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Bhattacharyya A, Laycock H, Brett SJ, Beatty F, Kemp HI. Health care professionals' experiences of pain management in the intensive care unit: a qualitative study. Anaesthesia 2024; 79:611-626. [PMID: 38153304 DOI: 10.1111/anae.16209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/29/2023]
Abstract
Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.
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Affiliation(s)
| | - H Laycock
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - S J Brett
- Division of Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Directorate of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - F Beatty
- Guy's and St Thomas' NHS Trust, London, UK
| | - H I Kemp
- The Pain Research Group, Imperial College London, London, UK
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Wilcox ME, Burry L, Englesakis M, Coman B, Daou M, van Haren FM, Ely EW, Bosma KJ, Knauert MP. Intensive care unit interventions to promote sleep and circadian biology in reducing incident delirium: a scoping review. Thorax 2024:thorax-2023-220036. [PMID: 38350730 DOI: 10.1136/thorax-2023-220036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/26/2024] [Indexed: 02/15/2024]
Abstract
RATIONALE/OBJECTIVES Despite plausible pathophysiological mechanisms, research is needed to confirm the relationship between sleep, circadian rhythm and delirium in patients admitted to the intensive care unit (ICU). The objective of this review is to summarise existing studies promoting, in whole or in part, the normalisation of sleep and circadian biology and their impact on the incidence, prevalence, duration and/or severity of delirium in ICU. METHODS A sensitive search of electronic databases and conference proceedings was completed in March 2023. Inclusion criteria were English-language studies of any design that evaluated in-ICU non-pharmacological, pharmacological or mixed intervention strategies for promoting sleep or circadian biology and their association with delirium, as assessed at least daily. Data were extracted and independently verified. RESULTS Of 7886 citations, we included 50 articles. Commonly evaluated interventions include care bundles (n=20), regulation or administration of light therapy (n=5), eye masks and/or earplugs (n=5), one nursing care-focused intervention and pharmacological intervention (eg, melatonin and ramelteon; n=19). The association between these interventions and incident delirium or severity of delirium was mixed. As multiple interventions were incorporated in included studies of care bundles and given that there was variable reporting of compliance with individual elements, identifying which components might have an impact on delirium is challenging. CONCLUSIONS This scoping review summarises the existing literature as it relates to ICU sleep and circadian disruption (SCD) and delirium in ICU. Further studies are needed to better understand the role of ICU SCD promotion interventions in delirium mitigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Burry
- Department of Pharmacy, Sinai Health System, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Briar Coman
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marietou Daou
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frank Mp van Haren
- School of Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
- University of New South Wales Medicine and Health, Sydney, New South Wales, Australia
- Intensive Care Unit, St George Hospital, Sydney, New South Wales, Australia
| | - E Wes Ely
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
| | - Karen J Bosma
- Department of Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
- Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melissa P Knauert
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Okano H, Kataoka Y, Sakuraya M, Aoki Y, Okamoto H, Imai E, Yamazaki T. Efficacy of Remifentanil in Patients Undergoing Cardiac Surgery: A Systematic Review and Network Meta-Analysis. Cureus 2023; 15:e51278. [PMID: 38161541 PMCID: PMC10756075 DOI: 10.7759/cureus.51278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/03/2024] Open
Abstract
Remifentanil, characterized by its ultra-short action duration and nonorgan-dependent metabolism, is applied in postcardiac surgery settings worldwide. While previous studies have compared its efficacy with that of other opioids, it has never been compared to a single specific opioid. Here, we evaluated whether remifentanil shortens mechanical ventilation (MV) times in patients after cardiac surgery. We identified randomized controlled trials that compared various opioids in adults (≥18 years) admitted to the intensive care unit after cardiac surgery. The primary outcome was the duration of MV, expressed as the mean difference (MD) in minutes, with a 95% confidence interval (CI). A 60-min reduction was considered significant based on prior research. Data were sourced from MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, the World Health Organization International Clinical Trials Platforms Search Portal, and ClinicalTrials.gov, and a frequentist network meta-analysis was conducted. The eight identified studies indicate no differences in the duration of MV between remifentanil and fentanyl (MD 0.09 min; 95%CI -36.89-37.08), morphine (MD -19 min; 95%CI -55.86-16.21), or sufentanil (MD -2.44 min; 95%CI -67.52-62.55). Our study revealed that remifentanil did not reduce MV times in patients after cardiac surgery. The study protocol was registered with the Open Science Forum (https://osf.io/) (DOI 10.17605/OSF.IO/YAHW2).
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Affiliation(s)
- Hiromu Okano
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, JPN
- Department of Social Medical Sciences, Graduate School of Medicine, International University of Health and Welfare, Tokyo, JPN
| | - Yuki Kataoka
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, JPN
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, JPN
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, JPN
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, JPN
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, JPN
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Hamamatsu, JPN
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, JPN
| | - Eriya Imai
- Division of Anesthesiology, Mitsui Memorial Hospital, Tokyo, JPN
| | - Tsutomu Yamazaki
- Department of Social Medical Sciences, Graduate School of Medicine, International University of Health and Welfare, Tokyo, JPN
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Doi M, Takahashi N, Nojiri R, Hiraoka T, Kishimoto Y, Inoue S, Oya N. Efficacy, safety, and pharmacokinetics of MR13A11A, a generic of remifentanil, for pain management of Japanese patients in the intensive care unit: a double-blinded, fentanyl-controlled, randomized, non-inferiority phase 3 study. J Intensive Care 2023; 11:51. [PMID: 37953283 PMCID: PMC10641973 DOI: 10.1186/s40560-023-00698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The aims of this study were to evaluate the efficacy, safety, and pharmacokinetics (PK) of continuous intravenous administration of remifentanil in mechanically ventilated patients in the intensive care unit (ICU). METHODS This was a multicenter, randomized, double-blinded, fentanyl-controlled, non-inferiority phase 3 study. Patients aged ≥ 20 years requiring 6 h to 10 days mechanical ventilation in an ICU and requiring pain relief were randomly assigned in a 1:1 ratio to receive either remifentanil (n = 98) or fentanyl (n = 98). Dose was titrated from an infusion rate of 1 mL/h (remifentanil: 0.025 µg/kg/min, fentanyl: 0.1 µg/kg/h) until the target level of analgesia (behavioral pain scale [BPS] ≤ 5 or numerical rating score [NRS] ≤ 3) was achieved by escalating the dose in 1 mL/h increasing. Administration was then adjusted to maintain the target level of analgesia until weaning from the ventilator. The primary endpoint was the proportion of patients who did not require rescue fentanyl. Safety was assessed according to standard procedures. PK of remifentanil in the arterial blood was assessed in 24 patients. RESULTS The proportion of patients achieving the primary endpoint in the remifentanil and fentanyl groups was 100% (92/92) and 97.8% (88/90), respectively. The difference between the groups was 2.2% (95% confidence interval, - 0.8-5.3) and non-inferiority of remifentanil to fentanyl was verified (p < 0.0001). The incidences of any adverse events in the remifentanil and fentanyl groups was 34 of 92 patients (37.0%) and 34 of 90 patients (37.8%), respectively. Adverse drug reactions was 12 in 92 patients (13.0%) and 15 in 90 patients (16.7%), respectively. In the PK analysis, blood remifentanil concentration decreased within 10 min to almost 50% of the end of administration, suggesting rapid offset of action following discontinuation of remifentanil. CONCLUSIONS Remifentanil can be used safely for pain management in mechanically ventilated Japanese patients in the ICU. TRIAL REGISTRATION Japan Registry of Clinical Trials, jRCT2080224954. Registered 20 November 2019, https://jrct.niph.go.jp/latest-detail/jRCT2080224954 .
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Affiliation(s)
- Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Naoki Takahashi
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Rumi Nojiri
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan.
| | - Takehiko Hiraoka
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Yusuke Kishimoto
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Shinichi Inoue
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
| | - Nobuyo Oya
- Clinical Development Department, Maruishi Pharmaceutical Co., Ltd., 2-2-18 Imazu-Naka, Tsurumi-Ku, Osaka, 538-0042, Japan
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Kuruppu NR, Chaboyer W, Abayadeera A, Ranse K. Augmentative and alternative communication tools for mechanically ventilated patients in intensive care units: A scoping review. Aust Crit Care 2023; 36:1095-1109. [PMID: 36774294 DOI: 10.1016/j.aucc.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/13/2022] [Accepted: 12/20/2022] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVES The aim of this scoping review was to understand the extent and type of evidence on augmentative and alternative communication tools used with mechanically ventilated patients in the intensive care unit. REVIEW METHOD USED This scoping review was conducted using Arksey and O'Malley's methodological framework, followed by PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to provide a structured approach to analysis of reviews. DATA SOURCES In December 2021, six electronic databases-CENTRAL, CINAHL, Embase, Medline (Ebscohost), PyscINFO, and Web of Science-were searched. Searches were supplemented with hand searching of reference lists of included studies. REVIEW METHODS Studies were selected according to inclusion and exclusion criteria. Full-text review was completed by two independent authors, with any disagreement resolved by consensus or with consultation with a third reviewer. A table was developed to extract key information from the eligible studies. The Mixed Methods Appraisal Tool and Supporting the Use of Research Evidence checklist were used to quality appraise the selected primary research and reviews, respectively. RESULTS Twenty-three studies (19 primary studies and four reviews) were included in the review. Findings highlighted five main patterns: (i) Co-designing of the augmentative and alternative communication tools; (ii) Patients' and healthcare professionals' training needs on augmentative and alternative communication tools; (iii) Implementation of validated communication assessment algorithms; (iv) Amalgamate several communication methods/approaches; (v) Technical competency required for high-technology augmentative and alternative communication tools. CONCLUSION Both low- and high-technology augmentative and alternative communication tools are widely used for mechanically ventilated patients in intensive care units, but there is a need for systematically assessing the communication needs and implementing communication interventions to promote meaningful patient-centred clinical outcomes.
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Affiliation(s)
- Nipuna R Kuruppu
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Queensland, Australia; Department of Nursing, Faculty of Health Sciences, The Open University of Sri Lanka, Nawala, Nugegoda, Sri Lanka.
| | - Wendy Chaboyer
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Anuja Abayadeera
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, University of Colombo, Sri Lanka; National Hospital of Sri Lanka, Sri Lanka
| | - Kristen Ranse
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Queensland, Australia
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List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
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Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
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Pota V, Coppolino F, Barbarisi A, Passavanti MB, Aurilio C, Sansone P, Pace MC. Pain in Intensive Care: A Narrative Review. Pain Ther 2022; 11:359-367. [PMID: 35220551 PMCID: PMC9098741 DOI: 10.1007/s40122-022-00366-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/09/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy.
| | - Francesco Coppolino
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Alfonso Barbarisi
- Department of Translational Medical Science, Telematic University Pegaso, Naples, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Caterina Aurilio
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialistic Surgery, University of Campania "L. Vanvitelli", Naples, Italy
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Kerbage SH, Garvey L, Lambert GW, Willetts G. Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. Int J Nurs Stud 2021; 122:104044. [PMID: 34399307 DOI: 10.1016/j.ijnurstu.2021.104044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/23/2021] [Accepted: 07/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment. OBJECTIVE To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting. DESIGN A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR). METHODS The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting. RESULTS The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency. CONCLUSION Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.
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Affiliation(s)
| | - Loretta Garvey
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Georgina Willetts
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design; Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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Deffland M, Spies C, Weiss B, Keller N, Jenny M, Kruppa J, Balzer F. Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study. PLoS One 2020; 15:e0234801. [PMID: 32877411 PMCID: PMC7467321 DOI: 10.1371/journal.pone.0234801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/02/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION clinicaltrials.gov NCT02265263, Registered 15 October 2014.
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Affiliation(s)
- Marc Deffland
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Bjoern Weiss
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Niklas Keller
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mirjam Jenny
- Science Communication Unit, Robert Koch Institute, Berlin, Germany
- Harding Center for Risk Literacy, Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Felix Balzer
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Sedighie L, Bolourchifard F, Rassouli M, Zayeri F. Effect of Comprehensive Pain Management Training Program on Awareness and Attitude of ICU Nurses. Anesth Pain Med 2020; 10:e98679. [PMID: 32754429 PMCID: PMC7341110 DOI: 10.5812/aapm.98679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 02/03/2020] [Accepted: 02/25/2020] [Indexed: 01/08/2023] Open
Abstract
Background Pain is one of the main complaints of many patients in intensive care units. However, most nurses and physicians are unable to properly monitor and relieve pain in these patients. Factors such as patients' inability to describe their pain and insufficient knowledge of nurses and physicians have made pain management difficult. Given that the knowledge and attitude of nurses play an important role in the effective implementation of the pain management process, this study aimed to investigate the effect of comprehensive pain management training program on the awareness and attitude of intensive care unit nurses. Methods This quasi-experimental single-group study was conducted in two phases (pre and post-intervention) to investigate the awareness and attitude of all nurses employed in the intensive care unit of Tehran Modarres Hospital, based on the determined inclusion and exclusion criteria. In the pre-intervention phase, the awareness and attitudes of the nurses were assessed using a questionnaire. After conducting the pain management training course, an executive program and algorithm were implemented for pain management in ICUs. Then, the nurses’ awareness and attitude toward pain management were assessed again. Finally, changes in the scores of the nurses’ awareness and attitude were analyzed by SPSS V. 22 software in two phases before and after applying the interventions using the Wilcoxon test. The relationship between some demographic variables and the level of awareness and attitude of nurses was also investigated using the Kruskal-Wallis and Mann-Whitney tests. Results The results of this study indicated that the mean score of the nurses’ awareness was significantly different in pre- and post-intervention phases (P < 0.05). Despite an increase in the post-intervention mean score of the nurses’ attitude (71.03), no statistically significant change was observed. Additionally, among the demographic variables, there was only a significant relationship between the nurses' job experience in ICUs and their attitudes. Conclusions Based on the results of this study, teaching and implementing a comprehensive program for pain management can play an effective role in promoting the nurses’ awareness. Therefore, it is proposed to use pain management models to improve the nurses' knowledge and attitude toward pain management in ICU patients.
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Affiliation(s)
- Ladan Sedighie
- Department of Nursing, Student Research Committee, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariba Bolourchifard
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Ph.D. in Nursing, Assistant Professor, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Maryam Rassouli
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Zayeri
- Department of Biostatistics, Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Chen P, Chen F, Lei J, Zhou B. Efficacy and safety of dexmedetomidine combined with tramadol for patient-controlled intravenous analgesia in Chinese surgical patients: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18825. [PMID: 32011494 PMCID: PMC7220458 DOI: 10.1097/md.0000000000018825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patient-controlled intravenous analgesia (PCIA) has been suggested as an effective method of pain relief. There are several randomized controlled trials (RCTs) of dexmedetomidine (DEX) combined with tramadol for PCIA in Chinese surgical patients. The purpose of this study was to perform a systematic review and meta-analysis to evaluate the efficacy and safety of DEX combined with tramadol for PCIA in Chinese surgical patients from current data. METHODS The RCTs of DEX combined with tramadol for PCIA were gathered from the PubMed, Excerpta Medica Database, Cochrane Library, Cochrane Library, China National Knowledge Infrastructure database, and VIP databases. After data extraction and quality assessment of the included RCTs, RevMan 5.3 software was employed for the meta-analysis of visual analog scale (VAS) scores, Ramsay sedation scores, effective pressure times for PCIA, tramadol consumption, and safety. RESULTS Fourteen RCTs were included. Compared with tramadol alone, postoperative intravenous tramadol-DEX combination PCA led to lower VAS scores (weighted mean differences [WMD]12h = 0.14, 95% confidence interval [CI] v1.50 to 1.79; WMD24h = 0.78, 95% CI -0.92 to -0.62; WMD48h = 0.51, 95% CI -0.66 to -0.38; all P < .05), lower Ramsay sedation scores (WMD24h = 0.08, 95% CI -0.14 to -0.02; WMD48h = 0.09, 95% CI -0.11 to -0.07; all P < .05), and less postoperative tramadol consumption (WMD0-24h = -102.59 mg, 95% CI -149.68 to -55.49; WMD0-48h = -152.91 mg, 95% CI -259.93 to -45.89; all P < .05). With regard to safety, there was a significant difference between DEX-tramadol and tramadol for PCIA in terms of the incidence of postoperative nausea and vomiting, dizziness, chills, and restlessness (all P < .05). CONCLUSION According to the domestic evidence, this systematic review and meta-analysis suggests that DEX-tramadol PCIA is superior to tramadol in terms of analgesic efficacy and safety for Chinese surgical patients. However, because of some clear limitations (sample size and heterogeneity), these results should be interpreted with caution. Further large-scale and well-designed studies are needed to summarize and analyze the data to draw a more convincing conclusion.
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Affiliation(s)
- Peng Chen
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan
| | - Fuchao Chen
- Department of Pharmacy, Dongfeng Hospital, Hubei University of Medicine, Shiyan
| | - Jiexin Lei
- Department of Endocrinology, Renmin Hospital of Wuhan University, Wuhan, Hubei, P.R. China
| | - Benhong Zhou
- Department of Pharmacy, Renmin Hospital of Wuhan University, Wuhan
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Nambiar D, Pearce JW, Bray J, Stephenson M, Nehme Z, Masters S, Brink D, Smith K, Arendts G, Fatovich D, Bernard S, Haskins B, Grantham H, Cameron P. Variations in the care of agitated patients in Australia and New Zealand ambulance services. Emerg Med Australas 2019; 32:438-445. [PMID: 31840407 DOI: 10.1111/1742-6723.13431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/13/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the present study is to examine variations in paramedic care of the agitated patient, including verbal de-escalation, physical restraint and sedation, provided by ambulance services in Australia and New Zealand. METHODS To examine the care of agitated patients, we first identified and reviewed all clinical practice guidelines for the management of agitated patients in Australian and New Zealand ambulance services between September and November 2018. We then conducted a structured questionnaire to obtain further information on the training, assessment and care of agitated patients by the ambulance services. Two authors extracted the data independently, and all interpretations and results were reviewed and confirmed by relevant ambulance services. RESULTS There were 10 independent clinical practice guidelines for the care of agitated patients in the 10 ambulance services. All services reported training in the management of agitated patients, and two services used a validated tool to assess the level of agitation. All services used physical restraint, although six services required police presence to restrain the patient. All ambulance services used some form of sedation, typically divided into the management of mild to moderate, and severe agitation. The most common agent for sedation was midazolam, while ketamine was the most common agent for sedating severely agitated patients. The maximum dose was varied, and contraindications for sedating agents varied between services. CONCLUSIONS There were wide variations across the ambulance services in terms of the assessment of agitation, as well as the use of physical restraint and sedation.
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Affiliation(s)
- Dhanya Nambiar
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James W Pearce
- South Australian Ambulance Service, Adelaide, South Australia, Australia
| | - Janet Bray
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Ziad Nehme
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Stacey Masters
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Deon Brink
- St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Glenn Arendts
- Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | | | | | - Hugh Grantham
- Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
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Influence of early elective tracheostomy on the incidence of postoperative complications in patients undergoing head and neck surgery. BMC Anesthesiol 2019; 19:43. [PMID: 30922231 PMCID: PMC6439993 DOI: 10.1186/s12871-019-0715-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 03/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background The incidence of postoperative complications after head and neck surgery is high. This study evaluated the influence of early elective tracheostomy on the incidence of postoperative pneumonia and delirium. Methods We reviewed the data of all patients who had undergone removal of an oropharyngeal tumor and microsurgical tissue transfer at our department in a two year period. Pearson’s Chi-squared test and the Fischer’s exact t-test were then used to measure the influence of patients’ preexisting conditions and risk factors and of early elective tracheostomy on the incidence of postoperative complications. Results In total, 47 cases were analyzed. Patients with an endotracheal tube were ventilated for a longer time (3.4 days vs. 1.5 days) and were transferred to the regular ward later (after 6.9 days vs. 4.7 days) than patients with tracheostomy. Only 1 (2.1%) of the patients with a tracheostomy developed pneumonia in contrast to 5 intubated patients (10.6%) and only 2 patients with a tracheostomy developed postoperative delirium (9.5%) in contrast to 8 intubated patients (30.8%). Conclusion Early primary tracheostomy in patients undergoing resection of oropharyngeal cancer seems to have numerous benefits, such as lower complication rates with regard to pneumonia and postoperative delirium and shorter duration of both mechanical ventilation and intensive care unit (ICU) stays. Further studies have to evaluate if these benefits also influence morbidity and mortality rates.
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Gaete Ortega D, Papathanassoglou E, Norris CM. The lived experience of delirium in intensive care unit patients: A meta-ethnography. Aust Crit Care 2019; 33:193-202. [PMID: 30871853 DOI: 10.1016/j.aucc.2019.01.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state. REVIEW METHODS The study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search. DATA SOURCES MEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool. RESULTS Based on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, "a perturbing altered reality" and four main themes were identified: "disturbed sense of time", "omnipresent feeling of fear", "impact of human connection", and "perceiving surreal events". These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU. CONCLUSIONS Critically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.
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Affiliation(s)
| | | | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada; Heart Health and Stroke Strategic Clinical Network-AHS, Canada; Division of Cardiac Surgery, Faculty of Medicine, Canada.
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