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Matsuura Y, Ohno Y, Toyoshima M, Ueno T. Effects of non-pharmacologic prevention on delirium in critically ill patients: A network meta-analysis. Nurs Crit Care 2023; 28:727-737. [PMID: 35624556 DOI: 10.1111/nicc.12780] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 04/22/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Delirium is a common complication among patients in the intensive care unit (ICU). It is important to prevent the occurrence of delirium in critically ill patients. AIM This review aimed to evaluate the efficacy of non-pharmacological interventions and determine what combination of these is effective in preventing delirium among Intensive Care Unit patients. STUDY DESIGN A systematic review and meta-analysis. This review follows the guidelines of the Preferred Reporting Items for Systematic reviews and Meta Analysis statements for Network Meta-Analysis (PRISMA-NMA). Data sources included the Cumulative Index to Nursing & Allied Health Literature., MEDLINE, and Cochrane library databases. The integrated data were investigated with odds ratio (OR) and 95% confidence interval (95% CI), using the random-effects Mantel-Haenszel model. Data were considered significant when p < 0.05. Furthermore, to reveal what combination of care is effective, we performed a network meta-analysis estimated OR, 95% CI. RESULTS We identified three randomized controlled trials and eight controlled before-after trials (11 in total, with 2549 participants). The pooled data from 11 trials of multicomponent intervention had a significant effect on delirium prevention (OR 0.58, 95% CI 0.44-0.76, p < 0.001). As a result of network meta-analysis, two bundles were effective compared to the control group in reducing the incidence of delirium: a) the combination of sleep promotion (SP), cognitive stimulation (CS), early mobilization (EM), pain control (PC), and assessment (AS) (OR 0.47, 95% CI 0.35-0.64, p < 0.002), and b) the combination of SP and CS (OR 0.46, 95% CI 0.28-0.75, p < 0.001). CONCLUSION This study revealed that non-pharmacological interventions, particularly multicomponent interventions, helped to prevent delirium in critically ill patients. In the network meta-analysis, the most effective care combination for reducing incidence of delirium was found to be multicomponent intervention, which comprises SP-CS-EM-PC-AS, and SP-CS. RELEVANCE TO CLINICAL PRACTICE These findings reveal an efficient combination of multicomponent interventions for preventing delirium, which may be a very important prerequisite in planning care programs in the future.
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Affiliation(s)
- Yutaka Matsuura
- Division of Nursing, Mie University Graduate School of Medicine, Tsu, Japan
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuko Ohno
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
| | - Miki Toyoshima
- Department of Intensive Care Unit, Osaka City General Hospital, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
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2
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Jarman A, Chapman K, Vollam S, Stiger R, Williams M, Gustafson O. Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis. J Intensive Care Soc 2023; 24:85-95. [PMID: 36874288 PMCID: PMC9975810 DOI: 10.1177/17511437221103689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62-1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.
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Affiliation(s)
- Annika Jarman
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keeleigh Chapman
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Sarah Vollam
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Robyn Stiger
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Mark Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Owen Gustafson
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
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3
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Nydahl P, Jeitziner MM, Vater V, Sivarajah S, Howroyd F, McWilliams D, Osterbrink J. Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis. Intensive Crit Care Nurs 2022. [DOI: 10.1016/j.iccn.2022.103334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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4
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2022; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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5
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Rahiminezhad E, Sadeghi M, Ahmadinejad M, Mirzadi Gohari SI, Dehghan M. A randomized controlled clinical trial of the effects of range of motion exercises and massage on muscle strength in critically ill patients. BMC Sports Sci Med Rehabil 2022; 14:96. [PMID: 35619171 PMCID: PMC9134983 DOI: 10.1186/s13102-022-00489-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
Background Atrophy and muscle weakness is a common problem in critically ill patients admitted to the intensive care unit (ICU). Muscle weakness in severe cases can lead to tetraplegia, reduced or lost tendon reflexes, delayed weaning from mechanical ventilation, physical disability, and increased mortality. The aim of this study was to compare the effects of range of motion exercises (ROM) and massage on muscle strength of the patients admitted to ICUs.
Methods This study was a single-blinded randomized controlled trial conducted in ICUs of Afzalipour hospital in Kerman, southeastern Iran. Ninety conscious ICU patients were randomly divided into three groups (massage, ROM exercises and control). The researcher/co-researcher massaged or did ROM exercises on the patients’ extremities once a day for seven consecutive days. Using a hand-held dynamometer, the co-researcher, rated the muscle strength before, on the fourth and seventh days of intervention at 8 p.m. Results The mean muscles strength of the right arm in the ROM exercise and massage groups increased by 0.63 kg, and 0.29 kg, respectively after the intervention compared with before the intervention. The muscle strength of the right arm in the control group reduced by 0.55 kg. The mean muscles strength of the left arm in the ROM exercise and massage groups increased by 0.61 kg and 0.28 kg after the intervention, respectively while it reduced by 0.56 kg in the control group. The mean muscles strength of the right leg in the ROM exercise and massage groups increased by 0.53 kg and 0.27 kg after the intervention compared with before the intervention while it reduced by 0.70 kg in the control group. The mean muscles strength of the left leg in the ROM exercise and massage groups increased by 0.54 kg and 0.26 kg after the intervention compared with before the intervention while it reduced by 0.71 kg in the control group. Conclusion The results of the present study showed that ROM exercises and massage were effective interventions in increasing muscle strength of the critically ill patients admitted to intensive care units. Supplementary Information The online version contains supplementary material available at 10.1186/s13102-022-00489-z.
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Affiliation(s)
- Elham Rahiminezhad
- Department of Critical Care Nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Sadeghi
- Department of Physical Therapy, Faculty of Allied Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Ahmadinejad
- Department of Anesthesiology, Shahid Bahonar Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Mahlagha Dehghan
- Department of Critical Care Nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran. .,Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran.
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6
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Chen TJ, Traynor V, Wang AY, Shih CY, Tu MC, Chuang CH, Chiu HY, Chang HC(R. Comparative Effectiveness of Non-Pharmacological Interventions for Preventing Delirium in Critically Ill Adults: A Systematic Review and Network Meta-Analysis. Int J Nurs Stud 2022; 131:104239. [DOI: 10.1016/j.ijnurstu.2022.104239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
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7
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Sheard KL, Lape JE, Weissberg K. Occupational Therapy-Led Delirium Management in Long-Term Acute Care: A Pilot. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2022. [DOI: 10.1080/02703181.2022.2043983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kendra L. Sheard
- Occupational Therapy Department, UVA Transitional Care Hospital, Charlottesville, Virginia, USA
| | - Jennifer E. Lape
- Occupational Therapy Department, Chatham University, Pittsburgh, Pennsylvania, USA
| | - Kathleen Weissberg
- Occupational Therapy Department, Chatham University, Pittsburgh, Pennsylvania, USA
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8
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NURSING INTERVENTIONS IN THE MANAGEMENT OF COVID-19-RELATED DELIRIUM IN INTENSIVE CARE UNITS: LITERATURE REVIEW. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2021. [DOI: 10.33457/ijhsrp.845184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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9
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Liang S, Chau JPC, Lo SHS, Li S, Gao M. Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey. Nurs Crit Care 2021; 26:386-396. [PMID: 33522036 DOI: 10.1111/nicc.12597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China. AIMS AND OBJECTIVES To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China. DESIGN A cross-sectional study was conducted. METHODS A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China. RESULTS Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families. CONCLUSIONS Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged. RELEVANCE TO CLINICAL PRACTICE Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.
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Affiliation(s)
- Surui Liang
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Janita Pak Chun Chau
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shunling Li
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mingrong Gao
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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10
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Burry LD, Cheng W, Williamson DR, Adhikari NK, Egerod I, Kanji S, Martin CM, Hutton B, Rose L. Pharmacological and non-pharmacological interventions to prevent delirium in critically ill patients: a systematic review and network meta-analysis. Intensive Care Med 2021; 47:943-960. [PMID: 34379152 PMCID: PMC8356549 DOI: 10.1007/s00134-021-06490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/19/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the effects of prevention interventions on delirium occurrence in critically ill adults. METHODS MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects. RESULTS Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials, N = 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha2 agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21-0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08-0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06-0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10-0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09-0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64-0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61-0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care. CONCLUSION Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
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Affiliation(s)
- Lisa D. Burry
- grid.416166.20000 0004 0473 9881Department of Pharmacy, Mount Sinai Hospital, Room 18-377, 600 University Avenue, Toronto, ON M5G 1X5 Canada ,grid.416166.20000 0004 0473 9881Department Medicine, Mount Sinai Hospital, Toronto, Canada ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Wei Cheng
- grid.47100.320000000419368710Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - David R. Williamson
- grid.14848.310000 0001 2292 3357Pharmacy Department, Université de Montréal, Montréal, Canada ,grid.414056.20000 0001 2160 7387Pharmacy Department and Research Centre, CIUSSS-NIM Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Neill K. Adhikari
- grid.413104.30000 0000 9743 1587Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Ingrid Egerod
- grid.475435.4Intensive Care Unit 4131, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark
| | - Salmaan Kanji
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - Claudio M. Martin
- grid.412745.10000 0000 9132 1600Division of Critical Care, London Health Sciences Centre, London, Canada ,grid.39381.300000 0004 1936 8884Department of Medicine, The University of Western Ontario, London, Canada
| | - Brian Hutton
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Louise Rose
- grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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11
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Liang S, Chau JPC, Lo SHS, Zhao J, Choi KC. Effects of nonpharmacological delirium-prevention interventions on critically ill patients' clinical, psychological, and family outcomes: A systematic review and meta-analysis. Aust Crit Care 2020; 34:378-387. [PMID: 33250403 DOI: 10.1016/j.aucc.2020.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Delirium is common in critically ill patients and may lead to severe complications, such as falls and injuries. Nonpharmacological interventions have been widely suggested to prevent delirium, yet the effects remain uncertain. OBJECTIVES The aim of the study was to determine the effects of nonpharmacological interventions on preventing delirium and improving critically ill patients' clinical, psychological, and family outcomes. METHODS Ten databases were searched from their inception to September 2020. Two reviewers assessed the methodological quality and extracted details of the included studies. The data were narratively or statistically pooled where appropriate. Dichotomous variables are presented as odds ratio (OR), and continuous variables are presented as mean difference (MD). The Grading of Recommendations Assessment, Development, and Evaluation criteria were used to assess the quality of evidence for each review outcome. RESULTS Thirty-four studies (10 randomised controlled trials, eight controlled clinical trials, and 16 before-and-after studies) were included in the analysis. Low-certainty evidence indicated that nonpharmacological interventions reduced delirium incidence (OR = 0.43, 95% confidence interval [CI] [0.33, 0.55]), delirium duration (MD = -1.43 days, 95% CI [-1.94, 0.92]), and length of stay in the intensive care unit (MD = -1.24 days, 95% CI [-2.05, -0.43]). Moderate-certainty evidence demonstrated no effect on mortality. Narrative synthesis further implied improvements in patients' psychological recovery (two studies, very low-certainty evidence) and families' satisfaction with care (two studies, very low-certainty evidence) through nonpharmacological interventions. As for effective intervention types, moderate-certainty evidence demonstrates that early mobilisation (OR = 0.33, 95% CI [0.24, 0.46], five studies, 859 participants, I2 = 24%), family participation (OR = 0.25, 95% CI [0.18, 0.34], four studies, 997 participants, I2 = 21%), and use of multicomponent interventions (OR = 0.48, 95% CI [0.34, 0.69], 13 studies, 3172 participants, I2 = 77%) are associated with reduced incidence of delirium. CONCLUSIONS Healthcare professionals are recommended to apply early mobilisation, family participation, or multicomponent interventions in clinical practice to prevent delirium. Further studies investigating the effects of nonpharmacological interventions on patients' psychological and family outcomes are warranted.
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Affiliation(s)
- Surui Liang
- The Nethersole School of Nursing, 6/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region
| | - Janita Pak Chun Chau
- The Nethersole School of Nursing, 8/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region.
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, 8/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region
| | - Jie Zhao
- The Nethersole School of Nursing, 6/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region
| | - Kai Chow Choi
- The Nethersole School of Nursing, 7/F, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Special Administrative Region
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12
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2020; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 08/26/2023] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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13
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Cupka JS, Hashemighouchani H, Lipori J, Ruppert MM, Bhaskar R, Ozrazgat-Baslanti T, Rashidi P, Bihorac A. The effect of non-pharmacologic strategies on prevention or management of intensive care unit delirium: a systematic review. F1000Res 2020; 9:1178. [PMID: 36110837 PMCID: PMC9449425 DOI: 10.12688/f1000research.25769.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 08/01/2023] Open
Abstract
Background: Post-operative delirium is a common complication among adult patients in the intensive care unit. Current literature does not support the use of pharmacologic measures to manage this condition, and several studies explore the potential for the use of non-pharmacologic methods such as early mobility plans or environmental modifications. The aim of this systematic review is to examine and report on recently available literature evaluating the relationship between non-pharmacologic management strategies and the reduction of delirium in the intensive care unit. Methods: Six major research databases were systematically searched for articles analyzing the efficacy of non-pharmacologic delirium interventions in the past five years. Search results were restricted to adult human patients aged 18 years or older in the intensive care unit setting, excluding terminally ill subjects and withdrawal-related delirium. Following title, abstract, and full text review, 27 articles fulfilled the inclusion criteria and are included in this report. Results: The 27 reviewed articles consist of 12 interventions with a single-component investigational approach, and 15 with multi-component bundled protocols. Delirium incidence was the most commonly assessed outcome followed by duration. Family visitation was the most effective individual intervention while mobility interventions were the least effective. Two of the three family studies significantly reduced delirium incidence, while one in five mobility studies did the same. Multi-component bundle approaches were the most effective of all; of the reviewed studies, eight of 11 bundles significantly improved delirium incidence and seven of eight bundles decreased the duration of delirium. Conclusions: Multi-component, bundled interventions were more effective at managing intensive care unit delirium than those utilizing an approach with a single interventional element. Although better management of this condition suggests a decrease in resource burden and improvement in patient outcomes, comparative research should be performed to identify the importance of specific bundle elements.
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Affiliation(s)
- Julie S Cupka
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Haleh Hashemighouchani
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Jessica Lipori
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Ria Bhaskar
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Tezcan Ozrazgat-Baslanti
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
| | - Parisa Rashidi
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32608, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, 32608, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, 32608, USA
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14
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Deng LX, Cao L, Zhang LN, Peng XB, Zhang L. Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis. J Crit Care 2020; 60:241-248. [PMID: 32919363 DOI: 10.1016/j.jcrc.2020.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare non-pharmacological interventions in their ability to prevent delirium in critically ill patients, and find the optimal regimen for treatment. METHODS Literature searches were conducted using PubMed, Embase, CINAHL, and Cochrane Library databases until the end of June 2019. We estimated the risk ratios (RRs) for the incidence of delirium and in-hospital mortality and found the mean difference (MD) for delirium duration and the length of ICU stay. The probabilities of interventions were ranked based on clinical outcomes. The study was registered on PROSPERO (CRD42020160757). RESULTS Twenty-six eligible studies were included in the network meta-analysis. Studies were grouped into seven intervention types: physical environment intervention (PEI), sedation reducing (SR), family participation (FP), exercise program (EP), cerebral hemodynamics improving (CHI), multi-component studies (MLT) and usual care (UC). In term of reducing the incidence of delirium, the two most effective interventions were FP (risk ratio (RR) 0.19, 95% confidence interval (CI) 0.08 to 0.44; surface under the cumulative ranking curve (SUCRA) = 94%) and MLT (RR 0.43, 95% CI 0.30 to 0.57; SUCRA = 68%) compared with observation. Although all interventions demonstrated nonsignificant efficacy in regards to delirium duration and the length of the patient's stay in the ICU, MLT (SUCRA = 78.6% and 71.2%, respectively) was found to be the most effective intervention strategy. In addition, EP (SUCRA = 97.2%) facilitated a significant reduction in hospital mortality, followed in efficacy by MLT (SUCRA = 73.2%), CHI (SUCRA = 35.8%), PEI (SUCRA = 34.8%), and SR (SUCRA = 31.8%). CONCLUSIONS Multi-component strategies are overall the optimal intervention techniques for preventing delirium and reducing ICU length of stay in critically ill patients by way of utilizing several interventions simultaneously. Additionally, family participation as a method of patient-centered care resulted in better outcomes for reducing the incidence of delirium.
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Affiliation(s)
- Lu-Xi Deng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China.
| | - Lan Cao
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, China.
| | - Li-Na Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
| | - Xiao-Bei Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
| | - Lei Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, China
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15
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Haley MN, Casey P, Kane RY, Dārziņš P, Lawler K. Delirium management: Let's get physical? A systematic review and meta‐analysis. Australas J Ageing 2019; 38:231-241. [DOI: 10.1111/ajag.12636] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 12/21/2022]
Affiliation(s)
| | - Penelope Casey
- Eastern Health and Eastern Health Clinical SchoolFaculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
| | - Richard Youlten Kane
- Eastern Health and Eastern Health Clinical SchoolFaculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
| | - Pēteris Dārziņš
- Eastern Health and Eastern Health Clinical SchoolFaculty of Medicine, Nursing and Health SciencesMonash University Melbourne Victoria Australia
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16
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Bannon L, McGaughey J, Verghis R, Clarke M, McAuley DF, Blackwood B. The effectiveness of non-pharmacological interventions in reducing the incidence and duration of delirium in critically ill patients: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1-12. [PMID: 30506354 DOI: 10.1007/s00134-018-5452-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/03/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the effect of non-pharmacological interventions versus standard care on incidence and duration of delirium in critically ill patients. METHODS We searched electronic and grey literature for randomised clinical trials up to March 2018. Two reviewers independently screened, selected and extracted data. Meta-analysis was undertaken using random effects modelling. RESULTS We identified 15 trials (2812 participants). Eleven trials reported incidence of delirium. Pooled data from four trials of bright light therapy showed no significant effect between groups (n = 829 participants, RR 0.45, 99% CI 0.10-2.13, P = 0.19, very low quality evidence). Seven trials of various individual interventions also failed to report any significant effects. A total of eight trials reported duration of delirium. Pooled data from two trials of multicomponent physical therapy showed no significant effect [n = 404 participants, MD (days) - 0.65, 99% CI - 2.73 to 1.44, P = 0.42, low quality of evidence]. Four trials of various individual interventions also reported no significant effects. A trial of family voice reorientation showed a beneficial effect [n = 30, MD (days) - 1.30, 99% CI - 2.41 to - 0.19, P = 0.003, very low quality evidence]. CONCLUSIONS Current evidence does not support the use of non-pharmacological interventions in reducing incidence and duration of delirium in critically ill patients. Future research should consider well-designed and well-described multicomponent interventions and include adequately defined outcome measures.
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Affiliation(s)
- Leona Bannon
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK.
| | - Jennifer McGaughey
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Rejina Verghis
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Winkelman C, Sattar A, Momotaz H, Johnson KD, Morris P, Rowbottom JR, Thornton JD, Feeney S, Levine A. Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter? Biol Res Nurs 2018; 20:522-530. [PMID: 29902939 PMCID: PMC6346319 DOI: 10.1177/1099800418780492] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. DESIGN Randomized interventional study with repeated measures and blinded assessment of outcomes. SETTING Four adult intensive care units (ICUs) in two academic medical centers. SUBJECTS Fifty-four patients with > 48 hr of mechanical ventilation (MV). INTERVENTION Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. MEASUREMENTS Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. MAIN RESULTS Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. CONCLUSION Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.
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Affiliation(s)
- Chris Winkelman
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA,Chris Winkelman, RN, PhD, CCRN, ACNP, FCCM, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA.
| | - Abdus Sattar
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Hasina Momotaz
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Peter Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky HealthCare System, Lexington, KY, USA
| | - James R. Rowbottom
- Department of Anesthesiology and Perioperative Medicine, University Hospitals, Cleveland Medical Center, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Alan Levine
- Department of Pharmacology, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Hyde-Wyatt J. Prevention, recognition and management of delirium in patients who are critically ill. Nurs Stand 2017; 32:41-52. [PMID: 29094525 DOI: 10.7748/ns.2017.e10667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/09/2022]
Abstract
Delirium is common in patients who are critically ill, often resulting in extended hospital stays and increased mortality and morbidity. There are several subtypes of delirium, which are often undiagnosed and untreated, resulting in suboptimal patient outcomes. This article examines delirium in patients in the intensive care unit, including its signs and symptoms, incidence, causes and subtypes. It outlines the assessment of delirium and the pharmacological and non-pharmacological interventions that can be used to manage the condition, as well as describing the optimal prevention measures.
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Affiliation(s)
- Jaime Hyde-Wyatt
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe, England
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