and April 1, 2017, were identified for selection. Presence of psychiatric morbidity (anxiety and/or depression) was determined with the Hospital Anxiety and Depression Subscale battery at long-term follow-up.

INTERVENTIONS

No interventions were made during this retrospective observational study.

MEASUREMENTS AND MAIN RESULTS

A total of 42 patients (21 male, 21 female, median age 49 [interquartile range {IQR} 36-57]) completed a telephone interview a median of 14.6 (IQR 7.7-21.1) months after ECLS decannulation. Cohorts were defined as possessing any psychiatric morbidity (anxiety and/or depression) as defined by the Hospital Anxiety and Depression Subscale battery (n = 22 [52%]) versus no psychiatric morbidity (n = 20 [48%]) at long-term follow-up. Patients who had clinically significant psychiatric morbidity received a median of 15.0 (IQR 11.0-17.0) days of continuous intravenous sedation compared with patients who had no psychiatric morbidity, who received a median of 10.0 (IQR 6.5-13.5) days of intravenous sedation; (p = 0.02).

CONCLUSIONS

This retrospective analysis identified a significant association between the presence of long-term post-VV-ECLS psychiatric symptoms and the total number of days of intravenous sedation.

Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis

Background

As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge.

Methods

We searched MEDLINE, EMBASE, LILACS, Web of Science, PsycNET, and Scopus databases from inception to September 2018. We included observational studies assessing the prevalence of PTSD symptoms in adult critical care survivors. Two reviewers independently screened studies and extracted data. Studies were meta-analyzed using a random-effects model to estimate PTSD symptom prevalence at different time points, also estimating confidence and prediction intervals. Subgroup and meta-regression analyses were performed to explore heterogeneity. Risk of bias was assessed using the Joanna Briggs Institute tool and the GRADE approach.

Results

Of 13,267 studies retrieved, 48 were included in this review. Overall prevalence of PTSD symptoms was 19.83% (95% confidence interval [CI], 16.72–23.13; I² = 90%, low quality of evidence). Prevalence varied widely across studies, with a wide range of expected prevalence (from 3.70 to 43.73% in 95% of settings). Point prevalence estimates were 15.93% (95% CI, 11.15–21.35; I² = 90%; 17 studies), 16.80% (95% CI, 13.74–20.09; I² = 66%; 13 studies), 18.96% (95% CI, 14.28–24.12; I² = 92%; 13 studies), and 20.21% (95% CI, 13.79–27.44; I² = 58%; 7 studies) at 3, 6, 12, and > 12 months after discharge, respectively.

Conclusion

PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge. ICU survivors should be screened for PTSD symptoms and cared for accordingly, given the potential negative impact of PTSD on quality of life. In addition, action should be taken to further explore the causal relationship between ICU stay and PTSD, as well as to propose early measures to prevent PTSD in this population.

Trial registration

PROSPERO, CRD42017075124, Registered 6 December 2017.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2489-3) contains supplementary material, which is available to authorized users.

Preventing Chronic Emotional Distress in Stroke Survivors and Their Informal Caregivers

BACKGROUND/OBJECTIVE

Chronic emotional distress (e.g., depression, anxiety, post-traumatic stress) is common after stroke and interdependent between patients and their informal caregivers. We measured stroke survivors', caregivers', and neurocritical care nurses' views of primary drivers of distress during the stroke experience, and needs and preferences for the structure, topics, mode of delivery, and timing of an intervention to promote emotional recovery.

METHODS

We conducted semi-structured interviews with 24 patient-caregiver dyads within the Neuroscience Intensive Care Unit (Neuro-ICU). Additionally, we conducted two focus groups with 15 nurses. Interviews and focus groups were audio-recorded, transcribed, and coded using NVivo 11 (QSR International) software.

RESULTS AND CONCLUSIONS

The challenges and impacts of stroke most commonly reported by dyads were: uncertainty about future health, fear of recurrent strokes, negative emotions, and role changes post-stroke. Dyads and nurses agreed that resiliency skills such as mindfulness/focusing on the present, problem solving, gratitude/optimism, self-care, interpersonal communication and developing a supportive team of family, friends, and medical staff are beneficial to optimize recovery. The potential barrier to intervention delivery was accessibility, due to challenges of time and travel to appointments. Participants agreed that starting the intervention at hospitalization and continuing via live video after discharge is an ideal delivery modality. Stroke survivors, caregivers, and Neuro-ICU nurses believe that a resiliency skills-based intervention to prevent chronic emotional distress is necessary and urgent. This qualitative study provides valuable information on the challenges faced by dyads, intervention topics to prioritize, and strategies to maximize feasibility, acceptability, and effect.

International Analgesia, Sedation, and Delirium Practices: a prospective cohort study

Background

While understanding of critical illness and delirium continue to evolve, the impact on clinical practice is often unknown and delayed. Our purpose was to provide insight into practice changes by characterizing analgesia and sedation usage and occurrence of delirium in different years and international regions.

Methods

We performed a retrospective analysis of two multicenter, international, prospective cohort studies. Mechanically ventilated adults were followed for up to 28 days in 2010 and 2016. Proportion of days utilizing sedation, analgesia, and performance of a spontaneous awakening trial (SAT), and occurrence of delirium were described for each year and region and compared between years.

Results

A total of 14,281 patients from 6 international regions were analyzed. Proportion of days utilizing analgesia and sedation increased from 2010 to 2016 (p < 0.001 for each). Benzodiazepine use decreased in every region but remained the most common sedative in Africa, Asia, and Latin America. Performance of SATs increased overall, driven mostly by the US/Canada region (24 to 35% of days with sedation, p < 0.001). Any delirium during admission increased from 7 to 8% of patients overall and doubled in the US/Canada region (17 to 36%, p < 0.001).

Conclusions

Analgesia and sedation practices varied widely across international regions and significantly changed over time. Opportunities for improvement in care include increasing delirium monitoring, performing SATs, and decreasing use of sedation, particularly benzodiazepines.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0379-z) contains supplementary material, which is available to authorized users.

The Use of Volatile Anesthetics as Sedatives for Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) remains to pose a high morbidity and mortality without any targeted therapies. Sedation, usually given intravenously, is an important part of clinical practice in intensive care unit (ICU), and the effect of sedatives on patients’ outcomes has been studied intensively. Although volatile anesthetics are not routine sedatives in ICU, preclinical and clinical studies suggested their potential benefit in pulmonary pathophysiology. This review will summarize the current knowledge of ARDS and the role of volatile anesthetic sedation in this setting from both clinical and mechanistic standpoints. In addition, we will review the infrastructure to use volatile anesthetics.

Awake and fully mobile patients on cardiac extracorporeal life support

Early mobilization of critically ill patients is increasingly being recognized as not only safe and feasible, but also as a potential means of optimizing outcomes in the intensive care unit (ICU). With the rapidly expanding use of extracorporeal life support (ECLS) for severe cardiopulmonary failure, there is a growing interest in the application of early mobilization to this patient population, which has been shown to be safe and feasible in select patient populations. However, some patients receiving ECLS support may benefit more than others. For instance, early mobilization may be particularly beneficial in patients awaiting heart or lung transplantation, as maintenance of physical conditioning may be an important component of a patient's transplant candidacy. The ability to engage critically ill patients in active physical therapy and early mobilization necessarily involves minimization of sedation and is often further facilitated by a strategy that favors endotracheal extubation. Whether an awake, extubated and mobile strategy can be applied in any given patient is often dictated by the severity of the underlying disease and the amount of extracorporeal support required. Additionally, whether this approach is superior to usual care, which patients might benefit or be harmed, and which patient characteristics are most likely to predict success of this strategy, are areas of ongoing investigation.

Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial

Background

Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure.

Methods

After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board’s recommendation to consult with the Department of Health and Human Services’ Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation.

Results

Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework.

Conclusions

The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials.

Trial registration

ClinicalTrials.gov, Identifiers: Pilot trial: NCT00142766; Retrospectively registerd on 2 September 2005.

Cluster randomized trial: NCT00814099. Registered on 23 December 2008.

Long-Term Outcomes after Protocolized Sedation versus Usual Care in Ventilated Pediatric Patients

RATIONALE

Whether a nurse-implemented goal-directed sedation protocol resulting in more awake yet calm intubated children affects postdischarge functional status, health-related quality of life, or risk for post-traumatic stress disorder is unknown.

OBJECTIVES

To compare postdischarge outcomes in children with acute respiratory failure cluster-randomized to a sedation protocol or usual care.

METHODS

A stratified random sample of 1,360 patients from 31 centers in the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) trial was assessed by mail, electronically, and/or telephone 6 months after ICU discharge. In treatment group comparisons, we controlled for age, baseline functional status, and severity of illness.

MEASUREMENTS AND MAIN RESULTS

We used the Pediatric Overall Performance Category and the Pediatric Cerebral Performance Category to characterize functional status, the Infant and Toddler Quality of Life Questionnaire (97-item full-length version) (<2 yr old) or Pediatric Quality of Life Inventory (≥2 yr old), and the Child Post-traumatic Stress Disorder Symptom Scale (≥8 yr old and developmentally able). Functional status worsened from baseline to follow-up in 20%. Decline in functional status did not differ by treatment arm and was more common among those with baseline impairment than those with baseline normal function (27 vs. 18%; P < 0.001). There were no significant differences in health-related quality of life total scores by treatment arm. Scores indicating risk of post-traumatic stress disorder occurred in 30%, with no difference between treatment arms.

CONCLUSIONS

A sedation strategy that allows patients to be more awake and exposes them to fewer sedative and analgesic medications produces no long-term harm. However, postdischarge morbidity after acute respiratory failure is common. Clinical trial registered with www.clinicaltrials.gov (NCT00814099).

Limiting sedation for patients with acute respiratory distress syndrome - time to wake up

PURPOSE OF REVIEW

Critically ill patients with acute respiratory distress syndrome (ARDS) may require sedation in their clinical care. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. This review discusses the current evidence for sedation management in patients with ARDS.

RECENT FINDINGS

Deep sedation strategies should be avoided in the care of patients with ARDS because deep sedation has been associated with increased time on mechanical ventilation, longer ICU and hospital length of stay, and higher mortality in critically ill patients. Adoption of protocol-based, light-sedation strategies is preferred and improves patient outcomes. Although the optimal sedative agent for ARDS patients is unclear, benzodiazepines should be avoided because of associations with oversedation, delirium, prolonged ICU and hospital length of stay, and increased mortality. Minimizing sedation in patients with ARDS facilitates early mobilization and early discharge from the ICU, potentially aiding in recovery from critical illness. Strategies to optimize ventilation in ARDS patients, such as low tidal volume ventilation and high positive end-expiratory pressure can be employed without deep sedation; however, deep sedation is required if patients receive neuromuscular blockade, which may benefit some ARDS patients. Knowledge gaps persist as to whether or not prone positioning and extracorporeal membrane oxygenation can be tolerated with light sedation.

SUMMARY

Current evidence supports the use of protocol-based, light-sedation strategies in critically ill patients with ARDS. Further research into sedation management specifically in ARDS populations is needed.

"Sedation is tricky": A qualitative content analysis of nurses' perceptions of sedation administration in mechanically ventilated intensive care unit patients

INTRODUCTION

Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients.

METHODS

This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses' perceptions of current sedation administration practices.

FINDINGS

Multiple factors guided sedation administration practices, including individual patient needs, nurses' synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing.

CONCLUSIONS

Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients.

The Effect of Daily Sedation-Weaning Application on Morbidity and Mortality in Intensive Care Unit Patients

Background/aims

Sedation is one of the most important components of intensive care unit (ICU) in patients who are mechanically ventilated at intensive care conditions. As a result of sedation and analgesia in the intensive care unit, the patient is to be awakened a comfortable and easy process. The aim of the study is to demonstrate the effects of day-time sedation interruptions in intensive care patients.

Material and methods

We made a retrospective review of 100 patients who were monitored, mechanically ventilated and treated at our intensive care unit between January 2008 and January 2013. Patients were divided into two groups, including Group P (continuous infusion of sedative agent) and Group D (daily sedation interruptions - daily recovery).

Demographics, mechanical ventilation time, stay at intensive care unit, hospitalization period, time of first weaning, success of weaning, ventilator-related pneumonia (VRP), total doses of drugs, re-intubation frequency, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) scores and mortality rates of patients were compared. Ramsay Sedation Score (RSS) was used to evaluate the level of sedation. Considering that ideal sedation level is "3" with RSS, RSS < 3 is considered as mild sedation, while RSS > 3 is considered as deep sedation.

Results

There was no difference between demographics of patients. Mechanical ventilation period was significantly longer in Group P than Group D (p < 0.001). When stay at ICU unit was considered, ICU stay was significantly longer in Group P than Group D (p < 0.001). No statistically significant difference was found between two groups with respect to hospitalization period. In inter-group comparison, time to start first weaning was significantly late in Group P than Group D (p < 0.05). There was no difference between groups in terms of frequency of success of weaning and mortality rate (p > 0.05). In inter-group comparison the frequency of reintubation viewed in Group D was significantly less than in Group P (p < 0.05). Considering development of VRP, it was significantly more common in Group P in comparison with Group D (p < 0.05). No statistically significant difference was found between groups in terms of doses of sedative agents (p > 0.05). Considering doses of opioid analgesics, the total dose of fentanyl was significantly higher in Group P than Group D (p = 0.04), while no difference was found for doses of morphine (p > 0.05). Again, no statistical difference was found in doses of muscle relaxant agents (p > 0.05).

Conclusion

It was observed that the sedation technique with daily interruption is superior to continuous infusion of sedatives. Accordingly, we believe that daily weaning will make positive contributions to patients who are mechanically ventilated at intensive care unit.

Enhancing Recovery From Sepsis: A Review

Importance

Survival from sepsis has improved in recent years, resulting in an increasing number of patients who have survived sepsis treatment. Current sepsis guidelines do not provide guidance on posthospital care or recovery.

Observations

Each year, more than 19 million individuals develop sepsis, defined as a life-threatening acute organ dysfunction secondary to infection. Approximately 14 million survive to hospital discharge and their prognosis varies. Half of patients recover, one-third die during the following year, and one-sixth have severe persistent impairments. Impairments include development of an average of 1 to 2 new functional limitations (eg, inability to bathe or dress independently), a 3-fold increase in prevalence of moderate to severe cognitive impairment (from 6.1% before hospitalization to 16.7% after hospitalization), and a high prevalence of mental health problems, including anxiety (32% of patients who survive), depression (29%), or posttraumatic stress disorder (44%). About 40% of patients are rehospitalized within 90 days of discharge, often for conditions that are potentially treatable in the outpatient setting, such as infection (11.9%) and exacerbation of heart failure (5.5%). Compared with patients hospitalized for other diagnoses, those who survive sepsis (11.9%) are at increased risk of recurrent infection than matched patients (8.0%) matched patients (P < .001), acute renal failure (3.3% vs 1.2%, P < .001), and new cardiovascular events (adjusted hazard ratio [HR] range, 1.1-1.4). Reasons for deterioration of health after sepsis are multifactorial and include accelerated progression of preexisting chronic conditions, residual organ damage, and impaired immune function. Characteristics associated with complications after hospital discharge for sepsis treatment are not fully understood but include both poorer presepsis health status, characteristics of the acute septic episode (eg, severity of infection, host response to infection), and quality of hospital treatment (eg, timeliness of initial sepsis care, avoidance of treatment-related harms). Although there is a paucity of clinical trial evidence to support specific postdischarge rehabilitation treatment, experts recommend referral to physical therapy to improve exercise capacity, strength, and independent completion of activities of daily living. This recommendation is supported by an observational study involving 30 000 sepsis survivors that found that referral to rehabilitation within 90 days was associated with lower risk of 10-year mortality compared with propensity-matched controls (adjusted HR, 0.94; 95% CI, 0.92-0.97, P < .001).

Conclusions and Relevance

In the months after hospital discharge for sepsis, management should focus on (1) identifying new physical, mental, and cognitive problems and referring for appropriate treatment, (2) reviewing and adjusting long-term medications, and (3) evaluating for treatable conditions that commonly result in hospitalization, such as infection, heart failure, renal failure, and aspiration. For patients with poor or declining health prior to sepsis who experience further deterioration after sepsis, it may be appropriate to focus on palliation of symptoms.

Improving Long-Term Outcomes After Sepsis

Although acute survival from sepsis has improved in recent years, a large fraction of sepsis survivors experience poor long-term outcomes. In particular, sepsis survivors have high rates of weakness, cognitive impairment, hospital readmission, and late death. To improve long-term outcomes, in-hospital care should focus on early, effective treatment of sepsis; minimization of delirium, distress, and immobility; and preparing patients for hospital discharge. In the posthospital setting, medical care should focus on addressing new disability and preventing medical deterioration, providing a sustained period out of the hospital to allow for recovery.