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Forget MF, Wang HT, Carignan R, Dessureault A, Gravel M, Bienvenue J, Bouchard M, Durivage C, Coveney R, Munshi L. Critically Ill Older Adults' Representation in Intervention Trials: A Systematic Review. Crit Care Explor 2024; 6:e1107. [PMID: 38919511 PMCID: PMC11196082 DOI: 10.1097/cce.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVES Older adults may be under-represented in critical care research, and results may not apply to this specific population. Our primary objective was to evaluate the prevalence of inclusion of older adults across critical care trials focused on common ICU conditions or interventions. Our secondary objective was to evaluate whether older age was used as a stratification variable for randomization or outcome analysis. DESIGN SETTING AND SUBJECTS We performed a systematic review of previously published systematic reviews of randomized controlled trials (RCTs) in critical care. We searched PubMed, Ovid, CENTRAL, and Cochrane from 2009 to 2022. Systematic reviews of any interventions across five topics: acute respiratory distress syndrome (ARDS), sepsis/shock, nutrition, sedation, and mobilization were eligible. MAIN RESULTS We identified 216 systematic reviews and included a total of 253 RCTs and 113,090 patients. We extracted baseline characteristics and the reported proportion of older adults. We assessed whether any upper age limit was an exclusion criterion for trials, whether age was used for stratification during randomization or data analysis, and if age-specific subgroup analysis was present. The most prevalent topic was sepsis (78 trials, 31%), followed by nutrition (62 trials, 25%), ARDS (39 trials, 15%), mobilization (38 trials, 15%), and sedation (36 trials, 14%). Eighteen trials (7%) had exclusion criteria based on older age. Age distribution with information on older adults prevalence was given in six trials (2%). Age was considered in the analysis of ten trials (5%) using analytic methods to evaluate the outcome stratified by age. Conclusions In this systematic review, the proportion of older critically ill patients is undetermined, and it is unclear how age is or is not an effect modifier or to what extent the results are valid for older adult groups. Reporting age is important to guide clinicians in personalizing care. These results highlight the importance of incorporating older critically ill patients in future trials to ensure the results are generalizable to this growing population.
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Affiliation(s)
- Marie-France Forget
- Department of Medicine, Division of Geriatric Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Han Ting Wang
- Department of Medicine, Division of Critical Care Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Raphaelle Carignan
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Alexandre Dessureault
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Mathieu Gravel
- Department of Medicine, Faculty of Medicine, Université de Laval, Québec, QC, Canada
| | - Jeanne Bienvenue
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Maude Bouchard
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Camille Durivage
- Department of Medicine, Division of Internal Medicine, Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Richard Coveney
- Teaching Division/Library, Hôpital Maisonneuve-Rosemont, CIUSSS de l’Est-de-l’île-de-Montréal, Montréal, QC, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, Sinai Health System, University of Toronto, Toronto, ON, Canada
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Sagun E, Akyol A, Kaymak C. Chrononutrition in Critical Illness. Nutr Rev 2024:nuae078. [PMID: 38904422 DOI: 10.1093/nutrit/nuae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
Circadian rhythms in humans are biological rhythms that regulate various physiological processes within a 24-hour time frame. Critical illness can disrupt the circadian rhythm, as can environmental and clinical factors, including altered light exposure, organ replacement therapies, disrupted sleep-wake cycles, noise, continuous enteral feeding, immobility, and therapeutic interventions. Nonpharmacological interventions, controlling the ICU environment, and pharmacological treatments are among the treatment strategies for circadian disruption. Nutrition establishes biological rhythms in metabolically active peripheral tissues and organs through appropriate synchronization with endocrine signals. Therefore, adhering to a feeding schedule based on the biological clock, a concept known as "chrononutrition," appears to be vitally important for regulating peripheral clocks. Chrononutritional approaches, such as intermittent enteral feeding that includes overnight fasting and consideration of macronutrient composition in enteral solutions, could potentially restore circadian health by resetting peripheral clocks. However, due to the lack of evidence, further studies on the effect of chrononutrition on clinical outcomes in critical illness are needed. The purpose of this review was to discuss the role of chrononutrition in regulating biological rhythms in critical illness, and its impact on clinical outcomes.
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Affiliation(s)
- Eylul Sagun
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, 06100, Turkey
| | - Asli Akyol
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, 06100, Turkey
| | - Cetin Kaymak
- Gülhane Faculty of Medicine, Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara Training and Research Hospital, Intensive Care Unit, Ankara, 06230, Turkey
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Singh G, Nguyen C, Kuschner W. Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review. J Intensive Care Med 2024:8850666241255345. [PMID: 38881385 DOI: 10.1177/08850666241255345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.
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Affiliation(s)
- Gaurav Singh
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Christopher Nguyen
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
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Bandyopadhyay A, Yaddanapudi LN, Saini V, Sahni N, Grover S, Puri S, Ashok V. Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial. CRITICAL CARE SCIENCE 2024; 36:e20240144en. [PMID: 38656078 PMCID: PMC11098074 DOI: 10.62675/2965-2774.20240144-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/16/2023] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. METHODS In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). RESULTS We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. CONCLUSION Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.
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Affiliation(s)
- Anjishnujit Bandyopadhyay
- All India Institute of Medical SciencesJai Prakash Narayan Apex Trauma CenterPain Medicine and Critical CareNew DelhiIndiaDepartment of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences - New Delhi, India.
| | - Lakshmi Narayana Yaddanapudi
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Vikas Saini
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Neeru Sahni
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Sandeep Grover
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of PsychiatryChandigarhIndiaDepartment of Psychiatry, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Sunaakshi Puri
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
| | - Vighnesh Ashok
- Nehru HospitalInstitute of Medical Education and ResearchDepartment of Anaesthesia and Intensive Care, Level 4ChandigarhIndiaDepartment of Anaesthesia and Intensive Care, Level 4, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Sector 12 - Chandigarh, India.
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Spies C, Piazena H, Deja M, Wernecke KD, Willemeit T, Luetz A. Modification in ICU Design May Affect Delirium and Circadian Melatonin: A Proof of Concept Pilot Study. Crit Care Med 2024; 52:e182-e192. [PMID: 38112493 PMCID: PMC10930376 DOI: 10.1097/ccm.0000000000006152] [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] [Indexed: 12/21/2023]
Abstract
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.
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Affiliation(s)
- Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Helmut Piazena
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Maria Deja
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Berlin, Lübeck, Germany
| | - Klaus-Dieter Wernecke
- Institute Department of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Willemeit
- Department of Architectural Research, GRAFT Architects Berlin, Berlin, Germany
| | - Alawi Luetz
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Healthcare Management, Technische Universität Berlin, Berlin, Germany
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6
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Jonescu EE, Farrel B, Ramanayaka CE, White C, Costanzo G, Delaney L, Hahn R, Ferrier J, Litton E. Mitigating Intensive Care Unit Noise: Design-Led Modeling Solutions, Calculated Acoustic Outcomes, and Cost Implications. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2024:19375867241237501. [PMID: 38512990 DOI: 10.1177/19375867241237501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
OBJECTIVES, PURPOSE, OR AIM The study aimed to decrease noise levels in the ICU, anticipated to have adverse effects on both patients and staff, by implementing enhancements in acoustic design. BACKGROUND Recognizing ICU noise as a significant disruptor of sleep and a potential hindrance to patient recovery, this study was conducted at a 40-bed ICU in Fiona Stanley Hospital in Perth, Australia. METHODS A comprehensive mixed-methods approach was employed, encompassing surveys, site analysis, and acoustic measurements. Survey data highlighted the importance of patient sleep quality, emphasizing the negative impact of noise on work performance, patient connection, and job satisfaction. Room acoustics analysis revealed noise levels ranging from 60 to 90 dB(A) in the presence of patients, surpassing sleep disruption criteria. RESULTS Utilizing an iterative 3D design modeling process, the study simulated significant acoustic treatment upgrades. The design integrated effective acoustic treatments within patient rooms, aiming to reduce noise levels and minimize transmission to adjacent areas. Rigorous evaluation using industry-standard acoustic software highlights the design's efficacy in reducing noise transmission in particular. Additionally, cost implications were examined, comparing standard ICU construction with acoustically treated options for new construction and refurbishment projects. CONCLUSIONS This study provides valuable insights into design-based solutions for addressing noise-related challenges in the ICU. While the focus is on improving the acoustic environment by reducing noise levels and minimizing transmission to adjacent areas. It is important to clarify that direct measurements of patient outcomes were not conducted. The potential impact of these solutions on health outcomes, particularly sleep quality, remains a crucial aspect for consideration.
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Affiliation(s)
- Emil E Jonescu
- Hames Sharley, Perth, Western Australia, Australia
- School of Arts and Humanities, Edith Cowan University, Perth, Western Australia, Australia
| | - Benjamin Farrel
- Gabriels Hearn Farrell Pty Ltd, South Perth, Western Australia, Australia
| | - Chamil Erik Ramanayaka
- Central Queensland University, School of Engineering and Technology, Brisbane, Queensland, Australia
| | | | | | - Lori Delaney
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Brisbane, Queensland, Australia
- College of Medicine and Health Sciences, Australian National University, Acton, Canberra, Australia
| | - Rebecca Hahn
- Heart and Lung Research Institute of WA, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Health and Medical Science, Surgery, University of Western Australia, Crawley, Western Australia, Australia
- Cardiothoracic and Transplant Surgery Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Janet Ferrier
- Intensive Care Unit, St. John of God Hospital, Subiaco, Western Australia, Australia
- ANZSCTS National Cardiac Surgery Data Base, St John of God Hospital, Perth Western Australia
| | - Edward Litton
- Intensive Care Unit, St. John of God Hospital, Subiaco, Western Australia, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
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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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Luetz A, Spies C, Kervezee L. It's about time: circadian medicine in the intensive care unit. Intensive Care Med 2024; 50:283-286. [PMID: 38112772 DOI: 10.1007/s00134-023-07297-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Alawi Luetz
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Healthcare Management, Technische Universität Berlin, Straße des 17. Juni, 10623, Berlin, Germany.
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Laura Kervezee
- Department of Cell and Chemical Biology, Leiden University Medical Center, Einthovenweg 20, 2333 ZC, Leiden, The Netherlands
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Heavner MS, Louzon PR, Gorman EF, Landolf KM, Ventura D, Devlin JW. A Rapid Systematic Review of Pharmacologic Sleep Promotion Modalities in the Intensive Care Unit. J Intensive Care Med 2024; 39:28-43. [PMID: 37403460 DOI: 10.1177/08850666231186747] [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] [Indexed: 07/06/2023]
Abstract
Background: The Society of Critical Care Medicine Clinical Practice Guidelines for Management of Pain, Agitation, Delirium, Immobility, and Sleep recommend protocolized non-pharmacologic sleep improvement. Pharmacologic interventions are frequently initiated to promote sleep but the evidence supporting these strategies remains controversial. Purpose: To systematically search and synthesize evidence evaluating pharmacologic sleep promotion modalities in critically ill adults. Methods: A rapid systematic review protocol was used to search Medline, Cochrane Library, and Embase for reports published through October 2022. We included randomized controlled trials (RCTs) and before-and-after cohort studies evaluating pharmacologic modalities intended to improve sleep in adult intensive care unit (ICU) patients. Sleep-related endpoints were the primary outcome of interest. Study and patient characteristics and relevant safety and non-sleep outcome data were also collected. The Cochrane Collaboration Risk of Bias or Risk of Bias in Non-Randomized Studies of Interventions were used to assess the risk of bias for all included studies. Results: Sixteen studies (75% RCTs) enrolling 2573 patients were included; 1207 patients were allocated to the pharmacologic sleep intervention. Most studies utilized dexmedetomidine (7/16; total n = 505 patients) or a melatonin agonist (6/16; total n = 592 patients). Only half of the studies incorporated a sleep promotion protocol as standard of care. Most (11/16, 68.8%) studies demonstrated a significant improvement in ≥1 sleep endpoint (n = 5 dexmedetomidine, n = 3 melatonin agonists, n = 2 propofol/benzodiazepines). Risk of bias was generally low for RCTs and moderate-severe for cohort studies. Conclusions: Dexmedetomidine and melatonin agonists are the most studied pharmacologic sleep promotion modalities, but current evidence does not support their routine administration in the ICU to improve sleep. Future RCTs evaluating pharmacologic modalities for ICU sleep should consider patients' baseline and ICU risks for disrupted sleep, incorporate a non-pharmacologic sleep improvement protocol, and evaluate the effect of these medication interventions on circadian rhythm, physiologic sleep, patient-perceived sleep quality, and delirium.
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Affiliation(s)
- Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Patricia R Louzon
- Critical Care and Emergency Department, AdventHealth Orlando, Orlando, FL, USA
| | - Emily F Gorman
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | - Kaitlin M Landolf
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Davide Ventura
- Department of Cardiology, AdventHealth Orlando, Orlando, FL, USA
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Northeastern University, Boston, MA, USA
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10
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Teng J, Qin H, Guo W, Liu J, Sun J, Zhang Z. Effectiveness of sleep interventions to reduce delirium in critically ill patients: A systematic review and meta-analysis. J Crit Care 2023; 78:154342. [PMID: 37302381 DOI: 10.1016/j.jcrc.2023.154342] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE To analyze the effectiveness of sleep interventions in reducing the incidence and duration of delirium in the ICU. MATERIALS AND METHODS We searched the PubMed, Embase, CINAHL, Web of Science, Scopus, and Cochrane databases for relevant randomized controlled trials from inception to August 2022. Literature screening, data extraction, and quality assessment were performed independently by two investigators. Data from the included studies were analyzed using Stata and TSA software. RESULTS Fifteen randomized controlled trials were eligible. Meta-analysis showed that the sleep intervention was associated with a reduced incidence of delirium in the ICU (RR = 0.73, 95% CI = 0.58 to 0.93, p < 0.001) compared to the control group. The results of the trial sequence analysis further confirm that sleep interventions are effective in reducing the occurrence of delirium. Pooled data from the three dexmedetomidine trials showed significant differences in the incidence of ICU delirium between groups (RR = 0.43, 95% CI = 0.32 to 0.59, p < 0.001). The respective pooled results of other sleep interventions (e.g., light therapy, earplugs, melatonin, and multicomponent nonpharmacologic treatments) did not find a significant effect on reducing the incidence and duration of ICU delirium (p > 0.05). CONCLUSIONS The current evidence suggests that non-pharmacological sleep interventions are not effective in preventing delirium in ICU patients. However, limited by the number and quality of included studies, future well-designed multicenter randomized controlled trials are still needed to validate the results of this study.
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Affiliation(s)
- Jiao Teng
- School of Nursing, Anhui University of Chinese Medicine, Hefei, Anhui Province, China
| | - Hanzhi Qin
- Department of Nursing, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui Province, China.
| | - Wenchao Guo
- School of Nursing, Anhui University of Chinese Medicine, Hefei, Anhui Province, China
| | - Jialong Liu
- School of Nursing, Anhui University of Chinese Medicine, Hefei, Anhui Province, China
| | - Jian Sun
- Department of Emergency Intensive Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui Province, China
| | - Zhenwei Zhang
- Department of Emergency Intensive Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui Province, China
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Wada M, Yasuda H, Nakajima S, Etani T, Miura A, Asada S, Yoshida K, Noda Y, Takeuchi H. Efficacy and moderators of prevention and treatment of delirium with melatonin receptor agonists: A systematic review and meta-analysis of randomized controlled trials. Gen Hosp Psychiatry 2023; 85:71-79. [PMID: 37826886 DOI: 10.1016/j.genhosppsych.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Delirium is a complex and heterogeneous condition that significantly affects patient outcome. This study aimed to conduct a systematic review and meta-analysis to investigate the effects of melatonin and melatonin receptor agonists (MRAs) on delirium prevention and treatment. METHOD Randomized controlled studies, using MRAs as an intervention and placebo as a control were included. We conducted meta-analyses with random-effects model and trial sequential analysis. RESULTS A total of 33 studies involving 4850 participants were included. The meta-analysis revealed a significant preventive effect of MRAs on delirium (risk ratio = 0.65, p < 0.01), while no significant therapeutic effect was observed. Additionally, MRAs were associated with a significant reduction in mortality rate (risk ratio = 0.90, p = 0.02) in delirium prevention studies. Furthermore, subgroup analyses revealed that assessment scales and the frequency of delirium detection may be significant moderators of the delirium-preventive efficacy of MRAs. CONCLUSION This study provides evidence of the potential effects of MRAs in preventing delirium and reducing mortality. Further research is required to elucidate the therapeutic potential of MRAs for delirium and identify specific patient populations that may benefit from this agent.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Yasuda
- Department of Psychiatry, Sekito Hospital, Shimane, Japan
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Takahide Etani
- School of Medicine, College of Medical, Pharmaceutical, and Health, Kanazawa University, Kanazawa, Japan; Graduate School of Media and Governance, Keio University, Fujisawa, Japan; Advanced Research Center for Human Sciences, Waseda University, Tokorozawa, Japan
| | - Akihiko Miura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Asada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Tanenbaum Centre for Pharmacogenetics, Neurogenetics Section, Molecular Brain Sciences Research Department, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
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Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
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Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Guo R, Zhang S, Yu S, Li X, Liu X, Shen Y, Wei J, Wu Y. Inclusion of frailty improved performance of delirium prediction for elderly patients in the cardiac intensive care unit (D-FRAIL): A prospective derivation and external validation study. Int J Nurs Stud 2023; 147:104582. [PMID: 37672971 DOI: 10.1016/j.ijnurstu.2023.104582] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 07/29/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The elderly patients admitted to cardiac intensive care unit (CICU) are at relatively high risk for developing delirium. A simple and reliable predictive model can benefit them from early recognition of delirium followed by timely and appropriate preventive strategies. OBJECTIVE To explore the role of frailty in delirium prediction and develop and validate a delirium predictive model including frailty for elderly patients in CICU. DESIGN A prospective, observational cohort study. SETTINGS CICU at China-Japan Friendship Hospital from March 1, 2022 to August 25, 2022 (derivation cohort); CICU at Beijing Anzhen Hospital affiliated to Capital Medical University from March 14, 2023 to May 8, 2023 (external validation cohort). PARTICIPANTS A total of 236 and 90 participants were enrolled in the derivation and external validation cohorts, respectively. Participants in the derivation cohort were assigned into either the delirium (n = 70) or non-delirium group (n = 166) based on the occurrence of delirium. METHODS The simplified Chinese version of the Confusion Assessment Method for the Diagnosis of Delirium in the Intensive Care Unit was used to assess delirium twice a day at 8:00-10:00 and 18:00-20:00 until the onset of delirium or discharge from the CICU. Frailty was assessed using the FRAIL scale during the first 24 h in the CICU. Other possible risk factors were collected prospectively through patient interviews and medical records review. After processing missing data via multiple imputations, univariate analysis and bootstrapped forward stepwise logistic regression were performed to select optimal predictors and develop the models. The models were internally validated using bootstrapping and evaluated comprehensively via discrimination, calibration, and clinical utility in both the derivation and external validation cohorts. RESULTS The study developed D-FRAIL predictive model using FRAIL score, hearing impairment, Acute Physiology and Chronic Health Evaluation-II score, and fibrinogen. The area under the receiver operating characteristic curve (AUC) was 0.937 (95% confidence interval [CI]: 0.907-0.967) and 0.889 (95%CI: 0.840-0.938) even after bootstrapping in the derivation cohort. Inclusion of frailty was demonstrated to improve the model performance greatly with the AUC increased from 0.851 to 0.937 (p < 0.001). In the external validation cohort, the AUC of D-FRAIL model was 0.866 (95%CI: 0.782-0.907). Calibration plots and decision curve analysis suggested good calibration and clinical utility of the D-FRAIL model in both the derivation and external validation cohorts. CONCLUSIONS For elderly patients in the CICU, FRAIL score is an independent delirium predictor and the D-FRAIL model demonstrates superior performance in predicting delirium.
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Affiliation(s)
- Rongrong Guo
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Shan Zhang
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Saiying Yu
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Xiangyu Li
- School of Nursing, Capital Medical University, Beijing 100069, China
| | - Xinju Liu
- Cardiac Intensive Care Unit, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yanling Shen
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing 100029, China
| | - Jinling Wei
- Cardiac Intensive Care Unit, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing 100029, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing 100069, China.
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14
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Melone MA, Becker TC, Wendt LH, Ten Eyck P, Patel SB, Poston J, Pohlman AS, Pohlman M, Miller A, Nedeltcheva A, Hall JB, Van Cauter E, Zabner J, Gehlbach BK. Disruption of the circadian rhythm of melatonin: A biomarker of critical illness severity. Sleep Med 2023; 110:60-67. [PMID: 37541132 DOI: 10.1016/j.sleep.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023]
Abstract
Circadian dysrhythmias occur commonly in critically ill patients reflecting variable effects of underlying illness, ICU environment, and treatments. We retrospectively analyzed the relationship between clinical outcomes and 24-h urinary 6-sulfatoxymelatonin (aMT6s) excretion profiles in 37 critically ill patients with shock and/or respiratory failure. Nonlinear regression was used to fit a 24-h cosine curve to each patient's aMT6s profile, with rhythmicity determined by the zero-amplitude test. From these curves we determined acrophase, amplitude, phase, and night/day ratio. After assessing unadjusted relationships, we identified the optimal multivariate models for hospital survival and for discharge to home (vs. death or transfer to another facility). Normalized aMT6s rhythm amplitude was greater (p = 0.005) in patients discharged home than in those who were not, while both groups exhibited a phase delay. Patients with rhythmic aMT6s excretion were more likely to survive (OR 5.25) and be discharged home (OR 8.89; p < 0.05 for both) than patients with arrhythmic profiles, associations that persisted in multivariate modelling. In critically ill patients with shock and/or respiratory failure, arrhythmic and/or low amplitude 24-h aMT6s rhythms were associated with worse clinical outcomes, suggesting a role for the melatonin-based rhythm as a novel biomarker of critical illness severity.
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Affiliation(s)
- Marie-Anne Melone
- Department of Pulmonary, Thoracic Oncology and Respiratory Intensive Care, Rouen University Hospital, Univ Rouen, F-76000, Rouen, France; CETAPS EA3832, Research Center for Sports and Athletic Activities Transformations, University of Rouen Normandy, F-76821, Mont-Saint-Aignan, France.
| | - Taylor C Becker
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Linder H Wendt
- Institute of Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Patrick Ten Eyck
- Institute of Clinical and Translational Science, University of Iowa, Iowa City, IA, USA
| | - Shruti B Patel
- Department of Internal Medicine, Loyola University of Chicago, Chicago, IL, USA
| | - Jason Poston
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anne S Pohlman
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Annette Miller
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Jesse B Hall
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Eve Van Cauter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Joseph Zabner
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Brian K Gehlbach
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA; Department of Neurology, University of Iowa, Iowa City, IA, USA
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15
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Cao Y, Song Y, Ding Y, Ni J, Zhu B, Shen J, Miao L. The role of hormones in the pathogenesis and treatment mechanisms of delirium in ICU: The past, the present, and the future. J Steroid Biochem Mol Biol 2023; 233:106356. [PMID: 37385414 DOI: 10.1016/j.jsbmb.2023.106356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
Delirium is an acute brain dysfunction. As one of the common psychiatric disorders in ICU, it can seriously affect the prognosis of patients. Hormones are important messenger substances found in the human body that help to regulate and maintain the function and metabolism of various tissues and organs. They are also one of the most commonly used drugs in clinical practice. Recent evidences suggest that aberrant swings in cortisol and non-cortisol hormones might induce severe cognitive impairment, eventually leading to delirium. However, the role of hormones in the pathogenesis of delirium still remains controversial. This article reviews the recent research on risk factors of delirium and the association between several types of hormones and cognitive dysfunction. These mechanisms are expected to offer novel ideas and clinical relevance for the treatment and prevention of delirium.
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Affiliation(s)
- Yuchun Cao
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuwei Song
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuan Ding
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jiayuan Ni
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Bin Zhu
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jianqin Shen
- Department of Blood Purification Center, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
| | - Liying Miao
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
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16
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Eschbach E, Wang J. Sleep and critical illness: a review. Front Med (Lausanne) 2023; 10:1199685. [PMID: 37828946 PMCID: PMC10566646 DOI: 10.3389/fmed.2023.1199685] [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] [Received: 04/03/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.
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Affiliation(s)
- Erin Eschbach
- Division of Pulmonary, Critical Care, and Sleep, Mount Sinai Hospital, New York, NY, United States
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17
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Faeder M, Hale E, Hedayati D, Israel A, Moschenross D, Peterson M, Peterson R, Piechowicz M, Punzi J, Gopalan P. Preventing and treating delirium in clinical settings for older adults. Ther Adv Psychopharmacol 2023; 13:20451253231198462. [PMID: 37701890 PMCID: PMC10493062 DOI: 10.1177/20451253231198462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
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Affiliation(s)
- Morgan Faeder
- University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15261, USA
| | - Elizabeth Hale
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel Hedayati
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Israel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Melanie Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariel Piechowicz
- University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Jonathan Punzi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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18
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Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023; 27:675-685. [PMID: 37719343 PMCID: PMC10504656 DOI: 10.5005/jp-journals-10071-24529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic use of melatonin and melatonergics has been shown to have a positive effect in reducing the incidence of delirium in many clinical trials. Our study was thus proposed to find out the role of melatonin on the incidence and severity of ICU delirium, ICU and hospital length of stay (LOS), requirement, duration of mechanical ventilation, and ICU mortality. Methodology A systematic search of various databases was performed to find out the trials which compare melatonin with a placebo or standard therapy for delirium prevention with the results conveyed as mean differences (MDs) or risk ratios. The statistical software, Review Manager (RevMan, version 5.4), was used for data synthesis. Results Twelve studies were included in the meta-analysis. Prophylactic administration of melatonin or ramelteon was not associated with a statistically significant reduction in the incidence of delirium (odds ratio [OR] 0.63; confidence interval [CI]: 0.60, 1.32; p = 0.22), the severity of delirium (MD: 0.22; 95% CI: From -1.36 to 1.81; p = 0.78), ICU LOS (MD: 0.05; 95% CI: From -0.65 to 0.75; p = 0.89), hospital LOS (MD: -1.46; 95% CI: From -4.50 to -1.59; p = 0.35), need for mechanical ventilation (OR: 0.74, 95% CI: 0.38-1.44; p = 0.37), and ICU mortality (MD: 0.78; 95% CI: 0.56; 1.11; p = 0.62). However, a significant reduction in the duration of mechanical ventilation (MD: -0.85; 95% CI: From -1.64 to -0.06; p = 0.03) was found. Conclusion Our meta-analysis suggests that melatonin when given prophylactically has no significant role in reducing the incidence and severity of delirium, ICU and hospital LOS, need for mechanical ventilation, duration of mechanical ventilation, and ICU mortality. Further studies are warranted. How to cite this article Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023;27(9):675-685.
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Affiliation(s)
- Ramkumar Mukundarajan
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California, United States of America
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Sadahiro R, Hatta K, Yamaguchi T, Masanori E, Matsuda Y, Ogawa A, Iwata Y, Tokoro A, Nakahara R, Hirayama T, Yanai Y, Ogawa Y, Kayano A, Ariyoshi K, Oyamada S, Uchitomi Y, Akechi T, Yamamoto N, Okita N, Yorikane E, Shimada K, Furukawa T, Hashimoto H, Maeda M, Sato T, Sekimoto A, Sasaki C, Saito E, Uezono Y, Matsuoka H. A multi-centre, double-blind, randomized, placebo-controlled trial to evaluate the effectiveness and safety of ramelteon for the prevention of postoperative delirium in elderly cancer patients: a study protocol for JORTC-PON2/J-SUPPORT2103/NCCH2103. Jpn J Clin Oncol 2023; 53:851-857. [PMID: 37340766 PMCID: PMC10473272 DOI: 10.1093/jjco/hyad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/25/2023] [Indexed: 06/22/2023] Open
Abstract
Postoperative delirium is an important issue in cancer patients, affecting surgical outcomes and the quality of life. Ramelteon is a melatonin receptor agonist with high affinity for MT1 and MT2 receptors. Clinical trials and observational studies in Japan, including in surgical cancer patients, have shown efficacy of ramelteon in delirium prevention, with no serious safety concerns. However, clinical trials from the USA have reported conflicting results. A Japanese phase II study investigated the efficacy and safety of ramelteon for delirium prevention following gastrectomy in patients aged ≥75 years, with findings suggesting the feasibility of a phase III trial. The aim of this multi-centre, double-blind, randomized placebo-controlled phase III trial is to evaluate the effectiveness and safety of oral ramelteon for postoperative delirium prevention in cancer patients aged ≥65 years as advanced medical care. The trial protocol is described here.
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Affiliation(s)
- Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Kotaro Hatta
- Department of Psychiatry, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Enokido Masanori
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Asao Ogawa
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Yusei Iwata
- Department of Psycho-Oncology, National Cancer Center East, National Cancer Center Japan, Chiba, Japan
| | - Akihiro Tokoro
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Rika Nakahara
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Yuko Yanai
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Yuko Ogawa
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Ayako Kayano
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | | | | | - Yosuke Uchitomi
- Division of Survivorship Research, Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Noboru Yamamoto
- Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan
| | - Natsuko Okita
- Clinical Trial Support Office, National Cancer Center Hospital, Tokyo, Japan
| | - Eiko Yorikane
- Clinical Trial Support Office, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuaki Shimada
- National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Tetsuya Furukawa
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Hironobu Hashimoto
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Makoto Maeda
- Department of Pharmacy, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Japan, Tokyo, Japan
| | - Asuko Sekimoto
- Department of Nursing, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Chiyuki Sasaki
- Department of Nursing, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
| | - Eiko Saito
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuhito Uezono
- Department of Pain Control Research, Jikei University School of Medicine, Tokyo, Japan
| | - Hiromichi Matsuoka
- Department of Psycho-Oncology, National Cancer Center Hospital, National Cancer Center Japan, Tokyo, Japan
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Jacobson JL, Tylka J, Glazer S, Zhang Y, Cosme R, Silvestri JM, Patwari PP. Melatonin Use in Pediatric Intensive Care Units: A Single-Center Experience. Med Sci (Basel) 2023; 11:55. [PMID: 37755159 PMCID: PMC10534299 DOI: 10.3390/medsci11030055] [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: 07/11/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Growing evidence indicates that altered melatonin secretion during critical illness may influence the quality and quantity of sleep, delirium, and overall recovery. However, limited data exist regarding the use of melatonin in pediatric critical illness. Data were reviewed over a 5-year period at a tertiary pediatric intensive care unit for pediatric patients (ages 0-18 years) who were prescribed melatonin with the aim of identifying the frequency of and indications for use. Data collection included the hospital day of initiation, the dose, the frequency, the duration of use, and the length of stay. The results demonstrate that melatonin was infrequently prescribed (6.0% of patients admitted; n = 182) and that the majority of patients received melatonin as continuation of home medication (46%; n = 83 of 182). This group had significantly earlier melatonin use (0.9 ± 2.3 day of hospitalization; p < 0.0001) and significantly reduced lengths of stay compared to the other groups (mean LOS 7.2 ± 9.3 days; p < 0.0001). Frequently, clear documentation of indication for melatonin use was absent (20%; n = 37). In conclusion, given that melatonin is infrequently used within a tertiary PICU with the most common indication as the continuation of home medication, and often without clear documentation for indication, this presents an opportunity to emphasize a more attentive and strategic approach regarding melatonin use in the PICU population.
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Affiliation(s)
- Jessica L. Jacobson
- Department of Pharmacy, Rush University Medical Center (RUMC), Chicago, IL 60612, USA;
| | - Joanna Tylka
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Savannah Glazer
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Yanyu Zhang
- Bioinformatics and Biostatistics Core, RUMC, Chicago, IL 60612, USA
| | - Rosario Cosme
- Department of Psychiatry, RUMC, Chicago, IL 60612, USA
| | - Jean M. Silvestri
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Pallavi P. Patwari
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
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21
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Duan Y, Yang Y, Zhu W, Wan L, Wang G, Yue J, Bao Q, Shao J, Wan X. Melatonin intervention to prevent delirium in the intensive care units: a systematic review and meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2023; 14:1191830. [PMID: 37564987 PMCID: PMC10410466 DOI: 10.3389/fendo.2023.1191830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/07/2023] [Indexed: 08/12/2023] Open
Abstract
Objective To determine the preventive effect of melatonin on delirium in the intensive care units. Methods We conducted a systematic search of the PubMed, Cochrane Library, Science, Embase, and CNKI databases, with retrieval dates ranging from the databases' inception to September 2022. Controlled trials on melatonin and placebo for preventing delirium in the intensive care units were included. The meta-analysis was performed using Review Manager software (version 5.3) and Stata software (version 14.0). Results Six studies involving 2374 patients were included in the meta-analysis. The results of the meta-analysis showed that melatonin did not reduce the incidence of delirium in ICU patients (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.46 to 1.12; p = 0.14). There was a strong hetero-geneity between the selected studies (I2 = 74%). Subgroup analysis results showed that melatonin reduced the incidence of delirium in cardiovascular care unit (CCU) patients (OR: 0.52; 95% CI: 0.37 to 0.73; p=0.0001), but did not in general intensive care unit (GICU) patients (OR: 1.14; 95% CI: 0.86 to 1.50; p=0.35). In terms of the secondary outcomes, there were no significant differences in all-cause mortality (OR: 0.85; 95% CI: 0.66 to 1.09; p=0.20), length of ICU stay (mean difference [MD]: 0.33; 95% CI: -0.53 to 1.18; p=0.45), or length of hospital stay (MD: 0.51; 95% CI: -1.17 to 2.19; p=0.55). Conclusion Melatonin reduced the incidence of delirium in CCU patients, but did not significantly reduce the incidence of delirium in GICU patients. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022367665.
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Affiliation(s)
- Yushan Duan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Yuan Yang
- Department of Anesthesiology, The First Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Weihua Zhu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Linjun Wan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Gang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Jinxi Yue
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Qi Bao
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, The First Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Xiaohong Wan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
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22
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Showler L, Ali Abdelhamid Y, Goldin J, Deane AM. Sleep during and following critical illness: A narrative review. World J Crit Care Med 2023; 12:92-115. [PMID: 37397589 PMCID: PMC10308338 DOI: 10.5492/wjccm.v12.i3.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 03/22/2023] [Indexed: 06/08/2023] Open
Abstract
Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.
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Affiliation(s)
- Laurie Showler
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Jeremy Goldin
- Sleep and Respiratory Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Adam M Deane
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
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Beaucage-Charron J, Rinfret J, Coveney R, Williamson D. Melatonin and Ramelteon for the treatment of delirium: A systematic review and meta-analysis. J Psychosom Res 2023; 170:111345. [PMID: 37150157 DOI: 10.1016/j.jpsychores.2023.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To assess the efficacy of melatonin and melatonergic agonist for the treatment of delirium in hospitalized patients. METHODS Embase, MEDLINE, PsycINFO, PubMed, CENTRAL, Cochrane Database of Systematic Reviews, TRIP Medical Database, ClinicalTrials.gov and Google were searched from inception to October 2022. Randomized controlled trials (RCT) and observational studies with any type of comparator evaluating melatonin or melatonergic agonist (ramelteon) enrolling any populations (ICU, surgery, geriatric) were included. Two reviewers independently selected and extracted data using the Cochrane risk of bias tools (RoB2 and ROBINSI). RESULTS Out of the 650 screened publications, three RCTs and six observational studies were included (n = 1211). All three RCTs compared melatonin to placebo, as the majority of observational studies compared melatonin or ramelteon to antipsychotics. Two RCTs reported the duration of delirium and a meta-analysis provided a statistical difference between melatonin and placebo (-1.72 days, 95% CI -2.66 to -0.77, p = 0.0004). Five observational studies reported the duration of delirium but only one reported a statistical reduction in the duration of delirium. CONCLUSION Although melatonin and ramelteon may be effective treatments for delirium, particularly to shorten the duration of delirium and to limit the use of rescue medication, current data is limited in number and in its quality. Clinicians should wait until higher quality data from ongoing RCTs are available before prescribing melatonin to delirious patients.
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Affiliation(s)
- Johannie Beaucage-Charron
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada.
| | - Justine Rinfret
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - Richard Coveney
- Direction of Education, Research and Innovation, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - David Williamson
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montréal, Canada; Faculty of Pharmacy, Université de Montréal, Montréal, Canada
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24
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Knauert MP, Ayas NT, Bosma KJ, Drouot X, Heavner MS, Owens RL, Watson PL, Wilcox ME, Anderson BJ, Cordoza ML, Devlin JW, Elliott R, Gehlbach BK, Girard TD, Kamdar BB, Korwin AS, Lusczek ER, Parthasarathy S, Spies C, Sunderram J, Telias I, Weinhouse GL, Zee PC. Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2023; 207:e49-e68. [PMID: 36999950 PMCID: PMC10111990 DOI: 10.1164/rccm.202301-0184st] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.
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25
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Abstract
PURPOSE OF REVIEW Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW. RECENT FINDINGS The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment. SUMMARY In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.
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Affiliation(s)
- Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
| | - Francesco A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
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26
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Barnes J, Sewart E, Armstrong RA, Pufulete M, Hinchliffe R, Gibbison B, Mouton R. Does melatonin administration reduce the incidence of postoperative delirium in adults? Systematic review and meta-analysis. BMJ Open 2023; 13:e069950. [PMID: 36990485 PMCID: PMC10069576 DOI: 10.1136/bmjopen-2022-069950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023] Open
Abstract
Postoperative delirium (POD) is common. It is associated with increased morbidity and mortality. Many cases may be preventable and melatonin offers promise as a preventative agent. OBJECTIVE This systematic review provides an up-to-date synthesis of the evidence on the effect of melatonin in preventing POD. DESIGN A systematic search of randomised controlled trials of melatonin in POD was run across multiple databases (EMBASE, MEDLINE, CINAHL, PsycINFO) and a clinical trials registry (ClinicalTrials.org) (1 January 1990 to 5 April 2022). Studies examining the effects of melatonin on POD incidence in adults are included. Risk of bias was assessed using the Cochrane risk of bias 2 tool. OUTCOME MEASURES The primary outcome is POD incidence. Secondary outcomes are POD duration and length of hospital stay. Data synthesis was undertaken using a random-effects meta-analysis and presented using forest plots. A summary of methodology and outcome measures in included studies is also presented. RESULTS Eleven studies, with 1244 patients from a range of surgical specialties were included. Seven studies used melatonin, in variable doses, and four used ramelteon. Eight different diagnostic tools were used to diagnose POD. Time points for assessment also varied. Six studies were assessed as low risk of bias and five as some concern. The combined OR of developing POD in the melatonin groups versus control was 0.41 (95% CI 0.21 to 0.80, p=0.01). CONCLUSION This review found that melatonin may reduce the incidence of POD in adults undergoing surgery. However, included studies displayed inconsistency in their methodology and outcome reporting. Further work to determine the optimum regime for melatonin administration, along with consensus of how best to evaluate results, would be beneficial. PROSPERO REGISTRATION NUMBER CRD42021285019.
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Affiliation(s)
- Jonathan Barnes
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
| | - Emma Sewart
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | | | | | - Robert Hinchliffe
- Department of Surgery, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
| | - Ben Gibbison
- Department of Anaesthesia, Bristol Royal Infirmary, Bristol, UK
- University of Bristol, Bristol, UK
| | - Ronelle Mouton
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol, UK
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27
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Austin CA, Palanca BJA, Smith K, Chapin B, Lin SY, Khan S, Lindroth H, Maya K, Oldham M. American Delirium Society 2022 Year in Review: Highlighting the Year's Most Impactful Delirium Research. DELIRIUM COMMUNICATIONS 2023; 2023:10.56392/001c.73356. [PMID: 38361911 PMCID: PMC10869120 DOI: 10.56392/001c.73356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background Since 2015, the American Delirium Society (ADS) Research Committee has conducted an annual survey of the delirium literature for presentation in its year-in-review session. Our objectives were to describe the review process used for the 2021-2022 and to summarise the selected publications. Methods Each member of the ADS Research Committee nominated up to 6 publications considered to be the most impactful primary delirium research published from September 1, 2021, to July 31, 2022. The 24 nominated studies were divided into three categories balanced by number of articles: medical intervention trials, non-medical intervention trials, and delirium detection/basic science studies. Each ADS Research Committee member ranked all studies in their assigned category for methodological rigor and for impact, each being scored as 0-10, for a total score of 0-20. It was decided a priori to select the top three highest-scoring articles in each category for presentation, with ties adjudicated by Committee consensus. Results Nineteen Research Committee members served as reviewers. Scores for each category were similar: medical interventions mean (standard deviation) 12.8 (1.1), non-medical interventions 13.1 (1.1), and detection/basic science 12.6 (1.0). We summarise the results of the papers presented in the 2022 ADS year-in-review session. Conclusion The diversity of studies presented for the 2022 ADS year-in-review session illustrates the breadth of the delirium field and the growing number of clinical trials. The dissemination of publications across a broad, diverse array of journals provides further justification of the need for delirium-specific journals.
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Affiliation(s)
- C. Adrian Austin
- Corresponding Author: C. Adrian Austin, MD, MSCR, Clinical Instructor, Division of Pulmonary and Critical Care Medicine Division of Geriatric Medicine, University of North Carolina at Chapel Hill, 130 Mason Farm Rd, CB 7020, Chapel Hill, NC 27514 919-966-2531,
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28
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Ali Abdelhamid Y, Deane A, Bellomo R. Recent advances in critical care. Med J Aust 2023; 218:153-156. [PMID: 36773964 DOI: 10.5694/mja2.51850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/06/2022] [Accepted: 01/18/2023] [Indexed: 02/13/2023]
Affiliation(s)
| | - Adam Deane
- University of Melbourne, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
| | - Rinaldo Bellomo
- University of Melbourne, Melbourne, VIC.,Austin Hospital, Melbourne, VIC
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29
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Aiello G, Cuocina M, La Via L, Messina S, Attaguile GA, Cantarella G, Sanfilippo F, Bernardini R. Melatonin or Ramelteon for Delirium Prevention in the Intensive Care Unit: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12020435. [PMID: 36675363 PMCID: PMC9863078 DOI: 10.3390/jcm12020435] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Melatonin modulates the circadian rhythm and has been studied as a preventive measure against the development of delirium in hospitalized patients. Such an effect may be more evident in patients admitted to the ICU, but findings from the literature are conflicting. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We assessed whether melatonin or ramelteon (melatonin agonist) reduce delirium incidence as compared to a placebo in ICU patients. Secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV) and mortality. Estimates are presented as risk ratio (RR) or mean differences (MD) with 95% confidence interval (CI). Nine RCTs were included, six of them reporting delirium incidence. Neither melatonin nor ramelteon reduced delirium incidence (RR 0.76 (0.54, 1.07), p = 0.12; I2 = 64%), although a sensitivity analysis conducted adding other four studies showed a reduction in the risk of delirium (RR = 0.67 (95%CI 0.48, 0.92), p = 0.01; I2 = 67). Among the secondary outcomes, we found a trend towards a reduction in the duration of MV (MD -2.80 (-6.06, 0.47), p = 0.09; I2 = 94%) but no differences in ICU-LOS (MD -0.26 (95%CI -0.89, 0.37), p = 0.42; I2 = 75%) and mortality (RR = 0.85 (95%CI 0.63, 1.15), p = 0.30; I2 = 0%). Melatonin and ramelteon do not seem to reduce delirium incidence in ICU patients but evidence is weak. More studies are needed to confirm this finding.
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Affiliation(s)
- Giuseppe Aiello
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Micol Cuocina
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luigi La Via
- Department of Anesthesiology and Intensive Care, AOU “Policlinico-San Marco”, 95123 Catania, Italy
| | - Simone Messina
- School of Specialization in Anesthesiology and Intensive Care, University “Magna Graecia”, 88100 Catanzaro, Italy
| | - Giuseppe A. Attaguile
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Correspondence:
| | - Filippo Sanfilippo
- Department of Anesthesiology and Intensive Care, AOU “Policlinico-San Marco”, 95123 Catania, Italy
| | - Renato Bernardini
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital of Catania, 95123 Catania, Italy
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30
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Dang V, Mansukhani MP, Wang Z, Kinzelman Vesely E, Kolla BP. Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A Systematic Review and Meta-Analyses. J Acad Consult Liaison Psychiatry 2023; 64:65-72. [PMID: 35718086 DOI: 10.1016/j.jaclp.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/19/2022] [Accepted: 06/09/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Small prospective studies, case reports, as well as some randomized placebo-controlled trials and previous meta-analyses have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium. OBJECTIVE The goal of this systemic review and meta-analyses was to assess the current evidence supporting the use of ramelteon in delirium prevention by including data from larger (>100 subjects) and more recent trials since the most recent meta-analyses were published in 2019. There were no exclusions for trial size, age, ramelteon dose, length of treatment, or hospital setting. METHODS Medline, Embase, PsycINFO, EBM Reviews, Scopus, and Web of Science databases were queried using the search terms delirium (with subterms including prevention and control), ramelteon, Rozerem, or melatonin receptor agonists, for English-language publications until March 16, 2021. Randomized placebo-controlled trials of hospitalized subjects receiving ramelteon for delirium prevention were included. The primary outcome of interest was delirium incidence. Odds ratios of the risk of developing incident delirium and 95% confidence intervals were calculated using a random effects model. RESULTS A total of 177 articles were identified by the literature search. Five studies (n = 443, 53.7% male) met criteria for inclusion in the final meta-analyses. The meta-analyses of the randomized placebo-controlled trials revealed that ramelteon did not result in a reduction in the risk of incident delirium (n = 443; odds ratio = 0.49; 95% confidence interval = 0.13-1.85). A moderate degree of heterogeneity was noted among the studies (I2 = 53%). CONCLUSIONS Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients.
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Affiliation(s)
- Vanessa Dang
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | - Zhen Wang
- Health Services Research, Rochester, MN
| | | | - Bhanu Prakash Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Center for Sleep Medicine, Mayo Clinic, Rochester, MN.
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31
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Melatonin for Insomnia in Medical Inpatients: A Narrative Review. J Clin Med 2022; 12:jcm12010256. [PMID: 36615056 PMCID: PMC9821578 DOI: 10.3390/jcm12010256] [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: 10/19/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.
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32
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Lee EY, Wilcox ME. Sleep in the intensive care unit. Curr Opin Pulm Med 2022; 28:515-521. [PMID: 36101905 DOI: 10.1097/mcp.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Sleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU) affects physiology and clinical outcomes, as well as the most recent advances in sleep and circadian rhythm promoting interventions including therapeutics. RECENT FINDINGS On a molecular level, clock genes dysrhythmia and altered immunity are clearly linked, particularly in sepsis. Melatonin may also be associated with insulin sensitivity in ICU patients. Clinically, changes in sleep architecture are associated with delirium, and sleep-promoting interventions in the form of multifaceted care bundles may reduce its incidence. Regarding medications, one recent randomized controlled trial (RCT) on melatonin showed no difference in sleep quality or incidence of delirium. SUMMARY Further investigation is needed to establish the clinical relevance of sleep and circadian disruption in the ICU. For interventions, standardized protocols of sleep promotion bundles require validation by larger multicenter trials. Administratively, such protocols should be individualized to both organizational and independent patient needs. Incorporating pharmacotherapy such as melatonin and nocturnal dexmedetomidine requires further evaluation in large RCTs.
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Affiliation(s)
- Eugenia Y Lee
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Department of Medicine, University Health Network, Toronto, Canada
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Yan W, Li C, Song X, Zhou W, Chen Z. Prophylactic melatonin for delirium in critically ill patients: A systematic review and meta-analysis with trial sequential analysis. Medicine (Baltimore) 2022; 101:e31411. [PMID: 36316858 PMCID: PMC9622662 DOI: 10.1097/md.0000000000031411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Up to 80% of patients in the intensive care unit (ICU) suffer from delirium. Studies on the preventative use of melatonin in the ICU have produced mixed results. We performed a systematic review and meta-analysis to evaluate whether early administration of melatonin reduces the prevalence of delirium in critically ill patients. METHODS We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing melatonin or melatonin agonists to placebo in ICU setting. The population included adult patients in the ICU. The primary outcome was the prevalence of delirium. Secondary outcomes included duration of delirium, delirium-free day, serum melatonin concentration, need for sedation, duration of mechanical ventilation, hospital and ICU length of stay (LOS), all-cause mortality, sleep quality, and adverse events. Trial sequential analysis (TSA) was performed on the primary outcome to prevent the risk of random error and multiplicity phenomenon as a result of repeated significance testing across all the included trials. RESULTS Twelve trials with a total of 2538 patients were analyzed. When all trials were pooled, the incidence of delirium in ICU patients who received melatonin was significantly lower than in those who received placebo (risk ratio, 0.77; 95% confidence interval: 0.61-0.96; I2 = 56%). There were no significant differences in secondary outcomes including duration of delirium, duration of mechanical ventilation, ICU LOS, hospital LOS, and mortality. TSA indicated that Z-curve crossed the traditional boundary, but did not cross the monitoring boundary for benefit, which indicated that it is still inconclusive that melatonin affects the incidence of delirium. CONCLUSIONS This meta-analysis found that early administration of melatonin may result in a decreased delirium prevalence in critically ill patients. However, the sensitivity analysis of high-quality studies did not support this finding. In addition, TSA demonstrated that the result may have false-positive error. Therefore, this finding should be interpreted with caution. Further studies are needed to examine the effectiveness of prophylactic melatonin on the prevalence and duration of ICU delirium in the future.
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Affiliation(s)
- Wenqing Yan
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Chen Li
- Department of Traumatology, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Xin Song
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Wenqiang Zhou
- Medical Department of Nanchang University, Nanchang, Jiangxi, China
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
| | - Zhi Chen
- Department of Emergency, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
- * Correspondence: Zhi Chen, Department of Emergency, Jiangxi Provincial People’s Hospital, 92 Ai Guo Street, Nanchang, Jiangxi 330006, China (e-mail: )
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Is There a Role for Medication in Managing Delirium with Dementia? Geriatrics (Basel) 2022; 7:geriatrics7050114. [PMID: 36286217 PMCID: PMC9602311 DOI: 10.3390/geriatrics7050114] [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: 09/05/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
People with dementia are more likely to develop delirium. We conducted a brief literature search and give a pragmatic overview of the key issues. Making rational and safe prescribing decisions is highly influenced by organisational culture and embedded staff practices. Comprehensive assessment for unmet physical, psychological, and social needs is an important intervention in itself. Taking a broad overview of possible pharmacological interventions should include stopping inappropriate medications and prescribing for key drivers of the underlying causes of delirium. Prescribing psychotropic medications may be indicated where there is significant distress or risk to the person with dementia and risk to those around them. It is vital to consider the dementia subtype and, where possible, involve family and friend carers in the decision-making process. Medications should be prescribed at the lowest possible dose for the least amount of time after carefully weighing risks versus benefits and documenting these. While these cases are challenging for staff and families, it can be rewarding to improve the quality of life and lessen distress for the person with dementia. There are also opportunities for informing family and friend carers, educating the wider multidisciplinary team, and promoting organisational change.
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Liu R, Luo X, Li J, Lei Y, Zeng F, Huang X, Lan Y, Yang F. Melatonin: A window into the organ-protective effects of sepsis. Biomed Pharmacother 2022; 154:113556. [PMID: 35994818 DOI: 10.1016/j.biopha.2022.113556] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/22/2022] [Accepted: 08/14/2022] [Indexed: 11/02/2022] Open
Abstract
Sepsis is an uncontrolled host response to infection. In some cases, it progresses to multi-organ insufficiency, leading to septic shock and increased risk of mortality. Various organ support strategies are currently applied clinically, but they are still inadequate in terms of reducing mortality. Melatonin is a hormone that regulates sleep and wakefulness, and it is associated with a reduced risk of death in patients with sepsis. Evidence suggests that melatonin may help protect organ function from sepsis-related damage. Here, we review information related to the role of melatonin in protecting organ function during sepsis and explore its potential clinical applications, with the aim of providing an effective therapeutic strategy for treating sepsis-induced organ insufficiency.
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Affiliation(s)
- Rongan Liu
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoxiu Luo
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiajia Li
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu Lei
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fan Zeng
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaobo Huang
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yunping Lan
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
| | - Fuxun Yang
- Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.
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Schmidt S, Hancke L, Haussmann R, Luetz A. [Chronobiological interventions for prevention and treatment of delirium in critically ill patients]. DER NERVENARZT 2022; 93:901-911. [PMID: 35867117 DOI: 10.1007/s00115-022-01348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
Circadian body and behavior rhythms serve to coordinate and maintain the physiological processes in the human body. A disruption of these rhythms frequently occurs in intensive care patients and can be the cause for the development of delirium. This review article discusses the underlying pathophysiological mechanisms and develops a chronobiologically oriented prevention and treatment approach for delirium in the context of intensive care medicine.
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Affiliation(s)
- Sebastian Schmidt
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Laura Hancke
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Robert Haussmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - Alawi Luetz
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland. .,Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin, Berlin, Deutschland.
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ICU Patients’ Perception of Sleep and Modifiable versus Non-Modifiable Factors That Affect It: A Prospective Observational Study. J Clin Med 2022; 11:jcm11133725. [PMID: 35807010 PMCID: PMC9267898 DOI: 10.3390/jcm11133725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Good sleep quantity and quality are essential for patient recovery while in the intensive care unit (ICU). Patients commonly report poor sleep while in the ICU, and therefore, identifying the modifiable factors that patients perceive as impacting their sleep is important to improve sleep and recovery. This study also assessed night-time light and sound levels in an ICU in an effort to find modifiable factors. Methods: A total of 137 patients (51F) aged 58.1 ± 16.8 years completed a survey including questions about their sleep before and during their ICU stay, factors contributing to poor sleep in the ICU, and perceived factors that may have improved their sleep in the ICU. Night-time light and sound levels were measured in patient rooms and nurses’ stations. Results: Patients reported poorer sleep quantity and quality while in the ICU compared to home. Among the most common reasons for poor sleep, easily modifiable factors included noise (50.4%) and lights (45.3%), potentially modifiable factors included pain (46.7%), and non-modifiable factors included IV lines (42.3%). Patients felt their sleep would have been improved with interventions such as dimming lights (58.4%) and closing doors/blinds at night (42.3%), as well as potentially implementable interventions such as a sleeping pill (51.8%). Overnight sound levels in bedrooms were above the recommended levels (40 dB) and light levels averaged over 100 lux. Conclusions: Sleep quality and quantity were both worse in ICU than at home. Modifiable factors such as sound and light are common factors that patients perceive impact their sleep in the ICU. Readily implementable sleep management strategies aimed at minimizing the impacts of sound and light levels in the ICU are ways to improve patients’ sleep in the ICU.
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Kong H, Xu LM, Wang DX. Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther 2022; 28:1147-1167. [PMID: 35652170 PMCID: PMC9253756 DOI: 10.1111/cns.13873] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/13/2022] Open
Abstract
Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.
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Affiliation(s)
- Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Long-Ming Xu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.,Outcomes Research Consortium, Cleveland, Ohio, USA
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Melatonin in ICU delirium: shining light on the hormone of darkness. Intensive Care Med 2022; 48:479-481. [PMID: 35257204 DOI: 10.1007/s00134-022-06656-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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