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Anis A, Patel R, Tanios MA. Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches. J Intensive Care Med 2024; 39:507-513. [PMID: 37670719 DOI: 10.1177/08850666231199055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
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.
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Affiliation(s)
- Antonious Anis
- Internal Medicine Residency Program, St. Mary Medical Center, Long Beach, CA, USA
- Critical Care Medicine Fellowship, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Ravi Patel
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
| | - Maged A Tanios
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
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2
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Brisard L, El Batti S, Borghese O, Maurel B. Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score. J Clin Med 2023; 12:7520. [PMID: 38137589 PMCID: PMC10743399 DOI: 10.3390/jcm12247520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.
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Affiliation(s)
- Laurent Brisard
- Department of Anesthesiology and Critical Care, Laënnec Hospital, University Hospital of Nantes, F-44000 Nantes, France;
| | - Salma El Batti
- Department of Vascular and Endovascular Surgery, Hôpital Européen Georges Pompidou—Hôpitaux de Paris, Université de Paris Cité, F-75015 Paris, France;
| | - Ottavia Borghese
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
| | - Blandine Maurel
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
- Inserm UMR 1087/CNRS UMR 6291, L’Institut du Thorax, Université de Nantes, F-44000 Nantes, France
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3
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Minami T, Watanabe H, Kato T, Ikeda K, Ueno K, Matsuyama A, Maeda J, Sakai Y, Harada H, Kuriyama A, Yamaji K, Kitajima N, Kamei J, Takatani Y, Sato Y, Yamashita Y, Mizota T, Ohtsuru S. Dexmedetomidine versus haloperidol for sedation of non-intubated patients with hyperactive delirium during the night in a high dependency unit: study protocol for an open-label, parallel-group, randomized controlled trial (DEX-HD trial). BMC Anesthesiol 2023; 23:193. [PMID: 37270483 DOI: 10.1186/s12871-023-02158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Delirium is common in critically ill patients. Haloperidol has long been used for the treatment of delirium. Dexmedetomidine has recently been used to treat delirium among intubated critically ill patients. However, the efficacy of dexmedetomidine for delirium in non-intubated critically ill patients remains unknown. We hypothesize that dexmedetomidine is superior to haloperidol for sedation of patients with hyperactive delirium, and would reduce the prevalence of delirium among non-intubated patients after administration. We will conduct a randomized controlled trial to compare dexmedetomidine and haloperidol for the treatment of nocturnal hyperactive delirium in non-intubated patients in high dependency units (HDUs). METHODS This is an open-label, parallel-group, randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for nocturnal hyperactive delirium in non-intubated patients at two HDUs of a tertiary hospital. We will recruit consecutive non-intubated patients who are admitted to the HDU from the emergency room, and allocate them in a 1:1 ratio to the dexmedetomidine or haloperidol group in advance. The allocated investigational drug will be administered only when participants develop hyperactive delirium (Richmond Agitation-Sedation Scale [RASS] score ≥1 and a positive score on the Confusion Assessment Method for the ICU between 19:00 and 6:00 the next day) during the night at an HDU. Dexmedetomidine is administered continuously, while haloperidol is administered intermittently. The primary outcome is the proportion of participants who achieve the targeted sedation level (RASS score of between -3 and 0) 2h after the administration of the investigational drug. Secondary outcomes include the sedation level and prevalence of delirium on the day following the administration of the investigational drugs, and safety. We plan to enroll 100 participants who develop nocturnal hyperactive delirium and receive one of the two investigational drugs. DISCUSSION This is the first randomized controlled trial to compare the efficacy and safety of dexmedetomidine and haloperidol for sedation of non-intubated critically ill patients with hyperactive delirium in HDUs. The results of this study may confirm whether dexmedetomidine could be another option to sedate patients with hyperactive delirium. TRIAL REGISTRATION Japan Registry of Clinical Trials, jRCT1051220015, registered on 21 April 2022.
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Affiliation(s)
- Takuma Minami
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Institute for Advancement of Clinical and Translational Science (iACT), Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Ikeda
- Institute for Advancement of Clinical and Translational Science (iACT), Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kentaro Ueno
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ai Matsuyama
- Department of Nursing, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Junya Maeda
- Department of Nursing, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoji Sakai
- Department of Nursing, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hisako Harada
- Department of Nursing, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akira Kuriyama
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Naoki Kitajima
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Jun Kamei
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yudai Takatani
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuki Sato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Rodriguez-Monguio R, Lun Z, Dickinson DT, Do C, Hyland B, Kocharyan E, Liu L, Steinman MA. Safety implications of concomitant administration of antidepressants and opioid analgesics in surgical patients. Expert Opin Drug Saf 2023; 22:477-484. [PMID: 36803512 PMCID: PMC11059447 DOI: 10.1080/14740338.2023.2181333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Commonly prescribed antidepressants (paroxetine, fluoxetine, duloxetine, bupropion) inhibit bioconversion of several prodrug opioid medications to their active metabolite, potentially decreasing analgesic effect. There is a paucity of studies assessing the risk-benefit of concomitant administration of antidepressants and opioids. RESEARCH DESIGN AND METHODS Observational study of adult patients taking antidepressants prior to scheduled surgery using 2017-2019 electronic medical record data to assess perioperative use of opioids and to determine the incidence and risk factors for developing postoperative delirium. We conducted a generalized linear regression with the Gamma log-link to assess the association between use of antidepressants and opioids and a logistic regression to assess the association between antidepressants use and the likelihood of developing postoperative delirium. RESULTS After controlling for patient demographic and clinical characteristics, and postoperative pain, use of inhibiting antidepressants was associated with 1.67 times greater use of opioids per hospitalization day (p = 0.00154), a two-fold increase in the risk for developing postoperative delirium (p = 0.0224), and an estimated average of four additional days of hospitalization (p < 0.00001) compared to use of non-inhibiting antidepressants. CONCLUSIONS Careful consideration to drug-drug interactions and risk of related adverse events remains critical in the safe and optimal management of postoperative pain in patients taking concomitantly antidepressants.
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Affiliation(s)
- Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
- Medication Outcomes Center, University of California San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, the University of California San Francisco, California, USA
| | - Zhixin Lun
- Medication Outcomes Center, University of California San Francisco, California, USA
| | - Drew T Dickinson
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
| | - Connie Do
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
| | - Bailey Hyland
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
| | - Eline Kocharyan
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
| | - Leanne Liu
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, School of Medicine, University of California San Francisco, California, USA
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5
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Hofhuis JGM, Schermer T, Spronk PE. Mental health-related quality of life is related to delirium in intensive care patients. Intensive Care Med 2022; 48:1197-1205. [PMID: 35984472 DOI: 10.1007/s00134-022-06841-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/25/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Delirium during intensive care unit (ICU) stay may be related to premorbid mental illness. In addition, delirium during ICU stay may also negatively affect long-term health-related quality of life. The aim of our study was to investigate if delirium in the ICU is related to premorbid mental quality of life and affects long-term mental quality of life after ICU stay. METHODS We performed a prospective cohort study in 1021 patients admitted for longer than 48 h in a medical-surgical ICU. We evaluated mental and physical quality of life using the Short-form-12 before ICU admission, at hospital discharge, and 3, 6 and 12 months after hospital discharge. Mixed model and logistic regression models were used to analyze the data. RESULTS Patients who experienced a delirium during ICU stay reported a worse pre-admission mental quality of life than those without delirium (p < 0.001). Furthermore, patients who suffered from delirium during their ICU stay exhibited a significant decrease in mental quality of life over time relative to patients without delirium (p = 0.035). CONCLUSION In this large follow-up study, we demonstrated that ICU survivors who experienced a delirium during ICU stay reported a significantly worse pre-admission mental health-related quality of life and a significant decrease in mental health-related quality of life in the year after hospital discharge compared with patients without delirium.
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Affiliation(s)
- José G M Hofhuis
- Department of Intensive Care, Gelre Hospitals, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands. .,Expertise Center for Intensive Care Rehabilitation Apeldoorn (ExpIRA), Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands.
| | - Tjard Schermer
- Department of Epidemiology, Gelre Hospitals, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands.,Expertise Center for Intensive Care Rehabilitation Apeldoorn (ExpIRA), Albert Schweitzerlaan 31, 7334 DZ, Apeldoorn, The Netherlands.,Department of Intensive Care, University Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Predicting hospital mortality and length of stay: A prospective cohort study comparing the Intensive Care Delirium Screening Checklist versus Confusion Assessment Method for the Intensive Care Unit. Aust Crit Care 2022; 36:378-384. [PMID: 35272910 DOI: 10.1016/j.aucc.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this study was to compare two tools, the Intensive Care Delirium Screening Checklist (ICDSC) and Confusion Assessment Method for the intensive care unit (ICU) (CAM-ICU), for their predictive validity for outcomes related to delirium, hospital mortality, and length of stay (LOS). METHODS The prospective study conducted in six medical ICUs at a tertiary care hospital in Taiwan enrolled consecutive patients (≥20 years) without delirium at ICU admission. Delirium was screened daily using the ICDSC and CAM-ICU in random order. Arousal was assessed by the Richmond Agitation-Sedation Scale (RASS). Participants with any one positive result were classified as ICDSC- or CAM-ICU-delirium groups. RESULTS Delirium incidence evaluated by the ICDSC and CAM-ICU were 69.1% (67/97) and 50.5% (49/97), respectively. Although the ICDSC identified 18 more cases as delirious, substantial concordance (κ = 0.63; p < 0.001) was found between tools. Independent of age, Acute Physiology and Chronic Health Evaluation II score, and Charlson Comorbidity Index, both ICDSC- and CAM-ICU-rated delirium significantly predicted hospital mortality (adjusted odds ratio: 4.93; 95% confidence interval [CI]:1.56 to 15.63 vs. 2.79; 95% CI: 1.12 to 6.97, respectively), and only the ICDSC significantly predicted hospital LOS with a mean of 17.59 additional days compared with the no-delirium group. Irrespective of delirium status, a sensitivity analysis of normal-to-increased arousal (RASS≥0) test results did not alter the predictive ability of ICDSC- or CAM-ICU-delirium for hospital mortality (adjusted odds ratio: 2.97; 95% CI: 1.06 to 8.37 vs. 3.82; 95% CI: 1.35 to 10.82, respectively). With reduced arousal (RASS<0), neither tool significantly predicted mortality or LOS. CONCLUSIONS The ICDSC identified more delirium cases and may have higher predictive validity for mortality and LOS than the CAM-ICU. However, arousal substantially affected performance. Future studies may want to consider patients' arousal when deciding which tool to use to maximise the effects of delirium identification on patient mortality.
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Kappenschneider T, Meyer M, Maderbacher G, Parik L, Leiss F, Quintana LP, Grifka J. [Delirium-an interdisciplinary challenge]. DER ORTHOPADE 2022; 51:106-115. [PMID: 35037987 DOI: 10.1007/s00132-021-04209-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delirium is a common and potentially life-threatening disease that often poses major problems for hospitals in terms of care. It mainly affects older patients and is multifactorial, especially in older people. Permanent functional and cognitive impairments after delirium are not uncommon in geriatric patients. DIAGNOSTIC Often, delirious syndromes are not recognized or are misinterpreted. This is especially the case with the hypoactive form of delirium. Various screening and test procedures are available for the detection of delirium, the routine use of which is essential. TREATMENT In many cases, delirium can be avoided with suitable preventive measures. Above all, nondrug prevention strategies and multidimensional approaches play an important role here. For the drug treatment of delirium in geriatric patients, low-potency, classic and atypical neuroleptics, as well as dexmedetomidine for severe courses are recommended.
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Affiliation(s)
- Tobias Kappenschneider
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - Matthias Meyer
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Günther Maderbacher
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Lukas Parik
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Franziska Leiss
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Loreto Pulido Quintana
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Joachim Grifka
- Klinik und Poliklinik für Orthopädie, Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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Ma Z, Camargo Penuela M, Law M, Joshi D, Chung HO, Lam JNH, Tsang JL. Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project. BMJ Open Qual 2021; 10:bmjoq-2020-001305. [PMID: 34887298 PMCID: PMC8663072 DOI: 10.1136/bmjoq-2020-001305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 11/23/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project. METHODS A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods. RESULTS Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses. DISCUSSION The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.
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Affiliation(s)
- Zechen Ma
- Niagara Regional Campus, McMaster University Michael G DeGroote School of Medicine, St. Catharines, Ontario, Canada
| | - Mercedes Camargo Penuela
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Madelyn Law
- Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Divya Joshi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Han-Oh Chung
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada
| | - Joyce Nga Hei Lam
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada
| | - Jennifer Ly Tsang
- Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada .,Medicine/Critical Care, Niagara Health, St. Catharines, Ontario, Canada
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Nicholas TA, Robinson R. Multimodal Analgesia in the Era of the Opioid Epidemic. Surg Clin North Am 2021; 102:105-115. [PMID: 34800380 DOI: 10.1016/j.suc.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article attempts to review the key components of a multimodal analgesic regimen for the treatment of acute pain. Adhering to these key components will help reduce the opioid burden to surgical patients while reducing acute pain. As well, this regimen is intended to reduce further negative contributions to the opioid crisis.
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Affiliation(s)
- Thomas Arthur Nicholas
- Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE, 68198-4455, USA.
| | - Raime Robinson
- Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE, 68198-4455, USA
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10
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Christianson-Silva P, Russell-Kibble A, Shaver J. A nurse practitioner-led care bundle approach for primary care of patients with complex health needs. J Am Assoc Nurse Pract 2021; 34:364-372. [PMID: 34560706 DOI: 10.1097/jxx.0000000000000628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/13/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Often developed for acute care and less frequently for primary care, care bundles are clusters of evidence-based practices for improving care delivery and patient outcomes. Care bundles usually arise when ineffective or costly outcomes are identified, are meant to make care more reliable, and require superb teamwork and communication. LOCAL PROBLEM Patients using the highest proportion of health care services are those living with complex health conditions and challenging sociocultural lives, statistics corroborated within our primary care clinic. In our nurse practitioner (NP)-led, interprofessional, team-based primary care program serving mainly low-income patients, we noted that many patients with multiple chronic conditions had an excess of clinic encounters, emergency department visits, and hospitalizations. METHODS To improve health status for these patients and reduce costly care inefficiencies, we developed a unique bundle of care practices for embedding within our NP-led complex care program. Our goals were to improve patient efficacy for self-management of chronic conditions and promote appropriate use of health care resources and services. INTERVENTIONS Using AEIØOU as a mnemonic, the derived care bundle better focused our team efforts and provided us with a planning, communication, and documentation schema for quality improvement. It was particularly useful for team-based care because tasks could be documented or communicated by letter or number and easily reviewed by team members or others involved in patients' care. RESULTS Use of the AEIØOU bundle within our program resulted in better coordination of team-based comprehensive care for our high-needs patients, seen anecdotally in fewer unnecessary contacts and missed appointments and in patient appreciation comments. Emergency department visits and hospitalization data for the six months before compared with 6 months after enrollment in the program showed significant reductions. CONCLUSIONS To improve the primary care of complex patient populations, we recommend further use and testing of the AEIØOU bundle within other care models.
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Affiliation(s)
| | | | - Joan Shaver
- University of Arizona College of Nursing, Tucson, Arizona
- University of Illinois at Chicago College of Nursing, Chicago, Illinois
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11
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Soltani F, Tabatabaei S, Jannatmakan F, Nasajian N, Amiri F, Darkhor R, Moravej M. Comparison of the Effects of Haloperidol and Dexmedetomidine on Delirium and Agitation in Patients with a Traumatic Brain Injury Admitted to the Intensive Care Unit. Anesth Pain Med 2021; 11:e113802. [PMID: 34540634 PMCID: PMC8438711 DOI: 10.5812/aapm.113802] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 12/27/2022] Open
Abstract
Background Patients under mechanical ventilation in the Intensive Care Unit (ICU) have a higher risk of delirium. To date, the ideal sedative combination for delirium treatment in terms of cost and side effects has not been determined. Objectives This study was designed to compare the effects of haloperidol and dexmedetomidine on delirium in trauma patients under mechanical ventilation in the ICU. Methods Sixty patients with a moderate traumatic brain injury were randomly divided into two groups. Patients in the haloperidol group received 2.5 mg of haloperidol intravenously every eight hours for ten minutes daily, and the dexmedetomidine group received 0.5 µg/kg of dexmedetomidine via intravenous infusion every other day. Delirium, agitation, length of hospitalization, duration of mechanical ventilation, and need for sedation up to seven days were measured and recorded in both groups. The Richmond Agitation-Sedation scale (RASS) and Acute Physiology and Chronic Health evaluation (APACHE II) scales were used to determine the level of agitation in patients. The Confusion Assessment method (CAM)-ICU criteria were used to determine the incidence of delirium. Results Based on the results of this study, age and sex of the two groups were not significantly different. The mean age of the patients was 36.83 years in the haloperidol group and 40.1 years in the dexmedetomidine group. After the intervention, there was no significant difference in terms of the level of consciousness, number of days required for ventilation (P = 0.17), and number of days in the ICU (P = 0.49); however, there was a significant difference between the two groups three to seven days after the intervention. Besides, there was a significant difference between the two groups regarding the incidence of delirium five to seven days after the intervention (P < 0.05). Conclusions There was a significant difference between the two groups in terms of the incidence of delirium and the level of agitation; the patients in the dexmedetomidine group were calmer and experienced less delirium.
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Affiliation(s)
- Farhad Soltani
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyedkamalaldin Tabatabaei
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farahzad Jannatmakan
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nozar Nasajian
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fereshteh Amiri
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Roya Darkhor
- Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesiology, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Casertano L, Nathanson R, Bassile CC, Quinn L. Neurological complications in COVID-19: a single case study of rehabilitation treatment. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2021. [DOI: 10.12968/ijtr.2020.0140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background/aims: COVID-19 is a global pandemic, which has seen over 198 million cases as of August 2021. This case study highlights the rehabilitation of a young patient with respiratory and neurologic sequalae of COVID-19 across the continuum of care, from the intensive care unit to the inpatient rehabilitation unit. Case description: A 45-year-old woman, with past medical history of fibromyalgia and morbid obesity, presented with complaints of shortness of breath. She tested positive for SARS-CoV-2, was transferred to the intensive care unit, and was intubated for 17 days. The day after extubation, she experienced worsened mental status; computed tomography and magnetic resonance imaging scans revealed bilateral strokes. On hospital day 21, she was transferred to the stroke step-down unit. On hospital day 24, she recovered some cognitive ability and movement of her lower extremities. On hospital day 30, she was admitted to the inpatient rehabilitation unit. Examination by occupational and physiotherapists found motor and sensory impairments of multiple peripheral nerves, including musculocutaneous, axillary and radial nerves. Interventions included passive range of motion, sitting balance, transfer training, rigid taping, upper extremity strengthening and functional training (gait, stair, activities of daily living). Her activities of daily living performance was limited by upper extremity weakness, sensory loss and pain. Conclusions This case highlights the medical, neurological and functional implications of COVID-19 on patients after prolonged hospitalisation. The plan of care was informed by collaboration between rehabilitation disciplines. Causes of her injuries are unclear but could include positioning, brachial plexus injuries, or post-critical illness syndrome. Further research on the evaluation and care of patients with COVID-19 that result in profound neurological impairments is warranted.
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Affiliation(s)
- Lorenzo Casertano
- Advanced Clinician-Acute Care Neurology Service, Department of Physical Therapy, New York-Presbyterian Hospital, New York, USA
| | - Rae Nathanson
- Department of Occupational Therapy, New York-Presbyterian Hospital, New York, USA
| | - Clare C Bassile
- Department of Rehabilitation and Regenerative Medicine (Physical Therapy Programs), Columbia University Irving Medical Center, New York, USA
| | - Lori Quinn
- Movement Science and Kinesiology, Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, USA
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Su L, Liu C, Chang F, Tang B, Han L, Jiang H, Zhu W, Hong N, Zhou X, Long Y. Selection strategy for sedation depth in critically ill patients on mechanical ventilation. BMC Med Inform Decis Mak 2021; 21:79. [PMID: 34330255 PMCID: PMC8322830 DOI: 10.1186/s12911-021-01452-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/22/2021] [Indexed: 11/30/2022] Open
Abstract
Background Analgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear. Methods The public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model. Results Based on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury. Conclusion Through latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.
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Affiliation(s)
- Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Chun Liu
- Digital Health China Technologies Co. Ltd., Floor 19, China Technology Exchange Building, 66 West Beisihuan Road, Haidian District, Beijing, 100080, China
| | - Fengxiang Chang
- Digital Health China Technologies Co. Ltd., Floor 19, China Technology Exchange Building, 66 West Beisihuan Road, Haidian District, Beijing, 100080, China
| | - Bo Tang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lin Han
- Digital Health China Technologies Co. Ltd., Floor 19, China Technology Exchange Building, 66 West Beisihuan Road, Haidian District, Beijing, 100080, China
| | - Huizhen Jiang
- Information Center Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Weiguo Zhu
- Information Center Department/Department of Information Management, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Na Hong
- Digital Health China Technologies Co. Ltd., Floor 19, China Technology Exchange Building, 66 West Beisihuan Road, Haidian District, Beijing, 100080, China.
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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Flamée P, Viaene K, Tosi M, Nogueira Carvalho H, de Asmundis C, Forget P, Poelaert J. Propofol for Induction and Maintenance of Anesthesia in Patients With Brugada Syndrome: A Single-Center, 25-Year, Retrospective Cohort Analysis. Anesth Analg 2021; 132:1645-1653. [PMID: 33857025 DOI: 10.1213/ane.0000000000005540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Propofol administration in patients with Brugada syndrome (BrS) is still a matter of debate. Despite lacking evidence for its feared arrhythmogenicity, up to date, expert cardiologists recommend avoiding propofol. The main aim of this study is to assess the occurrence of malignant arrhythmias or defibrillations in patients with BrS, during and 30 days after propofol administration. The secondary aim is to investigate the occurrence of adverse events during propofol administration and hospitalization, as the 30-day readmission and 30-day mortality rate. METHODS We performed a retrospective cohort study on patients with BrS who received propofol anytime from January 1, 1996 to September 30, 2020. Anesthesia was induced by propofol in both groups. In the total intravenous anesthesia (TIVA) group, anesthesia was maintained by propofol, while in the BOLUS group, volatile anesthesia was provided. The individual anesthetic charts and the full electronic medical records up to 30 postprocedural days were scrutinized. RESULTS One hundred thirty-five BrS patients who underwent a total of 304 procedures were analyzed. The TIVA group included 27 patients for 33 procedures, and the BOLUS group included 108 patients for 271 procedures. In the TIVA group, the median time of propofol infusion was 60 minutes (interquartile range [IQR] = 30-180). The estimated plasma or effect-site concentration ranged between 1.0 and 6.0 µg·mL-1 for target-controlled infusion (TCI). The infusion rate for manually driven TIVA varied between 0.8 and 10.0 mg·kg-1·h-1. In the BOLUS group, the mean propofol dose per kilogram total body weight was 2.4 ± 0.9 mg·kg-1. No malignant arrhythmias or defibrillations were registered in both groups. The estimated 95% confidence interval (CI) of the risk for malignant arrhythmias in the BOLUS and TIVA groups was 0-0.011 and 0-0.091, respectively. CONCLUSIONS The analysis of 304 anesthetic procedures in BrS patients, who received propofol, either as a TIVA or as a bolus during induction of volatile-based anesthesia, revealed no evidence of malignant arrhythmias or defibrillations. The present data do not support an increased risk with propofol-based TIVA compared to propofol-induced volatile anesthesia. Prospective studies are needed to investigate the electrophysiologic effects of propofol in BrS patents.
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Affiliation(s)
- Panagiotis Flamée
- From the Department of Anesthesiology and Perioperative Medicine and
| | - Kea Viaene
- From the Department of Anesthesiology and Perioperative Medicine and
| | - Maurizio Tosi
- From the Department of Anesthesiology and Perioperative Medicine and
| | | | - Carlo de Asmundis
- Department of Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Patrice Forget
- Department of Anesthesia, Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, National Health Service Grampian, Aberdeen, United Kingdom
| | - Jan Poelaert
- From the Department of Anesthesiology and Perioperative Medicine and
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Ammar MA, Tran LJ, McGill B, Ammar AA, Huynh P, Amin N, Guerra M, Rouse GE, Lemieux D, McManus D, Topal JE, Davis MW, Miller L, Yazdi M, Leber MB, Pulk RA. Pharmacists leadership in a medication shortage response: Illustrative examples from a health system response to the COVID-19 crisis. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021; 4:1134-1143. [PMID: 34230910 PMCID: PMC8250559 DOI: 10.1002/jac5.1443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 12/17/2022]
Abstract
As medication experts, clinical pharmacists play an active and dynamic role in a medication shortage response. Supplementing existing guidelines with an actionable framework of discrete activities to support effective medication shortage responses can expand the scope of pharmacy practice and improve patient care. Dissemination of best practices and illustrative, networked examples from health systems can support the adoption of innovative solutions. In this descriptive report, we document the translation of published shortage mitigation guidelines into system success through broad pharmacist engagement and the adaption and implementation of targeted strategies. The profound, wide‐reaching medication shortages that accompanied the coronavirus disease 2019 (COVID‐19) pandemic are used to highlight coordinated but distinct practices and how they have been combined to expand the influence of the pharmacy enterprise.
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Affiliation(s)
- Mahmoud A Ammar
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Lydia J Tran
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Bryan McGill
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Abdalla A Ammar
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Phu Huynh
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | - Nilesh Amin
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Michael Guerra
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Ginger E Rouse
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Diana Lemieux
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Dayna McManus
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Jeffrey E Topal
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - Matthew W Davis
- Department of Pharmacy Services Yale-New Haven Hospital New Haven Connecticut USA
| | - LeeAnn Miller
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | - Marina Yazdi
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
| | | | - Rebecca A Pulk
- Corporate Pharmacy Services Yale New Haven Health New Haven Connecticut USA
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Assessment of Procedural Distress in Sedated/Intubated Children Under 3 Years Old Using the Newborn Infant Parasympathetic Evaluation: A Diagnostic Accuracy Pilot Study. Pediatr Crit Care Med 2020; 21:e1052-e1060. [PMID: 32740184 DOI: 10.1097/pcc.0000000000002454] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Newborn infant parasympathetic evaluation index is based on heart rate variability and is related to the autonomic response to pain or stress. The Comfort Behavior Scale is used to assess distress intensity in sedated intubated children. The objective of this study was to assess the validity and performance of newborn infant parasympathetic evaluation as a distress indicator during procedural distress. DESIGN Monocentric, prospective, noninterventional pilot study of diagnostic accuracy between October 1, 2017, and April 30, 2019. SETTING PICU in a tertiary care university hospital. PATIENTS Sedated intubated children under 3 years old. INTERVENTIONS We continuously obtained mean newborn infant parasympathetic evaluation and instantaneous newborn infant parasympathetic evaluation scores and compared them to Comfort Behavior scores obtained before (T1 period), during (T2 period), and after (T3 period) care procedures. MEASUREMENTS AND MAIN RESULTS We obtained 54 measurements from 32 patients. The median age was 4 months (23 d to 31 mo). Between T1 and T2, there was a significant decrease in the instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores (64 ± 2 to 42 ± 1 [p 0.0001] and 64 ± 1 to 59 ± 1 [p = 0.007], respectively) and a significant increase in the Comfort Behavior scores (from 12 ± 0 to 16 ± 1; p 0.0001). Comfort Behavior scores and instantaneous newborn infant parasympathetic evaluation and mean newborn infant parasympathetic evaluation scores were significantly inversely correlated (r = -0.44, p 0.0001 and r = -0.19, p = 0.01, respectively). With a instantaneous newborn infant parasympathetic evaluation score threshold of 53, the sensitivity, specificity, positive predictive, and negative predictive values to predict a Comfort Behavior Scale up to 17 were 80.0%, 73.5%, 43.8%, and 93.5%, respectively. CONCLUSIONS Instantaneous newborn infant parasympathetic evaluation is valid for assessing distress in sedated/intubated children in the PICU. Further studies are needed to confirm these results and for newborn infant parasympathetic evaluation-based comparisons of sedation-analgesia protocols.
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Pain Management in the Unstable Trauma Patient. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Larsen LK, Møller K, Petersen M, Egerod I. Cognitive function and health-related quality of life 1 year after acute brain injury: An observational study. Acta Anaesthesiol Scand 2020; 64:1469-1476. [PMID: 32700324 DOI: 10.1111/aas.13682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/31/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cognitive impairment and reduced health-related quality of life (HRQoL) are well-established sequelae of critical illness. Studies on survivors of critical illness have found delirium to be a predictor of these conditions, but evidence regarding survivors of acute brain injury is sparse. We aimed to explore if delirium duration was associated with 1-year cognitive impairment and reduced HRQoL in patients with acute brain injury. METHOD Intensive care unit (ICU) delirium was assessed using the Intensive Care Delirium Screening Checklist. Cognitive status was assessed using the Repeatable Battery for Neuropsychological Status (RBANS) and HRQoL using the European Quality of Life 5-dimension questionnaire (EQ-5D). We used a multiple linear regression for testing the association of delirium duration with cognitive impairment and quality of life, respectively. RESULTS Forty-seven survivors of acute brain injury participated in follow-up and 35 completed RBANS. Delirium was present in 39 of 47 (83%) with a median duration of 4 days. Delirium duration did not predict cognitive impairment (95% CI -4.1 to 0.5) or lower HRQoL (95% CI -1.4 to 2.7). Moderate-to-severe cognitive impairment was present in 17 of 35 (49%) participants, and they had a mean EQ-5D health visual analogue scale of 70.9 vs 81.6 for the Danish age-matched norm. CONCLUSIONS Our sample did not demonstrate an association between delirium and 1-year cognitive impairment or reduced HRQoL. Still, a large proportion of the participants were cognitively impaired, and their quality of life was lower compared to norm. Larger studies are necessary to explore these associations further.
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Affiliation(s)
- Laura Krone Larsen
- Department of Neuroanaesthesiology, Rigshospitalet University Hospital of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Rigshospitalet University Hospital of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
| | - Marian Petersen
- Department of Surgery Zealand University Hospital Køge Denmark
- Department of Regional Health Research Southern Danish University Odense Denmark
| | - Ingrid Egerod
- Department of Intensive Care RigshospitaletUniversity Hospital of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine Faculty of Health Sciences University of Copenhagen Copenhagen Denmark
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Nora GJ, Reddy CC. Acute Delirium and Post-Delirium Encephalopathy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Therapeutic options for agitation in the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:639-646. [PMID: 32777434 DOI: 10.1016/j.accpm.2020.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/20/2022]
Abstract
Agitation is common in the intensive care unit (ICU). There are numerous contributing factors, including pain, underlying disease, withdrawal syndrome, delirium and some medication. Agitation can compromise patient safety through accidental removal of tubes and catheters, prolong the duration of stay in the ICU, and may be related to various complications. This review aims to analyse evidence-based medical literature to improve management of agitation and to consider pharmacological strategies. The non-pharmacological approach is considered to reduce the risk of agitation. Pharmacological treatment of agitated patients is detailed and is based on a judicious choice of neuroleptics, benzodiazepines and α2 agonists, and on whether a withdrawal syndrome is identified. Specific management of agitation in elderly patients, brain-injured patients and patients with sleep deprivation are also discussed. This review proposes a practical approach for managing agitation in the ICU.
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Boehm LM, Pun BT, Stollings JL, Girard TD, Rock P, Hough CL, Hsieh SJ, Khan BA, Owens RL, Schmidt GA, Smith S, Ely EW. A multisite study of nurse-reported perceptions and practice of ABCDEF bundle components. Intensive Crit Care Nurs 2020; 60:102872. [PMID: 32389395 DOI: 10.1016/j.iccn.2020.102872] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 02/25/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES ABCDEF bundle implementation in the Intensive Care Unit (ICU) is associated with dose dependent improvements in patient outcomes. The objective was to compare nurse attitudes about the ABCDEF bundle to self-reported adherence to bundle components. RESEARCH METHODOLOGY/DESIGN Cross-sectional study. SETTING Nurses providing direct patient care in 28 ICUs within 18 hospitals across the United States. MAIN OUTCOME MEASURES 53-item survey of attitudes and practice of the ABCDEF bundle components was administered between November 2011 and August 2015 (n = 1661). RESULTS We did not find clinically significant correlations between nurse attitudes and adherence to Awakening trials, Breathing trials, and sedation protocol adherence (rs = 0.05-0.28) or sedation plan discussion during rounds and Awakening and Breathing trial Coordination (rs = 0.19). Delirium is more likely to be discussed during rounds when ICU physicians and nurse managers facilitate delirium reduction (rs = 0.27-0.36). Early mobilization is more likely to occur when ICU physicians, nurse managers, staffing, equipment, and the ICU environment facilitate early mobility (rs = 0.36-0.47). Physician leadership had the strongest correlation with reporting an ICU environment that facilitates ABCDEF bundle implementation (rs = 0.63-0.74). CONCLUSIONS Nurse attitudes about bundle implementation did not predict bundle adherence. Nurse manager and physician leadership played a large role in creating a supportive ICU environment.
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Affiliation(s)
- Leanne M Boehm
- Vanderbilt University School of Nursing, Nashville, TN, United States; VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
| | - Brenda T Pun
- Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
| | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States; Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States; University of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, United States.
| | - Peter Rock
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, United States.
| | - Catherine L Hough
- University of Washington and Harborview Medical Center, Seattle, WA, United States.
| | - S Jean Hsieh
- Mount Sinai School of Medicine, New York, NY, United States.
| | - Babar A Khan
- Indiana University School of Medicine, Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, United States.
| | - Robert L Owens
- UC San Diego School of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, San Diego, CA, United States.
| | - Gregory A Schmidt
- University of Iowa, College of Medicine, Department of Internal Medicine, Iowa City, IA, United States.
| | - Susan Smith
- Baylor University Medical Center, Critical Care, Dallas, TX, United States.
| | - E Wesley Ely
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, United States; Vanderbilt University, Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Nashville, TN, United States; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt, Nashville, TN, United States.
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Schulte PJ, Warner DO, Martin DP, Deljou A, Mielke MM, Knopman DS, Petersen RC, Weingarten TN, Warner MA, Rabinstein AA, Hanson AC, Schroeder DR, Sprung J. Association Between Critical Care Admissions and Cognitive Trajectories in Older Adults. Crit Care Med 2020; 47:1116-1124. [PMID: 31107280 DOI: 10.1097/ccm.0000000000003829] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients requiring admission to an ICU may subsequently experience cognitive decline. Our objective was to investigate longitudinal cognitive trajectories in older adults hospitalized in ICUs. We hypothesized that individuals hospitalized for critical illness develop greater cognitive decline compared with those who do not require ICU admission. DESIGN A retrospective cohort study using prospectively collected cognitive scores of participants enrolled in the Mayo Clinic Study of Aging and ICU admissions retrospectively ascertained from electronic medical records. A covariate-adjusted linear mixed effects model with random intercepts and slopes assessed the relationship between ICU admissions and the slope of global cognitive z scores and domains scores (memory, attention/executive, visuospatial, and language). SETTING ICU admissions and cognitive scores in the Mayo Clinic Study of Aging from October 1, 2004, to September 11, 2017. PATIENTS Nondemented participants age 50 through 91 at enrollment in the Mayo Clinic Study of Aging with an initial cognitive assessment and at least one follow-up visit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 3,673 participants, 372 had at least one ICU admission with median (25-75th percentile) follow-up after first ICU admission of 2.5 years (1.2-4.4 yr). For global cognitive z score, admission to an ICU was associated with greater decline in scores over time compared with participants not requiring ICU admission (difference in annual slope = -0.028; 95% CI, -0.044 to -0.012; p < 0.001). ICU admission was associated with greater declines in memory (-0.029; 95% CI, -0.047 to -0.011; p = 0.002), attention/executive (-0.020; 95% CI, -0.037 to -0.004; p = 0.016), and visuospatial (-0.013; 95% CI, -0.026 to -0.001; p = 0.041) domains. ICU admissions with delirium were associated with greater declines in memory (interaction p = 0.006) and language (interaction p = 0.002) domains than ICU admissions without delirium. CONCLUSIONS In older adults, ICU admission was associated with greater long-term cognitive decline compared with patients without ICU admission. These findings were more pronounced in those who develop delirium while in the ICU.
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Affiliation(s)
- Phillip J Schulte
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David O Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David P Martin
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Atousa Deljou
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Michelle M Mielke
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN.,Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - David S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Ronald C Petersen
- Department of Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN.,Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Toby N Weingarten
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Darrell R Schroeder
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Juraj Sprung
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
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Gerresheim G, Handschu R, Winkler B, Ritt M, Schwemmer U, Schuh A. [Prevention of postoperative delirium]. MMW Fortschr Med 2020; 162:50-57. [PMID: 32342402 DOI: 10.1007/s15006-020-0013-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Götz Gerresheim
- Klinik für Anästhesiologie und Intensivmedizin, Kliniken des Landkreises Neumarkt i. d. OPf.Kliniken des Landkreises Neumarkt i. d. OPf., Nürnberger Str. 12, D-92318, Neumarkt, Deutschland.
| | - René Handschu
- Neurologische Klinik, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Barbara Winkler
- Leitung Pflegedienst, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Martin Ritt
- Klinik III, Allgemeine Innere Medizin, Akutgeriatrie, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Ulrich Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
| | - Alexander Schuh
- Muskuloskelettales Zentrum, Kliniken des Landkreises Neumarkt i. d. OPf., Deutschland
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Sawyer KN, Camp-Rogers TR, Kotini-Shah P, Del Rios M, Gossip MR, Moitra VK, Haywood KL, Dougherty CM, Lubitz SA, Rabinstein AA, Rittenberger JC, Callaway CW, Abella BS, Geocadin RG, Kurz MC. Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e654-e685. [DOI: 10.1161/cir.0000000000000747] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.
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Larsen LK, Møller K, Petersen M, Egerod I. Delirium prevalence and prevention in patients with acute brain injury: A prospective before-and-after intervention study. Intensive Crit Care Nurs 2020; 59:102816. [PMID: 32089416 DOI: 10.1016/j.iccn.2020.102816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/29/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Knowledge regarding delirium prevention in patients with acute brain injury remains limited. We tested the hypothesis that an intervention bundle which targeted sedation, sleep, pain, and mobilisation would reduce delirium in patients with acute brain injury. DESIGN A prospective before-after intervention study: a five-month phase of standard care was followed by a six-month intervention phase. SETTING The neuro-intensive care unit, University Hospital of Copenhagen, Denmark. MAIN OUTCOME MEASURES The Intensive Care Delirium Screening Checklist was used to detect delirium. Primary outcome was delirium duration; secondary outcomes were delirium prevalence, ICU length of stay and one year mortality. RESULTS Forty-four patients were included during the standard care phase, and 50 during the intervention phase. Delirium was present in 90% of patients in the standard care group and 88% in the intervention group (p = 1.0), and time with delirium was 4 days vs 3.5 days (p = 0.26), respectively. Also, ICU length of stay (13 vs. 10.5 days (p = 0.4)) and the one year mortality (21% vs 12% (p = 0.38))) were similar between groups. CONCLUSION We found a high prevalence of delirium in patients with acute brain injury. The intervention bundle did not significantly reduce prevalence or duration of delirium, ICU length of stay or one year mortality.
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Affiliation(s)
- Laura Krone Larsen
- Department of Neuroanaesthesiology, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Marian Petersen
- Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark.
| | - Ingrid Egerod
- Department of Intensive Care, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark.
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van den Boogaard M, Wassenaar A, van Haren FMP, Slooter AJC, Jorens PG, van der Jagt M, Simons KS, Egerod I, Burry LD, Beishuizen A, Pickkers P, Devlin JW. Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Aust Crit Care 2020; 33:420-425. [PMID: 32035691 DOI: 10.1016/j.aucc.2019.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 12/05/2019] [Accepted: 12/12/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Guidelines advocate intensive care unit (ICU) patients be regularly assessed for delirium using either the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC). Single-centre studies, primarily with the CAM-ICU, suggest level of sedation may influence delirium screening results. OBJECTIVE The objective of this study was to determine the association between level of sedation and delirium occurrence in critically ill patients assessed with either the CAM-ICU or the ICDSC. METHODS This was a secondary analysis of a multinational, prospective cohort study performed in nine ICUs from seven countries. Consecutive ICU patients with a Richmond Agitation-Sedation Scale (RASS) of -3 to 0 at the time of delirium assessment where a RASS ≤ 0 was secondary to a sedating medication. Patients were assessed with either the CAM-ICU or the ICDSC. Logistic regression analysis was used to account for factors with the potential to influence level of sedation or delirium occurrence. RESULTS Among 1660 patients, 1203 patients underwent 5741 CAM-ICU assessments [9.6% were delirium positive; at RASS = 0 (3.3% were delirium positive), RASS = -1 (19.3%), RASS = -2 (35.1%); RASS = -3 (39.0%)]. The other 457 patients underwent 3210 ICDSC assessments [11.6% delirium positive; at RASS = 0 (4.9% were delirium positive), RASS = -1 (15.8%), RASS = -2 (26.6%); RASS = -3 (20.6%)]. A RASS of -3 was associated with more positive delirium evaluations (odds ratio: 2.31; 95% confidence interval: 1.34-3.98) in the CAM-ICU-assessed patients (vs. the ICDSC-assessed patients). At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations (odds ratio: 0.58; 95% confidence interval: 0.43-0.78). At a RASS of -1 or -2, no association was found between the delirium assessment method used (i.e., CAM-ICU or ICDSC) and a positive delirium evaluation. CONCLUSIONS The influence of level of sedation on a delirium assessment result depends on whether the CAM-ICU or ICDSC is used. Bedside ICU nurses should consider these results when evaluating their sedated patients for delirium. Future research is necessary to compare the CAM-ICU and the ICDSC simultaneously in sedated and nonsedated ICU patients. TRIAL REGISTRATION ClinicalTrials.gov; NCT02518646.
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Affiliation(s)
- Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, the Netherlands.
| | - Annelies Wassenaar
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, the Netherlands.
| | - Frank M P van Haren
- Intensive Care Unit, The Canberra Hospital, Woden, Canberra, Australia; Australian National University Medical School, Canberra, Australia; University of Canberra, Faculty of Health, Canberra, Australia.
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Antwerp, Belgium.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, the Netherlands.
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Lisa D Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Mount Sinai Hospital, Sinai Health System, Toronto, Canada.
| | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands.
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Center for Infectious Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, USA.
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Zoremba N, Coburn M, Schälte G. [Delirium in intensive care patients : A multiprofessional challenge]. Anaesthesist 2019; 67:811-820. [PMID: 30298270 DOI: 10.1007/s00101-018-0497-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. Due to the close connection between delirium, agitation and pain, sedation and analgesia must be evaluated at least every 8 h analogous to delirium screening. According to current knowledge, a multifactorial and multiprofessional approach is favored in the prevention and treatment of delirium. Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.
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Affiliation(s)
- N Zoremba
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Sankt Elisabeth Hospital Gütersloh, Stadtring Kattenstroth 130, 33332, Gütersloh, Deutschland.
| | - M Coburn
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
| | - G Schälte
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
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Lee Y, Kim K, Lim C, Kim JS. Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study. J Adv Nurs 2019; 76:588-599. [PMID: 31729768 DOI: 10.1111/jan.14267] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Abstract
AIM To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS). DESIGN This is a retrospective study. METHODS We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014). RESULTS In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle. CONCLUSION The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness. IMPACT The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.
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Affiliation(s)
- YoonMi Lee
- Department of Nursing, Samgsung Medical Center, Seoul, Republic of Korea
| | - Kyunghee Kim
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Changwon Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Ji-Su Kim
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
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Abstract
RATIONALE Poor sleep quality is common in the intensive care unit (ICU) and may be associated with adverse outcomes. Hence, ICU-based efforts to promote sleep are gaining attention, motivating interest in methods to measure sleep in critically ill patients. Actigraphy evaluates rest and activity by algorithmically processing gross motor activity data, usually collected by a noninvasive wristwatch-like accelerometer device. In critically ill patients, actigraphy has been used as a surrogate measure of sleep; however, its use has not been systematically reviewed. OBJECTIVES To conduct a systematic review of ICU-based studies that used actigraphy as a surrogate measure of sleep, including its feasibility, validity, and reliability as a measure of sleep in critically ill patients. METHODS We searched PubMed, EMBASE, CINAHL, Proquest, and Web of Science for studies that used actigraphy to evaluate sleep in five or more patients in an ICU setting. RESULTS Our search yielded 4,869 citations, with 13 studies meeting eligibility criteria. These 13 studies were conducted in 10 countries, and eight (62%) were published since 2008. Across the 13 studies, the mean total sleep time of patients in the ICU, as estimated using actigraphy, ranged from 4.4 to 7.8 hours at nighttime and from 7.1 to 12.1 hours over a 24-hour period, with 1.4 to 49.0 mean nocturnal awakenings and a sleep efficiency of 61 to 75%. When compared side-by-side with other measures of sleep (polysomnography, nurse assessments, and patient questionnaires), actigraphy consistently yielded higher total sleep time and sleep efficiency, fewer nighttime awakenings (vs. polysomnography), and more overall awakenings (vs. nurse assessment and patient questionnaires). None of the studies evaluated the association between actigraphy-based measures of sleep and outcomes of patients in the ICU. CONCLUSIONS In critically ill patients, actigraphy is being used more frequently as a surrogate measure of sleep; however, because actigraphy only measures gross motor activity, its ability to estimate sleep is limited by the processing algorithm used. Prior ICU-based studies involving actigraphy were heterogeneous and lacked data regarding actigraphy-based measures of sleep and patient outcomes. Larger, more rigorous and standardized studies are needed to better understand the role of actigraphy in evaluating sleep and sleep-related outcomes in critically ill patients.
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Zoremba N, Coburn M. Acute Confusional States in Hospital. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:101-106. [PMID: 30905333 DOI: 10.3238/arztebl.2019.0101] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 09/21/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute confusional state (delirium) is an acute disturbance of brain function. The incidence of such states varies according to the group of patients con- cerned: it ranges from 30% to 80% among patients in intensive care and from 5.1% to 52.2% among surgical patients, depending on the type of procedure. The earlier German term "Durchgangssyndrom" (usually rendered as "transitory psychotic syn- drome") tended to imply a self-limited and thus relatively harmless condition. In fact, however, delirium is associated with longer hospital stays, poorer treatment out- comes, and higher mortality. Approximately 25% of patients who have experienced an acute confusional state have residual cognitive deficits thereafter. METHODS This review is based on publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and in the International Standard Randomised Controlled Trial Number (ISRCTN) registry. RESULTS Validated instruments are available for the reliable diagnosis of an acute confusional state, e.g., the Confusion Assessment Method for the ICU (CAM-ICU) for patients in intensive care and the 3D-CAM or CAM-S for patients on regular hospital wards. The prevention and treatment of this condition are achieved primarily by a nonpharmacological, multidimensional approach including early mobilization, reorientation, improvement of sleep, adequate pain relief, and the avoidance of polypharmacy. A meta-analysis has shown that these measures lower the incidence of delirium by 44%. The authors find no basis in the current literature for recommending prophylactic medication, although current data promisingly suggest that the incidence of delirium in surgical patients can be lowered by the perioperative administration of dexmedetomidine (odds ratio 0.35). The pharmaco- therapy of acute confusional states involves a careful choice of drug based on the clinical manifestations in the individual case. CONCLUSION The key elements of success in the treatment of acute confusional states in the hospital are adequate prevention, rapid diagnosis, the identification of precipitating factors, and the rapid initiation of both causally oriented and symptom- directed treatment.
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Affiliation(s)
- Norbert Zoremba
- Department of Anesthesiology, Critical Care and Pain Therapy, St. Elisabeth Hospital Gütersloh, Gütersloh, Germany; Department of Anesthesiology, Uniklinik RWTH Aachen, Aachen, Germany
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Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect. Crit Care Med 2019; 46:1486-1491. [PMID: 29727363 DOI: 10.1097/ccm.0000000000003194] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Benzodiazepine use may be associated with delirium in critically ill children. However, benzodiazepines remain the first-line sedative choice in PICUs. Objectives were to determine the temporal relationship between administration of benzodiazepines and delirium development, control for time-varying covariates such as mechanical ventilation and opiates, and evaluate the association between dosage of benzodiazepines and subsequent delirium. DESIGN Retrospective observational study. SETTING Academic tertiary care PICU. PATIENTS All consecutive admissions from January 2015 to June 2015. INTERVENTIONS Retrospective assessment of benzodiazepine exposure in a population that had been prospectively screened for delirium. MEASUREMENTS AND MAIN RESULTS All subjects were prospectively screened for delirium throughout their stay, using the Cornell Assessment for Pediatric Delirium, with daily cognitive status assigned as follows: delirium, coma, or normal. Multivariable mixed effects modeling determined predictors of delirium overall, followed by subgroup analysis to assess effect of benzodiazepines on subsequent development of delirium. Marginal structural modeling was used to create a pseudorandomized sample and control for time-dependent variables, obtaining an unbiased estimate of the relationship between benzodiazepines and next day delirium. The cumulative daily dosage of benzodiazepines was calculated to test for a dose-response relationship. Benzodiazepines were strongly associated with transition from normal cognitive status to delirium, more than quadrupling delirium rates (odds ratio, 4.4; CI, 1.7-11.1; p < 0.002). Marginal structural modeling demonstrated odds ratio 3.3 (CI, 1.4-7.8), after controlling for time-dependent confounding of cognitive status, mechanical ventilation, and opiates. With every one log increase in benzodiazepine dosage administered, there was a 43% increase in risk for delirium development. CONCLUSIONS Benzodiazepines are an independent and modifiable risk factor for development of delirium in critically ill children, even after carefully controlling for time-dependent covariates, with a dose-response effect. This temporal relationship suggests causality between benzodiazepine exposure and pediatric delirium and supports limiting the use of benzodiazepines in critically ill children.
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Abstract
OBJECTIVES We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success. DATA SOURCES Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles. STUDY SELECTION Original articles, review articles, and systematic reviews were considered. DATA EXTRACTION Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles. DATA SYNTHESIS "Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care. CONCLUSIONS A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.
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Muñoz-Narbona L, Roldán-Merino J, Lluch-Canut T, Juvé-Udina E, Llorca MB, Cabrera-Jaime S. Impact of a Training Intervention on the Pain Assessment in Advanced Dementia (PAINAD) Scale in Noncommunicative Inpatients. Pain Manag Nurs 2019; 20:468-474. [PMID: 31103507 DOI: 10.1016/j.pmn.2019.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/25/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Public hospitals in Catalonia (Spain) recommend using the Spanish version of the Pain Assessment in Advanced Dementia (PAINAD-Sp) scale for assessing pain in adult patients unable to self-report. However, since its inclusion in Catalonian nursing care plans in 2010, there have been no training programs for nurses, contributing to its current underuse. AIMS The aim of this study was to assess the impact of a nurse training intervention on the PAINAD-Sp scale in noncommunicative inpatients unable to self-report. DESIGN Before-after study. SETTINGS Two public hospitals in Catalonia (Spain). PARTICIPANTS/SUBJECTS Four hundred and one nurses participated in the training course and 219 patients received PAINAD-Sp assessments. METHODS We used a before-after study design, evaluating the use of the PAINAD-Sp scale over two 6-month periods before and after an online training intervention for nurses in February 2017, in two public hospitals. Data were collected from patient records in each center. The primary outcome was the number of patients receiving PAINAD-Sp assessments during admission. Secondary outcomes were the number of assessments undertaken per patient during admission, the total (0-10) and item-specific (0-2) PAINAD-Sp score, and pharmacologic treatment administered. RESULTS There were 401 nurses who took part in the training program. Over the study period, 219 patients received PAINAD-Sp assessments: 29 in the preintervention period and 190 in the postintervention period (p < .001). Administration of analgesics and antipyretics decreased (p < .001) after the intervention, whereas use of hypnotic drugs and sedatives increased. CONCLUSIONS Theoretical and practical training may be an effective way to improve nurses' approach to identifying, assessing, and managing pain in patients unable to self-report.
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Affiliation(s)
- Lucia Muñoz-Narbona
- Institute for Health Science Research, Germans Trias I Pujol (IGTP), Department of Neurosciences, Barcelona, Spain; RETICS Research Group (Redes Temáticas de Investigación Cooperativa en Salud), Health Institute Carlos III, Madrid, Spain.
| | - Juan Roldán-Merino
- Teaching Campus Sant Joan de Déu-Fundació Privada School of Nursing, University of Barcelona, Barcelona, Spain; GIES Research Group (Grupo de investigación en Enfermería, Educación y Sociedad), Barcelona, Spain; GEIMAC Research Group (Gruop Consolidad 2017-1681: Grupo de Estudios de Invarianza de los Instrumentos de Medida y Análisis del Cambio en los Ámbitos Social y de la Salud), Barcelona, Spain; GIRISAME Research Group (International Researchers Group of Mental Health Nursing Care), Madrid, Spain; REICESMA Research Group (Red Española Investigación de Enfermería en Cuidados de Salud Mental y Adicciones), Madrid, Spain
| | - Teresa Lluch-Canut
- GEIMAC Research Group (Gruop Consolidad 2017-1681: Grupo de Estudios de Invarianza de los Instrumentos de Medida y Análisis del Cambio en los Ámbitos Social y de la Salud), Barcelona, Spain; School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Eulàlia Juvé-Udina
- School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain; Nursing Research Group (GRIN), IDIBELL, Biomedical Research Institute, Barcelona, Spain
| | | | - Sandra Cabrera-Jaime
- Nursing Research Group (GRIN), IDIBELL, Biomedical Research Institute, Barcelona, Spain; Nursing Research, Institut Català d'Oncologia, Barcelona, Spain; University of Barcelona, University School of Nursing, Health Sciences Campus of Bellvitge, Barcelona, Spain; Care Management, Institut Català d'Oncologia, Barcelona, Spain
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Kim SY, Jeong SJ, Lee JG, Park MS, Paik HC, Na S, Kim J. Critical Care after Lung Transplantation. Acute Crit Care 2018; 33:206-215. [PMID: 31723887 PMCID: PMC6849028 DOI: 10.4266/acc.2018.00360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 12/28/2022] Open
Abstract
Since the first successful lung transplantation in 1983, there have been many advances in the field. Nevertheless, the latest data from the International Society for Heart and Lung Transplantation revealed that the risk of death from transplantation is 9%. Various aspects of postoperative management, including mechanical ventilation, could affect intensive care unit stay, hospital stay, and immediate postoperative morbidity and mortality. Complications such as reperfusion injury, graft rejection, infection, and dehiscence of anastomosis increase fatal adverse side effects immediately after surgery. In this article, we review the possible immediate complications after lung transplantation and summarize current knowledge on prevention and treatment.
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Affiliation(s)
- Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
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Improving the Accuracy of Delirium Assessments in Neuroscience Patients: Scaling a Quality Improvement Program to Improve Nurses' Skill, Compliance, and Accuracy in the Use of the Confusion Assessment Method in the Intensive Care Unit Tool. Dimens Crit Care Nurs 2018; 37:26-34. [PMID: 29194171 DOI: 10.1097/dcc.0000000000000277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Delirium affects up to 80% of critically ill patients; however, many cases of delirium go unrecognized because of inaccurate assessments. The effectiveness of interventions to improve assessment accuracy among the general population has been established, but assessments among neuroscience patients are uniquely complicated due to the presence of structural neurologic changes. OBJECTIVES The purposes of this quality improvement project were to improve the accuracy of nurse's delirium assessments among neuroscience patients and to determine the comparative effectiveness of the intervention between medical and neuroscience patients. METHODS A multifaceted nurse-led intervention was implemented, and a retrospective analysis of preintervention and postintervention data on assessment accuracy was completed. Results were stratified by population, level of sedation, and level of care. Differences were analyzed using Fisher exact test. RESULTS Data from 1052 delirium assessments were analyzed and demonstrated improvement in assessment accuracy from 56.82% to 95.07% among all patients and from 29.79% to 92.98% among sedate or agitated patients. Although baseline accuracy was significantly lower among neuroscience patients versus medical intensive care unit patients, no significant differences in postintervention accuracy were noted between groups. CONCLUSION Results from this project demonstrate the effectiveness of the nurse-led intervention among neuroscience patients. Future research is needed to explore the effectiveness of this nurse-led intervention across other institutions and to describe the effectiveness of new interventions to improve outcomes at the patient and organizational levels.
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Van Rompaey B, Sabbe K, Dilles T, van den Boogaard M. Delirium, introduction to a confused mind. Intensive Crit Care Nurs 2018; 47:1-4. [DOI: 10.1016/j.iccn.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Damico V, Cazzaniga F, Murano L, Ciceri R, Nattino G, Dal Molin A. Impact of a Clinical Therapeutic Intervention on Pain Assessment, Management, and Nursing Practices in an Intensive Care Unit: A before-and-after Study. Pain Manag Nurs 2018; 19:256-266. [DOI: 10.1016/j.pmn.2018.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 11/17/2022]
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Abstract
Delirium is a common, often underdiagnosed, geriatric syndrome characterized by an acute change in attention and consciousness. As a neuropsychiatric disorder with an underlying organic cause, delirium has been considered a diagnosis reserved for the hospital setting. However, delirium is known to occur as both an acute and subacute condition that carries significant morbidity and mortality. Combined with its association with dementia and aging, this makes delirium an important topic for primary care providers to become more familiar with as they are tasked with caring for an aging population.
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Rood P, Huisman-de Waal G, Vermeulen H, Schoonhoven L, Pickkers P, van den Boogaard M. Effect of organisational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis. Aust Crit Care 2018; 31:180-187. [PMID: 29545081 DOI: 10.1016/j.aucc.2018.02.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 01/05/2018] [Accepted: 02/01/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Delirium occurs frequently in intensive care unit (ICU) patients and is associated with numerous deleterious outcomes. There is a large variation in reported delirium occurrence rates, ranging from 4% to 89%. Apart from patient and treatment-related factors, organisational factors could influence delirium incidence, but this is currently unknown. OBJECTIVE To systematically review delirium incidence and determine whether or not organisational factors may contribute to the observed delirium incidence in adult ICU patients. METHODS Systematic review of prospective cohort studies reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Included articles were independently assessed by two researchers. Quality of the articles was determined using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Subsequently, apart from patient characteristics, a meta-regression analysis was performed on available organisational factors, including hospital type, screening method and screening frequency. DATA SOURCES PubMed, Embase, CINAHL, and Cochrane Library databases were searched from inception to 27 January 2017, without language limitation. RESULTS A total of 9357 articles were found, of which 19 articles met the inclusion criteria and were considered as true delirium incidence studies. The articles were of good methodological quality (median [interquartile range] 32/38 [30-35] points), published between 2005 and 2016, originated from 17 countries. A total of 9867 ICU patients were included. The incidence rate of delirium varied between 4% and 55%, with a mean ± standard deviation of 29 ± 14%. Data relating to three organisational factors were included in the studies, but they were not significantly associated with the reported delirium incidence: hospital type (p 0.48), assessment methods (p 0.41), and screening frequency (p 0.28). CONCLUSIONS The mean incidence of delirium in the ICU was 29%. The organisational factors found including methods of delirium assessment, screening frequency, and hospital type were not related to the reported ICU delirium incidence.
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Affiliation(s)
- Paul Rood
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Getty Huisman-de Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisette Schoonhoven
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex), United Kingdom
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Clinical practices to promote sleep in the ICU: A multinational survey. Int J Nurs Stud 2018; 81:107-114. [PMID: 29567559 DOI: 10.1016/j.ijnurstu.2018.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/26/2018] [Accepted: 03/02/2018] [Indexed: 02/01/2023]
Abstract
PURPOSE To describe sleep assessment and strategies to promote sleep in adult ICUs in ten countries. METHODS Multicenter, self-administered survey sent to nurse managers. RESULTS Response rate was 66% with 522 ICUs providing data. 'Lying quietly with closed eyes' was the characteristic most frequently perceived as indicative of sleep by >60% of responding ICUs in all countries except Italy. Few ICUs (9%) had a protocol for sleep management or used sleep questionnaires (1%). Compared to ICUs in Northern Europe, those in central Europe were more likely to have a sleep promoting protocol (p < 0.001), and to want to implement a protocol (p < 0.001). In >80% of responding ICUs, the most common non-pharmacological sleep-promoting interventions were reducing ICU staff noise, light, and nurse interventions at night; only 18% used earplugs frequently. Approximately 50% of ICUs reported sleep medication selection and assessment of effect were performed by physicians and nurses collaboratively. A multivariable model identified perceived nursing influence on sleep decision-making was associated with asking patients or family about sleep preferences (p = 0.004). CONCLUSIONS We found variation in sleep promotion interventions across European regions with few ICUs using sleep assessment questionnaires or sleep promoting protocols. However, many ICUs perceive implementation of sleep protocols important, particularly those in central Europe.
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van den Boogaard M, Slooter AJC, Brüggemann RJM, Schoonhoven L, Beishuizen A, Vermeijden JW, Pretorius D, de Koning J, Simons KS, Dennesen PJW, Van der Voort PHJ, Houterman S, van der Hoeven JG, Pickkers P. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA 2018; 319:680-690. [PMID: 29466591 PMCID: PMC5839284 DOI: 10.1001/jama.2018.0160] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Results of studies on use of prophylactic haloperidol in critically ill adults are inconclusive, especially in patients at high risk of delirium. OBJECTIVE To determine whether prophylactic use of haloperidol improves survival among critically ill adults at high risk of delirium, which was defined as an anticipated intensive care unit (ICU) stay of at least 2 days. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled investigator-driven study involving 1789 critically ill adults treated at 21 ICUs, at which nonpharmacological interventions for delirium prevention are routinely used in the Netherlands. Patients without delirium whose expected ICU stay was at least a day were included. Recruitment was from July 2013 to December 2016 and follow-up was conducted at 90 days with the final follow-up on March 1, 2017. INTERVENTIONS Patients received prophylactic treatment 3 times daily intravenously either 1 mg (n = 350) or 2 mg (n = 732) of haloperidol or placebo (n = 707), consisting of 0.9% sodium chloride. MAIN OUTCOME AND MEASURES The primary outcome was the number of days that patients survived in 28 days. There were 15 secondary outcomes, including delirium incidence, 28-day delirium-free and coma-free days, duration of mechanical ventilation, and ICU and hospital length of stay. RESULTS All 1789 randomized patients (mean, age 66.6 years [SD, 12.6]; 1099 men [61.4%]) completed the study. The 1-mg haloperidol group was prematurely stopped because of futility. There was no difference in the median days patients survived in 28 days, 28 days in the 2-mg haloperidol group vs 28 days in the placebo group, for a difference of 0 days (95% CI, 0-0; P = .93) and a hazard ratio of 1.003 (95% CI, 0.78-1.30, P=.82). All of the 15 secondary outcomes were not statistically different. These included delirium incidence (mean difference, 1.5%, 95% CI, -3.6% to 6.7%), delirium-free and coma-free days (mean difference, 0 days, 95% CI, 0-0 days), and duration of mechanical ventilation, ICU, and hospital length of stay (mean difference, 0 days, 95% CI, 0-0 days for all 3 measures). The number of reported adverse effects did not differ between groups (2 [0.3%] for the 2-mg haloperidol group vs 1 [0.1%] for the placebo group). CONCLUSIONS AND RELEVANCE Among critically ill adults at high risk of delirium, the use of prophylactic haloperidol compared with placebo did not improve survival at 28 days. These findings do not support the use of prophylactic haloperidol for reducing mortality in critically ill adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01785290.
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Affiliation(s)
- Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Lisette Schoonhoven
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Wessex, United Kingdom
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medical Spectrum Twente, Enschede, the Netherlands
| | - J. Wytze Vermeijden
- Department of Intensive Care Medicine, Medical Spectrum Twente, Enschede, the Netherlands
| | - Danie Pretorius
- Department of Intensive Care Medicine, St Jansdal Hospital Harderwijk, the Netherlands
| | - Jan de Koning
- Department of Intensive Care Medicine, Máxima Medical Center Veldhoven, the Netherlands
| | - Koen S. Simons
- Department of Intensive Care Medicine, Jeroen Bosch Hospital Den-Bosch, the Netherlands
| | - Paul J. W. Dennesen
- Department of Intensive Care Medicine, Haaglanden Medical Center, The Hague, the Netherlands
| | - Peter H. J. Van der Voort
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
- TIAS School for Business and Society, Tilburg University, Tilburg, the Netherlands
| | | | - J. G. van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Perbet S, Bourdeaux D, Lenoire A, Biboulet C, Pereira B, Sadoune M, Plaud B, Launay JM, Bazin JE, Sautou V, Mebazaa A, Houze P, Constantin JM, Legrand M. Sevoflurane for procedural sedation in critically ill patients: A pharmacokinetic comparative study between burn and non-burn patients. Anaesth Crit Care Pain Med 2018; 37:551-556. [PMID: 29455032 DOI: 10.1016/j.accpm.2018.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Sevoflurane has anti-inflammatory proprieties and short lasting effects making it of interest for procedural sedation in critically ill patients. We evaluated the pharmacokinetics of sevoflurane and metabolites in severely ill burn patients and controls. The secondary objective was to assess potential kidney injury. METHODS Prospective interventional study in a burn and a surgical intensive care unit; 24 mechanically ventilated critically ill patients (12 burns, 12 controls) were included. The sevoflurane was administered with an expired fraction target of 2% during short-term procedural sedation. Plasma concentrations of sevoflurane, hexafluoroisopropanolol (HFIP) and free fluoride ions were recorded at different times. Kinetic Pro (Wgroupe, France) was used for pharmacokinetic analysis. Kidney injury was assessed with neutrophil gelatinase-associated lipocalin (NGAL). RESULTS The mean total burn surface area was 36±11%. The average plasma concentration of sevoflurane was 70.4±37.5mg·L-1 in burns and 57.2±28.1mg·L-1 in controls at the end of the procedure (P=0.58). The volume of distribution was higher (46.8±7.2 vs 22.2±2.50L, P<0.001), and the drug half-life longer in burns (1.19±0.28h vs 0.65±0.04h, P<0.0001). Free metabolite HFIP was higher in burns. Plasma fluoride was not different between burns and controls. NGAL did not rise after procedures. CONCLUSION We observed an increased volume of distribution, slower elimination rate, and altered metabolism of sevoflurane in burn patients compared to controls. Repeated use for procedural sedation in burn patients needs further evaluation. No renal toxicity was detected. TRIAL REGISTRY NUMBER ClinicalTrials.gov Identifier NCT02048683.
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Affiliation(s)
- Sebastien Perbet
- Intensive Care Unit, Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Inserm U1103, GReD, CNRS 6293, université Clermont-Auvergne, 63000 Clermont-Ferrand, France
| | - Daniel Bourdeaux
- Pharmacy department, CHU Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand, France; EA4676C-BIOSENSS, Clermont University, Université d'Auvergne, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France
| | - Alexandre Lenoire
- Department of Anaesthesiology and Critical Care and Burn Unit, St-Louis Hospital, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Claire Biboulet
- Intensive Care Unit, Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, DRCI, Gabriel-Montpied Hospital, CHU Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand, France
| | - Malha Sadoune
- UMR Inserm 942, French National Institute of Health and Medical Research (Inserm), Lariboisière hospital, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - Benoit Plaud
- Department of Anaesthesiology and Critical Care and Burn Unit, St-Louis Hospital, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France; UMR Inserm 942, French National Institute of Health and Medical Research (Inserm), Lariboisière hospital, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Paris Diderot University, Sorbonne Paris Cité, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France
| | - Jean-Marie Launay
- UMR Inserm 942, French National Institute of Health and Medical Research (Inserm), Lariboisière hospital, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Paris Diderot University, Sorbonne Paris Cité, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Department of biochemistry, Lariboisière hospital, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - Jean-Etienne Bazin
- Intensive Care Unit, Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Valerie Sautou
- Pharmacy department, CHU Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand, France; EA4676C-BIOSENSS, Clermont University, Université d'Auvergne, 28, place Henri-Dunant, 63000 Clermont-Ferrand, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care and Burn Unit, St-Louis Hospital, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France; UMR Inserm 942, French National Institute of Health and Medical Research (Inserm), Lariboisière hospital, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Paris Diderot University, Sorbonne Paris Cité, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France
| | - Pascal Houze
- Department of Pharmacology, St-Louis hospital, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - Jean-Michel Constantin
- Intensive Care Unit, Department of Perioperative Medicine, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; Inserm U1103, GReD, CNRS 6293, université Clermont-Auvergne, 63000 Clermont-Ferrand, France
| | - Matthieu Legrand
- Department of Anaesthesiology and Critical Care and Burn Unit, St-Louis Hospital, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France; UMR Inserm 942, French National Institute of Health and Medical Research (Inserm), Lariboisière hospital, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Paris Diderot University, Sorbonne Paris Cité, 1, avenue Claude-Vellefaux, 75475 Paris cedex 10, France.
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Freeman S, Yorke J, Dark P. Patient agitation and its management in adult critical care: A integrative review and narrative synthesis. J Clin Nurs 2018; 27:e1284-e1308. [PMID: 29314320 DOI: 10.1111/jocn.14258] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
AIMS AND OBJECTIVE To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies. BACKGROUND Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness. STUDY DESIGN Integrative review and narrative synthesis. METHODS A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach. RESULTS A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management. CONCLUSIONS Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance. RELEVANCE TO CLINICAL PRACTICE The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.
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Affiliation(s)
| | | | - Paul Dark
- University of Manchester, Manchester, UK
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A Novel Picture Guide to Improve Spiritual Care and Reduce Anxiety in Mechanically Ventilated Adults in the Intensive Care Unit. Ann Am Thorac Soc 2018; 13:1333-42. [PMID: 27097049 DOI: 10.1513/annalsats.201512-831oc] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Hospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited. OBJECTIVES To determine the feasibility and measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU). METHODS We conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, we performed semistructured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, we measured anxiety (on 100-mm visual analog scales [VAS]) immediately before and after the first chaplain visit, and we performed semistructured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS). MEASUREMENTS AND MAIN RESULTS The mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7-29 d), and 15 (30%) died in-hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, -20; 95% confidence interval, -33 to -7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semistructured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semistructured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, -72 to -24) and no significant change in physical pain that they attributed to picture-guided spiritual care. CONCLUSIONS Chaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission.
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Rains J, Chee N. The role of occupational and physiotherapy in multi-modal approach to tackling delirium in the intensive care. J Intensive Care Soc 2017; 18:318-322. [PMID: 29123562 PMCID: PMC5661800 DOI: 10.1177/1751143717720589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The presence of delirium within critical care remains a long-standing challenge for patients and clinicians alike. A myriad of pre-disposing and precipitating factors lead to this patient cohort being high risk for developing delirium during their critical care stay. Until now, non-pharmacological management of these patients usually encompasses a 'bundle' of principles to reduce delirium days. These bundles have limited focus on the entire multi-disciplinary team (including occupational therapists and physiotherapists) who could assist with the reduction of delirium. The purpose of this analysis is to review the current literature and develop a mnemonic, which may help facilitate collaborative working for patients with delirium. Electronic databases were searched for non-pharmacological managements of delirium within intensive care settings, after 2006. Critical appraisal using Critical Appraisal Skills Programme methodology was completed by the author. Multi-intervention approaches and bundles are successful at reducing delirium days, and in some cases, reducing hospital length of stay. The key components of these bundles include spontaneous breathing trials, daily sedation holds, addressing pain relief, early mobilisation and to a small extent normalisation of a daily routine. There is limited research into the role of therapy within this patient group, but there is a role for cognitive therapy, functional tasks, and a greater rehab emphasis within other patient populations such as stroke and elderly care. The critical care population have similar rehabilitation needs to these groups, and therefore would benefit from similar treatment plans. Critical care patients with delirium may benefit from a range of additional therapeutic activities to reduce the duration of delirium. The D.E.L.I.R.I.U.M mnemonic has been developed to encompass all the key elements of current delirium research in a simplistic memorable fashion. Further work is needed to trial the usefulness of the mnemonic in clinical practice to enable the entire multi-disciplinary team work collaboratively to reduce delirium with the intensive care.
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Affiliation(s)
- Jenny Rains
- Royal Bournemouth and Christchurch Hospitals, NHS Foundation Trust, Bournemouth, UK
| | - Nigel Chee
- Royal Bournemouth and Christchurch Hospitals, NHS Foundation Trust, Bournemouth, UK
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LeBlanc A, Bourbonnais FF, Harrison D, Tousignant K. The experience of intensive care nurses caring for patients with delirium: A phenomenological study. Intensive Crit Care Nurs 2017; 44:92-98. [PMID: 28993046 DOI: 10.1016/j.iccn.2017.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The purpose of this research was to seek to understand the lived experience of intensive care nurses caring for patients with delirium. The objectives of this inquiry were: 1) To examine intensive care nurses' experiences of caring for adult patients with delirium; 2) To identify factors that facilitate or hinder intensive care nurses caring for these patients. RESEARCH METHODOLOGY This study utilised an interpretive phenomenological approach as described by van Manen. SETTING Individual conversational interviews were conducted with eight intensive care nurses working in a tertiary level, university-affiliated hospital in Canada. FINDINGS The essence of the experience of nurses caring for patients with delirium in intensive care was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's aReally Big Job; Everyone Is Unique; Riding It Out With Families and Taking Every Experience With You. CONCLUSION The findings contribute to an understanding of how intensive care nurses help patients and their families through this complex and distressing experience.
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Affiliation(s)
- Allana LeBlanc
- University of Ottawa, 75 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada.
| | | | - Denise Harrison
- University of Ottawa, 75 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Kelly Tousignant
- University of Ottawa, 75 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
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Abstract
The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.
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Affiliation(s)
- Steven E Brooks
- Geriatric Trauma Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA; Pediatric Intensive Care Unit, Division of Trauma, Surgical Critical Care, Acute Care Surgery, Department of Surgery, John A. Griswold Trauma Center, Texas Tech University Health Sciences Center, 3601 4th Street MS 8312, Lubbock, TX 79430, USA.
| | - Allan B Peetz
- Emergency General Surgery, Division of Trauma, Surgical Critical Care, Vanderbilt University Medical Center, Medical Arts Building Suite 404, 1211 21st Avenue South, Nashville, TN 37212, USA
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Postoperative delirium in elderly patients is associated with subsequent cognitive impairment. Br J Anaesth 2017; 119:316-323. [DOI: 10.1093/bja/aex130] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 02/02/2023] Open
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Cui V, Tedeschi CM, Kronzer VL, McKinnon SL, Avidan MS. Protocol for an observational study of delirium in the post-anaesthesia care unit (PACU) as a potential predictor of subsequent postoperative delirium. BMJ Open 2017; 7:e016402. [PMID: 28698343 PMCID: PMC5541504 DOI: 10.1136/bmjopen-2017-016402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Postoperative delirium can be a serious consequence of major surgery, associated with longer hospital stays, readmission, cognitive and functional deterioration and mortality. Delirium is an acute, reversible disorder characterised by fluctuating course, inattention, disorganised thinking and altered level of consciousness. Delirium occurring in the hours immediately following anaesthesia and delirium occurring in the postoperative period of 1-5 days have been described as distinct clinical entities. This protocol describes an observational study with the aim of determining if delirium in the first hour following tracheal tube removal is a predictor of delirium in the 5 subsequent postoperative days. Improved understanding regarding the development of postoperative delirium would improve patient care and allow more effective implementation of delirium prevention measures. METHODS AND ANALYSIS Patients enrolled to the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomised controlled trial will be eligible for this substudy. A validated delirium assessment method, the 3-min Diagnostic Confusion Assessment Method and the Richmond Agitation and Sedation Scale will be used to assess 100 patients for delirium at 30 min and 60 min following tracheal tube removal. Patients will also be assessed for delirium over postoperative days 1-5 using three validated methods, the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit and structured chart review. Logistic regression analysis will then be performed to test whether immediately postoperative delirium independently predicts subsequent postoperative delirium. ETHICS AND DISSEMINATION This observational substudy of ENGAGES has been approved by the ethics board of Washington University School of Medicine. Enrolment began in June 2016 and will continue until June 2017. Dissemination plans include presentations at scientific conferences and scientific publications. TRIAL REGISTRATION NUMBER NCT02241655.
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Affiliation(s)
- Victoria Cui
- Department of Anesthesia, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Catherine M Tedeschi
- Department of Anesthesia, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Vanessa L Kronzer
- Department of Anesthesia, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Sherry L McKinnon
- Department of Anesthesia, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesia, Washington University School of Medicine, Saint Louis, Missouri, USA
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