Adaptation to the Intensive Care Environment (ATICE): Development and validation of a new sedation assessment instrument

Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes

Background

Neuromuscular weakness may manifest subsequent to critical illness in intensive care unit (ICU) patients. This weakness termed as “ICU-acquired weakness” (ICUAW) has a significant bearing on the length of mechanical ventilation, duration of ICU stays, long-term disability, and survival rate. Early identification of ICUAW helps in planning appropriate strategies, as well as in predicting the prognosis and long-term outcomes of these patients.

Aims and objectives

To identify the incidence of new-onset neuromuscular weakness developing among patients admitted in the ICU (ICUAW) and study its clinical course and impact on the duration of ICU stay.

Methods

This prospective observational study evaluated patients admitted to the ICU over a period of 1 year and 3 months (November 1, 2015, to January 31, 2017). All patients fulfilling the inclusion and exclusion criteria were evaluated with the Medical Research Council (MRC) score for muscle strength. Patients with an average score <4 were diagnosed with ICUAW. Included patients were examined on alternate days to study the clinical progression of the weakness till ICU discharge or death of the patient. The duration of ICU stay was noted.

Results and conclusion

The study revealed a significant association of ICUAW with age, Acute Physiology And Chronic Health Evaluation (APACHE II) Score, duration of mechanical ventilation, and ICU mortality. The incidence of the weakness was found to be 7.83% among the patients who survived and 50% among those patients who did not survive critical illness.

How to cite this article

Baby S, George C, Osahan NM. Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes. Indian J Crit Care Med 2021;25(9):1006–1012.

Tools Are Needed to Promote Sedation Practices for Mechanically Ventilated Patients

Suboptimal sedation practices continue to be frequent, although the updated guidelines for management of pain, agitation, and delirium in mechanically ventilated (MV) patients have been published for several years. Causes of low adherence to the recommended minimal sedation protocol are multifactorial. However, the barriers to translation of these protocols into standard care for MV patients have yet to be analyzed. In our view, it is necessary to develop fresh insights into the interaction between the patients' responses to nociceptive stimuli and individualized regulation of patients' tolerance when using analgesics and sedatives. By better understanding this interaction, development of novel tools to assess patient pain tolerance and to define and predict oversedation or delirium may promote better sedation practices in the future.

Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic-Narrative Overview

It has become a standard measure in recent years to utilise evidence-based practice, which is associated with a greater need to implement and use advanced, reliable methods of summarising the achievements of various scientific disciplines, including such highly specialised approaches as personalised medicine. The aim of this paper was to discuss the current state of knowledge related to improvements in "nursing" involving management of delirium in intensive care units during the SARS-CoV-2 pandemic. This narrative review summarises the current knowledge concerning the challenges associated with assessment of delirium in patients with COVID-19 by ICU nurses, and the role and tasks in the personalised approach to patients with COVID-19.

Associations between stressors and difficulty sleeping in critically ill patients admitted to the intensive care unit: a cohort study

Background

Patients admitted to the intensive care unit (ICU) experience sleep disruption caused by a variety of conditions, such as staff activities, alarms on monitors, and overall noise. In this study, we explored the relationship between noise and other factors associated with poor sleep quality in patients.

Methods

This was a prospective cohort study. We used the Richards–Campbell Sleep Questionnaire to explore sleep quality in a sample of patients admitted to the ICU of a private hospital. We measured the noise levels within each ICU three times a day. After each night during their ICU stay, patients were asked to complete a survey about sleep disturbances. These disturbances were classified as biological (such as anxiety or pain) and environmental factors (such as lighting and ICU noise).

Results

We interviewed 71 patients; 62% were men (mean age 54.46 years) and the mean length of stay was 8 days. Biological factors affected 36% and environmental factors affected 20% of the patients. The most common biological factor was anxiety symptoms, which affected 28% of the patients, and the most common environmental factor was noise, which affected 32.4%. The overall mean recorded noise level was 62.45 dB. Based on the patients’ responses, the environmental factors had a larger effect on patients’ sleep quality than biological factors. Patients who stayed more than 5 days reported less sleep disturbance. Patients younger than 55 years were more affected by environmental and biological factors than were those older than 55 years.

Conclusions

Patient quality of sleep in the ICU is associated with environmental factors such as noise and artificial lighting, as well as biological factors related to anxiety and pain. The noise level in the ICU is twice that recommended by international guides. Given the stronger influence of environmental factors, the use of earplugs or sleeping masks is recommended. The longer the hospital stay, the less these factors seem to affect patients’ sleep quality.

Neurally adjusted ventilatory assist versus pressure support ventilation: a randomized controlled feasibility trial performed in patients at risk of prolonged mechanical ventilation

BACKGROUND

The clinical effectiveness of neurally adjusted ventilatory assist (NAVA) has yet to be demonstrated, and preliminary studies are required. The study aim was to assess the feasibility of a randomized controlled trial (RCT) of NAVA versus pressure support ventilation (PSV) in critically ill adults at risk of prolonged mechanical ventilation (MV).

METHODS

An open-label, parallel, feasibility RCT (n = 78) in four ICUs of one university-affiliated hospital. The primary outcome was mode adherence (percentage of time adherent to assigned mode), and protocol compliance (binary-≥ 65% mode adherence). Secondary exploratory outcomes included ventilator-free days (VFDs), sedation, and mortality.

RESULTS

In the 72 participants who commenced weaning, median (95% CI) mode adherence was 83.1% (64.0-97.1%) and 100% (100-100%), and protocol compliance was 66.7% (50.3-80.0%) and 100% (89.0-100.0%) in the NAVA and PSV groups respectively. Secondary outcomes indicated more VFDs to D28 (median difference 3.0 days, 95% CI 0.0-11.0; p = 0.04) and fewer in-hospital deaths (relative risk 0.5, 95% CI 0.2-0.9; p = 0.032) for NAVA. Although overall sedation was similar, Richmond Agitation and Sedation Scale (RASS) scores were closer to zero in NAVA compared to PSV (p = 0.020). No significant differences were observed in duration of MV, ICU or hospital stay, or ICU, D28, and D90 mortality.

CONCLUSIONS

This feasibility trial demonstrated good adherence to assigned ventilation mode and the ability to meet a priori protocol compliance criteria. Exploratory outcomes suggest some clinical benefit for NAVA compared to PSV. Clinical effectiveness trials of NAVA are potentially feasible and warranted.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01826890. Registered 9 April 2013.

Role of the Bispectral Index in Sedation Monitoring in the ICU

Objective:

To review and critique evidence for the use of the bispectral index (BIS) in intensive care unit (ICU) patients.

Data Sources:

A computer search of English-language articles in MEDLINE (1966–July 2005), International Pharmaceutical Abstracts (1971–July 2005), and Scientific Citation Index Expanded (1980–July 2005) was conducted. A manual search of abstracts was also performed using the key search terms BIS, sedation, and critical care.

Study Selection and Data Extraction:

Case series, letters, editorials, and clinical studies that evaluated BIS in ICU patients were considered for inclusion.

Data Synthesis:

Nineteen studies comparing the BIS with sedation scales were evaluated, revealing that the BIS trends lower with increasing sedation. The BIS appeared to correlate better when sedation scores were grouped rather than individual values. However, correlations between BIS and subjective scales were low in most studies (r2 0.21–0.93). Additionally, there was poor correlation between drug dosage and the BIS. Randomized, controlled trials demonstrating improved outcomes with BIS monitoring have not been reported.

Conclusions:

Interpreting literature on the usefulness of the BIS in the ICU is difficult for reasons that include heterogeneous populations, different methods of collecting BIS data, and use of different versions of BIS software and hardware. Outcomes data are lacking. The 2002 Society of Critical Care Medicine Sedation Guidelines recommendation that more data are needed before the BIS should be used routinely in the ICU remains unchanged. We recommend that further studies be conducted to determine the optimal method of obtaining BIS data and evaluate the impact of the BIS on relevant patient outcomes.

Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial

PURPOSE

Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation.

METHODS

A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality.

RESULTS

In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (P = 0.66), the asynchrony index was 14.7 vs. 26.7 % (P < 0.001), the ventilator-free days at day 7 were 1.0 day [1.0-4.0] vs. 0.0 days [0.0-1.0] (P < 0.01), the ventilator-free days at day 28 were 21 days [4-25] vs. 17 days [0-23] (P = 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (P = 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (P < 0.01).

CONCLUSIONS

NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient-ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02018666.

Complications of Sedation in Critical Illness: An Update

Sedation is a necessary component of care for the critically ill. Oversedation, however, is associated with immediate complications and long-term problems, termed post-intensive care unit syndrome. It also contributes to unnecessary costs of care. This article describes the physical, functional, psychiatric, and cognitive complications of oversedation, and multiple research-based strategies that minimize complications.

Measurement of Heart Rate Variability to Assess Pain in Sedated Critically Ill Patients: A Prospective Observational Study

Introduction

The analgesia nociception index (ANI) assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The aim of this study is to determine the effectiveness of ANI in detecting pain in deeply sedated critically ill patients.

Methods

This prospective observational study was performed in two medical ICUs. All patients receiving invasive mechanical ventilation and deep sedation were eligible. In all patients, heart rate and ANI were continuously recorded using the Physiodoloris^® device during 5 minutes at rest (T1), during a painful stimulus (T2), and during 5 minutes after the end of the painful stimulus (T3). The chosen painful stimulus was patient turning for washstand. Pain was evaluated at T2, using the behavioral pain scale (BPS). The primary objective was to determine the effectiveness of ANI in detecting pain. Secondary objectives included the impact of norepinephrine on the effectiveness of ANI in detecting pain, and the correlation between ANI and BPS.

Results

Forty-one patients were included. ANI was significantly lower at T2 (Med (IQR) 69(55–78)) compared with T1 (85(67–96), p<0.0001), or T3 (81(63–89), p<0.0001). Similar results were found in the subgroups of patients with (n = 21) or without (n = 20) norepinephrine. ANI values were significantly higher in patients with norepinephrine compared with those without norepinephrine at T1, and T2. No significant correlation was found between ANI and BPS at T2.

Conclusions

ANI is effective in detecting pain in deeply sedated critically ill patients, including those patients treated with norepinephrine. No significant correlation was found between ANI and BPS.

A review of sedation scales for the cardiac catheterization laboratory

PURPOSE

Sedation scales have the potential to facilitate effective procedural sedation and analgesia in the cardiac catheterization laboratory (CCL). For this potential to become realized, a scale that is suitable for use in the CCL either needs to be identified or developed.

DESIGN

A structured review strategy was applied.

METHODS

To identify sedation scales, a review of Medline and CINHAL was conducted.

FINDINGS

One sedation scale for the CCL, the North American Society for Pacing and Electrophysiology Sedation Scale, and 15 intensive care unit (ICU) scales met the inclusion and exclusion criteria. Analysis of the scale's item structures and psychometric properties was then performed.

CONCLUSION

None of these scales were deemed suitable for use in the CCL. As such, further research is required to develop a new scale. The new scale should consist of more than one item to make it more effective for tracking the patient's response to medications. Specific tests required to conduct a rigorous evaluation of the new scale's psychometric properties are outlined in this article.

Entropy correlates with Richmond Agitation Sedation Scale in mechanically ventilated critically ill patients

Sedation is routinely used in intensive care units. However due to absence of objective scoring systems like Bispectral Index and entropy our ability to regulate the degree of sedation is limited. This deficiency is further highlighted by the fact that agitation scores used in intensive care units (ICU) have no role in paralyzed patients. The present study compares entropy as a sedation scoring modality with Richmond Agitation Sedation Scale (RASS) in mechanically ventilated, critically ill patients in an ICU. Twenty-seven, mechanically ventilated, critically ill patients of either sex, 16-65 years of age, were studied over a period of 24 h. They received a standard sedation regimen consisting of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 lg/kg followed by infusions of propofol and fentanyl ranging from 1.5 to 5 mg/kg/h and 0.5 to 2.0 lg/kg/h, respectively. Clinically relevant values of RASS for optimal ICU sedation (between 0 and -3) in non-paralyzed patients were compared to corresponding entropy values, to find if any significant correlation exists between the two. These entropy measurements were obtained using the Datex-Ohmeda-M-EntropyTM module. This module is presently not approved by Food and Drug Administration (FDA) for monitoring sedation in ICU. A total of 527 readings were obtained. There was a statistically significant correlation between the state entropy (SE) and RASS [Spearman's rho/rs = 0.334, p\0.0001]; response entropy (RE) and RASS [Spearman's rho/rs = 0.341, p\0.0001]). For adequate sedation as judged by a RASS value of 0 to -3, the mean SE was 57.86 ± 16.50 and RE was 67.75 ± 15.65. The present study illustrates that entropy correlates with RASS (between scores 0 and -3) when assessing the level of sedation in mechanically ventilated critically ill patients.

The validity, reliability, responsiveness and applicability of observation sedation-scoring instruments for use with adult patients in the emergency department: a systematic literature review

AIM

This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed.

BACKGROUND

Emergency nurses are increasingly responsible for the ongoing assessment, monitoring and titration of continuous intravenous sedation, in addition to analgesia for the critically ill adult patient. One method to optimise patient sedation is to use a validated observational sedation-scoring tool. It is not clear however what the optimal instrument available is for use in this clinical context.

METHODS

A systematic literature review methodology was employed. A range of electronic databases were searched for the period 1946-2013. Search terms incorporated "sedation scale", "sedation scoring system", "measuring sedation", and "sedation tool" and were used to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. Articles were assessed using the Critical Appraisal Skills Program (CASP) making sense of evidence tools.

RESULTS

A total of 27 observational sedation-scoring instruments were identified. Sedation-scoring instruments can be categorised as linear or composite, the former being the most common. A wide variety of patient behaviours are used within the instruments to measure depth and quality of patient sedation. Typically sedation-scoring instruments incorporated three patient behaviours, which were then rated to generate a numerical score. The majority of the instruments have been subjected to validity and reliability testing, however few have been examined for responsiveness or applicability.

CONCLUSIONS

None of the 27 observational sedation-scoring instruments were designed or trialled within ED. The Richmond Agitation and Assessment Scale was identified as most suitable to be trialled prospectively within an Australian ED.

Septic encephalopathy

Every year, more cases of sepsis appear in intensive care units. The most frequent complication of sepsis is septic encephalopathy (SE), which is also the essential determinant of mortality. Despite many years of research, it still is not known at which stage of sepsis the first signs of SE appear; however, it is considered the most frequent form of encephalopathy. Patients have dysfunction of cognitive abilities and consciousness, and sometimes even epileptic seizures. Despite intensive treatment, the effects of SE remain for many years and constitute an important social problem. Numerous studies indicate that changes in the brain involve free radicals, nitric oxide, increased synthesis of inflammatory factors, disturbances in cerebral circulation, microthromboses, and ischemia, which cause considerable neuronal destruction in different areas of the brain. To determine at what point during sepsis the first signs of SE appear, different experimental models are needed to detect the aforementioned changes and to select the proper therapy for this syndrome.

Sepsis Associated Encephalopathy

Sepsis associated encephalopathy (SAE) is a common but poorly understood neurological complication of sepsis. It is characterized by diffuse brain dysfunction secondary to infection elsewhere in the body without overt CNS infection. The pathophysiology of SAE is complex and multifactorial including a number of intertwined mechanisms such as vascular damage, endothelial activation, breakdown of the blood brain barrier, altered brain signaling, brain inflammation, and apoptosis. Clinical presentation of SAE may range from mild symptoms such as malaise and concentration deficits to deep coma. The evaluation of cognitive dysfunction is made difficult by the absence of any specific investigations or biomarkers and the common use of sedation in critically ill patients. SAE thus remains diagnosis of exclusion which can only be made after ruling out other causes of altered mentation in a febrile, critically ill patient by appropriate investigations. In spite of high mortality rate, management of SAE is limited to treatment of the underlying infection and symptomatic treatment for delirium and seizures. It is important to be aware of this condition because SAE may present in early stages of sepsis, even before the diagnostic criteria for sepsis can be met. This review discusses the diagnostic approach to patients with SAE along with its epidemiology, pathophysiology, clinical presentation, and differential diagnosis.

Psychometric analysis of subjective sedation scales in critically ill adults

OBJECTIVE

To describe and analyze the development and psychometric properties of subjective sedation scales developed for critically ill adult patients.

DATA SOURCES

PubMed, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, ISI Web of Science, and the International Pharmaceutical Abstracts.

STUDY SELECTION

English-only publications through December 2012 with at least 30 patients older than 18 years, which included the key words of adult, critically ill, subjective sedation scale, sedation scale, validity, and reliability.

DATA EXTRACTION

Two independent reviewers evaluated the psychometric properties using a standardized sedation scale psychometric scoring system.

DATA SYNTHESIS

Among the 19,000+ citations extracted for the 2013 Society of Critical Care Medicine's Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium and from December 2010 to 2012, 36 articles were identified compassing 11 sedation scales. The scale development process, psychometric properties, feasibility, and implementation of sedation scales were analyzed using a 0-20 scoring system. Two scales demonstrated scores indicating "very good" published psychometric properties: Richmond Agitation-Sedation Scale (19.5) and the Sedation-Agitation Scale (19). Scores with "moderate" properties include the Vancouver Interaction and Calmness Scale (14.3), Adaptation to the Intensive Care Environment (13.7), Ramsay Sedation Scale (13.2), Minnesota Sedation Assessment Tool (13), and the Nursing Instrument for the Communication of Sedation (12.8). Scales with "low" properties included the Motor Activity Assessment Scale (11.5) and the Sedation Intensive Care Score (10.5). The New Sheffield Sedation Scale (8.5) and the Observer's Assessment of Alertness/Sedation Scale (3.7) demonstrated "very low" published properties.

CONCLUSIONS

Based on the current literature, and using a predetermined psychometric scoring system, the Richmond Agitation-Sedation Scale and the Sedation-Agitation Scale are the most valid and reliable subjective sedation scales for use in critically ill adult patients.

Exploring the impact of augmenting sedation assessment with physiologic monitors

BACKGROUND

Pharmacological sedation is a necessary tool in the management of critically ill, mechanically ventilated patients. The intensive care unit (ICU) sedation strategy is to use the least amount of medication to meet safety and comfort goals. Titration of pharmacological agents is currently guided by clinical assessment tools. The purpose of this study was to determine whether the addition of a neurophysiological monitor, bispectral index (BIS), aided the ICU nurse in reducing the amount of drug used, compared to a clinical tool alone, in a general critical care population.

METHODS

In this prospective clinical trial, mechanically ventilated adults (N=300) were randomised to sedation assessment using only the observational assessment tool (RASS) or a combination of observational and physiologic measures (RASS+BIS). Subjects were enrolled from a medical ICU (N=154), a trauma ICU (N=72) and a general mixed-use ICU (N=74).

RESULTS

BIS-augmented sedation was only associated with the reduction of drug use when patients were sedated with propofol or narcotic agents (propofol [1.61 mg/kg/h vs. 1.77 mg/kg/h; p<0.0001], fentanyl [54.73 mcg/h vs. 66.81 mcg/h; p<0.0001], and hydromorphone [0.97 mg/h vs. 4.00 mg/h: p<0.0001] compared to RASS alone. In contrast, patients sedated with dexmedetomidine or benzodiazepines were given higher doses under the BIS-augmented dexmedetomidine [0.46 mcg/kg/h vs. 0.33 mcg/kg/h; p<0.0001], lorazepam [4.13 mg/h vs. 3.29 mg/h p<0.0001], and midazolam [3.73 mg/h vs 2.86 mg/h; p<0.0001]) protocol compared to clinical assessment alone.

CONCLUSION

The clinical evaluation of depth of sedation remains the most reliable method for the titration of pharmacological sedation in the critical care unit. However, BIS-augmented assessment is helpful in reducing the amount of propofol and narcotic medication used and may be considered an adjunct when these agents are utilised.

Pattern of brain injury in the acute setting of human septic shock

Background

Sepsis-associated brain dysfunction has been linked to white matter lesions (leukoencephalopathy) and ischemic stroke. Our objective was to assess the prevalence of brain lesions in septic shock patients requiring magnetic resonance imaging (MRI) for an acute neurologic change.

Method

Seventy-one septic shock patients were included in a prospective observational study. Patients underwent daily neurological examination. Brain MRI was obtained in patients who developed focal neurological deficit, seizure, coma, or delirium. Electroencephalogy was performed in case of coma, delirium, or seizure. Leukoencephalopathy was graded and considered present when white matter lesions were either confluent or diffuse. Patient outcome was evaluated at 6 months with the Glasgow Outcome Scale (GOS).

Results

We included 71 patients with median age of 65 years (56 to 76) and SAPS II at admission of 49 (38 to 60). MRI was indicated on focal neurological sign in 13 (18%), seizure in 7 (10%), coma in 33 (46%), and delirium in 35 (49%). MRI was normal in 37 patients (52%) and showed cerebral infarcts in 21 (29%), leukoencephalopathy in 15 (21%), and mixed lesions in 6 (8%). EEG malignant pattern was more frequent in patients with ischemic stroke or leukoencephalopathy. Ischemic stroke was independently associated with disseminated intravascular coagulation (DIC), focal neurologic signs, increased mortality, and worse GOS at 6 months.

Conclusions

Brain MRI in septic shock patients who developed acute brain dysfunction can reveal leukoencephalopathy and ischemic stroke, which is associated with DIC and increased mortality.

Sepsis-induced brain dysfunction

Systemic infection is often revealed by or associated with brain dysfunction, which is characterized by alteration of consciousness, ranging from delirium to coma, seizure or focal neurological signs. Its pathophysiology involves an ischemic process, secondary to impairment of cerebral perfusion and its determinants and a neuroinflammatory process that includes endothelial activation, alteration of the blood-brain barrier and passage of neurotoxic mediators. Microcirculatory dysfunction is common to these two processes. This brain dysfunction is associated with increased mortality, morbidity and long-term cognitive disability. Its diagnosis relies essentially on neurological examination that can lead to specific investigations, including electrophysiological testing or neuroimaging. In practice, cerebrospinal fluid analysis is indisputably required when meningitis is suspected. Hepatic, uremic or respiratory encephalopathy, metabolic disturbances, drug overdose, sedative or opioid withdrawal, alcohol withdrawal delirium or Wernicke's encephalopathy are the main differential diagnoses. Currently, treatment consists mainly of controlling sepsis. The effects of insulin therapy and steroids need to be assessed. Various drugs acting on sepsis-induced blood-brain barrier dysfunction, brain oxidative stress and inflammation have been tested in septic animals but not yet in patients.

Use of bispectral index to monitor the depth of sedation in mechanically ventilated patients in the prehospital setting

BACKGROUND

Sedative drug administration is a challenging aspect of the management of mechanically ventilated patients in the out-of-hospital critical care medicine. We hypothesised that the bispectral index of the EEG (BIS) could be a helpful tool in evaluating the depth of sedation in this difficult environment. The main objective of the present study was to assess the agreement of BIS with the clinical scales in the out-of-hospital setting.

METHODS

This prospective study included mechanically ventilated patients. BIS values were blindly recorded continuously. A Ramsay score was performed every 5 min. The main judgement criterion was the correlation between BIS values and the Ramsay score.

RESULTS

72 patients were included, mostly presenting with toxic coma (36%) or neurological coma (21%). The median (IQR) BIS value was 85 (84-86) when the Ramsay score was 3, 80 (76-84) when the Ramsay score was 4, 61 (55-80) when the Ramsay score was 5 and 45 (38-60) when the Ramsay score was 6. According to Receiver operating characteristic (ROC) curves, BIS was categorised into three classes (BIS<54 corresponding to Ramsay score 6, 54≤BIS<72 for Ramsay score 5 and BIS≥73 for Ramsay score ≤4). Based on these categories, the proportion of appropriate BIS values was 67% (217/323). The concordance correlation coefficient for repeated measurements was 0.54 (0.43-0.64). The agreement between BIS and the Ramsay score is moderate.

CONCLUSIONS

Prehospital measured BIS values appear poorly correlated with clinical assessment of the depth of sedation. For this reason, the use of BIS to guide prehospital sedation cannot be recommended.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Nurses' perceptions of unpleasant symptoms and signs in ventilated and sedated patients

AIMS AND OBJECTIVES

To describe intensive care nurses' perceptions and assessments of unpleasant symptoms and signs in mechanically ventilated and sedated adult intensive care patients.

BACKGROUND

Mechanically ventilated patients are unable to express themselves verbally and depend upon nurses to control their symptoms by understanding their unpleasant experiences, such as pain, anxiety or delirium and interpret the relevant signs. Nurses must have enough knowledge to adjust their analgesics and sedatives appropriately and to avoid under- or oversedation.

DESIGN

A cross-sectional survey design.

METHODS

A study with a self-administrated questionnaire was undertaken in October 2007 to February 2008, with a convenience sample of 183 intensive care nurses in Norway.

RESULTS

The questionnaire was completed by 86 (47%) nurses. Most perceived that critical illness polyneuropathy/myopathy occurred frequently. Half the nurses underestimated pain, anxiety and delirium. Signs such as a response to contact, cough reflex, wakefulness and muscle tone were considered most important in assessing oversedation. Agitation, facial grimacing, tube intolerance and wakefulness were considered most important in assessing undersedation. The Comfort Scale and Adoption of the Intensive Care Environment corresponded best to the signs identified by the nurses.

CONCLUSION

The nurses underestimated unpleasant symptoms other than critical illness polyneuropathy/myopathy. A further mapping of patients' experiences should be conducted, with an emphasis on the more 'silent' distressing symptoms. Further tools to facilitate the communication of consciousness levels and the intolerance of unpleasant symptoms must be developed and implemented.

RELEVANCE TO CLINICAL PRACTICE

A deeper understanding of unpleasant symptoms and signs focused in learning activities may help nurses to recognize patients' early problems and allow targeted interventions. A more active stimulus-response assessment of ICU patients is required to detect oversedation, critical illness polyneuropathy/myopathy and hypoactive delirium. Assessment tools should reflect both the patient's tolerance of various unpleasant symptoms and the level of consciousness.

Management of delirium in critically ill older adults

Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.

Clinical and critical care concerns in severely ill obese patient

The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients.

Critical care nurses' role in implementing the "ABCDE bundle" into practice

Imagine working in an environment where all patients undergoing mechanical ventilation are alert, calm, and delirium free. Envision practicing in an environment where nonvocal patients can effectively express their need for better pain control, repositioning, or emotional reassurance. Picture an intensive care unit where a nurse-led, interprofessional team practices evidence-based, patient-centered care focused on preserving and/or restoring their clients' physical, functional, and neurocognitive abilities. A recently proposed bundle of practices for the intensive care unit could advance the current practice environment toward this idealized environment. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle incorporates the best available evidence related to delirium, immobility, sedation/analgesia, and ventilator management in the intensive care unit for adoption into everyday clinical practice.

Clinical assessment of sleep among pediatric burn patients does not correlate with polysomnography

A vast amount of sleep research relies on subjective, observational assessments of wakefulness and sleep. The authors had the unique opportunity to compare observational and polysomnographic (PSG) determinations of sleep in a randomized crossover study of sleep-inducing medication in a group of pediatric burn patients. Pediatric burn patients were randomized to one of two regimens with sleep-inducing agents over a 2-week period. PSG was conducted for three consecutive nights each week, between 7-13 and 14-20 days postburn. The first night of monitoring each week was conducted without medication to serve as a baseline. Observational sleep assessments (awake, drowsy, or asleep) were simultaneously recorded every 15 minutes. PSG concordance with observation was based on the PSG sleep stages identified during the 2 minutes before the observations. If all 30-second epochs in the two minutes were designated as sleep stage 1 or above, then the PSG record was categorized as asleep. If all epochs demonstrated wakefulness, an awake status was recorded. Otherwise, the corresponding PSG finding was classified as mixed. Forty patients were enrolled into the study, with a mean age of 9.4 ± 0.6 years, TBSA burn of 50.1 ± 2.9%, and third-degree burn surface area of 43.2 ± 3.6%. Patients were judged according to observational criteria to be awake 9% of the nocturnal study period compared with PSG recordings indicating that the patients were awake 52.3% of the time. The correlation between observation and PSG was poor regardless of sleep agent administration. In conclusion, observational determination of wakefulness in pediatric burn patients correlates poorly with PSG; therefore, PSG is vital in the accurate evaluation of sleep-inducing medications among burn patients.

Protocolized and target-based sedation and analgesia in the ICU

Protocolized target-based sedation and analgesia is central to effective management of sedation. Important components include identifying goals and specific targets,using valid and reliable tools to measure pain, agitation, and sedation, and titrating a logically selected combination of sedatives and analgesics to defined end-points.A variety of approaches to structured management have been tested in controlled trials with major categories of (1) sedation algorithms and protocols and (2) daily interruption of sedation. Although not all studies that compare new interventions to “usual care” document dramatic improvements, many studies show that by reducing oversedation, using a structured approach, faster recovery from respiratory failure may ensue. The somewhat discrepant results illustrate, however, that various approaches,such as DIS, may not be optimal for all patients. Further research will be necessary to define these patients and examine alternative strategies. Finally, implementation of structured approaches to sedation management is a challenging, time-consuming process for clinicians that must be supported with sufficient resources to be successful.

Current sedation practices: lessons learned from international surveys

Limitations are inherent to surveys. Most surveys have low response rates, which raises the issue of responder bias. Another limitation of self-report surveys stems from the possible differences between stated and actual practice. That is, what physicians report that they do in surveys often contrasts significantly with what they do in observational studies, as highlighted by the Canadian surveys conducted in 2002 and 2008. Some surveys report estimates provided by ICU nurse managers or physician directors, potentially resulting in inaccurate estimates or data reflecting the individuals practice rather than the entire ICU. Surveys may not reflect how different specialists practice; for example, the German surveys collected data only in ICUs run by anesthesiologists.Notwithstanding these limitations, surveys provide a wealth of information on current practice and determinants of practice, and serve as a useful tool to guide future research and educational interventions. The authors identified substantial international variation in the use of sedative and analgesic drugs, and marked changes over the last 10 years. Overall, there is a trend toward lighter sedation, along with a shift from benzodiazepines toward propofol, and from morphine toward fentanyl and remifentanil. Despite the publication of numerous studies and guidelines for sedation and analgesia, actual practice differs from recommended practice, suggesting that the impact of clinical trials and guidelines on physician practice is quite low. It is clear that there remain substantial barriers to the incorporation of sedation scales, protocols,and daily interruption into routine ICU care.

Sedation and analgesia in the mechanically ventilated patient

Sedation and analgesia are important components of care for the mechanically ventilated patient in the intensive care unit (ICU). An understanding of commonly used medications is essential to formulate a sedation plan for individual patients. The specific physiological changes that a critically ill patient undergoes can have direct effects on the pharmacology of drugs, potentially leading to interpatient differences in response. Objective assessments of pain, sedation, and agitation have been validated for use in the ICU for assessment and titration of medications. An evidence-based strategy for administering these drugs can lead to improvements in short- and long-term outcomes for patients. In this article, we review advances in the field of ICU sedation to provide an up-to-date perspective on management of the mechanically ventilated ICU patient.

Analytic reviews: managing the agitated patient in the ICU: sedation, analgesia, and neuromuscular blockade

Physical and psychological distress is exceedingly common among critically ill patients and manifests generically as agitation. The dangers of over- and undertreatment of agitation have been well described, and the intensive care unit (ICU) physician must strike a balance in the fast-paced, dynamic ICU environment. Identification of common reversible etiologies for distress may obviate the need for pharmacologic therapy, but most patients receive some combination of sedative, analgesic, and neuroleptic medications during the course of their critical illness. As such, understanding key pharmacologic features of commonly used agents is critical. Structured protocols and objective assessment tools can optimize drug delivery and may ultimately improve patient outcomes by reducing ventilator days, ICU length of stay, and by reducing cognitive dysfunction.

Actigraphy: analyzing patient movement

BACKGROUND

Actigraphic data during simulated participant movements were evaluated to differentiate among patient behavior states.

METHODS

Arm and leg actigraphic data were collected on 30 volunteers who simulated 3 behavioral states (calm, restless, agitated) for 10 minutes; counts of observed participant movements (head, torso, extremities) were documented.

RESULTS

The mean age of participants was 34.7 years, and 60% were female. Average movement was significantly different among the states (P < .0001; calm [mean = .48], restless [mean = 2.16], agitated [mean = 3.75]). Mean actigraphic measures were significantly different among states for both arm (P < .0001; calm [mean = 6.8], restless [mean = 28.5], agitated [mean = 52.6]) and leg (P < .0001; calm [mean = 3.5], restless [mean = 18.7], agitated [mean = 37.7]).

CONCLUSION

Distinct levels of behavioral states were successfully simulated. Actigraphic data can provide an objective indicator of patient activity over a variety of behavioral states, and these data may offer a standard for comparison among these states.

[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.

Facial expression and pain in the critically ill non-communicative patient: state of science review

The aim of this review is to analyse the evidence related to the relationship between facial expression and pain assessment tools in the critically ill non-communicative patients. Pain assessment is a significant challenge in critically ill adults, especially those who are unable to communicate their pain level. During critical illness, many factors alter verbal communication with patients including tracheal intubation, reduced level of consciousness and administration of sedation and analgesia. The first step in providing adequate pain relief is using a systematic, consistent assessment and documentation of pain. However, no single tool is universally accepted for use in these patients. A common component of behavioural pain tools is evaluation of facial behaviours. Although use of facial expression is an important behavioural measure of pain intensity, there are inconsistencies in defining descriptors of facial behaviour. Therefore, it is important to understand facial expression in non-communicative critically ill patients experiencing pain to assist in the development of concise descriptors to enhance pain evaluation and management. This paper will provide a comprehensive review of the current state of science in the study of facial expression and its application in pain assessment tools.