Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals

Prevention and management of delirium in critically ill adult patients in the intensive care unit: a review based on the 2018 PADIS guidelines

Delirium is an acute, confusional state characterized by altered consciousness and a reduced ability to focus, sustain, or shift attention. It is associated with a number of complex underlying medical conditions and can be difficult to recognize. Many critically ill patients (e.g., up to 80% of patients in the intensive care unit [ICU]) experience delirium due to underlying medical or surgical health problems, recent surgical or other invasive procedures, medications, or various noxious stimuli (e.g., underlying psychological stressors, mechanical ventilation, noise, light, patient care interactions, and drug-induced sleep disruption or deprivation). Delirium is associated with a longer duration of mechanical ventilation and ICU admittance as well as an increased risk of death, disability, and long-term cognitive dysfunction. Therefore, the early recognition of delirium is important and ICU medical staff should devote careful attention to both watching for the occurrence of delirium and its prevention and management. This review presents a brief overview of delirium and an update of the literature with reference to the 2018 Society of Critical Care Medicine Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU.

Update in Neurocritical Care: a summary of the 2018 Paris international conference of the French Society of Intensive Care

The 2018 Paris Intensive Care symposium entitled "Update in Neurocritical Care" was organized in Paris, June 21-22, 2018, under the auspices of the French Intensive Care Society. This 2-day post-graduate educational symposium comprised several chapters, aiming first to provide all-board intensivists with current standards for the clinical assessment of altered consciousness states (including coma and delirium) and peripheral nervous system in critically ill patients, monitoring of brain function (specifically, electro-encephalography) and best practices for sedation-analgesia-delirium management. An update on the treatment of specific severe brain pathologies-including ischaemic/haemorrhagic stroke, cerebral venous thrombosis, hypoxic-ischaemic brain injury, immune-mediated and infectious encephalitis and refractory status epilepticus-was also provided. Finally, we discuss how to approach some difficult decisions, namely the role of decompressive craniectomy and prognostication models in patients with head injury. For each chapter, the scope of the present review was to provide important issues and key messages, provide most recent and relevant literature in the field, and briefly describe new developments in the field.

Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review

INTRODUCTION

Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research.

OBJECTIVE

To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management.

METHODS

The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review.

RESULTS

Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep.

CONCLUSION

A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.

Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in a Canadian community intensive care unit: a quality improvement study protocol

BACKGROUND

Pain and agitation are closely linked to the development of delirium, which affects 60%-87% of critically ill patients. Delirium is associated with increased mortality and morbidity. Clinical guidelines that suggest routine assessment, treatment and prevention of pain, agitation and delirium (PAD) is crucial to improving patient outcomes. However, the adoption of and adherence to PAD guidelines remain suboptimal, especially in community hospitals. The aim of this quality improvement study is to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community intensive care unit (ICU).

METHODS

This is a quality improvement, uncontrolled, before-and-after study of a multifaceted and multidisciplinary intervention targeting nurses (educational modules, visual reminders), family members (interviews, educational pamphlets and an educational video), physicians (multidisciplinary round script) and the multidisciplinary team as a whole (delirium poster). We will collect data every day for 6 weeks before implementing the intervention. Data collection will include clinical information and information on process of care. We will then implement the intervention. Four weeks after, we will collect data daily for 6 weeks to evaluate the effect of the intervention. On the basis of the volume of the ICU, we expect to enroll approximately 280 patients. We have obtained local ethics approval from the Hamilton Integrated Research Ethics Board (HiREB 18-040-C).

INTERPRETATION

The results of this quality improvement study will provide information on adherence to PAD guidelines in a Canadian community ICU setting. They will also supply information on the feasibility of implementing multifaceted and multidisciplinary PAD interventions in community ICUs.

Early mobilisation of ventilated patients in the intensive care unit: A survey of critical care clinicians in an Australian tertiary hospital

INTRODUCTION

Mobilising mechanically ventilated patients is safe and beneficial and improves outcomes. However, early mobilisation is not widely practiced and barriers to its implementation still exist.

OBJECTIVE

The objective of this study was to assess clinician perceptions, knowledge, attitudes, and behaviours towards mobilising critically ill ventilated patients in the intensive care unit, as well as perceived barriers and facilitators towards mobilisation.

METHODS

A prospective questionnaire based on three existing questionnaires was administered to nurses, physicians, and physiotherapists from a single mixed medical/surgical intensive care unit in an Australian tertiary hospital. The 32-item questionnaire focused on knowledge, attitudes, behaviour, and perceived facilitators and barriers. Various response options were used, and data were analysed using descriptive statistics.

RESULTS

The overall response rate was 56.6% (82 of 145). Overall, clinicians' knowledge score was 4.1 (standard deviation = 1.4) out of a possible score of 6. Early mobilisation was not perceived as a top priority by 40.2% of participants. One important facilitator was that majority of the participants perceived early mobilisation was important. The most common perceived barriers to early mobilisation were medical instability, delirium, sedation, and limited staffing. Clinicians' opinions varied on the timing and appropriateness for instituting early mobilisation.

CONCLUSIONS

Clinicians had various levels of knowledge on early mobilisation as a therapy for critically ill patients. Most clinicians believed that early mobility was important and were willing to reduce sedation; however, several key barriers were identified which need to be addressed by using targeted interventions. This will reduce or close the gap between knowledge and practice.

Differences in prevalence of ICU protocols between neurologic and non-neurologic patient populations

PURPOSE

To compare the differences in the presence of protocols aimed at addressing complications for neurologically injured patients vs. non-neurologic injured patients in a large sample of ICUs across the United States.

MATERIALS AND METHODS

Prospective observational multi-center cohort study. This was a subgroup analysis of the multi-centered prospective observational cohort study of medical, surgical, and mixed intensive care units from across the country. USCIITG-CIOS study group.

RESULTS

Sixty-nine ICUs participated in the study of which 25 (36%) were medical, 24 were surgical (35%) and 20 (29%) were of mixed type, and 64 (93%) were in teaching hospitals. There were 6179 patients across all sites with 1266 (20.4%) with central nervous system diagnoses. Protocol utilization in central nervous system vs. non- central nervous system patients was as follows: Sedation interruption 973/1266 (76.9%) vs. 3840/4913 (78.2%) (p = .32); acute lung injury ventilation 847/1266 (66.9%) vs. 4069/4913 (82.8%) (p < .0001); ventilator associated pneumonia 1193/1266 (94.2%) vs. 4760/4913 (96.9%) (p < .0001); ventilator weaning 1193/1266 (94.2%) vs. 4490/4913 (91.4%) (p = .0009); and early mobility 378/1266 (29.9%) vs. 1736/4913 (35.3%) (p = .0002).

CONCLUSION

In this cohort, we found differences in the prevalence of respiratory illness prevention protocols between critically ill patients with neurologic illness and the general critically ill population.

Pathways, Contributors, and Correlates of Functional Limitation Across Specialties: Workshop Summary

Traditional clinical care models focus on the measurement and normalization of individual organ systems and de-emphasize aspects of health related to the integration of physiologic systems. Measures of physical, cognitive and sensory, and psychosocial or emotional function predict important health outcomes like death and disability independently from the severity of a specific disease, cumulative co-morbidity, or disease severity measures. A growing number of clinical scientists in several subspecialties are exploring the utility of functional assessment to predict complication risk, indicate stress resistance, inform disease screening approaches and risk factor interpretation, and evaluate care. Because a substantial number of older adults in the community have some form of functional limitation, integrating functional assessment into clinical medicine could have a large impact. Although interest in functional implications for health and disease management is growing, the science underlying functional capacity, functional limitation, physical frailty, and functional metrics is often siloed among different clinicians and researchers, with fragmented concepts and methods. On August 25-26, 2016, participants at a trans-disciplinary workshop, supported by the National Institute on Aging and the John A. Hartford Foundation, explored what is known about the pathways, contributors, and correlates of physical, cognitive, and sensory functional measures across conditions and disease states; considered social determinants and health disparities; identified knowledge gaps, and suggested priorities for future research. This article summarizes those discussions.

Ability to predict team members' behaviors in ICU teams is associated with routine ABCDE implementation

PURPOSE

Poor coordination may impede delivery of the Awakening, Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle. Developing a shared mental model (SMM), where all team members are on the same page, may support coordination.

MATERIALS AND METHODS

We administered a survey at the 2016 MHA Keystone Center ICU workshop. We measured different components of SMMs using five items from a validated survey, each on a 5-point Likert scale (strongly agree-strongly disagree). We measured self-reported routine ABCDE implementation using a single item 4-point Likert scale (ABCDE is routine-Made no steps to implement ABCDE). We examined the relationship between SMMs and routine ABCDE implementation using logistic regression, adjusting for confounders.

RESULTS

Among the 206 (75%) responses, 157 (84%) reported using the ABCDE bundle and 80 (51% of 157) reported routine use. When clinicians agreed it was difficult to predict team members' behaviors, the odds of reporting routine ABCDE implementation significantly decreased [0.26 (0.10-0.66)]. Other SMM components related to knowing team members' skills, access to information, team adaptability, and team help behavior, were not significantly associated with the outcome.

CONCLUSION

Increasing awareness of team members' behaviors may be a mechanism to improve the implementation of complex care bundles like ABCDE.

The Life Course Health Development Model: A theoretical research framework for paediatric delirium

AIMS AND OBJECTIVES

To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium.

BACKGROUND

Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory.

DESIGN

Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed.

METHODS

The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change.

CONCLUSIONS

The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory.

RELEVANCE TO CLINICAL PRACTICE

By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of non-pharmacological interventions versus standard care on incidence and duration of delirium in critically ill patients.

METHODS

We searched electronic and grey literature for randomised clinical trials up to March 2018. Two reviewers independently screened, selected and extracted data. Meta-analysis was undertaken using random effects modelling.

RESULTS

We identified 15 trials (2812 participants). Eleven trials reported incidence of delirium. Pooled data from four trials of bright light therapy showed no significant effect between groups (n = 829 participants, RR 0.45, 99% CI 0.10-2.13, P = 0.19, very low quality evidence). Seven trials of various individual interventions also failed to report any significant effects. A total of eight trials reported duration of delirium. Pooled data from two trials of multicomponent physical therapy showed no significant effect [n = 404 participants, MD (days) - 0.65, 99% CI - 2.73 to 1.44, P = 0.42, low quality of evidence]. Four trials of various individual interventions also reported no significant effects. A trial of family voice reorientation showed a beneficial effect [n = 30, MD (days) - 1.30, 99% CI - 2.41 to - 0.19, P = 0.003, very low quality evidence].

CONCLUSIONS

Current evidence does not support the use of non-pharmacological interventions in reducing incidence and duration of delirium in critically ill patients. Future research should consider well-designed and well-described multicomponent interventions and include adequately defined outcome measures.

Delirium in the critically ill patient

Delirium is an acute and transient brain dysfunction that is characterized by disturbances in consciousness, affecting both its content (i.e., attention) and level (i.e., arousal). It affects as many as 50% of those admitted to an intensive care unit (ICU). Once believed to be an inconsequential outcome of critical illness, it is now recognized that delirium is harmful in both the short- and long-term. Despite occurring frequently in critically ill patients, delirium often goes unrecognized. Well-validated delirium screening tools, designed for use in the ICU, should be used to reliably detect delirium. The first step in delirium treatment is to identify and address potentially modifiable risk factors. Multiple trials have shown that benzodiazepines are a risk factor for delirium in a dose-dependent manner. Sedation with nonbenzodiazepine-based strategies are an effective means by which to reduce delirium. Nonpharmacologic strategies such as those which seek to reduce sensory impairment, sleep deprivation, and immobility are effective. Pharmacologic treatment with antipsychotics, though commonly used, is not supported by findings from placebo-controlled trials. Recent data support from multiple trials support the use of the "ABCDEF bundle" as a means by which to reduce delirium.

Implementing the comprehensive unit-based safety program model to improve the management of mechanically ventilated patients in Saudi Arabia

BACKGROUND

Ventilator-associated events are common in mechanically ventilated patients. They are associated with more days on mechanical ventilation, longer intensive care unit (ICU) stay, and increased risk of mortality. Theoretically, interventions that prevent ventilator-associated events should also reduce associated morbidity. We evaluated the Comprehensive Unit-based Safety Program approach to improve the care of mechanically ventilated patients.

METHODS

All mechanically ventilated patients admitted to the ICU between October 1, 2015, and October 31, 2016, were prospectively monitored for the development of ventilator-associated events according to the National Healthcare Safety Network criteria. A process care bundle (endotracheal intubation with subglottic suctioning, head-of-bed elevation ≥30°, target sedation scores, daily spontaneous awakening trials, spontaneous breathing trials), daily delirium assessment, and an early mobility protocol were instituted. The bundle compliance, ventilator-associated events rates, ICU length of stay, and mortality rate were noted. The database allowed viewing of current rates, trends, and averages of all participating sites.

RESULTS

In the study period, 2,321 patients were admitted to the ICU, and 1,231 required mechanical ventilation (10,342 ventilator days). There were 115 ventilator-associated events: 82 ventilator-associated conditions, 15 infection-related ventilator-associated conditions, and 18 possible cases of ventilator-associated pneumonia. The ICU mortality rate was 13.3%, compared with 28.7% for those mechanically ventilated patients with ventilator-associated events (P = .0001). There was increased compliance for spontaneous awakening trials (51.5%-76.9%, P = .0008) and spontaneous breathing trials (54.2%-72.2%, P = .02) and a decrease in infection-related ventilator-associated conditions (4.2-3.5 per 1,000 days), possible cases of ventilator-associated pneumonia (2.1-1.7 per 1,000 days), ICU mortality (45.3%-19.1%, P = .045), and ventilator-associated events associated mortality rates (33.3%-8.3%, P < .37). Physical therapy participation and mobility were 60.8% and 26.4%, respectively.

CONCLUSION

The implementation of a multipronged program like the Comprehensive Unit-based Safety Program could improve the care processes and outcomes of mechanically ventilated patients.

Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness

BACKGROUND

There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU).

METHODS

In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation.

RESULTS

Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms.

CONCLUSIONS

The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).

Integrating a Mobility Champion in the Intensive Care Unit

In recent years, early progressive mobilization programs have become mainstays in intensive care units (ICUs). Significant evidence exists that early mobility programs decrease length of stay, reduce time on the ventilator, and decrease the development of delirium in ICU patients. Yet, current literature still describes many barriers to performing early mobility, such as the time required, staffing pressures, and increased workload. Our critical care leaders found that defining and implementing a dedicated mobility champion team member was successful in improving the effectiveness of our early mobility program. This article describes how to define the mobility champion role, consider options for the person in the role, and integrate this new role into the ICU team.

Validation of the Prediction of Delirium for Intensive Care model to predict subsyndromal delirium

Aim

Subsyndromal delirium is associated with prolonged intensive care unit stays, and prolonged mechanical ventilation requirements. The Prediction of Delirium for Intensive Care (PRE‐DELIRIC) model can predict delirium. This study was designed to verify if it can also predict development of subsyndromal delirium.

Methods

We undertook a single‐center, retrospective observation study in Japan. We diagnosed subsyndromal delirium based on the Intensive Care Delirium Screening Checklist. We calculated the sensitivity and specificity of the PRE‐DELIRIC model and obtained a diagnostic cut‐off value.

Results

We evaluated data from 70 patients admitted to the mixed medical intensive care unit of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. The prevalence of subsyndromal delirium by Intensive Care Delirium Screening Checklist was 31.4%. The area under the receiver operating characteristic curve was 0.83 of the PRE‐DELIRIC model for subsyndromal delirium. The calculated cut‐off value was 36 points with a sensitivity of 94.3% and specificity of 57.1%. Subsyndromal delirium was associated with a higher incidence of delirium (odds ratio, 8.81; P < 0.01).

Conclusion

The PRE‐DELIRIC model could be a tool for predicting subsyndromal delirium using a cut‐off value of 36 points.

Pain, agitation and delirium assessment and management in a community medical-surgical ICU: results from a prospective observational study and nurse survey

Background

Delirium is a common manifestation in the intensive care unit (ICU) that is associated with increased mortality and morbidity. Guidelines suggested appropriate management of pain, agitation and delirium (PAD) is crucial in improving patient outcomes. However, the practice of PAD assessment and management in community hospitals is unclear and the mechanisms contributing to the potential care gap are unknown.

Objectives

This quality improvement initiative aimed to review the practice of PAD assessment and management in a community medical-surgical ICU (MSICU) and to explore the community MSICU nurses’ perceived comfort and satisfaction with PAD management in order to understand the mechanisms of the observed care gap and to inform subsequent quality improvement interventions.

Methods

We prospectively collected basic demographic data, clinical information and daily data on PAD process measures including PAD assessment and target Richmond Agitation-Sedation Scale (RASS) score ordered by intensivists on all patients admitted to a community MSICU for >24 hours over a 20-week period. All ICU nurses in the same community MSICU were invited to participate in an anonymous survey.

Results

We collected data on a total of 1101 patient-days (PD). 653 PD (59%), 861 PD (78%) and 439 PD (39%) had PAD assessment performed, respectively. Target RASS was ordered by the intensivists on 515 PD (47%). Our nurse survey revealed that 88%, 85% and 41% of nurses were comfortable with PAD assessment, respectively.

Conclusions

Delirium assessment was not routinely performed. This is partly explained by the discomfort nurses felt towards conducting delirium assessment. Our results suggested that improvement in nurse comfort with delirium assessment and management is needed in the community MSICU setting.

Recent evidence on early mobilization in critical-Ill patients

PURPOSE OF REVIEW

To examine the benefits of early mobilization and summarize the results of most recent clinical studies examining early mobilization in critically ill patients followed by a presentation of recent developments in the field.

RECENT FINDINGS

Early mobilization of ICU patients, defined as mobilization within 72 h of ICU admission, is still uncommon. In medical and surgical critically ill patients, mobilization is well tolerated even in intubated patients. In neurocritical care, evidence to support early mobilization is either lacking (aneurysmal subarachnoid hemorrhage), or the results are inconsistent (e.g. stroke). Successful implementation of early mobilization requires a cultural change; preferably based on an interprofessional approach with clearly defined responsibilities and including a mobilization scoring system. Although the evidence for the majority of the technical tools is still limited, the use of a bed cycle ergometer and a treadmill with strap system has been promising in smaller trials.

SUMMARY

Early mobilization is well tolerated and feasible, resulting in improved outcomes in surgical and medical ICU patients. Implementation of early mobilization can be challenging and may need a cultural change anchored in an interprofessional approach and integrated in a patient-centered bundle. Scoring systems should be integrated to define daily goals and used to verify patients' achievements or identify barriers immediately.

Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?

PURPOSE OF REVIEW

Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined.

RECENT FINDINGS

Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value.

SUMMARY

Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.

Mesures de prévention non pharmacologiques du delirium de réanimation

Le delirium est défini par un changement brutal ou rapidement progressif de l’état mental ou une modification de l’humeur associés à une baisse des capacités de concentration, à une désorganisation de la pensée, à une confusion et à une altération du niveau de conscience. L’incidence du delirium en réanimation est variable d’environ 4 à 83 %, selon les études. Cela est probablement lié à la variété des outils de mesure employés, au niveau d’entraînement des professionnels de santé établissant ces scores, à la profondeur de la sédation et aux différences de populations étudiées. Son étiologie semble être multifactorielle. Il a été montré que la survenue du delirium a un fort impact sur le pronostic vital et fonctionnel des patients en réanimation, car son incidence est associée à une augmentation de la mortalité hospitalière précoce et tardive, et le déclin cognitif qui lui est associé peut persister à distance du séjour en réanimation. Il est important de souligner que la prise en charge dans les soins critiques est très hétérogène. Néanmoins, de nouvelles données de la littérature apportent des éléments concrets sur la prise charge de ce syndrome et fournissent un guide utile à la pratique paramédicale dans la prévention et le dépistage de ce trouble cognitif. L’objectif de ce travail est d’apporter une synthèse autour de la littérature disponible dans ce domaine, mettant en lumière le rôle clé de la profession paramédicale dans ce contexte afin d’identifier des éléments diagnostiques et thérapeutiques susceptibles de modifier pertinemment les pratiques soignantes.

Ability of suvorexant to prevent delirium in patients in the intensive care unit: a randomized controlled trial

Aim

There are no effective, tolerable, and established medications for preventing delirium in critically ill patients admitted to the intensive care unit (ICU). We investigated whether suvorexant was effective in preventing ICU delirium.

Methods

This randomized controlled study evaluated 70 adult patients (age ≥20 years) admitted to the mixed medical ICU of the Tokyo Medical University Hospital (Tokyo, Japan) between May 2015 and February 2017. Patients were randomized using a sealed envelope method to receive either suvorexant (n = 34; 15 mg for elderly patients and 20 mg for younger adults) or conventional treatment (n = 36) for a 7-day period. The primary outcome was delirium incidence based on the definition in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.

Results

No significant between-group differences were observed in the demographic or clinical characteristics. Kaplan-Meier estimates revealed that time to delirium onset was significantly longer in the suvorexant group than in the conventional group (P < 0.05).

Conclusion

Suvorexant might be effective in preventing delirium in ICU patients.

Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care

BACKGROUND

A recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to "liberate" patients from the ICU. They "bundle" evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation-to make formal recommendations in clinical practice guidelines or a position statement.

METHODS/DESIGN

The authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen's Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available.

DISCUSSION

Using the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017078909.

Preoperative STOP-BANG Scores and Postoperative Delirium and Coma in Thoracic Surgery Patients

BACKGROUND

Obstructive sleep apnea (OSA) is associated with higher rates of postoperative delirium. The relationship between preoperative OSA risk and postoperative delirium and coma in thoracic surgery patients hospitalized in the intensive care unit (ICU) is not well understood. This study tests the hypothesis that thoracic surgery patients hospitalized in ICU with a higher preoperative risk for OSA are more likely to develop postoperative delirium and coma, resulting in longer hospital stays.

METHODS

Preoperative OSA risk was measured using the STOP-BANG questionnaire. STOP-BANG scores of greater than or equal to 3 were defined as intermediate-high risk for OSA; 128 patients who underwent major thoracic surgery completed the STOP-BANG questionnaire preoperatively. The Richmond Agitation and Sedation Scale was used to assess level of consciousness. The Confusion Assessment Method for the ICU was used to assess for delirium. Linear regression was used to assess the relationship between risk of OSA and outcome measures. Results were adjusted for age, sex, body mass index, Charlson Comorbidity Index, instrumental activities of daily living, and surgery type.

RESULTS

A total of 96 of 128 patients (76%) were in the intermediate-high-risk OSA group. Adjusted analyses showed that the intermediate-high-risk OSA group had a longer duration of postoperative ICU delirium and coma compared with the low-risk OSA group (1.4 ± 1.3 days versus 0.9 ± 1.4 days; P = 0.04). Total number of hospital days was not significantly different.

CONCLUSIONS

Higher preoperative risk for OSA in thoracic surgery patients was associated with a longer duration of postoperative delirium and coma.

Delirium in a Latin American intensive care unit. A prospective cohort study of mechanically ventilated patients

Objective

To establish the prevalence of delirium in a general intensive care unit and to identify associated factors, clinical expression and the influence on outcomes.

Methods

This was a prospective cohort study in a medical surgical intensive care unit. The Richmond Agitation-Sedation Scale and Confusion Assessment Method for the Intensive Care Unit were used daily to identify delirium in mechanically ventilated patients.

Results

In this series, delirium prevalence was 80% (N = 184 delirious patients out of 230 patients). The number of patients according to delirium psychomotor subtypes was as follows: 11 hyperactive patients (6%), 9 hypoactive patients (5%) and 160 mixed patients (89%). Multiple logistic regression modeling using delirium as the dependent outcome variable (to study the risk factors for delirium) revealed that age > 65 years, history of alcohol consumption, and number of mechanical ventilation days were independent variables associated with the development of delirium. The multiple logistic regression model using hospital mortality as the dependent outcome variable (to study the risk factors for death) showed that severity of illness, according to the Acute Physiology and Chronic Health Evaluation II, mechanical ventilation for more than 7 days, and sedation days were all independent predictors for excess hospital mortality.

Conclusion

This Latin American prospective cohort investigation confirmed specific factors important for the development of delirium and the outcome of death among general intensive care unit patients. In both analyses, we found that the duration of mechanical ventilation was a predictor of untoward outcomes.

What is new in the prevention of nosocomial pneumonia in the ICU?

PURPOSE OF REVIEW

To summarize and contextualize recent evidence on preventing ventilator-associated pneumonia (VAP).

RECENT FINDINGS

Many centers continue to report dramatic decreases in VAP rates after implementing ventilator bundles. Interpreting these reports is complicated, however, by the subjectivity and lack of specificity of VAP definitions. More objective data suggest VAP rates may not have meaningfully changed over the past decade. If so, this compels us to re-examine and revise the prevention bundles we have been using to prevent VAP. New analyses suggest that most hospitals' ventilator bundles include a mix of helpful and potentially harmful elements. Spontaneous awakening trials, spontaneous breathing trials, head-of-bed elevation, and thromboprophylaxis appear beneficial. Oral chlorhexidine and stress ulcer prophylaxis may be harmful. Subglottic secretion drainage, probiotics, and novel endotracheal cuff designs do not clearly improve objective outcomes. Selective digestive decontamination by contrast appears to lower VAP and mortality rates. Effective implementation is as important as choosing the right bundle components. Best practices include engaging and educating staff, creating structures that facilitate bundle adherence, and providing regular feedback on process measure performance and outcome rates.

SUMMARY

VAP rates may still be elevated despite multiple reports to the contrary. Recent evidence suggests new ways to optimize the selection of ventilator bundle components and their implementation.

Nonpharmacologic and Medication Minimization Strategies for the Prevention and Treatment of ICU Delirium: A Narrative Review

Delirium is a multifactorial entity, and its understanding continues to evolve. Delirium has been associated with increased morbidity, mortality, length of stay, and cost for hospitalized patients, especially for patients in the intensive care unit (ICU). Recent literature on delirium focuses on specific pharmacologic risk factors and pharmacologic interventions to minimize course and severity of delirium. While medication management clearly plays a role in delirium management, there are a variety of nonpharmacologic interventions, pharmacologic minimization strategies, and protocols that have been recently described. A PubMed search was performed to review the evidence for nonpharmacologic management, pharmacologic minimization strategies, and prevention of delirium for patients in the ICU. Recent approaches were condensed into 10 actionable steps to manage delirium and minimize medications for ICU patients and are presented in this review.

Prospective Observational Evaluation of Sedation and Pain Management Guideline Adherence Across New Jersey Intensive Care Units

BACKGROUND

The practice guidelines for the management of pain, agitation, and delirium (PAD) from the Society of Critical Care Medicine shifted from primarily focusing on the treatment of anxiety in 2002 to the treatment of pain in 2013.

OBJECTIVE

This prospective, observational, multicenter study aimed to assess the degree of practice adherence to the PAD guidelines for ventilated patients in New Jersey intensive care units (ICUs).

METHODS

Pharmacist investigators at 8 centers designated 4 days at least 10 days apart to evaluate all patients on mechanical ventilation. The primary outcomes included adherence to 4 guideline recommendations: treatment of pain before sedation, use of nonnarcotic analgesic medications, use of nonbenzodiazepine sedative medications, and use of goal-directed sedation.

RESULTS

Of 138 patients evaluated, 50% had a primary medical diagnosis (as opposed to surgical, cardiac, or neurological diagnosis), and the median Sequential Organ Failure Assessment (SOFA) score was 7. Pain was treated prior to administration of sedatives in 55.4% of subjects, with fentanyl being the primary analgesic used. In addition, 19% received no analgesia, and 11.5% received nonopioid analgesia. Sedative agents were administered to 87 subjects (48 nonbenzodiazepine and 39 benzodiazepine). Of those receiving benzodiazepines, 22 received intermittent bolus regimens and 16 received continuous infusions, of which 5 were for another indication besides sedation. Validated scales measuring the degree of sedation were completed at least once in 56 (81.6%) patients receiving sedatives.

CONCLUSIONS

Current sedation practices suggest that integration of evidence-based PAD guidelines across New Jersey adult ICUs is inconsistent despite pharmacist involvement.

The 2014 updated version of the Confusion Assessment Method for the Intensive Care Unit compared to the 5th version of the Diagnostic and Statistical Manual of Mental Disorders and other current methods used by intensivists

BACKGROUND

One third of patients admitted to an intensive care unit (ICU) will develop delirium. However, delirium is under-recognized by bedside clinicians without the use of delirium screening tools, such as the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU). The CAM-ICU was updated in 2014 to improve its use by clinicians throughout the world. It has never been validated compared to the new reference standard, the Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5).

METHODS

We made a prospective psychometric study in a 16-bed medical-surgical ICU of a French academic hospital, to measure the diagnostic performance of the 2014 updated CAM-ICU compared to the DSM-5 as the reference standard. We included consecutive adult patients with a Richmond Agitation Sedation Scale (RASS) ≥ -3, without preexisting cognitive disorders, psychosis or cerebral injury. Delirium was independently assessed by neuropsychological experts using an operationalized approach to DSM-5, by investigators using the CAM-ICU and the ICDSC, by bedside clinicians and by ICU patients. The sensitivity, specificity, positive and negative predictive values were calculated considering neuropsychologist DSM-5 assessments as the reference standard (primary endpoint). CAM-ICU inter-observer agreement, as well as that between delirium diagnosis methods and the reference standard, was summarized using κ coefficients, which were subsequently compared using the Z-test.

RESULTS

Delirium was diagnosed by experts in 38% of the 108 patients included for analysis. The CAM-ICU had a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 91%. Compared to the reference standard, the CAM-ICU had a significantly (p < 0.05) higher agreement (κ = 0.86 ± 0.05) than the physicians,' residents' and nurses' diagnoses (κ = 0.65 ± 0.09; 0.63 ± 0.09; 0.61 ± 0.09, respectively), as well as the patient's own impression of feeling delirious (κ = 0.02 ± 0.11). Differences between the ICDSC (κ = 0.69 ± 0.07) and CAM-ICU were not significant (p = 0.054). The CAM-ICU demonstrated a high reliability for inter-observer agreement (κ = 0.87 ± 0.06).

CONCLUSIONS

The 2014 updated version of the CAM-ICU is valid according to DSM-5 criteria and reliable regarding inter-observer agreement in a research setting. Delirium remains under-recognized by bedside clinicians.

Improving Long-Term Outcomes After Sepsis

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

Perioperative management of the obese surgical patient

INTRODUCTION

The escalation in the prevalence of obesity throughout the world has led to an upsurge in the number of obese surgical patients to whom perioperative care needs to be delivered.

SOURCES OF DATA

After determining the scope of the review, the authors used PubMed with select phrases encompassing the words in the scope. Both preclinical and clinical reports were considered.

AREAS OF AGREEMENT

There were no controversies regarding preoperative management and the intraoperative care of the obese surgical patient.

AREAS OF CONTROVERSY

Is there a healthy obese state that gives rise to the obesity paradox regarding postoperative complications?

GROWING POINTS

This review considers how to prepare for and manage the obese surgical patient through the entire spectrum, from preoperative assessment to possible postoperative intensive care.

AREAS TIMELY FOR DEVELOPING RESEARCH

What results in an obese patient developing 'unhealthy' obesity?

The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care

The presence of delirium within critical care remains a long-standing challenge for patients and clinicians alike. A myriad of pre-disposing and precipitating factors lead to this patient cohort being high risk for developing delirium during their critical care stay. Until now, non-pharmacological management of these patients usually encompasses a 'bundle' of principles to reduce delirium days. These bundles have limited focus on the entire multi-disciplinary team (including occupational therapists and physiotherapists) who could assist with the reduction of delirium. The purpose of this analysis is to review the current literature and develop a mnemonic, which may help facilitate collaborative working for patients with delirium. Electronic databases were searched for non-pharmacological managements of delirium within intensive care settings, after 2006. Critical appraisal using Critical Appraisal Skills Programme methodology was completed by the author. Multi-intervention approaches and bundles are successful at reducing delirium days, and in some cases, reducing hospital length of stay. The key components of these bundles include spontaneous breathing trials, daily sedation holds, addressing pain relief, early mobilisation and to a small extent normalisation of a daily routine. There is limited research into the role of therapy within this patient group, but there is a role for cognitive therapy, functional tasks, and a greater rehab emphasis within other patient populations such as stroke and elderly care. The critical care population have similar rehabilitation needs to these groups, and therefore would benefit from similar treatment plans. Critical care patients with delirium may benefit from a range of additional therapeutic activities to reduce the duration of delirium. The D.E.L.I.R.I.U.M mnemonic has been developed to encompass all the key elements of current delirium research in a simplistic memorable fashion. Further work is needed to trial the usefulness of the mnemonic in clinical practice to enable the entire multi-disciplinary team work collaboratively to reduce delirium with the intensive care.

Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle

OBJECTIVES

To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines.

DESIGN

Worldwide online survey.

SETTING

Intensive care.

INTERVENTION

A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle.

MEASUREMENT AND MAIN RESULTS

There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits.

CONCLUSIONS

The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

The experience of intensive care nurses caring for patients with delirium: A phenomenological study

OBJECTIVES

The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients.

RESEARCH METHODOLOGY

This study utilised an interpretive phenomenological approach as described by van Manen.

SETTING

Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada.

FINDINGS

The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You.

CONCLUSION

The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience.