Anxiety, delirium, and pain in the intensive care unit

Effectiveness of aromatherapy on anxiety and sleep quality among adult patients admitted into intensive care units: A systematic review

PURPOSE

This review aims to evaluate the effectiveness of aromatherapy on anxiety and sleep quality among adult patients admitted to an intensive care unit.

MATERIALS AND METHODS

A systematic search for published and unpublished studies across nine databases and sources were conducted. Randomised Controlled Trials and Controlled Clinical Trials, which assessed the effectiveness of aromatherapy on anxiety and sleep quality among intensive care unit patients, were included in this review. Only studies that used aromatherapy as a single intervention were included. Narrative synthesis was conducted across all outcomes due to high heterogeneity across studies.

RESULTS

A total of 26 studies involving 2176 participants across six countries were included in this review. Most studies had an overall high risk of bias. Publication bias was detected in the studies. Findings have shown that aromatherapy may be effective in reducing anxiety based on the low GRADE certainty of evidence, and improving sleep quality based on the very low GRADE certainty of evidence. Inconsistencies in findings were also observed.

CONCLUSION

Aromatherapy might be beneficial on anxiety and sleep quality among intensive care unit patients, however, the level of evidence is very low, based on the low quality of studies. Considerations can be made to incorporate aromatherapy into existing interventions that improve anxiety and sleep quality in the intensive care unit. Due to inconsistencies in findings, further research can be done to investigate and strengthen these evidence.

IMPLICATION FOR CLINICAL PRACTICE

This review has demonstrated that aromatherapy may have benefits on anxiety and sleep quality. Despite uncertain evidence, aromatherapy may still be considered as a complementary or alternative option to improve anxiety and sleep quality among intensive care patients as it is relatively safe, cost-effective and easy to implement (Buckle, 2014). However, proper training by a professional clinical aromatherapist is needed to ensure there is screening of patients for suitability, proper technique for administering aromatherapy, safe handling of essential oils and monitoring for adverse events (Farrar & Farrar, 2020).

Postoperative Delirium in Lung Cancer Anatomical Resection-Analysis of Risk Factors and Prognosis

BACKGROUND

The incidence of postoperative delirium after anatomical lung resection ranges from 5 to 16%. This study aimed to analyze the risk factors and prognosis of postoperative delirium in anatomical lung resection for lung cancer.

METHODS

This study included 1351 patients undergoing anatomical lung resection between April 2010 and October 2020. We analyzed the perioperative risk factors of postoperative delirium. We also compared postoperative complications and survival between the delirium and non-delirium groups.

RESULTS

Postoperative delirium was identified in 44 (3.3%) of 1351 patients who underwent anatomical lung resection for lung cancer. Age, peripheral vascular disease, depression, and current smoking status were independent risk factors for postoperative delirium in the multivariate analysis. The percentage of postoperative delirium was 0.6% in never smokers and 6.0% in current smokers. The delirium and non-delirium groups showed significant differences in overall survival (p = 0.0144) and non-disease-specific survival (p = 0.0080). After propensity score matching, the two groups did not significantly differ in overall survival (p = 0.9136), non-disease-specific survival (p = 0.8146), or disease-specific survival (p = 0.6804).

CONCLUSIONS

Age, peripheral vascular disease, depression, and current smoking status were considered independent risk factors for postoperative delirium in anatomical lung resection for lung cancer. Smoking cessation for at least four weeks before surgery is recommended for reducing incidence of post-operative delirium.

Perioperative Pain Management in the Critically Ill Patient

PURPOSE OF REVIEW

The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant.

RECENT FINDINGS

The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Community Consultation for Planned Emergent Use Research: Experiences From an Academic Medical Center

BACKGROUND

Emergent use research-research involving human subjects that have a life-threatening medical condition and who are unlikely to provide informed consent-in critical illness is fraught with challenges related to obtaining informed consent. Per federal regulations, to meet criteria to conduct such trials, the investigators have to seek community consultations. Effective ways of obtaining this consultation remains ill-defined.

OBJECTIVE

We sought to describe methods, interpretations, and our experiences of conducting community consultation in a planned emergent use randomized controlled trial.

METHODS

As part of a planned emergent use clinical trial in our study, community consultation consisted of four focus groups sessions with members from the community in which the clinical trial was conducted. Three focus group sessions were conducted with members who had an affiliation to Mayo Clinic, and the other focus group session was conducted with non-Mayo affiliation members. The feedback from the focus group sessions led to the creation of the public notification plan. The public was notified of the trial through community meetings as well as social media.

RESULTS

As compared to community meetings, focus group sessions resulted in greater attendance with more interactive discussions. Moreover, focus group sessions resulted in greater in-depth conversations leading to institutional acceptance of the clinical trial under study.

CONCLUSIONS

Exception from informed consent can be acceptable to the community. Focus groups provided better participation and valuable interactive insight as compared to community meetings in our study. This could serve as a valuable guide for investigators pursuing exception from informed consent in their research studies.

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

PURPOSE

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

METHODS

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

ANALYSIS

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

CONCLUSIONS

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

Care-related pain in hospitalized patients: severity and patient perception of management

BACKGROUND

Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP.

METHODS

All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included.

RESULTS

From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases.

CONCLUSIONS

Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

Fluctuations in vital signs and behavioural responses of brain surgery patients in the Intensive Care Unit: are they valid indicators of pain?

AIM

To examine the validity of behaviours and fluctuations in vital signs for pain assessment of postbrain surgery adults in the neurosurgical intensive care unit.

BACKGROUND

Many patients in an intensive care unit may be unable to self-report their pain. In such cases, the use of observable indicators is recommended. Very little research has explored the validity of the use of behaviours and vital signs for pain assessment of neurocritically ill patients.

DESIGN

Prospective repeated-measure within-subject observational design.

METHODS

A total of 43 postbrain surgery patients were video recorded before, during and 15 minutes after a non-nociceptive (non-invasive blood pressure cuff inflation) and a nociceptive (turning) procedures. Their behaviours and vital signs were collected with a pre-tested behavioural checklist and a data collection computer connected to the bedside monitor. The patients' self-report of pain was obtained whenever possible. Data were collected between June-December in 2011.

RESULTS

A larger number of pain-related behaviours were exhibited by participants during the nociceptive procedure compared with the non-nociceptive procedure supporting discriminant validation. Among vital signs, only respiratory rate differed significantly between the two procedures. Regarding criterion validation, only behaviours were positively correlated with self-reports of pain.

CONCLUSION

Behaviours were found valid indicators of pain in neurocritically ill patients after elective brain surgery. Fluctuations in vital signs may suggest the presence of pain, but their validity for such use is not supported. They should only be used in combination with other validated pain assessment methods.

Can we identify risk factors for postoperative delirium in cardiac coronary patients? Our experience

INTRODUCTION

Delirium is a temporary mental disorder that frequently occurs among elderly hospitalized patients. Patients who undergo cardiac operations have an increased risk of postoperative delirium, which is associated with higher mortality and morbidity rates, a prolonged hospital stay, and reduced cognitive and functional recovery.

PATIENTS AND METHODS

In our prospective study, we included 370 consecutive adult patients who underwent on-pump coronary artery surgery between January 1, 2011, and July 1, 2011. We selected 21 potential risk factors and divided them into preoperative, intraoperative, and postoperative groups. Delirium was diagnosed with the Confusion Assessment Method.

RESULTS

Postoperative delirium was diagnosed in 74 patients (20%). Four predictive factors were associated with postoperative delirium: diabetes mellitus, cerebrovascular disease, peripheral vascular disease, and prolonged intubation (P < .05).

CONCLUSION

Three of the four predictive factors significantly associated with delirium are preoperative. They are relatively easy to measure and can be used to identify patients at higher risk. Fast extubation of these patients and preventive interventions can be taken to prevent negative consequences of this postoperative complication.

Reliability and validity of shortened state trait anxiety inventory in Spanish patients receiving mechanical ventilation

BACKGROUND

In order to measure anxiety in physically and cognitively debilitated patients, such as patients receiving invasive mechanical ventilation, the use of reliable and valid instruments is recommended; however, these instruments should be short.

OBJECTIVE

To analyze the reliability and validity of a short version of the state subscale from the Spielberger State-Trait Anxiety Inventory, developed by Chlan and colleagues and translated into Spanish (STAI-E6), in patients receiving invasive mechanical ventilation.

METHODS

An instrumental study was conducted of 80 patients receiving invasive mechanical ventilation in the intensive care unit at the Hospital of Alicante (Spain). The patients completed the 6-item STAI-E6 scale. Before the patients completed the scale, the interviewers indicated their impression of each patient's level of anxiety by using a linear scale. Internal consistency, construct validity, and convergent validity of the scale were analyzed.

RESULTS

The scale did not present a floor/ceiling effect, the Cronbach α was 0.79, and the single-factor structure of the original scale was maintained. Scores on the scale correlated positively with the subjective assessment of the health professional. Significant differences were found only between anxiety level and duration of intubation.

CONCLUSIONS

The 6-item version of the state subscale from the STAI-E6 shows satisfactory reliability and validity for Spanish patients receiving invasive mechanical ventilation.

Efficacy of an Intravenous Bolus of Morphine 2.5 versus Morphine 7.5 mg for Procedural Pain Relief in Postoperative Cardiothoracic Patients in the Intensive Care Unit: A Randomised Double-Blind Controlled Trial

As pain in the intensive care unit (ICU) is still common despite important progress in pain management, we studied the efficacy of an intravenous bolus of morphine 2.5 vs 7.5 mg for procedural pain relief in patients after cardiothoracic surgery in the ICU. In a prospective double-blind randomised study, 117 ICU patients after cardiothoracic surgery were included. All patients were treated according a pain titration protocol for pain at rest, consisting of continuous morphine infusions and paracetamol, applied during the entire ICU stay. On the first postoperative day, patients were randomised to intravenous morphine 2.5 (n=59) or 7.5 mg (n=58) 30 minutes before a painful intervention (turning of patient and/or chest drain removal). Pain scores using the numeric rating scale (Numeric Rating Scale, range 0 to 10) were rated at rest (baseline) and around the painful procedure. At rest (baseline), overall incidence of unacceptable pain (Numeric Rating Scale ≥4) was low (Numeric Rating Scale >4; 14 vs 17%, P=0.81) for patients allocated to morphine 2.5 and 7.5 mg respectively. For procedure-related pain, there was no difference in incidence of unacceptable pain (28 vs 22%, P=0.53) mean pain scores (2.6 [95% confidence interval 2.0 to 3.2] vs 2.7 [95% confidence interval 2.0 to 3.4]) between patients receiving morphine 2.5 and 7.5 mg respectively. In intensive care patients after cardiothoracic surgery with low pain levels for pain at rest, there was no difference in efficacy between intravenous morphine 2.5 mg or morphine 7.5 mg for pain relief during a painful intervention.

Pain in the ICU: a psychiatric perspective

Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.

Recovery and long-term outcome in acute respiratory distress syndrome

Interest in longer-term outcomes after acute respiratory distress syndrome (ARDS) and the understanding of patterns of recovery have increased enormously over the past 10 years. This article highlights important advances in outcomes after ARDS and describes pulmonary outcomes, the most recent data on functional and neuropsychological disability in patients, health care cost, family caregivers, and early models of rehabilitation and intervention.

[Opinion of different professional categories about the intensity of procedural pain in adult intensive care units]

OBJECTIVES

to assess the procedures considered as the most painful by health personnel of two adult critical care units.

METHODS

individual written survey with a questionnaire about 46 potentially painful procedures. Each individual has to estimate the pain intensity as well as the frequency of performance for each painful procedures.

RESULTS

one hundred questionnaires were provided (15 physicians, 71 nurses and 14 auxiliaries). The rate of answer was 53 % and 2110 scores were recorded and analyzed. The insertion of a pleural drain was associated with the higher pain score (7.5 [6.5-9]). Discrepancies were observed between the professional categories in ranking painful procedures. However, the mobilization of a severe trauma patient, the removal of an otorhinolaryngological or a pleural drain were classified in the 10 most painful procedures by physicians, nurses as well as auxiliaries. Whatever the procedure was, the median global scores estimated by the auxiliaries (n=385; 6 [4-7]) were higher than those corresponding to the nurses (n=1267; 5 [3-7]) (p<0.01). Nurses attributed a higher score than the physicians for 39 of 46 procedures. No relation was found between the estimated pain intensity and the estimated frequency of the procedures.

CONCLUSION

as in paediatrics, adult intensivist physicians underestimate pain during procedure comparing with nurses and auxiliaries. Consequently, health care professionals should elaborate protocols to accurately assess, prevent, or treat painful procedures in intensive care units.

Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome

OBJECTIVE

Depression and anxiety are common morbidities of critical illness. We assessed risk factors of depression and anxiety in Acute Respiratory Distress Syndrome (ARDS) survivors at 1 and 2 years post-hospital discharge.

METHOD

Risk factors for depression and anxiety at 1 and 2 years were assessed using stepwise multiple regression analyses, with and without 1-year outcomes.

RESULTS

ARDS survivors had depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. Predictors of depression at 1 year were alcohol dependence, female gender and younger age (P=.006). Predictors of anxiety were ratio of arterial oxygen tension to inspired oxygen fraction and duration of mechanical ventilation (P<.005). Predictors of depression at 2 years were depression at 1 year and the presence of cognitive sequelae (P<.0001). Predictors of anxiety at 2 years was anxiety at 1 year (P<.0001).

CONCLUSIONS

Medical variables that predicted depression or anxiety at 1 year no longer predicted depression and anxiety at 2 years. Medical variables appear to have a short-term effect on psychiatric outcomes. At 2 years lifestyle behaviors including history of smoking along with cognitive sequelae, depression and anxiety at 1 year predict depression and anxiety.

Scales for evaluating self-perceived anxiety levels in patients admitted to intensive care units: a review

OBJECTIVE

To review studies of anxiety in critically ill patients admitted to an intensive care unit to describe the level of anxiety and synthesize the psychometric properties of the instruments used to measure anxiety.

METHODS

The CUIDEN, IME, ISOC, CINAHL, MEDLINE, and PSYCINFO databases for 1995 to 2005 were searched. The search focused on 3 concepts: anxiety, intensive care, and mechanical ventilation for the English-language databases and ansiedad, cuidados intensivos, and ventilación mecánica for the Spanish-language databases. Information was extracted from 18 selected articles on the level of anxiety experienced by patients and the psychometric properties of the instruments used to measure anxiety.

RESULTS

Moderate levels of anxiety were reported. Levels were higher in women than in men, and higher in patients undergoing positive pressure ventilation regardless of sex. Most multi-item instruments had high coefficients of internal consistency. The reliability of instruments with only a single item was not demonstrated, even though the instruments had moderate-to-high correlations with other measurements.

CONCLUSION

Midlength scales, such the anxiety subscale of the Brief Symptom Inventory or the shortened state version of the State-Trait Anxiety Inventory are best for measuring anxiety in critical care patients.

Patients' memory and psychological distress after ICU stay compared with expectations of the relatives

PURPOSE

To compare patients' psychological distress and memories from intensive care unit (ICU) treatment 4-6 weeks after ICU discharge with expectations of their relatives. Further, to explore the relationship between personality traits and ICU memories with psychological distress.

METHODS

A cross-sectional study of 255 patients and 298 relatives. The questionnaire included: hospital anxiety and depression scale (HADS), impact of event scale (IES), life orientation test, ICU memory tool and memory of ICU; technical procedures, pain, lack of control and inability to express needs. Relatives were assessed for their expectations of the patients' memories and psychological distress.

RESULTS

Twenty-five percent of the patients reported severe posttraumatic stress symptoms, IES-total >or= 35. The levels of anxiety and depression were significantly higher than in the general population, mean anxiety was 5.6 versus 4.2 (p < 0.001), and mean depression was 4.8 versus 3.5 (p < 0.001). Relatives expected more psychological distress and the relatives thought the patient was less able to express needs than the patients reported (p < 0.001). Higher age, unemployment, respirator treatment, pessimism, memory of pain, lack of control and inability to express needs were independent predictors of posttraumatic stress symptoms (p < 0.01).

CONCLUSIONS

Psychological distress symptoms were frequent among ICU survivors. Relatives expected the patients to be more distressed after ICU treatment than the patients reported. The strongest predictors of posttraumatic stress symptoms from the ICU were memoris about pain, lack of control and inability to express needs. Pessimism may be a reason for psychological distress and should be addressed during follow up, as pessimistic patients may need more motivation and support.

Ventilatory weaning: a case study of protracted weaning

BACKGROUND

Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning.

AIM

To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process.

ANALYSIS

This case study examines one patient's experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well-being.

CONCLUSIONS

This reflective analysis highlights the benefits and importance of the nurse-patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.

The septic brain

Sepsis is a major disease entity with important clinical implications. Sepsis-induced multiple organ failure is associated with a high mortality rate in humans and is clinically characterized by pulmonary, cardiovascular, renal and gastrointestinal dysfunction. Recently, several studies have demonstrated that sepsis survivors present long-term cognitive impairment, including alterations in memory, attention, concentration and/or global loss of cognitive function. However, the pathogenesis and natural history of septic encephalopathy and cognitive impairment are still poorly known and further understanding of these processes is necessary for the development of effective preventive and therapeutic interventions. This review discusses the clinical presentation and underlying pathophysiology of the encephalopathy and cognitive impairment associated with sepsis.

Research in critically ill patients: standards of informed consent

Patients in critical care lose their capability to make a judgement, and constitute a 'vulnerable population' needing special and reinforced protection. Even if the standard of informed consent is an essential way of demonstrating respect for the patient's autonomy, the usual informed-consent procedure is not as applicable as required or sufficient to warrant this ethical principle in critical care.

Improving palliative care in intensive care units: identifying strategies and interventions that work

The disciplines of critical care and palliative care may initially seem to be polar opposites, yet they share fundamental features. Both focus on the sickest patients in the healthcare system. Each discipline's primary goal-extending life for critical care and comfort and quality of life for palliative care-represents an important secondary goal for the other. A tremendous body of work in the last decade has laid the foundation for improving palliative care in intensive care units of the future. Pioneering projects have demonstrated the feasibility and acceptance of integrating palliative aspects of care within critical care settings and practice. This article introduces this special supplement of Critical Care Medicine, which describes the developments that have occurred moving us toward integration of palliative and critical care, and lays the foundation for the articles published in this supplement.

Quality of life, emotional abnormalities, and cognitive dysfunction in survivors of acute lung injury/acute respiratory distress syndrome

This article provides a brief discussion of the recent literature linking quality-of-life impairment to physical dysfunction after acute lung injury/acute respiratory distress syndrome. Its main focus is a review of the current knowledge concerning cognitive and emotional outcomes after lung injury and their impact on long-term quality of life.

Physiological modelling of agitation–sedation dynamics including endogenous agitation reduction

Sedation administration and agitation management are fundamental activities in any intensive care unit. A lack of objective measures of agitation and sedation, as well as poor understanding of the underlying dynamics, contribute to inefficient outcomes and expensive healthcare. Recent models of agitation-sedation pharmacodynamics have enhanced understanding of the underlying dynamics and enable development of advanced protocols for semi-automated sedation administration. However, these initial models do not capture all observed dynamics, particularly periods of low sedative infusion. A physiologically representative model that incorporates endogenous agitation reduction (EAR) dynamics is presented and validated using data from 37 critical care patients. High median relative average normalised density (RAND) values of 0.77 and 0.78 support and minimum RAND values of 0.51 and 0.55 for models without and with EAR dynamics respectively show that both models are valid representations of the fundamental agitation-sedation dynamics present in a broad spectrum of intensive care unit (ICU) patients. While the addition of the EAR dynamic increases the ability of the model to capture the observed dynamics of the agitation-sedation system, the improvement is relatively small and the sensitivity of the model to the EAR dynamic is low. Although this may represent a limitation of the model, the inclusion of EAR is shown to be important for accurately capturing periods of low, or no, sedative infusion, such as during weaning prior to extubation.

Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommendations for practice

The quality of sedation management in mechanically ventilated patients has been a source of concern in recent years. This paper summarises the literature on the principles of optimal sedation, discusses the consequences of over and undersedation, highlighting the importance of appropriate pain management, and presents a case study using the results of an audit of 48 mechanically ventilated adults. As a result of the review and audit, we are implementing changes to practice. The most important recommendations from the literature are the use of a sedation scale, setting of a goal sedation score, appropriate pain management and implementation of a nurse initiated sedation algorithm. Other recommendations include use of bolus rather than continuous sedative infusions and recommencing regular medications for anxiety, depression and other phychiatric disorders as soon as possible. A recommendation arising from our audit was the need to identify patients at high risk of oversedation and undersedation and adopt a proactive rather than reactive approach to management. The practice goal is to provide adequate and appropriate analgesia and anxiolysis for patients. This will improve patient comfort while reducing length of mechanical ventilation and minimising risk of complications.

Physiological modelling of agitation–sedation dynamics

Agitation-sedation cycling in critically ill patients, characterized by oscillations between states of agitation and over-sedation, damages patient health and increases length of stay and cost. A model that captures the essential dynamics of the agitation-sedation system and is physiologically representative is developed, and validated using data from 37 critical care patients. It is more physiologically representative than a previously published agitation-sedation model, and captures more realistic and complex dynamics. The median time in the 90% probability band is 90%, and the total drug dose, relative to recorded drug dose data, is a near ideal 101%. These statistical model validation metrics are 5-13% better than a previously validated model. Hence, this research provides a platform to develop and test semi-automated sedation management controllers that offer the significant clinical potential of improved agitation management and reduced length of stay in critical care.

Dexmedetomidine does not improve patient satisfaction when compared with propofol during mechanical ventilation*

OBJECTIVE

Dexmedetomidine (DEX) may provide a sedation level that enables sleep and communication, with less amnesia and pain medication requirements, during mechanical ventilation. Our study directly assessed patient-perceived satisfaction with coronary artery bypass graft surgery after administration of DEX or propofol for intensive care unit (ICU) sedation.

DESIGN

Prospective, randomized clinical study with subsequent questionnaire administration.

SETTING

Tertiary care surgical ICU.

PATIENTS

A total of 89 adult, nonemergent, coronary artery bypass graft patients with an expected length of intubation of <24 hrs.

INTERVENTIONS

Patients were randomized to either DEX or propofol; drug administration was performed via standardized anesthesia and nursing protocols.

MEASUREMENTS

Patients reported perceptions of their ICU experience after mechanical ventilation with a modified numerical-scale Hewitt questionnaire, validated specifically for ICU patients. Patients were questioned regarding awareness, recall, generalized comfort, level of pain, ability to interact with healthcare providers and family, feelings of agitation and anxiety, perceived ease of extubation, ability to sleep or rest, and satisfaction with ICU experience.

MAIN RESULTS

Groups were well matched at baseline, with a mean +/- sd age of 63.0 +/- 10.4 yrs and weight of 88.7 +/- 16.7 kg. No difference was observed for length of surgery, length of intubation, or ICU stay (p > .05). DEX patients perceived a shorter length of intubation (p = .044). A deeper sedation level was found in the propofol group (p = .021), with similar morphine and midazolam requirements (p = .317). Patient-rated level of overall awareness as a marker of amnesia did not differ between groups (p = .653). The ability to rest or sleep trended toward significance favoring propofol (p = .051). On evaluation of questionnaire ratings, DEX patients expressed more discomfort (p = .046), pain (p = .096), and sleeping difficulty (p = .036). Similar comfort levels were reported during extubation (p = .179).

CONCLUSIONS

Despite theoretical advantages of DEX to improve overall patient satisfaction, the two agents provide similar responses to amnesia and pain control. According to our findings, DEX does not seem to have any advantage compared with propofol for short-term sedation after coronary artery bypass graft surgery.

Factors Associated With Postoperative Delirium After Thoracic Surgery

BACKGROUND

Postoperative delirium is an acute confusional state characterized by fluctuating consciousness and is associated with increased morbidity and mortality. We analyzed the incidence and risk factors of delirium following thoracic surgery.

METHODS

All patients (n = 432) who underwent thoracotomy or sternotomy from 1996 to 2003 were analyzed retrospectively. The diagnosis of postoperative delirium was based on Diagnostic and Statistical Manual of Mental Disorders- IV criteria.

RESULTS

Postoperative delirium developed in 23 patients (5.32%) between postoperative days 2 to 12 (mean, 4.4 +/- 2.6 days). There were 15 males and 8 females, with a mean age of 59.4 years (24 to 77 years). The delirium group was older (59.4 +/- 14.6 vs 51.3 +/- 15.5 years, p < 0.01) and had a longer operation time than the nondelirious group (5.34 +/- 1.58 vs 4.38 +/- 1.6 hours, p = 0.005). Morbidity and mortality rates were not significantly different between the two groups (56.5% vs 47.1%; 13.0% vs 3.66%, respectively). Univariate analysis showed that the older age, markedly abnormal postoperative levels of sodium, potassium, or glucose, sleep deprivation, operation time, and diabetes mellitus were risk factors (p < 0.05). According to multivariate analyses, four factors were selected as predictive risk factors: (1) markedly abnormal postoperative levels of sodium, potassium, or glucose (p = 0.038); (2) sleep deprivation (p = 0.05); (3) age (p = 0.033); and (4) operation time (p = 0.041).

CONCLUSIONS

Postoperative delirium may cause higher morbidity and mortality rates after thoracic surgery. Close postoperative follow-up and early identification of predisposing factors such as older age, sleep deprivation, abnormal postoperative levels of sodium, potassium, or glucose, and longer operation time can prevent occurrence of postoperative delirium.

Two-Year Cognitive, Emotional, and Quality-of-Life Outcomes in Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) has a high mortality and is associated with significant morbidity. Prior outcome studies have focused predominant on short-term outcomes (6-12 months). We assessed longitudinal neurocognitive, emotional, and quality of life in ARDS survivors at hospital discharge, and 1 and 2 years after hospital discharge using neuropsychologic tests and emotional and quality-of-life questionnaires. Neurocognitive sequelae occurred in 73% (54 of 74) of ARDS survivors at hospital discharge, 46% (30 of 66) at 1 year, and 47% (29 of 62) at 2 years. ARDS survivors report moderate to severe depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. The ARDS survivors had decreased quality of life, with the physical domains improving at 1 year, with no additional change at 2 years. Role emotional, pain, and general health did not change from hospital discharge to 2 years. Mental health improved during the first year and declined at 2 years. ARDS results in significant neurocognitive and emotional morbidity and decreased quality of life that persists at least 2 years after hospital discharge. ARDS can cause significant long-term, brain-related morbidity manifest by neurocognitive impairments and decreased quality of life.

Modeling and control of the agitation-sedation cycle for critical care patients

Agitation-sedation cycling in critically ill patients, characterized by oscillations between states of agitation and over-sedation, is damaging to patient health, and increases length of stay and healthcare costs. The mathematical model presented captures the essential dynamics of the agitation-sedation system for the first time, and is statistically validated using recorded infusion data for 37 patients. Constant patient-specific patient parameters are used, illustrating the commonality of these fundamental dynamics over a broad range of patients. The validated model serves as a basis for comparison of sedation administration methods, devices, therapeutics and protocols. Heavy derivative feedback control is shown to be an effective means of managing agitation, given consistent agitation measurement. The improved agitation management reduces the modeled mean and peak agitation levels 68.4% and 52.9% on average, respectively. Some patients showed over 90% reduction in mean agitation level through increased control gains. This improved agitation management is achieved via heavy derivative feedback control of sedation administration, which provides an essentially bolus-driven management approach, aligned with recent sedation practices.

Quantifying agitation in sedated ICU patients using digital imaging

Agitation is a significant problem in the Intensive Care Unit (ICU), affecting 71% of sedated adult patients during 58% of ICU patient-days. Subjective scale based assessment-methods focused primarily on assessing excessive patient motion are currently used to assess the level of patient agitation, but are limited in their accuracy and resolution. This research quantifies this approach by developing an objective agitation measurement from patient motion that is sensed using digital video image processing. A fuzzy inference system (FIS) is developed to classify levels of motion that correlate with observed patient agitation, while accounting for motion due to medical staff working on the patient. Clinical tests for five ICU patients have been performed to verify the validity of this approach in comparison to agitation graded by nursing staff using the Riker Sedation-Agitation Scale (SAS). All trials were performed in the Christchurch Hospital Department of Intensive Care, with ethics approval from the Canterbury Ethics Committee. Results show good correlation with medical staff assessment with no false positive results during calm periods. Clinically, this initial agitation measurement method promises the ability to consistently and objectively quantify patient agitation to enable better management of sedation and agitation through optimised drug delivery leading to reduced length of stay and improved outcome.

Clinical identification of cognitive impairment in ICU survivors: insights for intensivists

BACKGROUND

A growing body of research has demonstrated the presence of ongoing cognitive impairment in large numbers of ICU survivors.

OBJECTIVE

This review offers a practical framework for practicing intensivists and those following patients after their ICU stay for the identification of cognitive impairment in ICU survivors.

CONCLUSIONS

Early detection of cognitive impairment in critically ill patients is an important and achievable goal, but overt cognitive impairment remains unrecognized in most cases. However, it can be identified by objective (test scores) or subjective evidence (clinical judgment, patient observation, family interaction).

Quality of life, emotional, and cognitive function following acute respiratory distress syndrome

Acute Respiratory Distress Syndrome (ARDS) is characterized by lung injury and hypoxemia, has a high mortality rate, and is associated with significant morbidity including cognitive and emotional sequelae and decreased quality of life. There is limited information regarding which of these factors are associated with decreased quality of life. This study assessed the relationships between quality of life, cognitive and emotional function in ARDS survivors at 1-year post-hospital discharge. Sixty-six ARDS survivors were administered a battery of neuropsychological tests, measures of emotional function and quality of life 1 year post-hospital discharge. At 1 year 45% of the ARDS patients had cognitive sequelae and 29% had mild to moderate symptoms of depression and anxiety. Depression, anxiety, and intensive care unit length of stay were significantly correlated with decreased quality of life. Cognitive impairments did not correlate with decreased quality of life. Illness severity and emotional function, but not cognitive sequelae, are associated with decreased quality of life 1 year following ARDS. ARDS is common and may result in significant cognitive and emotional morbidity and decreased quality of life.

Research issues in the evaluation of cognitive impairment in intensive care unit survivors

Neuropsychological assessment has been utilized extensively in the research of cognitive outcomes associated with medical illnesses, such as HIV, and post-surgical procedures, such as coronary artery bypass graft. However, few investigations of intensive care unit (ICU) survivors have examined cognitive function as a clinical outcome. Significant clinical questions exist regarding the impact of critical illness on long-term cognitive function. Many of these questions can be systematically evaluated through the use of standardized neuropsychological assessment instruments within the context of well designed, prospective research trials. This review will provide information for clinical researchers interested in the study of neuropsychological outcomes in intensive care unit survivors ( a comparison article in this issue will address clinical issues related to cognitive functioning).

Screening for delirium in an adult intensive care unit

Delirium is an acute, reversible disorder of attention and cognition and may be viewed as cerebral dysfunction similar to the failure of any other organ. The development of delirium is associated with increased morbidity and mortality, extended length-of-stay in the intensive care unit and longer time spent sedated and ventilated. Nearly every clinical, pharmacological and environmental factor present and necessary in the ICU setting has the potential to cause delirium. Since all of these factors cannot be removed, it is paramount to increase the awareness amongst health care professionals so as to minimise under-recognition and encourage future research into factors that may improve the long-term outcome for ICU patients. There is a need for user-friendly, validated assessment tools for the intubated and ventilated ICU patient, which can be applied at the time of ICU admission without the need for lengthy psychiatric assessment. Nursing professionals are at the forefront of those who are able to provide holistic care through meaningful conversation and empathetic touch. A 6-month Quality Improvement (QI) project screening patients for signs of delirium provided a foundation for discussion. All patients admitted to ICU for more than 72 h, with a hospital length-of-stay less than 96 h prior to ICU admission were screened. Patients admitted following neurological insults or with pre-existing altered mental state were excluded. The QI project showed the incidence of delirium to be 40% of the total sample (n = 73) in a mixed medical/surgical and elective/emergency patient population.

Quantifying agitation in sedated ICU patients using heart rate and blood pressure

Agitation is a significant problem in the intensive care unit (ICU), affecting 71% of sedated adult patients during 58% of ICU patient-days (Fraser and Riker 2001 NY Health-Syst. Pharm. 20 17-24). Subjective scale-based assessment methods are currently used to assess the level of patient agitation, but are limited in their accuracy and resolution. This research develops an objective agitation measurement method using heart rate variability (HRV), systolic blood pressure (BP) and blood pressure variability (BPV) data, processed by wavelet transforms and autoregressive signal processing. A fuzzy inference system (FIS) is developed to classify changes in these signals that correlate with observed patient agitation, and combine them into a final agitation level. Proof of concept clinical trials on 13 normal subjects and 5 ICU patients has been performed to verify the validity of this approach in comparison with agitation graded by nursing staff using the Riker sedation-agitation scale (SAS). Results show good correlation with medical staff assessment with no false positive results during calm periods. Clinically, this initial agitation measurement method promises the ability to consistently and objectively quantify patient agitation to enable better management of sedation and agitation through optimized drug delivery leading to reduced length of stay.

Management of sedation in mechanically ventilated patients

PURPOSE OF REVIEW

There are many new and exciting studies in the sedation literature. Recent studies of new scoring systems to monitor sedation, new medications, and new insights into post-intensive care unit (ICU) sequelae have brought about interesting ideas for achieving an adequate level of sedation of our patients while minimizing complications.

RECENT FINDINGS

The recent literature focuses on monitoring the level of a patient's sedation with new bedside clinical scoring systems and new technology. Outcomes studies have highlighted problems with both inadequate sedation and excessive sedation in regard to patients' post-ICU psychological health. More insight into drug withdrawal and addiction as complications of ICU care were examined. A new medication for sedation in the ICU has been approved for use, but its role is not yet defined.

SUMMARY

Many patients in the ICU receive mechanical ventilation and will require sedative medications. A frequently overlooked cause of agitation in the ventilated patient is pain, and assessing the adequacy of analgesia is an important part of the continuous assessment of a patient. The goal of sedation is to provide relief while minimizing the development of drug dependency and oversedation. Careful monitoring with bedside scoring systems, the appropriate use of medications, and a strategy of daily interruption can lead to diminished time on the ventilator and in the ICU.

Severe agitation among ventilated medical intensive care unit patients: frequency, characteristics and outcomes

OBJECTIVE

To determine the frequency, characteristics and outcomes of severe agitation among ventilated medical intensive care unit (MICU) patients.

DESIGN

Prospective cohort study.

SETTING

Eighteen-bed MICU in 964-bed tertiary care center.

PATIENTS

All ventilated patients, aged 18 years or older and admitted for more than 24 h between January 1, 2001 and May 8, 2001.

INTERVENTIONS

None.

MEASUREMENTS

Data were collected daily by concurrent chart abstractions. Variables included sociodemographic, clinical, laboratory, pharmacologic and non-pharmacologic interventions, ventilator settings and adverse events. Severe agitation, the main outcome variable, was defined as two or more Motor Activity Assessment Scale (MAAS) scores above 4 in a 24-h period and sedative and/or narcotic doses above the established sedation and analgesia protocol or a combination of two or more sedatives.

RESULTS

Twenty-three (16.1%) of 143 enrolled patients exhibited severe agitation. Agitated patients were younger (hazard ratio [HR] 1.32), more likely to be admitted from an outside hospital ICU (HR 2.48), had lower pH (HR 1.55) and PaO(2)/FIO(2) less than 200 mmHg (HR 2.59). Agitated patients had longer MICU stays (median 12 versus 5 days, p<0.0001) and more ventilator days (median 14 versus 6, p<0.0001). Agitated patients were more likely to self-extubate (26% versus 6%, p=0.002). Benzodiazepines, narcotics and neuromuscular blocking agents were administered more frequently and at higher doses, but haloperidol was not.

CONCLUSION

Severe agitation occurs commonly in critically ill patients and is associated with adverse events including longer ICU stays, duration of mechanical ventilation and self-extubation.

Delirium, depression, and anxiety

Patients who are critically ill often develop a variety of psychiatric symptoms, which require assessment and treatment. The most common psychiatric disorder in the intensive care unit is delirium. Depressed mood and anxiety also occur, at times as discrete disorders, but more often secondary to delirium. Patients with severe mental illnesses, such as schizophrenia and bipolar affective disorder, also may become critically ill--assessment and management of these patients often requires specialized psychiatric care and is not addressed here.

Therapies to reduce stress and anxiety

Creativity in meeting patients' needs is required daily by the staff in acute and critical care environments. For critical care patients, many alternative and complementary therapies including aromatherapy, hydrotherapy, humor, imagery, massage, music, and relaxation can be used successfully as adjunct therapies to help decrease stress.