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Martucci KT. Neuroimaging of opioid effects in humans across conditions of acute administration, chronic pain therapy, and opioid use disorder. Trends Neurosci 2024:S0166-2236(24)00063-8. [PMID: 38762362 DOI: 10.1016/j.tins.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/01/2024] [Accepted: 04/21/2024] [Indexed: 05/20/2024]
Abstract
Evidence of central nervous system (CNS) exogenous opioid effects in humans has been primarily gained through neuroimaging of three participant populations: individuals after acute opioid administration, those with opioid use disorder (OUD), and those with chronic pain receiving opioid therapy. In both the brain and spinal cord, opioids alter processes of pain, cognition, and reward. Opioid-related CNS effects may persist and accumulate with longer opioid use duration. Meanwhile, opioid-induced benefits versus risks to brain health remain unclear. This review article highlights recent accumulating evidence for how exogenous opioids impact the CNS in humans. While investigation of CNS opioid effects has remained largely disparate across contexts of opioid acute administration, OUD, and chronic pain opioid therapy, integration across these contexts may enable advancement toward effective interventions.
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Affiliation(s)
- Katherine T Martucci
- Human Affect and Pain Neuroscience Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Center for Translational Pain Medicine, Duke University School of Medicine, Durham, NC, USA; Duke Institute for Brain Sciences, Duke University, Durham, NC, USA.
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Liu T, Zhao H, Zhao X, Qu M. Comparison of Remimazolam and Propofol on Postoperative Delirium in Elderly Patients Undergoing Radical Resection of Colon Cancer: A Single-Center Prospective Randomized Controlled Study. Med Sci Monit 2024; 30:e943784. [PMID: 38594896 PMCID: PMC11017933 DOI: 10.12659/msm.943784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 02/21/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND We compared the effect of remimazolam and propofol intravenous anesthesia on postoperative delirium in elderly patients undergoing laparoscopic radical resection of colon cancer. MATERIAL AND METHODS One hundred patients undergoing elective radical operation of colon cancer under general anesthesia were divided into a remimazolam group (group R) and propofol group (group P) by a random number table method. During anesthesia induction and maintenance, group R was intravenously injected with remimazolam to exert sedation; however, in group P, propofol was injected instead of remimazolam. The occurrence of postoperative delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit scale and postoperative pain was assessed with the visual analogue score (VAS). The primary outcome measures were the incidence and duration of delirium within 7 days following surgery. Secondary outcome measures included postoperative VAS scores, intraoperative anesthetic drug dosage, and adverse reactions, including nausea and vomiting, hypoxemia, and respiratory depression. RESULTS There was no significant difference in baseline data between the 2 groups (P>0.05). There was no statistically significant difference in the incidence and duration of postoperative delirium between the 2 groups (P>0.05). There were no significant differences in VAS scores, remifentanil consumption, and adverse reactions, including nausea and vomiting, hypoxemia, and respiratory depression between the 2 groups (P>0.05). CONCLUSIONS In elderly patients undergoing radical colon cancer surgery, remimazolam administration did not improve or aggravate the incidence and duration of delirium, compared with propofol.
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Zhou X, Mao W, Zhao L, Zhu H, Chen L, Xie Y, Li L. Effect of thoracic paravertebral nerve block on delirium in patients after video-assisted thoracoscopic surgery: a systematic review and meta-analysis of randomized controlled trials. Front Neurol 2024; 15:1347991. [PMID: 38660094 PMCID: PMC11039859 DOI: 10.3389/fneur.2024.1347991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024] Open
Abstract
Background Nerve blocks are widely used in various surgeries to alleviate postoperative pain and promote recovery. However, the impact of nerve block on delirium remains contentious. This study aims to systematically evaluate the influence of Thoracic Paravertebral Nerve Block (TPVB) on the incidence of delirium in patients post Video-Assisted Thoracoscopic Surgery (VATS). Methods We conducted a systematic search of PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases in June 2023. The search strategy combined free-text and Medical Subject Headings (MeSH) terms, including perioperative cognitive dysfunction, delirium, postoperative cognitive dysfunction, paravertebral nerve block, thoracic surgery, lung surgery, pulmonary surgery, and esophageal/esophagus surgery. We utilized a random effects model for the analysis and synthesis of effect sizes. Results We included a total of 9 RCTs involving 1,123 participants in our study. In VATS, TPVB significantly reduced the incidence of delirium on postoperative day three (log(OR): -0.62, 95% CI [-1.05, -0.18], p = 0.01, I2 = 0.00%) and postoperative day seven (log(OR): -0.94, 95% CI [-1.39, -0.49], p < 0.001, I2 = 0.00%). Additionally, our study indicates the effectiveness of TPVB in postoperative pain relief (g: -0.82, 95% CI [-1.15, -0.49], p < 0.001, I2 = 72.60%). Conclusion The comprehensive results suggest that in patients undergoing VATS, TPVB significantly reduces the incidence of delirium and notably diminishes pain scores. Systematic review registration CRD42023435528. https://www.crd.york.ac.uk/PROSPERO.
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Affiliation(s)
| | | | | | | | | | | | - Linji Li
- Department of Anesthesiology, The Second Clinical Medical College, North Sichuan Medical College, Nanchong Central Hospital, Nanchong, China
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Komninou MA, Egli S, Rossi A, Ernst J, Krauthammer M, Schuepbach RA, Delgado M, Bartussek J. Former smoking, but not active smoking, is associated with delirium in postoperative ICU patients: a matched case-control study. Front Psychiatry 2024; 15:1347071. [PMID: 38559401 PMCID: PMC10979642 DOI: 10.3389/fpsyt.2024.1347071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To examine the relationship between current and former smoking and the occurrence of delirium in surgical Intensive Care Unit (ICU) patients. Methods We conducted a single center, case-control study involving 244 delirious and 251 non-delirious patients that were admitted to our ICU between 2018 and 2022. Using propensity score analysis, we obtained 115 pairs of delirious and non-delirious patients matched for age and Simplified Acute Physiology Score II (SAPS II). Both groups of patients were further stratified into non-smokers, active smokers and former smokers, and logistic regression was performed to further investigate potential confounders. Results Our study revealed a significant association between former smoking and the incidence of delirium in ICU patients, both in unmatched (adjusted odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.83) and matched cohorts (OR: 3.0, CI: 1.53-5.89). Active smoking did not demonstrate a significant difference in delirium incidence compared to non-smokers (unmatched OR = 0.98, CI: 0.62-1.53, matched OR = 1.05, CI: 0.55-2.0). Logistic regression analysis of the matched group confirmed former smoking as an independent risk factor for delirium, irrespective of other variables like surgical history (p = 0.010). Notably, also respiratory and vascular surgeries were associated with increased odds of delirium (respiratory: OR: 4.13, CI: 1.73-9.83; vascular: OR: 2.18, CI: 1.03-4.59). Medication analysis showed that while Ketamine and Midazolam usage did not significantly correlate with delirium, Morphine use was linked to a decreased likelihood (OR: 0.27, 95% CI: 0.13-0.55). Discussion Nicotine's complex neuropharmacological impact on the brain is still not fully understood, especially its short-term and long-term implications for critically ill patients. Although our retrospective study cannot establish causality, our findings suggest that smoking may induce structural changes in the brain, potentially heightening the risk of postoperative delirium. Intriguingly, this effect seems to be obscured in active smokers, potentially due to the recognized neuroprotective properties of nicotine. Our results motivate future prospective studies, the results of which hold the potential to substantially impact risk assessment procedures for surgeries.
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Affiliation(s)
- Maria Angeliki Komninou
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Simon Egli
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Aurelio Rossi
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Jutta Ernst
- Center of Clinical Nursing Sciences, University Hospital Zurich, Zurich, Switzerland
| | - Michael Krauthammer
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Reto A. Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Marcos Delgado
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department of Anesthesia and Intensive Care Medicine, Tiefenau Hospital, Insel Group. University of Bern, Bern, Switzerland
| | - Jan Bartussek
- Institute of Intensive Care Medicine, University Hospital Zurich & University of Zurich, Zurich, Switzerland
- Department for Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
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Casamento A, Ghosh A, Hui V, Neto AS. Hospital and long-term opioid use according to analgosedation with fentanyl vs. morphine: Findings from the ANALGESIC trial. CRIT CARE RESUSC 2024; 26:24-31. [PMID: 38690190 PMCID: PMC11056422 DOI: 10.1016/j.ccrj.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 05/02/2024]
Abstract
Objectives Opioid use disorder is extremely common. Many long-term opioid users will have their first exposure to opioids in hospitals. We aimed to compare long-term opioid use in patients who received fentanyl vs. morphine analgosedation and assess ICU related risk factors for long-term opioid use. Design We performed a post-hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation in mechanically ventilated patients. Setting Two mixed, adult, university affiliated intensive care units in Melbourne, Australia. Participants Adult patients who were mechanically ventilated and received fentanyl or morphine for analgosedation in the ANALGESIC trial. Main outcome measures We assessed discharge and long-term (90-365 days) opioid use in opioid-naïve patients at hospital admission according to the agent used for analgosedation. Results We studied 477 patients (242 fentanyl and 235 morphine). There were no differences between discharge (16.5% vs. 14.0%, p = 0.45), 90-180 day post-discharge use (3.7% vs 2.1%, p = 0.30) or 180-365 day post-discharge use (3.4% vs 1.3%, p = 0.22) of opioids when comparing those patients who received fentanyl vs. those who received morphine. Surgical diagnosis and one chronic condition were associated with increased hospital discharge prescription of opioids, whereas increasing APACHE II score was associated with decreased discharge prescription. No ICU-related factors were associated with long-term opioid use. Conclusions Approximately one in seven opioid-naïve patients who receive analgosedation for mechanical ventilation in ICU will be prescribed opioid medications at hospital discharge. There was no difference in discharge prescription or long-term use of opioids depending on whether fentanyl or morphine was used for analgosedation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Victor Hui
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Casamento A, Ghosh A, Neto AS, Young M, Lawrence M, Taplin C, Eastwood GM, Bellomo R. The effect of age on clinical dose equivalency of fentanyl and morphine analgosedation in mechanically ventilated patients: Findings from the ANALGESIC trial. Aust Crit Care 2024; 37:236-243. [PMID: 37574387 DOI: 10.1016/j.aucc.2023.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/18/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND The dose equivalency of fentanyl vs. morphine is widely considered to be approximately 1:100. However, little is known about the effect of age on this ratio when these agents are used as infusions for analgosedation. OBJECTIVES To assess the impact of age on the clinical dose equivalency of fentanyl and morphine when used as infusions for analgosedation in mechanically ventilated intensive care unit patients. METHODS We performed a post hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation. Dose and analgosedative clinical equivalency of fentanyl and morphine were assessed by age and by using different body-size descriptors. RESULTS We studied 663 patients (338 fentanyl, 325 morphine). Median (interquartile range) hourly dose of fentanyl and morphine were 58.1 (40.0-89.2) mcg and 3400 (2200-5000) mcg, respectively. The ratio of total dose of fentanyl:morphine was 1:93 in the 18- to 29-year-old group and 1:25 in the ≥80-year-old group (p = 0.015), respectively, with fentanyl becoming relatively less clinically effective as age increased. This effect was also seen when comparing dosing by different body-size descriptors with the strongest age-related change when using body surface area as body-size descriptor (p = 0.009). CONCLUSION The analgosedative clinical dose equivalency of fentanyl vs. morphine is heterogeneous when used as infusions for analgosedation, with fentanyl becoming relatively less clinically effective as age increases. This information can help guide prescription of these agents during transition from one agent to the other in critically ill patients.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia
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Latronico N, Eikermann M, Ely EW, Needham DM. Improving management of ARDS: uniting acute management and long-term recovery. Crit Care 2024; 28:58. [PMID: 38395902 PMCID: PMC10893724 DOI: 10.1186/s13054-024-04810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors.
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Affiliation(s)
- Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
- Department of Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy.
- "Alessandra BONO" Interdepartmental University Research Center on Long-Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy.
| | - M Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, USA
- Klinik fur Anästhesiologie und Intensivmedizin, Universitaet Duisburg-Essen, Essen, Germany
| | - E W Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Tarrell A, Giles L, Smith B, Traube C, Watt K. Delirium in the NICU. J Perinatol 2024; 44:157-163. [PMID: 37684547 DOI: 10.1038/s41372-023-01767-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023]
Abstract
Delirium in the NICU is an underrecognized phenomenon in infants who are often complex and critically ill. The current understanding of NICU delirium is developing and can be informed by adult and pediatric literature. The NICU population faces many potential risk factors for delirium, including young age, developmental delay, mechanical ventilation, severe illness, and surgery. There are no diagnostic tools specific to infants. The mainstay of delirium treatment is to treat the underlying cause, address modifiable risk factors, and supportive care. This review will summarize current knowledge and areas where more research is needed.
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Affiliation(s)
- Ariel Tarrell
- University of Utah School of Medicine, Department of Pediatrics, Division of Neonatology, Salt Lake City, UT, USA.
| | - Lisa Giles
- University of Utah School of Medicine, Department of Pediatrics, Division of Pediatric Behavioral Health and Psychiatry, Salt Lake City, UT, USA
| | - Brian Smith
- Duke University Medical Center, Division of Neonatology, Durham, NC, USA
| | - Chani Traube
- Weill Cornell Medical College, Division of Pediatric Critical Care Medicine, New York, NY, USA
| | - Kevin Watt
- University of Utah School of Medicine, Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Clinical Pharmacology, Salt Lake City, UT, USA
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Leong AY, Burry L, Fiest KM, Doig CJ, Niven DJ. Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol. BMJ Open 2024; 14:e078395. [PMID: 38262636 PMCID: PMC10806641 DOI: 10.1136/bmjopen-2023-078395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults. METHODS AND ANALYSIS MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values. ETHICS AND DISSEMINATION Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals. PROSPERO REGISTRATION NUMBER The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).
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Affiliation(s)
- Amanda Y Leong
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Pharmacy Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanebaum Research Institute and Departments of Pharmacy and Medicine, Mount Sinai Hospital, Sinai Health, Toronto, Ontario, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher J Doig
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Sharif S, Munshi L, Burry L, Mehta S, Gray S, Chaudhuri D, Duffett M, Siemieniuk RA, Rochwerg B. Ketamine sedation in the intensive care unit: a survey of Canadian intensivists. Can J Anaesth 2024; 71:118-126. [PMID: 37884773 DOI: 10.1007/s12630-023-02608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE We sought to understand the beliefs and practices of Canadian intensivists regarding their use of ketamine as a sedative in critically ill patients and to gauge their interest in a randomized controlled trial (RCT) examining its use in the intensive care unit (ICU). METHODS We designed and validated an electronic self-administered survey examining the use of ketamine as a sedative infusion for ICU patients. We surveyed 400 physician members of the Canadian Critical Care Society (CCCS) via email between February and April 2022 and sent three reminders at two-week intervals. The survey was redistributed in January 2023 to improve the response rate. RESULTS We received 87/400 (22%) completed questionnaires. Most respondents reported they rarely use ketamine as a continuous infusion for sedation or analgesia in the ICU (52/87, 58%). Physicians reported the following conditions would make them more likely to use ketamine: asthma exacerbation (73/87, 82%), tolerance to opioids (68/87, 77%), status epilepticus (44/87, 50%), and severe acute respiratory distress syndrome (33/87, 38%). Concern for side-effects that limited respondents' use of ketamine include adverse psychotropic effects (61/87, 69%) and delirium (47/87, 53%). The majority of respondents agreed there is need for an RCT to evaluate ketamine as a sedative infusion in the ICU (62/87, 71%). CONCLUSION This survey of Canadian intensivists illustrates that use of ketamine as a continuous infusion for sedation is limited, and is at least partly driven by concerns of adverse psychotropic effects. Canadian physicians endorse the need for a trial investigating the safety and efficacy of ketamine as a sedative for critically ill patients.
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Affiliation(s)
- Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Hamilton General Hospital, 237 Barton St East, 2nd Floor McMaster Wing, Room 252, Hamilton, ON, L8L 2X2, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Sara Gray
- Division of Emergency Medicine, and the Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Network, University of Toronto, Toronto, ON, Canada
| | - Dipayan Chaudhuri
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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11
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Wu TT, Vernooij LM, Duprey MS, Zaal IJ, Gélinas C, Devlin JW, Slooter AJC. Relationship Between Pain and Delirium in Critically Ill Adults. Crit Care Explor 2023; 5:e1012. [PMID: 38053750 PMCID: PMC10695586 DOI: 10.1097/cce.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVES Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium. DESIGN Prospective cohort study. SETTING A 32-bed academic medical-surgical ICU. PATIENTS Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated. RESULTS Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose. CONCLUSIONS After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.
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Affiliation(s)
- Ting Ting Wu
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Matthew S Duprey
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Irene J Zaal
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Intensive Care Medicine, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
- Centre for Nursing Research, Jewish General Hospital, Montreal, QC, Canada
| | - John W Devlin
- Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Psychiatry, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
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12
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Zabawa L, Choubey AS, Drake B, Mayo J, Mejia A. Dementia and Hip Fractures: A Comprehensive Review of Management Approaches. JBJS Rev 2023; 11:01874474-202312000-00002. [PMID: 38079493 DOI: 10.2106/jbjs.rvw.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.
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Affiliation(s)
- Luke Zabawa
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Apurva S Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Joel Mayo
- University of Illinois College of Medicine, Chicago, Illinois
| | - Alfonso Mejia
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
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13
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McKenzie C, Skrobik Y, Devlin JW. Scheduled intravenous opioids. Intensive Care Med 2023; 49:1541-1543. [PMID: 37922011 PMCID: PMC10709215 DOI: 10.1007/s00134-023-07254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Cathrine McKenzie
- National Institute of Health and Social Care Research (NIHR) Biomedical Research Centre, School of Medicine, Perioperative and Critical Care Theme and NIHR Applied Research Collaborative (ARC), University of Southampton, Wessex, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton NHS Foundation Trust, Southampton, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmacy, King's College London, London, UK
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John W Devlin
- School of Pharmacy and Pharmaceutical Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA, USA.
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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14
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Wang XD, Zhou Y, Guo ZJ, Jiao L, Han F, Yang XD. Efficacy of ultrasound guided superior laryngeal nerve block on sedation for delayed extubation in maxillofacial surgery with free flap reconstruction. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101589. [PMID: 37543208 DOI: 10.1016/j.jormas.2023.101589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/30/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Superior laryngeal nerve block (SLNB) is a regional anesthesia technique for addressing airway response. However, SLNB on the efficacy of sedation in patients with delayed extubation is unknown, particularly for maxillofacial surgery (MS). The aim of the study was to assess whether ultrasound guided (UG) SLNB reduces the incidence of moderate to severe cough for delayed extubation in MS with free flap reconstruction. METHODS 60 patients were randomly assigned to the GEA group (control group) and the SLNB group (UG-SLNB postoperatively, study group). During the initial two postoperative hours, the incidence of moderate and severe cough, agitation, and the number of patients requiring rescue propofol and flurbiprofen were recorded. Additionally, the time spent under the target level of sedation, postoperative hemodynamics, and the total does of propofol during the postoperative 24 h were recorded. RESULTS The data showed the SLNB group had a significantly lower incidence of moderate to severe cough and agitation (p < 0.05), and a longer sedation time (p < 0.05). The number of patients required rescue propofol and flurbiprofen, as well as the hemodynamic changes, were significantly different between the two groups (p < 0.05). CONCLUSION The use of UG-SLNB is associated with reduced incidence of postoperative cough. Moreover, SLNB can enhance the efficacy of postoperative sedation with need of fewer agents postoperatively. CLINICAL TRIAL REGISTRATION ChiCTR2000039982.
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Affiliation(s)
- Xiao-Dong Wang
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Yi Zhou
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Zi-Jian Guo
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Liang Jiao
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Fang Han
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Xu-Dong Yang
- Department of Anesthesiology, Peking University School and Hospital of Stomatology, Beijing, PR China.
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15
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Devlin JW. Buprenorphine: Its Emerging Role as a Strategy to Reduce Full Opioid Agonist Use in the ICU. Crit Care Med 2023; 51:1817-1819. [PMID: 37971335 DOI: 10.1097/ccm.0000000000006052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- John W Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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16
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Bracht H, Meiser A, Wallenborn J, Guenther U, Kogelmann KM, Faltlhauser A, Schwarzkopf K, Soukup J, Becher T, Kellner P, Knafelj R, Sackey P, Bellgardt M. ICU- and ventilator-free days with isoflurane or propofol as a primary sedative - A post- hoc analysis of a randomized controlled trial. J Crit Care 2023; 78:154350. [PMID: 37327507 DOI: 10.1016/j.jcrc.2023.154350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE To compare ICU-free (ICU-FD) and ventilator-free days (VFD) in the 30 days after randomization in patients that received isoflurane or propofol without receiving the other sedative. MATERIALS AND METHODS A recent randomized controlled trial (RCT) compared inhaled isoflurane via the Sedaconda® anaesthetic conserving device (ACD) with intravenous propofol for up to 54 h (Meiser et al. 2021). After end of study treatment, continued sedation was locally determined. Patients were eligible for this post-hoc analysis only if they had available 30-day follow-up data and never converted to the other drug in the 30 days from randomization. Data on ventilator use, ICU stay, concomitant sedative use, renal replacement therapy (RRT) and mortality were collected. RESULTS Sixty-nine of 150 patients randomized to isoflurane and 109 of 151 patients randomized to propofol were eligible. After adjusting for potential confounders, the isoflurane group had more ICU-FD than the propofol group (17.3 vs 13.8 days, p = 0.028). VFD for the isoflurane and propofol groups were 19.8 and 18.5 respectively (p = 0.454). Other sedatives were used more frequently (p < 0.0001) and RRT started in a greater proportion of patients in the propofol group (p = 0.011). CONCLUSIONS Isoflurane via the ACD was not associated with more VFD but with more ICU-FD and less concomitant sedative use.
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Affiliation(s)
- Hendrik Bracht
- University Hospital Bielefeld Bethel, Campus Bielefeld-Bethel, Department of Anesthesiology, Intensive Care, Emergency and Transfusion Medicine and Pain Therapy, Bielefeld, Germany.
| | - Andreas Meiser
- University Hospital Homburg/Saar, Department of Anaesthesiology, Homburg, Germany
| | - Jan Wallenborn
- HELIOS Klinikum Aue, Department of Anaesthesiology, AUE, Germany
| | - Ulf Guenther
- University Clinic of Anaesthesiology, Klinikum Oldenburg, Oldenburg Research Network Emergency- and Intensive Care Medicine (OFNI), Faculty VI - Medicine and Health Sciences, Carl v. Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Andreas Faltlhauser
- Central Emergency Care Unit and Admission HDU, Wels General Hospital, Wels, Austria
| | - Konrad Schwarzkopf
- Department of Anesthesia and Intensive Care, Klinikum Saarbruecken, Saarbruecken, Germany
| | - Jens Soukup
- Department of Anaesthesiology, Intensive Care Medicine and Palliative Care Medicine, Carl-Thiem-Hospital, Cottbus, Germany
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Patrick Kellner
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Rihard Knafelj
- University Medical Center Ljubljana, Klinični oddelek za interno Intenzivno Medicine, KOIIM, Ljubljana, Slovenia
| | - Peter Sackey
- Department of Physiology and Pharmacology, Unit of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Martin Bellgardt
- Department of Anaesthesiology and intensive Care Medicine, St. Josef-Hospital, University Hospital of Ruhr-University of Bochum, Germany
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17
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Nagata C, Hata M, Miyazaki Y, Masuda H, Wada T, Kimura T, Fujii M, Sakurai Y, Matsubara Y, Yoshida K, Miyagawa S, Ikeda M, Ueno T. Development of postoperative delirium prediction models in patients undergoing cardiovascular surgery using machine learning algorithms. Sci Rep 2023; 13:21090. [PMID: 38036664 PMCID: PMC10689441 DOI: 10.1038/s41598-023-48418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
Associations between delirium and postoperative adverse events in cardiovascular surgery have been reported and the preoperative identification of high-risk patients of delirium is needed to implement focused interventions. We aimed to develop and validate machine learning models to predict post-cardiovascular surgery delirium. Patients aged ≥ 40 years who underwent cardiovascular surgery at a single hospital were prospectively enrolled. Preoperative and intraoperative factors were assessed. Each patient was evaluated for postoperative delirium 7 days after surgery. We developed machine learning models using the Bernoulli naive Bayes, Support vector machine, Random forest, Extra-trees, and XGBoost algorithms. Stratified fivefold cross-validation was performed for each developed model. Of the 87 patients, 24 (27.6%) developed postoperative delirium. Age, use of psychotropic drugs, cognitive function (Mini-Cog < 4), index of activities of daily living (Barthel Index < 100), history of stroke or cerebral hemorrhage, and eGFR (estimated glomerular filtration rate) < 60 were selected to develop delirium prediction models. The Extra-trees model had the best area under the receiver operating characteristic curve (0.76 [standard deviation 0.11]; sensitivity: 0.63; specificity: 0.78). XGBoost showed the highest sensitivity (AUROC, 0.75 [0.07]; sensitivity: 0.67; specificity: 0.79). Machine learning algorithms could predict post-cardiovascular delirium using preoperative data.Trial registration: UMIN-CTR (ID; UMIN000049390).
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Affiliation(s)
- Chie Nagata
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Masahiro Hata
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuki Miyazaki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirotada Masuda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tamiki Wada
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tasuku Kimura
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Makoto Fujii
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yasushi Sakurai
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Yasuko Matsubara
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Kiyoshi Yoshida
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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18
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Vizzacchi BA, Pezzini TR, de Souza JM, Caruso P, Nassar AP. Long-term mortality of critically ill patients with cancer and delirium who survived to discharge: a retrospective cohort study. Can J Anaesth 2023; 70:1789-1796. [PMID: 37610551 DOI: 10.1007/s12630-023-02538-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 08/24/2023] Open
Abstract
PURPOSE Delirium is common in critically ill patients and has been associated with lower short-term survival; however, its association with long-term survival has been scarcely evaluated and few studies have shown divergent results. METHODS We conducted a retrospective cohort study of adult patients with cancer admitted to the intensive care unit (ICU) and discharged from hospital from January 2015 to December 2018. We considered delirium present if the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) result was positive. We assessed the association between delirium during ICU stay and long-term mortality (up to three years after discharge). We also assessed the association between delirium type (hypoactive, hyperactive, and mixed) with long-term mortality. RESULTS We included 3,079 patients. Of these, 430 (14%) were considered delirious at some point during their ICU stay. Delirium was associated with one-year mortality after hospital discharge (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.36 to 1.83) after adjustment for potential confounders, but not with one to three year-mortality (HR, 0.92; 95% CI, 0.61 to 1.39). Hypoactive and mixed delirium were associated with one-year mortality (HR, 1.77; 95% CI, 1.46 to 2.14 and HR, 1.56; 95% CI, 1.21 to 2.00, respectively), but none of the delirium motor types was associated with one to three-year mortality. CONCLUSIONS We observed that delirium during ICU stay was associated with increased one-year mortality, but was not with mortality after one year. This association was observed in hypoactive and mixed delirium types but not with hyperactive delirium.
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Affiliation(s)
- Barbara A Vizzacchi
- Rehabilitation and Palliative Care Supervision, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Tainara R Pezzini
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Jessica M de Souza
- Scientific Research Program for Undergraduates, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Pedro Caruso
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Antonio Paulo Nassar
- Intensive Care Unit, A. C. Camargo Cancer Center, São Paulo, SP, Brazil.
- Program to Support Institutional Development of the Brazil's Unified Health System, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
- , Rua Professor Antonio Prudente, 211, 6th Floor, São Paulo, CEP 01509-001, Brazil.
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Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
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Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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20
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Sun X, Zhang M, Zhang H, Fei X, Bai G, Li C. Efficacy and safety of ciprofol for long-term sedation in patients receiving mechanical ventilation in ICUs: a prospective, single-center, double-blind, randomized controlled protocol. Front Pharmacol 2023; 14:1235709. [PMID: 37670942 PMCID: PMC10475522 DOI: 10.3389/fphar.2023.1235709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023] Open
Abstract
Introduction: Critically ill patients who receive mechanical ventilation after endotracheal intubation commonly experience discomfort and pressure. The major sedative drugs that are currently used in clinical practice present with many complications, such as hypotension, bradycardia, and respiratory depression. Ciprofol (HSK3486), which is a newly developed structural analog of propofol, is a short-acting gamma-aminobutyric acid (GABA) receptor agonist, and its mechanism of action is sedation or anesthesia by enhancing GABA-mediated chloride influx. The high efficacy of ciprofol for short-term sedation is comparable to that of propofol, and it has a relatively low incidence of adverse effects and high level of safety, which has been confirmed by multiple clinical studies. However, few studies have examined its safety and efficacy for long-term sedation. The purpose of the study is to evaluate the efficacy and safety of ciprofol for long-term sedation in mechanically ventilated patients. Methods: A prospective, single-center, double-blind, randomized, propofol-controlled, non-inferiority trial is proposed. The study will enroll 112 mechanically ventilated patients hospitalized in the intensive care unit (ICU) of the Shanghai Fourth People's Hospital affiliated with Tongji University based on the inclusion and exclusion criteria of the study, and randomly assign them to a group sedated with either ciprofol or propofol. The primary outcome is the percentage of time spent under target sedation, and secondary outcomes include drug dose, number of cases requiring additional dextrometropine, incidence of systolic blood pressure <80 or >180 mmHg, incidence of diastolic blood pressure <50 or >100 mmHg, incidence of heart rate <50 beats per minute (bpm) or >120 bpm, inflammatory indicators, blood lipid levels, liver and kidney functions, nutritional indicators, ventilator-free days within the 7-day period after enrollment, 28-day mortality, ICU stay duration, and hospitalization costs. Discussion: We hypothesize that the efficacy and safety of ciprofol for long-term sedation in mechanically ventilated ICU patients will not be inferior to that of propofol. Trial registration: Chinese Clinical Trials Registry identifier ChiCTR2200066951.
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Affiliation(s)
| | | | | | | | - Gang Bai
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Cheng Li
- Department of Anesthesiology and Perioperative Medicine, Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
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21
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Gutowski M, Klimkiewicz J, Michałowski A, Ordak M, Możański M, Lubas A. ICU Delirium Is Associated with Cardiovascular Burden and Higher Mortality in Patients with Severe COVID-19 Pneumonia. J Clin Med 2023; 12:5049. [PMID: 37568451 PMCID: PMC10420272 DOI: 10.3390/jcm12155049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/13/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND COVID-19 can lead to functional disorders and complications, e.g., pulmonary, thromboembolic, and neurological. The neuro-invasive potential of SARS-CoV-2 may result in acute brain malfunction, which manifests as delirium as a symptom. Delirium is a risk factor for death among patients hospitalized due to critical illness. Taking the above into consideration, the authors investigated risk factors for delirium in COVID-19 patients and its influence on outcomes. METHODS A total of 335 patients hospitalized due to severe forms of COVID-19 were enrolled in the study. Data were collected from medical charts. RESULTS Delirium occurred among 21.5% of patients. In the delirium group, mortality was significantly higher compared to non-delirium patients (59.7% vs. 28.5%; p < 0.001). Delirium increased the risk of death, with an OR of 3.71 (95% CI 2.16-6.89; p < 0.001). Age, chronic atrial fibrillation, elevated INR, urea, and procalcitonin, as well as decreased phosphates, appeared to be the independent risk factors for delirium occurrence. CONCLUSIONS Delirium occurrence in patients with severe COVID-19 significantly increases the risk of death and is associated with a cardiovascular burden. Hypophosphatemia is a promising reversible factor to reduce mortality in this group of patients. However, larger studies are essential in this area.
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Affiliation(s)
- Mateusz Gutowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Jakub Klimkiewicz
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Andrzej Michałowski
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Michal Ordak
- Department of Pharmacotherapy and Pharmaceutical Care, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Marcin Możański
- Department of Anesthesiology and Intensive Care, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland; (J.K.); (A.M.); (M.M.)
| | - Arkadiusz Lubas
- Department of Internal Diseases Nephrology and Dialysis, Military Institute of Medicine—National Research Institute, 04-141 Warsaw, Poland;
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22
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Ma CH, Tworek KB, Kung JY, Kilcommons S, Wheeler K, Parker A, Senaratne J, Macintyre E, Sligl W, Karvellas CJ, Zampieri FG, Kutsogiannis DJ, Basmaji J, Lewis K, Chaudhuri D, Sharif S, Rewa OG, Rochwerg B, Bagshaw SM, Lau VI. Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials. Crit Care Explor 2023; 5:e0938. [PMID: 37396930 PMCID: PMC10309528 DOI: 10.1097/cce.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients. DATA SOURCES We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. STUDY SELECTION Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. DATA EXTRACTION In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. CONCLUSIONS In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.
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Affiliation(s)
- Chen Hsiang Ma
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kimberly B Tworek
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janice Y Kung
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Sebastian Kilcommons
- Department of Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Kathleen Wheeler
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Arabesque Parker
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Erika Macintyre
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Wendy Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Constantine J Karvellas
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Demetrios Jim Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
| | - Kimberley Lewis
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sameer Sharif
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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23
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Rengel KF, Mart MF, Wilson JE, Ely EW. Thinking Clearly: The History of Brain Dysfunction in Critical Illness. Crit Care Clin 2023; 39:465-477. [PMID: 37230551 DOI: 10.1016/j.ccc.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37213, USA.
| | - Matthew F Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA; Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Vanderbilt Psychiatric Hospital, 1601 23rd Avenue South, Nashville, TN 37212, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4th Floor, Nashville, TN 37203, USA; Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Health System, VA Tennessee Valley Healthcare system, 1310 24th Avenue South, Nashville, TN 37212, USA
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24
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Casamento A, Neto AS, Lawrence M, Chudleigh L, Browne E, Taplin C, Eastwood GM, Bellomo R. Delirium in ventilated patients receiving fentanyl and morphine for Analgosedation: Findings from the ANALGESIC trial. J Crit Care 2023; 77:154343. [PMID: 37235918 DOI: 10.1016/j.jcrc.2023.154343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/30/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE The differential effect of fentanyl vs. morphine analgosedation on the development of hospital inpatient delirium in patients receiving mechanical ventilation is unknown. We aimed to compare the incidence of coding for delirium and antipsychotic medication use in patients treated with fentanyl vs. morphine in the ANALGESIC trial. MATERIALS AND METHODS We obtained data from a cluster randomized, cluster crossover trial of fentanyl vs. morphine for analgosedation on antipsychotic use and coding diagnosis of delirium and compared these outcomes according to treatment allocation. We assessed the relationship between opioid choice and dose, hospital inpatient delirium, and outcomes. RESULTS Among 681 patients enrolled in the ANALGESIC trial, 160/344 (46.5%) in the fentanyl group vs. 132/337 (39.1%) in the morphine group (absolute difference 7.34% [95% CI -0.9 to 14.78]; RR: 1.19 [95%CI 1.00 to 1.41]; p = 0.053) developed hospital inpatient delirium. Antipsychotic use was linearly related to opioid dose. Antipsychotic use was not associated with increased mortality. CONCLUSIONS Fentanyl is associated with a higher incidence of hospital inpatient delirium when used for analgosedation compared with morphine, and the dose of opioid is linearly related to the need for antipsychotic medication administration. The role of analgosedation in promoting delirium requires further investigation.
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Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Northern Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Laura Chudleigh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Emma Browne
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Data Analytics Research & Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia.
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25
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Glaser I. [Polypharmacy and Delirium in the Elderly]. PRAXIS 2023; 112:335-339. [PMID: 37042399 DOI: 10.1024/1661-8157/a003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Polypharmacy and Delirium in the Elderly Abstract: Delirium often occurs in elderly hospitalized patients. Multimorbidity and associated polypharmacy are known risk factors for developing delirium. Moreover, delirium itself often leads to the prescription of additional drugs. This article aims to enlighten the interrelation of delirium and polypharmacy in the context of recent evidence. It also tries to show possibilities of deprescribing.
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26
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Matsuoka A, Sogawa R, Murakawa-Hirachi T, Mizoguchi Y, Monji A, Shimanoe C, Shinada K, Koami H, Sakamoto Y. Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study. Gen Hosp Psychiatry 2023; 83:123-129. [PMID: 37182281 DOI: 10.1016/j.genhosppsych.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room. METHOD This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis. RESULTS Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81). CONCLUSION DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Toru Murakawa-Hirachi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yoshito Mizoguchi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Akira Monji
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan; Wakahisa Hospital, 5-3-1, Wakahisa, Minami-ku, Fukuoka 815-0042, Japan.
| | - Chisato Shimanoe
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
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27
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Wu X, Zhang L, Huang H, Huang L, Lu X, Wang Z, Xiao J. Signal mining and analysis for central nervous system adverse events due to taking oxycodone based on FAERS database. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:422-434. [PMID: 37164926 PMCID: PMC10930086 DOI: 10.11817/j.issn.1672-7347.2023.220304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Central nervous system adverse events (AEs) occur when oxycodone is used in combination with benzodiazepines, antidepressants and anticonvulsants. There have been no reports of central nervous system AEs with oxycodone alone or in combination with oxycodone. Based on USA Food and Drug Administration Adverse Event Reporting System (FAERS) data, this study aims to explore the risk signals of central nervous system AEs with oxycodone alone or in combination with benzodiazepines, antidepressants and anticonvulsants, and to provide a reference for the safe and rational use of this drug. METHODS Extracted AEs data from the FAERS for oxycodone alone and in combination with benzodiazepines, antidepressants, and anticonvulsants from Q1 2004 to Q2 2021. The risk signal mining analysis of AEs was performed using the proportional imbalance method and Bayesian method. Number of reports ≥3 and lower 95% CI limit of reporting odds ratio (ROR)>1; number of reports ≥3, proportional reporting ratio (PRR)≥2 and χ2≥4; lower information components (IC) lower 95% CI limit (IC025)>0; empirical Bayes geometric mean (EBGM) lower 95% CI limit (EBGM05)>2, and N>0 were defined as positive signals. RESULTS A total of 5 793 reports of central nervous system AEs with oxycodone alone were tapped, and 366, 622, and 740 reports of combined benzodiazepines, antidepressants, and anticonvulsants, respectively. Consumers and physicians were the main reporting population. The age distribution of oxycodone alone was mainly from 61 to 80 years old. The age distribution of oxycodone in combination with related drugs was mainly from 46 to 60 years old. The risk of AEs was greater in women than in men, and the United States was the predominant reporting country. Oxycodone alone was strongly associated with myoclonus [ROR=2.92, 95% CI 2.28 to 3.76); PRR=2.92, χ2(77.49); IC=1.52, IC025(0.65); EBGM=2.89, EBGM05(2.33)], delirium [ROR=4.69, 95% CI 4.24 to 5.21; PRR=4.66, χ2(1 052.64); IC=2.17, IC025(1.81); EBGM=4.50, EBGM05 (4.13)], mental disorder [ROR=2.95, 95% CI 2.53 to 3.44; PRR=2.94, χ2(206.93); IC=1.56, IC025(0.96); EBGM=2.95, EBGM05(2.58)], and acute central respiratory depression [ROR=2.87, 95% CI 2.68 to 3.08); PRR=2.82, χ2(971.62); IC=1.52, IC025(1.33), EBGM=2.87, EBGM05 (2.76)]. Combination of benzodiazepines was most strongly associated with mental disorder [ROR=10.08, 95% CI 9.38 to 10.78; PRR=9.90, χ2(64.06); IC=3.33, IC025 (1.65); EBGM=10.08, EBGM05(5.61)], and tremor [ROR=3.09, 95% CI 2.76 to 3.42); PRR=3.08, χ2(48.93); IC=1.63, IC025 (1.17); EBGM=3.09, EBGM05(2.34)]. Combination of antidepressants was most strongly associated with delirium [ROR=13.23, 95% CI 12.23 to 14.23; PRR=12.87, χ2(43.86); IC=3.69, IC025(1.36); EBGM=12.23, EBGM05 (5.32)] and somnolence [ROR=6.74, 95% CI 6.15 to 7.33); PRR=6.73, χ2(53.42); IC=2.75, IC025(1.52); EBGM=6.73, EBGM05(4.10)]. Combination of anticonvulsants was most strongly associated with myoclonus [ROR=17.89, 95% CI 17.46 to 18.32; PRR=17.72, χ2(971.39); IC=4.16, IC025(2.70); EBGM=17.89, EBGM05(12.46)] and delirium [ROR=4.86, 95% CI 4.45 to 5.27); PRR=4.82, χ2(69.49); IC=2.28, IC025 (1.51); EBGM=4.86, EBGM05(3.44)]. CONCLUSIONS Based on pharmacovigilance studies of the FAERS database, clinical medication monitoring of oxycodone alone and in combination with benzodiazepines, antidepressants, and anticonvulsants should be strengthened to be alert to the occurrence of central nervous system-related AEs.
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Affiliation(s)
- Xiangping Wu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008.
- School of Pharmacy, Dali University, Dali Yunnan, 671000.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008.
| | - Lu Zhang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008
| | - Hangxing Huang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008
- School of Pharmacy, Dali University, Dali Yunnan, 671000
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008
| | - Ling Huang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008
| | - Xikui Lu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008
- School of Pharmacy, Dali University, Dali Yunnan, 671000
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008
| | - Zhenting Wang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008
- School of Pharmacy, Dali University, Dali Yunnan, 671000
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008
| | - Jian Xiao
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha 410008.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital; Laboratory for Rational and Safe Use of Elderly, Changsha 410008.
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28
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Bodnar RJ. Endogenous opiates and behavior: 2021. Peptides 2023; 164:171004. [PMID: 36990387 DOI: 10.1016/j.peptides.2023.171004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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29
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Morales Castro D, Dresser L, Granton J, Fan E. Pharmacokinetic Alterations Associated with Critical Illness. Clin Pharmacokinet 2023; 62:209-220. [PMID: 36732476 PMCID: PMC9894673 DOI: 10.1007/s40262-023-01213-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
Haemodynamic, metabolic, and biochemical derangements in critically ill patients affect drug pharmacokinetics and pharmacodynamics making dose optimisation particularly challenging. Appropriate therapeutic dosing depends on the knowledge of the physiologic changes caused by the patient's comorbidities, underlying disease, resuscitation strategies, and polypharmacy. Critical illness will result in altered drug protein binding, ionisation, and volume of distribution; it will also decrease oral drug absorption, intestinal and hepatic metabolism, and renal clearance. In contrast, the resuscitation strategies and the use of vasoactive drugs may oppose these effects by leading to a hyperdynamic state that will increase blood flow towards the major organs including the brain, heart, kidneys, and liver, with the subsequent increase of drug hepatic metabolism and renal excretion. Metabolism is the main mechanism for drug clearance and is one of the main pharmacokinetic processes affected; it is influenced by patient-specific factors, such as comorbidities and genetics; therapeutic-specific factors, including drug characteristics and interactions; and disease-specific factors, like organ dysfunction. Moreover, organ support such as mechanical ventilation, renal replacement therapy, and extracorporeal membrane oxygenation may contribute to both inter- and intra-patient variability of drug pharmacokinetics. The combination of these competing factors makes it difficult to predict drug response in critically ill patients. Pharmacotherapy targeted to therapeutic goals and therapeutic drug monitoring is currently the best option for the safe care of the critically ill. The aim of this paper is to review the alterations in drug pharmacokinetics associated with critical illness and to summarise the available evidence.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada. .,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.
| | - Linda Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9-MaRS, Toronto, ON, M5G 2N2, Canada.,Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Muacevic A, Adler JR, Burke H, Spurling B, Czuma R, Varghese R, Cohen A, Hartney K, Sullivan G, Kozel FA, Maldonado JR. A Retrospective Analysis of Guanfacine for the Pharmacological Management of Delirium. Cureus 2023; 15:e33393. [PMID: 36751225 PMCID: PMC9899070 DOI: 10.7759/cureus.33393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/07/2023] Open
Abstract
Background Delirium is a syndrome of acute brain failure that represents a change from an individual's baseline cognitive functioning characterized by deficits in attention and multiple aspects of cognition that fluctuate in severity over time. The symptomatic management of delirium's behavioral manifestations remains difficult. The alpha-2 agonists, dexmedetomidine and clonidine, are efficacious, but their potential cardiovascular adverse effects limit their utilization. Guanfacine is an oral alpha-2 agonist with a lower potential for such adverse outcomes; however, its use in delirium has not been studied. Methods A retrospective descriptive analysis of guanfacine for managing hyperactive or mixed delirium at Tampa General Hospital from January 2020 to October 2020 was conducted. The primary outcome was the time reduction in acute sedative administration. Secondary outcomes included renewed participation in physical therapy or occupational therapy (PT/OT), decreased opioid use, and an incidence of cardiovascular adverse effects. Results One hundred forty-nine patients were identified as having received guanfacine for managing delirium during the study period. All experienced a reduction in acute sedative use after the initiation of guanfacine. In 93 patients receiving PT/OT and no longer participating due to behavioral agitation, 74% had a documented renewal of services within four days. Of 112 patients on opioids, 70% experienced a 25% reduction in opioid administration within four days. No patients experienced consecutive episodes of hypotension that required a change in their clinical care. Two patients experienced a single episode of consecutive bradycardia that led to the discontinuation of guanfacine. Conclusions Based on our retrospective study, guanfacine is a well-tolerated medication for the management of delirium. Even in medically and critically ill patients, cardiovascular adverse events were rare with guanfacine. Patients treated with guanfacine experienced decreased acute sedative use for behavioral agitation. Additionally, patients treated with guanfacine received fewer opioids and were better able to participate in PT/OT. Future studies with prospective, randomized, placebo-controlled designs are warranted to evaluate this promising intervention for delirium further.
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Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci 2022; 14:1068278. [PMID: 36620772 PMCID: PMC9813601 DOI: 10.3389/fnagi.2022.1068278] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.
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Affiliation(s)
- Yang Chen
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shuai Liang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Huiwen Wu
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shihao Deng
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Ciren Lunzhu
- Department of Orthopedics, Shannan City People’s Hospital, Shannan, China
| | - Jun Li
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China,*Correspondence: Jun Li,
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32
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Duprey MS, Devlin JW. In Response. Anesth Analg 2022; 135:e38-e39. [PMID: 36269994 DOI: 10.1213/ane.0000000000006188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew S Duprey
- College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
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Casamento A, Jones D, Warrillow S. Measuring analgesia in ICU: no pain, no gain? CRIT CARE RESUSC 2022; 24:200-201. [PMID: 38046209 PMCID: PMC10692612 DOI: 10.51893/2022.3.e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew Casamento
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Intensive Care, Northern Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne,VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
- Critical Care Institute, Epworth HealthCare, Melbourne, VIC, Australia
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Tiberio PJ, Prendergast NT, Girard TD. Pharmacologic Management of Delirium in the Intensive Care Unit. Clin Chest Med 2022; 43:411-424. [PMID: 36116811 DOI: 10.1016/j.ccm.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Delirium, often underdiagnosed in the intensive care unit, is a common complication of critical illness that contributes to significant morbidity and mortality. Clinicians should be aware of common risk factors and triggers and should work to mitigate these as much as possible to reduce the occurrence of delirium. This review first provides an overview of the epidemiology, pathophysiology, evaluation, and consequences of delirium in critically ill patients. Presented next is the current evidence for the pharmacologic management of delirium, focusing on prevention and treatment of delirium in the intensive care unit. It concludes by outlining some emerging treatments of delirium.
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Affiliation(s)
- Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, NW 628 UPMC Montefiore, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Timothy D Girard
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, 3520 Fifth Avenue, 101 Keystone Building, Pittsburgh, PA, 15213, USA.
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Baseline Anxiety and Depression and Risk for ICU Delirium: A Prospective Cohort Study. Crit Care Explor 2022; 4:e0743. [PMID: 35923592 PMCID: PMC9307302 DOI: 10.1097/cce.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES: Anxiety and depression are common mental disorders in adults admitted to the ICU. Although depression increases postsurgical delirium and anxiety does not, their associations with ICU delirium in critically ill adults remain unclear. We evaluated the association between ICU baseline anxiety and depression and ICU delirium occurrence. DESIGN: Subgroup analysis of a prospective cohort study. SETTING: Single, 36-bed mixed ICU. PATIENTS: Nine-hundred ninety-one ICU patients admitted with or without delirium between July 2016 and February 2020; patients admitted after elective surgery or not assessed for anxiety/depression were excluded. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTs: The Hospital Anxiety and Depression Scale questionnaire was administered at ICU admission to determine baseline anxiety and depression. All patients were assessed with the Confusion Assessment Method for the ICU (CAM-ICU) q8h; greater than or equal to 1 +CAM-ICU assessment and/or scheduled antipsychotic use represented a delirium day. Multivariable logistic and Quasi-Poisson regression models, adjusted for ICU days and nine delirium risk variables (“Pre-ICU”: age, Charlson Comorbidity Index, cognitive impairment; “ICU baseline”: Acute Physiology and Chronic Health Evaluation-IV, admission type; “Daily ICU”: opioid and/or benzodiazepine use, Sequential Organ Failure Assessment score, coma), were used to evaluate associations between baseline anxiety and/or depression and ICU delirium. Among the 991 patients, 145 (14.6%) had both anxiety and depression, 78 (7.9%) had anxiety only, 91 (9.2%) had depression only, and 677 (68.3%) had neither. Delirium occurred in 406 of 991 total cohort (41.0%) patients; in the baseline anxiety and depression group, it occurred in 78 of 145 (53.8%), in the anxiety only group, 37 of 78 (47.4%), in the depression only group, 39 of 91 (42.9%), and in the group with neither in 252 of 677 (37.2%). Presence of both baseline anxiety and depression was associated with greater delirium occurrence (adjusted odds ratio, 1.99; 95% CI, 1.10–3.53; p = 0.02) and duration (adjusted risk ratio, 1.62; 95% CI, 1.17–2.23; p < 0.01). CONCLUSIONS: Baseline anxiety and depression are associated with increased ICU delirium occurrence and should be considered when delirium risk reduction strategies are being formulated.
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36
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Simić A, Nesek Adam V, Rošić D, Kočet N, Svetec M, Herceg A, Keranović A, Rašić Ž. PERIPHERAL NERVE BLOCKS FOR HIP FRACTURES
IN EMERGENCY MEDICINE. Acta Clin Croat 2022; 61:78-83. [PMID: 36304813 PMCID: PMC9536168 DOI: 10.20471/acc.2022.61.s1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hip fractures represent a major public health issue with increasing incidence as a population ages. The aim of this review is to describe peripheral nerve block techniques (the fascia iliaca compartment block and the pericapsular nerve group block) as pain management for hip fractures in emergency medicine, and to emphasize their benefits. Hip fractures are extremely painful injuries. The pain itself is unpleasant for patients and if left untreated it can lead to multiple complications during preoperative, operative and postoperative patient management. Pain management for elderly hip fracture patients is often challenging. Non-steroidal anti-inflammatory drugs are not recommended due to their side effects, the increased risk of gastrointestinal bleeding, renal function impairment and platelet aggregation inhibition. Paracetamol alone is often insufficient, and opioids have many potentially harmful side effects, such as delirium development. Peripheral nerve blocks for hip fractures are safe and effective, also in emergency medicine settings. The benefits for patients are greater pain relief, especially during movement, less opioid requirements and decreased incidence of delirium. Regional analgesia should be routinely used in hip fracture pain management.
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Affiliation(s)
- Anđela Simić
- Institute of Emergency Medicine Varaždin County;
| | - Višnja Nesek Adam
- University Hospital Sveti Duh, Emergency Medicine Department;,University Hospital Sveti Duh, University Department of Anesthesiology, Resuscitation and Intensive Care;,Josip Juraj Strossmayer University in Osijek, Medical School Osijek;,Libertas International University, Zagreb
| | - Damir Rošić
- Institute of Emergency Medicine of Primorje – Gorski Kotar County;,The Medical School of the Catholic University of Croatia;
| | - Nikola Kočet
- Institute of Emergency Medicine Varaždin County;
| | - Maja Svetec
- Institute of Emergency Medicine Varaždin County;
| | - Ana Herceg
- Institute of Emergency Medicine Varaždin County;
| | - Adis Keranović
- University Hospital Center Zagreb, Emergency Medicine Department;
| | - Žarko Rašić
- University Hospital Sveti Duh, University Department of Surgery;,University in Zagreb, School of Medicine
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Lewis K, Alshamsi F, Carayannopoulos KL, Granholm A, Piticaru J, Al Duhailib Z, Chaudhuri D, Spatafora L, Yuan Y, Centofanti J, Spence J, Rochwerg B, Perri D, Needham DM, Holbrook A, Devlin JW, Nishida O, Honarmand K, Ergan B, Khorochkov E, Pandharipande P, Alshahrani M, Karachi T, Soth M, Shehabi Y, Møller MH, Alhazzani W. Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2022; 48:811-840. [PMID: 35648198 DOI: 10.1007/s00134-022-06712-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
Conventional gabaminergic sedatives such as benzodiazepines and propofol are commonly used in mechanically ventilated patients in the intensive care unit (ICU). Dexmedetomidine is an alternative sedative that may achieve lighter sedation, reduce delirium, and provide analgesia. Our objective was to perform a comprehensive systematic review summarizing the large body of evidence, determining if dexmedetomidine reduces delirium compared to conventional sedatives. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov and the WHO ICTRP from inception to October 2021. Independent pairs of reviewers identified randomized clinical trials comparing dexmedetomidine to other sedatives for mechanically ventilated adults in the ICU. We conducted meta-analyses using random-effects models. The results were reported as relative risks (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs). In total, 77 randomized trials (n = 11,997) were included. Compared to other sedatives, dexmedetomidine reduced the risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty), the duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71; low certainty), and ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty). Dexmedetomidine use increased the risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty). In mechanically ventilated adults, the use of dexmedetomidine compared to other sedatives, resulted in a lower risk of delirium, and a modest reduction in duration of mechanical ventilation and ICU stay, but increased the risks of bradycardia and hypotension.
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Affiliation(s)
- Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joshua Piticaru
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Zainab Al Duhailib
- Department of Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Canada
| | - John Centofanti
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Jessica Spence
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada.,Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dan Perri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, USA.,Armstrong Institute for Patient Safety and Quality, John Hopkins University, Baltimore, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - John W Devlin
- School of Pharmacy, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Northeastern University, Boston, MA, USA
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Kimia Honarmand
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Eugenia Khorochkov
- Department of Medical Imaging, Memorial University of Newfoundland, St. John's, Canada
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, College of Medicine, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Tim Karachi
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Mark Soth
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yahya Shehabi
- Department of Intensive Care, Monash Health School of Clinical Sciences, The School of Clinical Medicine, University of New South Wales, Clayton, VIC 3168, Randwick, 2031, Australia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Hanidziar D, Westover MB. Monitoring of sedation in mechanically ventilated patients using remote technology. Curr Opin Crit Care 2022; 28:360-366. [PMID: 35653256 PMCID: PMC9434805 DOI: 10.1097/mcc.0000000000000940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected. RECENT FINDINGS High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity. SUMMARY Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.
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Affiliation(s)
- Dusan Hanidziar
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Use of dexmedetomidine for sedation in mechanically ventilated adult ICU patients: a rapid practice guideline. Intensive Care Med 2022; 48:801-810. [PMID: 35587274 DOI: 10.1007/s00134-022-06660-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/24/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM‑RPG) was to formulate evidence‑based guidance for the use of dexmedetomidine for sedation in invasively mechanically ventilated adults in the intensive care unit (ICU). METHODS We adhered to the methodology for trustworthy clinical practice guidelines, including use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and the Evidence-to-Decision framework to generate recommendations. The guideline panel comprised 28 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. Through teleconferences and web‑based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, feasibility, acceptability, and research priorities. RESULTS The ICM‑RPG panel issued one weak recommendation (suggestion) based on overall moderate certainty of evidence: "In invasively mechanically ventilated adult ICU patients, we suggest using dexmedetomidine over other sedative agents, if the desirable effects including a reduction in delirium are valued over the undesirable effects including an increase in hypotension and bradycardia". CONCLUSION This ICM-RPG provides updated evidence-based guidance on the use of dexmedetomidine for sedation in mechanically ventilated adults, and outlines uncertainties and research priorities.
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Naloxegol to Prevent Constipation in ICU Adults Receiving Opioids: A Randomized Double-Blind Placebo-Controlled Pilot Trial. Crit Care Res Pract 2022; 2022:7541378. [PMID: 35356796 PMCID: PMC8958087 DOI: 10.1155/2022/7541378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background Constipation is frequent in critically ill adults receiving opioids. Naloxegol (N), a peripherally acting mu-receptor antagonist (PAMORA), may reduce constipation. The objective of this trial was to evaluate the efficacy and safety of N to prevent constipation in ICU adults receiving opioids. Methods and Patients. In this single-center, double-blind, randomized trial, adults admitted to a medical ICU receiving IV opioids (≥100 mcg fentanyl/day), and not having any of 17 exclusion criteria, were randomized to N (25 mg) or placebo (P) daily randomized to receive N (25mg) or placebo (P) and docusate 100 mg twice daily until ICU discharge, 10 days, or diarrhea (≥3 spontaneous bowel movement (SBM)/24 hours) or a serious adverse event related to study medication. A 4-step laxative protocol was initiated when there was no SBM ≥3 days. Results Only 318 (20.6%) of the 1542 screened adults during the 1/17–10/19 enrolment period met all inclusion criteria. Of these, only 19/381 (4.9%) met all eligibility criteria. After 7 consent refusals, 12 patients were randomized. The study was stopped early due to enrolment futility. The N (n = 6) and P (n = 6) groups were similar. The time to first SBM (N 41.4 ± 31.7 vs. P 32.5 ± 25.4 hours, P = 0.56) was similar. The maximal daily abdominal pressure was significantly lower in the N group (N 10 ± 4 vs. P 13 ± 5, P = 0.002). The median (IQR) daily SOFA scores were higher in N (N 7 (4, 8) vs. P 4 (3, 5), P < 0.001). Laxative protocol use was similar (N 83.3% vs. P 66.6%; P = 0.51). Diarrhea prevalence was high but similar (N 66.6% vs. P 66.6%; P = 1.0). No patient experienced opioid withdrawal. Conclusions Important recruitment challenges exist for ICU trials evaluating the use of PAMORAs for constipation prevention. Despite being underpowered, our results suggest time to first SBM with naloxegol, if different than P, may be small. The effect of naloxegol on abdominal pressure, SOFA, and the interaction between the two requires further research.
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Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care 2022; 50:108-126. [PMID: 35172616 DOI: 10.1177/0310057x211070008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Affiliation(s)
- Benjamin L Moran
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Department of Intensive Care, 90112Gosford Hospital, Gosford Hospital, Gosford, Australia.,Department of Anaesthesia and Pain Medicine, Gosford Hospital, Gosford, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - John A Myburgh
- Critical Care Program, The George Institute of Global Health, Sydney, Australia.,Faculty of Medicine, 7800University of New South Wales, University of New South Wales, Kensington, Australia.,St George Hospital, Kogarah, Australia
| | - David A Scott
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Fitzroy, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Lee S, Okoro UE, Swanson MB, Mohr N, Faine B, Carnahan R. Opioid and benzodiazepine use in the emergency department and the recognition of delirium within the first 24 hours of hospitalization. J Psychosom Res 2022; 153:110704. [PMID: 34959040 PMCID: PMC9348903 DOI: 10.1016/j.jpsychores.2021.110704] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/12/2021] [Accepted: 12/12/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Delirium is a common and serious brain dysfunction. The objective of our study was to test the hypothesis that opioids and benzodiazepines exposure in the emergency department (ED) is associated with delirium. METHODS This was a retrospective cohort study, including patients aged 65 years and older who were hospitalized from ED at an academic medical center from 2014 to 2017. Medication administration records were used to identify opioids and benzodiazepines given during the ED stay. Nurses used the Delirium Observation Screening Scale (DOSS) twice daily to assess delirium during hospitalization. The outcome was a positive DOSS within 1 day of ED encounter. We used logistic regression to predict the outcome of positive delirium screening by opioids and benzodiazepines. RESULTS A total of 7927 ED encounters that resulted in hospitalization were included in the analysis. We identified 2008 visits (25.3%) with a positive delirium screen. A total of 3304 (41.7%) received opioids, and 1801 (22.7%) received benzodiazepines. In this cohort, opioids were not associated with an increased odds of delirium (OR 1.00, 95% CI 0.87-1.15). Benzodiazepines were associated with increased odds of delirium (OR 1.37, 95% CI 1.13-1.65), as were benzodiazepines combined with opioids (OR 1.61, 95% CI 1.33-1.97). CONCLUSION In this study, the use of benzodiazepines was associated with a risk of delirium. The use of opioids did not increase the risk of delirium. Our findings imply that judicious pain management with opioids in the ED might not increase the risk of delirium.
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Affiliation(s)
- Sangil Lee
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA.
| | - Uche Eseoghene Okoro
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Morgan Bobb Swanson
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Nicholas Mohr
- Department of Emergency Medicine, Anesthesia, and Epidemiology, The University of Iowa Carver College of Medicine, USA
| | - Brett Faine
- Department of Emergency Medicine, The University of Iowa Carver College of Medicine, USA
| | - Ryan Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, USA
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Swarbrick CJ, Partridge JSL. Evidence‐based strategies to reduce the incidence of postoperative delirium: a narrative review. Anaesthesia 2022; 77 Suppl 1:92-101. [DOI: 10.1111/anae.15607] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 12/18/2022]
Affiliation(s)
- C. J. Swarbrick
- Department of Anaesthesia Royal Devon and Exeter Hospital Exeter UK
| | - J. S. L. Partridge
- Peri‐operative medicine for Older People undergoing Surgery Department of Ageing and Health Guy's and St Thomas' NHS Foundation Trust London UK
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Delirium in Critically Ill Cancer Patients With COVID-19. J Acad Consult Liaison Psychiatry 2022; 63:539-547. [PMID: 35660676 PMCID: PMC9162788 DOI: 10.1016/j.jaclp.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND COVID-19 has been a devastating pandemic with little known of its neuropsychiatric complications. Delirium is one of the most common neuropsychiatric syndromes among hospitalized cancer patients with incidence ranging from 25% to 40% and rates of up to 85% in the terminally ill. Data on the incidence, risk factors, duration, and outcomes of delirium in critically ill cancer patients with COVID-19 are lacking. OBJECTIVE To report the incidence, risks and outcomes of critically ill cancer patients who developed COVID-19. METHODS This is a retrospective single-center study evaluating delirium frequency and outcomes in all critically ill cancer patients with COVID-19 admitted between March 1 and July 10, 2020. Delirium was assessed by Confusion Assessment Method for Intensive Care Unit, performed twice daily by trained intensive care unit (ICU) nursing staff. Patients were considered to have a delirium-positive day if Confusion Assessment Method for Intensive Care Unit was positive at least once per day. RESULTS A total of 70 patients were evaluated. Of those 70, 53 (75.7%) were found to be positive for delirium. Patients with delirium were significantly older than patients without delirium (median age 67.5 vs 60.3 y, P = 0.013). There were no significant differences in demographic characteristics, chronic medical conditions, neuropsychiatric history, cancer type, or application of prone positioning between the 2 groups. Delirium patients were less likely to receive cancer-directed therapies (58.5% vs 88.2%, P = 0.038) but more likely to receive antipsychotics (81.1% vs 41.2%, P = 0.004), dexmedetomidine (79.3% vs 11.8%, P < 0.001), steroids (84.9% vs 58.8%, P = 0.039), and vasopressors (90.6% vs 58.8%, P = 0.006). Delirium patients were more likely to be intubated (86.8% vs 41.2%, P < 0.001), and all tracheostomies (35.9%) occurred in patients with delirium. ICU length of stay (19 vs 8 d, P < 0.001) and hospital length of stay (37 vs 12 d, P < 0.001) were significantly longer in delirium patients, but there was no statistically significant difference in hospital mortality (43.4% vs 58.8%, P = 0.403) or ICU mortality (34.0% vs 58.8%, P = 0.090). CONCLUSIONS Delirium in critically ill cancer patients with COVID-19 was associated with less cancer-directed therapies and increased hospital and ICU length of stay. However, the presence of delirium was not associated with an increase in hospital or ICU mortality.
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Casamento AJ, Serpa Neto A, Young M, Lawrence M, Taplin C, Eastwood GM, Ghosh A, Bellomo R. A Phase II Cluster-Crossover Randomized Trial of Fentanyl versus Morphine for Analgosedation in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2021; 204:1286-1294. [PMID: 34543581 DOI: 10.1164/rccm.202106-1515oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: The continuous infusion of fentanyl or morphine is often prescribed to assist with analgesia and sedation (analgosedation) during mechanical ventilation. Objectives: To compare the effect of fentanyl versus morphine on patient-centered outcomes in ventilated patients. Methods: We conducted a cluster-randomized, cluster-crossover trial between July 2019 and August 2020 in two adult ICUs. We compared two continuous infusion regimens (fentanyl versus morphine). One ICU was randomized to the fentanyl-morphine sequence and the other to the morphine-fentanyl sequence. The primary outcome was the number of ventilator-free days at Day 28. Secondary outcomes included, among others, duration of mechanical ventilation in survivors and ICU-free days at Day 28. Measurements and Main Results: Via cluster allocation, we randomized 737 patients. Of these, 56 were excluded because of the opt-out consent process, leaving 681 (344 to fentanyl and 337 to morphine) for primary analysis (median [interquartile range] age, 59 [44-69] years). Median ventilator-free days at Day 28 were 26.1 (20.7-27.3) in the fentanyl versus 25.3 (19.1-27.2) in the morphine group (median difference, 0.79 [95% confidence interval, 0.31 to 1.28], P = 0.001). ICU-free days were greater (P < 0.001) and length of stay in the ICU for survivors shorter (P < 0.001) in the fentanyl group. All other secondary outcomes were not statistically different by treatment group. Conclusions: Among adult patients requiring mechanical ventilation, compared with morphine, fentanyl infusion significantly increased the median number of ventilator-free days at Day 28. The choice of opioid infusion agent may affect clinical outcomes and requires further investigation.
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Affiliation(s)
- Andrew J Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus Young
- Department of Critical Care and.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
| | - Mervin Lawrence
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Christina Taplin
- Department of Intensive Care, Northern Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and
| | - Angajendra Ghosh
- Department of Intensive Care, Northern Hospital, Melbourne, Australia.,Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Department of Critical Care and.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Center, University of Melbourne and Austin Hospital, Melbourne, Australia; and
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Sutton S, McCrobie TR, Kovacevic MR, Dube KM, Szumita PM, Herod K, Bezio A, Choi H, Duprey MS, Zeballos J, Devlin JW. Impact of the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Guidelines on Nonopioid Analgesic Use and Related Outcomes in Critically Ill Adults After Major Surgery. Crit Care Explor 2021; 3:e0564. [PMID: 34723188 PMCID: PMC8549685 DOI: 10.1097/cce.0000000000000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We compared ICU nonopioid analgesic use, opioid use, and pain before and after Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication at one academic center among critically ill adults receiving an opioid infusion and greater than or equal to 24 hours of mechanical ventilation after major surgery. The 2017 (n = 77) and 2019 (n = 57) groups were similar at baseline. The 2019 (vs 2017) patients were more likely to receive scheduled IV/oral acetaminophen (84% vs 69%; p = 0.05), less likely to receive a lidocaine patch (33% vs 50%; p = 0.05), and just as likely to receive ketamine (4% vs 3%; p = 1.0), an nonsteroidal anti-inflammatory drug (7% vs 3%; p = 0.26), or gabapentin/pregabalin (16% vs 9%; p = 0.23). Daily average opioid exposure (in IV morphine milligram equivalent) was not different (70 [42–99] [2017] vs 78 mg [49–109 mg]; p = 0.94). The 2019 (vs 2017) group spent more ICU days with severe pain (p = 0.04). At our center, Pain, Agitation/Sedation, Delirium, Immobility, and Sleep guideline publication had little effect on nonopioid analgesic or opioid prescribing practices in critically ill surgical adults.
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Affiliation(s)
- Spencer Sutton
- Department of Pharmacy, Boston Medical Center, Boston, MA
| | | | - Mary R Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Kevin M Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA
| | - Kyle Herod
- School of Pharmacy, Northeastern University, Boston, MA
| | - Aaron Bezio
- School of Pharmacy, Northeastern University, Boston, MA
| | - Hannah Choi
- School of Pharmacy, Northeastern University, Boston, MA
| | | | - Jose Zeballos
- Division of Anesthesiology, Brigham and Women's Hospital, Boston, MA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA.,Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Louzon PR, Heavner MS, Herod K, Wu TT, Devlin JW. Sleep-Promotion Bundle Development, Implementation, and Evaluation in Critically Ill Adults: Roles for Pharmacists. Ann Pharmacother 2021; 56:839-849. [PMID: 34612725 DOI: 10.1177/10600280211048494] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To review evidence for intensive care unit (ICU) sleep improvement bundle use, identify preferred sleep bundle components and implementation strategies, and highlight the role for pharmacists in developing and evaluating bundle efforts. DATA SOURCES Multiple databases were searched from January 1, 1990, to September 1, 2021, using the MeSH terms sleep, intensive care or critical care, protocol or bundle to identify comparative studies evaluating ICU sleep bundle implementation. STUDY SELECTION AND DATA EXTRACTION Study screening, data extraction, and risk-of-bias evaluation were conducted in tandem. The ICU quality improvement literature and Institute for Healthcare Improvement bundle improvement guidance were also reviewed to identify recommended strategies for successful sleep bundle use. DATA SYNTHESIS Nine studies (3 randomized, 1 quasi-experimental, 5 before-and-after) were identified. Bundle elements varied and were primarily focused on nonpharmacological interventions designed to be performed during either the day or night; only 2 studies included a medication-based strategy. Five studies were associated with reduced delirium; 2 studies were associated with improved total sleep time and 2 with improved patient-perceived sleep. Pharmacists were involved directly in 4 studies. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Sleep improvement bundles are recommended for use in all critically ill adults; specific bundle elements and ICU team member roles should be individualized at the institution/ICU level. Pharmacists can help lead bundle development efforts and routinely deliver key elements. CONCLUSIONS Pharmacists can play an important role in the development and implementation of ICU sleep bundles. Further research regarding the relative benefit of individual bundle elements on relevant patient outcomes is needed.
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Affiliation(s)
| | | | - Kyle Herod
- Portsmouth Regional Hospital, Portsmouth NH, USA
| | - Ting Ting Wu
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - John W Devlin
- Northeastern University, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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Abstract
Ketamine is increasingly being used for analgosedation, but its effect on delirium remains unclear. We compared delirium risk variables and ketamine analgosedation use between adults who developed incident delirium and those who did not, evaluated whether ketamine analgosedation increases delirium risk, and compared ICU delirium characteristics, treatments, and outcomes between ketamine and nonketamine patients with delirium. DESIGN Secondary, subgroup analysis of a cohort study. SETTING Single, 36-bed mixed medical-surgical ICU in the Netherlands from July 2016 to February 2020. PATIENTS Consecutive adults were included. Patients admitted after elective surgery, not expected to survive greater than or equal to 48 hours, admitted with delirium, or where delirium occurred prior to ketamine use were excluded. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Trained ICU nurses evaluated patients without coma (Richmond Agitation Sedation Scale. -4/-5) every 8 hours with the Confusion Assessment Method ICU; a delirium day was defined by greater than or equal to1 + Confusion Assessment Method ICU and/or scheduled antipsychotic use. Among 11 variables compared between the delirium and nondelirium groups (Baseline: age, Charlson Comorbidity score, cognitive impairment, admission type, and Acute Physiology and Chronic Health Evaluation-IV score, daily ICU [until delirium occurrence or discharge]: Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) and total ICU days, 7 (age, Charlson score, Sequential Organ Failure Assessment score, coma, benzodiazepine, opioid, and ketamine use) were significantly different and were entered, along with delirium occurrence, in a logistic regression model. A total of 332 of 925 of patients (36%) developed delirium. Ketamine use was greater in patients with delirium (54 [16%] vs 4 [0.7%]; p < 0.01). Ketamine use (adjusted odds ratio, 5.60; 95% CI, 1.09-29.15), age (adjusted odds ratio, 1.03; 95% CI, 1.01-1.06), coma (adjusted odds ratio, 2.10; 95% CI, 1.15-3.78), opioid use (adjusted odds ratio, 171.17; 95% CI, 66.45-553.68), and benzodiazepine use (adjusted odds ratio, 34.07; 95% CI, 8.12-235.34) were each independently and significantly associated with increased delirium. Delirium duration, motoric subtype, delirium treatments, and outcomes were not different between the ketamine and nonketamine groups. CONCLUSIONS Ketamine analgosedation may contribute to increased ICU delirium. The characteristics of ketamine and nonketamine delirium are similar. Further prospective research is required to evaluate the magnitude of risk for delirium with ketamine use.
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Abstract
Social determinants of health may affect ICU outcome, but the association between social determinants of health and delirium remains unclear. We evaluated the association between three social determinants of health and delirium occurrence and duration in critically ill adults.
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