Different depths of sedation versus risk of delirium in adult mechanically ventilated patients: A systematic review and meta-analysis

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

None.

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study

How to cite this article: Karim HMR, Mitra JK. Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study. Indian J Crit Care Med 2022;26(11):1227-1228.

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

INTRODUCTION

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

METHODS AND ANALYSES

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

ETHICS AND DISSEMINATION

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

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross-Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices

Purpose

The study aimed to explore factors associated with deep sedation practice in intensive care units (ICUs).

Materials and Methods

A post hoc analysis was conducted for a cross–sectional survey on sedation practices in mechanically ventilated (MV) patients, combined with a questionnaire for physicians regarding their preferences for light sedation (P–pls Score) in 92 Chinese ICUs.

Results

There were 457 and 127 eligible MV patients in the light and deep sedation groups respectively. A multivariable logistic regression analysis demonstrated that the control mode of mechanical ventilation, plasma lactate level, and the Sequential Organ Failure Assessment (SOFA) score were independent risk factors for deep sedation practice (p <0.01). Notably, the adjusted odds ratio (95% CI) of the average P–pls score in the ICU ≤ 2 for deep sedation practice was 1.861 (1.163, 2.978, p = 0.01). In addition, the areas under curves of receiver operating characteristics (AUC–ROC) of the model to predict the probability of deep sedation practice were 0.753 (0.699, 0.806) and 0.772 (0.64, 0.905) in the training set and the validation set, respectively. The 28–day mortality was increased in patients with exposure to deep sedation practice but not significantly.

Conclusion

Both factors related to stressful stimuli and the ICU physicians' perception of patient tolerability in mechanical ventilation were likely associated with deep sedation practice in MV patients.

Non-Pharmacological Interventions for Minimizing Physical Restraints Use in Intensive Care Units: An Umbrella Review

Background

There is a relationship between the application of physical restraints and negative physiological and psychological effects on critically ill patients. Many organizations have supported and advocated minimizing the use of physical restraints. However, it is still common practice in many countries to apply physical restraints to patients in intensive care.

Objective

This study aimed to assess the effectiveness of various non-pharmacological interventions used to minimize physical restraints in intensive care units and provide a supplement to the evidence summary for physical restraints guideline adaptation.

Methods

Based on the methodology of umbrella review, electronic databases, including Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, MEDLINE, EMBASE, CINAHL, Web of Science, PsycInfo/Psyc Articles/Psychology and Behavioral Science Collection, China National Knowledge Infrastructure, SinoMed, and Wanfang Data, were searched to identify systematic reviews published from January 2016 to December 2020. Two independent reviewers undertook screening, data extraction, and quality appraisal. The methodological quality of systematic reviews was evaluated by AMSTAR 2. Evidence quality of each intervention was assessed according to GRADE. The corrected covered area was calculated as a measure of overlap.

Results

A total of 47 systematic reviews were included in the umbrella review, of which six were evaluated as high quality, five were of moderate quality, and the rest were of low or critically low quality. The corrected covered area range was from 0.0 to 0.269, which indicated that there was mild overlap between systematic reviews. The included systematic reviews evaluated various types of non-pharmacological interventions for minimizing physical restraints in intensive care units, which included multicomponent interventions involving healthcare professionals' education, family engagement/support, specific consultations and communication, rehabilitation and mobilization (rehabilitation techniques, early mobilization, inspiratory muscle training), interventions related to reducing the duration of mechanical ventilation (weaning modes or protocols, ventilator bundle or cough augmentation techniques, early tracheostomy, high-flow nasal cannula), and management of specific symptoms (delirium, agitation, pain, and sleep disturbances).

Conclusion

The number of systematic reviews related to physical restraints was limited. Multicomponent interventions involving healthcare professionals' education may be the most direct non-pharmacological intervention for minimizing physical restraints use in intensive care units. However, the quality of evidence was very low, and conclusions should be taken with caution. Policymakers should consider incorporating non-pharmacological interventions related to family engagement/support, specific consultations and communication, rehabilitation and mobilization, interventions related to reducing the duration of mechanical ventilation, and management of specific symptoms as part of the physical restraints minimization bundle. All the evidence contained in the umbrella review provides a supplement to the evidence summary for physical restraints guideline adaptation.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242586, identifier: CRD42021242586.

Major Publications in the Critical Care Pharmacotherapy Literature: 2020

OBJECTIVES

To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2020.

DATA SOURCES

The Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update group screened 36 journals monthly for impactful publications.

STUDY SELECTION

The group reviewed a total of 119 articles during 2020 according to relevance for practice.

DATA EXTRACTION

Articles were selected with consensus and importance to clinical practice from those included in the monthly Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. The group reviewed articles according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. Articles with a 1A grade were selected.

DATA SYNTHESIS

Several trials were summarized, including two meta-analyses and five original research trials. Original research trials evaluating vitamin C, hydrocortisone, and thiamine versus hydrocortisone in sepsis, the use of nonsedation strategies, dexmedetomidine in cardiac surgery, remdesivir for severe acute respiratory syndrome coronavirus 2, and thrombectomy in acute ischemic stroke. Two meta-analyses determining the impact of norepinephrine initiation in patients with septic shock and the use of corticosteroids in severe acute respiratory syndrome coronavirus 2 was included.

CONCLUSIONS

This clinical review provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2020.

Factors associated with delirium among survivors of acute respiratory distress syndrome: a nationwide cohort study

Background

The prevalence of delirium, its associated factors, and its impact on long-term mortality among survivors of acute respiratory distress syndrome (ARDS) is unclear.

Methods

Since this was a population-based study, data were extracted from the National Health Insurance database in South Korea. All adults who were admitted to intensive care units with a diagnosis of ARDS between January 1, 2010, and December 31, 2019, and who survived for ≥ 60 days were included. The International Statistical Classification of Diseases and Related Health Problems, tenth revision code of delirium (F05) was used to extract delirium cases during hospitalization.

Results

A total of 6809 ARDS survivors were included in the analysis, and 319 patients (4.7%) were diagnosed with delirium during hospitalization. In the multivariable logistic regression analysis after covariate adjustment, male sex (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.23, 2.08; P < 0.001), longer duration of hospitalization (OR 1.02, 95% CI 1.01, 1.03; P < 0.001), neuromuscular blockade use (OR 1.50, 95% CI 1.12, 2.01; P = 0.006), benzodiazepine (OR 1.55, 95% CI 1.13, 2.13; P = 0.007) and propofol (OR 1.48, 95% CI 1.01, 2.17; P = 0.046) continuous infusion, and concurrent depression (OR 1.31, 95% CI 1.01, 1.71; P = 0.044) were associated with a higher prevalence of delirium among ARDS survivors. In the multivariable Cox regression analysis after adjustment for covariates, the occurrence of delirium was not significantly associated with 1-year all-cause mortality, when compared to the other survivors who did not develop delirium (hazard ratio: 0.85, 95% CI 1.01, 1.71; P = 0.044).

Conclusions

In South Korea, 4.7% of ARDS survivors were diagnosed with delirium during hospitalization in South Korea. Some factors were potential risk factors for the development of delirium, but the occurrence of delirium might not affect 1-year all-cause mortality among ARDS survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01714-0.

Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

Suboptimal sedation practices continue to be frequent, although the updated guidelines for management of pain, agitation, and delirium in mechanically ventilated (MV) patients have been published for several years. Causes of low adherence to the recommended minimal sedation protocol are multifactorial. However, the barriers to translation of these protocols into standard care for MV patients have yet to be analyzed. In our view, it is necessary to develop fresh insights into the interaction between the patients' responses to nociceptive stimuli and individualized regulation of patients' tolerance when using analgesics and sedatives. By better understanding this interaction, development of novel tools to assess patient pain tolerance and to define and predict oversedation or delirium may promote better sedation practices in the future.