Sedation and sleep disturbances in the ICU

Effect of midazolam on delirium in critically ill patients: a propensity score analysis

Objective

To observe the association between exposure to midazolam within 24 hours prior to delirium assessment and the risk of delirium.

Methods

We performed a systematic cohort study with two sets of cohorts to estimate the relative risks of outcomes among patients administered midazolam within 24 hours prior to delirium assessment. Propensity score matching was performed to generate a balanced 1:1 matched cohort and identify potential prognostic factors. The outcomes included the odds of delirium, mortality, length of intensive care unit stay, length of hospitalization, and odds of being discharged home.

Results

A total of 78,364 patients were included in this study, of whom 22,159 (28.28%) had positive records. Propensity matching successfully balanced covariates for 9348 patients (4674 per group). Compared with no administration of midazolam, midazolam administration was associated with a significantly higher risk of delirium, higher mortality, and a longer intensive care unit stay. Patients treated with midazolam were relatively less likely to be discharged home. There was no significant difference in hospitalization duration.

Conclusions

Midazolam may be an independent risk factor for delirium in critically ill patients.

An Edge Computing and Ambient Data Capture System for Clinical and Home Environments

The non-contact patient monitoring paradigm moves patient care into their homes and enables long-term patient studies. The challenge, however, is to make the system non-intrusive, privacy-preserving, and low-cost. To this end, we describe an open-source edge computing and ambient data capture system, developed using low-cost and readily available hardware. We describe five applications of our ambient data capture system. Namely: (1) Estimating occupancy and human activity phenotyping; (2) Medical equipment alarm classification; (3) Geolocation of humans in a built environment; (4) Ambient light logging; and (5) Ambient temperature and humidity logging. We obtained an accuracy of 94% for estimating occupancy from video. We stress-tested the alarm note classification in the absence and presence of speech and obtained micro averaged F1 scores of 0.98 and 0.93, respectively. The geolocation tracking provided a room-level accuracy of 98.7%. The root mean square error in the temperature sensor validation task was 0.3°C and for the humidity sensor, it was 1% Relative Humidity. The low-cost edge computing system presented here demonstrated the ability to capture and analyze a wide range of activities in a privacy-preserving manner in clinical and home environments and is able to provide key insights into the healthcare practices and patient behaviors.

The Nexus Between Sleep Disturbance and Delirium Among Intensive Care Patients

Sleep in intensive care is hampered due to many factors; the clinical environment itself exacerbates sleep disturbance. Research suggests that interventions aimed at improving sleep quality have produced positive effects in reducing incidences and duration of delirium. Sleep disturbance is well documented among intensive care patients; however, its prognostic impact is not fully understood. Delirium, disproportionally prevalent among intensive care patients, has significant prognostic factors related to patient outcomes, in which sleep disturbance often is present. The relationship between sleep disturbance and delirium is complex, sharing commonalities in relation to neurobiological and neurohormonal alterations, which may contribute to a bidirectional relationship.

Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Atypical EEG patterns not consistent with standard sleep staging criteria have been observed in medical intensive care unit (ICU) patients. Our aim was to examine the relationship between sleep architecture and sedation in critically ill mechanically ventilated patients pre- and post-extubation. We performed a prospective observational repeated measures study where 50 mechanically ventilated patients with 31 paired analyses were examined at an academic medical centre. The sleep efficiency was 58.3 ± 25.4% for intubated patients and 45.6 ± 25.4% for extubated patients (p = .02). Intubated patients spent 76.33 ± 3.34% of time in non-rapid eye movement (NREM) sleep compared to 64.66 ± 4.06% of time for extubated patients (p = .02). REM sleep constituted 1.36 ± 0.67% of total sleep time in intubated patients and 2.06 ± 1.09% in extubated patients (p = .58). Relative sleep atypia was higher in intubated patients compared to extubated patients (3.38 ± 0.87 versus 2.79 ± 0.42; p < .001). Eleven patients were sedated with propofol only, 18 patients with fentanyl only, 11 patients with fentanyl and propofol, and 10 patients had no sedation. The mean sleep times on "propofol", "fentanyl", "propofol and fentanyl," and "no sedation" were 6.54 ± 0.64, 4.88 ± 0.75, 6.20 ± 0.75 and 4.02 ± 0.62 hr, respectively. The sigma/alpha values for patients on "propofol", "fentanyl", "propofol and fentanyl" and "no sedation" were 0.69 ± 0.04, 0.54 ± 0.01, 0.62 ± 0.02 and 0.57 ± 0.02, respectively. Sedated patients on mechanical ventilation had higher sleep efficiency and more atypia compared to the same patients following extubation. Propofol was associated with higher sleep duration and less disrupted sleep architecture compared to fentanyl, propofol and fentanyl, or no sedation.

Implementing a Multicomponent Intervention to Prevent Delirium Among Critically Ill Patients

BACKGROUND

Delirium is common among the critically ill. Nonpharmacologic interventions are reportedly effective in reducing incident delirium, but limited data specific to this population exist.

OBJECTIVES

To assess the efficacy and describe the implementation strategy of a multicomponent intervention to prevent delirium in an intensive care unit.

METHODS

A before-and-after study was conducted in an intensive care unit between May 2014 through August 2015. Adult participants were enrolled consecutively, excluding only those who refused to participate. Tailored interventions took available evidence into consideration. Components included early mobilization, physical therapy, reorientation, cognitive stimulation, drug reviews, environmental stimulation, avoidance of sensory deprivation, pain control, restraint use avoidance, and family participation. Incident delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Multivariate logistic regression was used to control for confounders.

RESULTS

The study included 227 patients (54.7% male; mean [SD] age, 63.3 [18.3] years). Our strategy significantly reduced delirium (from 38% to 24%; relative risk, 0.62; 95% CI, 0.40–0.94; P = .02), an association that remained significant after adjusting for confounders. Adherence rates were more than 85% in all intervention domains (except daily reorientation) that were overseen by health care providers.

CONCLUSIONs

The strategy was successful in reducing delirium. Self-removals of invasive implements decreased, an observation that has not been previously described. No difference in mortality rate was seen, as has been reported in other studies. Early participation of the whole team, shared leadership, and the provision of concrete tasks were key to the success of this multicomponent intervention.

Risk Factors of Delirium in Sequential Sedation Patients in Intensive Care Units

Background

Delirium is a primary adverse event in ventilated patients who receive long-term monosedative treatment. Sequential sedation may reduce these adverse effects. This study evaluated risk factors for delirium in sequential sedation patients.

Methods

A total of 141 patients who underwent sequential sedation were enrolled. Delirium was diagnosed using Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale. Univariate and multivariate Cox proportional hazards regressions were used to predict risk factors.

Results

Older age (≥51) (RR = 2.432, 95% CL 1.316–4.494, p = 0.005), higher SOFA score (≥14) (RR = 2.022, 95% CL 1.076–3.798, p = 0.029), regular smoking (RR = 2.366, 95% CL 1.277–4.382, p = 0.006), and higher maintenance dose of midazolam (RR = 1.052, 95% CL 1.000–1.107, p = 0.049) and fentanyl (RR = 1.045, 95% CL 1.019–1.072, p = 0.001) when patients met sequential criteria, were independent risk factors of delirium. Sequential sedation with dexmedetomidine (RR = 0.448, 95% CL 0.209–0.963, p = 0.040) was associated with a lower risk of delirium.

Conclusions

Older age, higher SOFA score, regular smoking, and higher maintenance dose of midazolam and fentanyl when patients met sequential criteria were independent risk factors of delirium in sequential sedation patients. Sequential sedation with dexmedetomidine reduced risk of delirium.

Factors Influencing Patients' Sleep in the Intensive Care Unit: Perceptions of Patients and Clinical Staff

BACKGROUND

Multiple factors are believed to contribute to disruption of patients' sleep and negatively affect clinical outcomes in the intensive care unit. Achieving restorative sleep for critically ill patients remains a challenge.

OBJECTIVES

To explore the perceptions and beliefs of staff, patients, and surrogates regarding the environmental and nonenvironmental factors in the medical intensive care unit that affect patients' sleep.

METHODS

This qualitative study included 24 medical intensive care unit staff (7 physicians, 5 respiratory therapists, 10 nurses, and 2 patient-care assistants), 8 patients, and 6 patient surrogates. Semistructured interviews were conducted, and qualitative analysis of content was used to code, categorize, and identify interview themes.

RESULTS

Interview responses revealed 4 themes with related subthemes: (1) The overnight medical intensive care unit environment does affect sleep, (2) nonenvironmental factors such as difficult emotions and anxiety also affect sleep, (3) respondents' perceptions about sleep quality in the medical intensive care unit were highly variable, and (4) suggestions for sleep improvement included reassuring patients and care-clustering strategies.

CONCLUSIONS

Results of this study suggest that environment is not the only factor influencing patients' sleep. Decreases in environmental sources of disturbance are necessary but not sufficient for sleep improvement. Guideline-recommended clustered care is needed to provide adequate sleep opportunity, but patients' emotions and anxiety also must be addressed.

Delirium in the Intensive Care Unit

Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.

Efficacy of Sleep Tool Education During Hospitalization: A Randomized Controlled Trial

BACKGROUND

Patients are commonly provided tools in the hospital to overcome poor sleep. Whether education on use of sleep tools can impact health outcomes from a patient perspective is not known.

METHODS

We recruited 120 adults admitted to a nonintensive care unit cardiac-monitored floor. All patients received a set of sleep-enhancing tools (eye mask, ear plugs, and a white noise machine) and were randomized to receive direct education on use of and benefit of these sleep-enhancing tools (intervention), or an equal amount of time was spent discussing general benefits of sleep (control). Measurement of several symptom domains was assessed daily by health outcome survey responses, and change from baseline was assessed for differences between groups. Inpatient opioid use and length of stay were also measured.

RESULTS

Participants randomized to receive the education intervention had a significantly greater decrease in fatigue scores over the 3 days, compared with controls (5.30 ± 6.93 vs 1.81 ± 6.96, t = 2.32, P = .028). There was a trend toward improvements in multiple other sleep-related domains, including sleep disturbance, sleep-related impairment, physical functioning, pain severity, or pain interference (all P >.140). There was no difference in length of stay between intervention and control groups (7.40 ± 7.29 vs 7.71 ± 6.06 days, P = .996). The change in number of opioid equivalents taken did not differ use between the groups (P = .688).

CONCLUSION

In a randomized trial of education in the use of sleep-enhancing tools while hospitalized, patient fatigue was significantly improved, whereas several other patient-reported outcomes showed a trend toward improvements. Implementation of this very low-cost approach to improving sleep and well-being could substantially improve the patient care experience.

Low-dose Dexmedetomidine Improves Sleep Quality Pattern in Elderly Patients after Noncardiac Surgery in the Intensive Care Unit

Background

Patients admitted to the intensive care unit (ICU) after surgery often develop sleep disturbances. The authors tested the hypothesis that low-dose dexmedetomidine infusion could improve sleep architecture in nonmechanically ventilated elderly patients in the ICU after surgery.

Methods

This was a pilot, randomized controlled trial. Seventy-six patients age 65 yr or older who were admitted to the ICU after noncardiac surgery and did not require mechanical ventilation were randomized to receive dexmedetomidine (continuous infusion at a rate of 0.1 μg kg−1 h−1; n = 38) or placebo (n = 38) for 15 h, i.e., from 5:00 pm on the day of surgery until 8:00 am on the first day after surgery. Polysomnogram was monitored during the period of study-drug infusion. The primary endpoint was the percentage of stage 2 non–rapid eye movement (stage N2) sleep.

Results

Complete polysomnogram recordings were obtained in 61 patients (30 in the placebo group and 31 in the dexmedetomidine group). Dexmedetomidine infusion increased the percentage of stage N2 sleep from median 15.8% (interquartile range, 1.3 to 62.8) with placebo to 43.5% (16.6 to 80.2) with dexmedetomidine (difference, 14.7%; 95% CI, 0.0 to 31.9; P = 0.048); it also prolonged the total sleep time, decreased the percentage of stage N1 sleep, increased the sleep efficiency, and improved the subjective sleep quality. Dexmedetomidine increased the incidence of hypotension without significant intervention.

Conclusions

In nonmechanically ventilated elderly patients who were admitted to the ICU after noncardiac surgery, the prophylactic low-dose dexmedetomidine infusion may improve overall sleep quality.

Circadian dysrhythmias in the intensive care unit

Circadian rhythms underlie nearly all physiologic functions and organ systems. Circadian abnormalities have attendant implications for critical illness survival. The intensive care unit (ICU) environment, with its lack of diurnal variation in sound, light, and social cues, may precipitate circadian dysrhythmias. Additional features of critical care, including mechanical ventilation and sedation, likely perpetuate circadian misalignment. Critical illness itself, from sepsis to severe brain injury, can compromise circadian health. Use of daylight, time-restricted feedings, and administration of melatonin can possibly restore circadian rhythm. However, further study is necessary to assess the effectiveness of these interventions and their impact on ICU outcomes.

Non-pharmacological interventions for sleep promotion in the intensive care unit

BACKGROUND

Adults in intensive care units (ICUs) often suffer from a lack of sleep or frequent sleep disruptions. Non-pharmacological interventions can improve the duration and quality of sleep and decrease the risk of sleep disturbance, delirium, post-traumatic stress disorder (PTSD), and the length of stay in the ICU. However, there is no clear evidence of the effectiveness and harms of different non-pharmacological interventions for sleep promotion in adults admitted to the ICU.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for sleep promotion in critically ill adults in the ICU.To establish whether non-pharmacological interventions are safe and clinically effective in improving sleep quality and reducing length of ICU stay in critically ill adults.To establish whether non-pharmacological interventions are cost effective.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 6), MEDLINE (OVID, 1950 to June 2014), EMBASE (1966 to June 2014), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to June 2014), Institute for Scientific Information (ISI) Web of Science (1956 to June 2014), CAM on PubMed (1966 to June 2014), Alt HealthWatch (1997 to June 2014), PsycINFO (1967 to June 2014), the China Biological Medicine Database (CBM-disc, 1979 to June 2014), and China National Knowledge Infrastructure (CNKI Database, 1999 to June 2014). We also searched the following repositories and registries to June 2014: ProQuest Dissertations & Theses Global, the US National Institutes of Health Ongoing Trials Register (www.clinicaltrials.gov), the metaRegister of Controlled Trials (ISRCTN Register) (www.controlled-trials.com), the Chinese Clinical Trial Registry (www.chictr.org.cn), the Clinical Trials Registry-India (www.ctri.nic.in), the Grey Literature Report from the New York Academy of Medicine Library (www.greylit.org), OpenGrey (www.opengrey.eu), and the World Health Organization International Clinical Trials Registry platform (www.who.int/trialsearch). We handsearched critical care journals and reference lists and contacted relevant experts to identify relevant unpublished data.

SELECTION CRITERIA

We included all randomized controlled trials (RCT) and quasi-RCTs that evaluated the effects of non-pharmacological interventions for sleep promotion in critically ill adults (aged 18 years and older) during admission to critical care units or ICUs.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the search results and assessed the risk of bias in selected trials. One author extracted the data and a second checked the data for accuracy and completeness. Where possible, we combined results in meta-analyses using mean differences and standardized mean differences for continuous outcomes and risk ratios for dichotomous outcomes. We used post-test scores in this review.

MAIN RESULTS

We included 30 trials, with a total of 1569 participants, in this review. We included trials of ventilator mode or type, earplugs or eye masks or both, massage, relaxation interventions, foot baths, music interventions, nursing interventions, valerian acupressure, aromatherapy, and sound masking. Outcomes included objective sleep outcomes, subjective sleep quality and quantity, risk of delirium, participant satisfaction, length of ICU stay, and adverse events. Clinical heterogeneity (e.g., participant population, outcomes measured) and research design limited quantitative synthesis, and only a small number of studies were available for most interventions. The quality of the evidence for an effect of non-pharmacological interventions on any of the outcomes examined was generally low or very low. Only three trials, all of earplugs or eye masks or both, provided data suitable for two separate meta-analyses. These meta-analyses, each of two studies, showed a lower incidence of delirium during ICU stay (risk ratio 0.55, 95% confidence interval (CI) 0.38 to 0.80, P value = 0.002, two studies, 177 participants) and a positive effect of earplugs or eye masks or both on total sleep time (mean difference 2.19 hours, 95% CI 0.41 to 3.96, P value = 0.02, two studies, 116 participants); we rated the quality of the evidence for both of these results as low.There was also some low quality evidence that music (350 participants; four studies) may improve subjective sleep quality and quantity, but we could not pool the data. Similarly, there was some evidence that relaxation techniques, foot massage, acupressure, nursing or social intervention, and sound masking can provide small improvements in various subjective measures of sleep quality and quantity, but the quality of the evidence was low. The effects of non-pharmacological interventions on objective sleep outcomes were inconsistent across 16 studies (we rated the quality of the evidence as very low): the majority of studies relating to the use of earplugs and eye masks found no benefit; results from six trials of ventilator modes suggested that certain ventilator settings might offer benefits over others, although the results of the individual trials did not always agree with each other. Only one study measured length of stay in the ICU and found no significant effect of earplugs plus eye masks. No studies examined the effect of any non-pharmacological intervention on mortality, risk of post-traumatic stress disorder, or cost-effectiveness; the included studies did not clearly report adverse effects, although there was very low quality evidence that ventilator mode influenced the incidence of central apnoeas and patient-ventilator asynchronies.

AUTHORS' CONCLUSIONS

The quality of existing evidence relating to the use of non-pharmacological interventions for promoting sleep in adults in the ICU was low or very low. We found some evidence that the use of earplugs or eye masks or both may have beneficial effects on sleep and the incidence of delirium in this population, although the quality of the evidence was low. Further high-quality research is needed to strengthen the evidence base.

A meta-analysis of sleep-promoting interventions during critical illness

BACKGROUND

Sleep quality and quantity are severely reduced in critically ill patients receiving mechanical ventilation with a potential for adverse consequences. Our objective was to synthesize the randomized controlled trials (RCTs) that measured the efficacy of sleep-promoting interventions on sleep quality and quantity in critically ill patients.

METHODS

We included RCTs that objectively measured sleep with electroencephalography or its derivatives and excluded observational studies and those that measured sleep by subjective reports. The research was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Of 6022 studies identified, 13 met eligibility criteria involving 296 critically ill patients. Eight trials looked at different modes of mechanical ventilation as sleep interventions, and the remaining 5 involved pharmacologic, nonpharmacologic, or environmental interventions. Meta-analysis of the studies revealed that sleep-promoting interventions improved sleep quantity (pooled standardized mean difference [SMD], 0.37; 95% confidence interval [CI], 0.05-0.69; P = .02) and sleep quality through reduction in sleep fragmentation (SMD, -0.31; 95% CI, -0.60 to -0.01; P = .04). Subgroup analysis revealed that timed modes of ventilation improved sleep quantity when compared with spontaneous modes of ventilation (SMD, 0.45; 95% CI, 0.10-0.81; P = .01). Nonmechanical ventilation interventions tended to improve sleep quantity (SMD, 0.65; 95% CI, -0.03 to 1.33; P = .06) and to reduce sleep fragmentation (SMD, -0.29; 95% CI, -0.61 to 0.03; P = .07).

CONCLUSIONS

The synthesized evidence suggests that both mechanical ventilation- and nonmechanical ventilation-based therapies improve sleep quantity and quality in critically ill patients, but the clinical significance is unclear. In the future, adequately powered multicenter RCTs involving pharmacologic interventions to promote sleep in critically ill patients are warranted.

Interpatient variability in dexmedetomidine response: a survey of the literature

Fifty-five thousand patients are cared for in the intensive care unit (ICU) daily with sedation utilized to reduce anxiety and agitation while optimizing comfort. The Society of Critical Care Medicine (SCCM) released updated guidelines for management of pain, agitation, and delirium in the ICU and recommended nonbenzodiazepines, such as dexmedetomidine and propofol, as first line sedation agents. Dexmedetomidine, an alpha-2 agonist, offers many benefits yet its use is mired by the inability to consistently achieve sedation goals. Three hypotheses including patient traits/characteristics, pharmacokinetics in critically ill patients, and clinically relevant genetic polymorphisms that could affect dexmedetomidine response are presented. Studies in patient traits have yielded conflicting results regarding the role of race yet suggest that dexmedetomidine may produce more consistent results in less critically ill patients and with home antidepressant use. Pharmacokinetics of critically ill patients are reported as similar to healthy individuals yet wide, unexplained interpatient variability in dexmedetomidine serum levels exist. Genetic polymorphisms in both metabolism and receptor response have been evaluated in few studies, and the results remain inconclusive. To fully understand the role of dexmedetomidine, it is vital to further evaluate what prompts such marked interpatient variability in critically ill patients.

Top 10 myths regarding sedation and delirium in the ICU

The management of pain, agitation, and delirium in critically ill patients can be complicated by multiple factors. Decisions to administer opioids, sedatives, and antipsychotic medications are frequently driven by a desire to facilitate patients' comfort and their tolerance of invasive procedures or other interventions within the ICU. Despite accumulating evidence supporting new strategies to optimize pain, sedation, and delirium practices in the ICU, many critical care practitioners continue to embrace false perceptions regarding appropriate management in these critically ill patients. This article explores these perceptions in more detail and offers new evidence-based strategies to help critical care practitioners better manage sedation and delirium, particularly in ICU patients.

A case-based approach to the practical application of dexmedetomidine in critically ill adults

Dexmedetomidine is a selective α(2) -adrenoceptor agonist that offers unique sedation because patients are readily awakened while administration continues and the drug does not suppress the respiratory center. Limitations of use include higher acquisition cost, inability to produce deep sedation, and bradycardia and hypotension. Using a case-based approach, the purpose of this review was to qualitatively assess the role of dexmedetomidine in the care of the critically ill and in the management of alcohol withdrawal, and to formulate recommendations regarding its clinical application. Sixty-six studies were identified that investigated dexmedetomidine for the provision of sedation. These studies were heterogeneous in design and patient populations; most investigated patients did not require heavy sedation, and few used propofol as the comparator. In general, though, the aggregate results of all studies demonstrate that dexmedetomidine provides comfort, possibly shortens the duration of mechanical ventilation to facilitate extubation, reduces the occurrence of acute brain dysfunction, and facilitates communication, but the drug is associated with hemodynamic instability and requires the supplemental use of traditional sedative and analgesic agents. These outcomes need to be substantiated in additional studies that include assessments of cost-effectiveness. Dexmedetomidine should be considered when patients require mild to moderate levels of sedation of short to intermediate time frames, and they qualify for daily awakenings with traditional sedative therapies. The data for dexmedetomidine in relation to alcohol withdrawal are limited to 12 retrospective reports representing a total of 127 patients. Its role for this indication requires further study, but it may be considered as adjunctive therapy when clinicians are concerned about respiratory suppression associated with escalating doses of γ-aminobutyric acid agonists. Regardless of the indication for dexmedetomidine, the practitioner must closely monitor patient comfort and the occurrence of hemodynamic deviations with the realization that as-needed administration of traditional sedatives and analgesics will be required and some degree of bradycardia and hypotension expected but intervention rarely required.

Extending the ABCDE bundle to the post-intensive care unit setting

A recently proposed interprofessional, evidence-based, multicomponent approach to mitigating the effects of intensive care unit (ICU)-acquired delirium and weakness has the potential to radically transform the way care is delivered to older adults requiring sedation, mechanical ventilation, or both. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle empowers members of the interdisciplinary ICU team to implement the best available evidence regarding mechanical ventilation, sedation, weakness, and delirium in a safe, effective, and patient-centered manner. Considering that critically ill older adults are cared for in a number of different settings during the course of hospitalization and recovery, the purpose of this article is to explore the rationale and possible benefits of extending the ABCDE bundle into the post-ICU setting. We provide a case study that illustrates how ABCDE bundle adoption could be the key to improving the quality of care provided to seriously ill older adults in the ICU and beyond.

Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium

OBJECTIVE

To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation.

DESIGN

Single-center, prospective cohort study nested within the Awakening and Breathing Controlled randomized trial.

SETTING

Saint Thomas Hospital in Nashville, TN, from 2004 to 2006.

PATIENTS

Adult patients receiving mechanical ventilation for >12 hrs with continuous recording of hourly sedation dosing.

INTERVENTIONS

We measured hourly doses of benzodiazepine and propofol exposure during the daytime (7 AM to 11 PM) and nighttime (11 PM to 7 AM) for 5 days. We quantified nighttime dose increases by subtracting the average hourly daytime dose on the preceding day from subsequent average hourly nighttime dose. We used multivariable logistic regression to determine whether daytime and nighttime dose increases were independently associated with delirium, coma, and delayed liberation from mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

Among 140 patients, the median Acute Physiology and Chronic Health Evaluation II score was 27 (interquartile range 22-33). Among those receiving the sedatives, benzodiazepine and propofol doses were increased at night on 40% and 41% of patient-days, respectively. Of 485 patient-days, delirium was present on 160 (33%) and coma on 206 (42%). In adjusted models, greater daytime benzodiazepine dose was independently associated with failed spontaneous breathing trial and extubation, and subsequent delirium (p<.02 for all). Nighttime increase in benzodiazepine dose was associated with failed spontaneous breathing trial (p<.01) and delirium (p=.05). Daytime propofol dose was marginally associated with subsequent delirium (p=.06).

CONCLUSIONS

Nearly half of mechanically ventilated intensive care unit patients received greater doses of sedation at night, a practice associated with failed spontaneous breathing trials, coma, and delirium. Over the first 5 days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the intensive care unit.

Temporal disorganization of circadian rhythmicity and sleep-wake regulation in mechanically ventilated patients receiving continuous intravenous sedation

OBJECTIVES

Sleep is regulated by circadian and homeostatic processes and is highly organized temporally. Our study was designed to determine whether this organization is preserved in patients receiving mechanical ventilation (MV) and intravenous sedation.

DESIGN

Observational study.

SETTING

Academic medical intensive care unit.

PATIENTS

Critically ill patients receiving MV and intravenous sedation.

METHODS

Continuous polysomnography (PSG) was initiated an average of 2.0 (1.0, 3.0) days after ICU admission and continued ≥ 36 h or until the patient was extubated. Sleep staging and power spectral analysis were performed using standard approaches. We also calculated the electroencephalography spectral edge frequency 95% SEF₉₅, a parameter that is normally higher during wakefulness than during sleep. Circadian rhythmicity was assessed in 16 subjects through the measurement of aMT6s in urine samples collected hourly for 24-48 hours. Light intensity at the head of the bed was measured continuously.

MEASUREMENTS AND RESULTS

We analyzed 819.7 h of PSG recordings from 21 subjects. REM sleep was identified in only 2/21 subjects. Slow wave activity lacked the normal diurnal and ultradian periodicity and homeostatic decline found in healthy adults. In nearly all patients, SEF₉₅ was consistently low without evidence of diurnal rhythmicity (median 6.3 [5.3, 7.8] Hz, n = 18). A circadian rhythm of aMT6s excretion was present in most (13/16, 81.3%) patients, but only 4 subjects had normal timing. Comparison of the SEF₉₅ during the melatonin-based biological night and day revealed no difference between the 2 periods (P = 0.64).

CONCLUSIONS

The circadian rhythms and PSG of patients receiving mechanical ventilation and intravenous sedation exhibit pronounced temporal disorganization. The finding that most subjects exhibited preserved, but phase delayed, excretion of aMT6s suggests that the circadian pacemaker of such patients may be free-running.

Incorporating the treatment of medical and psychiatric disorders in the critical care area

Critical care areas are fast moving, often chaotic, and therefore confusing, even frightening, to patients attempting to understand what has happened to them. The nurse acts to mitigate these reactions by understanding the range of possibilities that can occur with patients, including potential psychiatric issues, and serving as patient advocate to ensure that appropriate treatment is initiated. Certainly there may be other psychiatric problems not described in the preceding text. The main possibilities are covered in this article. Assessing and acting early are tools the critical care nurse uses to meet patient needs and prevent behavioral problems that can interfere with life-preserving care.

Sleep disturbances and sedation practices in the intensive care unit--a postal survey in the Netherlands

BACKGROUND

Sleep disturbances are common in critically ill patients treated in the intensive care unit (ICU) with possible serious consequences.

OBJECTIVE

The aim of this study was to get insight into sleeping and sedation practices in the adult ICUs in the Netherlands and survey which factors are important with respect to sleep in critically ill patients in the ICU.

METHOD

A multi-centre, exploratory survey sent via mail to nurse managers of all adult ICUs in the Netherlands.

RESULTS

Interventions without medication to improve the sleep of the critically ill patients were mostly defined as keeping patients awake during the day (94.2%), reducing noise of the ICU staff (89.7%) and reducing nursing interventions at night (86.8%). None of the ICUs used a sleep questionnaire. Nursing autonomy regarding sleep and sedation practices for patients (rated on a 10-point numerical scale) was judged as moderate (median 5, interquartile range (IQR) 3-7). How often nursing observations influence sleeping practices in the ICU was judged as good (median 8, IQR 7-8). How the average ICU patient was sleeping was judged as moderately well (median 6, IQR 5-7). Most intensive care units (83.8%) did not have a sleeping protocol, but 67.6% of these intensive care units suggested they should implement a sleeping protocol.

CONCLUSIONS

The average critically ill patient has sleep disturbances, that is, is sleeping moderately well according to nurses' views and opinions, mostly due to a disturbed sleep-awake cycle, delirium and nursing interventions. Intensive care nurses perceive only a moderate feeling of autonomy and influence regarding the management of sleeping practices.

Control of breathing during mechanical ventilation: who is the boss?

Over the past decade, concepts of control of breathing have increasingly moved from being theoretical concepts to "real world" applied science. The purpose of this review is to examine the basics of control of breathing, discuss the bidirectional relationship between control of breathing and mechanical ventilation, and critically assess the application of this knowledge at the patient's bedside. The principles of control of breathing remain under-represented in the training curriculum of respiratory therapists and pulmonologists, whereas the day-to-day bedside application of the principles of control of breathing continues to suffer from a lack of outcomes-based research in the intensive care unit. In contrast, the bedside application of the principles of control of breathing to ambulatory subjects with sleep-disordered breathing has out-stripped that in critically ill patients. The evolution of newer technologies, faster real-time computing abilities, and miniaturization of ventilator technology can bring the concepts of control of breathing to the bedside and benefit the critically ill patient. However, market forces, lack of scientific data, lack of research funding, and regulatory obstacles need to be surmounted.

[Sedation and analgesia in intensive care: physiology and application]

Many therapeutic and diagnostic procedures in intensive care medicine are perceived as painful by most patients. As a consequence analgesia and sedation represent two of the main pillars in the treatment of the critically ill. Adaptation to the individual needs of the patients poses one of the biggest challenges that we are confronted with. Both morbidity and mortality can be positively influenced by adequate treatment. In the first part of this review we will discuss the physiology of sleep patterns and pain. Furthermore modes of action and side effects of the most common anesthetics and analgetics will be presented. Finally, the last part of the manuscript deals with the practical application of these therapeutics and their monitoring in intensive care medicine.