Cognitive functioning, mental health, and quality of life in ICU survivors: an overview

Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial

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.

Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs

OBJECTIVES

To measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization.

DESIGN

Retrospective cohort study.

SETTING

Two medical ICUs within Montefiore Health System (Bronx, NY).

PATIENTS

Four hundred and seventy-two mechanically ventilated patients admitted to the medical ICUs during a hospitalization which began and ended between January 1, 2013 and December 31, 2013.

INTERVENTIONS

The full (A)wakening, (B)reathing, (C)oordination, (D)elirium Monitoring/Management and (E)arly Mobilization bundle was implemented in the intervention ICU while a portion of the bundle (A, B, and D components) was implemented in the comparison ICU.

MEASUREMENTS AND MAIN RESULTS

Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P = 0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P = 0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P = 0.002; diagnostic radiology: 0.75 [0.59, 0.96], P = 0.020).

CONCLUSIONS

Full ABCDE bundle implementation resulted in a decrease in total hospital laboratory costs and total hospital laboratory and diagnostic resource utilization while leading to an increase in physical therapy costs.

Accelerated brain ageing in sepsis survivors with cognitive long-term impairment

In the last years, cognitive impairment was emphasized to be a prominent long-term sequelae of sepsis. The level of cognitive impairment is comparable with that in mild cognitive impairment (MCI) patients. Whether sepsis survivors also show a comparable brain atrophy is still unclear. For the analysis of brain atrophy, a novel method named brain age gap estimation (BrainAGE) was used. In this analysis approach, an algorithm identifies age-specific atrophy across the whole brain and calculates a BrainAGE score in years. In case of accelerated brain atrophy, the BrainAGE score is increased in comparison to the healthy age reference group, indicating a difference in estimated chronological age. 20 survivors of severe sepsis (longer than 2 years post sepsis) with persistent cognitive deficits were investigated with a battery of neuropsychological tests. Their MRI images were compared to an age- and sex-matched control group. Sepsis survivors showed a significant higher BrainAGE score of 4.5 years compared to healthy controls. We also found a close relationship between the BrainAGE score and severity of cognitive impairment (a higher BrainAGE score was associated with more severe cognitive impairment). Consequently, sepsis survivors with persistent cognitive impairment showed an accelerated brain ageing, which was closely associated with the severity of cognitive impairment (similar to MCI patients).

Building Resiliency in Dyads of Patients Admitted to the Neuroscience Intensive Care Unit and Their Family Caregivers: Lessons Learned From William and Laura

Sustaining a stroke, regardless of its severity, is a life-changing and often traumatizing event that can lead to chronic depression, anxiety, and posttraumatic stress in both survivors and their family caregivers. Psychosocial interventions for emotional distress after stroke are limited, have emphasized psychoeducation rather than skills, treatment of chronic emotional distress rather than prevention, and have targeted either the patient or their caregiver without accounting for the context of their interpersonal relationship. Here we discuss "Recovering Together," a novel program for dyads of patients with stroke and their family caregivers aimed at preventing chronic emotional distress by using cognitive behavioral principles to teach resiliency and interpersonal communication skills beginning during hospitalization in a neuroscience intensive care unit and continuing after discharge via telehealth. We illustrate the case of a pilot dyad enrolled in the Recovering Together program, to showcase how patients and caregivers can engage with and benefit from it. This dyad's experience suggests that Recovering Together is credible, feasible, and useful. The potential dyadic benefit of this intervention lies not only in providing the opportunity to optimize recovery and prevent long-term emotional distress, but also in creating the space to come together as a pair and make meaning from critical illness.

Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF.

METHODS

We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality.

ANALYSIS

Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety).

CONCLUSIONS

Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.

Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill

Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay.

Preventive strategies and potential therapeutic interventions for delirium in sepsis

Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.

Depression and cognitive impairment following recovery from thrombotic thrombocytopenic purpura

After recovery from an acute episode of acquired thrombotic thrombocytopenic purpura (TTP), patients often describe problems with memory, concentration, and endurance. We have previously reported the occurrence of depression and cognitive impairment in these patients. In this study, we describe the frequency, severity, and clinical course of depression and cognitive impairment. Fifty-two (85%) out of 61 eligible Oklahoma Registry patients who had recovered from TTP, documented by ADAMTS13 activity <10%, have had at least one (median, four) evaluation for depression over 11 years using the Beck Depression Inventory-II; 31 (59%) patients screened positive for depression at least once; in 15 (29%), the results suggested severe depression at least once. Nine of these 15 patients had a psychiatric interview, the definitive diagnostic evaluation; the diagnosis of major depressive disorder was established in eight (89%) patients. In 2014, cognitive ability was evaluated in 33 patients by the Montreal Cognitive Assessment and the Repeatable Battery for Assessment of Neuropsychological Status (RBANS). Both tests detected significant cognitive impairment in the patients as a group. Fifteen out of the 33 patients had been evaluated by extensive cognitive tests in 2006. The 2014 RBANS results were significantly worse than the 2006 results for the overall score and two out of the five RBANS domains (immediate and delayed memory). Neither depression nor cognitive impairment was significantly associated with the occurrence of relapses or ADAMTS13 activity <10% during remission. These observations emphasize the importance of screening evaluations for depression and cognitive impairment after recovery from acquired TTP.

The Impact of High Versus Low Sedation Dosing Strategy on Cognitive Dysfunction in Survivors of Intensive Care Units: A Systematic Review and Meta-Analysis

BACKGROUND

The practice of low vs. high sedation dosing strategy may impact the cognitive and mental health function in the intensive care unit (ICU). We aim to demonstrate that high sedation strategy will result in change of mental health function in ICU patients.

METHODS

We performed a systemic search and meta-analysis of medical databases in MEDLINE (from 1966 to March 2013) and EMBASE (from 1980 to March 2013), as well as the Cochrane Library using the MESH terms "Intensive Care Unit," and "Mental Health, for assessing the impact of sedation on posttraumatic stress disorder (PTSD) or anxiety/depression and delirium in the mix ICU setting including cardiac surgery patients. A total of 1216 patients were included in the final analysis.

RESULTS

We included 11 studies in the final analysis and concluded that high dose sedation strategy resulted in higher incidence of cognitive dysfunction with P value of 0.009. The result for subgroup of delirium showed P = 0.11 and PTSD/depression or anxiety of P = 0.001, Heterogeneity I2 was 64%. Overall analysis was statistically significant with a P value of 0.002.

CONCLUSION

High sedation dosing strategy will negatively affect cognitive function in critically ill patients. Large randomized trials are needed to address cognitive dysfunction in subgroup of patients with delirium.

TNFR1 absence protects against memory deficit induced by sepsis possibly through over-expression of hippocampal BDNF

The involvement of TNF-α type 1 receptor (TNFR1) in memory deficits induced by sepsis was explored by using TNFR1 knockout (KO) mice. We reported that wild type (WT) mice presented memory deficits in the novel object recognition test 10 days after sepsis induced by cecum ligation and perforation (CLP). These deficits were not observed in TNFR1 KO mice. The involvement of serum and brain cytokines TNF-α, IL-1β, IL-6, IFN-γ and IL-10 was then investigated. TNFR1 KO mice had higher serum levels of TNF-α and IL-1β, and brain levels of TNF-α than WT mice. After CLP, the brain levels of TNF-α, IL-1β, IL-6 and IFN-γ increased in both WT and KO mice. Our next step was to determine the expression of inflammatory cytokines, BDNF and TrKb in the hippocampus. The absence of TNFR1 in mice subjected to polymicrobial sepsis resulted in higher BDNF expression in the hippocampus. In conclusion, after CLP, memory is preserved in the absence of TNFR1. This finding was associated with increased BDNF expression in the hippocampus.

PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial

BACKGROUND

It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS.

METHODS/DESIGN

PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space.

DISCUSSION

PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrials.gov under reference number NCT02153294 on 23 May 2014.

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children

BACKGROUND

Automated closed loop systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. This review was originally published in 2013 with an update published in 2014.

OBJECTIVES

The primary objective for this review was to compare the total duration of weaning from mechanical ventilation, defined as the time from study randomization to successful extubation (as defined by study authors), for critically ill ventilated patients managed with an automated weaning system versus no automated weaning system (usual care).Secondary objectives for this review were to determine differences in the duration of ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), mortality, and adverse events related to early or delayed extubation with the use of automated weaning systems compared to weaning in the absence of an automated weaning system.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8); MEDLINE (OvidSP) (1948 to September 2013); EMBASE (OvidSP) (1980 to September 2013); CINAHL (EBSCOhost) (1982 to September 2013); and the Latin American and Caribbean Health Sciences Literature (LILACS). Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles. The original search was run in August 2011, with database auto-alerts up to August 2012.

SELECTION CRITERIA

We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an ICU.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted study data and assessed risk of bias. We combined data in forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria.

MAIN RESULTS

We included 21 trials (19 adult, two paediatric) totaling 1676 participants (1628 adults, 48 children) in this updated review. Pooled data from 16 eligible trials reporting weaning duration indicated that automated closed loop systems reduced the geometric mean duration of weaning by 30% (95% confidence interval (CI) 13% to 45%), however heterogeneity was substantial (I(2) = 87%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of an effect on mortality rates, hospital LOS, reintubation rates, self-extubation and use of non-invasive ventilation following extubation. Prolonged mechanical ventilation > 21 days and tracheostomy were reduced in favour of automated systems (relative risk (RR) 0.51, 95% CI 0.27 to 0.95 and RR 0.67, 95% CI 0.50 to 0.90 respectively). Overall the quality of the evidence was high with the majority of trials rated as low risk.

AUTHORS' CONCLUSIONS

Automated closed loop systems may result in reduced duration of weaning, ventilation and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Improving patient care through the prism of psychology: application of Maslow's hierarchy to sedation, delirium, and early mobility in the intensive care unit

The intensive care unit (ICU) is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and although the overall number of hospital beds remains stable in the United States, the percentage of that total devoted to ICU beds is rising. These 2 realities engender a demographic imperative to address patient safety in the critical care setting. This article addresses the medical community's resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This article is not intended to provide a comprehensive review of the literature but rather a framework to rethink our currently outdated culture of critical care by employing Maslow's hierarchy of needs, along with a few novel analogies. Application of Maslow's hierarchy will help propel health care professionals toward comprehensive care of the whole person not merely for survival but toward restoration of pre-illness function of mind, body, and spirit.

ICU early mobilization: from recommendation to implementation at three medical centers

OBJECTIVE

To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients.

DESIGN

Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act.

INTERVENTION

Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each profession-nursing, physical therapy, physician, and respiratory care-were identified to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution.

SETTING

The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center.

RESULTS

Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program.

CONCLUSION

Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems.

Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study

OBJECTIVES

To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population.

DESIGN

Multicentered prospective observational study.

SETTING

Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States).

PATIENTS

A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012.

INTERVENTIONS

Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to -4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items.

MEASUREMENTS AND MAIN RESULTS

151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay.

CONCLUSIONS

Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children

BACKGROUND

Automated closed loop systems may improve adaptation of the mechanical support to a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation.

OBJECTIVES

To compare the duration of weaning from mechanical ventilation for critically ill ventilated adults and children when managed with automated closed loop systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); MEDLINE (OvidSP) (1948 to August 2011); EMBASE (OvidSP) (1980 to August 2011); CINAHL (EBSCOhost) (1982 to August 2011); and the Latin American and Caribbean Health Sciences Literature (LILACS). In addition we received and reviewed auto-alerts for our search strategy in MEDLINE, EMBASE, and CINAHL up to August 2012. Relevant published reviews were sought using the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA Database). We also searched the Web of Science Proceedings; conference proceedings; trial registration websites; and reference lists of relevant articles.

SELECTION CRITERIA

We included randomized controlled trials comparing automated closed loop ventilator applications to non-automated weaning strategies including non-protocolized usual care and protocolized weaning in patients over four weeks of age receiving invasive mechanical ventilation in an intensive care unit (ICU).

DATA COLLECTION AND ANALYSIS

Two authors independently extracted study data and assessed risk of bias. We combined data into forest plots using random-effects modelling. Subgroup and sensitivity analyses were conducted according to a priori criteria.

MAIN RESULTS

Pooled data from 15 eligible trials (14 adult, one paediatric) totalling 1173 participants (1143 adults, 30 children) indicated that automated closed loop systems reduced the geometric mean duration of weaning by 32% (95% CI 19% to 46%, P = 0.002), however heterogeneity was substantial (I(2) = 89%, P < 0.00001). Reduced weaning duration was found with mixed or medical ICU populations (43%, 95% CI 8% to 65%, P = 0.02) and Smartcare/PS™ (31%, 95% CI 7% to 49%, P = 0.02) but not in surgical populations or using other systems. Automated closed loop systems reduced the duration of ventilation (17%, 95% CI 8% to 26%) and ICU length of stay (LOS) (11%, 95% CI 0% to 21%). There was no difference in mortality rates or hospital LOS. Overall the quality of evidence was high with the majority of trials rated as low risk.

AUTHORS' CONCLUSIONS

Automated closed loop systems may result in reduced duration of weaning, ventilation, and ICU stay. Reductions are more likely to occur in mixed or medical ICU populations. Due to the lack of, or limited, evidence on automated systems other than Smartcare/PS™ and Adaptive Support Ventilation no conclusions can be drawn regarding their influence on these outcomes. Due to substantial heterogeneity in trials there is a need for an adequately powered, high quality, multi-centre randomized controlled trial in adults that excludes 'simple to wean' patients. There is a pressing need for further technological development and research in the paediatric population.

Understanding terminology of delirium and long-term cognitive impairment in critically ill patients

Delirium, an acute brain dysfunction, frequently affects intensive care unit (ICU) patients during the course of a critical illness. Besides the acute morbidities, ICU survivors often experience long-term sequelae in the form of cognitive impairment (LTCI-CI). Though delirium and LTCI-CI are associated with adverse outcomes, little is known on the terminology used to define these acute and chronic co-morbidities. The use of a correct terminology is a key factor to spread the knowledge on clinical conditions. Therefore, we first review the epidemiology, definition of delirium and its related terminology. Second, we report on the epidemiology of LTCI-CI and compare its definition to other forms of cognitive impairments. In particular, we define mild cognitive impairment, dementia and finally postoperative cognitive dysfunction. Future research is needed to interpret the trajectories of LTCI-CI, to differentiate it from neurodegenerative diseases and to provide a formal disease classification.

Sedation practice in Nordic and non-Nordic ICUs: a European survey

BACKGROUND AND AIMS

A trend towards lighter sedation has been evident in many intensive care units (ICUs). The aims of the survey were to describe sedation practice in European ICUs and to compare sedation practice in Nordic and non-Nordic countries.

DESIGN AND METHODS

A cross-sectional survey of ICU nurses attending the fourth European federation of Critical Care Nursing associations (EfCCNa) in Denmark, 2011. Data included use of protocols; sedation, pain and delirium assessment tools; collaborative decision-making; sedation and analgesic medications; and educational preparation related to sedation.

RESULTS

Response rate was 42% (n = 291) from 22 countries where 53% (n = 148) used sedation protocols. Nordic nurses reported greater use of sedation (91% versus 67%, p < 0·01) and pain (91% versus 69%, p < 0·01) assessment tools than non-Nordic nurses. Decision-making on sedation was more inter-professionally collaborative in Nordic ICUs (83% versus 61%, p < 0·01), units were smaller (10 versus 15 beds, p < 0·01) and nurse-patient ratio was higher (1:1, 75% versus 26%, p < 0·01). Nordic nurses reported greater consistency in maintaining circadian rhythm (66% versus 49%, p < 0·01), less use of physical restraints (14% versus 36%, p < 0·01), less use of neuromuscular blocking agents (3% versus 16%, p < 0·01), and received more sedation education (92% versus 76%, p < 0·01). Delirium assessment was not performed systematically in most settings.

CONCLUSIONS

Organizational and contextual factors, such as ICU size, staffing ratio and inter-professional collaboration, are contributing factors to sedation management in European ICUs. The Nordic context might be more germane to the goal of lighter sedation and better pain management.

RELEVANCE TO CLINICAL PRACTICE

Our study raises awareness of current sedation practice, paving the way towards optimized ICU sedation management.

Improving post-intensive care unit neuropsychiatric outcomes: understanding cognitive effects of physical activity

Critical illness and its treatment often result in long-term neuropsychiatric morbidities. Consequently, there is a need to focus on means to prevent or ameliorate these morbidities. Animal models provide important data regarding the neurobiological effects of physical activity, including angiogenesis, neurogenesis, and release of neurotrophic factors that enhance plasticity. Studies in noncritically ill patients demonstrate that exercise is associated with increased cerebral blood flow, neurogenesis, and brain volume, which are associated with improved cognition. Clinically, research in both healthy and diseased human subjects suggests that exercise improves neuropsychiatric outcomes. In the critical care setting, early physical rehabilitation and mobilization are safe and feasible, with demonstrated improvements in physical functional outcomes. Such activity may also reduce the duration of delirium in the intensive care unit (ICU) and improve neuropsychiatric outcomes, although data are limited. Barriers exist regarding implementing ICU rehabilitation in routine care, including use of sedatives and lack of awareness of post-ICU cognitive impairments. Further research is necessary to determine whether prior animal and human research, in conjunction with preliminary results from existing ICU studies, can translate into improvements for neuropsychiatric outcomes in critically ill patients. Studies are needed to evaluate biological mechanisms, risk factors, the role of pre-ICU functional level, and the timing, duration, and type of physical activity for optimal patient outcomes.