Sedation selection to reduce delirium risk: Why dexmedetomidine may be a better choice

Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.

Delirium detection using GAMMA wave and machine learning: A pilot study

Delirium occurs in as many as 80% of critically ill older adults and is associated with increased long-term cognitive impairment, institutionalization, and mortality. Less than half of delirium cases are identified using currently available subjective assessment tools. Electroencephalogram (EEG) has been identified as a reliable objective measure but has not been feasible. This study was a prospective pilot proof-of-concept study, to examine the use of machine learning methods evaluating the use of gamma band to predict delirium from EEG data derived from a limited lead rapid response handheld device. Data from 13 critically ill participants aged 50 or older requiring mechanical ventilation for more than 12 h were enrolled. Across the three models, accuracy of predicting delirium was 70 or greater. Stepwise discriminant analysis provided the best overall method. While additional research is needed to determine the best cut points and efficacy, use of a handheld limited lead rapid response EEG device capable of monitoring all five cerebral lobes of the brain for predicting delirium hold promise.

Minimizing Post-Intensive Care Syndrome to Improve Outcomes for Intensive Care Unit Survivors

TOPIC

Post-intensive care syndrome is a collection of symptoms that more than half of patients who survive a critical illness, and their family caregivers, experience after the illness. Those symptoms include weakness/ fatigue, sleep disturbances/insomnia, cognitive dysfunction, posttraumatic stress disorder, other mental health conditions, and a lack of effective coping strategies.

CLINICAL RELEVANCE

To minimize the risk of a patient developing post-intensive care syndrome, intensive care unit nurses must adopt practices that reduce the severity of disability and optimize patient outcomes. They must also advocate for patients who need additional expert care.

PURPOSE

To describe interventions that critical care nurses can implement to minimize a patient's risk for post-intensive care syndrome.

CONTENT COVERED

This article describes patients who have a high risk of developing post-intensive care syndrome and interventions that are within nurses' purview.

Understanding Disorders of Consciousness: Opportunities for Critical Care Nurses

BACKGROUND

Disorders of consciousness are powerful predictors of outcomes including mortality among critically ill patients. Encephalopathy, delirium, and coma are disorders of consciousness frequently encountered by critical care nurses but often classified incorrectly.

OBJECTIVE

To provide a greater understanding of disorders of consciousness and to provide standardized assessments and nursing interventions for these disorders.

METHODS

A literature search was conducted by using the terms consciousness, mental status, awareness, arousal, wakefulness, assessment, disorders of consciousness, delirium, encephalopathy, coma, vegetative state, and minimal consciousness. Articles were published in the past 10 years in CINAHL and PubMed. Articles were excluded if they were not in English or directly related to caring for patients with a disorder of consciousness. The remaining 142 articles were evaluated for inclusion; 81 articles received full review.

RESULTS

A disorder of consciousness signifies that the threshold for compensation has been surpassed with potentially irreversible damage. Altered thalamocortical interactions and reduced cortical activity impair communication networks across the various parts of the brain, causing a disturbance in consciousness.

DISCUSSION

The cue-response theory is a model that describes the process and impact of nursing care on recovery from acute brain injury. Appropriate standardized assessments and interventions must be used to manage altered levels of consciousness in critically ill patients.

CONCLUSIONS

Paying close attention to neurological changes and monitoring them with standardized assessments are critical to implementing early measures to prevent complications.

Delirium Tremens in the Older Adult

INTRODUCTION

Caring for patients experiencing alcohol withdrawal syndrome can be challenging. Patients 65 and older are at increased risk for alcohol withdrawal syndrome related complications. The higher prevalence of co-morbidities, including cognitive impairment, longer drinking history and greater sensitivity to alcohol withdrawal syndrome treatment are the result of decreased ability of the brain to adapt to stressors such as illness, trauma, or surgery.

DELIRIUM TREMENS

Symptoms may appear earlier from the last drink and present with a wide range of symptoms. The most effective interventions require high-quality nursing care delivery to prevent, decrease the severity and shorten the duration of delirium.

NURSING IMPLICATIONS

Strategies that help minimize these challenges starts with obtaining the patient's selfreport of their alcohol use history. Nurses should be diligent in their monitoring for signs of active alcohol withdrawal. Screening and assessment tools such as the Clinical Institute Withdrawal Assessment for Alcohol-Revised should guide pharmacological management. To support nurses in identifying delirium tremens, this manuscript seek to describe the underlying pathophysiology, key assessment components and nursing management of delirium tremens in the older adult.