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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [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: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Hume NE, Zerfas I, Wong A, Klein-Fedyshin M, Smithburger PL, Buckley MS, Devlin JW, Kane-Gill SL. Clinical Impact of the Implementation Strategies Used to Apply the 2013 Pain, Agitation/Sedation, Delirium or 2018 Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption Guideline Recommendations: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:626-636. [PMID: 38193764 PMCID: PMC10939834 DOI: 10.1097/ccm.0000000000006178] [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: 01/10/2024]
Abstract
OBJECTIVES To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines. DATA SOURCES PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268). STUDY SELECTION Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS). DATA EXTRACTION Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. DATA SYNTHESIS Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS. CONCLUSIONS Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations.
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Affiliation(s)
- Nicole E Hume
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY
| | - Isabelle Zerfas
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI
| | - Adrian Wong
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Pamela L Smithburger
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
- Department of Pharmacy and Therapeutics, UPMC, Pittsburgh, PA
| | - Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, AZ
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Pharmacy and Therapeutics, School of Pharmacy, Northeastern University, Boston, MA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
- Department of Pharmacy and Therapeutics, UPMC, Pittsburgh, PA
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Adams AMN, Chamberlain D, Grønkjær M, Thorup CB, Conroy T. Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review. Aust Crit Care 2021; 35:454-465. [PMID: 34373173 DOI: 10.1016/j.aucc.2021.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 05/16/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role. OBJECTIVES The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU. METHODS A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715. RESULTS Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues. CONCLUSIONS This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.
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Affiliation(s)
- Anne Mette N Adams
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia.
| | - Diane Chamberlain
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
| | - Mette Grønkjær
- Alborg University Hospital & Department of Clinical Medicine, Aalborg University, Denmark
| | - Charlotte Brun Thorup
- Department of Intensive Care and Clinical Nursing Research Unit, Aalborg University Hospital, Denmark
| | - Tiffany Conroy
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, 5042 SA, GPO Box 2100, Adelaide 5001, SA, Australia
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[Study protocol to improve the quality of delirium management in intensive care]. Med Klin Intensivmed Notfmed 2020; 115:428-436. [PMID: 32248245 DOI: 10.1007/s00063-020-00676-1] [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: 07/20/2019] [Revised: 12/31/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far. HYPOTHESIS In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration. METHODS Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients. INCLUSION CRITERIA (a) ≥18 years, (b) consent for research with their data. EXCLUSION CRITERIA (a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics. OBJECTIVES The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.
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Bilotta F, Weiss B, Neuner B, Kramer S, Aldecoa C, Bettelli G, Sanders RD, Delp SM, Spies CD. Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists. Acta Anaesthesiol Scand 2020; 64:494-500. [PMID: 31883373 DOI: 10.1111/aas.13535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology Critical Care and Pain Medicine, "Sapienza" University of Rome Rome Italy
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sylvia Kramer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - César Aldecoa
- Department of Anaesthesiology & Intensive Care Hospital Universitario Rio Hortega Valladolid Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery Italian National Research Centres on Aging/IRCCS Ancona Italy
- Department of Anaesthesia, Analgesia and Intensive Care Italian National Research Centres on Aging/IRCCS Ancona Italy
| | | | - Simon M. Delp
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Barbateskovic M, Krauss SR, Collet MO, Andersen‐Ranberg NC, Mathiesen O, Jakobsen JC, Perner A, Wetterslev J. Haloperidol for the treatment of delirium in critically ill patients: A systematic review with meta-analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2020; 64:254-266. [PMID: 31663112 DOI: 10.1111/aas.13501] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Haloperidol is the most frequently used drug to treat delirium in the critically ill patients. Yet, no systematic review has focussed on the effects of haloperidol in critically ill patients with delirium. METHODS We conducted a systematic review with meta-analysis and Trial Sequential Analysis of randomized clinical trials (RCTs) assessing the effects of haloperidol vs any intervention on all-cause mortality, serious adverse reactions/events, days alive without delirium, health-related quality of life (HRQoL), cognitive function and delirium severity in critically ill patients with delirium. We also report on QTc prolongation, delirium resolution and extrapyramidal symptoms. RESULTS We included 8 RCTs with 11 comparisons (n = 951). We adjudicated one trial as having overall low risk of bias. Three trials used rescue haloperidol; excluding these, we did not find an effect of haloperidol vs control on all-cause mortality (RR 1.01; 95% CI 0.33-3.06; I2 = 0%; 112 participants; 3 trials; 4 comparisons; very low certainty) or delirium severity (SMD -0.15; 95% CI -0.61-0.30; I2 = 27%; 134 participants; 3 trials; 4 comparisons; very low certainty). No trials reported adequately on serious adverse reactions/events. Only one trial reported on days alive without delirium, cognitive function and QTc prolongation, and no trials reported on HRQoL. Sensitivity analyses, including trials using rescue haloperidol, did not change the results. CONCLUSIONS The evidence for the use of haloperidol to treat critically ill patients with delirium is sparse, of low quality and inconclusive. We therefore have no certainty regarding any beneficial, harmful or neutral effects of haloperidol in these patients.
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Sara R. Krauss
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
| | - Marie O. Collet
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Nina C. Andersen‐Ranberg
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Centre for Anaesthesiological Research Department of Anaesthesiology and Intensive Care Zealand University Hospital Koege Denmark
| | - Ole Mathiesen
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Centre for Anaesthesiological Research Department of Anaesthesiology and Intensive Care Zealand University Hospital Koege Denmark
- Department of Clinical Medicine Faculty of Health and Medical Sciences Copenhagen University Copenhagen Denmark
| | - Janus C. Jakobsen
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Cardiology Holbaek Hospital Holbaek Denmark
- Department of Regional Health Research The Faculty of Heath Sciences University of Southern Denmark Odense Denmark
| | - Anders Perner
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
- Department of Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit Centre for Clinical Intervention Research Copenhagen Denmark
- Centre for Research in Intensive Care Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
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Hermes C, Acevedo-Nuevo M, Berry A, Kjellgren T, Negro A, Massarotto P. Gaps in pain, agitation and delirium management in intensive care: Outputs from a nurse workshop. Intensive Crit Care Nurs 2018; 48:52-60. [DOI: 10.1016/j.iccn.2018.01.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 01/16/2018] [Accepted: 01/28/2018] [Indexed: 11/27/2022]
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Louis C, Godet T, Chanques G, Bourguignon N, Morand D, Pereira B, Constantin JM. Effects of dexmedetomidine on delirium duration of non-intubated ICU patients (4D trial): study protocol for a randomized trial. Trials 2018; 19:307. [PMID: 29866205 PMCID: PMC5987410 DOI: 10.1186/s13063-018-2656-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/28/2018] [Indexed: 11/12/2022] Open
Abstract
Background Delirium during intensive care unit (ICU) stay is frequent and associated with significant morbidity, mortality and healthcare-related costs. International guidelines suggest its prevention. However, curative treatment remains unclearly established. Despite contradictory and ambiguous academic literature, international guidelines suggest the use of second-generation (atypical) antipsychotics over haloperidol. However, haloperidol remains the most widely used neuroleptic worldwide as a first-line treatment of agitation and/or delirium. Dexmedetomidine, an alpha2-adrenergic receptors agonist, has shown its efficiency in the treatment of delirium in intubated patients but also in its prevention. Dexmedetomidine represents a widely used alternative to haloperidol. Only few studies have compared the efficacy of dexmedetomidine in non-intubated ICU patients as a first-line curative treatment of delirium. The main objective of the 4D trial is to demonstrate that dexmedetomidine decreases delirium duration compared to placebo. Methods/design The 4D trial is an investigator-initiated, prospective, multicenter, randomized, double-blinded, two-arm trial, randomizing 300 non-intubated ICU patients with a diagnosis of agitated delirium to receive dexmedetomidine or placebo as a cure. In case of agitation (RASS≥ + 2), immediate haloperidol administration will be allowed, to protect patient and staff in charge, while waiting for study treatment action. The primary outcome measure is a composite of duration of agitation or delirium or the use of intubation with deep sedation and mechanical ventilation. Secondary outcomes include mortalities at 7 and 30 days, ICU length of stay and occurrence of adverse effects related to dexmedetomidine use (bradycardia or hypotension requesting any treatment; or haloperidol use (neuroleptic malignant syndrome, extrapyramidal syndrome, prolonged QTc). The sample size will allow the detection of a 50% decrease of agitation duration (120 min), of an absolute reduction of delirium duration (1 day) and of a 50% relative decrease of intubation and mechanical ventilation, with a type 1 error rate of 1.8% (error risk inflation due to components of composite) and power of 90%, assuming a 15% incidence of intubation and mechanical ventilation requirements, an agitation duration of 240 min and a delirium duration of 3 days. One hundred and ten patients by group will be needed. An intermediate analysis is scheduled and requires the inclusion of 150 patients. Discussion The 4D trial may provide important data on the safety of commonly used sedative dexmedetomidine and could have a significant impact on future treatment of non-intubated ICU patients presenting with agitated delirium. Trial registration ClinicalTrials.gov, ID: NCT 03317067. Registered on 23 October 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2656-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clémence Louis
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - Thomas Godet
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63003, Clermont-Ferrand, France. .,GReD; UMR/CNRS6293; Université Clermont-Auvergne; INSERM U1103, 63003, Clermont-Ferrand, France. .,Département de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, 63003, Clermont-Ferrand, France.
| | - Gérald Chanques
- Département d'Anesthésie-Réanimation B, Hôpital Saint-Eloi, Centre Hospitalier Universitaire (CHU) Montpellier, 34090, Montpellier, France
| | - Nathalie Bourguignon
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - Dominique Morand
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - Bruno Pereira
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Délégation à la Recherche Clinique et à l'Innovation (DRCI), 63000, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Département de Médecine Périopératoire (MPO), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63003, Clermont-Ferrand, France.,GReD; UMR/CNRS6293; Université Clermont-Auvergne; INSERM U1103, 63003, Clermont-Ferrand, France
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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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Nydahl P, Dewes M, Dubb R, Hermes C, Kaltwasser A, Krotsetis S, von Haken R. Survey among critical care nurses and physicians about delirium management. Nurs Crit Care 2017; 23:23-29. [DOI: 10.1111/nicc.12299] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Nydahl
- Department of Nursing Research; University Hospital of Schleswig-Holstein; Campus Kiel, Brunswiker Str. 10, Kiel Germany
| | - Michael Dewes
- Department of Critical Care; Centre Hospitalier Emile Mayrisch; Esch-sur-Alzette Luxembourg
| | - Rolf Dubb
- Nursing Education District Hospital of Reutlingen GmbH; Reutlingen Germany
| | | | - Arnold Kaltwasser
- Nursing Education; District Hospital of Reutlingen GmbH; Reutlingen Germany
| | - Susanne Krotsetis
- Department of Nursing Research; University Hospital of Schleswig-Holstein; Campus Lübeck Germany
| | - Rebecca von Haken
- Department of Anesthesia and Critical Care; University Hospital Heidelberg; Heidelberg Germany
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