1
|
Rajamani A, Subramaniam A, Lung B, Masters K, Gresham R, Whitehead C, Lowrey J, Seppelt I, Kumar H, Kumar J, Hassan A, Orde S, Bharadwaj PA, Arvind H, Huang S. Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients. CRIT CARE RESUSC 2023; 25:216-222. [PMID: 38234321 PMCID: PMC10790007 DOI: 10.1016/j.ccrj.2023.10.012] [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: 09/26/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. Design Single-center, open-labelled, pRCT with blinded analysis. Setting Australian tertiary intensive care unit (ICU). Participants Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. Interventions Open-label fentanyl and remifentanil infusions per existing ICU protocols. Outcomes Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results 208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). Conclusions We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.
Collapse
Affiliation(s)
- Arvind Rajamani
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW 2747, Australia
| | | | - Brian Lung
- Department of Anaesthesia, Nepean Hospital, Kingswood, NSW 2747, Australia
| | - Kristy Masters
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Rebecca Gresham
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Christina Whitehead
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Julie Lowrey
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
- Faculty of Medicine, University of Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Hemant Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Jayashree Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Anwar Hassan
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | | | | | - Stephen Huang
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
| | | |
Collapse
|
2
|
Schmidt D, Piva TC, Glaeser SS, Piekala DM, Berto PP, Friedman G, Sbruzzi G. Intensive Care Unit-Acquired Weakness in Patients With COVID-19: Occurrence and Associated Factors. Phys Ther 2022; 102:6540311. [PMID: 35233607 PMCID: PMC8903454 DOI: 10.1093/ptj/pzac028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/14/2021] [Accepted: 01/08/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The primary objective of this study was to identify the occurrence and factors associated with intensive care unit (ICU)-acquired weakness (ICUAW) in patients with COVID-19. Secondarily, we monitored the evolution of muscle strength and mobility among individuals with ICUAW and those without ICUAW and the association of these variables with length of stay, mechanical ventilation (MV), and other clinical variables. METHODS In this prospective observational study, individuals admitted to the ICU for >72 hours with COVID-19 were evaluated for muscle strength and mobility at 3 times: when being weaned from ventilatory support, discharged from the ICU, and discharged from the hospital. Risk factors for ICUAW were monitored. RESULTS The occurrences of ICUAW at the 3 times evaluated among the 75 patients included were 52%, 38%, and 13%. The length of the ICU stay (29.5 [IQR = 16.3-42.5] vs 11 [IQR = 6.5-16] days), the length of the hospital stay (43.5 [IQR = 22.8-55.3] vs 16 [IQR = 12.5-24] days), and time on MV (25.5 [IQR = 13.8-41.3] vs 10 [IQR = 5-22.5] days) were greater in patients with ICUAW. Muscle strength and mobility were lower at all times assessed in patients with ICUAW. Bed rest time for all patients (relative risk = 1.14; 95% CI = 1.02 to 1.28) and use of corticosteroids (relative risk = 1.01; 95% CI = 1.00 to 1.03) for those who required MV were factors independently associated with ICUAW. Muscle strength was found to have a positive correlation with mobility and a negative correlation with lengths of stay in the ICU and hospital and time on MV. CONCLUSION The occurrence of ICUAW was high on patients' awakening in the ICU but decreased throughout hospitalization; however, strength and mobility remained compromised at hospital discharge. Bed rest time and use of corticosteroids (for those who needed MV) were factors independently associated with ICUAW in patients with COVID-19. IMPACT Patients who had COVID-19 and developed ICUAW had longer periods of ICU stay, hospital stay, and MV. Bed rest time and use of corticosteroids (for those who required MV) were factors independently associated with ICUAW.
Collapse
Affiliation(s)
- Débora Schmidt
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil,Postgraduate Program in Human Movement Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brasil,Address all correspondence to
| | - Taila Cristina Piva
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | - Sheila Suzana Glaeser
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | - Daniele Martins Piekala
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | | | - Gilberto Friedman
- Serviço de Medicina Intensiva, HCPA, Porto Alegre, Rio Grande do Sul, Brasil
| | - Graciele Sbruzzi
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil,Postgraduate Program in Human Movement Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brasil
| |
Collapse
|
3
|
Harrold ME, Salisbury LG, Webb SA, Allison GT. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:336. [PMID: 26370550 PMCID: PMC4570617 DOI: 10.1186/s13054-015-1033-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 08/14/2015] [Indexed: 01/07/2023]
Abstract
Introduction Mobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses. Methods The objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU. Results Ten tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers. Conclusions This is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.
Collapse
Affiliation(s)
- Meg E Harrold
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, 6845, Australia. .,Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia.
| | - Lisa G Salisbury
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK.
| | - Steve A Webb
- Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia. .,Department of Medicine and Pharmacology, University of Western Australia, Perth, Australia.
| | - Garry T Allison
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, 6845, Australia. .,Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia.
| | | |
Collapse
|
4
|
Beeton A. Quoted ERCP: sedation or general anaesthesia? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2011.10872755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
5
|
Abstract
Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner.
Collapse
Affiliation(s)
- Jun Gwon Choi
- Department of Anesthesiology and Pain Medicine, Ilsan Hospital, Dongguk University Medical Center, Goyang, Korea
| |
Collapse
|
6
|
Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013; 39:910-8. [PMID: 23344834 PMCID: PMC3625407 DOI: 10.1007/s00134-013-2830-2] [Citation(s) in RCA: 225] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 12/22/2012] [Indexed: 11/29/2022]
Abstract
Purpose To ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality. Methods We conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients (n = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤−3. Results The cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients (P < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89–0.97, P = 0.003], hospital death (HR 1.11, 95 % CI 1.05–1.18, P < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04–1.15, P = 0.002), but not time to delirium (HR 0.98, P = 0.23). Delirium occurred in 114 (44 %) of patients. Conclusion Irrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.
Collapse
|
7
|
Perpiñá-Galvañ J, Richart-Martínez M. Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: a review. Am J Crit Care 2009; 18:571-80. [PMID: 19880959 DOI: 10.4037/ajcc2009682] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To review studies of anxiety in critically ill patients admitted to an intensive care unit to describe the level of anxiety and synthesize the psychometric properties of the instruments used to measure anxiety. METHODS The CUIDEN, IME, ISOC, CINAHL, MEDLINE, and PSYCINFO databases for 1995 to 2005 were searched. The search focused on 3 concepts: anxiety, intensive care, and mechanical ventilation for the English-language databases and ansiedad, cuidados intensivos, and ventilación mecánica for the Spanish-language databases. Information was extracted from 18 selected articles on the level of anxiety experienced by patients and the psychometric properties of the instruments used to measure anxiety. RESULTS Moderate levels of anxiety were reported. Levels were higher in women than in men, and higher in patients undergoing positive pressure ventilation regardless of sex. Most multi-item instruments had high coefficients of internal consistency. The reliability of instruments with only a single item was not demonstrated, even though the instruments had moderate-to-high correlations with other measurements. CONCLUSION Midlength scales, such the anxiety subscale of the Brief Symptom Inventory or the shortened state version of the State-Trait Anxiety Inventory are best for measuring anxiety in critical care patients.
Collapse
Affiliation(s)
- Juana Perpiñá-Galvañ
- Juana Perpiñá-Galvañ is a registered nurse with a master of science degree in nursing and Miguel Richart-Martínez is a doctor in psychology in the Nursing Department, Universidad de Alicante, Alicante, Spain
| | - Miguel Richart-Martínez
- Juana Perpiñá-Galvañ is a registered nurse with a master of science degree in nursing and Miguel Richart-Martínez is a doctor in psychology in the Nursing Department, Universidad de Alicante, Alicante, Spain
| |
Collapse
|