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Adams AMN, Chamberlain D, Brun Thorup C, Maiden MJ, Waite C, Dafny HA, Bruce K, Conroy T. Patient Agitation in the Intensive Care Unit: A Concept Analysis. J Adv Nurs 2025. [PMID: 40277282 DOI: 10.1111/jan.17000] [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: 01/08/2025] [Revised: 03/18/2025] [Accepted: 04/12/2025] [Indexed: 04/26/2025]
Abstract
AIM Exploring the concept of patient agitation in the intensive care unit. BACKGROUND Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management. DESIGN Concept Analysis. METHOD Walker and Avant's eight-step concept analysis approach. DATA SOURCES A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation. RESULTS Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff. CONCLUSION Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours. IMPLICATIONS A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research. PATIENT OR PUBLIC CONTRIBUTION This concept analysis was developed with input from a patient representative.
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Affiliation(s)
- Anne Mette N Adams
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
| | - Diane Chamberlain
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
| | - Charlotte Brun Thorup
- Research Centre of Health and Applied Technology & Department of Radiography, University College Northern Denmark, Denmark
| | - Matthew J Maiden
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Cherie Waite
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
- Southern Adelaide Local Health Network, South Australia, Australia
| | - Hila Ariela Dafny
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
| | - Kay Bruce
- Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Tiffany Conroy
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
- Southern Adelaide Local Health Network, South Australia, Australia
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Asmare TB, Tawuye HY, Tegegne BA, Admass BA. Incidence and factors associated with agitation in patients on mechanical ventilators in Amhara Region, North-West Ethiopia: a multi-center study. Sci Rep 2025; 15:5958. [PMID: 39966461 PMCID: PMC11836337 DOI: 10.1038/s41598-025-90148-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 02/11/2025] [Indexed: 02/20/2025] Open
Abstract
Agitation is a common psychomotor disorder among critically ill patients on mechanical ventilators, posing significant risks to patients and adding strain to clinical services. Despite its importance, there is a lack of data on the incidence and contributing factors of agitation in the study area and across Ethiopia. This study, therefore, aims to assess the incidence and factors associated with agitation in patients on mechanical ventilators in the intensive care units of comprehensive specialized hospitals in the Amhara Region, North-West Ethiopia. A multi-center prospective follow-up study was conducted among 253 critically ill adult patients on mechanical ventilators in the Amhara region of Ethiopia from April 17, 2024, to July 16, 2024. Data were collected using a semi-structured questionnaire through chart reviews, observations, and interviews. Participants were selected using a consecutive sampling technique. The data were entered into Epi-Data version 4.6 and transferred to Stata version 17 for analysis. Bivariable and multivariable logistic regression analyses were performed to identify factors associated with agitation. Variables with a p value of less than 0.2 in the bivariable analysis were included in the multivariable analysis. Crude and adjusted odds ratios with 95% confidence intervals were used to identify factors associated with agitation. The results were presented in the form of text, tables, and figures. In the multivariable analysis, variables with a p value of less than 0.05 were considered statistically significant predictors. The overall incidence of agitation among patients on mechanical ventilators in intensive care units was 87.35% (95% CI 82.6, 91.2). Anxiety (Adjusted Odds Ratio (AOR) 3.5; 95% CI 1.28, 9.45), delirium (AOR 3.01; 95% CI 1.13, 7.97), pain (AOR 3.23; 95% CI 1.18, 8.85), hyperthermia (AOR 3.49; 95% CI 1.004, 12.15), hyponatremia (AOR 3.64; 95% CI 1.009, 13.11), and the use of restraints (AOR 3.49; 95% CI 1.11, 8.67) were statistically significant factors associated with agitation. In this study, the majority of participants experienced agitation. To reduce the incidence of agitation, we recommend addressing or preventing the development of anxiety, pain, delirium, hyperthermia, and hyponatremia, as well as minimizing the use of restraints in intensive care units.
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Affiliation(s)
- Temesgen Birlie Asmare
- Department of Anesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Hailu Yimer Tawuye
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biruk Adie Admass
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Saavedra-Mitjans M, David PM, Arbour C, Perreault MM, Roux M, Frenette AJ, Khwaja K, Bernard F, Williamson DR. Experiences and attitudes towards agitated behaviours in TBI ICU patients (EXSTATIC): understanding various management practices through qualitative interviews with nurses. Brain Inj 2025; 39:598-609. [PMID: 39895622 DOI: 10.1080/02699052.2025.2460022] [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: 11/22/2024] [Revised: 01/23/2025] [Accepted: 01/24/2025] [Indexed: 02/04/2025]
Abstract
INTRODUCTION & OBJECTIVES Agitation is a common complication after an acute TBI in ICU patients. Professionals have a range of strategies to address agitation. Yet the absence of evidence-based guidelines and how these strategies are implemented complicates the management and safety may often be compromised for both ICU professionals and patients. This project explores experiences and attitudes of ICU-nurses to better understand the management of agitated behaviors in acute TBI-patients. METHODS Semi-structured interviews were conducted with 12 ICU-nurses from two Level-1 trauma centers in Canada. The interviews explored experiences and perceptions of managing agitation in critically ill TBI-patients. Interviews were analyzed using thematic analysis, facilitating the examination of how management practices interface with contextual variables and clinical strategies. RESULTS Five themes were identified: (1) a variety of symptoms differing according to patient profile and time since awakening, (2) different agitation management approaches stem from different concerns, (3) strategies used by nurses to manage agitation, (4) contextual factors influence management, and (5) potential opportunities to improve integrated care model. CONCLUSIONS This research describes nurses' perceptions and helps understand management of agitation, by considering underlying contexts and factors affecting TBI-agitated patients management, how ICU itself contributes to agitation and potential areas for improvement.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal (CIUSSS-NIM), Montreal, Canada
| | | | - Caroline Arbour
- Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal (CIUSSS-NIM), Montreal, Canada
- Faculty of Nursing, Université de Montréal, Montreal, Canada
| | - Marc M Perreault
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Department of Critical Care, McGill University Health Center - Montreal General Hospital, Montreal, Canada
| | - Maxime Roux
- Department of Pharmacy, Centre Hospitalier d'Antibes-Juan-Les-Pins, Antibes, France
| | - Anne Julie Frenette
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal (CIUSSS-NIM), Montreal, Canada
- Department of Critical Care, Hopital du Sacre-Coeur de Montréal, Montreal, Canada
| | - Kosar Khwaja
- Department of Critical Care, McGill University Health Center - Montreal General Hospital, Montreal, Canada
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Francis Bernard
- Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal (CIUSSS-NIM), Montreal, Canada
- Department of Critical Care, Hopital du Sacre-Coeur de Montréal, Montreal, Canada
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - David R Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Research Centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal (CIUSSS-NIM), Montreal, Canada
- Department of Critical Care, Hopital du Sacre-Coeur de Montréal, Montreal, Canada
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Dauvergne JE, Ferey K, Croizard V, Chauvin M, Mainguy N, Mathelier N, Jehanno A, Maugars N, Badre G, Maze F, Chartier M, Vastral S, Epain G, Baudiniere L, Ronceray M, Lebidan M, Flattres D, Ambrosi X. Prevalence and risk factors of the use of physical restraint and impact of a decision support tool: A before-and-after study. Nurs Crit Care 2024; 29:987-996. [PMID: 37400076 DOI: 10.1111/nicc.12945] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Physical restraint is frequently used in intensive care units to prevent patients' life-threatening removal of indwelling devices. In France, their use is poorly studied. Therefore, to evaluate the need for physical restraint, we have designed and implemented a decision support tool. AIMS Besides describing the prevalence of physical restraint use, this study aimed to assess whether the implementation of a nursing decision support tool had an impact on restraint use and to identify the factors associated with this use. STUDY DESIGN A large observational, multicentre study with a repeated one-day point prevalence design was conducted. All adult patients hospitalized in intensive care units were eligible for this study. Two study periods were planned: before (control period) and after (intervention period) the deployment of the decision support tool and staff training. A multilevel model was performed to consider the centre effect. RESULTS During the control period, 786 patients were included, and 510 were in the intervention period. The prevalence of physical restraint was 28% (95% CI: 25.1%-31.4%) and 25% (95% CI: 21.5%-29.1%) respectively (χ2 = 1.35; p = .24). Restraint was applied by the nurse and/or nurse assistant in 96% of cases in both periods, mainly to wrists (89% vs. 83%, p = .14). The patient-to-nurse ratio was significantly lower in the intervention period (1:3.0 ± 1 vs. 1:2.7 ± 0.7, p < .001). In multivariable analysis, mechanical ventilation was associated with physical restraint (aOR [95% CI] = 6.0 [3.5-10.2]). CONCLUSION The prevalence of physical restraint use in France was lower than expected. In our study, the decision support tool did not substantially impact physical restraint use. Hence, the decision support tool would deserve to be assessed in a randomized controlled trial. RELEVANCE TO CLINICAL PRACTICE The decision to physically restrain a patient could be protocolised and managed by critical care nurses. A regular evaluation of the level of sedation could allow the most deeply sedated patients to be exempted from physical restraint.
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Affiliation(s)
- Jérôme E Dauvergne
- Service d'anesthésie-réanimation, hôpital Laënnec, Centre hospitalier universitaire de Nantes, Nantes, Cedex, France
| | - Kim Ferey
- Service de réanimation polyvalente, Centre hospitalier de Blois, Blois, Cedex, France
| | - Véronique Croizard
- Service de réanimation chirurgicale, hôpital Trousseau, Centre hospitalier universitaire de Tours, Tours, Cedex, France
| | - Morgan Chauvin
- Service de réanimation chirurgicale, Centre hospitalier universitaire de Rennes, Rennes, Cedex, France
| | - Nolwenn Mainguy
- Service de réanimation polyvalente, Centre hospitalier bretagne-atlantique, Vannes, Cedex, France
| | - Noeline Mathelier
- Service d'anesthésie-réanimation chirurgicale et brûlés, Hôtel Dieu, Centre hospitalier universitaire de Nantes, Nantes, Cedex, France
| | - Anaëlle Jehanno
- Service de réanimation, Centre hospitalier bretagne sud, Lorient, Cedex, France
| | - Nadège Maugars
- Service de soins intensifs de pneumologie, hôpital Laënnec, Centre hospitalier universitaire de Nantes, Nantes, Cedex, France
| | - Gaëtan Badre
- Service de réanimation polyvalente, Centre hospitalier de Chartres, Chartres, France
| | - Françoise Maze
- Service de réanimation chirurgicale, Centre hospitalier universitaire de Brest, Brest, France
| | - Marie Chartier
- Service de réanimation chirurgicale, Centre hospitalier universitaire d'Angers, Angers, France
| | - Servane Vastral
- Service de réanimation polyvalente, Centre hospitalier de Saint Nazaire, Saint-Nazaire, France
| | - Graziella Epain
- Service de réanimation chirurgicale, Centre hospitalier universitaire de Poitiers, Poitiers, France
| | - Lucie Baudiniere
- Service de réanimation neurochirurgicale, Centre hospitalier universitaire de Poitiers, Poitiers, France
| | - Mathilde Ronceray
- Service de réanimation neurochirurgicale, hôpital Bretonneau, Centre hospitalier universitaire de Tours, Tours, Cedex, France
| | - Mathias Lebidan
- Service de réanimation chirurgie thoracique et cardio vasculaire, Centre hospitalier universitaire de Rennes, Rennes, Cedex, France
| | - Delphine Flattres
- Service d'anesthésie-réanimation chirurgicale et brûlés, Hôtel Dieu, Centre hospitalier universitaire de Nantes, Nantes, Cedex, France
| | - Xavier Ambrosi
- Service d'anesthésie-réanimation, hôpital Laënnec, Centre hospitalier universitaire de Nantes, Nantes, Cedex, France
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Saavedra-Mitjans M, Frenette AJ, McCredie VA, Burry L, Arbour C, Mehta S, Charbonney E, Wang HT, Albert M, Bernard F, Williamson D. Physicians' beliefs and perceived importance of traumatic brain injury-associated agitation in critically ill patients: a survey of Canadian intensivists. Can J Anaesth 2024; 71:264-273. [PMID: 38129356 DOI: 10.1007/s12630-023-02666-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 12/23/2023] Open
Abstract
PURPOSE Agitation is a common behavioural problem following traumatic brain injury (TBI). Intensive care unit (ICU) physicians' perspectives regarding TBI-associated agitation are unknown. Our objective was to describe physicians' beliefs and perceived importance of TBI-associated agitation in critically ill patients. METHODS Following current standard guidance, we built an electronic, self-administrated, 42-item survey, pretested it for reliability and validity, and distributed it to 219 physicians working in 18 ICU level-1 trauma centres in Canada. We report the results using descriptive statistics. RESULTS The overall response rate was 93/219 (42%), and 76/93 (82%) respondents completed the full survey. Most respondents were men with ten or more years of experience. Respondents believed that pre-existing dementia (90%) and regular recreational drug use (86%) are risk factors for agitation. Concerning management, 91% believed that the use of physical restraints could worsen agitation, 90% believed that having family at the bedside reduces agitation, and 72% believed that alpha-2 adrenergic agonists are efficacious for managing TBI agitation. Variability was observed in beliefs on epidemiology, sex, gender, age, socioeconomic status, and other pharmacologic options. Respondents considered TBI agitation frequent enough to justify the implementation of management protocols (87%), perceived the current level of clinical evidence on TBI agitation management to be insufficient (84%), and expressed concerns about acute and long-term detrimental outcomes and burden to patients, health care professionals, and relatives (85%). CONCLUSION Traumatic brain injury-associated agitation in critically ill patients was perceived as an important issue for most ICU physicians. Physicians agreed on multiple approaches to manage TBI-associated agitation although agreement on epidemiology and risk factors was variable.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada.
| | - Anne Julie Frenette
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Victoria A McCredie
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada
- Krembil Research Institute, Toronto, ON, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Caroline Arbour
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - Sangeeta Mehta
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health, Toronto, ON, Canada
| | - Emmanuel Charbonney
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Han Ting Wang
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Research Centre, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Francis Bernard
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - David Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Research Center, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, QC, Canada
- Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
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White G, Adessky N, Chen FW, Regazzoni A, Tourian L, Chagnon M, Gursahaney A, Alharbi M, Williamson D, Perreault MM. Valproic acid for agitation in the intensive care unit: an observational study of psychiatric consults. Int J Clin Pharm 2024; 46:177-185. [PMID: 38071694 DOI: 10.1007/s11096-023-01661-2] [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: 06/23/2023] [Accepted: 10/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Agitation is a common clinical problem encountered in the intensive care unit (ICU). Treatment options are based on clinical experience and sparse quality literature. AIM The aim of this study was to describe the effect of valproic acid (VPA) as adjuvant treatment for agitation in the ICU, identify predictors of response to VPA and evaluate the independent effect of VPA on agitation compared to standard of care (SOC). METHOD This retrospective single center observational study evaluated adult patients admitted to the ICU for whom a psychiatric consultation was requested for agitation management, with agitation defined as a Richmond Agitation Sedation Score of 2 or greater. A descriptive analysis of the proportion of agitation-free patients per day of follow-up, the incidence of agitation-related-events, as well as the evolution of co-medications use over time are presented. A logistic regression model was used to assess predictors of VPA response, defined as being agitation-free on Day 7 and generalized estimating equations were used to evaluate the independent effect of VPA as adjuvant therapy for agitation in the critically ill. RESULTS One hundred seventy-five patients were included in the study with 78 receiving VPA. The percentage of agitation-free patients on VPA was 6.5% (5/77) on Day 1, 14.1% (11/78) on Day 3 and 39.5% (30/76) on Day 7. Multivariate regression model for clinical and demographic variables identified female gender as predictor of response on Day 7 (OR 6.10 [1.18-31.64], p = 0.03). The independent effect of VPA was non-significant when compared to SOC. CONCLUSION Although VPA used as adjuvant treatment was associated with a decrease in agitation, its effect when compared to SOC did not yield significant results.
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Affiliation(s)
- Geneviève White
- Department of Pharmacy, Réseau local de Gaspé, CISSS de la Gaspésie, 215 Boul York W, Gaspé, QC, G4X 2W2, Canada.
| | - Noah Adessky
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Fei-Wen Chen
- Department of Pharmacy, CIUSSS Centre-Sud-de-l'île-de-Montréal, Hôpital Notre-Dame, 1560 Sherbrooke St E, Montreal, QC, H2L 4M1, Canada
| | - Anne Regazzoni
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Leon Tourian
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistic, University of Montreal, 2920 Chemin de la Tour, Montreal, QC, H3C 3J7, Canada
| | - Ashvini Gursahaney
- McGill University Health Centre, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Medicine and Critical Care, McGill University, Montreal, Canada
| | - Majed Alharbi
- Department of Psychiatry, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Department of Adult Mental Health, King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - David Williamson
- Department of Pharmacy and Research Center, Hôpital du Sacré-Coeur de Montréal, 5400 Gouin West, Montreal, QC, H4J 1C5, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc M Perreault
- Department of Pharmacy, Montreal General Hospital, McGill University Health Center, 1650 Cedar Ave., Montreal, QC, H3G 1A4, Canada
- Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
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7
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Young AM, Strobel RJ, Kaplan E, Norman AV, Ahmad R, Kern J, Yarboro L, Yount K, Hulse M, Teman NR. Delirium is associated with failure to rescue after cardiac surgery. JTCVS OPEN 2023; 16:464-476. [PMID: 38204716 PMCID: PMC10775056 DOI: 10.1016/j.xjon.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective Postoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. Methods We studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. Results Any episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. Conclusions A single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.
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Affiliation(s)
- Andrew M. Young
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J. Strobel
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Emily Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Anthony V. Norman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Raza Ahmad
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - John Kern
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Leora Yarboro
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Kenan Yount
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
| | - Matthew Hulse
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Nicholas R. Teman
- Division of Cardiac Surgery, University of Virginia, Charlottesville, Va
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8
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Pruskowski KA, Feth M, Hong L, Wiggins AR. Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients. Surg Clin North Am 2023; 103:495-504. [PMID: 37149385 DOI: 10.1016/j.suc.2023.02.003] [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: 05/08/2023]
Abstract
The majority of hospitalized burn patients experience pain, agitation, and delirium. The development of each one of these conditions can also lead to, or worsen, the others. Providers, therefore, need to thoroughly assess the underlying issue to determine the most effective treatment. Multimodal pharmacologic regimens are often used in conjunction with non-pharmacologic strategies to manage pain, agitation, and delirium. This review focuses on the pharmacologic management of these complicated patients in a critical-care setting.
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Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Maximilian Feth
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Linda Hong
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
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Ware LR, Schuler BR, Goodberlet MZ, Marino KK, Lupi KE, DeGrado JR. Evaluation of Dexmedetomidine as an Adjunct to Phenobarbital for Alcohol Withdrawal in Critically Ill Patients. J Intensive Care Med 2023; 38:553-561. [PMID: 36703284 DOI: 10.1177/08850666231152837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Dexmedetomidine (DEX) is commonly used with benzodiazepines for the management of alcohol withdrawal syndrome (AWS), but limited data exist regarding its use with phenobarbital (PHB). This analysis evaluated the utility of DEX in addition to PHB for AWS in adult patients admitted to the intensive care unit (ICU). METHODS This was a single-center, retrospective cohort analysis of critically ill adult patients who received PHB plus either DEX or different adjunctive therapies (NO-DEX) for AWS between 2018 and 2021. Patients were excluded if they had underlying altered mental status or seizure disorder unrelated to AWS or received PHB at outside hospitals. Coarsened exact matching (CEM) was performed to match patients on baseline characteristics in a 1:1 ratio. The primary outcome was ICU length of stay (LOS). A multivariate linear regression analysis was performed to assess the effects of DEX on ICU LOS when accounting for confounders. Secondary outcomes included days with delirium and incidence of mechanical ventilation after PHB administration. RESULTS Of the 606 encounters evaluated, 197 met criteria for inclusion. After CEM, 56 encounters remained in each group for analysis. The median ICU LOS was 97.2 [50.1:139.5] hours for the DEX group and 47.5 [28.8:88.1] hours for the NO-DEX group (P = .002). The multivariate linear regression analysis showed the use of DEX (P = .008) was independently associated with an increased ICU LOS by 49.8 h. The DEX group had higher rates of total delirium days (208 vs 143 days, P < .001) and a higher incidence of mechanical ventilation after PHB administration (32% vs 9%, P < .001). CONCLUSION This analysis suggests the use of adjunctive DEX with PHB for AWS was associated with a prolonged ICU LOS. Additional studies are needed to further understand the role of adjunctive DEX in the treatment of AWS in critically ill patients.
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Rajendraprasad S, Wheeler M, Wieruszewski E, Gottwald J, Wallace LA, Gerberi D, Wieruszewski PM, Smischney NJ. Clonidine use during dexmedetomidine weaning: A systematic review. World J Crit Care Med 2023; 12:18-28. [PMID: 36683967 PMCID: PMC9846870 DOI: 10.5492/wjccm.v12.i1.18] [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: 09/13/2022] [Revised: 11/15/2022] [Accepted: 11/30/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Dexmedetomidine is a centrally acting alpha-2A adrenergic agonist that is commonly used as a sedative and anxiolytic in the intensive care unit (ICU), with prolonged use increasing risk of withdrawal symptoms upon sudden discontinuation. As clonidine is an enterally available alpha-2A adrenergic agonist, it may be a suitable agent to taper off dexmedetomidine and reduce withdrawal syndromes. The appropriate dosing and conversion strategies for using enteral clonidine in this context are not known. The objective of this systematic review is to summarize the evidence of enteral clonidine application during dexmedetomidine weaning for prevention of withdrawal symptoms.
AIM To systematically review the practice, dosing schema, and outcomes of enteral clonidine use during dexmedetomidine weaning in critically ill adults.
METHODS This was a systematic review of enteral clonidine used during dexmedetomidine weaning in critically ill adults (≥ 18 years). Randomized controlled trials, prospective cohorts, and retrospective cohorts evaluating the use of clonidine to wean patients from dexmedetomidine in the critically ill were included. The primary outcomes of interest were dosing and titration schema of enteral clonidine and dexmedetomidine and risk factors for dexmedetomidine withdrawal. Other secondary outcomes included prevalence of adverse events associated with enteral clonidine use, re-initiation of dexmedetomidine, duration of mechanical ventilation, and ICU length of stay.
RESULTS A total of 3427 studies were screened for inclusion with three meeting inclusion criteria with a total of 88 patients. All three studies were observational, two being prospective and one retrospective. In all included studies, the choice to start enteral clonidine to wean off dexmedetomidine was made at the discretion of the physician. Weaning time ranged from 13 to 167 h on average. Enteral clonidine was started in the prospective studies in a similar protocolized method, with 0.3 mg every 6 h. After starting clonidine, patients remained on dexmedetomidine for a median of 1-28 h. Following the termination of dexmedetomidine, two trials tapered enteral clonidine by increasing the interval every 24 h from 6 h to 8h, 12h, and 24 h, followed by clonidine discontinuation. For indicators of enteral clonidine withdrawal, the previously tolerable dosage was reinstated for several days before resuming the taper on the same protocol. The adverse events associated with enteral clonidine use were higher than patients on dexmedetomidine taper alone with increased agitation. The re-initiation of dexmedetomidine was not documented in any study. Only 17 (37%) patients were mechanically ventilated with median duration of 3.5 d for 13 patients in one of the 2 studies. ICU lengths of stay were similar.
CONCLUSION Enteral clonidine is a strategy to wean critically ill patients from dexmedetomidine. There is an association of increased withdrawal symptoms and agitation with the use of a clonidine taper.
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Affiliation(s)
- Sanu Rajendraprasad
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN 55905, United States
| | - Molly Wheeler
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Erin Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Joseph Gottwald
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Lindsey A. Wallace
- Critical Care Medicine Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN 55905, United States
| | - Danielle Gerberi
- Mayo Medical Libraries, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Nathan J Smischney
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Pota V, Coppolino F, Barbarisi A, Passavanti MB, Aurilio C, Sansone P, Pace MC. Pain in Intensive Care: A Narrative Review. Pain Ther 2022; 11:359-367. [PMID: 35220551 PMCID: PMC9098741 DOI: 10.1007/s40122-022-00366-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/09/2022] [Indexed: 11/26/2022] Open
Abstract
All critically ill adult patients in intensive care units (ICU) typically experience pain. Critically ill adults suffer pain of different intensities. It depends on individual characteristics, specific procedural interventions, and underlying diseases. Inadequate management of acute pain is a risk factor for the emergence of chronic pain, where the incidence is up to 33% into the ICU survivor population. For the management of pain, agitation, and delirium, several coexisting clinical practice guidelines have been published. The first problem is that the patient recovered in intensive care unit should not be able to communicate its pain state. Opioids are the analgesic drugs of choice in critically ill patients with non-neuropathic pain. All intravenous opioids have the same effects, respecting the equianalgesic table. Observational research has shown that opioids are the main analgesic treatment in over 80% of mechanically ventilated patients. It is interesting that opioid consumption in an ICU and the memory of painful experience are linked to the development of post-traumatic stress disorder after ICU discharge. In order to reduce the side effects and maintain analgesia, it is useful to associate adjuvant medications with opioids. An opportunity to improve patients' experience in an ICU is to manage pain through multimodal approaches.
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Affiliation(s)
- Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Francesco Coppolino
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Alfonso Barbarisi
- Department of Translational Medical Science, Telematic University Pegaso, Naples, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Caterina Aurilio
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
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Nonpharmacological interventions for agitation in the adult intensive care unit: A systematic review. Aust Crit Care 2022; 36:385-400. [PMID: 35513998 DOI: 10.1016/j.aucc.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Person-centred nonpharmacological strategies should be used whenever possible to reduce agitation in the intensive care unit due to issues related to an overreliance on physical restraints and psychoactive drugs. However, the effect of nonpharmacological interventions to reduce agitation is unclear. OBJECTIVES The objectives of this study were to systematically review studies that evaluate the effectiveness of nonpharmacological interventions designed to prevent and minimise or manage patient agitation in the adult intensive care unit. METHODS This systematic review was conducted following the Joanna Briggs Institute's Systematic Review of Effectiveness method and a priori PROSPERO protocol. Quantitative studies were identified from seven databases, including MEDLINE, EmCare, CINAHL, Web of Science, PsycINFO, Scopus, and Cochrane Library. In addition, grey literature from several repositories and trial registers was searched. The primary outcome of interest was the effect on prevention, minimisation, and management of agitation. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RESULTS Eleven studies were included (n = 882). Meta-analyses of two studies demonstrated significantly lower levels of agitation (measured with the Richmond Agitation Sedation Scale) in the group receiving a multicomponent nonpharmacological intervention than in those receiving usual care. Individual studies showed a significant effect of nature-based sounds, music, foot reflexology, healing touch, and aromatherapy. The type of the endotracheal suction system did not affect levels of agitation. Overall, the certainty of the findings was rated very low. Harms and adverse effects were not reported in any studies. CONCLUSIONS Nonpharmacological interventions have the potential to reduce levels of agitation in the intensive care unit. However, inconsistencies in reporting, low quality of methodological designs, and small sample sizes impact the certainty of the results. Future trials must include larger sample sizes, use rigorous methods to improve knowledge in this field, and consider a range of other outcomes.
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Early Clinical and Electrophysiological Brain Dysfunction Is Associated With ICU Outcomes in COVID-19 Critically Ill Patients With Acute Respiratory Distress Syndrome: A Prospective Bicentric Observational Study. Crit Care Med 2022; 50:1103-1115. [PMID: 35135966 PMCID: PMC9196923 DOI: 10.1097/ccm.0000000000005491] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES: Describe the prevalence of acute cerebral dysfunction and assess the prognostic value of an early clinical and electroencephalography (EEG) assessment in ICU COVID-19 patients. DESIGN: Prospective observational study. SETTING: Two tertiary critical care units in Paris, France, between April and December 2020. PATIENTS: Adult critically ill patients with COVID-19 acute respiratory distress syndrome. INTERVENTIONS: Neurologic examination and EEG at two time points during the ICU stay, first under sedation and second 4–7 days after sedation discontinuation. MEASUREMENTS AND MAIN RESULTS: Association of EEG abnormalities (background reactivity, continuity, dominant frequency, and presence of paroxystic discharges) with day-28 mortality and neurologic outcomes (coma and delirium recovery). Fifty-two patients were included, mostly male (81%), median (interquartile range) age 68 years (56–74 yr). Delayed awakening was present in 68% of patients (median awakening time of 5 d [2–16 d]) and delirium in 74% of patients who awoke from coma (62% of mixed delirium, median duration of 5 d [3–8 d]). First, EEG background was slowed in the theta-delta range in 48 (93%) patients, discontinuous in 25 patients (48%), and nonreactive in 17 patients (33%). Bifrontal slow waves were observed in 17 patients (33%). Early nonreactive EEG was associated with lower day-28 ventilator-free days (0 vs 16; p = 0.025), coma-free days (6 vs 22; p = 0.006), delirium-free days (0 vs 17; p = 0.006), and higher mortality (41% vs 11%; p = 0.027), whereas discontinuous background was associated with lower ventilator-free days (0 vs 17; p = 0.010), coma-free days (1 vs 22; p < 0.001), delirium-free days (0 vs 17; p = 0.001), and higher mortality (40% vs 4%; p = 0.001), independently of sedation and analgesia. CONCLUSIONS: Clinical and neurophysiologic cerebral dysfunction is frequent in COVID-19 ARDS patients. Early severe EEG abnormalities with nonreactive and/or discontinuous background activity are associated with delayed awakening, delirium, and day-28 mortality.
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Wang T, Zhou D, Zhang Z, Ma P. Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients. Front Med (Lausanne) 2021; 8:744297. [PMID: 34869436 PMCID: PMC8632766 DOI: 10.3389/fmed.2021.744297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/20/2021] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Tao Wang
- Critical Care Medicine Department, Guiqian International General Hospital, Guiyang, China
| | - Dongxu Zhou
- Critical Care Medicine Department, Guiqian International General Hospital, Guiyang, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Penglin Ma
- Critical Care Medicine Department, Guiqian International General Hospital, Guiyang, China
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15
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Harorani M, Garshasbi M, Sediqi M, Farahani Z, Habibi D, Farahani M, Amini N, Velashjerdi Z. The effect of Shiatsu massage on agitation in mechanically ventilated patients: A randomized controlled trial. Heart Lung 2021; 50:893-897. [PMID: 34403892 DOI: 10.1016/j.hrtlng.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/14/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients admitted to the intensive care units encounter many complications due to the nature of the disease and invasive medical procedures such as intubation and mechanical ventilation. Among these complications, agitation is a frequently-observed and serious problem. OBJECTIVES This study aimed to investigate the effect of Shiatsu massage on agitation in mechanically ventilated patients. METHODS In this randomized controlled trial, a total of 68 mechanically ventilated patients were selected and then randomly assigned to two groups of intervention and control. Patients in the intervention group received three 5-minute periods of Shiatsu massage with a 2-minute break between them, while patients in the control group only received a touch on the area considered for the message. Data were collected before and after the intervention using the Richmond Agitation-Sedation Scale (RASS) and then analyzed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA). RESULTS The results showed that the level of agitation significantly decreased in the intervention group compared to the control group (p=.001). CONCLUSION Application of shiatsu massage seems to be effective in managing agitation in mechanically ventilated patients. Further studies with greater sample size and longer follow-up period are needed to confirm the current findings.
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Affiliation(s)
- Mehdi Harorani
- Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran; Traditional and Complementary Medicine Research Center (TCMRC), Arak University of Medical Sciences, Arak, Iran.
| | - Masoumeh Garshasbi
- Student Research Committee, Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Mohamad Sediqi
- Student Research Committee, Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Zohreh Farahani
- Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Danial Habibi
- Department of Biostatistics and Epidemiology, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahtab Farahani
- Student Research Committee, Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Nazanin Amini
- Department of paramedicine, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Velashjerdi
- Master of Nursing, Valiasr Arak Hospital, Arak University of Medical Sciences, Arak, Iran
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The effect of the family presence on anxiety and agitation of patients under mechanical ventilation after open heart surgery: a randomized clinical trial. Perioper Med (Lond) 2021; 10:40. [PMID: 34719406 PMCID: PMC8557965 DOI: 10.1186/s13741-021-00207-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background Family-centered care has been considered as a philosophy of care. Family presence in intensive care units (ICUs), especially in the acute phase of the disease is controversial. This study has been carried out in order to determine the effect of the family presence on anxiety and agitation in patients undergoing coronary artery bypass grafting (CABG). Materials and methods In a clinical trial, 70 patients were randomly allocated into groups of experimental and control. In the experimental group, during the weaning process from the mechanical ventilation, a family member was present at the bedside. The degree of anxiety and Richmond’s Agitation and Sedation Scale (RASS) were compared in seven consecutive time stages, including the time of entry into the ICU, the first respiratory drive, the family entrance, 20 min and 1 h after the presence of the family member, the time of extubation, and 1 h after extubation. Results There was a significant difference between the two groups in the mean scores of the anxiety scale in the first (P =0.008), second (P=0.002), and third stages (P =0.005). This difference was not significant in the fourth to seventh stages (P>0.05). As the baseline anxiety levels were different, a covariate adjustment was used for comparisons between treatments, adjusting the main analyses for baseline anxiety levels. Analysis showed that groups were not different. Also, there was no significant difference in the mean scores of RASS between the two experimental and control groups at any of the seven stages (P> 0.05). Conclusion According to the findings of the present study, the presence of a family member does not reduce the level of anxiety and agitation of patients undergoing cardiac surgery. However, it can be concluded that this intervention is feasible in acute and complex situations after open heart surgeries. Trial registration This study has been registered in the Iranian Registry of Clinical Trials with the code IRCT201609014299N4.
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Adams AMN, Chamberlain D, Grønkjær M, Thorup CB, Conroy T. Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review. Aust Crit Care 2021; 35:454-465. [PMID: 34373173 DOI: 10.1016/j.aucc.2021.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role. OBJECTIVES The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU. METHODS A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715. RESULTS Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues. CONCLUSIONS This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.
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Affiliation(s)
- Anne Mette N Adams
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia.
| | - Diane Chamberlain
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
| | - Mette Grønkjær
- Alborg University Hospital & Department of Clinical Medicine, Aalborg University, Denmark
| | - Charlotte Brun Thorup
- Department of Intensive Care and Clinical Nursing Research Unit, Aalborg University Hospital, Denmark
| | - Tiffany Conroy
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
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Saavedra-Mitjans M, David PM, Frenette AJ, Arbour C, Perreault M, Williams V, Bernard F, Williamson D. EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC): a protocol for an interprofessional mixed-method study. BMJ Open 2021; 11:e045816. [PMID: 34261680 PMCID: PMC8280902 DOI: 10.1136/bmjopen-2020-045816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Agitation and violent behaviours are common conditions developed by patients with acute traumatic brain injury (TBI) in intensive care units (ICUs). Healthcare professionals caring for these patients have various tools to manage these behaviours, but lack of a formal protocol to assess and manage them makes caring for these patients a challenge. Moreover, safety may often be compromised for both ICU professionals and patients encountering such situations. The EXperienceS and aTtitudes towards Agitated behaviours in Traumatic brain injury in the Intensive Care unit patients (EXSTATIC) study aims to explore the experiences and attitudes of ICU nurses and other ICU healthcare professionals on the management of agitated behaviours in patients with acute TBI. METHODS AND ANALYSIS EXSTATIC is a multicenter mixed methods convergent study exploring experiences and attitudes of ICU healthcare professionals caring of agitated patients with TBI. The study includes three qualitative methods (observation, semistructured interviews and focus groups) and one quantitative method (retrospective cohort). The integration of the different methods will be done using sequential steps of the research and by the integration of results for each step. Qualitative data will be evaluated following a thematic analysis derived from a grounded theory approach. Quantitative data will be analysed using descriptive statistics. Qualitative and quantitative results will be combined in a convergent interactive interpretative design. Gender and race perspective will be integrated in collection, analysis and interpretation of data. ETHICS AND DISSEMINATION This study has been approved by the Centre intégré universitaire de santé et de services sociaux du nord de l'île de Montréal (CIUSSS-NÎM) Research Ethics Board. The findings will be disseminated locally with ICU staff and health managers, international peer-reviewed journals, a PhD dissertation, and national and international conferences. The knowledge derived from this study is key in the development of clinical protocols to manage agitation and related behaviours in patients with TBI and designing further interventional studies targeting this specific problematic. TRIAL REGISTRATION NUMBER NCT04741399.
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Affiliation(s)
- Mar Saavedra-Mitjans
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
| | | | - Anne-Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
- Faculty of Nursing Sciences, Université de Montréal, Montreal, Quebec, Canada
| | - Marc Perreault
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Pharmacy Department, Montreal General Hospital, Montreal, Quebec, Canada
| | - Virginie Williams
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
| | - Francis Bernard
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
- Critical Care Unit, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
- Research Centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Montreal, Quebec, Canada
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Williamson DR, Cherifa SI, Frenette AJ, Saavedra Mitjans M, Charbonney E, Cataford G, Williams V, Lainer Palacios J, Burry L, Mehta S, Arbour C, Bernard F. Agitation, confusion, and aggression in critically ill traumatic brain injury-a pilot cohort study (ACACIA-PILOT). Pilot Feasibility Stud 2020; 6:193. [PMID: 33308318 PMCID: PMC7729148 DOI: 10.1186/s40814-020-00736-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/30/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Agitated behaviors are problematic in intensive care unit (ICU) patients recovering from traumatic brain injury (TBI) as they create substantial risks and challenges for healthcare providers. To date, there have been no studies evaluating their epidemiology and impact in the ICU. Prior to planning a multicenter study, assessment of recruitment, feasibility, and pilot study procedures is needed. In this pilot study, we aimed to evaluate the feasibility of conducting a large multicenter prospective cohort study. METHODS This feasibility study recruited adult patients admitted to the ICU with TBI and an abnormal cerebral CT scan. In all patients, we documented Richmond Agitation Sedation Score (RASS) and agitated behaviors every 8-h nursing shift using a dedicated tool documenting 14 behaviors. Our feasibility objectives were to obtain consent from at least 2 patients per month; completion of screening logs for agitated behaviors by bedside nurses for more than 90% of 8-h shifts; completion of data collection in an average of 6 h or less; and obtain 6-month follow-up for surviving patients. The main clinical outcome was the incidence of agitation and individual agitated behaviors. RESULTS In total, 47 eligible patients were approached for inclusion and 30 (64% consent rate) were recruited over a 10-month period (3 patients/month). In total, 794 out of 827 (96%) possible 8-h periods of agitated behavior logs were completed by bedside nurses, with a median of 24 observations (IQR 28.0) per patient. During the ICU stay, 17 of 30 patients developed agitation (56.7%; 95% CI 0.37-0.75) defined as RASS ≥ 2 during at least one observation period and for a median of 4 days (IQR 5.5). At 6 months post-TBI, among the 24 available patients, an unfavorable score (GOS-E < 5 including death) was reported in 12 patients (50%). In the 14 patients who were alive and available at 6 months, the median QOLIBRI score was 74.5 (IQR 18.5). CONCLUSIONS This study demonstrates the feasibility of conducting a larger cohort study to evaluate the epidemiology and impact of agitated behaviors in critically ill TBI patients. This study also shows that agitated behaviors are frequent and are associated with adverse events.
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Affiliation(s)
- David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada. .,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada. .,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.
| | - Sofia Ihsenne Cherifa
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Anne Julie Frenette
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Pharmacy Department, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Mar Saavedra Mitjans
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Emmanuel Charbonney
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Gabrielle Cataford
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.,Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Virginie Williams
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Julia Lainer Palacios
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Pharmacy Department, Mount Sinai Hospital, Toronto, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Arbour
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de sciences infirmières, Université de Montréal, Montréal, Canada
| | - Francis Bernard
- Research centre, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada.,Faculté de Médecine, Université de Montréal, Montréal, Canada.,Critical care, Hôpital du Sacré-Cœur de Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'île-de-Montréal, Montréal, Canada
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Weeden M, Desai N, Sriram S, Swami Palaniswami M, Wang B, Talbot L, Deane A, Bellomo R, Yan B. A pilot study of high frequency accelerometry-based sedation and agitation monitoring in critically ill patients. CRIT CARE RESUSC 2020; 22:245-252. [PMID: 32900331 PMCID: PMC10699079 DOI: 10.1016/s1441-2772(23)00392-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2025]
Abstract
OBJECTIVE The degree of sedation or agitation in critically ill patients is typically assessed with the Richmond Agitation and Sedation Scale (RASS). However, this approach is intermittent and subject to unrecognised variation between assessments. High frequency accelerometry may assist in achieving a quantitative and continuous assessment of sedation while heralding imminent agitation. DESIGN We undertook a prospective, observational pilot study. SETTING An adult tertiary intensive care unit in Melbourne, Australia. PARTICIPANTS 20 patients with an admission diagnosis of trauma. MAIN OUTCOME MEASURES Accelerometers were applied to patients' wrists and used to continuously record patient movement. Video data of patient behaviour were simultaneously collected, and observers blinded to accelerometry data were adjudicated the RASS score every 30 seconds. Exploratory analyses were undertaken. RESULTS Patients were enrolled for a median duration of 9.7 hours (interquartile range [IQR], 0-22.8) and a total of 160 hours. These patients had a median RASS score of 0 (IQR, -4 to 0). A 2-minute moving window of amplitude variance was seen to reflect contemporaneous fluctuations in motor activity and was proportional to the RASS score. Furthermore, the moving window of amplitude variance was observed to spike immediately before ≥ 2 point increases in the RASS score. CONCLUSIONS We describe a novel approach to the analysis of wrist accelerometry data in critically ill patients. This technique not only appears to provide novel and continuous information about the depth of sedation or degree of agitation, it is also notable in its aptitude to anticipate impending transitions to higher RASS values.
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Affiliation(s)
- Mark Weeden
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Nandakishor Desai
- Department of Electrical and Electronic Engineering, The University of Melbourne, Melbourne, VIC, Australia
| | - Shyamala Sriram
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Bo Wang
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Lachlan Talbot
- Department of Neuroscience, University of Melbourne, Melbourne, VIC, Australia
| | - Adam Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
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21
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Therapeutic options for agitation in the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:639-646. [PMID: 32777434 DOI: 10.1016/j.accpm.2020.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/20/2022]
Abstract
Agitation is common in the intensive care unit (ICU). There are numerous contributing factors, including pain, underlying disease, withdrawal syndrome, delirium and some medication. Agitation can compromise patient safety through accidental removal of tubes and catheters, prolong the duration of stay in the ICU, and may be related to various complications. This review aims to analyse evidence-based medical literature to improve management of agitation and to consider pharmacological strategies. The non-pharmacological approach is considered to reduce the risk of agitation. Pharmacological treatment of agitated patients is detailed and is based on a judicious choice of neuroleptics, benzodiazepines and α2 agonists, and on whether a withdrawal syndrome is identified. Specific management of agitation in elderly patients, brain-injured patients and patients with sleep deprivation are also discussed. This review proposes a practical approach for managing agitation in the ICU.
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22
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Long L, Ren S, Gong Y, Zhao H, He C, Shen L, Zhao H, Ma P. Different depths of sedation versus risk of delirium in adult mechanically ventilated patients: A systematic review and meta-analysis. PLoS One 2020; 15:e0236014. [PMID: 32673352 PMCID: PMC7365415 DOI: 10.1371/journal.pone.0236014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 06/27/2020] [Indexed: 01/04/2023] Open
Abstract
Background Delirium is multifactorial. This study aimed at determining the association between different depths of sedation and the risk of delirium in adult mechanically ventilated patients. Methods A systematic literature retrieval was conducted in databases including Cochrane Central Register of Controlled Trials, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature for publications available till December 2019 without limitation in study type, and followed by a secondary retrieval for related literature. STATA15.1 and WinBugs 14.3 were used in statistical analyses for different sedation depths as the intervention. The main endpoint was delirium occurrence. Secondary endpoints were agitation-related adverse events and mortality. Results We included 18 studies comprising 8001 mechanically ventilated patients. Different sedation depths were not associated with the occurrence of delirium (OR = 1.00, 95%CI: 0.64–1.58, P = 0.993). Among the 18 enrolled studies, this finding was not confounded by the dosage of benzodiazepines (OR = 0.96, 95%CI: 0.79–1.17, P = 0.717) in eight randomized controlled trials(RCTs) or the patients’ disease severity(OR 0.95, 95%CI: 0.79–1.13, P = 0.548) in 10 RCTs. However, contrasting results were found in non-RCTs. The deeper sedation group had a significantly increased risk for death(OR = 1.82, 95% CI: 1.23–2.69, P = 0.003), whereas lighter sedation seemed a potential risk for agitation-related adverse events (OR = 0.61, 95%CI: 0.45–0.84, P = 0.002). Conclusions It is inconclusive whether significantly different sedation depths would change the risk of delirium in adult mechanically ventilated patients. Trial registration number The study was registered in PROSPERO(http://www.crd.york.ac.uk/PROSPERO/) under registration number CRD42019145276.
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Affiliation(s)
- Ling Long
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Shan Ren
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Yichun Gong
- SICU, the 8th Medical Center, General Hospital of PLA, Beijing City, China
| | - Haotian Zhao
- Ultrasound Department, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Cong He
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Limin Shen
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Heling Zhao
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
| | - Penglin Ma
- Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang City, Hebei Province, China
- Critical Care Medicine Department, Peking University Third Hospitial, Beijing City, China
- * E-mail:
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23
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Buckley MS, Smithburger PL, Wong A, Fraser GL, Reade MC, Klein-Fedyshin M, Ardiles T, Kane-Gill SL. Dexmedetomidine for Facilitating Mechanical Ventilation Extubation in Difficult-to-Wean ICU Patients: Systematic Review and Meta-Analysis of Clinical Trials. J Intensive Care Med 2020; 36:925-936. [PMID: 32627672 DOI: 10.1177/0885066620937673] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Agitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes. METHODS A literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia. RESULTS A total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: -11.61 hours, 95% CI: -16.5 to -6.7, P = .005) and ICU length of stay (WMD: -3.04 days; 95% CI: -4.66 to -1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: -2.67 days; 95% CI: -7.73 to 2.39). CONCLUSIONS Dexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, 22386Banner-University Medical Center Phoenix, Phoenix, AZ, USA
| | - Pamela L Smithburger
- Department of Pharmacy and Therapeutics, 15523University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Adrian Wong
- Department of Pharmacy Practice, 1825MCPHS University, Boston, MA, USA
| | - Gilles L Fraser
- Department of Medicine, 12261Tufts University School of Medicine, Boston, MA, USA.,Maine Medical Center, Portland, ME, USA
| | - Michael C Reade
- University of Queensland, 3883Royal Brisbane and Women's Hospital, Queensland, Australia
| | | | - Thomas Ardiles
- 42283University of Arizona Phoenix School of Medicine, Phoenix, AZ, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Critical Care Medicine, Clinical Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.,Department of Pharmacy, 199716University Pittsburgh Medical Center, Pittsburgh, PA, USA
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24
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Cucci MD, Cunningham BS, Patel JS, Shimer AT, Mofleh DI, Mullen CL. Impact of Early Reinitiation of Neuropsychiatric Medications on Agitation and Delirium in the Intensive Care Unit: A Retrospective Study. Ann Pharmacother 2020; 55:15-24. [PMID: 32567359 DOI: 10.1177/1060028020935589] [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: 11/17/2022] Open
Abstract
BACKGROUND Approximately 17% of intensive care unit (ICU) patients are prescribed at least 1 home neuropsychiatric medication (NPM). When abruptly discontinued, withdrawal symptoms may occur manifesting as agitation or delirium in the ICU setting. OBJECTIVE To evaluate the impact of early reinitiation of NPMs. METHODS This was a retrospective, observational cohort of adult ICU patients in a tertiary care hospital. Patients were included if admitted to the ICU and prescribed a NPM prior to arrival. Study groups were based on the timing of reinitiation of at least 50% of NPMs: ≤72 hours (early group) versus >72 hours (late group). RESULTS The primary outcome was the proportion of patients with at least 1 agitation or delirium episode in the first 72 hours. Agitation and delirium were defined as at least 1 RASS assessment between +2 to +4 and a positive CAM-ICU assessment, respectively. A total of 300 patients were included, with 187 (62%) and 113 (38%) in the early and late groups, respectively. There was no difference in agitation or delirium (late 54 [48%] vs early 62 [33%]; adjusted odds ratio [aOR] = 1.5; 95% CI = 0.8-2.8; P = 0.193). Independent risk factors found to be associated with the primary outcome were restraints (aOR = 12.9; 95% CI = 6.9-24.0; P < 0.001) and benzodiazepines (BZDs; aOR = 2.0; 95% CI = 1.0-3.7; P = 0.038). CONCLUSIONS After adjustment for baseline differences, there was no difference in agitation or delirium. Independent risk factors were restraint use and newly initiated BZDs.
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25
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Goyal K, Garg N, Bithal P. Central fever: a challenging clinical entity in neurocritical care. JOURNAL OF NEUROCRITICAL CARE 2020. [DOI: 10.18700/jnc.190090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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26
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Épisodes d’agitation et d’hallucinations dans les suites d’une intoxication aux tricycliques : à partir de deux cas cliniques. Therapie 2020; 75:311-314. [DOI: 10.1016/j.therap.2019.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/08/2019] [Accepted: 03/15/2019] [Indexed: 11/21/2022]
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27
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Gong Y, Yang H, Xie J, Liu J, Zhou J, Ma P. ICU Physicians' Perception of Patients' Tolerance Levels in Light Sedation Impacts Sedation Practice for Mechanically Ventilated Patients. Front Med (Lausanne) 2019; 6:226. [PMID: 31681782 PMCID: PMC6813223 DOI: 10.3389/fmed.2019.00226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022] Open
Abstract
Purpose: To investigate physicians' perception of patients' tolerance levels regarding sedation, which could affect sedation practice for mechanically ventilated (MV) patients. Methods: This is a questionnaire survey combined with a 24 h cross-sectional study. The physician's propensity score for light sedation (PS-LS) was estimated by his/her response to the given answers for each item of the questionnaire, which tested the levels of interviewee's desire to manage MV patient with light sedation. Thereby, the mean physicians' PS-LS of each participating ICU (ICU-meanPS-LS) was calculated. The practical measurements of all variables listed on the questionnaire were used to semi-quantitatively assess stimulus intensity of what the recruited patients suffered (i.e., semi-quantitative stimulus intensity, SSI). Sedation depth was assessed by Richmond Agitation Sedation Scale (RASS). Results: 555 of 558 (99.5%) physicians from 102 ICUs were concerned with patients' tolerance levels regarding sedation while titrating sedation depth. The physician's PS-LS was non-normally distributed with median (IQR) of 3 (0–5). ICU-meanPS-LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from −5 to 7 with a median (IQR) of 2.37 (0.16–4.33). A significant increasing trend in prevalence of light sedation was observed over increasing ICU-meanPS-LS quartiles (from Q1 to Q4, χ2-test for trend, p = 0.002). Moreover, odds ratio for probability of light sedation remained significant in MV patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE II score (OR, 2.332; 95% CI: 1.463–3.717; p < 0.001) or SSI score (OR, 2.445; 95% CI: 1.468–4.074; p = 0.001). Notably, adjusted OR for mortality was significant in deeply sedated MV patients (OR, 2.034; 95% CI: 1.435–2.884; p < 0.001). Conclusions: ICU physician's individualized perception for patients' tolerance levels regarding sedation, in light sedation affected sedation practice for MV patients.
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Affiliation(s)
- Yichun Gong
- Medical School of Chinese PLA, Beijing, China.,SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | | | - Junqing Xie
- Feng Tai District Center for Disease Control and Prevention, Beijing, China
| | - Jingtao Liu
- SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Jianxin Zhou
- NICU, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Penglin Ma
- Medical School of Chinese PLA, Beijing, China.,SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
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28
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An Integrative Literature Review of Psychiatric Rapid Response Teams and Their Implementation for De-escalating Behavioral Crises in Nonpsychiatric Hospital Settings. ACTA ACUST UNITED AC 2019; 49:297-302. [DOI: 10.1097/nna.0000000000000756] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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29
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Choi M, Barra ME, Newman K, Sin JH. Safety and Effectiveness of Intravenous Chlorpromazine for Agitation in Critically Ill Patients. J Intensive Care Med 2018; 35:1118-1122. [PMID: 30558470 DOI: 10.1177/0885066618818787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Agitation is common in the intensive care unit (ICU). Although antipsychotics are frequently used as first-line therapy, chlorpromazine has fallen out of favor due to risk of cardiovascular complications and severe hypotension. Although chlorpromazine is used anecdotally, there is a lack of data regarding its safety and effectiveness. The objective of this study was to investigate the use of intravenous (IV) chlorpromazine for agitation in the ICU setting. METHODS A retrospective review was performed at a tertiary care academic medical center. Patients were included if they received IV chlorpromazine in the ICU for agitation, infused at a rate of 1 mg/min. Primary end points were change in systolic blood pressure (SBP), heart rate (HR), and mean arterial pressure (MAP) within 4 hours of administration. Secondary end points included change in vasopressor and adjunct sedative medication requirements, achievement of Richmond-Agitation Sedation Scale (RASS) 0 to -1, and incidence of cardiac arrhythmias. RESULTS A total of 39 patients encompassing 107 IV chlorpromazine administrations were included. The median dose was 25 mg. Median vital signs prior to infusion were SBP 129 mm Hg, HR 90 beats/minute, and MAP 88 mm Hg. Over the subsequent 4 hours, SBP and HR did not change significantly (P = .83 and P = .10, respectively). Mean arterial pressure decreased from a median of 88 to 83 mm Hg (P = .04). There were no significant changes in vasopressor requirements, adjunct sedative medication requirements, or achievement of RASS goal. No patients developed symptomatic cardiac arrhythmias. CONCLUSION In our small retrospective study, the use of IV chlorpromazine at routine doses did not result in clinically significant hemodynamic changes when infused at a rate of 1 mg/min. Intravenous chlorpromazine may be considered as a potential treatment option for agitation in ICU patients with appropriate monitoring.
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Affiliation(s)
- Mia Choi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Kelly Newman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan H Sin
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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30
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McGovern C, Cowan R, Appleton R, Miles B. Pain, agitation and delirium in the intensive care unit. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2018. [DOI: 10.1016/j.mpaic.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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31
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Stewart D, Kinsella J, McPeake J, Quasim T, Puxty A. The influence of alcohol abuse on agitation, delirium and sedative requirements of patients admitted to a general intensive care unit. J Intensive Care Soc 2018; 20:208-215. [PMID: 31447913 DOI: 10.1177/1751143718787748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Purpose Patients with alcohol-related disease constitute an increasing proportion of those admitted to intensive care unit. There is currently limited evidence regarding the impact of alcohol use on levels of agitation, delirium and sedative requirements in intensive care unit. This study aimed to determine whether intensive care unit-admitted alcohol-abuse patients have different sedative requirements, agitation and delirium levels compared to patients with no alcohol issues. Methods This retrospective analysis of a prospectively acquired database (June 2012-May 2013) included 257 patients. Subjects were stratified into three risk categories: alcohol dependency (n = 69), at risk (n = 60) and low risk (n = 128) according to Fast Alcohol Screening Test scores and World Health Organisation criteria for alcohol-related disease. Data on agitation and delirium were collected using validated retrospective chart-screening methods and sedation data were extracted and then log-transformed to fit the regression model. Results Incidence of agitation (p = 0.034) and delirium (p = 0.041) was significantly higher amongst alcohol-dependent patients compared to low-risk patients as was likelihood of adverse events (p = 0.007). In contrast, at-risk patients were at no higher risk of these outcomes compared to the low-risk group. Alcohol-dependent patients experienced suboptimal sedation levels more frequently and received a wider range of sedatives (p = 0.019) but did not receive higher daily doses of any sedatives. Conclusions Our analysis demonstrates that when admitted to intensive care unit, it is those who abuse alcohol most severely, alcohol-dependent patients, rather than at-risk drinkers who have a significantly increased risk of agitation, delirium and suboptimal sedation. These patients may require closer assessment and monitoring for these outcomes whilst admitted.
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Affiliation(s)
- Donald Stewart
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - John Kinsella
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Joanne McPeake
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
PURPOSE OF REVIEW Monitoring of mental status and peripheral circulatory changes can be accomplished noninvasively in patients in the ICU. Emphasis on physical examination in conditions such as sepsis have gained increased attention as these evaluations can often serve as a surrogate marker for short-term treatment efficacy of therapeutic interventions. Sepsis associated encephalopathy and mental status changes correlate with worse prognosis in patients. Evaluation of peripheral circulation has been shown to be a convenient, easily accessible, and accurate marker for prognosis in patients with septic shock. The purpose of this article is to emphasize the main findings according to recent literature into the monitoring of physical examination changes in patients with sepsis. RECENT FINDINGS Several recent studies have expanded our knowledge about the pathophysiology of mental status changes and the clinical assessment of peripheral circulation in patients with sepsis. Sepsis-associated encephalopathy is associated with an increased rate of morbidity and mortality in an intensive care setting. Increased capillary refill time (CRT) and persistent skin mottling are strongly predictive of mortality, whereas temperature gradients can reveal vasoconstriction and more severe organ dysfunction. SUMMARY Monitoring of physical examination changes is a significant and critical intervention in patients with sepsis. Utilizing repeated neurologic evaluations, and assessing CRT, mottling score, and skin temperature gradients should be emphasized as important noninvasive diagnostic tools. The significance of these methods can be incorporated during the utilization of therapeutic strategies in resuscitation protocols in patients with sepsis.
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Freeman S, Yorke J, Dark P. Patient agitation and its management in adult critical care: A integrative review and narrative synthesis. J Clin Nurs 2018; 27:e1284-e1308. [PMID: 29314320 DOI: 10.1111/jocn.14258] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
AIMS AND OBJECTIVE To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies. BACKGROUND Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness. STUDY DESIGN Integrative review and narrative synthesis. METHODS A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach. RESULTS A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management. CONCLUSIONS Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance. RELEVANCE TO CLINICAL PRACTICE The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.
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Affiliation(s)
| | | | - Paul Dark
- University of Manchester, Manchester, UK
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Mahmood S, Mahmood O, El-Menyar A, Asim M, Al-Thani H. Predisposing factors, clinical assessment, management and outcomes of agitation in the trauma intensive care unit. World J Emerg Med 2018; 9:105-112. [PMID: 29576822 DOI: 10.5847/wjem.j.1920-8642.2018.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Agitation occurs frequently among critically ill patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS A total of 102 intubated patients were enrolled; of which 46 (45%) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95% CI=1.35-18.27), subarachnoid hemorrhage (OR=5.11; 95% CI=1.38-18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95% CI=1.16-15.35) were independent predictors for agitation (P<0.01). CONCLUSION Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.
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Affiliation(s)
- Saeed Mahmood
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar.,Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Department of Surgery, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
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Tilouche N, Hassen MF, Ali HBS, Jaoued O, Gharbi R, El Atrous SS. Delirium in the Intensive Care Unit: Incidence, Risk Factors, and Impact on Outcome. Indian J Crit Care Med 2018; 22:144-149. [PMID: 29657370 PMCID: PMC5879855 DOI: 10.4103/ijccm.ijccm_244_17] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: The incidence and risk factors for delirium vary among studies. Objective: We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study. Patients: All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU. Results: A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6–20] vs. 2 days[0–7]) respectively and length of stay in ICU (21.5 days [10.5–32.5] vs. 8 days [5–13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39–12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31–8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47–8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05–7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08–13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality. Conclusion: Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.
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Affiliation(s)
- Nejla Tilouche
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
| | - Mohamed Fekih Hassen
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
| | - Habiba Ben Sik Ali
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
| | - Oussamma Jaoued
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
| | - Rim Gharbi
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
| | - S Souheil El Atrous
- Intensive Care Unit, University Hospital Taher Sfar Mahdia 5100, Tunisia.,University of Monastir, Research Laboratory, LR 12SP15
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Oral Agents for the Management of Agitation and Agitated Delirium in Critically Ill Patients. Crit Care Nurs Q 2017; 40:344-362. [PMID: 28834857 DOI: 10.1097/cnq.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Agitation is one of the most common issues that critically ill patients experience. Medications used to manage agitation are often administered intravenously or intramuscularly in the acutely agitated, critically ill patient. However, a multimodal approach that utilizes multiple routes of administration may be appropriate. This review summarizes the available literature on oral antipsychotics, clonidine, and valproic acid to manage agitation in critically ill patients while also focusing on their pharmacology and appropriate monitoring. Despite inconclusive findings from different studies, antipsychotics, clonidine, and valproic acid may provide benefit for specific patient populations. As more evidence emerges, these agents may start playing a greater role in the management of agitation, which is not amenable to first-line agents. As health care professionals, it is prudent to be familiar with their dosing regimens, common adverse effects, and the monitoring required to maximize patient benefits and minimize harms.
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Leal MLM, Loyola ABAT, Hueb AC, Silva JDD, Mesquita M, Paiva LFD, Guerrieri MLJ, Fernandes JPN, Barros AC, Ferreira LM. Fixation of the short-term central venous catheter. A comparison of two techniques. Acta Cir Bras 2017; 32:680-690. [PMID: 28902944 DOI: 10.1590/s0102-865020170080000010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/05/2017] [Indexed: 11/22/2022] Open
Abstract
Purpose: To compare the fixation of the central venous catheter (CVC) using two suture techniques. Methods: A clinical, analytical, interventional, longitudinal, prospective, controlled, single-blind and randomized study in adult, intensive care unit (ICU) patients. After admission and indication of CVC use, the patients were allocated to the Wing group (n = 35, catheter fixation with clamping wings and retainers) or Shoelace group (n = 35, catheter fixation using shoelace cross-tied sutures around the device). Displacement, kinking, fixation failure, hyperemia at the insertion site, purulent secretion, loss of the device, psychomotor agitation, mental confusion, and bacterial growth at the insertion site were evaluated. Results: Compared with the Wing group, the Shoelace group had a lower occurrence of catheter displacement (n=0 versus n =4; p = 0.04), kinking (n=0 versus n=8; p=0.001), and fixation failure (n=2 versus n=8; p=0.018). No significant difference was found in bacterial growth (n=20 versus n=14; p=0.267) between groups. Conclusion: The Shoelace fixation technique presented fewer adverse events than the Wing fixation technique.
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Affiliation(s)
- Mário Lúcio Marques Leal
- Fellow Master degree, Professional Master's Program in Applied Health Sciences, Universidade do Vale do Sapucaí (UNIVÁS), Pouso Alegre-MG, Brazil. Conception, design, intellectual and scientific content of the study; acquisition, interpretation and analysis of data; manuscript writing
| | - Ana Beatriz Alkmim Teixeira Loyola
- PhD, Associate Professor, Professional Master's Program in Applied Health Sciences, UNIVÁS, Pouso Alegre-MG, Brazil. Conception, design, intellectual and scientific content of the study; interpretation and analysis of data; manuscript writing; critical revision; final approval
| | - Alexandre Ciappina Hueb
- PhD, Head, Department of Cardiac Surgery, Hospital das Clínicas Samuel Libânio, UNIVÁS, Pouso Alegre-MG, Brazil. Critical revision
| | - José Dias da Silva
- PhD, Associate Professor, Professional Master's Program in Applied Health Sciences, UNIVÁS, Pouso Alegre-MG, Brazil. Critical revision
| | - Marcos Mesquita
- PhD, Full Professor, Department of Biostatistics, UNIVÁS, Pouso Alegre-MG, Brazil. Interpretation of data, statistical analysis, critical revision
| | | | | | - João Paulo Nunes Fernandes
- MD, Intensive Care Department, Hospital das Clínicas Samuel Libânio, UNIVÁS, Pouso Alegre-MG, Brazil. Technical procedures, acquisition of data
| | | | - Lydia Masako Ferreira
- PhD, Chairwoman, Head, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), Brazil. Critical revision, final approval
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Chanques G, Conseil M, Roger C, Constantin JM, Prades A, Carr J, Muller L, Jung B, Belafia F, Cissé M, Delay JM, de Jong A, Lefrant JY, Futier E, Mercier G, Molinari N, Jaber S, Chanques G, Conseil M, Prades A, Carr J, Jung B, Belafia F, Cissé M, Delay JM, De Jong A, Verzilli D, Clavieras N, Jaber S, Mercier G, Molinari N, Mathieu E, Bertet H, Roger C, Muller L, Lefrant JY, Boutin C, Constantin JM, Futier E, Cayot S, Perbet S, Jabaudon M. Immediate interruption of sedation compared with usual sedation care in critically ill postoperative patients (SOS-Ventilation): a randomised, parallel-group clinical trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:795-805. [DOI: 10.1016/s2213-2600(17)30304-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/25/2022]
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Wang J, Ji Y, Wang N, Chen W, Bao Y, Qin Q, Xiao Q, Li S. Risk factors for the incidence of delirium in cerebrovascular patients in a Neurosurgery Intensive Care Unit: A prospective study. J Clin Nurs 2017; 27:407-415. [PMID: 28677160 DOI: 10.1111/jocn.13943] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 01/29/2023]
Abstract
AIMS AND OBJECTIVES To explore the incidence of delirium in cerebrovascular patients admitted in our Neurosurgery Intensive Care Unit and analyse the risk factors leading to delirium. BACKGROUND Delirium is one of the most common mental disorders in general hospitals, but the incidence of different kinds of diseases and studies varies. Cerebrovascular patients in our Neurosurgery Intensive Care Unit are high-risk groups for delirium; identifying risk factors for delirium and taking early interventions are crucial for patient prognosis. DESIGN A prospective study. METHODS A convenience sampling method was used to collect data from 128 patients in the Neurosurgery Intensive Care Unit of Xuanwu Hospital, Capital Medical University, Beijing, China, between May 2016-January 2017. Researchers used Confusion Assessment Method for the Intensive Care Unit (Chinese version) to assess each patient's delirium statement twice a day at regular times. We also collected other independent data variables and followed up the short-term clinical outcomes daily. RESULTS On the basis of Confusion Assessment Method for the Intensive Care Unit evaluation, patients were divided into a delirium group and a nondelirium group. The prevalence of delirium among the 128 patients was 42.2%. Multivariate analysis showed that severity of illness, fever, the use of physical restraints and sleep deprivation were independent predictors of delirium in cerebrovascular patients in the Neurosurgery Intensive Care Unit. CONCLUSIONS Cerebrovascular patients in the Neurosurgery Intensive Care Unit with a critical condition, fever or use of physical restraints or experiencing sleep deprivation were more prone to delirium. RELEVANCE TO CLINICAL PRACTICE Cerebrovascular patients in the Neurosurgery Intensive Care Unit showed a high incidence of delirium. There are many risk factors leading to delirium, some of which are independent predictors of intensive care delirium. Patients with delirium will suffer various adverse effects upon their short-term clinical outcomes. Therefore, nurses should pay close attention to changes in a patient's mental state and learn about the risk factors associated with delirium, in order to be able to take early measures to prevent delirium.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ning Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenjin Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuehong Bao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qinpu Qin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qian Xiao
- School of Nursing, Capital Medical University, Beijing, China
| | - Shulan Li
- School of Nursing, Capital Medical University, Beijing, China
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Gaudry S, Sztrymf B, Sonneville R, Megarbane B, Van Der Meersch G, Vodovar D, Cohen Y, Ricard JD, Hajage D, Salomon L, Dreyfuss D. Loxapine to control agitation during weaning from mechanical ventilation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:235. [PMID: 28877705 PMCID: PMC5586048 DOI: 10.1186/s13054-017-1822-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023]
Abstract
Background Weaning from mechanical ventilation (MV) may be impeded by the occurrence of agitation. Loxapine has the ability to control agitation without affecting spontaneous ventilation. The aim of this study was to establish whether loxapine would reduce MV weaning duration in agitated patients. Methods We performed a multicentre, double-blind, placebo-controlled, parallel group, randomised trial. Patients who were potential candidates for weaning but exhibited agitation (Richmond Agitation-Sedation Scale score ≥ 2) after sedation withdrawal were randomly assigned to receive either loxapine or placebo. In case of severe agitation, conventional sedation was immediately resumed. The primary endpoint was the time between first administration of loxapine or placebo and successful extubation. Results The trial was discontinued after 102 patients were enrolled because of an insufficient inclusion rate. Median times to successful extubation were 3.2 days in the loxapine group and 5 days in the placebo group (relative risk 1.2, 95% CI 0.75–1.88, p = 0.45). During the first 24 h, sedation was more frequently resumed in the placebo group (44% vs 17%, p = 0.01). Conclusions In this prematurely stopped trial, loxapine did not significantly shorten weaning from MV. However, loxapine reduced the need for resuming sedation. Trial registration Clinicaltrials.gov, NCT01193816. Registered on 26 August 2010.
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Affiliation(s)
- Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France.,Epidémiologie Clinique et Évaluation Économique Appliqué aux Populations Vulnérables (ECEVE), UMR 1123, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France
| | - Benjamin Sztrymf
- Service de Réanimation Polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, F-92140, Clamart, France.,INSERM U999, Université Paris Sud, F-92060, Le Plessis Robinson, France
| | - Romain Sonneville
- Service de Réanimation Médicale et maladies infectieuses, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Bruno Megarbane
- Service de Réanimation Médicale, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Guillaume Van Der Meersch
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | - Dominique Vodovar
- Service de Réanimation Médicale, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Yves Cohen
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny, France
| | - Jean-Damien Ricard
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France
| | - David Hajage
- Epidémiologie Clinique et Évaluation Économique Appliqué aux Populations Vulnérables (ECEVE), UMR 1123, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France.,Département d'Epidémiologie et Recherche Clinique, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, 178 rue des Renouillers, F-92700, Colombes, France
| | - Laurence Salomon
- Département d'Epidémiologie et Recherche Clinique, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, 178 rue des Renouillers, F-92700, Colombes, France
| | - Didier Dreyfuss
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, F-92700, Colombes, France. .,Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, F-75018, Paris, France. .,Present address: Intensive Care Unit, Hôpital Louis Mourier, 178 rue des Renouillers, 92110, Colombes, France.
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Potentially modifiable factors contributing to sepsis-associated encephalopathy. Intensive Care Med 2017; 43:1075-1084. [PMID: 28466149 DOI: 10.1007/s00134-017-4807-z] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Identifying modifiable factors for sepsis-associated encephalopathy may help improve patient care and outcomes. METHODS We conducted a retrospective analysis of a prospective multicenter database. Sepsis-associated encephalopathy (SAE) was defined by a score on the Glasgow coma scale (GCS) <15 or when features of delirium were noted. Potentially modifiable risk factors for SAE at ICU admission and its impact on mortality were investigated using multivariate logistic regression analysis and Cox proportional hazard modeling, respectively. RESULTS We included 2513 patients with sepsis at ICU admission, of whom 1341 (53%) had sepsis-associated encephalopathy. After adjusting for baseline characteristics, site of infection, and type of admission, the following factors remained independently associated with sepsis-associated encephalopathy: acute renal failure [adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) 1.19-1.67], hypoglycemia <3 mmol/l (aOR = 2.66, 95% CI 1.27-5.59), hyperglycemia >10 mmol/l (aOR = 1.37, 95% CI 1.09-1.72), hypercapnia >45 mmHg (aOR = 1.91, 95% CI 1.53-2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48-3.57), and S. aureus (aOR = 1.54, 95% CI 1.05-2.25). Sepsis-associated encephalopathy was associated with higher mortality, higher use of ICU resources, and longer hospital stay. After adjusting for age, comorbidities, year of admission, and non-neurological SOFA score, even mild alteration of mental status (i.e., a score on the GCS of 13-14) remained independently associated with mortality (adjusted hazard ratio = 1.38, 95% CI 1.09-1.76). CONCLUSIONS Acute renal failure and common metabolic disturbances represent potentially modifiable factors contributing to sepsis-associated encephalopathy. However, a true causal relationship has yet to be demonstrated. Our study confirms the prognostic significance of mild alteration of mental status in patients with sepsis.
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Kowalski M, Udy AA, McRobbie HJ, Dooley MJ. Nicotine replacement therapy for agitation and delirium management in the intensive care unit: a systematic review of the literature. J Intensive Care 2016; 4:69. [PMID: 27891229 PMCID: PMC5109763 DOI: 10.1186/s40560-016-0184-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/09/2016] [Indexed: 11/16/2022] Open
Abstract
Background Active smokers are prevalent within the intensive care setting and place a significant burden on healthcare systems. Nicotine withdrawal due to forced abstinence on admission may contribute to increased agitation and delirium in this patient group. The aim of this systematic review was to determine whether management of nicotine withdrawal, with nicotine replacement therapy (NRT), reduces agitation and delirium in critically ill patients admitted to the intensive care unit (ICU). Methods The following sources were used in this review: MEDLINE, EMBASE, and CINAHL Plus databases. Included studies reported delirium or agitation outcomes in current smokers, where NRT was used as management of nicotine withdrawal, in the intensive care setting. Studies were included regardless of design or number of participants. Data were extracted on ICU classification; study design; population baseline characteristics; allocation and dose of NRT; agitation and delirium assessment methods; and the frequency of agitation, delirium, and psychotropic medication use. Results Six studies were included. NRT was mostly prescribed for smokers with heavier smoking histories. Three studies reported an association between increased agitation or delirium and NRT use; one study could not find any significant benefit or harm from NRT use; and two described a reduction of symptomatic nicotine withdrawal. A lack of consistent and validated assessment measures, combined with limitations in the quality of reported data, contribute to conflicting results. Conclusions Current evidence for the use of NRT in agitation and delirium management in the ICU is inconclusive. An evaluation of risk versus benefit on an individual patient basis should be considered when prescribing NRT. Further studies that consider prognostic balance, adjust for confounders, and employ validated assessment tools are urgently needed.
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Affiliation(s)
- Melanie Kowalski
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ; Intensive Care Unit, Alfred Health, Melbourne, Australia ; Monash University, Melbourne, Australia
| | - Andrew A Udy
- Intensive Care Unit, Alfred Health, Melbourne, Australia ; Monash University, Melbourne, Australia
| | - Hayden J McRobbie
- Wolfson Institute of Preventive Medicine, London, UK ; Queen Mary University of London, London, UK
| | - Michael J Dooley
- Pharmacy Department, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ; Monash University, Melbourne, Australia
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de Almeida TML, de Azevedo LCP, Nosé PMG, de Freitas FGR, Machado FR. Risk factors for agitation in critically ill patients. Rev Bras Ter Intensiva 2016; 28:413-419. [PMID: 28099638 PMCID: PMC5225916 DOI: 10.5935/0103-507x.20160074] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/21/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE: To evaluate the incidence of agitation in the first 7 days after intensive care unit admission, its risk factors and its associations with clinical outcomes. METHODS: This single-center prospective cohort study included all patients older than 18 years with a predicted stay > 48 hours within the first 24 hours of intensive care unit admission. Agitation was defined as a Richmond Agitation Sedation Scale score ≥ +2, an episode of agitation or the use of a specific medication recorded in patient charts. RESULTS: Agitation occurred in 31.8% of the 113 patients. Multivariate analysis showed that delirium [OR = 24.14; CI95% 5.15 - 113.14; p < 0.001], moderate or severe pain [OR = 5.74; CI95% 1.73 - 19.10; p = 0.004], mechanical ventilation [OR = 10.14; CI95% 2.93 - 35.10; p < 0.001], and smoking habits [OR = 4.49; CI95% 1.33 - 15.17; p = 0.015] were independent factors for agitation, while hyperlactatemia was associated with a lower risk [OR = 0.169; CI95% 0.04 - 0.77; p = 0.021]. Agitated patients had fewer mechanical ventilation-free days at day 7 (p = 0.003). CONCLUSION: The incidence of agitation in the first 7 days after admission to the intensive care unit was high. Delirium, moderate/severe pain, mechanical ventilation, and smoking habits were independent risk factors. Agitated patients had fewer ventilator-free days in the first 7 days.
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Affiliation(s)
- Thiago Miranda Lopes de Almeida
- Anesthesiology, Pain and Intensive Care Department,
Escola Paulista de Medicina, Universidade Federal de São Paulo - Sao
Paulo (SP), Brazil
| | - Luciano Cesar Pontes de Azevedo
- Anesthesiology, Pain and Intensive Care Department,
Escola Paulista de Medicina, Universidade Federal de São Paulo - Sao
Paulo (SP), Brazil
| | - Paulo Maurício Garcia Nosé
- Anesthesiology, Pain and Intensive Care Department,
Escola Paulista de Medicina, Universidade Federal de São Paulo - Sao
Paulo (SP), Brazil
| | - Flavio Geraldo Resende de Freitas
- Anesthesiology, Pain and Intensive Care Department,
Escola Paulista de Medicina, Universidade Federal de São Paulo - Sao
Paulo (SP), Brazil
| | - Flávia Ribeiro Machado
- Anesthesiology, Pain and Intensive Care Department,
Escola Paulista de Medicina, Universidade Federal de São Paulo - Sao
Paulo (SP), Brazil
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Gagnon DJ, Fontaine GV, Smith KE, Riker RR, Miller RR, Lerwick PA, Lucas FL, Dziodzio JT, Sihler KC, Fraser GL. Valproate for agitation in critically ill patients: A retrospective study. J Crit Care 2016; 37:119-125. [PMID: 27693975 DOI: 10.1016/j.jcrc.2016.09.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/18/2016] [Accepted: 09/01/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose was to describe the use of valproate therapy for agitation in critically ill patients, examine its safety, and describe its relationship with agitation and delirium. MATERIALS AND METHODS This retrospective cohort study evaluated critically ill adults treated with valproate for agitation from December 2012 through February 2015. Information on valproate prescribing practices and safety was collected. Incidence of agitation, delirium, and concomitant psychoactive medication use was compared between valproate day 1 and valproate day 3. Concomitant psychoactive medication use was analyzed using mixed models. RESULTS Fifty-three patients were evaluated. The median day of valproate therapy initiation was ICU day 7, and it was continued for a median of 7 days. The median maintenance dose was 1500 mg/d (23 mg/kg/d). The incidence of agitation (96% vs 61%, P < .0001) and delirium (68% vs 49%, P = .012) significantly decreased by valproate day 3. Treatment with opioids (77% vs 65%, P = .02) and dexmedetomidine (47% vs 24%, P = .004) also decreased. In mixed models analyses, valproate therapy was associated with reduced fentanyl equivalents (-185 μg/d, P = .0003) and lorazepam equivalents (-2.1 mg/d, P = .0004). Hyperammonemia (19%) and thrombocytopenia (13%) were the most commonly observed adverse effects. CONCLUSIONS Valproate therapy was associated with a reduction in agitation, delirium, and concomitant psychoactive medication use within 48 hours of initiation.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Gabriel V Fontaine
- Department of Pharmacy and Neurosciences Institute, Intermountain Medical Center, 5121 South Cottonwood St, Murray, UT 84107.
| | - Kathryn E Smith
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Richard R Riker
- Neuroscience Institute, Maine Medical Center, 22 Bramhall St, Portland, ME 04102; Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Russell R Miller
- Department of Critical Care Medicine, Intermountain Medical Center, 5121 South Cottonwood St, Murray, UT 84107.
| | - Patricia A Lerwick
- Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - F L Lucas
- Center for Outcomes Research & Evaluation, 509 Forest Ave, Suite 200, Portland, ME 04101.
| | - John T Dziodzio
- Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Kristen C Sihler
- Department of Surgical/Trauma Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
| | - Gilles L Fraser
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME 04102; Department of Critical Care Medicine, Maine Medical Center, 22 Bramhall St, Portland, ME 04102.
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Latorre-Marco I, Acevedo-Nuevo M, Solís-Muñoz M, Hernández-Sánchez L, López-López C, Sánchez-Sánchez MM, Wojtysiak-Wojcicka M, de Las Pozas-Abril J, Robleda-Font G, Frade-Mera MJ, De Blas-García R, Górgolas-Ortiz C, De la Figuera-Bayón J, Cavia-García C. Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients. Med Intensiva 2016; 40:463-473. [PMID: 27590592 DOI: 10.1016/j.medin.2016.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/01/2016] [Accepted: 06/03/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. PROCEDURE Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.
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Affiliation(s)
- I Latorre-Marco
- Medical Intensive Care Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain.
| | - M Acevedo-Nuevo
- Medical Intensive Care Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - M Solís-Muñoz
- Nursing and Healthcare, Research Area, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - L Hernández-Sánchez
- Medical Intensive Care Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - C López-López
- Emergency and Trauma Intensive Care Unit, Hospital Universitario Doce de Octubre, Madrid, Spain
| | | | - M Wojtysiak-Wojcicka
- Intensive Care Unit, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Spain
| | - J de Las Pozas-Abril
- Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - G Robleda-Font
- Intensive Care Unit, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - M J Frade-Mera
- Intensive Care Unit, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - R De Blas-García
- Postsurgical Intensive Care Unit, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - C Górgolas-Ortiz
- Postsurgical Intensive Care Unit, Hospital Universitario de Basurto, Bilbao, Spain
| | | | - C Cavia-García
- Intensive Care Unit, Hospital Universitario de Cruces, Barakaldo, Spain
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Zhang LN, Wang XH, Wu L, Huang L, Zhao CG, Peng QY, Ai YH. Diagnostic and Predictive Levels of Calcium-binding Protein A8 and Tumor Necrosis Factor Receptor-associated Factor 6 in Sepsis-associated Encephalopathy: A Prospective Observational Study. Chin Med J (Engl) 2016; 129:1674-81. [PMID: 27411454 PMCID: PMC4960956 DOI: 10.4103/0366-6999.185860] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite its high prevalence, morbidity, and mortality, sepsis-associated encephalopathy (SAE) is still poorly understood. The aim of this prospective and observational study was to investigate the clinical significance of calcium-binding protein A8 (S100A8) in serum and tumor necrosis factor receptor-associated factor 6 (TRAF6) in peripheral blood mononuclear cells (PBMCs) in diagnosing SAE and predicting its prognosis. METHODS Data of septic patients were collected within 24 h after Intensive Care Unit admission from July 2014 to March 2015. Healthy medical personnel served as the control group. SAE was defined as cerebral dysfunction in the presence of sepsis that fulfilled the exclusion criteria. The biochemical indicators, Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation score II, TRAF6 in PBMC, serum S100A8, S100β, and neuron-specific enolase were evaluated in SAE patients afresh. TRAF6 and S100A8 were also measured in the control group. RESULTS Of the 57 enrolled patients, 29 were diagnosed with SAE. The S100A8 and TRAF6 concentrations in SAE patients were both significantly higher than that in no-encephalopathy (NE) patients, and higher in NE than that in controls (3.74 ± 3.13 vs. 1.08 ± 0.75 vs. 0.37 ± 0.14 ng/ml, P < 0.01; 3.18 ± 1.55 vs. 1.02 ± 0.63 vs. 0.47 ± 0.10, P < 0.01). S100A8 levels of 1.93 ng/ml were diagnostic of SAE with 92.90% specificity and 69.00% sensitivity in the receiver operating characteristic (ROC) curve, and the area under the curve was 0.86 (95% confidence interval [CI]: 0.76-0.95). TRAF6-relative levels of 1.44 were diagnostic of SAE with 85.70% specificity and 86.20% sensitivity, and the area under the curve was 0.94 (95% CI: 0.88-0.99). In addition, S100A8 levels of 2.41 ng/ml predicted 28-day mortality of SAE with 90.00% specificity and 73.70% sensitivity in the ROC curve, and the area under the curve was 0.88. TRAF6 relative levels of 2.94 predicted 28-day mortality of SAE with 80.00% specificity and 68.40% sensitivity, and the area under the curve was 0.77. Compared with TRAF6, the specificity of serum S100A8 in diagnosing SAE and predicting mortality was higher, although the sensitivity was low. In contrast, the TRAF6 had higher sensitivity for diagnosis. CONCLUSIONS Peripheral blood levels of S100A8 and TRAF6 in SAE patients were elevated and might be related to the severity of SAE and predict the outcome of SAE. The efficacy and specificity of S100A8 for SAE diagnosis were superior, despite its weak sensitivity. S100A8 might be a better biomarker for diagnosis of SAE and predicting prognosis.
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Affiliation(s)
- Li-Na Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Xiao-Hong Wang
- Department of Anesthesiology and Critical Care Medicine, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan 410008, China
| | - Long Wu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Li Huang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Chun-Guang Zhao
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Qian-Yi Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Yu-Hang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
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The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review. Infect Control Hosp Epidemiol 2016; 37:1234-42. [PMID: 27322888 DOI: 10.1017/ice.2016.129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.
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Broucqsault-Dédrie C, De Jonckheere J, Jeanne M, Nseir S. Measurement of Heart Rate Variability to Assess Pain in Sedated Critically Ill Patients: A Prospective Observational Study. PLoS One 2016; 11:e0147720. [PMID: 26808971 PMCID: PMC4726693 DOI: 10.1371/journal.pone.0147720] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/07/2016] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The analgesia nociception index (ANI) assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The aim of this study is to determine the effectiveness of ANI in detecting pain in deeply sedated critically ill patients. METHODS This prospective observational study was performed in two medical ICUs. All patients receiving invasive mechanical ventilation and deep sedation were eligible. In all patients, heart rate and ANI were continuously recorded using the Physiodoloris® device during 5 minutes at rest (T1), during a painful stimulus (T2), and during 5 minutes after the end of the painful stimulus (T3). The chosen painful stimulus was patient turning for washstand. Pain was evaluated at T2, using the behavioral pain scale (BPS). The primary objective was to determine the effectiveness of ANI in detecting pain. Secondary objectives included the impact of norepinephrine on the effectiveness of ANI in detecting pain, and the correlation between ANI and BPS. RESULTS Forty-one patients were included. ANI was significantly lower at T2 (Med (IQR) 69(55-78)) compared with T1 (85(67-96), p<0.0001), or T3 (81(63-89), p<0.0001). Similar results were found in the subgroups of patients with (n = 21) or without (n = 20) norepinephrine. ANI values were significantly higher in patients with norepinephrine compared with those without norepinephrine at T1, and T2. No significant correlation was found between ANI and BPS at T2. CONCLUSIONS ANI is effective in detecting pain in deeply sedated critically ill patients, including those patients treated with norepinephrine. No significant correlation was found between ANI and BPS.
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Affiliation(s)
- Céline Broucqsault-Dédrie
- Intensive Care Unit, Hôpital Victor Provo, 35 rue de Barbieux - CS 60359 - 59056 Roubaix Cedex, France
| | - Julien De Jonckheere
- CHU Lille, Clinical Investigation Center - Innovative Technologies, INSERM CIC-IT 1403, F-59000 Lille, France
| | - Mathieu Jeanne
- CHU Lille, Clinical Investigation Center - Innovative Technologies, INSERM CIC-IT 1403, F-59000 Lille, France
- CHU Lille, Anesthesia and Surgical Critical Care Department, F-59000 Lille, France
| | - Saad Nseir
- CHU Lille, Critical Care Center, F-59000 Lille, France
- Univ. Lille, Medicine School, F-59000 Lille, France
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Gagnon DJ, Riker RR, Glisic EK, Kelner A, Perrey HM, Fraser GL. Transition from dexmedetomidine to enteral clonidine for ICU sedation: an observational pilot study. Pharmacotherapy 2016; 35:251-9. [PMID: 25809176 DOI: 10.1002/phar.1559] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Enteral clonidine represents a potentially less costly alternative to dexmedetomidine for sedation in intensive care unit (ICU) patients. This study describes our practice of transitioning selected adult ICU patients from dexmedetomidine to clonidine with a focus on efficacy, safety, and drug acquisition costs. METHODS We conducted a single-center prospective observational pilot study from January through March 2014. Consecutive patients 18 years and older treated with dexmedetomidine and transitioned to clonidine were followed. The transition was assessed in five phases: dexmedetomidine maintenance, transition, clonidine maintenance, clonidine taper, and post clonidine. Efficacy data included any occurrence of significant pain, excessive agitation or oversedation, delirium, and need for ancillary psychoactive medications. Safety data included any occurrence of bradycardia, hypotension, new second- or third-degree atrioventricular node blockade, and clonidine withdrawal syndrome. Drug acquisition cost avoidances were estimated using average wholesale price. RESULTS Twenty patients were evaluated. Fifteen (75%) were successfully transitioned from dexmedetomidine within 48 hours of starting clonidine. The initial and maintenance clonidine regimens were 0.3 mg every 6 hours. Clonidine was the sole α2A -receptor agonist administered for 45 hours while in the ICU and for 54 hours outside the ICU. Fentanyl requirements were lower when clonidine was administered as the sole α2A -receptor agonist as compared to dexmedetomidine alone (387 vs. 891 μg/day, p = 0.03). Otherwise, there were no statistically significant differences in efficacy data during the dexmedetomidine and clonidine maintenance phases. No statistically significant differences in safety data were observed. Clonidine withdrawal syndrome criteria were met in one patient. The potential drug acquisition cost avoidance was $819-$2338 per patient during the 3-month study. CONCLUSIONS Transitioning from dexmedetomidine to clonidine may be an efficacious, safe, and less costly method of maintaining α2A -receptor agonist therapy in critically ill adults; these results warrant confirmation in expanded studies.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, Maine
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Lee JS. Restraint in the Intensive Care Unit. JOURNAL OF NEUROCRITICAL CARE 2015. [DOI: 10.18700/jnc.2015.8.2.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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