Monitoring delirium in the intensive care unit: Diagnostic accuracy of the CAM-ICU tool when performed by certified nursing assistants - A prospective multicenter study

BACKGROUND

Monitoring delirium in critically ill patients is recognized as a major challenge. Although involving certified nursing assistants could be a valuable help in this field, such strategy has never been formally investigated.

OBJECTIVES

Following theoretical training, we conducted a prospective multicenter study assessing the diagnostic accuracy of a CAM-ICU delirium screening strategy performed by CNAs in clinical settings, compared to parallel blinded evaluations conducted by nurses and physicians.

METHODS

From October 2020 to June 2022, adult intensive care patients admitted in three French University teaching hospitals with Richmond Agitation Sedation Scale ≥-2 were independently assessed for delirium by the three members of the care team (clinical nursing assistant, nurse and physician) using CAM-ICU in a random order. Physician's assessment served as the reference standard for comparisons.

RESULTS

We analyzed results from 268 triplets of CAM-ICU assessments performed sequentially on 203 patients. Prevalence of delirium was 22%. Compared to physician's assessments, clinical nursing assistants demonstrated a sensitivity (Se) of 88% CI95% [80-96] and a specificity (Sp) of 95% [92-98] in detecting delirium. There was no significant difference in the performance of clinical nursing assistants and nurses (Se = 90 % [82-97] p = 0.77, Sp = 98 % [95-100] p = 0.19). We observed high agreement between results obtained by physicians and clinical nursing assistants (ĸ = 0.82) and clinical nursing assistants performance remained consistent in the subgroups at higher risk of delirium.

CONCLUSION

Evaluation of the CAM-ICU by clinical nursing assistants is feasible and should be seen as an opportunity to increase routine monitoring of delirium in intensive care patients.

IMPLICATION FOR CLINICAL PRACTICE

Delirium is a severe and underestimated complication of intensive care unit stay. This study results demonstrate the great performance of trained clinical nursing assistants in detecting delirium using the CAM-ICU. Further research is needed to define the most effective role for clinical nursing assistants in the routine management of delirium in intensive care patients.

Preemptive ganciclovir for mechanically ventilated patients with cytomegalovirus reactivation

Background

The effect of cytomegalovirus (CMV) reactivation on the length of mechanical ventilation and mortality in immunocompetent ICU patients requiring invasive mechanical ventilation remains controversial. The main objective of this study was to determine whether preemptive intravenous ganciclovir increases the number of ventilator-free days in patients with CMV blood reactivation.

Methods

This double-blind, placebo-controlled, randomized clinical trial involved 19 ICUs in France. Seventy-six adults ≥ 18 years old who had been mechanically ventilated for at least 96 h, expected to remain on mechanical ventilation for ≥ 48 h, and exhibited reactivation of CMV in blood were enrolled between February 5th, 2014, and January 23rd, 2019. Participants were randomized to receive ganciclovir 5 mg/kg bid for 14 days (n = 39) or a matching placebo (n = 37).

Results

The primary endpoint was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included day 60 mortality. The trial was stopped for futility based on the results of an interim analysis by the DSMB. The subdistribution hazard ratio for being alive and weaned from mechanical ventilation at day 60 for patients receiving ganciclovir (N = 39) compared with control patients (N = 37) was 1.14 (95% CI from 0.63 to 2.06; P = 0.66). The median [IQR] numbers of ventilator-free days for ganciclovir-treated patients and controls were 10 [0–51] and 0 [0–43] days, respectively (P = 0.46). Mortality at day 60 was 41% in patients in the ganciclovir group and 43% in the placebo group (P = .845). Creatinine levels and blood cells counts did not differ significantly between the two groups.

Conclusions

In patients mechanically ventilated for ≥ 96 h with CMV reactivation in blood, preemptive ganciclovir did not improve the outcome.

Acyclovir for Mechanically Ventilated Patients With Herpes Simplex Virus Oropharyngeal Reactivation: A Randomized Clinical Trial

IMPORTANCE

The role of herpes simplex virus (HSV) reactivation on morbidity and mortality in patients in the intensive care unit requiring mechanical ventilation remains unknown.

OBJECTIVE

To determine whether preemptive treatment with intravenous acyclovir reduces the duration of mechanical ventilation in patients with HSV oropharyngeal reactivation.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, placebo-controlled randomized clinical trial was conducted in 16 intensive care units in France. Participants included 239 adults (age, >18 years) who received mechanical ventilation for at least 96 hours and continued to receive mechanical ventilation for 48 hours or more, with HSV oropharyngeal reactivation. Patients were enrolled between February 2, 2014, and February 22, 2018.

INTERVENTIONS

Participants were randomized to receive intravenous acyclovir, 5 mg/kg, 3 times daily for 14 days or a matching placebo.

MAIN OUTCOMES AND MEASURES

The primary end point was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included mortality at 60 days. Main analyses were conducted on an intention-to-treat basis.

RESULTS

Of 239 patients enrolled and randomized, 1 patient withdrew consent, leaving 238 patients, with 119 patients in both the acyclovir and placebo (control) groups (median [IQR] age, 61 [50-70] years; 76 [32%] women) available for primary outcome measurement. On day 60, the median (IQR) numbers of ventilator-free days were 35 (0-53) for acyclovir recipients and 36 (0-50]) for controls (P = .17 for between-group comparison). Among secondary outcomes, 26 patients (22%) and 39 patients (33%) had died at day 60 (risk difference, 0.11, 95% CI, -0.004 to 0.22, P = .06). The adverse event frequency was similar for both groups (28% in the acyclovir group and 23% in the placebo group, P = .40), particularly acute renal failure post randomization affecting 3 acyclovir recipients (3%) and 2 controls (2%). Four patients (3%) in the acyclovir group vs none in the placebo group stopped the study drug for treatment-related adverse events.

CONCLUSIONS AND RELEVANCE

In patients receiving mechanical ventilation for 96 hours or more with HSV reactivation in the throat, use of acyclovir, 5 mg/kg, 3 times daily for 14 days, did not increase the number of ventilator-free days at day 60, compared with placebo. These findings do not appear to support routine preemptive use of acyclovir in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02152358.

[Acetaminophene-induced hypotension in intensive care unit: a prospective study]

OBJECTIVES

The aim of this study was to evaluate the incidence of paracetamol-induced hypotension in intensive care unit (ICU). The secondary end-point was the description of pathophysiologic phenomenon during this hypotension and risk factors.

STUDY DESIGN

An observational study in three ICU of a French teaching hospital.

PATIENTS AND METHODS

All consecutives patients whom benefit from intravenous paracetamol administration were included in the study. When a 20% droop in arterial blood pressure occurred, plasma samples were obtained and tryptases were measured at 6 and 48 hours. Clinical, biological characteristics and paracetamol administration duration were prospectively monitored.

RESULTS

During a 2-months period, 127 ICU patients were included in the study with 1507 paracetamol administration. Twenty droops in arterial blood pressure were recorded in ICU. The incidence rate was 1.33%. Administration duration was 32+/-9 min. No respiratory nor cutaneous manifestations occurred during hypotensions. A specific treatment was administrated in half of the patients. Hypotension incidence was higher (3.9%) in patients with brain injury. Eighty percent of patients with hypotension have a severe sepsis or a septic shock.

CONCLUSION

In this cohort of ICU patients, hypotension incidence was higher than reported in drug legal mentions. Immunoallergic phenomenon was excluded. Brain injury and sepsis seems to be risk factors.

[Tolerance of caspofungin in intensive care unit: a prospective study]

OBJECTIVE

Caspofungin has shown efficacy and very low toxicity in empirical antifungal therapy in refractory invasive Aspergillus infections and invasive candidiasis in neutropenic (or non) patients. To date, there is no data on tolerability of caspofungin in ICU patients. The aim of this study was to evaluate caspofungine tolerability in critical care patients.

PATIENTS AND METHOD

Over a 36-month period, 1430 patients were admitted in a general intensive care unit. All patients data were collected in a prospective database. All the clinical or biological side effects reported in the multicentric studies were required. The patients were laminated in two groups, according to the initial hepatic function.

RESULTS

Seventy-three patients were treated with caspofungin (5.1%) and 58% were immunocompromised. Immunosuppression was due to acute leukemia (30%), solid organ transplant (20%) or other causes of immunosuppression. In this group, SAPS2 was higher (51+/-20 versus 44+/-20; p<0.05) as mortality rate was (60% versus 23%). More than 90% of patients were ventilated and 55% needed extrarenal therapy. Caspofungin treatment was initiated for aspergillosis in 12 patients, candidiasis in 33 patients and others indications. Partial or complete response to treatment was 72%. Median duration of caspofungin administration was 11 days, no liver dysfunction or acute renal failure due to caspofungin was reported whatever initial liver function was.

CONCLUSION

This prospective open study demonstrate the very low toxicity of caspofungin even in critical care patients.

Respiratory effects of different recruitment maneuvers in acute respiratory distress syndrome

Introduction

Alveolar derecruitment may occur during low tidal volume ventilation and may be prevented by recruitment maneuvers (RMs). The aim of this study was to compare two RMs in acute respiratory distress syndrome (ARDS) patients.

Methods

Nineteen patients with ARDS and protective ventilation were included in a randomized crossover study. Both RMs were applied in each patient, beginning with either continuous positive airway pressure (CPAP) with 40 cm H₂O for 40 seconds or extended sigh (eSigh) consisting of a positive end-expiratory pressure maintained at 10 cm H₂O above the lower inflection point of the pressure-volume curve for 15 minutes. Recruited volume, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂), and hemodynamic parameters were recorded before (baseline) and 5 and 60 minutes after RM. All patients had a lung computed tomography (CT) scan before study inclusion.

Results

Before RM, PaO₂/FiO₂ was 151 ± 61 mm Hg. Both RMs increased oxygenation, but the increase in PaO₂/FiO₂ was significantly higher with eSigh than CPAP at 5 minutes (73% ± 25% versus 44% ± 28%; P < 0.001) and 60 minutes (68% ± 23% versus 35% ± 22%; P < 0.001). Only eSigh significantly increased recruited volume at 5 and 60 minutes (21% ± 22% and 21% ± 25%; P = 0.0003 and P = 0.001, respectively). The only difference between responders and non-responders was CT lung morphology. Eleven patients were considered as recruiters with eSigh (10 with diffuse loss of aeration) and 6 with CPAP (5 with diffuse loss of aeration). During CPAP, 2 patients needed interruption of RM due to a drop in systolic arterial pressure.

Conclusion

Both RMs effectively increase oxygenation, but CPAP failed to increase recruited volume. When the lung is recruited with an eSigh adapted for each patient, alveolar recruitment and oxygenation are superior to those observed with CPAP.

Response to recruitment maneuver influences net alveolar fluid clearance in acute respiratory distress syndrome

BACKGROUND

Alveolar fluid clearance is impaired in the majority of patients with acute respiratory distress syndrome (ARDS). Experimental studies have shown that a reduction of tidal volume increases alveolar fluid clearance. This study was aimed at assessing the impact of the response to a recruitment maneuver (RM) on net alveolar fluid clearance.

METHODS

In 15 patients with ARDS, pulmonary edema fluid and plasma protein concentrations were measured before and after an RM, consisting of a positive end-expiratory pressure maintained 10 cm H2O above the lower inflection point of the pressure-volume curve during 15 min. Cardiorespiratory parameters were measured at baseline (before RM) and 1 and 4 h later. RM-induced lung recruitment was measured using the pressure-volume curve method. Net alveolar fluid clearance was measured by measuring changes in bronchoalveolar protein concentrations before and after RM.

RESULTS

In responders, defined as patients showing an RM-induced increase in arterial oxygen tension of 20% of baseline value or greater, net alveolar fluid clearance (19 +/- 13%/h) and significant alveolar recruitment (113 +/- 101 ml) were observed. In nonresponders, neither net alveolar fluid clearance (-24 +/- 11%/h) nor alveolar recruitment was measured. Responders and nonresponders differed only in terms of lung morphology: Responders had a diffuse loss of aeration, whereas nonresponders had a focal loss of aeration, predominating in the lower lobes.

CONCLUSION

In the absence of alveolar recruitment and improvement in arterial oxygenation, RM decreases the rate of alveolar fluid clearance, suggesting that lung overinflation may be associated with epithelial dysfunction.

Remifentanil-based sedation to treat noninvasive ventilation failure: a preliminary study

OBJECTIVE

To assess the feasibility and safety of remifentanil-based sedation during noninvasive ventilation (NIV) in patients with NIV failure.

DESIGN AND SETTING

Prospective clinical investigation in a 16-bed intensive care unit of a university hospital in France.

PATIENTS

Thirteen patients in NIV failure due to discomfort and/or refusal to continue this ventilatory support: 10 with acute respiratory failure and 3 with acute hypercapnic respiratory failure.

INTERVENTION

Patients were administered methylene blue and were sedated (Ramsay scale 2-3) by a continuous perfusion of remifentanil during NIV. Cardiorespiratory and ventilatory parameters, blood gas analysis, and adverse events were prospectively recorded.

MEASUREMENTS AND RESULTS

The 13 patients received a total of 125 NIV sessions, totaling 1200 h, of NIV under remifentanil-based sedation (mean remifentanil dose 0.1+/-0.03 microg/kg per minute). Three patients also required propofol. PaO2/FIO2 ratio increased from 134+/-69 to 187+/-43 mmHg after 1 h. In patients with acute respiratory failure respiratory rate decreased from 34+/-12 per minute before remifentanil to 25+/-4 per minute after 1h. In the three patients with acute hypercapnic respiratory failure PaCO2 decreased from 69+/-7 to 42+/-5 mmHg. Four patients required endotracheal intubation without aspiration pneumonia. Twelve of the 13 patients left the ICU.

CONCLUSION

This pilot study shows that remifentanil-based sedation is safe and effective in the treatment of NIV failure due to low tolerance.

Lemierre's syndrome and genetic polymorphisms: a case report

Background

Lemierre's syndrome presents a classic clinical picture, the pathophysiology of which remains obscure. Attempts have been made to trace genetic predispositions that modify the host detection of pathogen or the resultant systemic reaction.

Case presentation

A 17-year old female, with no previous medical history, was admitted to the intensive care unit for septic shock, acute respiratory distress syndrome and Lemierre's syndrome. Her DNA was assayed for single nucleotide polymorphisms previously incriminated in the detection of the pathogen, the inflammatory response and the coagulation cascade. We observed functional variations in her Toll like 5 receptor (TLR 5) gene and two coagulation variations (Tissue Factor (TF) 603 and Plasminogen-Activator-Inhibitor-1 (PAI-1) 4G-4G homozygosity) associated with thrombotic events.

Conclusion

The innate immune response and the prothrombogenic mutations could explain, at least in part, the symptoms of Lemierre's syndrome. Genomic study of several patients with Lemierre's syndrome may reveal its pathophysiology.