Mutual relationship between anxiety and pain in the intensive care unit and its effect on medications

The relationship between pain, anxiety and depression in patients with post-intensive care syndrome

PURPOSE

Survivors of critical illness frequently experience long-term symptoms including physical symptoms such as pain and emotional symptoms such as anxiety and depression. These symptoms frequently co-exist, however, at present there is limited understanding of these relationships. The aim of this study was to quantify the relationship between pain, anxiety and depression across the recovery trajectory.

METHODS

This study is a secondary analysis of data from a multi-centre, prospective, cohort study which followed-up patients recovering from critical illness. Data was available at multiple time points and for 3 distinct cohorts. Structural equation modelling was used to investigate the relationship between outcome measures of pain, anxiety and depression.

RESULTS

Data from 414 patients was analysed. Pain was significantly associated with both anxiety and depression in all cohorts and at all time points sampled. Path coefficients for the covariances between pain and depression ranged between 0.39 and 0.72 (p < 0.01). Path coefficients for the covariances between pain and anxiety ranged between 0.39 and 0.65 (p < 0.01).

CONCLUSIONS

Pain, anxiety and depression are highly correlated in survivors of critical illness. Pharmacological treatments for pain management may be ineffective alone and further research is required to assess interventions targeting these symptoms in combination.

Clinical Features of Delirium among Patients in the Intensive Care Unit According to Motor Subtype Classification: A Retrospective Longitudinal Study

PURPOSE

Delirium in the intensive care unit (ICU) poses a significant safety and socioeconomic burden to patients and caregivers. However, invasive interventions for managing delirium have severe drawbacks. To reduce unnecessary interventions during ICU hospitalization, we aimed to investigate the features of delirium among ICU patients according to the occurrence of hypoactive symptoms, which are not expected to require invasive intervention.

MATERIALS AND METHODS

Psychiatrists assessed all patients with delirium in the ICU during hospitalization. Patients were grouped into two groups: a "non-hypoactive" group that experienced the non-hypoactive motor subtype once or more or a "hypoactive only" group that only experienced the hypoactive motor subtype. Clinical variables routinely gathered for clinical management were collected from electronic medical records. Group comparisons and logistic regression analyses were conducted.

RESULTS

The non-hypoactive group had longer and more severe delirium episodes than the hypoactive only group. Although the non-hypoactive group was prescribed more antipsychotics and required restraints longer, the hypoactive only group also received both interventions. In multivariable logistic regression analysis, BUN [odds ratio (OR): 0.993, pH OR: 0.202], sodium (OR: 1.022), RASS score (OR: 1.308) and whether restraints were applied [OR: 1.579 (95% confidence interval 1.194-2.089), p<0.001] were significant predictors of hypoactive only group classification.

CONCLUSION

Managing and predicting delirium patients based on whether patients experienced non-hypoactive delirium may be clinically important. Variables obtained during the initial 48 hours can be used to determine which patients are likely to require invasive interventions.

Relationship between body mass index and risk of delirium in an intensive care unit

OBJECTIVE

Delirium in the intensive care unit (ICU) is a common and critical condition that leads to poor prognosis in older patients, but the association between body mass index (BMI) and the incidence of delirium remains unclear.

METHODS

We retrospectively analyzed 5,622 patients admitted to the ICU of a tertiary referral hospital between 2013 and 2022. We collected sociodemographic data, vital signs, laboratory results, and delirium scale scores. We subdivided the patients into four categories: underweight (<18.5 kg/m²), normal weight (18.5-22.9 kg/m²), overweight (23-24.9 kg/m²), and obese (>25 kg/m²). The primary outcome was the incidence of delirium according to the BMI categories. We performed multivariable logistic regression analysis, adjusted for sex, age, past smoking and alcohol history, benzodiazepine use, and laboratory abnormalities.

RESULTS

Among the 5,622 patients in the ICU (mean age, 72.9 years; male, 60.1%; mean BMI, 24.2 kg/m²⁾, the incidence of delirium was 19.0% (1,069 patients). The mean modified incidence of delirium was higher among underweight patients (odds ratio [OR]=1.51, confidence interval [CI]=1.07-2.12, p = 0.02) than among normal-weight patients. Overweight and obese status were not independently associated with delirium (OR=0.90, CI=0.70-1.17, p = 0.43; OR= 0.97; CI=0.77-1.21, p = 0.78, respectively). The area under the receiver-operating characteristic curve of the multivariable logistic regression model was 0.71 (95% CI=0.69-0.73).

CONCLUSIONS

Underweight status is an independent risk factor for delirium in the ICU. Additional caution is required when evaluating underweight patients for delirium. Obese or overweight status are not associated with delirium, providing evidence for the obesity paradox.

Virtually Augmented Self-Hypnosis in Peripheral Vascular Intervention: A Randomized Controlled Trial

PURPOSE

Hypnosis is useful for diminishing distress during medical procedures. This study investigated the efficacy of virtually augmented self-hypnosis as an adjunctive non-pharmacological method for procedural pain and anxiety relief during endovascular interventions (EVI).

METHODS

We compared an immersive distraction experience (clinicaltrials.gov identifier NCT04561596) featuring virtual reality (VR) using a head-mounted display versus treatment as usual (TAU). Patients followed the "Aqua" module (Oncomfort™) consisting of a scuba dive and breathing exercises. They experienced a self-induced dissociative state similar to clinical hypnosis without direct intervention of a professional. Enrollment followed a 1:1 randomized open study (VR or TAU). Patients' feelings were evaluated just before and after the procedure, and 3 months following intervention. Anxiety was evaluated using the State Trait Anxiety Inventory (STAI) and pain (sensory, emotional, and memory) with a visual analogue scale (VAS).

RESULTS

This study included 100 patients. Mean anxiety (pre-post) was significantly reduced within groups and between groups (difference of 4.2 points, p = 0.016). The percentage of responders to anxiety lowering were 76 and 46% for VR and TAU, respectively (p = 0.004). The two groups did not significantly differ in mean sensory-intensity and affective emotional pain (pre-post) using VAS, in negative memories concerning remembered pain at 3 months (difference > 1 from immediate post-procedural reported pain intensity), mean procedural time, or the need for analgesic or sedative drugs.

CONCLUSIONS

VR self-hypnosis has the potential to improve the management of patients' distress during radiological procedures. It is safe and effective for reducing anxiety during EVI.

The Relationship between Delirium and Statin Use According to Disease Severity in Patients in the Intensive Care Unit

Objective

The aim of this study was to investigate the association between the use of statins and the occurrence of delirium in a large cohort of patients in the intensive care unit (ICU), considering disease severity and statin properties.

Methods

We obtained clinical and demographical information from 3,604 patients admitted to the ICU from January 2013 to April 2020. This included information on daily statin use and delirium state, as assessed by the Confusion Assessment Method for ICU. We used inverse probability of treatment weighting and categorized the patients into four groups based on the Acute Physiology and Chronic Health Evaluation II score (group 1: 0-10 - mild; group 2: 11-20 - mild to moderate; group 3: 21-30 - moderate to severe; group 4: > 30 - severe). We analyzed the association between the use of statin and the occurrence of delirium in each group, while taking into account the properties of statins.

Results

Comparisons between statin and non-statin patient groups revealed that only in group 2, patients who were administered statin showed significantly higher occurrence of delirium (p = 0.004, odds ratio [OR] = 1.58) compared to the patients who did not receive statin. Regardless of whether statins were lipophilic (p = 0.036, OR = 1.47) or hydrophilic (p = 0.032, OR = 1.84), the occurrence of delirium was higher only in patients from group 2.

Conclusion

The use of statins may be associated with the increases in the risk of delirium occurrence in patients with mild to moderate disease severity, irrespective of statin properties.

Use of Virtual Reality for Reducing Pain and Anxiety After Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial

AIM

The present study aimed to evaluate the effect of virtual reality on pain and anxiety in patients who had undergone laparoscopic sleeve gastrectomy.

METHOD

The study was conducted between September 1, 2019, and December 31, 2019, in the surgical intensive care unit at a government hospital. The participants were 110 patients who met the inclusion criteria and agreed to participate in the study. According to the study procedure, while the control group received standard care, the intervention group watched a virtual reality video. Data were collected with a personal information form, the Numeric Pain Rating Scale, and the Faces Anxiety Scale.

RESULTS

The mean post-test Numeric Pain Rating Scale score was significantly lower in the intervention group than in the control group (p < .001). However, the mean Faces Anxiety Scale scores did not differ significantly between the groups (p = .087).

CONCLUSIONS

Virtual reality can effectively reduce pain and anxiety in patients who have undergone laparoscopic sleeve gastrectomy in intensive care units.

Potential Usefulness of Blood Urea Nitrogen to Creatinine Ratio in the Prediction and Early Detection of Delirium Motor Subtype in the Intensive Care Unit

Prediction and early detection of delirium can improve patient outcomes. A high blood urea nitrogen to creatinine ratio (BCR), which reflects dehydration, has been reported as a risk factor for delirium. Additionally, BCR represents skeletal muscle loss in intensive care unit (ICU) patients, which can have critical implications for clinical outcomes. We investigated whether BCR could be used to predict the occurrence and motor subtype of delirium in ICU patients through a retrospective cohort study that included 7167 patients (50 years or older) admitted to the ICU. Patients were assessed daily using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for ICU and categorized according to the delirium subtype. Participants were split into 10 groups according to BCR at ICU admission and the prevalence of each delirium subtype was compared. Multivariable logistic regression was then used for analysis. A higher BCR at ICU admission was associated with the development of hypoactive delirium. Moreover, BCR > 24.9 was associated with higher rates of hypoactive delirium. Our findings showed that a high BCR at ICU admission was associated with the development of hypoactive delirium, which suggested that BCR could be a potential biomarker for hypoactive delirium in ICU patients.

Delirium and Anxiety Outcomes Related to Visiting Policy Changes in the Intensive Care Unit During the COVID-19 Pandemic

Objective

To evaluate the effect of intensive care unit (ICU) visit on the incidence of delirium, delirium subtype, and anxiety level in ICU patients.

Methods

Trained psychiatrists and nurses evaluated ICU patients for delirium, delirium subtypes, and anxiety. Propensity score matching (PSM) was used to retrospectively analyze the data. Then, we compared the differences in the incidence of delirium, delirium subtypes, and anxiety level before and after the ICU visit ban. Logistic regression was conducted to identify the risk factors for delirium subtypes and high anxiety levels.

Results

After PSM, there was no statistically significant difference in the incidence of delirium between the non-visiting and restrictive visiting groups (non-visiting 27.4% versus restrictive visiting 30.9%, p = 0.162). The proportion of hyperactive and mixed subtypes was higher in the non-visiting than in the restrictive visiting group (non-visiting 35.3 and 30.1% versus restrictive visiting 27.7 and 20.1%, p = 0.002). The anxiety level was higher in the non-visiting than in the restrictive visiting group (state-trait anxiety inventory score: non-visiting 53.46 ± 4.58 versus restrictive visiting 52.22 ± 6.50, p = 0.009). Patients who stayed in the ICU during the visit ban were more likely to have hyperactive (p = 0.005) and mixed subtype (p = 0.001) than those who did not. Moreover, patients who stayed in the ICU during the visit ban were more likely to experience high anxiety levels than those who did not (p < 0.001).

Conclusion

Prohibition of ICU visits during COVID-19 pandemic did not affect the incidence of delirium during COVID-19 but could change the delirium subtype and raise anxiety level. Moreover, visiting prohibition was a risk factor for non-hypoactive delirium subtype and high anxiety levels. Therefore, ICU visits are important in dealing with delirium subtypes and anxiety in ICU patients.

Development and Validation of Simplified Delirium Prediction Model in Intensive Care Unit

BACKGROUND

The intensive care unit (ICU) is where various medical staffs and patients with diverse diseases convene. Regardless of complexity, a delirium prediction model that can be applied conveniently would help manage delirium in the ICU.

OBJECTIVE

This study aimed to develop and validate a generally applicable delirium prediction model in the ICU based on simple information.

METHODS

A retrospective study was conducted at a single hospital. The outcome variable was defined as the occurrence of delirium within 30 days of ICU admission, and the predictors consisted of a 12 simple variables. Two models were developed through logistic regression (LR) and random forest (RF). A model with higher discriminative power based on the area under the receiver operating characteristics curve (AUROC) was selected as the final model in the validation process.

RESULTS

The model was developed using 2,588 observations (training dataset) and validated temporally with 1,109 observations (test dataset) of ICU patients. The top three influential predictors of the LR and RF models were the restraint, hospitalization through emergency room, and drainage tube. The AUROC of the LR model was 0.820 (CI 0.801-0.840) and 0.779 (CI 0.748-0.811) in the training and test datasets, respectively, and that of the RF model was 0.762 (CI 0.732-0.792) and 0.698 (0.659-0.738), respectively. The LR model showed better discriminative power (z = 4.826; P < 0.001).

CONCLUSION

The LR model developed with brief variables showed good performance. This simplified prediction model will help screening become more accessible.

Scoping review of the use of virtual reality in intensive care units

BACKGROUND

A wide range of reviews have demonstrated the effectiveness and tolerability of Virtual Reality (VR) in a range of clinical areas and subpopulations. However, no previous review has explored the current maturity, acceptability, tolerability, and effectiveness of VR with intensive care patients.

AIMS

To identify the range of uses of VR for intensive care patients, classify their current phase of development, effectiveness, acceptability, and tolerability.

METHODS

A scoping review was conducted. A multi-database search was undertaken (inception to January 2021). Any type of study which examined the use of VR with the target application population of intensive care patients were included. Screening, data extraction, and assessment of quality were undertaken by a single reviewer. A meta-analysis and a descriptive synthesis were undertaken.

RESULTS

Six hundred and forty-seven records were identified, after duplicate removal and screening 21 studies were included (weak quality). The majority of studies for relaxation, delirium, and Post Traumatic Stress Disorder (PTSD) were at the early stages of assessing acceptability, tolerability, and initial clinical efficacy. Virtual Reality for relaxation and delirium were well-tolerated with completion rates of target treatment of 73.6%, (95% CI:51.1%-96%, I²  = 98.52%) 52.7% (95% CI:52.7%-100%, I²  = 96.8%). The majority of reasons for non-completion were due to external clinical factors. There were some potential benefits demonstrated for the use of VR for relaxation, delirium, and sleep.

CONCLUSION

Virtual Reality for intensive care is a new domain of research with the majority of areas of application being in the early stages of development. There is great potential for the use of VR in this clinical environment. Further robust assessment of effectiveness is required before any clinical recommendations can be made.

Authorized Agent-Controlled Analgesia for Pain Management in Critically Ill Adult Patients

BACKGROUND

Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent-controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults.

OBJECTIVE

To evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients.

METHODS

A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent-controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent-controlled analgesia. Authorized agent-controlled analgesia was administered by nurses only.

RESULTS

The mean (SD) change in pain score was -3.4 (2.0) (95% CI, -4.0 to -2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent-controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P < .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent-controlled analgesia initiation on pain scores remained significant (P < .001).

CONCLUSIONS

Use of authorized agent-controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

Use of music to enhance sleep and psychological outcomes in critically ill patients: a protocol for a systematic review and meta-analysis

INTRODUCTION

Music listening is used as a non-pharmacological intervention in various populations with positive results; however, evidence for its effect on sleep and psychological outcomes in critically ill patients remains unclear. It is essential to understand the impact of music listening for critically ill patients to optimise care and minimise the risk for harm. We will assess whether music listening improves sleep and psychological outcomes in critically ill patients.

METHODS AND ANALYSIS

We will systematically search scientific databases for relevant studies, including PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, ProQuest, the Cochrane Central Register of Controlled Trials, China Biological Medicine Database, China National Knowledge Infrastructure Library, Wan fang databases, VIP Database for Chinese Technical Periodicals and the Chinese Clinical Trial Registry. Databases will be searched for articles published from inception to 10 June 2020. Music therapy journals and reference lists in some articles will be hand-searched. Grey literature will also be searched. We will include randomised and quasi-randomised controlled trials that used music listening to improve sleep and psychological outcomes in critically ill patients. The primary outcomes will be sleep-related outcomes, and secondary outcomes will be anxiety and depression scores and physiological outcomes. Two reviewers will independently verify study eligibility and methodological quality; disagreements will be resolved by a third reviewer or through discussion. The risk of bias will be independently determined using the Cochrane Risk of Bias Tool. The Consolidated Standards of Reporting Trials checklist will be used to examine the quality of included papers. Data will be extracted from eligible studies by two researchers. RevMan V.5.3 will be used for meta-analysis.

ETHICS AND DISSEMINATION

This work will review existing trial data and will not introduce new patient data or interventions; therefore, ethics committee approval is not required. We will disseminate this protocol in a related peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019147202.

Tools for assessment of acute psychological distress in critical illness: A scoping review

OBJECTIVES

Patients' experience of psychological distress in the intensive care unit (ICU) is associated with adverse effects, reduced satisfaction, and delayed physical and psychological recovery. There are no specific guidelines for the assessment and management of acute psychological distress during hospitalisation in the ICU. We reviewed existing tools for the assessment of acute psychological distress in ICU patients, examined evidence on their metric properties, and identified potential gaps and methodological considerations.

METHOD

A scoping review based on literature searches (Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted as per current scoping review guidelines.

FINDINGS

Overall, 14 assessment tools were identified having been developed in diverse ICU settings. The identified tools assess mainly anxiety and depressive symptoms and ICU stressors, and investigators have reported various validity and reliability metrics. It was unclear whether available tools can be used in specific groups, such as noncommunicative patients and patients with delirium, brain trauma, stroke, sedation, and cognitive impairments.

CONCLUSION

Available tools have methodological limitations worth considering in future investigations. Given the high prevalence of psychiatric morbidity in ICU survivors, rigorously exploring the metric integrity of available tools used for anxiety, depressive, and psychological distress symptom assessment in the vulnerable ICU population is a practice and research priority.

RELEVANCE TO CLINICAL PRACTICE

These results have implications for the selection and implementation of psychological distress assessment methods as a means for promoting meaningful patient-centred clinical outcomes and humanising ICU care experiences.

Neutrophil-Lymphocyte Ratio as a Potential Biomarker for Delirium in the Intensive Care Unit

Background: Recognition and early detection of delirium in the intensive care unit (ICU) is essential to improve ICU outcomes. To date, neutrophil-lymphocyte ratio (NLR), one of inflammatory markers, has been proposed as a potential biomarker for brain disorders related to neuroinflammation. This study aimed to investigate whether NLR could be utilized in early detection of delirium in the ICU. Methods: Of 10,144 patients who admitted to the ICU, 1,112 delirium patients (DE) were included in the current study. To compare among inflammatory markers, NLR, C-reactive protein (CRP), and white blood cell (WBC) counts were obtained: the mean NLR, CRP levels, and WBC counts between the initial day of ICU admission and the day of initial delirium onset within DE were examined. The inflammatory marker of 1,272 non-delirium patients (ND) were also comparatively measured as a supplement. Further comparisons included a subgroup analysis based on delirium subtypes (non-hypoactive vs. hypoactive) or admission types (elective vs. emergent). Results: The NLR and CRP levels in DE increased on the day of delirium onset compared to the initial admission day. ND also showed increased CRP levels on the sixth day (the closest day to average delirium onset day among DE) of ICU admission compared to baseline, while NLR in ND did not show significant difference over time. In further analyses, the CRP level of the non-hypoactive group was more increased than that of the hypoactive group during the delirium onset. NLR, however, was more significantly increased in patients with elective admission than in those with emergent admission. Conclusion: Elevation of NLR was more closely linked to the onset of delirium compared to other inflammatory markers, indicating that NLR may play a role in early detection of delirium.

The Effect of Aromatherapy by Rose Essence on Anxiety and Physiological Indices of Conscious Patients Admitted at Intensive Care Units

Background: Anxiety in patients admitted at the Intensive Care Unit (ICU) is common and usually moderate or severe. Anxiety affects endocrine and physiological responses. Objectives: This study aimed to determine the effect of aromatherapy by rose essence on anxiety and physiological indices of conscious patients admitted at ICU. Methods: In this clinical trial, 60 conscious patients admitted at ICU wards in Ali Ibn Abi Talib Hospital of Rafsanjan were selected and randomly allocated into two groups of intervention and control. In the intervention group, three drops of 10% rose essence were poured on the gauze and placed 20 cm from the patients’ nose on their shirt, and the patients inhaled it for 20 minutes three times a day. In the control group, three drops of distilled water were used likewise. Data collection tools included Spielberger State-Trait Anxiety Inventory (STAI) and the demographic questionnaire. Data were analyzed using SPSS V.18. Results: According to the results, in the intervention group, the systolic and diastolic blood pressure significantly increased (paired t-test, P < 0.05) in the second time after the intervention and significantly decreased (paired t-test, P < 0.05) in the third time. The mean oxygen saturation of arterial blood also significantly increased in the second time in this group after the intervention (paired t-test, P = 0.001). However, there was no significant difference in anxiety score before and after the intervention in each group. Conclusions: Although aromatherapy using rose essence was statistically significant on some of the physiological indices of conscious patients in ICU, these differences were not clinically significant.

Nurse's Evaluation of a Pain Management Algorithm in Intensive Care Units

BACKGROUND

Many patients have memories of pain during intensive care unit stay. To improve pain management, practice guidelines recommend that pain management should be guided by routine pain assessment and suggest an assessment-driven, protocol-based, stepwise approach. This recommendation prompted the development of a pain-management algorithm.

AIM

Evaluate the feasibility and clinical utility of this algorithm.

DESIGN

A descriptive survey.

SETTINGS

One medical/surgical intensive care unit, one surgical intensive care unit, and one postanesthesia care unit at two hospitals in Norway.

PARTICIPANTS/SUBJECTS

Nurses working at the three units.

METHODS

A pain-management algorithm, including three pain assessment tools and a guide to pain assessment and pain management, was developed and implemented in three intensive care units. Nurses working at the three units (n = 129) responded to a questionnaire regarding the feasibility and clinical utility of the algorithm used.

RESULTS

Our results suggested that nurses considered the new pain-management algorithm to have relatively high feasibility, but somewhat lower clinical utility. Less than half of respondents thought that pain treatment in clinical practice had become more targeted using the tree pain-assessment tools (45%) and the algorithm for pain assessment and pain management (24%).

CONCLUSIONS

Pain-management algorithms may be appropriate and useful in clinical practice. However, to increase clinical utility and to achieve more targeted pain treatment, more focus on pain-treatment actions and reassessment of patients' pain is needed. Further focus in clinical practice on how to implement an algorithm and more focus on pain-treatment action and reassessment of patients' pain is needed.

The effects of noise levels on pain, anxiety, and sleep in patients

BACKGROUND

Intensive care is a noisy environment for patients and one that affects pain, anxiety levels, and sleep quality.

AIMS AND OBJECTIVES

To determine the relationship between noise levels and pain, anxiety, and sleep levels in patients in intensive care units.

DESIGN

A descriptive and observational study design was used.

METHODS

This study was conducted between June and December 2018 in a public hospital and included 111 patients admitted to surgical critical care for at least 24 hours. Three Benetech Gm1351 manual sound level metres were used to measure noise. A Patient Information Form, a pain Visual Analog Scale (VAS), the Spielberger State-Trait Anxiety Inventory, and the Richards Campbell Sleep Questionnaire (RCSQ) were used for data collection.

RESULTS

The mean age of the patients was 57.29 years. The mean noise level detected in the intensive care unit was 66.52 dB (dB). Patients' mean pain VAS score was 3.79 ± 1.72, the mean State Anxiety Inventory score was 39.74 ± 2.98, and the mean total RCSQ score was 25.10 ± 13.17. Our findings show that patients in the intensive care unit are exposed to high noise levels and that, while this has no effect on pain, it significantly impacts anxiety and quality of sleep.

CONCLUSIONS

Noise levels in intensive care units significantly exceed recommended thresholds, and this adversely affects patients' anxiety levels and sleep quality. It is important for suitably restful conditions to be provided for patients, to be aware of the potential for anxiety, and for these factors to be borne in mind when planning nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

Further studies on the effects of noise levels on pain, anxiety, and sleep levels in patients admitted to intensive care units are needed.

Psychogenic stress in hospitalized veterinary patients: Causation, implications, and therapies

OBJECTIVE

To review the sources, adverse effects, diagnosis, treatment, and prevention of psychogenic stress in hospitalized human and veterinary patients.

DATA SOURCES

Data were collected by searching PubMed for veterinary and human literature from the past 10 years.

HUMAN DATA SYNTHESIS

Psychogenic stress has been linked to immune suppression; gastrointestinal, cardiovascular, and cutaneous diseases; delayed wound healing; alterations in pain perception; and neurologic impairment. Sources of psychogenic stress include environmental alterations such as excessive noise and light, social and physical factors, sleep disruption, drugs, and underlying disease. Nonpharmacologic options for stress reduction include environmental and treatment modifications, music therapy, and early mobilization. Pharmacologic options include sedation with benzodiazepines and dexmedetomidine. Trazodone and melatonin have been examined for use in sleep promotion but are not currently recommended as standard treatments in ICU.

VETERINARY DATA SYNTHESIS

Activation of the stress response in veterinary patients is largely the same as in people, as are the affected body systems. Possible sources of stress can include social, physical, and environmental factors. No gold standard currently exists for the identification and quantification of stress. A combination of physical examination findings and the results of serum biochemistry, CBC, and biomarker testing can be used to support the diagnosis. Stress scales can be implemented to identify stressed patients and assess severity. Nonpharmacologic treatment options include low-stress handling, pheromones, environmental modifications, and sleep promotion. Pharmacologic options include trazodone, benzodiazepines, dexmedetomidine, and melatonin.

CONCLUSION

The prevalence and clinical significance of psychogenic stress in hospitalized veterinary patients is unknown. Future studies are needed to specifically examine the causative factors of psychogenic stress and the effects of various therapies on stress reduction. The recognition and reduction of psychogenic stress in veterinary patients can lead to improvements in patient care and welfare.

Prediction and early detection of delirium in the intensive care unit by using heart rate variability and machine learning

OBJECTIVE

Delirium is an important syndrome found in patients in the intensive care unit (ICU), however, it is usually under-recognized during treatment. This study was performed to investigate whether delirious patients can be successfully distinguished from non-delirious patients by using heart rate variability (HRV) and machine learning.

APPROACH

Electrocardiography data of 140 patients was acquired during daily ICU care, and HRV data were analyzed. Delirium, including its type, severity, and etiologies, was evaluated daily by trained psychiatrists. HRV data and various machine learning algorithms including linear support vector machine (SVM), SVM with radial basis function (RBF) kernels, linear extreme learning machine (ELM), ELM with RBF kernels, linear discriminant analysis, and quadratic discriminant analysis were utilized to distinguish delirium patients from non-delirium patients.

MAIN RESULTS

HRV data of 4797 ECGs were included, and 39 patients had delirium at least once during their ICU stay. The maximum classification accuracy was acquired using SVM with RBF kernels. Our prediction method based on HRV with machine learning was comparable to previous delirium prediction models using massive amounts of clinical information.

SIGNIFICANCE

Our results show that autonomic alterations could be a significant feature of patients with delirium in the ICU, suggesting the potential for the automatic prediction and early detection of delirium based on HRV with machine learning.

The Effects of a Delirium Notification Program on the Clinical Outcomes of the Intensive Care Unit: A Preliminary Pilot Study

Background

Delirium is common among intensive care unit (ICU) patients, so recent clinical guidelines recommended routine delirium monitoring in the ICU. But, its effect on the patient’s clinical outcome is still controversial. In particular, the effect of systems that inform the primary physician of the results of monitoring is largely unknown.

Methods

The delirium notification program using bedside signs and electronic chart notifications was applied to the pre-existing delirium monitoring protocol. Every patient was routinely evaluated for delirium, pain, and anxiety using validated tools. Clinical outcomes, including duration of delirium, ICU stay, and mortality were reviewed and compared for 3 months before and after the program implementation.

Results

There was no significant difference between the two periods of delirium, ICU stay, and mortality. However, anxiety, an important prognostic factor in the ICU survivor’s mental health, was significantly reduced and pain tended to decrease.

Conclusions

Increasing the physician’s awareness of the patient’s mental state by using a notification program could reduce the anxiety of ICU patients even though it may not reduce delirium. The results suggested that the method of delivering the results of monitoring was also an important factor in the success of the delirium monitoring program.

Delirium characteristics and outcomes in medical and surgical lnpatients: A subgroup analysis

PURPOSE

Persistent delirium can negatively affect patients, increase healthcare costs, and extend the length of hospital stays. This investigation was undertaken to explore associations between patient characteristics and delirium outcomes.

MATERIALS AND METHODS

Intensive care unit (ICU) and medical and surgical ward inpatients for whom psychiatric consultation was requested for delirium were included in this study. Delirium screening and ongoing assessments were conducted using the Confusion Assessment Method for ICU patients.

RESULTS

Postoperative delirium developing as a secondary complication following surgery was found to be of significantly longer duration and associated with greater length of hospitalization compared with postoperative delirium attributable to surgery and delirium in medical patients. Medical patients with delirium had lower delirium recovery rates at discharge compared with surgical patients.

CONCLUSIONS

The findings that patient type and timing of postoperative delirium are associated with differential delirium outcomes suggest that targeted screening and intervention approaches may be needed. Medical patients were more likely to be discharged before recovery from delirium compared with surgical patients. Differences in underlying chronic medical conditions may account for the observed differences in discharge condition between medical and surgical patients with delirium.

Comparison of the Effect of Open and Closed Endotracheal Suctioning Methods on Pain and Agitation in Medical ICU Patients: A Clinical Trial

Background

Endotracheal suctioning is a necessary procedure practiced by nurses in intensive care units to remove lung secretions. This procedure leads to higher oxygenation levels and reduced breathing difficulties. It also prevents atelectasis, pulmonary infections, and the accumulation of secretions.

Objectives

The present study aims to compare the effectiveness of open and closed endotracheal suction tube systems on pain and agitation in patients under mechanical ventilation.

Methods

A randomized controlled clinical trial was conducted in the general intensive care units of Khatam-ol-Anbia hospital and Sina hospital, Tehran, Iran, in 2015. In total, 60 patients who were qualified to be included in the study were randomly assigned to either the intervention group or the control group. When necessary, suction was carried out for each patient using the standard technique. The patients’ level of pain and agitation was measured in both groups at five stages (before, during, immediately after, 5 minutes after, and 15 minutes after the intervention) using the behavioral pain scale and the Richmond agitation sedation scale.

Results

Significant statistical differences in the pain and agitation at different times within each of the two groups were observed for both open and closed suction (P > 0.001). However, these changes at different times between the two groups was not significant (P < 0.05).

Conclusions

Although statistical differences were observed in the levels of pain and agitation in the two groups, the type of suction system did not have any effect on the level of pain and agitation of patients under mechanical ventilation. The researchers recommend that other studies with larger sample sizes should be carried out.

[Analgesia in intensive care medicine]

BACKGROUND

The administration of sedatives and analgesics on the intensive care unit (ICU) is routine daily practice. The correct discrimination between delirium, pain and anxiety or confusion is essential for the strategy and selection of medication. The correct pain therapy and sedation are essential for patient quality of life on the ICU and for the prognosis.

OBJECTIVE

The aim of this article is to present state of the art recommendations on the classification of pain and pain therapy on the ICU.

MATERIAL AND METHODS

An online search was carried out in PubMed for publications on the topics of "pain" and "ICU".

RESULTS

Critical care patients are frequently subjected to many procedures and situations which can cause pain. The perception of pain is, among other things, influenced by the degree of orientation, anxiety and the degree of sedation. The administration of analgesics and non-pharmacological approaches are effective in reducing the stress perceived by patients.

DISCUSSION

The main aim is improvement in the awareness of nursing and medical personnel for pain inducers and pain perception in ICU patients. The classification of pain must be made objectively. Therapeutic targets must be defined and in addition to the correct selection of pain medication, non-pharmacological approaches must also be consistently implemented.