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Karlsen MMW, Heyn LG, Heggdal K. Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation. Int J Qual Stud Health Well-being 2024; 19:2322174. [PMID: 38431874 PMCID: PMC10911109 DOI: 10.1080/17482631.2024.2322174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
PURPOSE Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness. METHODS The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care. RESULTS A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences. CONCLUSION The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.
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Affiliation(s)
| | - Lena Günterberg Heyn
- Department of postgraduate and master studies, University of South-Eastern Norway, Kongsberg, Norway
| | - Kristin Heggdal
- Faculty of Health Sciences, VID Specialized University, Oslo, Norway
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Sürmeli M, Boy Y, Pazarli AC. Postintensive care syndrome: Development and psychometric validation of a knowledge test. J Eval Clin Pract 2024; 30:1059-1065. [PMID: 38798159 DOI: 10.1111/jep.14019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Postintensive care syndrome (PICS) is a combination of short-, medium- and long-term morbidities that occur in patients discharged from the Intensive care unit (ICU). ICU professionals have a crucial role in managing and understanding the PICS. This study aimed to develop the PICS Knowledge Test (PICS-KT), which measures ICU professionals' awareness and knowledge levels regarding PICS, and to determine its validity and reliability. METHODS The databases were searched in detail, scientific research related to PICS was analyzed, and the draft scale was created accordingly. A total of 117 doctors and nurses who had been working in the ICU for at least 6 months were included in the study. For the validity and reliability analysis of the test, content validity ratio, item difficulty index, item discrimination index values and Cronbach α were examined. RESULTS The Cronbach's α reliability coefficient for the 46-item PICS-KT is 0.93, indicating high reliability. Scores range from 0 to 46, with 32 or higher considered successful, suggesting adequate knowledge of PICS among ICU professionals. Scores of 14 or less indicate minimal knowledge. Those with scores between 14 and 32 possess some knowledge but need improvement. PICS-KT assesses knowledge in four main areas: general information, risk factors/causes, symptoms and findings and interventions. ICU professionals show high awareness of interventions for preventing and treating PICS, as indicated by a high mean score in the interventions subdimension. CONCLUSION The PICS-KT is crucial in assessing healthcare professionals' understanding of the various short-, medium- and long-term morbidities associated with PICS. The study ensures that the test is a robust and dependable instrument for evaluating ICU professionals' knowledge about PICS.
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Affiliation(s)
- Mahmut Sürmeli
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - Yasemin Boy
- Department of Nursing, Faculty of Health Sciences, Tokat Gaziosmanpaşa University, Tokat, Turkey
| | - Ahmet Cemal Pazarli
- Department of Pulmonary Diseases, Faculty of Medicine, Tokat Gaziosmanpasa University, Tokat, Turkey
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Barker AK, Valley TS, Kenes MT, Sjoding MW. Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study. Chest 2024; 166:118-126. [PMID: 38218219 PMCID: PMC11317814 DOI: 10.1016/j.chest.2024.01.019] [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: 08/22/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION We found that among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.
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Affiliation(s)
- Anna K Barker
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
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Lorente L, Sabater-Riera J, Rello J. Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events. Expert Rev Anti Infect Ther 2024; 22:317-332. [PMID: 38642072 DOI: 10.1080/14787210.2024.2345877] [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: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Joan Sabater-Riera
- IDIBELL, Hospitalet de Llobregat, Spain, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Rello
- CRIPS (Clinical Research in Pneumonia & Sepsis); Vall d'Hebron Institute of Research, Barcelona, Spain
- Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Ceric A, Holgersson J, May TL, Skrifvars MB, Hästbacka J, Saxena M, Aneman A, Delaney A, Reade MC, Delcourt C, Jakobsen JC, Nielsen N. Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis. EClinicalMedicine 2024; 71:102569. [PMID: 38572080 PMCID: PMC10990717 DOI: 10.1016/j.eclinm.2024.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/05/2024] Open
Abstract
Background Sedation is routinely administered to critically ill patients to alleviate anxiety, discomfort, and patient-ventilator asynchrony. However, it must be balanced against risks such as delirium and prolonged intensive care stays. This study aimed to investigate the effects of different levels of sedation in critically ill adults. Methods Systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials including critically ill adults admitted to the intensive care unit. CENTRAL, MEDLINE, Embase, LILACS, and Web of Science were searched from their inception to 13 June 2023. Risks of bias were assessed using the Cochrane risk of bias tool. Primary outcome was all-cause mortality. Aggregate data were synthesised with meta-analyses and TSA, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO: CRD42023386960. Findings Fifteen trials randomising 4352 patients were included, of which 13 were assessed high risk of bias. Meta-analyses comparing lighter to deeper sedation showed no evidence of a difference in all-cause mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.83-1.06; p = 0.28; 15 trials; moderate certainty evidence), serious adverse events (RR 0.99, CI 0.92-1.06; p = 0.80; 15 trials; moderate certainty evidence), or delirium (RR 1.01, 95% CI 0.94-1.09; p = 0.78; 11 trials; moderate certainty evidence). TSA showed that when assessing mortality, a relative risk reduction of 16% or more between the compared interventions could be rejected. Interpretation The level of sedation has not been shown to affect the risks of death, delirium, and other serious adverse events in critically ill adult patients. While TSA suggests that additional trials are unlikely to significantly change the conclusion of the meta-analyses, the certainty of evidence was moderate. This suggests a need for future high-quality studies with higher methodological rigor. Funding None.
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Affiliation(s)
- Ameldina Ceric
- Anesthesia & Intensive Care, Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Johan Holgersson
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
| | - Teresa L. May
- Maine Medical Center, Department of Critical Care, Portland, Maine, USA
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Manoj Saxena
- Division of Critical Care, George Institute for Global Health, Australia
- St. George Hospital, South Eastern Sydney Local Health District, Sydney, Australia
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, South Western Sydney Clinical School, University of New South Wales, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Michael C. Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit – Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
| | - Niklas Nielsen
- Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden
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Heily M, Gerdtz M, Jarden RJ, Yap CY, Darvall J, Coventry AE, Rogers A, Vernon J, Bellomo R. Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units. Aust Crit Care 2024; 37:67-73. [PMID: 37919133 DOI: 10.1016/j.aucc.2023.09.003] [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: 06/16/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Anaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described. OBJECTIVES The objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU). METHODS A prospective, observational pilot study was implemented. Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia. The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed. Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2. RESULTS Fifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05). CONCLUSIONS In patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.
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Affiliation(s)
- Meredith Heily
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia; Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Marie Gerdtz
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Rebecca J Jarden
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia; Austin Health, Melbourne, Australia.
| | - Celene Yl Yap
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Jai Darvall
- Intensive Care Unit & Department of Anaesthetics, The Royal Melbourne Hospital, Grattan St, Parkville, 3050, Australia; Department of Critical Care, Faculty of Medicine, Dentistry & Health Sciences, The University of Melbourne, Grattan St, Parkville, 3010, Australia.
| | - Andrew Ej Coventry
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Amy Rogers
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Julie Vernon
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Rinaldo Bellomo
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia; Department of Critical Care, Faculty of Medicine, Dentistry & Health Sciences, The University of Melbourne, Grattan St, Parkville, 3010, Australia; Intensive Care Unit, Austin Health, Australia.
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7
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Walsh TS, Aitken LM, McKenzie CA, Boyd J, Macdonald A, Giddings A, Hope D, Norrie J, Weir C, Parker RA, Lone NI, Emerson L, Kydonaki K, Creagh-Brown B, Morris S, McAuley DF, Dark P, Wise MP, Gordon AC, Perkins G, Reade M, Blackwood B, MacLullich A, Glen R, Page VJ. Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B Trial): protocol for a multicentre phase 3 pragmatic clinical and cost-effectiveness randomised trial in the UK. BMJ Open 2023; 13:e078645. [PMID: 38072483 PMCID: PMC10729141 DOI: 10.1136/bmjopen-2023-078645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care. METHODS AND ANALYSIS Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of -2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40-50 UK ICUs. ETHICS AND DISSEMINATION The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03653832.
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Affiliation(s)
- Timothy Simon Walsh
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Julia Boyd
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Alix Macdonald
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Annabel Giddings
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No. 9, Bioquarter, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Nazir I Lone
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Benedict Creagh-Brown
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Stephen Morris
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | | | - Paul Dark
- Intensive Care Unit, University of Manchester, Greater Manchester, UK
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick, Birmingham, UK
| | - Michael Reade
- University of Queensland, Brisbane, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | | | - Valerie J Page
- Intensive Care, West Hertfordshire Hospitals NHS Trust, Watford, UK
- Faculty of Medicine, Imperial College London, London, UK
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Favre E, Bernini A, Miroz JP, Abed-Maillard S, Ramelet AS, Oddo M. Early processed electroencephalography for the monitoring of deeply sedated mechanically ventilated critically ill patients. Nurs Crit Care 2023. [PMID: 37997530 DOI: 10.1111/nicc.13009] [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: 08/04/2023] [Revised: 10/22/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Deep sedation may be indicated in the intensive care unit (ICU) for the management of acute organ failure, but leads to sedative-induced delirium. Whether processed electroencephalography (p-EEG) is useful in this setting is unclear. METHODS We conducted a single-centre observational study of non-neurological ICU patients sedated according to a standardized guideline of deep sedation (Richmond Agitation Sedation Scale [RASS] between -5 and -4) during the acute phase of respiratory and/or cardio-circulatory failure. The SedLine (Masimo Incorporated, Irvine, California) was used to monitor the Patient State Index (PSI) (ranging from 0 to 100, <25 = very deep sedation and >50 = light sedation to full awareness) during the first 72 h of care. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). RESULTS The median duration of PSI monitoring was 43 h. Patients spent 49% in median of the total PSI monitoring duration with a PSI <25. Patients with delirium (n = 41/97, 42%) spent a higher percentage of total monitored time with PSI <25 (median 67% [19-91] vs. 47% [12.2-78.9]) in non-delirious patients (p .047). After adjusting for the cumulative dose of analgesia and sedation, increased time spent with PSI <25 was associated with higher delirium (odds ratio 1.014; 95% CI 1.001-1.027, p = .036). CONCLUSIONS A clinical protocol of deep sedation targeted to RASS at the acute ICU phase may be associated with prolonged EEG suppression and increased delirium. Whether PSI-targeted sedation may help reducing sedative dose and delirium deserves further clinical investigation. RELEVANCE TO CLINICAL PRACTICE Patients requiring deep sedation are at high risk of being over-sedated and developing delirium despite the application of an evidence-based sedation guideline. Development of early objective measures are essential to improve sedation management in these critically ill patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
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Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Waydhas C, Deffner T, Gaschler R, Häske D, Hamsen U, Herbstreit F, Hierundar A, Kumpf O, Rohe G, Spiekermann A, Vonderhagen S, Waeschle RM, Riessen R. Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey. BMC Anesthesiol 2022; 22:384. [PMID: 36503427 PMCID: PMC9743767 DOI: 10.1186/s12871-022-01887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.
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Affiliation(s)
- Christian Waydhas
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany ,Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Teresa Deffner
- grid.275559.90000 0000 8517 6224Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Jena, Bachstrasse 18, 07743 Jena, Germany
| | - Robert Gaschler
- Fakultät Für Psychologie, Lehrgebiet Allgemeine Psychologie: Lernen, Motivation, Emotion, FernUniversität in Hagen, Universitätsstrasse 33, 58084 Hagen, Germany
| | - David Häske
- grid.411544.10000 0001 0196 8249Center for Public Health and Health Services Research, University Hospital Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Uwe Hamsen
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Frank Herbstreit
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Anke Hierundar
- grid.413108.f0000 0000 9737 0454Klinik Für Anästhesiologie Und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Kumpf
- grid.7468.d0000 0001 2248 7639Klinik Für Anästhesiologie Mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte Und Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Rohe
- grid.5560.60000 0001 1009 3608University Clinic for Anaesthesiology / Intensive Care Medicine / Emergency Medicine / Pain Medicine, Klinikum Oldenburg, Medical Campus of the University Oldenburg), Rahel Straus - Str. 10, 26133 Oldenburg, Germany
| | - Aileen Spiekermann
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Sonja Vonderhagen
- Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Reiner M. Waeschle
- grid.411984.10000 0001 0482 5331Klinik Für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099 Göttingen, Germany
| | - Reimer Riessen
- grid.411544.10000 0001 0196 8249Department Für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany
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Ceric A, Holgersson J, May T, Skrifvars MB, Hästbacka J, Saxena M, Aneman A, Delaney A, Reade MC, Delcourt C, Jakobsen J, Nielsen N. Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis. BMJ Open 2022; 12:e061806. [PMID: 36691212 PMCID: PMC9462111 DOI: 10.1136/bmjopen-2022-061806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/10/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients. METHODS AND ANALYSES We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation. ETHICS AND DISSEMINATION No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.
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Affiliation(s)
- Ameldina Ceric
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Johan Holgersson
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Teresa May
- Department of Critical Care, Maine Medical Center, Portland, Maine, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Manoj Saxena
- Senior Lecturer, Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anders Aneman
- Intensive Care Unit, South Western Sydney Local Health District, Liverpool Hospital, South Western Sydney Local Health District, South Western Sydney Clinical School, University of New South Wales, and Faculty of Medicine, Health and Human Sciences, Macquarie University, Liverpool, New South Wales, Australia
| | - Anthony Delaney
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Michael C Reade
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark, Denmark
| | - Candice Delcourt
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Janus Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark, Denmark
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Helsingborg Hospital, Helsingborg, Sweden
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Xie Q, Wang XL, Pei JH, Wu YP, Guo Q, Su YJ, Yan H, Nan RL, Chen HX, Dou XM. Machine Learning-Based Prediction Models for Delirium: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2022; 23:1655-1668.e6. [DOI: 10.1016/j.jamda.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/22/2022] [Accepted: 06/18/2022] [Indexed: 10/16/2022]
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13
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Gitti N, Renzi S, Marchesi M, Bertoni M, Lobo FA, Rasulo FA, Goffi A, Pozzi M, Piva S. Seeking the Light in Intensive Care Unit Sedation: The Optimal Sedation Strategy for Critically Ill Patients. Front Med (Lausanne) 2022; 9:901343. [PMID: 35814788 PMCID: PMC9265444 DOI: 10.3389/fmed.2022.901343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/20/2022] [Indexed: 12/12/2022] Open
Abstract
The clinical approach to sedation in critically ill patients has changed dramatically over the last two decades, moving to a regimen of light or non-sedation associated with adequate analgesia to guarantee the patient’s comfort, active interaction with the environment and family, and early mobilization and assessment of delirium. Although deep sedation (DS) may still be necessary for certain clinical scenarios, it should be limited to strict indications, such as mechanically ventilated patients with Acute Respiratory Distress Syndrome (ARDS), status epilepticus, intracranial hypertension, or those requiring target temperature management. DS, if not indicated, is associated with prolonged duration of mechanical ventilation and ICU stay, and increased mortality. Therefore, continuous monitoring of the level of sedation, especially when associated with the raw EEG data, is important to avoid unnecessary oversedation and to convert a DS strategy to light sedation as soon as possible. The approach to the management of critically ill patients is multidimensional, so targeted sedation should be considered in the context of the ABCDEF bundle, a holistic patient approach. Sedation may interfere with early mobilization and family engagement and may have an impact on delirium assessment and risk. If adequately applied, the ABCDEF bundle allows for a patient-centered, multidimensional, and multi-professional ICU care model to be achieved, with a positive impact on appropriate sedation and patient comfort, along with other important determinants of long-term patient outcomes.
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Affiliation(s)
- Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Stefania Renzi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Marchesi
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Francisco A. Lobo
- Institute of Anesthesiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Frank A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Science and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- *Correspondence: Simone Piva,
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14
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Devlin JW, Seth B, Train S, Needham DM. Maintaining light sedation is important: next steps for research. Thorax 2021; 76:1069-1070. [PMID: 34272337 DOI: 10.1136/thoraxjnl-2021-217337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Affiliation(s)
- John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA .,School of Pharmacy, Northeastern University, Boston, Massachusetts, USA
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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