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Rhodes A, Wilson C, Zelenkov D, Adams K, Poyant JO, Han X, Faugno A, Montalvo C. "The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist". J Intensive Care Med 2024:8850666241275582. [PMID: 39169853 DOI: 10.1177/08850666241275582] [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: 08/23/2024]
Abstract
Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.
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Affiliation(s)
- Allison Rhodes
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | | | | | - Kathryne Adams
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | | | - Xuan Han
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | - Anthony Faugno
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | - Cristina Montalvo
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
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Bertolini F, Robertson L, Bisson JI, Meader N, Churchill R, Ostuzzi G, Stein DJ, Williams T, Barbui C. Early pharmacological interventions for prevention of post-traumatic stress disorder (PTSD) in individuals experiencing acute traumatic stress symptoms. Cochrane Database Syst Rev 2024; 5:CD013613. [PMID: 38767196 PMCID: PMC11103774 DOI: 10.1002/14651858.cd013613.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Acute traumatic stress symptoms may develop in people who have been exposed to a traumatic event. Although they are usually self-limiting in time, some people develop post-traumatic stress disorder (PTSD), a severe and debilitating condition. Pharmacological interventions have been proposed for acute symptoms to act as an indicated prevention measure for PTSD development. As many individuals will spontaneously remit, these interventions should balance efficacy and tolerability. OBJECTIVES To assess the efficacy and acceptability of early pharmacological interventions for prevention of PTSD in adults experiencing acute traumatic stress symptoms. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase and two other databases. We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 23 January 2023. SELECTION CRITERIA We included randomised controlled trials on adults exposed to any kind of traumatic event and presenting acute traumatic stress symptoms, without restriction on their severity. We considered comparisons of any medication with placebo, or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Using a random-effects model, we analysed dichotomous data as risk ratios (RR) and calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). Our primary outcomes were PTSD severity and dropouts due to adverse events. Secondary outcomes included PTSD rate, functional disability and quality of life. MAIN RESULTS We included eight studies that considered four interventions (escitalopram, hydrocortisone, intranasal oxytocin, temazepam) and involved a total of 779 participants. The largest trial contributed 353 participants and the next largest, 120 and 118 participants respectively. The trials enrolled participants admitted to trauma centres or emergency departments. The risk of bias in the included studies was generally low except for attrition rate, which we rated as high-risk. We could meta-analyse data for two comparisons: escitalopram versus placebo (but limited to secondary outcomes) and hydrocortisone versus placebo. One study compared escitalopram to placebo at our primary time point of three months after the traumatic event. There was inconclusive evidence of any difference in terms of PTSD severity (mean difference (MD) on the Clinician-Administered PTSD Scale (CAPS, score range 0 to 136) -11.35, 95% confidence interval (CI) -24.56 to 1.86; 1 study, 23 participants; very low-certainty evidence), dropouts due to adverse events (no participant left the study early due to adverse events; 1 study, 31 participants; very low-certainty evidence) and PTSD rates (RR 0.59, 95% CI 0.03 to 13.08; NNTB 37, 95% CI NNTB 15 to NNTH 1; 1 study, 23 participants; very low-certainty evidence). The study did not assess functional disability or quality of life. Three studies compared hydrocortisone to placebo at our primary time point of three months after the traumatic event. We found inconclusive evidence on whether hydrocortisone was more effective in reducing the severity of PTSD symptoms compared to placebo (MD on CAPS -7.53, 95% CI -25.20 to 10.13; I2 = 85%; 3 studies, 136 participants; very low-certainty evidence) and whether it reduced the risk of developing PTSD (RR 0.47, 95% CI 0.09 to 2.38; NNTB 14, 95% CI NNTB 8 to NNTH 5; I2 = 36%; 3 studies, 136 participants; very low-certainty evidence). Evidence on the risk of dropping out due to adverse events is inconclusive (RR 3.19, 95% CI 0.13 to 75.43; 2 studies, 182 participants; low-certainty evidence) and it is unclear whether hydrocortisone might improve quality of life (MD on the SF-36 (score range 0 to 136, higher is better) 19.70, 95% CI -1.10 to 40.50; 1 study, 43 participants; very low-certainty evidence). No study assessed functional disability. AUTHORS' CONCLUSIONS This review provides uncertain evidence regarding the use of escitalopram, hydrocortisone, intranasal oxytocin and temazepam for people with acute stress symptoms. It is therefore unclear whether these pharmacological interventions exert a positive or negative effect in this population. It is important to note that acute traumatic stress symptoms are often limited in time, and that the lack of data prevents the careful assessment of expected benefits against side effects that is therefore required. To yield stronger conclusions regarding both positive and negative outcomes, larger sample sizes are required. A common operational framework of criteria for inclusion and baseline assessment might help in better understanding who, if anyone, benefits from an intervention. As symptom severity alone does not provide the full picture of the impact of exposure to trauma, assessment of quality of life and functional impairment would provide a more comprehensive picture of the effects of the interventions. The assessment and reporting of side effects may facilitate a more comprehensive understanding of tolerability.
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Affiliation(s)
- Federico Bertolini
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Nicholas Meader
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Dan J Stein
- SAMRC Unit on Risk & Resilience in Mental Disorders, Dept of Psychiatry & Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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Anderson BJ, Schweickert WD. Measuring Bundle Implementation Work Requires a Calibrated Scale. Crit Care Med 2023; 51:1824-1826. [PMID: 37971338 DOI: 10.1097/ccm.0000000000006005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Brian J Anderson
- Both authors: Pulmonary, Allergy and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Vogt KM, Pryor KO. Anesthesia and the neurobiology of fear and posttraumatic stress disorder. Curr Opin Anaesthesiol 2022; 35:593-599. [PMID: 35993581 PMCID: PMC9469898 DOI: 10.1097/aco.0000000000001176] [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] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Dysfunction of fear memory systems underlie a cluster of clinically important and highly prevalent psychological morbidities seen in perioperative and critical care patients, most archetypally posttraumatic stress disorder (PTSD). Several sedative-hypnotics and analgesics are known to modulate fear systems, and it is theoretically plausible that clinical decisions of the anesthesiologist could impact psychological outcomes. This review aims to provide a focused synthesis of relevant literature from multiple fields of research. RECENT FINDINGS There is evidence in some contexts that unconscious fear memory systems are less sensitive to anesthetics than are conscious memory systems. Opiates may suppress the activation of fear systems and have benefit in the prevention of PTSD following trauma. There is inconsistent evidence that the use of propofol and benzodiazepines for sedation following trauma may potentiate the development of PTSD relative to other drugs. The benefits of ketamine seen in the treatment of major depression are not clearly replicated in PTSD-cluster psychopathologies, and its effects on fear processes are complex. SUMMARY There are multiple theoretical mechanisms by which anesthetic drugs can modulate fear systems and clinically important fear-based psychopathologies. The current state of research provides some evidence to support further hypothesis investigation. However, the absence of effectiveness studies and the inconsistent signals from smaller studies provide insufficient evidence to currently offer firm clinical guidance.
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Affiliation(s)
- Keith M. Vogt
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, School of Medicine
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh
- Center for the Neural Basis of Cognition
- Clinical and Translational Science Institute, University of Pittsburgh
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medicine
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Bulbuloglu S, Çınar F, Çürük GN. The Effect of Environmental Stressors on Patient Experience in Medical, Surgical, and COVID-19 Intensive Care Unit. J Patient Exp 2022; 9:23743735221092545. [PMID: 35434297 PMCID: PMC9008315 DOI: 10.1177/23743735221092545] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This study was conducted to evaluate the effects of environmental stressors on
patients’ intensive care experiences in medical, surgical, and COVID-19
intensive care units (ICUs). The sample group consisted of 231 patients
hospitalized in medical and surgical ICUs and agreed to participate in the
study. The data analysis was performed with IBM SPSS Statistics 25. The average
age of the patients was 53.67 ± 13.3, 55.4% were male, 47.6% were high school
graduates, and 45.5% were followed up in the COVID-19 ICU. It was also found
that there was a negative and moderate degree of correlation between the
Intensive Care Experience Scale (ICES) and the Intensive Care Unit Environmental
Stressors Scale (ICUESS). Environmental stressors in ICUs are associated with
patient experiences. It is clear that ICU stressors create a negative perception
in the patient and this situation is emotionally exhausting.
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Affiliation(s)
- Semra Bulbuloglu
- Surgical Nursing Division, Nursing Department, Faculty of Health Sciences, Istanbul Aydin University, Istanbul, Turkey
| | - Fadime Çınar
- Surgical Nursing Division, Nursing Department, Health Sciences High School, Istanbul Nisantasi University, Istanbul, Turkey
| | - Gülsüm Nihal Çürük
- Internal Medicine Nursing Division, Nursing Department, Health Sciences Faculty, Izmir Ekonomi University, Izmir, Turkey
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Campos B, Vinder V, Passos RBF, Coutinho ESF, Vieira NCP, Leal KB, Mendlowicz MV, Figueira I, Luz MP, Marques-Portela C, Vilete LMP, Berger W. To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis. J Psychopharmacol 2022; 36:449-459. [PMID: 35437077 DOI: 10.1177/02698811221080464] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD). METHODS We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170). RESULTS The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I2 = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79). CONCLUSION The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.
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Affiliation(s)
- Bruna Campos
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Vitor Vinder
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | - Evandro Silva Freire Coutinho
- National School of Public Health, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil.,Institute of Social Medicine, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Norma Cavalcanti Pontilhão Vieira
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Katherine Branco Leal
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Mauro Vitor Mendlowicz
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.,Department of Psychiatry and Mental Health, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Ivan Figueira
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Mariana Pires Luz
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Carla Marques-Portela
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Liliane Maria Pereira Vilete
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - William Berger
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Bertolini F, Robertson L, Bisson JI, Meader N, Churchill R, Ostuzzi G, Stein DJ, Williams T, Barbui C. Early pharmacological interventions for universal prevention of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2022; 2:CD013443. [PMID: 35141873 PMCID: PMC8829470 DOI: 10.1002/14651858.cd013443.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a severe and debilitating condition. Several pharmacological interventions have been proposed with the aim to prevent or mitigate it. These interventions should balance efficacy and tolerability, given that not all individuals exposed to a traumatic event will develop PTSD. There are different possible approaches to preventing PTSD; universal prevention is aimed at individuals at risk of developing PTSD on the basis of having been exposed to a traumatic event, irrespective of whether they are showing signs of psychological difficulties. OBJECTIVES To assess the efficacy and acceptability of pharmacological interventions for universal prevention of PTSD in adults exposed to a traumatic event. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trial Register (CCMDCTR), CENTRAL, MEDLINE, Embase, two other databases and two trials registers (November 2020). We checked the reference lists of all included studies and relevant systematic reviews. The search was last updated on 13 November 2020. SELECTION CRITERIA We included randomised clinical trials on adults exposed to any kind of traumatic event. We considered comparisons of any medication with placebo or with another medication. We excluded trials that investigated medications as an augmentation to psychotherapy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. In a random-effects model, we analysed dichotomous data as risk ratios (RR) and number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH). We analysed continuous data as mean differences (MD) or standardised mean differences (SMD). MAIN RESULTS We included 13 studies which considered eight interventions (hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare enteral formula, Oxepa enteral formula and 5-hydroxytryptophan) and involved 2023 participants, with a single trial contributing 1244 participants. Eight studies enrolled participants from emergency departments or trauma centres or similar settings. Participants were exposed to a range of both intentional and unintentional traumatic events. Five studies considered participants in the context of intensive care units with traumatic events consisting of severe physical illness. Our concerns about risk of bias in the included studies were mostly due to high attrition and possible selective reporting. We could meta-analyse data for two comparisons: hydrocortisone versus placebo, but limited to secondary outcomes; and propranolol versus placebo. No study compared hydrocortisone to placebo at the primary endpoint of three months after the traumatic event. The evidence on whether propranolol was more effective in reducing the severity of PTSD symptoms compared to placebo at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, serious inconsistency amongst the studies' results, and very serious imprecision of the estimate of effect (SMD -0.51, 95% confidence interval (CI) -1.61 to 0.59; I2 = 83%; 3 studies, 86 participants; very low-certainty evidence). No study provided data on dropout rates due to side effects at three months post-traumatic event. The evidence on whether propranolol was more effective than placebo in reducing the probability of experiencing PTSD at three months after the traumatic event is inconclusive, because of serious risk of bias amongst the included studies, and very serious imprecision of the estimate of effect (RR 0.77, 95% CI 0.31 to 1.92; 3 studies, 88 participants; very low-certainty evidence). No study assessed functional disability or quality of life. Only one study compared gabapentin to placebo at the primary endpoint of three months after the traumatic event, with inconclusive evidence in terms of both PTSD severity and probability of experiencing PTSD, because of imprecision of the effect estimate, serious risk of bias and serious imprecision (very low-certainty evidence). We found no data on dropout rates due to side effects, functional disability or quality of life. For the remaining comparisons, the available data are inconclusive or missing in terms of PTSD severity reduction and dropout rates due to adverse events. No study assessed functional disability. AUTHORS' CONCLUSIONS This review provides uncertain evidence only regarding the use of hydrocortisone, propranolol, dexamethasone, omega-3 fatty acids, gabapentin, paroxetine, PulmoCare formula, Oxepa formula, or 5-hydroxytryptophan as universal PTSD prevention strategies. Future research might benefit from larger samples, better reporting of side effects and inclusion of quality of life and functioning measures.
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Affiliation(s)
- Federico Bertolini
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Nicholas Meader
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Dan J Stein
- Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- MRC Unit on Risk & Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa
| | - Taryn Williams
- Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
- Cochrane Global Mental Health, University of Verona, Verona, Italy
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Nedergaard HK, Korkmaz S, Olsen HT, Jensen HI, Strøm T, Toft P. Failure of non-sedation strategy in critically ill, mechanically ventilated patients - a retrospective, post-hoc analysis of the NONSEDA trial. J Crit Care 2021; 68:66-71. [PMID: 34922314 DOI: 10.1016/j.jcrc.2021.12.001] [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] [Received: 06/24/2021] [Revised: 08/25/2021] [Accepted: 12/01/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE There is a growing awareness on minimizing sedation in ICUs. In the NONSEDA trial 700 critically ill patients were randomized to light sedation or non-sedation during mechanical ventilation. Approximately 40% of patients randomized to non-sedation needed sedation. The aim of this study is to obtain knowledge on patients, who experienced failure of non-sedation. MATERIALS AND METHODS This study is a retrospective post-hoc analysis of the NONSEDA trial. Patients, who were randomized to non-sedation are sub-divided into those who did not require sedation during mechanical ventilation ("non-sedation success"), and those who needed continuous sedation at least once ("non-sedation failure"). RESULTS 348 patients were randomized to non-sedation, 199 experienced non-sedation success, whereas 149 experienced non-sedation failure. Patients in the two groups were comparable with regards to age, BMI, disease severity scores and admission diagnoses. Patients with non-sedation failure were more often male. Propofol was mainly used as rescue sedation. Patients with non-sedation failure had less days alive without sedation, coma, delirium, organ support, mechanical ventilation, ICU- and hospital admission. Mortality and long-term outcomes did not differ between groups. CONCLUSION Patients with non-sedation success had better in-hospital outcomes, but mortality and long-term outcomes were not affected by success or failure of non-sedation.
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Affiliation(s)
- Helene Korvenius Nedergaard
- Department of Anesthesiology and Intensive care, University Hospital of Southern Denmark, Kolding. Sygehusvej 24, DK-6000 Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Winsløwsparken 19, 3., DK-5000 Odense C, Denmark.
| | - Serkan Korkmaz
- Department of Business and Economics, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark
| | - Hanne Tanghus Olsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløwsvej 4, DK-5000 Odense C, Denmark.
| | - Hanne Irene Jensen
- Department of Anesthesiology and Intensive care, University Hospital of Southern Denmark, Kolding. Sygehusvej 24, DK-6000 Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Winsløwsparken 19, 3., DK-5000 Odense C, Denmark.
| | - Thomas Strøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløwsvej 4, DK-5000 Odense C, Denmark; Department of Anesthesiology and Intensive Care, Hospital of Southern Denmark, Kresten Philipsens vej 15, DK-6200 Aabenraa, Denmark.
| | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløwsvej 4, DK-5000 Odense C, Denmark.
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System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas. Crit Care Explor 2021; 3:e0403. [PMID: 33912833 PMCID: PMC8078413 DOI: 10.1097/cce.0000000000000403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback. Methods: Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders. Results: The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas’ involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting. Conclusions: Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.
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