Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation

PURPOSE

Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness.

METHODS

The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care.

RESULTS

A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences.

CONCLUSION

The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Fospropofol disodium versus propofol for long-term sedation during invasive mechanical ventilation: A pilot randomized clinical trial

STUDY OBJECTIVE

Fospropofol disodium is a propofol prodrug that is water-soluble and has a reduced risk of bacterial contamination and hypertriglyceridemia compared with propofol. Prior to implementing a large randomized trial, we investigated the feasibility, initial efficacy, and safety of fospropofol disodium compared with propofol in long-term mild-to-moderate sedation in intensive care units (ICUs).

DESIGN

Single-centered, prospective, unblind, randomized, parallel-group clinical trial.

SETTING

The general ICU of university-affiliated teaching hospital.

PATIENTS

Adult patients (n = 60) expected to have mechanical ventilation for >24 h were enrolled and randomly assigned to the fospropofol or propofol group.

INTERVENTIONS

The fospropofol group received continuous fospropofol disodium infusions and the propofol group received continuous propofol infusions. The sedation goal was a score of -3 to 0 on the Richmond Agitation and Sedation Scale (RASS).

MEASUREMENTS

The primary outcome was the percentage of time spent in the target sedation range without rescue sedation. Safety outcomes were based on adverse events. Blood samples were collected to measure formate concentration in plasma.

MAIN RESULTS

The median dose was 4.33 (IQR, 3.08-4.94) mg/kg/h in the fospropofol group and 1.96 (IQR, 1.44-2.94) mg/kg/h in the propofol group. The median percentage of time spent in the target RASS range without rescue sedation was identical in both groups, with 83.33% (IQR, 74.43%-100.00%) in the fospropofol group and 83.33% (IQR, 77.45%-100.00%) in the propofol group (p = 0.887). At least one adverse event was identifed in 23 (76.7%) fospropofol patients and 27 (90.0%) propofol patients. The most common adverse events were tachycardia and hypotension. No paresthesia, catheter-related bloodstream infection or propofol infusion syndrome in both groups was reported. Three patients in the fospropofol group had mild hypertriglyceridemia, and nine patients in propofol group had hypertriglyceridemia (mild in eight patients and moderate in one patient) (10% versus 30%, p = 0.104). The formate concentration in plasma was very low, and no significant difference was identified at any time point between the two groups.

CONCLUSIONS

Fospropofol disodium appears to be a feasible, effective and safe sedative for patients receiving invasive mechanical ventilation with long-term sedation.

Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study

BACKGROUND

The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools.

OBJECTIVE

The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity.

RESEARCH METHOD

CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed.

DESIGN

A prospective observational study performed between October and December 2020.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity.

RESULTS

In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively.

CONCLUSION

Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.

Dynamic delirium - Nursing intervention to reduce delirium in patients critically Ill, a randomized control trial

OBJECTIVE

To determine the effectiveness of a nursing intervention based on the Dynamic Symptom Model (DSM) and scientific evidence versus daily care in reducing the incidence and duration of delirium in intensive care patients.

METHOD

We designed the intervention named "DyDel" (By Dynamic Delirium) based on the theoretical approach of the DSM and from scientific evidence. A double-masked clinical trial of parallel groups was developed to test DyDel, with 213 patients older than 18 admitted to the intensive care unit (ICU) randomized to the study groups. The intervention group received DyDel each shift from day 0 until discharged from the ICU, while the control group received daily care in the ICU. At the same time, all participants were followed to measure primary (incidence and duration of delirium) and secondary outcomes (level of sedation and pain, days of mechanical ventilation, stay in ICU, and physical restriction).

RESULTS

Overall, the study population were older than 60 years (60.3 ± 15.2 years), the male gender (59.6 %), and the diagnosis of acute myocardial infarction (73.7 %) were predominant. Comparing groups of study, the incidence of delirium was lower in the intervention group (5.6 %) than in the control group (14.8 %) (p = 0.037). The intervention group had lower days with delirium (0.07 ± 0.308) than the control group (0.34 ± 1.28) (p = 0.016), lower pain intensity (p = 0.002) and lower days of physical restraints (p = 0.06).

CONCLUSION

Non-pharmacological care, like the DyDel intervention, includes the family and focuses on the different patient's needs, which can help to reduce the incidence and duration of delirium in patients admitted to adult ICUs.

IMPLICATIONS FOR CLINICAL PRACTICE

DyDel was non-pharmacological and included the family. The DyDel's activities were focused on physiological, psychological, spiritual, and social needs and the experience and trajectory of delirium. The nurse can give humanized care in the ICU by applying DyDel.

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

Variation in Use of Medications for Opioid Use Disorder in Critically Ill Patients Across the United States

OBJECTIVES

To describe practice patterns surrounding the use of medications to treat opioid use disorder (MOUD) in critically ill patients.

DESIGN

Retrospective, multicenter, observational study using the Premier AI Healthcare Database.

SETTING

The study was conducted in U.S. ICUs.

PATIENTS

Adult (≥ 18 yr old) patients with a history of opioid use disorder (OUD) admitted to an ICU between 2016 and 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 108,189 ICU patients (658 hospitals) with a history of OUD, 20,508 patients (19.0%) received MOUD. Of patients receiving MOUD, 13,745 (67.0%) received methadone, 2,950 (14.4%) received buprenorphine, and 4,227 (20.6%) received buprenorphine/naloxone. MOUD use occurred in 37.9% of patients who received invasive mechanical ventilation. The median day of MOUD initiation was hospital day 2 (interquartile range [IQR] 1-3) and the median duration of MOUD use was 4 days (IQR 2-8). MOUD use per hospital was highly variable (median 16.0%; IQR 10-24; range, 0-70.0%); admitting hospital explained 8.9% of variation in MOUD use. A primary admitting diagnosis of unintentional poisoning (aOR 0.41; 95% CI, 0.38-0.45), presence of an additional substance use disorder (aOR 0.66; 95% CI, 0.64-0.68), and factors indicating greater severity of illness were associated with reduced odds of receiving MOUD in the ICU.

CONCLUSIONS

In a large multicenter, retrospective study, there was large variation in the use of MOUD among ICU patients with a history of OUD. These results inform future studies seeking to optimize the approach to MOUD use during critical illness.

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study

Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.

Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study

BACKGROUND

Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive.

METHODS

Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles.

RESULTS

A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16).

CONCLUSIONS

In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive.

EDITOR’S PERSPECTIVE

Psychometric properties and structural validity of traditional Chinese version of the Richards-Campbell Sleep Questionnaire in intensive care unit patients without physical restraint

BACKGROUND

Sleep assessment in the intensive care unit (ICU) is difficult and often unreliable. The most commonly used questionnaire for assessing ICU sleep, the Richards-Campbell Sleep Scale (RCSQ), has not been tested for reliability and construct validity in the Mandarin-Taiwanese speaking population.

OBJECTIVE

The objective of this study was to test the construct validity and criterion validity of the traditional Chinese version of RCSQ (TC-RCSQ) in critically ill patients without physical restraint.

METHODS

We adopted a cross-sectional study design. Adults aged 20 years and above were recruited from a plastic surgery ICU of a medical center. The Cronbach's alpha was used to test internal consistency; the validity testing included content validity, criterion validity, and construct validity. Criterion validity was analysed by testing the association of TC-RCSQ with the Chinese version of Verran and Snyder-Halpern Sleep Questionnaire and sleep parameter of actigraphy using the Pearson correlation coefficient; construct validity was analysed using exploratory factor analysis.

RESULTS

A total of 100 patients were included with a mean age of 49.78 years. Internal consistency reliability suggested Cronbach's alpha of 0.93. Moderate to strong correlations of TC-RCSQ with Verran-Snyder-Halpern Sleep Questionnaire were identified (r = 0.36 to 0.80, P < 0.05). We found significant correlations of actigraphic sleep efficiency with difficulty of falling sleep, awakening times, sleep quality, and total score of the TC-RCSQ (r = 0.23, 0.23, 0.20, and 0.23, P < 0.05). One factor (named as overall sleep quality) was extracted by exploratory factor analysis with a total variance explained of 78.40 %, which had good construction validity.

CONCLUSIONS

The TC-RCSQ yields satisfactory reliability and validity in critically ill patients. Actigraphic sleep efficiency may be a single index for objectively sleep assessment of sleep quality in patients without physical restraint. Both the TC-RCSQ and actigraphy can aid nurses to evaluate the sleep quality in critically ill patients without physical restraint.

Effects of an Early Intensive Blood Pressure-lowering Strategy Using Remifentanil and Dexmedetomidine in Patients with Spontaneous Intracerebral Hemorrhage: A Multicenter, Prospective, Superiority, Randomized Controlled Trial

BACKGROUND

Although it has been established that elevated blood pressure and its variability worsen outcomes in spontaneous intracerebral hemorrhage, antihypertensives use during the acute phase still lacks robust evidence. A blood pressure-lowering regimen using remifentanil and dexmedetomidine might be a reasonable therapeutic option given their analgesic and antisympathetic effects. The objective of this superiority trial was to validate the efficacy and safety of this blood pressure-lowering strategy that uses remifentanil and dexmedetomidine in patients with acute intracerebral hemorrhage.

METHODS

In this multicenter, prospective, single-blinded, superiority randomized controlled trial, patients with intracerebral hemorrhage and systolic blood pressure (SBP) 150 mmHg or greater were randomly allocated to the intervention group (a preset protocol with a standard guideline management using remifentanil and dexmedetomidine) or the control group (standard guideline-based management) to receive blood pressure-lowering treatment. The primary outcome was the SBP control rate (less than 140 mmHg) at 1 h posttreatment initiation. Secondary outcomes included blood pressure variability, neurologic function, and clinical outcomes.

RESULTS

A total of 338 patients were allocated to the intervention (n = 167) or control group (n = 171). The SBP control rate at 1 h posttreatment initiation in the intervention group was higher than that in controls (101 of 161, 62.7% vs. 66 of 166, 39.8%; difference, 23.2%; 95% CI, 12.4 to 34.1%; P < 0.001). Analysis of secondary outcomes indicated that patients in the intervention group could effectively reduce agitation while achieving lighter sedation, but no improvement in clinical outcomes was observed. Regarding safety, the incidence of bradycardia and respiratory depression was higher in the intervention group.

CONCLUSIONS

Among intracerebral hemorrhage patients with a SBP 150 mmHg or greater, a preset protocol using a remifentanil and dexmedetomidine-based standard guideline management significantly increased the SBP control rate at 1 h posttreatment compared with the standard guideline-based management.

EDITOR’S PERSPECTIVE

Implementing integrative therapies in adult critical care: Barriers and strategies

BACKGROUND

Critically ill patients experience intense physical and psychological stressors in the intensive care unit (ICU). More than half of ICU survivors report overwhelming mental health symptoms after ICU discharge, such as post-traumatic stress symptoms, anxiety, and depression. Relaxation-inducing integrative therapies such as guided imagery, massage, therapeutic touch, music therapy, and spirituality-based healing practices have the potential to promote comfort and relaxation and improve patient outcomes.

OBJECTIVES

The aim of this study was to explore the attitudes of healthcare professionals towards the implementation of relaxation-inducing integrative therapies in critical care, barriers to implementation, and potential strategies to overcome them.

METHODS

We conducted seven focus group interviews with 23 critical care clinicians (70% nurses, 17% allied health professionals, 13% physicians). Interviews were audiotaped and transcribed verbatim. Data were thematically analysed using an inductive content analysis approach.

FINDINGS

Results reveal a constant interplay between mostly positive personal attitudes towards implementation of integrative therapies and the perceived culture and priorities of the unit. The main benefits for critically ill patients as perceived by participants were promotion of comfort, sleep, and coping, increase of trust, and decrease of pain and stress. As for barriers, dominant themes were a perceived lack of evidence, cost, and time constraints and the fear of loss of professional credibility. Participants related nurses' education and training, family involvement, and leadership were seen as main strategies for implementation.

CONCLUSIONS

The dominant ICU culture needs to be considered when implementing integrative therapies. Education, access to evidence, and role modelling are proposed as means to shift the ICU culture towards utilisation of integrative therapies in critical care.

Antipsychotics in the Treatment of Delirium in Critically Ill Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To conduct a systematic review and meta-analysis assessing whether the use of antipsychotic medications in critically ill adult patients with delirium impacts patient-important outcomes.

DATA SOURCES

A medical librarian searched Ovid MEDLINE, EMBASE, APA PsycInfo, and Wiley's Cochrane Library as well as clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2023.

STUDY SELECTION

Independently and in duplicate, reviewers screened abstracts and titles for eligibility, then full text of qualifying studies. We included parallel-group randomized controlled trials (RCTs) that included critically ill adult patients with delirium. The intervention group was required to receive antipsychotic medications at any dose, whereas the control group received usual care or placebo.

DATA EXTRACTION

Reviewers extracted data independently and in duplicate using a piloted abstraction form. Statistical analyses were conducted using RevMan software (version 5.4).

DATA SYNTHESIS

Five RCTs ( n = 1750) met eligibility criteria. The use of antipsychotic medications compared with placebo did not increase the number of delirium- or coma-free days (mean difference 0.90 d; 95% CI, -0.32 to 2.12; moderate certainty), nor did it result in a difference in mortality, duration of mechanical ventilation, ICU, or hospital length of stay. The use of antipsychotics did not result in an increased risk of adverse events (risk ratio 1.27; 95% CI, 0.71-2.30; high certainty). Subgroup analysis of typical versus atypical antipsychotics did not identify any subgroup effect for any outcome.

CONCLUSIONS

In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in delirium- or coma-free days when delirious critically ill adults are treated with antipsychotic medications. Further studies in the subset of patients with hyperactive delirium may be of benefit.

Generalized music therapy to reduce neuroactive drug needs in critically ill patients. Study protocol for a randomized trial

BACKGROUND

Critically ill patients are exposed to several physical and emotional stressors, needing analgesic and sedative drugs to tolerate invasive procedures and the harsh intensive care unit (ICU) environment. However, this pharmacological therapy presents several side effects: guidelines suggest using a light sedation target, keeping critically ill patients calm, conscious, and cooperative. Personalized music therapy (MT) can reduce stress and anxiety, decreasing the need for drugs. The aim of the current investigation is to compare different approaches for MT in the ICU: a personalized approach, with music selected by patients/families and listened through headphones, or a generalized approach, with ambient music chosen by a music therapist and transmitted through speakers.

PRIMARY OUTCOME

number of days "free from neuroactive drugs" in the first 28 days after ICU admission.

SECONDARY OUTCOMES

total amount of neuroactive drugs (midazolam, propofol, morphine, fentanyl, haloperidol), stress during ICU stay (sleep at night, anxiety and agitation, use of physical restraints, stressors evaluated at discharge), the feasibility of generalized MT (interruptions requested by staff members and patients/families).

METHODS

Randomized, controlled trial with three groups of critically ill adults: a control group, without MT; a personalized MT group, with music for at least 2 h per day; a generalized MT group, with music for 12.5 h/day, subdivided into fifteen 50-min periods.

DISCUSSION

One hundred fifty-three patients are expected to be enrolled. This publication presents the rationale and the study methods, particularly the strategies used to build the generalized MT playlist. From a preliminary analysis, generalized MT seems feasible in the ICU and is positively received by staff members, critically ill patients, and families.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03280329. September 12, 2017.

The effect of an improved ICU physical environment on outcomes and post-ICU recovery-a protocol

BACKGROUND

Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by similar advances in ICU bedspace design. Environmental factors including excessive noise, suboptimal lighting, and lack of natural lights and views can adversely impact staff wellbeing and short- and long-term patient outcomes. The personal, social, and economic costs associated with this are potentially large. The ICU of the Future project was conceived to address these issues. This is a mixed-method project, aiming to improve the ICU bedspace environment and assess impact on patient outcomes. Two innovative and adaptive ICU bedspaces capable of being individualised to patients' personal and changing needs were co-designed and implemented. The aim of this study is to evaluate the effect of an improved ICU bedspace environment on patient outcomes and operational impact.

METHODS

This is a prospective multi-component, mixed methods study including a randomised controlled trial. Over a 2-year study period, the two upgraded bedspaces will serve as intervention beds, while the remaining 25 bedspaces in the study ICU function as control beds. Study components encompass (1) an objective environmental assessment; (2) a qualitative investigation of the ICU environment and its impact from the perspective of patients, families, and staff; (3) sleep investigations; (4) circadian rhythm investigations; (5) delirium measurements; (6) assessment of medium-term patient outcomes; and (7) a health economic evaluation.

DISCUSSION

Despite growing evidence of the negative impact the ICU environment can have on patient recovery, this is an area of critical care medicine that is understudied and commonly not considered when ICUs are being designed. This study will provide new information on how an improved ICU environment impact holistic patient recovery and outcomes, potentially influencing ICU design worldwide.

TRIAL REGISTRATION

ACTRN12623000541606. Registered on May 22, 2023. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385845&isReview=true .

Practical approach to inhaled sedation in the critically ill patient. Sedation, analgesia and Delirium Working Group (GTSAD) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

The use of sedatives in Intensive Care Units (ICU) is essential for relieving anxiety and stress in mechanically ventilated patients, and it is related to clinical outcomes, duration of mechanical ventilation, and length of stay in the ICU. Inhaled sedatives offer benefits such as faster awakening and extubation, decreased total opioid and neuromuscular blocking agents (NMB) doses, as well as bronchodilator, anticonvulsant, and cardiopulmonary and neurological protective effects. Inhaled sedation is administered using a specific vaporizer. Isoflurane is the recommended agent due to its efficacy and safety profile. Inhaled sedation is recommended for moderate and deep sedation, prolonged sedation, difficult sedation, patients with acute respiratory distress syndrome (ARDS), status asthmaticus, and super-refractory status epilepticus. By offering these significant advantages, the use of inhaled sedatives allows for a personalized and controlled approach to optimize sedation in the ICU.

Exploring Antipsychotic Use for Delirium Management in Adults in Hospital, Sub-Acute Rehabilitation and Aged Care Settings: A Systematic Literature Review

BACKGROUND

International guidelines discourage antipsychotic use for delirium; however, concerns persist about their continued use in clinical practice.

OBJECTIVES

We aimed to describe the prevalence and patterns of antipsychotic use in delirium management with regard to best-practice recommendations. Primary outcomes investigated were prevalence of use, antipsychotic type, dosage and clinical indication.

METHODS

Eligibility criteria: studies of any design that examined antipsychotic use to manage delirium in adults in critical care, acute care, palliative care, rehabilitation, and aged care were included. Studies of patients in acute psychiatric care, with psychiatric illness or pre-existing antipsychotic use were excluded.

INFORMATION SOURCES

we searched five health databases on 16 August, 2023 (PubMed, CINAHL, Embase, APA PsycInfo, ProQuest Health and Medical Collection) using MeSH terms and relevant keywords, including 'delirium' and 'antipsychotic'. Risk of bias: as no included studies were randomised controlled trials, all studies were assessed for methodological quality using the Mixed Methods Appraisal Tool.

SYNTHESIS OF RESULTS

descriptive data were extracted in Covidence and synthesised in Microsoft Excel.

RESULTS

Included studies: 39 studies published between March 2004 and August 2023 from 13 countries (n = 1,359,519 patients). Most study designs were retrospective medical record audits (n = 16).

SYNTHESIS OF RESULTS

in 18 studies, participants' mean age was ≥65 years (77.79, ±5.20). Palliative care had the highest average proportion of patients with delirium managed with antipsychotics (70.87%, ±33.81%); it was lower and varied little between intensive care unit (53.53%, ±19.73%) and non-intensive care unit settings [medical, surgical and any acute care wards] (56.93%, ±26.44%) and was lowest in in-patient rehabilitation (17.8%). Seventeen different antipsychotics were reported on. In patients aged ≥65 years, haloperidol was the most frequently used and at higher than recommended mean daily doses (2.75 mg, ±2.21 mg). Other antipsychotics commonly administered were olanzapine (mean 11 mg, ±8.54 mg), quetiapine (mean 64.23 mg, ±43.20 mg) and risperidone (mean 0.97 mg, ±0.64 mg).

CONCLUSIONS

The use of antipsychotics to manage delirium is strongly discouraged in international guidelines. Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people. However, this study has provided evidence that clinicians continue to use antipsychotics for delirium management, the dose, frequency and duration of which are often outside evidence-based guideline recommendations. Clinicians continue to choose antipsychotics to manage delirium symptoms to settle agitation and maintain patient and staff safety, particularly in situations where workload pressures are high. Sustained efforts are needed at the individual, team and organisational levels to educate, train and support clinicians to prioritise non-pharmacological interventions early before deciding to use antipsychotics. This could prevent delirium and avert escalation in behavioural symptoms that often lead to antipsychotic use.

Early Mobilization Dose Reporting in Randomized Clinical Trials With Patients Who Were Mechanically Ventilated: A Scoping Review

OBJECTIVE

The aim of this scoping review was to investigate the mobilization dose reporting in the randomized clinical trials (RCTs) of patients receiving mechanical ventilation in the intensive care unit.

METHODS

In this scoping review, RCTs published from inception to December 2022 were searched in relevant electronic databases. Trials that involved adults receiving mechanical ventilation (>48 hours) and any early mobilization modality were analyzed. Two independent authors screened, selected, and extracted data. The mobilization doses of the intervention groups (IGs) and the comparator groups (CGs) were assessed as the proportion of reported items/total applicable from the main items of the Consensus on Exercise Reporting Template (CERT).

RESULTS

Twenty-three RCTs comprising 2707 patients (1358 from IG and 1349 from CG) were included, involving studies on neuromuscular electrical stimulation (n = 7), progressive mobility (n = 6), leg cycling (n = 3), tilt table (n = 1), and multicomponent (n = 6) mobilization. The pooled reporting of CERT items was 68% (86% for IG and 50% for CG). The most reported CERT items were type of exercise (100%) and weekly frequency (100%) for IG, whereas the least reported were intensity (4%) and individualization (22%) for CG. Regardless of the group, individualization, progression, and intensity of mobilization were the least reported items. Eight IGs (35%) reported all CERT items, whereas no CGs reported all of them.

CONCLUSIONS

Deficits in mobilization dose reporting of intensive care unit RCTs were identified, especially for exercise intensity in adults receiving mechanical ventilation. One-third of IG reported all exercise dosing items, whereas no CG reported all of them. Future studies should investigate the details of optimal dosage reporting, particularly for CG.

IMPACT

The lack of dose reporting may partially explain the inconsistency in the meta-analysis results of early mobilization trials, thus limiting the interpretation for clinical practice in the intensive care unit.

Preventive Effects of Ramelteon, Suvorexant, and Lemborexant on Delirium in Hospitalized Patients With Physical Disease: A Retrospective Cohort Study

BACKGROUND

New sleep-inducing drugs (eg, ramelteon, suvorexant, and lemborexant) have been shown to prevent delirium in high-risk groups. However, no single study has simultaneously evaluated the delirium-preventing effects of all novel sleep-inducing drugs in hospitalized patients. Therefore, this study aimed to clarify the relationship between sleep-inducing drugs and delirium prevention in patients hospitalized in general medical-surgical settings for nonpsychiatric conditions who underwent liaison interventions for insomnia.

METHODS

This retrospective cohort study included patients treated in general medical-surgical settings for nonpsychiatric conditions with consultation-liaison psychiatry consult for insomnia. Delirium was diagnosed by fully certified psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders 5th edition. The following items were retrospectively examined from medical records as factors related to delirium development: type of sleep-inducing drugs, age, sex, and delirium risk factors. The risk factors of delirium development were calculated using adjusted odds ratios (aORs) via multivariate logistic regression analysis.

RESULTS

Among the 710 patients analyzed, 257 (36.2%) developed delirium. Suvorexant (aOR, 0.61; 95% confidence interval [CI], 0.40-0.94; P = 0.02) and lemborexant (aOR, 0.23; 95% CI, 0.14-0.39; P < 0.0001) significantly reduced the risk of developing delirium. Benzodiazepines (aOR, 1.90; 95% CI, 1.15-3.13; P = 0.01) significantly increased this risk. Ramelteon (aOR, 1.30; 95% CI, 0.84-2.01; P = 0.24) and Z-drugs (aOR, 1.27; 95% CI, 0.81-1.98; P = 0.30) were not significantly associated with delirium development.

CONCLUSIONS

The use of suvorexant and lemborexant may prevent delirium in patients with a wide range of medical conditions.

Association Between Pupil Light Reflex and Delirium in Adults With Traumatic Brain Injury: Preliminary Findings

ABSTRACT

BACKGROUND: Delirium is a common neurological complication in patients admitted to the intensive care unit (ICU) after moderate to severe traumatic brain injury (TBI). Although current clinical guidelines prioritize delirium prevention, no specific tool is tailored to detect early signs of delirium in TBI patients. This preliminary 2-phase observational study investigated the correlation between the pupillary light reflex (PLR), measured with a pupillometer during mechanical ventilation, and the development of postextubation delirium in TBI patients. METHODS: A convenience sample of 26 adults with moderate to severe TBI under mechanical ventilation was recruited during their ICU stay. In phase I, PLR measurements were performed in the first 3 days of ICU admission using automated infrared pupillometry. In phase II, 2 raters independently extracted delirium data in the 72 hours post extubation period from medical records. Delirium was confirmed with a documented medical diagnosis. Point-biserial correlations (rpb) were used to examine the association between PLR scores and the presence of postextubation delirium. Student t tests were also performed to compare mean PLR scores between patients with and without delirium. RESULTS: Ten TBI patients (38%) were diagnosed with postextubation delirium, whereas 16 (62%) were not. Significant correlations between delirium and 2 PLR variables were found: pupil constriction percentage (rpb(24) = -0.526, P = .006) and constriction velocity (rpb(24) = -0.485, P = .012). The t test also revealed a significant difference in constriction percentage and velocity scores between TBI patients with and without delirium (P ≤ .01). CONCLUSION: Our findings suggest that the use of pupillometry in the first 3 days of mechanical ventilation during an ICU stay may help identify TBI patients at risk for delirium after extubation. Although further research is necessary to support its validity, this technological tool may enable ICU nurses to better screen TBI patients for delirium and prevent its development.

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

The Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Urosepsis-Associated Delirium

Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.

Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.

Enhancing European Management of Analgesia, Sedation, and Delirium: A Multinational, Prospective, Interventional Before-After Trial

BACKGROUND

The objective of this study was to analyze the impact of a structured educational intervention on the implementation of guideline-recommended pain, agitation, and delirium (PAD) assessment.

METHODS

This was a prospective, multinational, interventional before-after trial conducted at 12 intensive care units from 10 centers in Germany, Austria, Switzerland, and the UK. Intensive care units underwent a 6-week structured educational program, comprising online lectures, instructional videos, educational handouts, and bedside teaching. Patient-level PAD assessment data were collected in three 1-day point-prevalence assessments before (T1), 6 weeks after (T2), and 1 year after (T3) the educational program.

RESULTS

A total of 430 patients were included. The rate of patients who received all three PAD assessments changed from 55% (107/195) at T1 to 53% (68/129) at T2, but increased to 73% (77/106) at T3 (p = 0.003). The delirium screening rate increased from 64% (124/195) at T1 to 65% (84/129) at T2 and 77% (82/106) at T3 (p = 0.041). The pain assessment rate increased from 87% (170/195) at T1 to 92% (119/129) at T2 and 98% (104/106) at T3 (p = 0.005). The rate of sedation assessment showed no signficiant change. The proportion of patients who received nonpharmacological delirium prevention measures increased from 58% (114/195) at T1 to 80% (103/129) at T2 and 91% (96/106) at T3 (p < 0.001). Multivariable regression revealed that at T3, patients were more likely to receive a delirium assessment (odds ratio [OR] 2.138, 95% confidence interval [CI] 1.206-3.790; p = 0.009), sedation assessment (OR 4.131, 95% CI 1.372-12.438; p = 0.012), or all three PAD assessments (OR 2.295, 95% CI 1.349-3.903; p = 0.002) compared with T1.

CONCLUSIONS

In routine care, many patients were not assessed for PAD. Assessment rates increased significantly 1 year after the intervention. Clinical trial registration ClinicalTrials.gov: NCT03553719.

Health care professionals' experiences of pain management in the intensive care unit: a qualitative study

Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.

The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients

Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.

Thiamine utilization and the lack of prescribing standardization: A critical examination

OBJECTIVES

Thiamine is often prescribed for thiamine deficiency during hospitalization despite the lack of US-based clinical guidelines. This study aims to evaluate thiamine prescribing patterns and key characteristics associated with the deficiency to address gaps in care.

METHODS

Data were obtained from electronic health records of hospitalized patients between September 1, 2021, and March 30, 2022. Alcohol use disorder (AUD) was defined by a positive Clinical Institute Withdrawal Assessment score or a positive serum alcohol level upon admission. Geriatric patients were defined as age ≥65. Cohort 1 was defined as: AUD, albumin <4 g/L, INR >1.5, and total bilirubin >3 mg/dL. Cohort 2 was defined as: age >65, albumin <4 g/L, hemoglobin <15 g/dL, and folate <4 ng/mL. A multivariable LASSO regression model was used to identify characteristics associated with higher thiamine dosing (>100 mg/day).

RESULTS

Among 780 patients, 520 (66.7%) were identified as AUD, of which 265 (50.1%) were between the ages of 45-64 years. The AUD cohort was significantly different (p < 0.05) in the mean serum albumin 4.16 g/L (IQR: 3.8-4.5), AST 73.55 U/L (23.75-82.00), ALT 52.57 U/L (17.00-57.00), total bilirubin 0.98 (0.3-1.0), and INR 1.1 (0.99-1.12), compared to non-AUD patients with a mean serum albumin 3.75 g/L (3.3-4.2), AST 35.07 U/L (11.00-42.00), ALT 32.77 U/L (5.00-34.00), total bilirubin 0.89 (0.2-0.9), and INR 1.21 (1.0-1.22). In the geriatric cohort, 136 patients (17%) had a mean serum albumin 3.77 g/L (3.4-4.2), AST 38.66 U/L (14.0-41.0), ALT 29.36 U/L (9.0-37.0), total bilirubin 0.62 mg/dL (0.30-0.90), and direct bilirubin 0.12 mg/dL (0.00-0.20), compared to the non-geriatric cohort with a mean serum albumin 4.10 g/L (3.8-4.40), AST 66.44 U/L (21.0-75.0), ALT 50.03 U/L (16.00-53.75), total bilirubin 1.02 mg/dL (0.30-1.00), and direct bilirubin 0.31 mg/dL (0.00-0.20). In cohort 1, 40.6% patients were between 51 and 64 years old, (66.5%) male, and had a BMI <25 (36.4%). In cohort 2, 52.6% were between 65 and 70 years old, (57.9%) male, and had a BMI <25 (57.9%). Cohort 1 were prescribed a dose of 100 mg (47.7 %), oral (63.5%), intramuscular (18.2%), daily (58.9%), one-day duration (49.4%) most frequently. Cohort 2 were prescribed a dose of 100 mg (56.0%), oral (77.2%), daily (77.2%), one-day duration (29.8%) most frequently. The AUD was significantly associated with having a higher dosage (e.g., >100 mg) of thiamine prescribed per day OR 1.62 (1.11-2.37) (p < 0.01).

CONCLUSIONS

This study confirms that thiamine prescribing patterns vary during hospitalization and suggest specific laboratory findings may aid in identifying cohorts associated with the deficiency.

Three patterns of symptom communication between patients and clinicians in the intensive care unit: A fieldwork study

AIM

To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit.

DESIGN

We conducted a fieldwork study with triangulation of participant observation and individual interviews.

METHODS

Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face-to-face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview.

FINDINGS

Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co-existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress.

CONCLUSION

Recognition of symptoms in non-speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress.

IMPLICATIONS FOR PATIENT CARE

Proactive and reactive symptom assessment of non-speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication.

IMPACT

This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units.

REPORTING METHOD

We used the consolidated criteria for reporting qualitative research.

PATIENT CONTRIBUTION

A user representative was involved in the design of the study.

Impact of delirium intervention on cognitive load among nurses in the intensive care unit: A multi-centre cluster randomized controlled trial

BACKGROUND

High cognitive load in nurses is a common problem in the intensive care unit (ICU). However, it remains unclear what different types of cognitive load the ICU nurses have experienced during the implementation of delirium interventions.

AIM

To describe the characteristics and explore the effect of implementing a delirium intervention on the cognitive load of nurses working in the ICU.

METHODS

A cluster-randomized controlled clinical trial was conducted. Six ICUs were randomized in a 1:1 ratio, and eligible nurses from these units provided either a delirium bundle intervention in addition to usual care (27 nurses) or usual care alone. An instrument was used to measure different types of cognitive load (MDT-CL), assessing intrinsic, extraneous and germane cognitive load. The repeated measures analysis of variance was used to detect between-group differences.

RESULTS

Among these nurses, significant between-group differences were identified in terms of their overall (P < 0.001), intrinsic (P < 0.001) and extraneous (P < 0.001) cognitive load. There was no significant change observed in the germane cognitive load (P = 0.489) in the delirium intervention group.

CONCLUSION

It is important to understand how the implementation of a delirium intervention affects different types of cognitive load in nurses, in order that tailored strategies can be applied to reduce cognitive load in ICU nurses.

The risk of delirium after sedation with propofol or midazolam in intensive care unit patients

AIM

Knowledge of risk factors may provide strategies to reduce the high burden of delirium in intensive care unit (ICU) patients. We aimed to compare the risk of delirium after deep sedation with propofol versus midazolam in ICU patients.

METHODS

In this prospective cohort study, ICU patients who were in an unarousable state for ≥24 h due to continuous sedation with propofol and/or midazolam were included. Patients admitted ≤24 h, those with an acute neurological disorder and those receiving palliative sedation were excluded. ICU patients were assessed daily for delirium during the 7 days following an unarousable state due to continuous sedation.

RESULTS

Among 950 included patients, 605 (64%) subjects were delirious during the 7 days after awaking. The proportion of subsequent delirium was higher after midazolam sedation (152/207 [73%] patients) and after both propofol and midazolam sedation (257/377 [68%] patients), compared to propofol sedation only (196/366 [54%] patients). Midazolam sedation (adjusted cause-specific hazard ratio [adj. cause-specific HR] 1.32, 95% confidence interval [CI] 1.05-1.66) and propofol and midazolam sedation (adj. cause-specific HR 1.29, 95% CI 1.06-1.56) were associated with a higher risk of subsequent delirium compared to propofol sedation only.

CONCLUSION

This study among sedated ICU patients suggests that, compared to propofol sedation, midazolam sedation is associated with a higher risk of subsequent delirium. This risk seems more apparent in patients with high cumulative midazolam intravenous doses. Our findings underpin the recommendations of the Society of Critical Care Medicine Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guidelines to use propofol over benzodiazepines for sedation in ICU patients.

ICU admission Braden score independently predicts delirium in critically ill patients with ischemic stroke

BACKGROUND

Delirium is a common and severe complication in intensive care unit (ICU) patients with acute ischemic stroke, exacerbating cognitive and physical impairments. It prolongs hospitalization, increases healthcare costs, and raises mortality risk. Early prediction is crucial because it facilitates prompt interventions that could possibly reverse or alleviate the detrimental consequences of delirium. Braden scores, traditionally used to assess pressure injury risk, could also signal frailty, providing an early warning of delirium and aiding in prompt and effective patient management.

OBJECTIVE

To examine the association between the Braden score and delirium.

METHODS

A retrospective analysis of adult ischemic stroke patients in the ICU of a tertiary academic medical center in Boston from 2008 to 2019 was performed. Braden scores were obtained on admission for each patient. Delirium, the primary study outcome, was assessed using the Confusion Assessment Method for Intensive Care Unit and a review of nursing notes. The association between Braden score and delirium was determined using Cox proportional hazards modeling, with hazard ratios (HR) and 95% confidence intervals (CI) calculated.

RESULTS

The study included 3,680 patients with a median age of 72 years, of whom 1,798 were women (48.9 %). The median Braden score at ICU admission was 15 (interquartile range 13-17). After adjustment for demographics, laboratory tests, severity of illness, and comorbidities, the Braden score was inversely associated with the risk of delirium (adjusted HR: 0.94, 95 % CI: 0.92-0.96, P < 0.001).

CONCLUSIONS

The Braden score may serve as a convenient and simple screening tool to identify the risk of delirium in ICU patients with ischemic stroke.

IMPLICATION FOR CLINICAL PRACTICE

The use of the Braden score as a predictor of delirium in ischemic stroke patients in the ICU allows early identification of high-risk patients. This facilitates timely intervention, thereby improving patient outcomes and potentially reducing healthcare costs.

Resistance training combined with β-hydroxy β-methylbutyrate for patients with critical illness: A four-arm, mixed-methods, feasibility randomised controlled trial

OBJECTIVES

This study aimed to assess the feasibility, safety, acceptability, and potential effectiveness of resistance training (RT) with or without β-Hydroxy β-Methylbutyrate (HMB) intervention program for ICU patients.

DESIGN

Open-label, parallel group, mixed method, randomized controlled trial.

SETTINGS

A tertiary general hospital in Fuzhou, China.

METHODS

Participants were randomly allocated to one of four groups. The RT group received supervised multilevel resistance training (RT) using elastic bands, administered by trained ICU nurses. The HMB group received an additional daily dose of 3.0 g HMB. The combination group underwent both interventions concurrently, while the control group received standard care. These interventions were implemented throughout the entire hospitalization period. Primary outcomes included feasibility indicators such as recruitment rate, enrollment rate, retention rate, and compliance rate. Secondary outcomes covered adverse events, acceptability (evaluated through questionnaires and qualitative interviews), and physical function. Quantitative analysis utilized a generalized estimation equation model, while qualitative analysis employed directed content analysis.

RESULTS

All feasibility indicators met predetermined criteria. Forty-eight patients were randomly assigned across four arms, achieving a 96% enrollment rate. Most patients adhered to the intervention until discharge, resulting in a 97.9% retention rate. Compliance rates for both RT and HMB interventions approached or exceeded 85%. No adverse events were reported. The intervention achieved 100% acceptability, with a prevailing expression of positive experiences and perception of appropriateness. The RT intervention shows potential improvement in physical function, while HMB does not.

CONCLUSIONS

Implementing nurse-led resistance training with elastic bands with or without HMB proved to be feasible and safe for ICU patients.

IMPLICATIONS FOR CLINICAL PRACTICE

A large-scale, multicenter clinical trials are imperative to definitively assess the impact of this intervention on functional outcomes in this population.

"It Kills Your Soul": A Mixed Methods Study of Ethical Sensitivity of Critical Care Nurses

BACKGROUND

Critically ill patients often experience distressful and impactful symptoms and conditions that include pain, agitation/sedation, delirium, immobility, and sleep disturbances (PADIS). The presence of PADIS can affect recovery and long-term patient outcomes. An integral part of critical care nursing is PADIS prevention, assessment, and management. Ethical sensitivity of everyday nursing practice related to PADIS is an imperative part of implementing evidence-based care for patients.

OBJECTIVE

The first 2 aims of this study were to determine the measured level of ethical awareness as an attribute of ethical sensitivity among the critical care nurse participants and to explore the ethical sensitivity of critical care nurses related to the implementation of PADIS care. The third aim was to examine how the measured level of ethical awareness and ethical sensitivity exploration results converge, diverge, and/or relate to each other to produce a more complete understanding of PADIS ethical sensitivity by critical care nurses.

METHODS

This was a convergent parallel mixed methods study (QUAL + quant). Ethical sensitivity was explored by conducting an ethnography of critical care nurses. The participants were 19 critical care nurses who were observed during patient care, interviewed individually, participated in a focus group (QUAL), and were administered the Ethical Awareness Scale (quant).

FINDINGS

Despite high levels of individual ethical awareness among nurses, themes of ambiguous beneficence, heedless autonomy, and moral distress were found to be related to PADIS care.

CONCLUSIONS

More effort is needed to establish moral community, ethical leadership, and individual ethical guidance for nurses to establish patient-centered decision-making and PADIS care.

Exploring patients' and families' preferences for auditory stimulation in ICU delirium prevention: A qualitative study

OBJECTIVES

To explore the preferences of patients and families for delirium prevention by auditory stimulation in intensive care units.

RESEARCH METHODOLOGY

One-on-one, face-to-face, semistructured interviews with 17 participants (6 patients and 11 family members) were conducted at a step-down unit in a tertiary general hospital using a descriptive qualitative design. The data were analyzed via inductive thematic analysis.

RESULTS

Four major themes and ten subthemes emerged from the interviews: (1) reality orientation; (2) emotional support; (3) links to the outside; and (4) promising future.

CONCLUSIONS

The results in this qualitative study shed light on patients' and families' preferences for auditory stimulation in preventing ICU delirium. The participation of family members plays a crucial role in preventing ICU delirium. Family members can assist patients in reducing confusion about the situation by providing accurate and clear reality orientation. The emotional support and promising future provided by family members can help patients regain confidence and courage, which are often lacking in ICU patients. Linking patients to the outside world helps them stay connected, understand what is happening outside and reduce feelings of isolation.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings can help health care staff gain insight into patients' and families' preferences and needs for auditory stimulation. Furthermore, these findings pave the way for crafting effective auditory interventions.

Multicentre implementation of a quality improvement initiative to reduce delirium in adult intensive care units: An interrupted time series analysis

PURPOSE

The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada.

MATERIAL AND METHODS

We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record.

RESULTS

44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events.

CONCLUSIONS

An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium.

What Is the Potential Value of a Randomized Trial of Different Thresholds to Initiate Invasive Ventilation? A Health Economic Analysis

OBJECTIVES

To estimate the expected value of undertaking a future randomized controlled trial of thresholds used to initiate invasive ventilation compared with usual care in hypoxemic respiratory failure.

PERSPECTIVE

Publicly funded healthcare payer.

SETTING

Critical care units capable of providing invasive ventilation and unconstrained by resource limitations during usual (nonpandemic) practice.

METHODS

We performed a model-based cost-utility estimation with individual-level simulation and value-of-information analysis focused on adults, admitted to critical care, receiving noninvasive oxygen. In the primary scenario, we compared hypothetical threshold A to usual care, where threshold A resulted in increased use of invasive ventilation and improved survival compared with usual care. In the secondary scenario, we compared hypothetical threshold B to usual care, where threshold B resulted in decreased use of invasive ventilation and similar survival compared with usual care. We assumed a willingness-to-pay of 100,000 Canadian dollars (CADs) per quality-adjusted life year.

RESULTS

In the primary scenario, threshold A was cost-effective compared with usual care due to improved hospital survival (78.1% vs. 75.1%), despite more use of invasive ventilation (62% vs. 30%) and higher lifetime costs (86,900 vs. 75,500 CAD). In the secondary scenario, threshold B was cost-effective compared with usual care due to similar survival (74.5% vs. 74.6%) with less use of invasive ventilation (20.2% vs. 27.6%) and lower lifetime costs (71,700 vs. 74,700 CAD). Value-of-information analysis showed that the expected value to Canadian society over 10 years of a 400-person randomized trial comparing a threshold for invasive ventilation to usual care in hypoxemic respiratory failure was 1.35 billion CAD or more in both scenarios.

CONCLUSIONS

It would be highly valuable to society to identify thresholds that, in comparison to usual care, either increase survival or reduce invasive ventilation without reducing survival.

The frequency of sepsis-associated delirium in intensive care unit and its effect on nurse workload

AIM

To determine the frequency of sepsis-associated delirium (SAD) in the intensive care unit and its effect on nurse workload.

DESIGN

A cross-sectional and correlational design was used.

METHODS

The study was conducted with 158 patients in the adult intensive care unit of a hospital between October 28 and July 28, 2022. Data analysis included frequency, chi-squared/fisher's exact test, independent samples t-test, correlation analysis, simple and multiple linear regression analyses. The study adhered to the STROBE guidelines.

RESULTS

Sepsis was detected in 12.7% of the patients, delirium in 39.9%, and SAD in 10.1%. SAD was more common in males (19%) and 56.3% of the patients were admitted to the unit from the emergency department. Patients developing SAD had significantly higher age and mean sequential organ failure evaluation, acute physiology and chronic health evaluation II, and C-reactive protein and lactate scores, but their Glasgow Coma Scale scores were significantly low. There was a moderate positive relationship between the patients' Sequential Organ Failure Assessment score and the presence of SAD. The most common source of infection in patients diagnosed with SAD was bloodstream infection (44.4%). SAD significantly increased nurse workload and average care time (1.8 h) and it explained 22.8% of the total variance in nurse workload. Additionally, the use of antibiotics, vasopressors and invasive mechanical ventilation significantly increased nurse workload.

CONCLUSION

In the study, in patients who developed SAD increased nurse workload and average care time significantly. Preventive nursing approaches and effective management of SAD can reduce the rate of development of SAD and nurse workload.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

It is important to work with routine screening, prevention and patient-nurse ratio appropriate to the workload for SAD.

Light, sleep and circadian rhythm in critical illness

PURPOSE OF REVIEW

Sleep and circadian disruption (SCD) are associated with worse outcomes in the ICU population. We discuss sleep, circadian physiology, the role of light in circadian entrainment and its possible role in treating SCD, with special attention to the use of light therapies and ICU design.

RECENT FINDINGS

The American Thoracic Society recently published an official research statement highlighting key areas required to define and treat ICU SCD. Recent literature has been predominantly observational, describing how both critical illness and the ICU environment might impair normal sleep and impact circadian rhythm. Emerging consensus guidance outlines the need for standardized light metrics in clinical trials investigating effects of light therapies. A recent proof-of-concept randomized controlled trial (RCT) showed improvement in delirium incidence and circadian alignment from ICU room redesign that included a dynamic lighting system (DLS).

SUMMARY

Further investigation is needed to define the optimal physical properties of light therapy in the ICU environment as well as timing and duration of light treatments. Work in this area will inform future circadian-promoting design, as well as multicomponent nonpharmacological protocols, to mitigate ICU SCD with the objective of improving patient outcomes.

Measuring pain or discomfort during routine nursing care in lightly sedated mechanically ventilated intensive care patients: A prospective preliminary cohort study

BACKGROUND

Pain is routinely measured on mechanically ventilated ICU patients. However, the tools used are not designed to discriminate between pain and non-pain discomfort, a distinction with therapeutic implications.

OBJECTIVES

To evaluate whether clinical measurement tools can discern both pain and non-pain discomfort.

METHODS

A prospective observational cohort study was conducted in a General ICU at a tertiary Medical Center in Israel. The Behavior Pain Scale (BPS) and Visual Analog Scale (VAS) of Discomfort were simultaneously assessed by a researcher and bedside nurse on thirteen lightly sedated patients during 71 routine nursing interventions in lightly sedated, mechanically ventilated, adult patients. Patients were asked whether they were in pain due to these interventions.

RESULTS

Statistically significant increases from baseline during interventions were observed [median change: 1.00 (-1-5), 1.5(-4-8.5), p < 0.001] as measured by BPS and VAS Discomfort Scale, respectively. BPS scores ranged between 4 and 6 when the majority (53 %) of the patients replied that they had no pain but were interpreted by the clinicians as discomfort. Endotracheal suctioning caused the greatest increase in BPS and VAS, with no statistically significant differences in BPS and VAS Discomfort Scale scores whether patients reported or did not report pain. A BPS>6 had a higher sensitivity and specificity to reported pain (accuracy of 76 %) compared to a BPS of 4-6.

CONCLUSIONS

Standard assessments are sensitive to pain caused by routine nursing care interventions. However, this study presents evidence that among lightly sedated ICU patients, moderate BPS scores could also measure non-pain discomfort. ICU nurses should be aware that signs of unpleasantness measured by a pain scale could reflect non-pain discomfort.

Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study

INTRODUCTION

Prognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and prevalence of early electroencephalogram (EEG) abnormalities in adult stroke patients receiving mechanical ventilation.

METHODS

This study is a pre-planned ancillary investigation within the prospective multicenter SPICE cohort study (2017-2019), conducted in 33 intensive care units (ICUs) in the Paris area, France. We included adult stroke patients requiring invasive mechanical ventilation, who underwent at least one intermittent EEG examination during their ICU stay. The primary endpoint was the functional neurological outcome at one year, determined using the modified Rankin scale (mRS), and dichotomized as unfavorable (mRS 4-6, indicating severe disability or death) or favorable (mRS 0-3). Multivariable regression analyses were employed to identify EEG abnormalities associated with functional outcomes.

RESULTS

Of the 364 patients enrolled in the SPICE study, 153 patients (49 ischemic strokes, 52 intracranial hemorrhages, and 52 subarachnoid hemorrhages) underwent at least one EEG at a median time of 4 (interquartile range 2-7) days post-stroke. Rates of diffuse slowing (70% vs. 63%, p = 0.37), focal slowing (38% vs. 32%, p = 0.15), periodic discharges (2.3% vs. 3.7%, p = 0.9), and electrographic seizures (4.5% vs. 3.7%, p = 0.4) were comparable between patients with unfavorable and favorable outcomes. Following adjustment for potential confounders, an unreactive EEG background to auditory and pain stimulations (OR 6.02, 95% CI 2.27-15.99) was independently associated with unfavorable outcomes. An unreactive EEG predicted unfavorable outcome with a specificity of 48% (95% CI 40-56), sensitivity of 79% (95% CI 72-85), and positive predictive value (PPV) of 74% (95% CI 67-81). Conversely, a benign EEG (defined as continuous and reactive background activity without seizure, periodic discharges, triphasic waves, or burst suppression) predicted favorable outcome with a specificity of 89% (95% CI 84-94), and a sensitivity of 37% (95% CI 30-45).

CONCLUSION

The absence of EEG reactivity independently predicts unfavorable outcomes at one year in severe stroke patients requiring mechanical ventilation in the ICU, although its prognostic value remains limited. Conversely, a benign EEG pattern was associated with a favorable outcome.

Early pathophysiology-driven airway pressure release ventilation versus low tidal volume ventilation strategy for patients with moderate-severe ARDS: study protocol for a randomized, multicenter, controlled trial

BACKGROUND

Conventional Mechanical ventilation modes used for individuals suffering from acute respiratory distress syndrome have the potential to exacerbate lung injury through regional alveolar overinflation and/or repetitive alveolar collapse with shearing, known as atelectrauma. Animal studies have demonstrated that airway pressure release ventilation (APRV) offers distinct advantages over conventional mechanical ventilation modes. However, the methodologies for implementing APRV vary widely, and the findings from clinical studies remain controversial. This study (APRVplus trial), aims to assess the impact of an early pathophysiology-driven APRV ventilation approach compared to a low tidal volume ventilation (LTV) strategy on the prognosis of patients with moderate to severe ARDS.

METHODS

The APRVplus trial is a prospective, multicenter, randomized clinical trial, building upon our prior single-center study, to enroll 840 patients from at least 35 hospitals in China. This investigation plans to compare the early pathophysiology-driven APRV ventilation approach with the control intervention of LTV lung-protective ventilation. The primary outcome measure will be all-cause mortality at 28 days after randomization in the intensive care units (ICU). Secondary outcome measures will include assessments of oxygenation, and physiology parameters at baseline, as well as on days 1, 2, and 3. Additionally, clinical outcomes such as ventilator-free days at 28 days, duration of ICU and hospital stay, ICU and hospital mortality, and the occurrence of adverse events will be evaluated.

TRIAL ETHICS AND DISSEMINATION

The research project has obtained approval from the Ethics Committee of West China Hospital of Sichuan University (2019-337). Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

TRIAL REGISTRATION

The study was registered at Clinical Trials.gov (NCT03549910) on June 8, 2018.

Impact of Continuous Infusion Ketamine Compared to Continuous Infusion Benzodiazepines on Delirium in the Intensive Care Unit

Purpose: The purpose of this study was to evaluate rates of delirium or coma-free days between continuous infusion sedative-dose ketamine and continuous infusion benzodiazepines in critically ill patients. Materials and Methods: In this single-center, retrospective cohort adult patients were screened for inclusion if they received continuous infusions of either sedative-dose ketamine or benzodiazepines (lorazepam or midazolam) for at least 24 h, were mechanically ventilated for at least 48 h and admitted to the intensive care unit of a large quaternary academic center between 5/5/2018 and 12/1/2021. Results: A total of 165 patients were included with 64 patients in the ketamine group and 101 patients in the benzodiazepine group (lorazepam n = 35, midazolam n = 78). The primary outcome of median (IQR) delirium or coma-free days within the first 28 days of hospitalization was 1.2 (0.0, 3.7) for ketamine and 1.8 (0.7, 4.6) for benzodiazepines (p = 0.13). Patients in the ketamine arm spent a significantly lower proportion of time with RASS -3 to +4, received significantly higher doses and longer durations of propofol and fentanyl infusions, and had a significantly longer intensive care unit length of stay. Conclusions: The use of sedative-dose ketamine had no difference in delirium or coma-free days compared to benzodiazepines.

Interpretable machine learning model for early prediction of delirium in elderly patients following intensive care unit admission: a derivation and validation study

Background and objective

Delirium is the most common neuropsychological complication among older adults admitted to the intensive care unit (ICU) and is often associated with a poor prognosis. This study aimed to construct and validate an interpretable machine learning (ML) for early delirium prediction in older ICU patients.

Methods

This was a retrospective observational cohort study and patient data were extracted from the Medical Information Mart for Intensive Care-IV database. Feature variables associated with delirium, including predisposing factors, disease-related factors, and iatrogenic and environmental factors, were selected using least absolute shrinkage and selection operator regression, and prediction models were built using logistic regression, decision trees, support vector machines, extreme gradient boosting (XGBoost), k-nearest neighbors and naive Bayes methods. Multiple metrics were used for evaluation of performance of the models, including the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, recall, F1 score, calibration plot, and decision curve analysis. SHapley Additive exPlanations (SHAP) were used to improve the interpretability of the final model.

Results

Nine thousand seven hundred forty-eight adults aged 65 years or older were included for analysis. Twenty-six features were selected to construct ML prediction models. Among the models compared, the XGBoost model demonstrated the best performance including the highest AUC (0.836), accuracy (0.765), sensitivity (0.713), recall (0.713), and F1 score (0.725) in the training set. It also exhibited excellent discrimination with AUC of 0.810, good calibration, and had the highest net benefit in the validation cohort. The SHAP summary analysis showed that Glasgow Coma Scale, mechanical ventilation, and sedation were the top three risk features for outcome prediction. The SHAP dependency plot and SHAP force analysis interpreted the model at both the factor level and individual level, respectively.

Conclusion

ML is a reliable tool for predicting the risk of critical delirium in elderly patients. By combining XGBoost and SHAP, it can provide clear explanations for personalized risk prediction and more intuitive understanding of the effect of key features in the model. The establishment of such a model would facilitate the early risk assessment and prompt intervention for delirium.

Buprenorphine in the Intensive Care Unit: Commentary on the Unanswered Questions

The removal of the X-waiver in the Mainstreaming Addiction Treatment (MAT) Act of 2023 has substantial implications for buprenorphine prescribing as one of the options to treat opioid use disorder. The purpose of this commentary is to discuss the unanswered questions regarding buprenorphine in the intensive care unit (ICU) including how the passage of the MAT Act will affect ICU providers, which patients should receive buprenorphine, what is the most appropriate route of administration and dose of buprenorphine, what medications interact with buprenorphine, and how can transitions of care be optimized for these patients.

Early physical rehabilitation dosage in the IntensiveCare Unit predicts hospital outcomes after criticalCOVID-19

Objective

to examine the relationship between physical rehabilitation parameters including a novel approach to quantifying dosage with hospital outcomes for patients with critical COVID-19.

Design

Retrospective practice analysis from March 5, 2020, to April 15, 2021.

Setting

Intensive care units (ICU) at four medical institutions.

Patients

n = 3,780 adults with ICU admission and diagnosis of COVID-19.

Interventions

We measured the physical rehabilitation treatment delivered in ICU and patient outcomes: 1) mortality; 2) discharge disposition; and 3) physical function at hospital discharge measured by the Activity Measure-Post Acute Care (AM-PAC) "6-Clicks" (6-24, 24=greater functional independence). Physical rehabilitation dosage was defined as the average mobility level scores in the first three sessions (a surrogate measure of intensity) multiplied by the rehabilitation frequency (PT + OT frequency in hospital).

Measurements and Main Results

The cohort was a mean 64 ± 16 years old, 41% female, mean BMI of 32 ± 9 kg/m2 and 46% (n=1739) required mechanical ventilation. For 2191 patients with complete data, rehabilitation dosage and AM-PAC at discharge were moderately, positively associated (Spearman's rho [r] = 0.484, p < 0.001). Multivariate linear regression (model adjusted R2= 0.68, p <0.001) demonstrates mechanical ventilation (β = -0.86, p = 0.001), average mobility score in first three sessions (β = 2.6, p <0.001) and physical rehabilitation dosage (β = 0.22, p = 0.001) were predictive of AM-PAC scores at discharge when controlling for age, sex, BMI, and ICU LOS.

Conclusions

Greater physical rehabilitation exposure early in the ICU is associated with physical function at hospital discharge.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.