Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

The medical treatment of cardiogenic shock

Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.

Onset of Prolonged High-Potency Benzodiazepine Use Among ICU Survivors: A Nationwide Cohort Study

OBJECTIVES

Exposure to critical illness and intensive care may lead to long-term psychologic and physical impairments. To what extent ICU survivors become prolonged users of benzodiazepines after exposure to critical care is not fully explored. This study aimed to describe the extent of onset of prolonged high-potency benzodiazepine use among ICU survivors not using these drugs before admission, identify factors associated with this use, and analyze whether such usage is associated with increased mortality.

DESIGN

Retrospective cohort study.

SETTING

Sweden, including all registered ICU admissions between 2010 and 2017.

PATIENTS

ICU patients surviving for at least 3 months, not using high-potency benzodiazepine before admission, were eligible for inclusion.

INTERVENTIONS

Admission to intensive care.

MEASUREMENTS AND MAIN RESULTS

A total of 237,904 patients were screened and 137,647 were included. Of these 5338 (3.9%) became prolonged users of high-potency benzodiazepines after ICU discharge. A peak in high-potency benzodiazepine prescriptions was observed during the first 3 months, followed by sustained usage throughout the follow-up period of 18 months. Prolonged usage was associated with older age, female sex, and a history of both somatic and psychiatric comorbidities, including substance abuse. Additionally, a longer ICU stay, a high estimated mortality rate, and prior consumption of low-potency benzodiazepines were associated with prolonged use. The risk of death between 6 and 18 months post-ICU admission was significantly higher among high-potency benzodiazepine users, with an adjusted hazard ratio of 1.8 (95% CI, 1.7-2.0; p < 0.001). No differences were noted in causes of death between users and nonusers.

Conclusions

Despite the lack of evidence supporting long-term treatment, prolonged usage of high-potency benzodiazepines 18 months following ICU care was notable and associated with an increased risk of death. Considering the substantial number of ICU admissions, prevention of benzodiazepine misuse may improve long-term outcomes following critical care.

Comparison of the effects of remimazolam tosylate and propofol on immune function and hemodynamics in patients undergoing laparoscopic partial hepatectomy: a randomized controlled trial

BACKGROUND

Laparoscopic partial hepatectomy inevitably decrease patient immune function. Propofol has been shown to have immunomodulatory effects but is associated with hemodynamic side effects. Despite studies showing a negligible impact of remimazolam tosylate on hemodynamics, it has not been reported for partial hepatectomy patients. Its influence on immune function also remains unexplored. This study sought to investigate the differences in immune function and intraoperative hemodynamics between patients who underwent laparoscopic partial hepatectomy with remimazolam tosylate and those who underwent laparoscopic partial hepatectomy with propofol.

METHODS

This was a single-center, randomized controlled trial involving 70 patients, who underwent elective laparoscopic partial hepatectomy. The patients were randomly divided into two groups: the remimazolam group (group R) and the propofol group (group P). In this study, the primary outcomes assessed included the patient's immune function and hemodynamic parameters, and the secondary outcomes encompassed the patient's liver function and adverse events.

RESULTS

Data from 64 patients (group R, n = 31; group P, n = 33) were analyzed. The differences in the percentages of CD3+, CD4+, CD8+, and NK cells and the CD4+/CD8+ ratio between the two groups were not statistically significant at 1 day or 3 days after surgery. Compared with those in group P, the MAP and HR at T2 and the MAP at T1 in group R were significantly increased(P < 0.05). The differences in HR and MAP at T0, T3, T4, T5, T6, and T7 and HR at T1 between the two groups were not statistically significant. There were no differences in liver function or adverse effects between the two groups, suggesting that remimazolam tosylate is a safe sedative drug(P > 0.05).

CONCLUSION

The effects of remimazolam tosylate on the immune function of patients after partial hepatectomy are comparable to those of propofol. Additionally, its minimal effect on hemodynamics significantly decreases the incidence of hypotension during anesthesia induction, thereby enhancing overall perioperative safety.

TRIAL REGISTRATION

The trial was registered on May 9, 2022 in the Chinese Clinical Trial Registry, registration number ChiCTR2200059715 (09/05/2022).

Headache management in traumatic brain injury

Traumatic brain injury (TBI) is estimated to rank as the third most important disease burden worldwide. About 60% of the survivors develop chronic headaches and visual symptoms, and the long-term management of headaches in these patients is controversial. Importantly, the care pathway of most patients is fragmented, complicating conclusive headache management. Here we review the epidemiology and aetiology of post traumatic headaches (PTH), discuss the diagnostic work up and summarise the acute and long-term management.

Incidence of Hypertriglyceridemia in Patients on Propofol, Clevidipine, or Both

BACKGROUND

Propofol and clevidipine (PC) are commonly used in the treatment of critically ill patients. While both medications are lipid emulsions, there is limited evidence concerning the incidence of hypertriglyceridemia (HTG) when these agents are used individually or concurrently.

OBJECTIVE

The objective of this study is to determine the effects of propofol, clevidipine, or concurrent PC on triglycerides (TGs) and related outcomes in critically ill adults.

METHODS

This was a retrospective cohort study conducted at an academic medical center. Patients were included if they received ≥24 hours of continuous propofol and/or clevidipine. Excluded were those without TG levels after ≥24 hours of infusion, baseline HTG, acute pancreatitis at admission, or receiving total parenteral nutrition with lipids. The primary outcome was incidence of HTG (defined as a TG level >400 mg/dL). Secondary outcomes included median and peak TG levels, hospital length of stay, intensive care unit length of stay, total lipid infused, time to peak TG level, peak lipase level, and development of pancreatitis.

RESULTS

In total, 190 patients were studied: 109 in the propofol group, 50 in the clevidipine group, and 31 in the PC group. Incidence of HTG was similar (19 [17.4%] vs 6 [12%] vs 4 [12.9%] patients, P = 0.6246). Peak and median TG levels were similar for propofol, clevidipine, and PC groups (216 mg/dL vs 189.5 mg/dL vs 205 mg/dL, P = 0.7069; 177 mg/dL vs 185.5 mg/dL vs 177 mg/dL, P = 0.6791).

CONCLUSIONS AND RELEVANCE

There was a similar incidence of HTG in all groups. The results of this study suggest that the concurrent use of PC should not modify the frequency of TG level monitoring.

Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.

Future directions in ventilator-induced lung injury associated cognitive impairment: a new sight

Mechanical ventilation is a widely used short-term life support technique, but an accompanying adverse consequence can be pulmonary damage which is called ventilator-induced lung injury (VILI). Mechanical ventilation can potentially affect the central nervous system and lead to long-term cognitive impairment. In recent years, many studies revealed that VILI, as a common lung injury, may be involved in the central pathogenesis of cognitive impairment by inducing hypoxia, inflammation, and changes in neural pathways. In addition, VILI has received attention in affecting the treatment of cognitive impairment and provides new insights into individualized therapy. The combination of lung protective ventilation and drug therapy can overcome the inevitable problems of poor prognosis from a new perspective. In this review, we summarized VILI and non-VILI factors as risk factors for cognitive impairment and concluded the latest mechanisms. Moreover, we retrospectively explored the role of improving VILI in cognitive impairment treatment. This work contributes to a better understanding of the pathogenesis of VILI-induced cognitive impairment and may provide future direction for the treatment and prognosis of cognitive impairment.

Augmentative and alternative communication tools for mechanically ventilated patients in intensive care units: A scoping review

OBJECTIVES

The aim of this scoping review was to understand the extent and type of evidence on augmentative and alternative communication tools used with mechanically ventilated patients in the intensive care unit.

REVIEW METHOD USED

This scoping review was conducted using Arksey and O'Malley's methodological framework, followed by PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to provide a structured approach to analysis of reviews.

DATA SOURCES

In December 2021, six electronic databases-CENTRAL, CINAHL, Embase, Medline (Ebscohost), PyscINFO, and Web of Science-were searched. Searches were supplemented with hand searching of reference lists of included studies.

REVIEW METHODS

Studies were selected according to inclusion and exclusion criteria. Full-text review was completed by two independent authors, with any disagreement resolved by consensus or with consultation with a third reviewer. A table was developed to extract key information from the eligible studies. The Mixed Methods Appraisal Tool and Supporting the Use of Research Evidence checklist were used to quality appraise the selected primary research and reviews, respectively.

RESULTS

Twenty-three studies (19 primary studies and four reviews) were included in the review. Findings highlighted five main patterns: (i) Co-designing of the augmentative and alternative communication tools; (ii) Patients' and healthcare professionals' training needs on augmentative and alternative communication tools; (iii) Implementation of validated communication assessment algorithms; (iv) Amalgamate several communication methods/approaches; (v) Technical competency required for high-technology augmentative and alternative communication tools.

CONCLUSION

Both low- and high-technology augmentative and alternative communication tools are widely used for mechanically ventilated patients in intensive care units, but there is a need for systematically assessing the communication needs and implementing communication interventions to promote meaningful patient-centred clinical outcomes.

Individualised analgesia, sedation, delirium and comfort management strategies in the ICU: a narrative review

This group is a product of the collaboration agreement signed by SOMIAMA (Sociedad de Medicina Intensiva de Madrid) and SAR MADRID (Sociedad de Anestesiología, Reanimación y Terapéutica del Dolor de Madrid) under which the organisations agreed to create joint working groups to improve critical patient care. Pain, discomfort, agitation, and delirium cause suffering, delay discharge, and can lead to serious complications in patients admitted to medical and surgical critical care units and post-anaesthesia care units. The main objectives in this type of unit include: Ensuring the comfort of patients suffering or recovering from a critical illness.Avoiding complications associated with the measures, particularly pharmacological, taken to ensure that comfort.

Clinical practice guideline recommendations for diagnosis and management of anxiety and depression in hospitalized adults with delirium: a systematic review

BACKGROUND

Delirium commonly occurs in hospitalized adults. Psychiatric disorders such as anxiety, depression, and post-traumatic stress disorder (PTSD) can co-occur with delirium, and can be recognized and managed by clinicians using recommendations found in methodological guiding statements called Clinical Practice Guidelines (CPGs). The specific aims of this review were to: [1] synthesize CPG recommendations for the diagnosis and management of anxiety, depression, and PTSD in adults with delirium in acute care; and [2] identify recent published literature in addition to those identified and reported in a 2017 review on delirium CPG recommendations and quality.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, and 21 sites on the Canadian Agency for Drugs and Technologies listed in the Health Grey Matters Lite tool were searched from inception to February 12, 2021. Selected CPGs focused on delirium in acute care, were endorsed by an international scientific society or governmental organization, and contained at least one recommendation for the diagnosis or management of delirium. Two reviewers independently extracted data in duplicate and independently assessed CPG quality using the AGREE-II tool. Narrative synthesis of CPG recommendations was conducted.

RESULTS

Title and abstract screening was completed on 7611 records. Full-text review was performed on 197 CPGs. The final review included 27 CPGs of which 7 (26%) provided recommendations for anxiety (4/7, 57%), depression (5/7, 71%), and PTSD (1/7, 14%) in delirium. Twenty CPGs provided recommendations for delirium only (e.g., assess patient regularly, avoid use of benzodiazepines). Recommendations for the diagnosis of psychiatric disorders with delirium included using evidence-based diagnostic criteria and standardized screening tools. Recommendations for the management of psychiatric disorders with delirium included pharmacological (e.g., anxiolytics, antidepressants) and non-pharmacological interventions (e.g., promoting patient orientation using clocks). Guideline quality varied: the lowest was Applicability (mean = 36%); the highest Clarity of Presentation (mean = 76%).

CONCLUSIONS

There are few available evidence-based CPGs to facilitate appropriate diagnosis and management of anxiety, depression, and PTSD in patients with delirium in acute care. Future guideline developers should incorporate evidence-based recommendations on the diagnosis and management of these psychiatric disorders in delirium.

SYSTEMATIC REVIEW REGISTRATION

Registration number: PROSPERO (CRD42021237056).

Sedation and shivering management after cardiac arrest

Management of sedation and shivering during targeted temperature management (TTM) after cardiac arrest is limited by a dearth of high-quality evidence to guide clinicians. Data from general intensive care unit (ICU) populations can likely be extrapolated to post-cardiac arrest patients, but clinicians should be mindful of key differences that exist between these populations. Most importantly, the goals of sedation after cardiac arrest are distinct from other ICU patients and may also involve suppression of shivering during TTM. Drug metabolism and clearance are altered considerably during TTM when a low goal temperature is used, which can delay accurate neuroprognostication. When neuromuscular blockade is used to prevent shivering, sedation should be deep enough to prevent awareness and providers should be aware that this can mask clinical manifestations of seizures. However, excessively deep or prolonged sedation is associated with complications including delirium, infections, increased duration of ventilatory support, prolonged ICU length of stay, and delays in neuroprognostication. In this manuscript, we review sedation and shivering management best practices in the post-cardiac arrest patient population.

Facilitators and Barriers Influencing Antipsychotic Medication Prescribing and Deprescribing Practices in Critically Ill Adult Patients: a Qualitative Study

BACKGROUND

Antipsychotic medications do not alter the incidence or duration of delirium, but these medications are frequently prescribed and continued at transitions of care in critically ill patients when they may no longer be necessary or appropriate.

OBJECTIVE

The purpose of this study was to identify and describe relevant domains and constructs that influence antipsychotic medication prescribing and deprescribing practices among physicians, nurses, and pharmacists that care for critically ill adult patients during and following critical illness.

DESIGN

We conducted qualitative semi-structured interviews with critical care and ward healthcare professionals including physicians, nurses, and pharmacists to understand antipsychotic prescribing and deprescribing practices for critically ill adult patients during and following critical illness.

PARTICIPANTS

Twenty-one interviews were conducted with 11 physicians, five nurses, and five pharmacists from predominantly academic centres in Alberta, Canada, between July 6 and October 29, 2021.

MAIN MEASURES

We used deductive thematic analysis using the Theoretical Domains Framework (TDF) to identify and describe constructs within relevant domains.

KEY RESULTS

Seven TDF domains were identified as relevant from the analysis: Social/Professional role and identity; Beliefs about capabilities; Reinforcement; Motivations and goals; Memory, attention, and decision processes; Environmental context and resources; and Beliefs about consequences. Participants reported antipsychotic prescribing for multiple indications beyond delirium and agitation including patient and staff safety, sleep management, and environmental factors such as staff availability and workload. Participants identified potential antipsychotic deprescribing strategies to reduce ongoing antipsychotic medication prescriptions for critically ill patients including direct communication tools between prescribers at transitions of care.

CONCLUSIONS

Critical care and ward healthcare professionals report several factors influencing established antipsychotic medication prescribing practices. These factors aim to maintain patient and staff safety to facilitate the provision of care to patients with delirium and agitation limiting adherence to current guideline recommendations.

Thinking Clearly: The History of Brain Dysfunction in Critical Illness

Brain dysfunction during critical illness (ie, delirium and coma) is extremely common, and its lasting effect has only become increasingly understood in the last two decades. Brain dysfunction in the intensive care unit (ICU) is an independent predictor of both increased mortality and long-term impairments in cognition among survivors. As critical care medicine has grown, important insights regarding brain dysfunction in the ICU have shaped our practice including the importance of light sedation and the avoidance of deliriogenic drugs such as benzodiazepines. Best practices are now strategically incorporated in targeted bundles of care like the ICU Liberation Campaign's ABCDEF Bundle.

Effect of binaural beat music and noise cancelling headphones on intraoperative anxiety in patients undergoing spinal anaesthesia - A randomised controlled study

Background and Aims

This study aimed to determine the effects of music and active noise cancellation on intraoperative anxiety in patients undergoing lower limb surgeries under spinal anaesthesia.

Methods

After obtaining ethical approval, this randomised controlled study was conducted in adult patients (18-50 years of age) of either gender. Patients were randomly allocated to binaural beat music (Group A), noise cancellation (Group B) or no headphones (Group C) group (n = 36 in each group). State-Trait Anxiety Inventory-6 (STAI-6) score and Visual Analogue Score for Satisfaction (VAS-S) were noted preoperatively and at the end of surgery. In addition, Ramsay sedation scores and Likert communication difficulty scores were noted at 30 min intraoperatively. Haemodynamic parameters were noted preoperatively and at different intervals intraoperatively till the end of the surgery.

Results

There was a significant decrease in anxiety scores in Group A, Group B and Group C with postoperative STAI-6 scores (mean ± standard deviation) of 7.8 ± 1.7, 11.7 ± 4.2 and 14.7 ± 5.3, respectively. The difference was significant in Groups A and B compared to Group C (P < 0.001). Patient satisfaction scores in Groups A and B were better than in Group C (7.3 ± 1.7 and 6.2 ± 1.6 vs. 5.2 ± 1.3, respectively). Sedation scores and communication difficulty was significantly better in Groups A and B compared to Group C. Systolic blood pressure was significantly better intra- and postoperatively. There were no significant differences in other haemodynamic parameters on most occasions.

Conclusion

Music and noise-cancellation headphones can reduce anxiety and improve satisfaction and sedation scores in patients undergoing spinal anaesthesia.

Intraoperative serum lactate levels as a prognostic predictor of outcome for emergency abdominal surgery: a retrospective study

BACKGROUND

The relationship between intraoperative lactate levels and prognosis after emergency gastrointestinal surgery remains unclear. The purpose of this study was to investigate the prognostic value of intraoperative lactate levels for predicting in-hospital mortality, and to examine intraoperative hemodynamic managements.

METHODS

We conducted a retrospective observational study of emergency GI surgeries performed at our institution between 2011 and 2020. The study group comprised patients admitted to intensive care units postoperatively, and whose intraoperative and postoperative lactate levels were available. Intraoperative peak lactate levels (intra-LACs) were selected for analysis, and in-hospital mortality was set as the primary outcome. The prognostic value of intra-LAC was assessed using logistic regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 551 patients included in the study, 120 died postoperatively. Intra-LAC in the group who survived and the group that died was 1.80 [interquartile range [IQR], 1.19-3.01] mmol/L and 4.22 [IQR, 2.15-7.13] mmol/L (P < 0.001), respectively. Patients who died had larger volumes of red blood cell (RBC) transfusions and fluid administration, and were administered higher doses of vasoactive drugs. Logistic regression analysis showed that intra-LAC was an independent predictor of postoperative mortality (odds ratio [OR] 1.210, 95% CI 1.070 -1.360, P = 0.002). The volume of RBCs, fluids transfused, and the amount of vasoactive agents administered were not independent predictors. The area under the curve (AUC) of the ROC curve for intra-LAC for in-hospital mortality was 0.762 (95% confidence interval [CI], 0.711-0.812), with a cutoff value of 3.68 mmol/L by Youden index.

CONCLUSIONS

Intraoperative lactate levels, but not hemodynamic management, were independently associated with increased in-hospital mortality after emergency GI surgery.

Prevalence of comorbidities post mild traumatic brain injuries: a traumatic brain injury model systems study

Traumatic brain injury (TBI) is associated with an increased risk of long-lasting health-related complications. Survivors of brain trauma often experience comorbidities which could further dampen functional recovery and severely interfere with their day-to-day functioning after injury. Of the three TBI severity types, mild TBI constitutes a significant proportion of total TBI cases, yet a comprehensive study on medical and psychiatric complications experienced by mild TBI subjects at a particular time point is missing in the field. In this study, we aim to quantify the prevalence of psychiatric and medical comorbidities post mild TBI and understand how these comorbidities are influenced by demographic factors (age, and sex) through secondary analysis of patient data from the TBI Model Systems (TBIMS) national database. Utilizing self-reported information from National Health and Nutrition Examination Survey (NHANES), we have performed this analysis on subjects who received inpatient rehabilitation at 5 years post mild TBI. Our analysis revealed that psychiatric comorbidities (anxiety, depression, and post-traumatic stress disorder (PTSD)), chronic pain, and cardiovascular comorbidities were common among survivors with mild TBI. Furthermore, depression exhibits an increased prevalence in the younger compared to an older cohort of subjects whereas the prevalence of rheumatologic, ophthalmological, and cardiovascular comorbidities was higher in the older cohort. Lastly, female survivors of mild TBI demonstrated increased odds of developing PTSD compared to male subjects. The findings of this study would motivate additional analysis and research in the field and could have broader implications for the management of comorbidities after mild TBI.

Time-course relationship between cerebrospinal fluid and serum concentrations of midazolam and albumin in patients with cardiac arrest undergoing targeted temperature management

AIM

To understand the serum and cerebrospinal fluid (CSF) distribution of midazolam is important for proper timing of neurological prognostication of targeted temperature management(TTM) patients. Midazolam binds extensively to albumin in serum although non protein bound form exist in CSF. We investigated the time-course of CSF, serum concentrations of midazolam and albumin in patients with cardiac arrest who underwent TTM.

METHODS

This prospective, single-center, observational study was conducted between May 2020 and April 2022. Midazolam and albumin concentrations in CSF and serum were quantified 0, 24, 48, and 72 h after the return of spontaneous circulation for comparison between the good (Cerebral Performance Category (CPC) 1 and 2) and poor (CPC 3, 4, and 5) neurologic outcome groups. The CSF/serum (C/S) ratios of midazolam and albumin concentrations were determined, along with their correlation coefficients.

RESULTS

Of the 19 enrolled patients, 13 experienced poor outcomes. At 0 h, serum midazolam concentrations were the lowest, whereas serum albumin levels were the highest; in the CSF, the concentrations of both peaked at 24 h. There were no significant inter-group differences in midazolam concentrations in CSF or serum. The C/S ratios of midazolam and albumin significantly differed between the groups. Moderate to strong positive correlations were observed between the midazolam and albumin C/S ratios.

CONCLUSION

In CSF, midazolam and albumin concentrations peaked 24 h post-cardiac arrest. Midazolam and albumin C/S ratios were significantly higher in the poor outcome group and positively correlated with each other, suggesting blood-brain barrier disruption 24 h post-cardiac arrest.

Dexmedetomidine versus haloperidol for sedation of non-intubated patients with hyperactive delirium during the night in a high dependency unit: study protocol for an open-label, parallel-group, randomized controlled trial (DEX-HD trial)

BACKGROUND

Delirium is common in critically ill patients. Haloperidol has long been used for the treatment of delirium. Dexmedetomidine has recently been used to treat delirium among intubated critically ill patients. However, the efficacy of dexmedetomidine for delirium in non-intubated critically ill patients remains unknown. We hypothesize that dexmedetomidine is superior to haloperidol for sedation of patients with hyperactive delirium, and would reduce the prevalence of delirium among non-intubated patients after administration. We will conduct a randomized controlled trial to compare dexmedetomidine and haloperidol for the treatment of nocturnal hyperactive delirium in non-intubated patients in high dependency units (HDUs).

METHODS

This is an open-label, parallel-group, randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for nocturnal hyperactive delirium in non-intubated patients at two HDUs of a tertiary hospital. We will recruit consecutive non-intubated patients who are admitted to the HDU from the emergency room, and allocate them in a 1:1 ratio to the dexmedetomidine or haloperidol group in advance. The allocated investigational drug will be administered only when participants develop hyperactive delirium (Richmond Agitation-Sedation Scale [RASS] score ≥1 and a positive score on the Confusion Assessment Method for the ICU between 19:00 and 6:00 the next day) during the night at an HDU. Dexmedetomidine is administered continuously, while haloperidol is administered intermittently. The primary outcome is the proportion of participants who achieve the targeted sedation level (RASS score of between -3 and 0) 2h after the administration of the investigational drug. Secondary outcomes include the sedation level and prevalence of delirium on the day following the administration of the investigational drugs, and safety. We plan to enroll 100 participants who develop nocturnal hyperactive delirium and receive one of the two investigational drugs.

DISCUSSION

This is the first randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for sedation of non-intubated critically ill patients with hyperactive delirium in HDUs. The results of this study may confirm whether dexmedetomidine could be another option to sedate patients with hyperactive delirium.

TRIAL REGISTRATION

Japan Registry of Clinical Trials, jRCT1051220015, registered on 21 April 2022.

Propofol in ICU Settings: Understanding and Managing Anti-Arrhythmic, Pro-Arrhythmic Effects, and Propofol Infusion Syndrome

Propofol has revolutionized anesthesia and intensive care medicine owing to its favorable pharmacokinetic characteristics, fast onset, and short duration of action. This drug has been shown to be remarkably effective in numerous clinical scenarios. In addition, propofol has maintained an overwhelmingly favorable safety profile; however, it has been associated with both antiarrhythmic and proarrhythmic effects. This review concisely summarizes the dual arrhythmic cardiovascular effects of propofol and a rare but serious complication, propofol infusion syndrome (PRIS). We also discuss the need for careful patient evaluation, compliance with recommended infusion rates, and vigilant monitoring.

Ketamine-propofol (ketofol) in procedural sedation: a narrative review

Sedation methods for dental treatment are increasingly explored. Recently, ketofol, which is a combination of ketamine and propofol, has been increasingly used because the advantages and disadvantages of propofol and ketamine complement each other and increase their effectiveness. In this review, we discuss the pharmacology of ketamine and propofol, use of ketofol in various clinical situations, and differences in efficacy between ketofol and other sedatives.

Development of a compounded propofol nanoemulsion using multiple non-invasive process analytical technologies

Propofol is the preferred anaesthetic for induction and maintenance of sedation in critically ill mechanically ventilated COVID-19 patients. However, during the outbreak of the COVID-19 pandemic, regular supply chains could not keep up with the sudden increase in global demand, causing drug shortages. Propofol is formulated as an oil-in-water emulsion which is administered intravenously. This study explores the extemporaneous preparation of a propofol emulsion without specialized manufacturing equipment to temporally alleviate such shortages. A commercially available lipid emulsion (IVLE, SMOFlipid 20%), intended for parenteral nutrition, was used to create a propofol loaded nanoemulsion via addition of liquid propofol drug substance and subsequent mixing. Critical quality attributes such as mean droplet size and the volume-weighted percentage of large-diameter (>5µm) droplets were studied. The evolution of droplet size and propofol distribution was monitored in situ and non-destructively, maintaining sterility, using Spatially Resolved Dynamic Light Scattering and Near Infrared Spectroscopy, respectively. Using response surface methodology, an optimum was found for a 4% w/v propofol formulation with a ∼15 minute mixing time in a flask shaker at a 40° shaking angle. This study shows that extemporaneous compounding is a viable option for emergency supply of propofol drug product during global drug shortages.

Sedation for adult ICU patients: A narrative review including a retrospective study of our own data

The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.

Exploration of teaching practice of analgesia and sedation in mainland China: CASER experience

Objective

Analgesia and sedation assessments vary widely in clinical performance. This study investigated the cognition of intensivist and the importance of training for analgesia and sedation through the Chinese Analgesia and Sedation Education & Research (CASER) group training program.

Methods

A total of 107 participants studied the training courses on the "Sedation, Analgesia and Consciousness Assessment of Critically Ill Patients" held by CASER from June 2020 to June 2021. Ninety-eight valid questionnaires were recovered. The content of the questionnaire included the preface, general information of the trainees, students' awareness of the importance of analgesia and sedation evaluation and related guidelines, and professional test questions.

Results

All respondents were senior professionals engaged in the ICU. A total of 92.86% believed that analgesia and sedation treatment were very important parts of the ICU, and 76.5% believed that they had mastered relevant professional knowledge. However, when evaluating the relevant professional theory and practice of the respondents from an objective point of view, it can be seen that only 28.57% of the respondents could reach the passing line in the specific case analysis scenario. Before participating in the training, 42.86% of the medical staff believed that analgesia and sedation treatment should be evaluated in the daily work of the ICU; after participating in the training, 62.24% of the medical staff believed that the evaluation was necessary and believed that they had improved after the training. Moreover, 69.4% of the respondents affirmed the necessity and significance of jointly undertaking the task of analgesia and sedation in Chinese ICUs.

Conclusion

This study revealed that the assessment of analgesia and sedation is not standardized in the ICU in mainland China. The importance and significance of standardized training for analgesia and sedation are presented. The CASER working group thus established has a long way to go in its future work.

Are GABAergic drugs beneficial in providing neuroprotection after traumatic brain injuries? A comprehensive literature review of preclinical studies

Traumatic brain injuries (TBI) caused by physical impact to the brain can adversely impact the welfare and well-being of the affected individuals. One of the leading causes of mortality and dysfunction in the world, TBI is a major public health problem facing the human community. Drugs that target GABAergic neurotransmission are commonly used for sedation in clinical TBI yet their potential to cause neuroprotection is unclear. In this paper, I have performed a rigorous literature review of the neuroprotective effects of drugs that increase GABAergic currents based on the results reported in preclinical literature. The drugs covered in this review include the following: propofol, benzodiazepines, barbiturates, isoflurane, and other drugs that are agonists of GABA_A receptors. A careful review of numerous preclinical studies reveals that these drugs fail to produce any neuroprotection after a primary impact to the brain. In numerous circumstances, they could be detrimental to neuroprotection by increasing the size of the contusional brain tissue and by severely interfering with behavioral and functional recovery. Therefore, anesthetic agents that work by enhancing the effect of neurotransmitter GABA should be administered with caution of TBI patients until a clear and concrete picture of their neuroprotective efficacy emerges in the clinical literature.

Cardiac Arrest Treatment Center Differences in Sedation and Analgesia Dosing During Targeted Temperature Management

BACKGROUND

Sedation and analgesia are recommended during targeted temperature management (TTM) after cardiac arrest, but there are few data to provide guidance on dosing to bedside clinicians. We evaluated differences in patient-level sedation and analgesia dosing in an international multicenter TTM trial to better characterize current practice and clinically important outcomes.

METHODS

A total 950 patients in the international TTM trial were randomly assigned to a TTM of 33 °C or 36 °C after resuscitation from cardiac arrest in 36 intensive care units. We recorded cumulative doses of sedative and analgesic drugs at 12, 24, and 48 h and normalized to midazolam and fentanyl equivalents. We compared number of medications used, dosing, and titration among centers by using multivariable models, including common severity of illness factors. We also compared dosing with time to awakening, incidence of clinical seizures, and survival.

RESULTS

A total of 614 patients at 18 centers were analyzed. Propofol (70%) and fentanyl (51%) were most frequently used. The average dosages of midazolam and fentanyl equivalents were 0.13 (0.07, 0.22) mg/kg/h and 1.16 (0.49, 1.81) µg/kg/h, respectively. There were significant differences in number of medications (p < 0.001), average dosages (p < 0.001), and titration at all time points between centers (p < 0.001), and the outcomes of patients in these centers were associated with all parameters described in the multivariate analysis, except for a difference in the titration of sedatives between 12 and 24 h (p = 0.40). There were associations between higher dosing at 48 h (p = 0.003, odds ratio [OR] 1.75) and increased titration of analgesics between 24 and 48 h (p = 0.005, OR 4.89) with awakening after 5 days, increased titration of sedatives between 24 and 48 h with awakening after 5 days (p < 0.001, OR > 100), and increased titration of sedatives between 24 and 48 h with a higher incidence of clinical seizures in the multivariate analysis (p = 0.04, OR 240). There were also significant associations between decreased titration of analgesics and survival at 6 months in the multivariate analysis (p = 0.048).

CONCLUSIONS

There is significant variation in choice of drug, dosing, and titration when providing sedation and analgesics between centers. Sedation and analgesia dosing and titration were associated with delayed awakening, incidence of clinical seizures, and survival, but the causal relation of these findings cannot be proven.

What Is Known about Midazolam? A Bibliometric Approach of the Literature

Midazolam is a drug with actions towards the central nervous system producing sedative and anticonvulsants effects, used for sedation and seizures treatments. A better understanding about its effects in the different scenarios presented in the literature could be helpful to gather information regarding its clinical indications, pharmacological interactions, and adverse events. From this perspective, the aim of this study was to analyze the global research about midazolam mapping, specifically the knowledge of the 100 most-cited papers about this research field. For this, a search was executed on the Web of Science-Core Collection database using bibliometric methodological tools. The search strategy retrieved 34,799 articles. A total of 170 articles were evaluated, with 70 articles being excluded for not meeting the inclusion criteria. The 100 most-cited articles rendered 42,480 citations on WoS-CC, ranging from 253 to 1744. Non-systematic review was the most published study type, mainly from North America, during the period of 1992 to 2002. The most frequent keywords were midazolam and pharmacokinetics. Regarding the authors, Thummel and Kunze were the ones with the greatest number of papers included. Our findings showed the global research trends about midazolam, mainly related to its different effects and uses throughout the time.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review

Background

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery.

Objective

Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients.

Design

We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients.

Settings

General adult intensive care units.

Participants

Health care professionals working in adult intensive care units.

Methods

Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis.

Results

Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation.

Conclusions

A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence.

Tweetable abstract

Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

Overview of the Medical Management of the Critically Ill Patient

The medical management of the critically ill patient focuses predominantly on treatment of the underlying condition (e g, sepsis or respiratory failure). However, in the past decade, the importance of initiating early prophylactic treatment for complications arising from care in the intensive care unit setting has become increasingly apparent. As survival from critical illness has improved, there is an increased prevalence of postintensive care syndrome-defined as a decline in physical, cognitive, or psychologic function among survivors of critical illness. The Intensive Care Unit Liberation Bundle, a major initiative of the Society of Critical Care Medicine, is centered on facilitating the return to normal function as early as possible, with the intent of minimizing iatrogenic harm during necessary critical care. These concepts are universally applicable to patients seen by nephrologists in the intensive care unit and may have particular relevance for patients with kidney failure either on dialysis or after kidney transplant. In this article, we will briefly summarize some known organ-based consequences associated with critical illness, review the components of the ABCDEF bundle (the conceptual framework for Intensive Care Unit Liberation), highlight the role nephrologists can play in implementing and complying with the ABCDEF bundle, and briefly discuss areas for additional research.

Thirst in adult patients in the intensive care unit: protocol for a scoping review

INTRODUCTION

Thirst is one of the most bothersome symptoms experienced by intensive care unit (ICU) patients. Effective diagnosis and management of thirst in the ICU is essential, particularly as patients are less sedated than previously and more aware of this problem. Currently, no overview of publications on thirst identification and management in ICU patients exists. The scoping review will address the broad question 'What is known about thirst as a symptom in adult critically ill patients?' It aims to provide an overview of the causes and risk factors, diagnosis and measurement, the symptom dimensions and its interaction with other symptoms, and thirst management.

METHODS AND ANALYSIS

The review will follow the Joanna Briggs Institute methodology framework to guide the process and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Methods include: defining the review questions, eligibility criteria, concepts of interest and context; and outlining the search strategy, study selection process, data extraction and analysis. PubMed, MEDLINE, EMBASE and CINAHL will be searched from inception to April 2022.

ETHICS AND DISSEMINATION

Ethical approval is not required, as the scoping review will synthesise information from available publications. The scoping review will be submitted for publication to a scientific journal, presented at relevant conferences and disseminated as part of future workshops with ICU support groups and the critical care professional community.

Role of acupuncture in critically ill patients: A systematic review

Acupuncture is part of a complex medical approach used in China for about 2000 years, known as Traditional Chinese Medicine, whose central assumption is that health occurs when the patterned energy flow throughout the body is balanced. Within this paradigm, acute illness occurs when a major state of imbalance or disruption arises, and the use of acupuncture may help in correcting these imbalances. While the Chinese hospital system often offers the integration of traditional and western medicine, in Europe and the United States this combined approach is infrequently practiced. However, several investigations have consistently shown the effectiveness of acupuncture for different aspects of critical illness. The aim of this systematic review is to increase the clinician's awareness of the current evidence regarding the use of acupuncture for the management of critically ill patients, both alone or as a complement to western medicine. The effects of acupuncture on critical illness, with a particular focus on respiratory function, pain and delirium treatment and prevention, circulatory function, nutritional support, and recovery after acute illness are explored and summarized, and evidence is provided that acupuncture is an acceptable and feasible option for the management of several aspects of critical illness. In addition, we suggest a practical selection of potentially useful acupuncture points in the critical care setting, with indications for simple localization and the correct puncture method.

The incidence of propofol infusion syndrome in critically-ill patients

PURPOSE

PRIS is a potentially fatal syndrome characterized by various clinical symptoms and abnormalities. Experts suggest that propofol treatment duration ≥48 h or dose ≥83 μg/kg/min is associated with developing PRIS. We hypothesized PRIS might be underdiagnosed due to the overlap of PRIS clinical manifestations with critical illnesses.

MATERIALS AND METHODS

Multihospital, retrospective study of adult patients who received continuous propofol infusion ≥48 h or dose ≥60μg/kg/min for >24 h since admission were assessed for the development of PRIS.

RESULTS

The incidence of PRIS was 2.9% with a PRIS-associated mortality rate of 36.8%. In PRIS patients, propofol was administered at a median dose of 36.4 μg/kg/min and over a median duration of 147.0 h. The development of PRIS was observed at a median of 125.0 h post-propofol initiation and a cumulative dose of 276.5 mg/kg. The development of metabolic acidosis (78.9%), cardiac dysfunction (52.6%), hypertriglyceridemia (100%), and rhabdomyolysis (26.3%) were observed in our PRIS patients.

CONCLUSION

PRIS can often be overlooked and underdiagnosed. It is important to monitor for early signs of PRIS in patients who are on prolonged propofol infusion. Prompt recognition and interventions can minimize the dangers resulting from PRIS.

Inhaled Anesthetics for Sedation in ICU: Widening Horizons!

How to cite this article: Krishna B. Inhaled Anesthetics for Sedation in ICU: Widening Horizons! Indian J Crit Care Med 2022;26(8):889–891.

Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Adult Patients: Recommendations from an International Expert Panel-Based Consensus

BACKGROUND

The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear.

METHODS

A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus.

RESULTS

According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues.

CONCLUSIONS

Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.

Opioid Prescribing Patterns Before, During, and After Critical Illness: An Observational Study

OBJECTIVES:

The association between opioid therapy during critical illness and persistent opioid use after discharge is understudied relative to ICU opioid exposure and modifiable risk factors. Our objectives were to compare persistent opioid use after discharge among patients with and without chronic opioid use prior to admission (OPTA) and identify risk factors associated with persistent use.

DESIGN:

Retrospective cohort study.

SETTING:

Medical, trauma/surgical, or neurologic ICU at an academic hospital.

PARTICIPANTS:

Adult patients surviving hospital admission.

INTERVENTIONS:

Opioid use during the ICU and post-ICU stays.

MEASUREMENTS AND MAIN RESULTS:

The primary outcome was persistent opioid use accounting for greater than 70% of days 4–6 months after discharge. Among 2,975 included patients, 257 (8.6%) were classified as OPTA, and 305 (10.2%) persistently filled opioid prescriptions, including 186/257 (72%) OPTA and 119/2,718 (4.4%) with no chronic opioid fills prior to admission. Among all patients, OPTA was strongly associated with persistent opioid use (odds ratio, 57.2 [95% CI, 41.4–80.0]). Multivariable logistic regression revealed that male sex, surgical procedure, and ICU opioid-free days were associated with reduced persistent opioid use for OPTA patients. Age and ICU opioid-free days were associated with reduced persistent opioid use for non-OPTA patients. Total ICU opioid dose and dose per day of ICU exposure were not associated with persistent use for either group.

CONCLUSIONS:

In this mixed cohort of ICU patients, 10.2% persistently filled opioid prescriptions 4–6 months after discharge. Although ICU opioid doses were not associated with persistent use, duration of ICU opioid administration is a modifiable risk factor that may reduce persistent opioid use after critical illness.

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross-Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices

Purpose

The study aimed to explore factors associated with deep sedation practice in intensive care units (ICUs).

Materials and Methods

A post hoc analysis was conducted for a cross–sectional survey on sedation practices in mechanically ventilated (MV) patients, combined with a questionnaire for physicians regarding their preferences for light sedation (P–pls Score) in 92 Chinese ICUs.

Results

There were 457 and 127 eligible MV patients in the light and deep sedation groups respectively. A multivariable logistic regression analysis demonstrated that the control mode of mechanical ventilation, plasma lactate level, and the Sequential Organ Failure Assessment (SOFA) score were independent risk factors for deep sedation practice (p <0.01). Notably, the adjusted odds ratio (95% CI) of the average P–pls score in the ICU ≤ 2 for deep sedation practice was 1.861 (1.163, 2.978, p = 0.01). In addition, the areas under curves of receiver operating characteristics (AUC–ROC) of the model to predict the probability of deep sedation practice were 0.753 (0.699, 0.806) and 0.772 (0.64, 0.905) in the training set and the validation set, respectively. The 28–day mortality was increased in patients with exposure to deep sedation practice but not significantly.

Conclusion

Both factors related to stressful stimuli and the ICU physicians' perception of patient tolerability in mechanical ventilation were likely associated with deep sedation practice in MV patients.

Dexmedetomidine Reduces Incidences of Ventricular Arrhythmias in Adult Patients: A Meta-Analysis

Purpose

To assess the antiarrhythmic properties of dexmedetomidine in patients in the intensive care unit.

Methods

A literature review was conducted with Ovid MEDLINE (R), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, and Scopus. Study Selection. Randomized controlled trials were included, examining the incidence of ventricular arrhythmias, ventricular tachycardia, or ventricular fibrillation with dexmedetomidine compared to placebo or an alternative sedative agent. For each publication that met the selection criteria, the patient demographics, incidence of arrhythmias, mortality, and adverse events were collected. Data extraction was carried out by two authors independently.

Results

We identified 6 out of 126 studies that met the selection criteria for our meta-analysis, all of which focused on the perioperative cardiac surgery period. Patients receiving dexmedetomidine demonstrated a significant reduction of the overall incidence of ventricular arrhythmias (RR 0.35, 95% CI 0.16, 0.76). In particular, dexmedetomidine significantly decreased the risk of ventricular tachycardia compared with control (RR 0.25, 95% CI 0.08, 0.80, I² 0%). Regarding adverse events, dexmedetomidine significantly increased the frequency of bradycardia (RR 2.78 95% CI 2.00, 3.87). However, there was no significant difference in mortality (RR 0.59 95% CI 0.12, 3.02).

Conclusion

From this meta-analysis, we report a decreased incidence of ventricular tachycardia with dexmedetomidine in critically ill patients. This result favors the use of dexmedetomidine for its antiarrhythmic properties.

Successful weaning of a patient with severe COVID-19 pneumonia under prolonged midazolam sedation using morphine

The coronavirus disease 2019 (COVID-19) pandemic continues to spread around the world. In April 2021, Japan experienced a fourth wave of COVID-19 infections, which led to the breakdown of the medical system. Osaka, Japan, was particularly affected, with many severe cases and the highest number of COVID-19-associated deaths in Japan. Herein, we present a patient with severe COVID-19 infection who received prolonged midazolam (MDZ) treatment since propofol was not available due to shortage of medical resources. Moreover, the duration of mechanical ventilation was extended due to the development of a pneumothorax. When MDZ tapering was initiated, tachypnea was observed, which resulted failure in ventilator weaning. However, the use of continuous morphine infusion led a successful weaning off the ventilator. We suggest that the administration of morphine may allow for a smoother weaning process for some patients with severe COVID-19 infection.

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.

Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis

BACKGROUND

Convulsive status epilepticus is defined as ≥ 5 minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. It is regarded as an emergency condition that requires prompt treatment to avoid hospitalisation and to reduce morbidity and mortality. Rapid pre-hospital first-line treatment of convulsive status epilepticus is currently benzodiazepines, administered either by trained caregivers in the community (e.g. buccal midazolam, rectal diazepam) or by trained health professionals via intramuscular or intravenous routes (e.g. midazolam, lorazepam). There is a lack of clarity about the optimal treatment for convulsive status epilepticus in the pre-hospital setting.

OBJECTIVES

To assess the current evidence on the clinical effectiveness and cost-effectiveness of treatments for adults with convulsive status epilepticus in the pre-hospital setting.

DATA SOURCES

We searched major electronic databases, including MEDLINE, EMBASE, PsycInfo®, CINAHL, CENTRAL, NHS Economic Evaluation Database, Health Technology Assessment Database, Research Papers in Economics, and the ISPOR Scientific Presentations Database, with no restrictions on publication date or language of publication. Final searches were carried out on 21 July 2020.

REVIEW METHODS

Systematic review of randomised controlled trials assessing adults with convulsive status epilepticus who received treatment before or on arrival at the emergency department. Eligible treatments were any antiepileptic drugs offered as first-line treatments, regardless of their route of administration. Primary outcomes were seizure cessation, seizure recurrence and adverse events. Two reviewers independently screened all citations identified by the search strategy, retrieved full-text articles, extracted data and assessed the risk of bias of the included trials. Results were described narratively.

RESULTS

Four trials (1345 randomised participants, of whom 1234 were adults) assessed the intravenous or intramuscular use of benzodiazepines or other antiepileptic drugs for the pre-hospital treatment of convulsive status epilepticus in adults. Three trials at a low risk of bias showed that benzodiazepines were effective in stopping seizures. In particular, intramuscular midazolam was non-inferior to intravenous lorazepam. The addition of levetiracetam to clonazepam did not show clear advantages over clonazepam alone. One trial at a high risk of bias showed that phenobarbital plus optional phenytoin was more effective in terminating seizures than diazepam plus phenytoin. The median time to seizure cessation from drug administration varied from 1.6 minutes to 15 minutes. The proportion of people with recurrence of seizures ranged from 10.4% to 19.1% in two trials reporting this outcome. Across trials, the rates of respiratory depression among participants receiving active treatments were generally low (from 6.4% to 10.6%). The mortality rate ranged from 2% to 7.6% in active treatment groups and from 6.2% to 15.5% in control groups. Only one study based on retrospective observational data met the criteria for economic evaluation; therefore, it was not possible to draw any robust conclusions on cost-effectiveness.

LIMITATIONS

The limited number of identified trials and their differences in terms of treatment comparisons and outcomes hindered any meaningful pooling of data. None of the included trials was conducted in the UK and none assessed the use of buccal midazolam or rectal diazepam. The review of economic evaluations was hampered by lack of suitable data.

CONCLUSIONS

Both intravenous lorazepam and intravenous diazepam administered by paramedics are more effective than a placebo in the treatments of adults with convulsive status epilepticus, and intramuscular midazolam is non-inferior to intravenous lorazepam. Large well-designed clinical trials are needed to establish which benzodiazepines are more effective and preferable in the pre-hospital setting.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020201953.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 20. See the NIHR Journals Library website for further project information.

The complications of opioid use during and post-intensive care admission: A narrative review

Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. As a result, these patients are potentially exposed to high opioid doses for prolonged periods, increasing the risk of adverse effects. Adverse effects relevant to these critically ill patients include delirium, intensive care unit-acquired infections, acute opioid tolerance, iatrogenic withdrawal syndrome, opioid-induced hyperalgesia, persistent opioid use, and chronic post-intensive care unit pain. Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.

Variations in analgesic, sedation, and delirium management between trauma and non-trauma critically ill children

INTRODUCTION

Studies have shown the benefit of intensive care unit (ICU) bundled protocols; however, they are primarily derived from medical patients. We hypothesized that patients and their medication profiles are different between critically ill medical, surgical, and trauma patients.

METHODS

The Pediatric Health Information System 2017 dataset was used to perform a retrospective cohort study of critically ill children. The pediatric medical, surgical, and trauma cohorts were separated based on ICD-10 codes. Data collected included demographics, secondary diagnoses, outcomes, and medication data. Medications were grouped as opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, paralytics, and "other" sedatives. A non-parametric Kolmogorov-Smirnov test (KS test) and odds ratios (reference group: medical cohort) were calculated to compare medication administration between the study cohorts for the first 30 ICU days.

RESULTS

A total of 4488 critically ill children (medical 2078, surgical 1650, and trauma 760) were identified. The trauma cohort had increased incidence of delirium (medical 10.8%, surgical 11.5%, trauma 13.8%; p < 0.01) and mortality (medical 5.4%, surgical 2.4%, trauma 11.7%; p < 0.01). For all study cohorts, > 50% received GABA-agonists on ICU days 0-30. With the KS test, there was a significant difference in administration of opiates, GABA-agonists, alpha-2 agonists, anti-psychotics, and "other" sedatives over the first 30 days in the ICU. Relative to medical patients, trauma patients had significantly higher odds of receiving anti-psychotics on ICU days 10-20 and 22-24.

CONCLUSION

Critically ill pediatric trauma, medical, and surgical patients are distinctly different patient populations with differing pharmacologic profiles for analgesia, sedation, and delirium.

LEVEL OF EVIDENCE

Level III (Retrospective Comparative Study).

Case Report: Sustained mitochondrial damage in cardiomyocytes in patients with severe propofol infusion syndrome

Introduction: Propofol infusion syndrome (PRIS) is rare but a potentially lethal adverse event. The pathophysiologic mechanism is still unknown.

Patient concerns: A 22-year-old man was admitted for the treatment of Guillain-Barré syndrome. On day six, he required mechanical ventilation due to progressive muscle weakness; propofol (3.5 mg/kg/hour) was administered for five days for sedation. On day 13, he had hypotension with abnormal electrocardiogram findings, acute kidney injury, hyperkalemia and severe rhabdomyolysis.

Diagnosis and interventions: The patient was transferred to our intensive care unit (ICU) on suspicion of PRIS. Administration of noradrenaline and renal replacement therapy and fasciotomy for compartment syndrome of lower legs due to PRIS-rhabdomyolysis were performed.

Outcomes: The patient gradually recovered and was discharged from the ICU on day 30. On day 37, he had repeated sinus bradycardia with pericardial effusion in echocardiography. Cardiac ¹⁸F-FDG PET on day 67 demonstrated heterogeneous ¹⁸F-FDG uptake in the left ventricle. Electron microscopic investigation of endomyocardial biopsy on day 75 revealed mitochondrial myelinization of the cristae, which indicated mitochondrial damage of cardiomyocytes. He was discharged without cardiac abnormality on day 192.

Conclusions: Mitochondrial damage in both morphological and functional aspects was observed in the present case. Sustained mitochondrial damage may be a therapeutic target beyond the initial therapy of discontinuing propofol administration.

Risk Factors for Delirium and Association of Antipsychotic Use with Delirium Progression in Critically Ill Trauma Patients

Background

Delirium occurs frequently in critically ill and injured patients and is associated with significant morbidity and mortality. Limited data exists on the risk factors for developing delirium in critically ill trauma patients and the effect of antipsychotic (AP) medications on delirium progression.

Objective

The objective of this study is to determine the incidence of delirium in critically ill trauma versus non-trauma surgical patients and determine if the presence of trauma was associated with intensive care unit (ICU) delirium. Secondary outcomes included identifying risk factors for delirium and determining the impact of AP medication use on delirium progression in critically ill trauma patients.

Methods

This retrospective review studies adult trauma/surgical ICU patients admitted between May 2017-July 2018 to a level I trauma and tertiary referral center. Regression modeling was used to determine the impact of AP use on delirium-free days.

Results

Delirium was more common in critically ill trauma patients versus non-trauma surgical ICU patients [54/157 (34.4%) vs 42/270 (15.6%), P < .001]. Of the 54 trauma patients with delirium, 28 (52%) received an AP medication for delirium treatment and in the multiple linear regression analysis, AP use was significantly associated with fewer delirium-free days ( P = .02).

Discussion

Higher admission sequential organ failure assessment scores and increased length of stay were significantly associated with delirium onset in critically ill trauma patients. Use of AP medications for delirium treatment in this population had a negative impact on delirium-free days.

Depression and anxiety increase the odds of developing delirium in ICU patients; a prospective observational study

BACKGROUND

Delirium is prevalent among hospitalised patients, especially in critically ill patients. Preventing delirium by recognising its modifiable risk factors could improve life quality, decrease mortality and restrain its devastating consequences.

METHOD

We investigated 50 patients who had been hospitalised in the general ICU and monitored them for developing delirium. We employed CAM and CAM-ICU Scales to assess delirium, RASS score to determine the consciousness level, HADS questionnaire for anxiety and depression, and the demographic data questionnaire.

RESULTS

We found that 20% of ICU patients developed delirium and found a meaningful correlation between the incident delirium, older ages, visual impairment, and higher anxiety and depression scores (HADS) of first and second days of hospitalisation. By utilising logistic regression, we found that older ages, visual impairment, higher anxiety and depression scores (HADS) of the first day of hospitalisation were statistically significant to predict the risk model of developing delirium.

CONCLUSION

Depressive and anxiety symptoms were associated with higher odds of transitioning to delirium; so, at the admission time, it may be useful to screen patients for the symptoms of affective disorders, particularly, who are at higher risks for developing delirium.