Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2

Background

Widespread drug shortages led to higher utilization of ketamine in our intensive care unit, especially among patients with SARS-CoV-2.

Objectives

To evaluate the impact of continuous infusion of ketamine on vasopressor requirements in patients with SARS-CoV-2.

Method

This was a single-center, retrospective, cohort study comparing mechanically ventilated (MV), adult patients with SARS-CoV-2 receiving either propofol or ketamine for at least 72 hours.

Results

84 patients (mean age of 61-year-old, 68% male) were analyzed. 31 patients received ketamine, and 53 patients received propofol. Mean vasopressor doses were not significantly different between ketamine and propofol groups at prespecified timepoints. However, mean arterial pressures (MAP) were higher in the ketamine group at 24 h, 48 h, and 96 h postsedative initiation. The median opioid infusion requirements were 3 vs. 12.5 mg/hr (p < 0.0001) for ketamine and propofol groups, respectively. Comparing to propofol, C-reactive protein (CRP) values were significantly lower in the ketamine group at 24 h (7.53 vs. 15.9 mg/dL, p=0.03), 48 h (5.23 vs. 14.1 mg/dL, p=0.0083), and 72 h (6.4 vs. 12.1 mg/dL, p=0.0085).

Conclusion

In patients with SARS-CoV-2 on MV, there was no difference in the vasopressor requirement in patients receiving ketamine compared to propofol. Nevertheless, the use of ketamine was associated with higher MAP, reductions in CRP in select timepoints, and overall lower opioid requirements.

Assessment of sedation by automated pupillometry in critically ill patients: a prospective observational study

BACKGROUND

Quantitative measurement of pupil change has not been assessed against the Richmond Agitation and Sedation Scale (RASS) and spectral edge frequency (SEF) during sedation. The aim of this study was to evaluate pupillometry against these measures in sedated critically ill adult patients.

METHODS

In ventilated and sedated patients, pupillary variables were measured by automated pupillometry at each RASS level from -5 to 0 after discontinuation of hypnotics, while processed electroencephalogram variables were displayed continuously and SEF was recorded at each RASS level. Correlations were made between percentage pupillary light reflex (%PLR) and RASS, and between %PLR and SEF. The ability of %PLR to differentiate light sedation (RASS ≥-2), moderate (RASS =-3), and deep sedation (RASS ≤-4) was assessed by areas under receiver operating characteristic (ROC) curves.

RESULTS

A total of 163 paired measurements were recorded in 38 patients. With decreasing sedation depth, median %PLR increased progressively from 20% (interquartile range 17-25%) to 36% (interquartile range 33-40%) (P<0.001). Strong correlations were found between %PLR and RASS (Rho=0.635) and between %PLR and SEF (R=0.641). Area under the curve (AUC) of 0.87 with a %PLR threshold of 28% differentiated moderate/light sedation from deep sedation with sensitivity of 83% and specificity of 83%. An AUC of 0.82 with a threshold of 31% distinguished light sedation from moderate/deep sedation with a sensitivity of 81% and a specificity of 75%.

CONCLUSIONS

Quantitative assessment of %PLR correlates with other indicators of sedation depth in critically ill patients.

Efficacy and safety of music therapy for the treatment of anxiety and delirium in ICU patients: a meta-analysis and systematic review of randomized controlled trials

INTRODUCTION

The medical application of music therapy (MT) has received widespread attention in recent years and some researchers have attempted to apply MT to the treatment of patients with anxiety and delirium in ICU.

EVIDENCE ACQUISITION

Relevant randomized controlled trials (randomized controlled trials s) were searched in databases, such as Web of Science, PubMed, Embase, Cochrane Library, Medline, Scopus, and CINAHL. Researchers performed literature screening, data extraction, literature quality assessment, and heterogeneity analysis among RCTs.

EVIDENCE SYNTHESIS

Fourteen studies met the inclusion criteria. In general, we included RCTs with low risk of bias, and the primary outcome indicators, including the Chinese version of the State-Trait Anxiety Inventory (C-STAI), Visual Analogue Scale for Anxiety Measurement (VAS-A), and Facial Anxiety Scale (FAS), with a recommended level of evidence of "strong". The pooled results indicated that MT was effective in alleviating the anxiety state of ICU patients (95% CI, SMD=-1.09 [-1.52, -0.67], P<0.05) and could reduce mental and physical fatigue in patients with anxious delirium in ICU (95% CI, WMD=-2.35 [-3.37, -1.33], P <0.05). There were significant differences in the therapeutic effects of MT with different intervention durations. Both 15-minute and 30-minute MT were effective in reducing anxiety levels in patients with anxiety disorders in the ICU (15min: 95%CI, SMD=-1.70[-2.15, -1.24], P<0.05; 30min: 95%CI, SMD=-0.73[-1.16, - 0.29], P<0.05). However, when the duration of MT exceeded 45 min, the overtreatment of MT instead interfered with patient rest and failed to produce a positive therapeutic effect (95% CI, SMD=-1.04 [-3.06, 0.97], P=0.31). In addition, a meta-analysis of physiological outcomes found that MT was effective in maintaining the stabilization of heart rate (HR), respiratory rate (RR), and systolic blood pressure (SBP) in ICU patients with anxiety (P<0.05), but did not affect patients' oxygen saturation, mean arterial pressure and diastolic blood pressure (P>0.05). No adverse events occurred during MT treatment in the reports of included 14 studies.

CONCLUSIONS

MT can safely and effectively reduce the anxiety level of patients with anxiety and delirium in ICU and relieve their psychological and physical fatigue. And MT was able to maintain the stability of HR, RR, and SBP in ICU patients.

Delirium and delirium severity screening in the intensive care-correspondence of screenings tools

BACKGROUND

Delirium severity scores are gaining acceptance for measuring delirium in the intensive care unit (ICU).

OBJECTIVE

The aim of this study was to evaluate the concordance between the Confusion Assessment Method for the intensive care unit (CAM-ICU)-7 and the Intensive Care Delirium Screening Checklist (ICDSC) as delirium severity measurement tools.

METHODS

This was a prospective, comparative, observational multicentre study. This study was conducted in 18 Danish ICUs. Delirium was assessed in adult critically ill patients admitted to an ICU with a Richmond Agitation and Sedation Score (RASS) of -2 or above. ICU nurses assessed delirium with randomised paired delirium screening instruments, using the CAM-ICU, the ICDSC, and the CAM-ICU-7. The correlation between the CAM-ICU-7 and the ICDSC severity scores was evaluated for all predefined patient subgroups.

RESULTS

A total of 1126 paired screenings were conducted by 127 ICU nurses in 850 patients. The patients' median age was 70 years (interquartile range: 61-77), 40% (339/850) were female, and 54% (457/850) had at least one positive delirium score. Delirium severity ranges (CAM-ICU-7: 0-7; and ICDSC: 0-8) were positively correlated (Pearson's correlation coefficient, r = 0.83; p < 0.0001). The overall agreement between the CAM-ICU-7 and the ICDSC for delirium measurement (CAM-ICU-7: >2, and ICDSC: >3) was substantial (kappa = 0.74), but the agreement decreased to fair (kappa = 0.38) if a patient had a RASS less than 0.

CONCLUSIONS

The agreement between the CAM-ICU-7 and the ICDSC for delirium severity measurement was substantial but might be affected by the patient's sedation and agitation level at the time of assessment.

IMPLICATIONS FOR PRACTICE

Both CAM-ICU-7 and ICDSC can be implemented for delirium severity measurement. Attention is warranted in both scores if a patient has a RASS of -2.

A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial

Aims and background

The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery.

Materials and methods

This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay.

Results

108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups.

Conclusion

This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate.

How to cite this article

Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.

Impact of knowledge, attitudes and self-reported practices of nurses on early mobilization of mechanically ventilated patients in the ICU

BACKGROUND

Many ICUs worldwide are striving to integrate early mobilization as part of critical care rehabilitation. However, ICU nurses, who are essential contributors to the early mobilization of critically ill patients, still lack comprehensive surveys assessing their knowledge, beliefs, and practices regarding the early mobilization of mechanically ventilated patients.

AIM

To analyse the knowledge, attitudes, and practices of intensive care unit (ICU) nurses regarding the early mobilization of mechanically ventilated patients and to explore the effects of these practices.

STUDY DESIGN

A multicentre cross-sectional study. ICU nurses in five tertiary hospitals in Zhejiang Province, China, were selected by convenience sampling and invited to complete an online questionnaire between 1 June 2021 and 15 June 2021. Sociodemographic data and the knowledge, attitudes, and practices of ICU nurses regarding early mobilization.

RESULTS

A total of 296 valid questionnaires were collected, for a response rate of approximately 77.5%. The average scores for knowledge, attitudes, and practices of ICU nurses regarding the early mobilization of mechanically ventilated patients were 42.7 ± 7.4, 34.3 ± 6.5, and 47.1 ± 6.5, respectively, which were good scores. Quantile regressions showed that at the 25% and 50% quartiles, increases in knowledge and attitude scores resulted in increases in practice scores (p < .001); however, at the 75% quartile, increases in knowledge scores did not result in practice score increases (t = 0.000, p = .999); moreover, there was still a 0.5-point increase in practice scores per 1-point increase in attitude scores (t = 0.500, p < .001).

CONCLUSIONS

The knowledge, attitudes, and self-reported practices of ICU nurses were good, although there is room for improvement. Considering that the influence of attitudes on practice improvement is more important than knowledge, ICU managers should promote knowledge transformation, strengthen attitudes, and adopt comprehensive measures to promote the early mobilization of mechanically ventilated patients in the ICU.

RELEVANCE TO CLINICAL PRACTICE

To optimize the early mobilization of mechanically ventilated patients in the ICU, introducing multipronged support strategies based on the knowledge and attitudes of ICU nurses is recommended to promote the implementation of such practices.

Requesting That Delirium Achieve Parity With Acute Encephalopathy in the MS-DRG System

Since 2007, the Medicare Severity Diagnosis Related Groups classification system has favored billing codes for acute encephalopathy over delirium codes in determining hospital reimbursement and several quality-of-care value metrics, despite broad overlap between these sets of diagnostic codes. Toxic and metabolic encephalopathy codes are designated as major complication or comorbidity, whereas causally specified delirium codes are designated as complication or comorbidity and thus associated with a lower reimbursement and lesser impact on value metrics. The authors led a submission to the U.S. Centers for Medicare and Medicaid Services requesting that causally specified delirium be designated major complication or comorbidity alongside toxic and metabolic encephalopathy. Delirium warrants reclassification because it satisfies U.S. Centers for Medicare and Medicaid Services' guiding principles for re-evaluating Medicare Severity Diagnosis Related Group severity levels. Delirium: (1) has a bidirectional relationship with the permanent condition of dementia (major neurocognitive disorder per DSM-5-TR), (2) indexes vulnerability across populations, (3) impacts healthcare systems across levels of care, (4) complicates postoperative recovery, (5) consigns patients to higher levels of care, (6) impedes patient engagement in care, (7) has several recent treatment guidelines, (8) often indicates neuronal/brain injury, and (9) represents a common expression of terminal illness. The proposal's impact was explored using the 2019 National Inpatient Sample, which suggested that increasing delirium's complexity designation would lead to an upcoding of less than 1% of eligible discharges. Parity for delirium is essential to enhancing awareness of delirium's clinical and economic costs. Appreciating delirium's impact would encourage delirium prevention and screening efforts, thereby mitigating its dire outcomes for patients, families, and healthcare systems.

Quality Improvement in an Anaesthesiology and Intensive Care Unit Through Pain Assessment and Control

The aim of the study is to determine whether the assessment of postoperative pain and timely measures to control it improve the quality of medical care in intensive care units (ICUs). To develop an improvement model with a focus on pain assessment and control. 151 patients were included in the study, divided into two groups: a retrospective group (RG)-60 patients and a prospective group (PG)-91 patients. A multimodal approach to pain control was applied to all patients. We administered the Critical Care Pain Observational Tool (CPOT) to PG upon admission to the ICU. Visual analog scale (VAS) for pain assessment was used in all non intubated patients in 6 hours intervals. In the PG, а model for improvement was applied using a PDSA (Plan, Do, Study/ Check, Act) cycle. The following indicators have been used: process, outcome, and balancing indicators. A survey of the PG was also conducted. The developed Model of improvement increased the VAS score reporting success rate from 40 to 95%, which allowed significantly better pain control. In PG the registered CPOT score was 1.71 ± 0.73. 90% of patients in PG have an average VAS score below 5 after the improvement model, while in RG-50% of patients, which is statistically significant (P < 0.001). There was no statistically significant difference in balancing indicators between the two groups. Conclusion: The conducted survey confirmed the positive effect of the model. Quality improvement in the ICU depends on accurate assessment of postoperative pain and timely and adequate treatment.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

None.

Family Members' Engagement in Symptom Communication, Assessment, and Management in the Intensive Care Unit: A Qualitative Study

BACKGROUND

Opportunities for communication and participation in decision making are limited for critically ill patients, but family members serving as surrogates enable empowerment of these patients.

OBJECTIVE

The aim of this study was to explore family members' engagement in symptom communication in the intensive care unit.

METHODS

A qualitative descriptive design using fieldwork methodology with triangulation of participant observation and individual interviews was conducted. Nine mechanically ventilated patients were observed in interaction with family members and clinicians in the intensive care unit. Six of the observed patients, 6 family members, and 9 clinicians were interviewed after participant observation. Field notes and transcripts were analyzed using Braun and Clarke's method of thematic analysis.

RESULTS

Family members engaged actively in symptom communication, assessment, and management, and there were barriers and facilitators to family engagement. Three main themes and 9 subthemes describing family engagement emerged: (1) intermediary role (recognize and report symptoms, provide patient information, and assist in communication), (2) independent role (provide familiarity, manage symptoms, and promote patient communication), and (3) conditions for family engagement (intensive care unit environment, relationship with the patient, and patient preferences).

DISCUSSION

Family members have unique knowledge of the patient that differs from and complement the competence of the staff, and might contribute to improved symptom communication. Future research should examine how family members can contribute to symptom communication, assessment, and management.

Effects of gabapentin on slow-wave sleep period in critically ill adult patients: A randomized controlled trial

Sleep deprivation is a prevalent problem in critically ill patients, which leads to delayed recovery and delirium. Slow-wave sleep (SWS) is essential to energy restoration, tissue repair, and immune system strengthening. This study aimed to investigate the effects of gabapentin on SWS in critically ill patients. We performed a prospective open-label randomized controlled study to compare SWS and the clinical outcomes of gabapentin versus a control intervention in critically ill adult patients admitted to the intensive care unit (ICU) within 24 h. The patients' characteristics and sleep-related outcomes were recorded. The sleep-related outcomes, namely, bispectral analysis (BIS), the Richards-Campbell Sleep Questionnaire (RCSQ), and insulin-like growth factor-1 (IGF-1) levels, were evaluated. Furthermore, clinical outcomes and safety were assessed. Sixty patients from 348 cases were eligible for randomization. On day 3 of the study, patients in the gabapentin group had significantly increased SWS (66.79 vs. 0.00 min; p < 0.001), total sleep time (TST) (331.39 vs. 46.16 min; p = 0.001), RCSQ score (55.05 ± 20.18 vs. 32.80 ± 15.31; p < 0.001), and IGF-1 concentrations (84.33 ± 12.40 vs. 44.00 ± 10.20 ng/mL, p < 0.001) compared with the control group. Improvements in clinical outcomes, such as delirium, ICU-free days, and mechanical ventilator-free days, were observed; however, these differences did not reach statistically significant. Gabapentin at bedtime increased SWS, TST, and IGF-1 concentrations in critically ill patients. This regimen might be beneficial to critically ill patients for improving their sleep quality.

"Beyond waking and walking. Intensive rehabilitation in patients requiring extended durations of advanced mechanical circulatory support: A case series"

Physical therapy (PT) utilization in patients requiring mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) has been reported; however, little is known about intensive rehabilitation and associated outcomes in patients requiring extended complex MCS and/or ECMO support.

Authors sought to explore safety, feasibility and outcomes associated with active rehabilitation in patients requiring prolonged advanced MCS/ECMO support.

Single-center retrospective series evaluated functional, clinical, and longitudinal outcomes of sample of eight critically ill, adult (≥18 years of age) patients who underwent a intensive rehabilitation while receiving prolonged MCS/ECMO through advanced configurations including: venovenous (VV-ECMO), venoarterial (VA-ECMO), oxygenator with right ventricular assist device (Oxy-RVAD) and right ventricular assist device (RVAD).

406 sessions were conducted; 246 during provision of advanced MCS/ECMO support.

Incidence of major adverse events-accidental decannulation, migration of cannulas, circuit failure, hemorrhage, major flow limitations, and major hemodynamic instability-was 1.2 events per 100 sessions. None of reported major adverse events impeded longitudinal ability to participate in PT. Increased time to PT initiation was associated with a statistically significant increase in intensive care unit (ICU) length-of-stay (β1 1.93, CI 0.55-3.30) and reduced ambulatory distance during last session on MCS/ECMO (β1 -47.64, CI - 93.93, -1.66). All patients survived to hospital discharge and 12 months from sentinel hospitalization. Amongst those patients discharged to an inpatient rehabilitation center (n = 4), all were discharged home within 3 months.

Findings support the safety and feasibility of active rehabilitational PT in patients requiring extended durations of advanced MCS/ECMO support. Moreover, it highlights potentially associated benefits of this degree of intensive rehabilitation for these unique patients. Further investigation is needed to identify associations with longitudinal clinical outcomes, as well as predictors of success in this population.

Patient and family engagement in Danish intensive care units: A national survey

BACKGROUND

Patient and family engagement in the intensive care unit increases the quality of care and patient safety.

AIM

The aim of our study was to describe current practice and experiences of contemporary patient and family engagement in the intensive care unit at the individual level, the organizational level, and in the research process according to critical care nurses.

DESIGN/METHOD

We conducted a national qualitative survey of intensive care units in Denmark from 5th May-5th June 2021. Questionnaires were piloted and sent to intensive care nurse specialists and research nurses at 41 intensive care units, allowing one respondent per unit. All respondents were provided with written information about the study by email, and by activating the survey link, they accepted participation.

RESULTS

Thirty-two nurses responded to the invitation, 24 completed and 8 partially completed the survey, yielding a response rate of 78%. At the individual level, 27 respondents stated that they involved patients and 25 said they involved family in daily treatment and care. At the organizational level, 28 intensive care units had an overall strategy or guideline for patient and family engagement, and 4 units had established a PFE panel. And, finally, 11 units engaged patients and families in the research process.

CONCLUSIONS

Our survey suggested that patient and family engagement was implemented to some degree at the individual level, organizational level, and in the research process, but only 4 units had established a PFE panel at the organizational level, which is key to engagement.

RELEVANCE TO CLINICAL PRACTICE

Patient engagement increases when patients are more awake, and family engagement increases when patients are unable to participate. Engagement increases when patient and family engagement panels are implemented.

Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis

BACKGROUND

Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis.

METHODS

In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272.

FINDINGS

After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only.

INTERPRETATION

Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm.

FUNDING

None.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Optimizing patient outcomes: a comprehensive evaluation of protocolized sedation in intensive care settings: a systematic review and meta-analysis

INTRODUCTION

Amidst the routine utilization of protocolized sedation in ventilated ICU patients, existing management guidelines exhibit a lack of unanimous recommendations for its widespread adoption. This study endeavors to comprehensively assess the effectiveness and safety of protocolized sedation in critically ill ventilated patients.

OBJECTIVE

The primary objective of this study was to systematically review and conduct a meta-analysis of clinical trials comparing protocolized sedation with standard management in critically ill ventilated patients. Key outcomes under scrutiny include ICU and hospital mortality, ventilation days, duration of ICU stay, and incidents of self-extubation. The evaluation incorporates the Risk of Bias 2 (RoB2) tool to assess the quality of included studies. Data analysis utilizes a random-effects model for relative risk (RR) and mean differences. Subgroup analysis categorizes sedation protocols into algorithmic or daily interruption, addressing potential heterogeneity. Additionally, a GRADE evaluation is performed to ascertain the overall certainty of the evidence.

RESULTS

From an initial pool of 1504 records, 10 studies met the inclusion criteria. Protocolized sedation demonstrated a reduced RR for mortality (RR: 0.80, 95% CI 0.68-0.93, p < 0.01, I2 = 0%) and a decrease in ventilation days (mean difference: - 1.12, 95% CI - 2.11 to - 0.14, p = 0.03, I2 = 84%). Furthermore, there was a notable reduction in ICU stay (mean difference: - 2.24, 95% CI - 3.59 to - 0.89, p < 0.01, I2 = 81%). However, incidents of self-extubation did not exhibit a significant difference (RR: 1.20, 95% CI 0.49-2.94, p = 0.69, I2 = 35%). Subgroup analyses effectively eliminated heterogeneity (I2 = 0%), and the GRADE evaluation yielded moderate results for mortality, ventilation days, and ICU duration.

CONCLUSION

Protocolized sedation, whether implemented algorithmically or through daily interruption, emerges as a safe and effective approach when compared to standard management in ventilated ICU patients. The findings from this study contribute valuable insights to inform evidence-based practices in sedation management for this critical patient population.

Propofol and Dexmedetomidine Ameliorate Endotoxemia-Associated Encephalopathy via Inhibiting Ferroptosis

Background

Sepsis is recognized as a multiorgan and systemic damage caused by dysregulated host response to infection. Its acute systemic inflammatory response highly resembles that of lipopolysaccharide (LPS)-induced endotoxemia. Propofol and dexmedetomidine are two commonly used sedatives for mechanical ventilation in critically ill patients and have been reported to alleviate cognitive impairment in many diseases. In this study, we aimed to explore and compare the effects of propofol and dexmedetomidine on the encephalopathy induced by endotoxemia and to investigate whether ferroptosis is involved, finally providing experimental evidence for multi-drug combination in septic sedation.

Methods

A total of 218 C57BL/6J male mice (20-25 g, 6-8 weeks) were used. Morris water maze (MWM) tests were performed to evaluate whether propofol and dexmedetomidine attenuated LPS-induced cognitive deficits. Brain injury was evaluated using Nissl and Fluoro-Jade C (FJC) staining. Neuroinflammation was assessed by dihydroethidium (DHE) and DCFH-DA staining and by measuring the levels of three cytokines. The number of Iba1+ and GFAP+ cells was used to detect the activation of microglia and astrocytes. To explore the involvement of ferroptosis, the levels of ptgs2 and chac1; the content of iron, malondialdehyde (MDA), and glutathione (GSH); and the expression of ferroptosis-related proteins were investigated.

Conclusion

The single use of propofol and dexmedetomidine mitigated LPS-induced cognitive impairment, while the combination showed poor performance. In alleviating endotoxemic neural loss and degeneration, the united sedative group exhibited the most potent capability. Both propofol and dexmedetomidine inhibited neuroinflammation, while propofol's effect was slightly weaker. All sedative groups reduced the neural apoptosis, inhibited the activation of microglia and astrocytes, and relieved neurologic ferroptosis. The combined group was most prominent in combating genetic and biochemical alterations of ferroptosis. Fpn1 may be at the core of endotoxemia-related ferroptosis activation.

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach

BACKGROUND

The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE.

OBJECTIVE

Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens.

METHODS

We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift.

RESULTS

From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys).

INTERPRETATION

Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study

BACKGROUND

Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms.

METHODS

This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition.

RESULTS

Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1 month post-CABG.

CONCLUSIONS

Women in this CABG cohort were more likely to have depression at baseline and 1 month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B trial): protocol for a mixed-methods process evaluation of a randomised controlled trial

INTRODUCTION

An association between deep sedation and adverse short-term outcomes has been demonstrated although this evidence has been inconsistent. The A2B (alpha-2 agonists for sedation in critical care) sedation trial is designed to determine whether the alpha-2 agonists clonidine and dexmedetomidine, compared with usual care, are clinically and cost-effective. The A2B intervention is a complex intervention conducted in 39 intensive care units (ICUs) in the UK. Multicentre organisational factors, variable cultures, perceptions and practices and the involvement of multiple members of the healthcare team add to the complexity of the A2B trial. From our pretrial contextual exploration it was apparent that routine practices such as type and frequency of pain, agitation and delirium assessment, as well as the common sedative agents used, varied widely across the UK. Anticipated challenges in implementing A2B focused on the impact of usual practice, perceptions of risk, ICU culture, structure and the presence of equipoise. Given this complexity, a process evaluation has been embedded in the A2B trial to uncover factors that could impact successful delivery and explore their impact on intervention delivery and interpretation of outcomes.

METHODS AND ANALYSIS

This is a mixed-methods process evaluation guided by the A2B intervention logic model. It includes two phases of data collection conducted during and at the end of trial. Data will be collected using a combination of questionnaires, stakeholder interviews and routinely collected trial data. A framework approach will be used to analyse qualitative data with synthesis of data within and across the phases. The nature of the relationship between delivery of the A2B intervention and the trial primary and secondary outcomes will be explored.

ETHICS AND DISSEMINATION

All elements of the A2B trial, including the process evaluation, are approved by Scotland A Research Ethics Committee (Ref. 18/SS/0085). Dissemination will be via publications, presentations and media engagement.

TRIAL REGISTRATION NUMBER

NCT03653832.

Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality

AIM OF THE STUDY

The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated.

MATERIALS AND METHODS

This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression.

RESULTS

Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070).

CONCLUSIONS

Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset.

IMPLICATIONS FOR CLINICAL PRACTICE

Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.

Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients

BACKGROUND

Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering.

AIMS

The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients.

DESIGN

The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks.

SETTINGS

On a six-bed adult inpatient Palliative Care Unit (PCU).

PARTICIPANTS/SUBJECTS

Nonverbal palliative care patients.

METHODS

Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption.

RESULTS

Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores.

CONCLUSIONS

MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

Anticipating ICU discharge and long-term follow-up

PURPOSE OF REVIEW

This review aims to summarize recent literature findings on long-term outcomes following critical illness and to highlight potential strategies for preventing and managing health deterioration in survivors of critical care.

RECENT FINDINGS

A substantial number of critical care survivors experience new or exacerbated impairments in their physical, cognitive or mental health, commonly named as postintensive care syndrome (PICS). Furthermore, those who survive critical illness often face an elevated risk of adverse outcomes in the months following their hospital stay, including infections, cardiovascular events, rehospitalizations and increased mortality. These findings underscore the need for effective prevention and management of long-term health deterioration in the critical care setting. While robust evidence from well designed randomized clinical trials is limited, potential interventions encompass sedation limitation, early mobilization, delirium prevention and family presence during intensive care unit (ICU) stay, as well as multicomponent transition programs (from ICU to ward, and from hospital to home) and specialized posthospital discharge follow-up.

SUMMARY

In this review, we offer a concise overview of recent insights into the long-term outcomes of critical care survivors and advancements in the prevention and management of health deterioration after critical illness.

Cognitive impairment in intensive care unit patients: A qualitative exploration through observations and interviews

OBJECTIVES

Many patients experience cognitive impairments while being admitted to an intensive care unit due to critical illness affecting their well-being and rehabilitation. Little is known about how patients experience cognitive impairments. This study aimed to explore patients' and relatives' experiences of patients' cognitive impairments while in the intensive care unit.

RESEARCH METHODOLOGY

A multi-centre qualitative study, inspired by Ricoeur's phenomenological-hermeneutic approach, was conducted at four intensive care units at two hospitals in Denmark. Data collection encompassed participant observation and semi-structured single or dyadic interviews with 20 patients and 15 relatives, conducted in the intensive care units. The Consolidated Criteria for Reporting Qualitative Research checklist was used.

FINDINGS

Four themes emerged during the analysis: 'Having a hazy memory and a foggy brain', 'Frustrations due to difficulties in speaking', 'An altered sense of self' and 'A feeling of disconnect between body and mind'. In the intensive care unit, patients experienced multiple cognitive impairments across several cognitive domains, significantly affecting their overall well-being.

CONCLUSIONS

The findings provided a nuanced exploration of how patients in the intensive care unit grapple with cognitive impairments, leaving them feeling exposed and vulnerable due to increased dependency and loss of dignity. Relatives' presence and help was a huge support during admission.

IMPLICATIONS FOR CLINICAL PRACTICE

This study highlights patients' and relatives' experiences of patients' cognitive impairments in the intensive care units. There is a need for nurses and allied healthcare professionals to address and manage reduced cognition in intensive care unit patients. This is particularly important to underpin recovery and rehabilitation processes, improve quality of life and optimise patients' return to everyday life. Future research must investigate how and when intensive care patients would benefit from preventive initiatives and initiatives to support recovery and rehabilitation of cognitive impairments.

Association of Early Dexmedetomidine Utilization With Clinical and Functional Outcomes Following Moderate-Severe Traumatic Brain Injury: A Transforming Clinical Research and Knowledge in Traumatic Brain Injury Study

OBJECTIVE

To examine early sedation patterns, as well as the association of dexmedetomidine exposure, with clinical and functional outcomes among mechanically ventilated patients with moderate-severe traumatic brain injury (msTBI).

DESIGN

Retrospective cohort study with prospectively collected data.

SETTING

Eighteen Level-1 Trauma Centers, United States.

PATIENTS

Adult (age > 17) patients with msTBI (as defined by Glasgow Coma Scale < 13) who required mechanical ventilation from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Using propensity-weighted models, we examined the association of early dexmedetomidine exposure (within the first 5 d of ICU admission) with the primary outcome of 6-month Glasgow Outcomes Scale Extended (GOS-E) and the following secondary outcomes: length of hospital stay, hospital mortality, 6-month Disability Rating Scale (DRS), and 6-month mortality. The study population included 352 subjects who required mechanical ventilation within 24 hours of admission. The initial sedative medication was propofol for 240 patients (68%), midazolam for 59 patients (17%), ketamine for 6 patients (2%), dexmedetomidine for 3 patients (1%), and 43 patients (12%) never received continuous sedation. Early dexmedetomidine was administered in 77 of the patients (22%), usually as a second-line agent. Compared with unexposed patients, early dexmedetomidine exposure was not associated with better 6-month GOS-E (weighted odds ratio [OR] = 1.48; 95% CI, 0.98-2.25). Early dexmedetomidine exposure was associated with lower DRS (weighted OR = -3.04; 95% CI, -5.88 to -0.21). In patients requiring ICP monitoring within the first 24 hours of admission, early dexmedetomidine exposure was associated with higher 6-month GOS-E score (OR 2.17; 95% CI, 1.24-3.80), lower DRS score (adjusted mean difference, -5.81; 95% CI, -9.38 to 2.25), and reduced length of hospital stay (hazard ratio = 1.50; 95% CI, 1.02-2.20).

CONCLUSION

Variation exists in early sedation choice among mechanically ventilated patients with msTBI. Early dexmedetomidine exposure was not associated with improved 6-month functional outcomes in the entire population, although may have clinical benefit in patients with indications for ICP monitoring.

Ketamine in Critically Ill Patients: Use, Perceptions, and Potential Barriers

Objective: To evaluate practitioner use of ketamine and identify potential barriers to use in acutely and critically ill patients. To compare characteristics, beliefs, and practices of ketamine frequent users and non-users. Methods: An online survey developed by members of the Society of Critical Care Medicine (SCCM) Clinical Pharmacy and Pharmacology Section was distributed to physician, pharmacist, nurse practitioner, physician assistant and nurse members of SCCM. The online survey queried SCCM members on self-reported practices regarding ketamine use and potential barriers in acute and critically ill patients. Results: Respondents, 341 analyzed, were mostly adult physicians, practicing in the United States at academic medical centers. Clinicians were comfortable or very comfortable using ketamine to facilitate intubation (80.0%), for analgesia (77.9%), procedural sedation (79.4%), continuous ICU sedation (65.8%), dressing changes (62.4%), or for asthma exacerbation and status epilepticus (58.8% and 40.4%). Clinicians were least comfortable with ketamine use for alcohol withdrawal and opioid detoxification (24.7% and 23.2%). Most respondents reported "never" or "infrequently" using ketamine preferentially for continuous IV analgesia (55.6%) or sedation (61%). Responses were mixed across dosing ranges and duration. The most common barriers to ketamine use were adverse effects (42.6%), other practitioners not routinely using the medication (41.5%), lack of evidence (33.5%), lack of familiarity (33.1%), and hospital/institutional policy guiding the indication for use (32.3%). Conclusion: Although most critical care practitioners report feeling comfortable using ketamine, there are many inconsistencies in practice regarding dose, duration, and reasons to avoid or limit ketamine use. Further educational tools may be targeted at practitioners to improve appropriate ketamine use.

Modification in ICU Design May Affect Delirium and Circadian Melatonin: A Proof of Concept Pilot Study

OBJECTIVES

Nonpharmacologic delirium management is recommended by current guidelines, but studies on the impact of ICU design are still limited. The study's primary purpose was to determine if a multicomponent change in room design prevents ICU delirium. Second, the influence of lighting conditions on serum melatonin was assessed.

DESIGN

Prospective observational cohort pilot study.

SETTING

The new design concept was established in two two-bed ICU rooms of a university hospital. Besides modifications aimed at stress relief, it includes a new dynamic lighting system.

PATIENTS

Seventy-four adult critically ill patients on mechanical ventilation with an expected ICU length of stay of at least 48 hours, treated in modified or standard rooms.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The clinical examination included a prospective assessment for depth of sedation, delirium, and pain every 8 hours using validated scores. Blood samples for serum melatonin profiles were collected every 4 hours for a maximum of three 24-hour periods. Seventy-four patients were included in the analysis. Seventy-six percent ( n = 28) of patients in the standard rooms developed delirium compared with 46% of patients ( n = 17) in the modified rooms ( p = 0.017). Patients in standard rooms (vs. modified rooms) had a 2.3-fold higher delirium severity (odds ratio = 2.292; 95% CI, 1.582-3.321; p < 0.0001). Light intensity, calculated using the measure of circadian effective irradiance, significantly influenced the course of serum melatonin ( p < 0.0001). Significant interactions ( p < 0.001) revealed that differences in serum melatonin between patients in standard and modified rooms were not the same over time but varied in specific periods of time.

CONCLUSIONS

Modifications in ICU room design may influence the incidence and severity of delirium. Dedicated light therapy could potentially influence delirium outcomes by modulating circadian melatonin levels.

Mobilisation during mechanical ventilation: A qualitative study exploring the practice of conscious patients, nurses and physiotherapists in intensive care unit

AIM

To explore the practice of mobilisation of conscious and mechanically ventilated patients and the interaction between patients, nurses and physiotherapists.

BACKGROUND

Long-term consequences of critical illness can be reduced by mobilisation starting in Intensive Care Units, but implementation in clinical practice is presently sparse.

DESIGN

A qualitative study with a phenomenological-hermeneutic approach.

METHODS

Participant observations in three Intensive Care Units involved twelve conscious mechanically ventilated patients, thirty-one nurses and four physiotherapists. Additionally seven semi-structured patient interviews, respectively at the ward and after discharge and two focus group interviews with healthcare professionals were conducted. The data analysis was inspired by Ricoeur's interpretation theory. The study adhered to the COREQ checklist.

FINDINGS

Healthcare professionals performed a balance of support and guidance to promote mobilisation practice. The complexity of ICU mobilisation required a flexible mobility plan. Furthermore, interaction with feedback and humour was found to be 'a leverage' for patient's motivation to partake in mobilisation. The practice of mobilisation found patients striving to cope and healthcare professionals promoting a 'balanced standing by' and negotiating the flexible mobility plan to support mobilisation.

CONCLUSION

The study revealed a need to clarify interprofessional communication to align expectations towards mobilisation of conscious and mechanically ventilated patients.

RELEVANCE TO CLINICAL PRACTICE

The study demonstrated the important role of healthcare professionals to perform a stepwise and 'balanced standing by' in adequately supporting and challenging the mobilisation of mechanically ventilated patients. Furthermore, a synergy can arise when nurses and physiotherapists use supplementary feedback and humour, and cooperate based on a flexible situation-specific mobility plan in intensive care.

Adjunctive Therapies in Acute Respiratory Distress Syndrome

Despite significant advances in understanding acute respiratory distress syndrome (ARDS), mortality rates remain high. The appropriate use of adjunctive therapies can improve outcomes, particularly for patients with moderate to severe hypoxia. In this review, the authors discuss the evidence basis behind prone positioning, recruitment maneuvers, neuromuscular blocking agents, corticosteroids, pulmonary vasodilators, and extracorporeal membrane oxygenation and considerations for their use in individual patients and specific clinical scenarios. Because the heterogeneity of ARDS poses challenges in finding universally effective treatments, an individualized approach and continued research efforts are crucial for optimizing the utilization of adjunctive therapies and improving patient outcomes.

A Comparison of Midazolam and Propofol for Deep Sedation in Patients with Acute Respiratory Distress Syndrome Requiring Neuromuscular Blocking Agents

Purpose: The optimal agent for deep sedation in patients undergoing continuous infusion (CI) neuromuscular blocking agent (NMBA) use for acute respiratory distress syndrome (ARDS) is unknown. The purpose of this study is to compare the efficacy and safety of propofol and midazolam in ARDS patients requiring CI NMBA. Methods: A multi-center, retrospective study was performed in mechanically ventilated (MV) adult patients requiring CI NMBA for management of ARDS. The primary outcome was to compare the time to liberation from MV in patients sedated with propofol vs midazolam. Results: In the 109 patients included, there was no difference in time to MV liberation with propofol as compared to midazolam (121 hr [Interquartile range (IQR) 67 195] vs 98 hr [IQR 48, 292], P = .72). Median time to sedation emergence after NMBA discontinuation was shorter in patients receiving propofol (12.9 hr [IQR 19.8, 72.5] vs 31.5 hr [IQR 6.4, 34.6], P < .01). There were no significant differences in time to therapeutic sedation, ICU stay, mortality, and adverse events. Conclusion: Propofol may be an effective and safe alternative to midazolam for patients undergoing CI NMBA for ARDS. Additionally, patients receiving propofol may have a quicker return to light sedation after NMBA discontinuation.

Acute encephalopathy in the ICU: a practical approach

PURPOSE OF REVIEW

Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury.

RECENT FINDINGS

Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes.

SUMMARY

Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.

Characterization of Opioid Use in the Intensive Care Unit and Its Impact Across Care Transitions: A Prospective Study

Purpose: The objective of this study is to characterize opioid intensity in the intensive care unit (ICU) and its association with opioid utilization across care transitions. Methods: This is a prospective cohort study. Medically ill ICU patients with complete medication histories who survived to discharge were included. Opioid intensity was characterized based on IV morphine milligram equivalents (IV MME). Primary outcomes were opioid prescribing upon ICU and hospital discharge. Results: Opioids were prescribed to 34.1% and 31.1% of patients upon ICU and hospital discharge. Within the ≥50 mean IV MME/ICU day cohort, 64.7% of patients received opioids after ICU discharge compared to 45.8% and 13.6% in the 1-49 mean IV MME/ICU day and no opioid groups (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 70.6% of patients were prescribed opioids after hospitalization compared to 37.3% and 13.6% of patients who received less or no opioids. (P < .05). Within the ≥50 mean IV MME/ICU day cohort, 29.4% of patients were opioid naïve and discharged with an opioid, which is over double compared to patients with lower opioid requirements (P < .05). Conclusion: Patients with higher mean daily ICU opioid requirements had increased opioid prescribing across care transitions despite preadmission opioid use.

Clinical Impact of the Implementation Strategies Used to Apply the 2013 Pain, Agitation/Sedation, Delirium or 2018 Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption Guideline Recommendations: A Systematic Review and Meta-Analysis

OBJECTIVES

To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines.

DATA SOURCES

PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268).

STUDY SELECTION

Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS).

DATA EXTRACTION

Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.

DATA SYNTHESIS

Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS.

CONCLUSIONS

Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations.

Impact of Pharmacist Monitoring of Serum Triglycerides for Critically Ill Patients Receiving Propofol

Background: Elevated serum triglycerides due to the use of propofol for sedation in the ICU is associated with adverse effects and serum triglyceride monitoring may be improved by pharmacists. Objective: To determine if there was improvement in serum triglyceride monitoring in ICU patients receiving propofol for sedation after implementation of a pharmacist-driven triglyceride monitoring protocol. Methods: This was a single-center pre-post-intervention retrospective cohort study. The protocol was implemented on January 10 2019. Data were collected over 1 year, and patients were divided between those started on propofol before and after protocol implementation. Results: There were 412 patients included in the final analysis with no significant differences between groups. There was a significant increase in the number of patients who had a triglyceride concentration obtained after protocol implementation (31.1% pre-vs 64.0% post-protocol; P < .001). For patients on propofol greater than 24 h, there was a significant increase in baseline triglyceride concentration obtained (7.6% pre-vs 15.1% post-protocol; P = .043). More instances of elevated triglyceride concentrations were identified by pharmacists than other providers (9 vs 5; P < .001). Time between propofol being ordered and first triglyceride concentration ordered was shorter (.86 days pre-protocol vs .71 days post-protocol; P = .064), but not statistically significant. Conclusion: Implementation of a pharmacist-driven protocol in the ICU increased the number of serum triglyceride levels obtained for patients receiving propofol for sedation. Pharmacists can improve triglyceride monitoring in patients receiving propofol and future studies should investigate the impact on outcomes.

Preoperative Intrathecal Morphine is Associated With Reduced Postoperative Pain, Agitation, and Delirium In Living Donor Kidney Transplantation Recipients

BACKGROUND

Postoperative delirium after organ transplantation can lead to increased length of hospital stay and mortality. Because pain is an important risk factor for delirium, perioperative analgesia with intrathecal morphine (ITM) may mitigate postoperative delirium development. We evaluated if ITM reduces postoperative delirium incidence in living donor kidney transplant (LDKT) recipients.

METHODS

Two hundred ninety-six patients who received LDKT between 2014 and 2018 at our hospital were retrospectively analyzed. Recipients who received preoperative ITM (ITM group) were compared with those who did not (control group). The primary outcome was postoperative delirium based on the Confusion Assessment Method for Intensive Care Unit results during the first 4 postoperative days.

RESULTS

Delirium occurred in 2.6% (4/154) and 7.0% (10/142) of the ITM and control groups, respectively. Multivariable analysis showed age (odds ratio [OR]: 1.07, 95% CI: 1.01-1.14; P = .031), recent smoking (OR: 7.87, 95% CI: 1.43-43.31; P = .018), preoperative psychotropics (OR: 23.01, 95% CI: 3.22-164.66; P = .002) were risk factors, whereas ITM was a protective factor (OR: 0.23, 95% CI: 0.06-0.89; P = .033).

CONCLUSIONS

Preoperative ITM showed an independent association with reduced post-LDKT delirium. Further studies and the development of regional analgesia for delirium prevention may enhance the postoperative recovery of transplant recipients.

Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial

Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy

Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Effectiveness of a self-assessment application in evaluating the care coordination competency of intensive care unit nurses in managing patients on life support: An intervention study

AIM

To examine the effectiveness of the feedback from the Nurses' Care Coordination Competency Scale (NCCCS) application (app) used for self-assessing the care coordination competency of intensive care unit (ICU) nurses in managing patients on life support.

METHODS

A non-randomized open-label study was conducted in Japan from November 2021 to March 2022. Participants were 318 ICU nurses from acute hospitals in Japan. They were divided manually into two groups based on their certification status. The intervention was immediate feedback on the results of the care coordination competency self-assessment through the NCCCS app; the control group performed the NCCCS survey with no feedback. The primary outcome was an increase in the NCCCS score 1 month after the intervention. Mann-Whitney U test was used to compare the scores of the intervention and control groups. Wilcoxon's signed rank sum test was used to compare the scores in the first and second NCCCS surveys.

RESULTS

Forty-one participants were lost to follow-up, leaving 277 participants (intervention = 141, control = 136) for analysis. One month later, NCCCS scores similarly increased in both groups. For nurses with at least 5 years of ICU experience (n = 152), the NCCCS score increased in the intervention group (n = 75) (rising point mean: 4.8, standard deviation [SD]: 9.8) compared with that in the control group (n = 77) (rising point mean: 1.3, SD: 8.3) (p = .048).

CONCLUSIONS

Feedback from the NCCCS app can improve care coordination behavior. However, a certain level of ICU experience may be required to translate feedback into improved behavior.

Invasive Mechanical Ventilation

Invasive mechanical ventilation allows clinicians to support gas exchange and work of breathing in patients with respiratory failure. However, there is also potential for iatrogenesis. By understanding the benefits and limitations of different modes of ventilation and goals for gas exchange, clinicians can choose a strategy that provides appropriate support while minimizing harm. The ventilator can also provide crucial diagnostic information in the form of respiratory mechanics. These, and the mechanical ventilation strategy, should be regularly reassessed.

Understanding the needs and perceptions of early mobilization for critically ill patients: A systematic review of qualitative studies

OBJECTIVE

To synthesize qualitative research findings on intensive care patients' perceptions of early mobilization to identify their needs and understand the factors influencing their participation.

METHODS

Studies that explored patients' experiences of early mobilization within the intensive care unit were searched. A comprehensive search was conducted by searching five English and four Chinese electronic databases. The systematic review was carried out in line with the Joanna Briggs Institute methodology for systematic reviews of qualitative evidence, and also the thematic synthesis method was used to analyze the data.

RESULTS

A total of eight studies were included. Eight descriptive themes were formed: patients' self-determination needs, patients' relationship needs, patients' needs for competency and self-control, perceived benefits of physical function, increased self-confidence, negative emotions, unpleasant experiences and suffering, negative attitudes, and three analytical themes related to patients' perceptions of early mobilization in the intensive care unit were identified, including patients' needs during early mobilization, facilitators prompting patients' actions in early mobilization, and obstacles influencing patients' actions in early mobilization.

CONCLUSION

Many factors influence the critically ill patients' actions in early mobilization. A better understanding of patients' potential needs and psychological responses to early mobilization in the intensive care unit may help health professionals develop strategies to promote the quality of early mobilization.

IMPLICATIONS FOR CLINICAL PRACTICE

Recognizing and developing the strategies to meet the needs are essential to improve the patients' actions in early mobilization in the intensive care unit.. Therefore, understanding the relationship between needs support and patients' actions in early mobilization can help them provider better support services during mobilization.

Patients' reports on their delusional memories from the intensive care unit: A systematic review of qualitative studies

OBJECTIVE

To critically summarise the qualitative literature to understand patients' experiences of delusional memories during their Intensive Care Unit stay.

RESEARCH METHODOLOGY

A systematic review of qualitative studies with meta-synthesis and meta-summary. We searched MEDLINE (via PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Web of Science to July 2022. All studies that provided qualitative insights into the subjective experience of adult patients with delusional memories in the Intensive Care Unit were selected. The Critical Assessment Skills Programme checklist was used for the quality assessment.

RESULTS

Fourteen studies were included. The 33 codes that emerged from the inductive thematic analysis were grouped into three themes: 'The sense of danger and the terrifying aspect of death' (feeling in danger, surrounded by death, persecuted by people around, and feeling unsafe), 'The presence of someone or something nearby' (perceiving the loved ones, feeling overwhelmed by scary creatures, and being neglected by those around me), and 'The reality behind the world perceived by the senses' (travelling the world, stimulating the senses, feeling peaceful, and living in a fantasy world). The most frequent code in the studies was 'Be with a family member', with an intensity of 35.7%.

CONCLUSION

The patient's experience described as delusional is considered a real event by the person experiencing it. Further research is needed to investigate the extent to which these experiences lead to poorer early and late outcomes for patients, and to test strategies to prevent this.

IMPLICATIONS FOR CLINICAL PRACTICE

A deeper understanding of the phenomenon may help healthcare professionals to recognise precursors, symptoms and consequences of delusional memories and intervene with appropriate help. One strategy would be to further humanise care and focus on family involvement and communication with patients to overcome the factual events that can potentially alter patients' quality of life.

Applied Artificial Intelligence in Healthcare: A Review of Computer Vision Technology Application in Hospital Settings

Computer vision (CV), a type of artificial intelligence (AI) that uses digital videos or a sequence of images to recognize content, has been used extensively across industries in recent years. However, in the healthcare industry, its applications are limited by factors like privacy, safety, and ethical concerns. Despite this, CV has the potential to improve patient monitoring, and system efficiencies, while reducing workload. In contrast to previous reviews, we focus on the end-user applications of CV. First, we briefly review and categorize CV applications in other industries (job enhancement, surveillance and monitoring, automation, and augmented reality). We then review the developments of CV in the hospital setting, outpatient, and community settings. The recent advances in monitoring delirium, pain and sedation, patient deterioration, mechanical ventilation, mobility, patient safety, surgical applications, quantification of workload in the hospital, and monitoring for patient events outside the hospital are highlighted. To identify opportunities for future applications, we also completed journey mapping at different system levels. Lastly, we discuss the privacy, safety, and ethical considerations associated with CV and outline processes in algorithm development and testing that limit CV expansion in healthcare. This comprehensive review highlights CV applications and ideas for its expanded use in healthcare.

Effects of the High-Intensity Early Mobilization on Long-Term Functional Status of Patients with Mechanical Ventilation in the Intensive Care Unit

Objective

Intensive care unit (ICU)-acquired weakness often occurs in patients with invasive mechanical ventilation (IMV). Early active mobility may reduce ICU-acquired weakness, improve functional status, and reduce disability. The aim of this study was to investigate whether high-intensity early mobility improves post-ICU discharge functional status of IMV patients.

Methods

132 adult patients in the ICU who were undergoing IMV were randomly assigned into two groups with a ratio of 1 : 1, with one group received high-intensity early mobility (intervention group, IG), while the other group received conventional treatment (control group, CG). The functional status (Barthel Index (BI)), capacity of mobility (Perme score and ICU Mobility Scale (IMS)), muscle strength (Medical Research Council sum scores (MRC-SS)), mortality, complication, length of ICU stay, and duration of IMV were evaluated at ICU discharge or after 3-month of ICU discharge.

Results

The patient's functional status was improved (BI scores 90.6 ± 18.0 in IG vs. 77.7 ± 27.9 in CG; p=0.005), and capacity of mobility was increased (Perme score 17.6 ± 7.1 in IG vs. 12.2 ± 8.5 in CG, p < 0.001; IMS 4.7 ± 2.6 in IG vs. 3.0 ± 2.6 in CG, p < 0.001). The IG had a higher muscle strength and lower incidence of ICU-acquired weakness (ICUAW) than that in the CG. The incidence of mortality and delirium was also lower than CG at ICU discharge. However, there were no differences in terms of length of ICU stay, duration of IMV, ventilator-associated pneumonia, and venous thrombosis.

Conclusions

High-intensity early mobility improved the patient's functional status and increased capacity of mobility with IMV. The benefits to functional status remained after 3 month of ICU discharge. Other benefits included higher muscle strength, lower incidence of ICUAW, mortality, and delirium in IG.

Feasibility and Acceptability of Using Wireless Limited Polysomnography to Capture Sleep Before, During, and After Hospitalization for Patients With Planned Cardiothoracic Surgery

BACKGROUND

Sleep disruption, a common symptom among patients requiring cardiovascular surgery, is a potential risk factor for the development of postoperative delirium. Postoperative delirium is a disorder of acute disturbances in cognition associated with prolonged hospitalization, cognitive decline, and mortality.

OBJECTIVE

The aim of this study was to evaluate the feasibility and acceptability of using polysomnography (PSG) to capture sleep in patients with scheduled cardiothoracic surgery.

METHODS

Wireless limited PSG assessed sleep at baseline (presurgery at home), postoperatively in the intensive care unit, and at home post hospital discharge. Primary outcomes were quality and completeness of PSG signals, and acceptability by participants and nursing staff.

RESULTS

Among 15 patients, PSG data were of high quality, and mean percentage of unscorable data was 5.5% ± 11.1%, 3.7% ± 5.4%, and 3.7% ± 8.4% for baseline, intensive care unit, and posthospitalization measurements, respectively. Nurses and patients found the PSG monitor acceptable.

CONCLUSIONS

Wireless, limited PSG to capture sleep across the surgical continuum was feasible, and data were of high quality. Authors of future studies will evaluate associations of sleep indices and development of postoperative delirium in this high-risk population.