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Yang X, Hu JH, Fan LP, Peng HP, Shi HJ, Zhuang MY, Ji FH, Peng K. Intraoperative dexmedetomidine on postoperative sleep disturbance in older patients undergoing major abdominal surgery: A randomized controlled trial protocol. Heliyon 2024; 10:e31668. [PMID: 38845907 PMCID: PMC11153091 DOI: 10.1016/j.heliyon.2024.e31668] [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: 04/06/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/09/2024] Open
Abstract
Background Postoperative sleep disturbance (PSD) occurs frequently in patients who undergo major abdominal surgical procedures. Dexmedetomidine is a promising agent to improve the quality of sleep for surgical patients. We designed this trial to investigate the effects of two different doses of intraoperative dexmedetomidine on the occurrence of PSD in elderly patients who have major abdominal surgery. Methods In this randomized, double-blind, controlled trial, 210 elderly patients aged ≥65 years will be randomized, with an allocation ratio of 1:1:1, to two dexmedetomidine groups (intraoperative infusion of 0.3 or 0.6 μg/kg/h) and a normal saline placebo group. The primary endpoint is the occurrence of PSD on the first night after surgery, assessed using the Athens Insomnia Scale. The secondary endpoints are (1) the incidence of PSD during the 2nd, 3rd, 5th, 7th, and 30th nights postoperatively; (2) pain at rest and on movement at 24 and 48 h postoperatively, assessed using the Numerical Rating Scale; (3) the incidence of postoperative delirium during 0-7 days postoperatively or until hospital discharge, assessed using the 3-min Confusion Assessment Method; (4) depressive symptoms during 0-7 days postoperatively or until hospital discharge, assessed using the 15-items Geriatric Depression Scale; and (5) quality of recovery on postoperative days 1, 2, and 3, assessed using the 15-items Quality of Recovery Scale. Patients' sleep data will also be collected by Xiaomi Mi Band 7 for further analysis. Discussion The findings of this trial will provide clinical evidence for improving the quality of sleep among elderly patients undergoing major abdominal surgery. Ethics and dissemination This trial was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (No. 2023-160). The results will be published in a peer-reviewed journal. Trial registration Chinese Clinical Trial Registry (ChiCTR2300073163).
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Affiliation(s)
- Xiu Yang
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-hui Hu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Li-ping Fan
- Jintan Traditional Chinese Medicine Hospital, Changzhou, Jiangsu, China
| | - Hui-ping Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hai-jing Shi
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Min-yuan Zhuang
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
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Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, Chokengarmwong N. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024; 28:467-474. [PMID: 38738208 PMCID: PMC11080087 DOI: 10.5005/jp-journals-10071-24710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Aims and background The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery. Materials and methods This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay. Results 108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups. Conclusion This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate. How to cite this article Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.
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Affiliation(s)
- Gamonmas Ekkapat
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nonthikorn Theerasuwipakorn
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jirapat Kittipongpattana
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Phatthanaphol Engsusophon
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Nephrology and Clinical Epidemiology, Department of Medicine, and Center of Excellence for Metabolic Bone Disease in CKD patients, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Nalin Chokengarmwong
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Tronstad O, Patterson S, Zangerl B, Flaws D, Holdsworth R, Irvine L, Yerkovich S, Pearse I, Fraser JF. The introduction of a sound reduction bundle in the intensive care unit and its impact on sound levels and patients. Aust Crit Care 2024:S1036-7314(24)00053-5. [PMID: 38604917 DOI: 10.1016/j.aucc.2024.02.011] [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: 09/03/2023] [Revised: 02/18/2024] [Accepted: 02/18/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND ICU outcomes are continuing to improve. However, this has not been matched by similar improvements of the ICU bedspace environment, which can detrimentally impact on patient outcomes. Excessive sound and noise, especially, has been linked with adverse and potentially preventable patient outcomes and staff errors. There are many sources of sound in the ICU, with alarms from bedside equipment frequently listed as a main source. The number of alarms is increasing in parallel with the introduction of new and more sophisticated technologies to monitor and support patients. However, most alarms are not accurate or critical and are commonly ignored by staff. OBJECTIVE The objective of this study was to evaluate the impact of a sound reduction bundle on sound levels, number of alarms, and patients' experience and perceived quality of sleep in the ICU. METHODS This was a pre-post, quasi-experimental study investigating the impact of three study interventions implemented sequentially (staff education, visual warnings when sound levels exceeded the preset levels, and monitor alarm reconfigurations). Effects of staff education were evaluated using pre-education and post-education questionnaires, and the impact on patients was evaluated via self-report questionnaires. A sound-level monitor was used to evaluate changes in sound levels between interventions. Alarm audits were completed before and after alarm reconfiguration. RESULTS Staff knowledge improved; however, sound levels did not change across interventions. The number of monthly monitor alarms reduced from 600,452 to 115,927. No significant differences were found in patients' subjective rating of their experience and sleep. CONCLUSION The interventions did not lead to a sound-level reduction; however, there was a large reduction in ICU monitor alarms without any alarm-related adverse events. As the sources of sound are diverse, multidimensional interventions, including staff education, alarm management solutions, and environmental redesign, are likely to be required to achieve a relevant, lasting, and significant sound reduction.
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - Sue Patterson
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; School of Dentistry, University of Queensland, Brisbane, Australia
| | - Barbara Zangerl
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Department of Mental Health, Metro North Mental Health, Caboolture Hospital, Caboolture, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Robert Holdsworth
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Lacey Irvine
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Stephanie Yerkovich
- Menzies School of Health Research and Faculty of Health, Qld University of Technology, Brisbane, Australia
| | - India Pearse
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; Intensive Care Unit, St. Andrews War Memorial Hospital, Brisbane, Australia
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van der Hoeven AE, Bijlenga D, van der Hoeven E, Schinkelshoek MS, Hiemstra FW, Kervezee L, van Westerloo DJ, Fronczek R, Lammers GJ. Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality. Intensive Crit Care Nurs 2024; 81:103603. [PMID: 38171236 DOI: 10.1016/j.iccn.2023.103603] [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: 07/10/2023] [Revised: 11/25/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024]
Abstract
AIM OF THE STUDY The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated. MATERIALS AND METHODS This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression. RESULTS Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070). CONCLUSIONS Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset. IMPLICATIONS FOR CLINICAL PRACTICE Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.
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Affiliation(s)
- Adrienne E van der Hoeven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Ernst van der Hoeven
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Mink S Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Floor W Hiemstra
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands; Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laura Kervezee
- Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands.
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Jonescu EE, Farrel B, Ramanayaka CE, White C, Costanzo G, Delaney L, Hahn R, Ferrier J, Litton E. Mitigating Intensive Care Unit Noise: Design-Led Modeling Solutions, Calculated Acoustic Outcomes, and Cost Implications. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2024:19375867241237501. [PMID: 38512990 DOI: 10.1177/19375867241237501] [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: 03/23/2024]
Abstract
OBJECTIVES, PURPOSE, OR AIM The study aimed to decrease noise levels in the ICU, anticipated to have adverse effects on both patients and staff, by implementing enhancements in acoustic design. BACKGROUND Recognizing ICU noise as a significant disruptor of sleep and a potential hindrance to patient recovery, this study was conducted at a 40-bed ICU in Fiona Stanley Hospital in Perth, Australia. METHODS A comprehensive mixed-methods approach was employed, encompassing surveys, site analysis, and acoustic measurements. Survey data highlighted the importance of patient sleep quality, emphasizing the negative impact of noise on work performance, patient connection, and job satisfaction. Room acoustics analysis revealed noise levels ranging from 60 to 90 dB(A) in the presence of patients, surpassing sleep disruption criteria. RESULTS Utilizing an iterative 3D design modeling process, the study simulated significant acoustic treatment upgrades. The design integrated effective acoustic treatments within patient rooms, aiming to reduce noise levels and minimize transmission to adjacent areas. Rigorous evaluation using industry-standard acoustic software highlights the design's efficacy in reducing noise transmission in particular. Additionally, cost implications were examined, comparing standard ICU construction with acoustically treated options for new construction and refurbishment projects. CONCLUSIONS This study provides valuable insights into design-based solutions for addressing noise-related challenges in the ICU. While the focus is on improving the acoustic environment by reducing noise levels and minimizing transmission to adjacent areas. It is important to clarify that direct measurements of patient outcomes were not conducted. The potential impact of these solutions on health outcomes, particularly sleep quality, remains a crucial aspect for consideration.
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Affiliation(s)
- Emil E Jonescu
- Hames Sharley, Perth, Western Australia, Australia
- School of Arts and Humanities, Edith Cowan University, Perth, Western Australia, Australia
| | - Benjamin Farrel
- Gabriels Hearn Farrell Pty Ltd, South Perth, Western Australia, Australia
| | - Chamil Erik Ramanayaka
- Central Queensland University, School of Engineering and Technology, Brisbane, Queensland, Australia
| | | | | | - Lori Delaney
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Brisbane, Queensland, Australia
- College of Medicine and Health Sciences, Australian National University, Acton, Canberra, Australia
| | - Rebecca Hahn
- Heart and Lung Research Institute of WA, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Health and Medical Science, Surgery, University of Western Australia, Crawley, Western Australia, Australia
- Cardiothoracic and Transplant Surgery Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Janet Ferrier
- Intensive Care Unit, St. John of God Hospital, Subiaco, Western Australia, Australia
- ANZSCTS National Cardiac Surgery Data Base, St John of God Hospital, Perth Western Australia
| | - Edward Litton
- Intensive Care Unit, St. John of God Hospital, Subiaco, Western Australia, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- School of Medicine, University of Western Australia, Crawley, Western Australia, Australia
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van Twist E, Hiemstra FW, Cramer AB, Verbruggen SC, Tax DM, Joosten K, Louter M, Straver DC, de Hoog M, Kuiper JW, de Jonge RC. An electroencephalography-based sleep index and supervised machine learning as a suitable tool for automated sleep classification in children. J Clin Sleep Med 2024; 20:389-397. [PMID: 37869968 PMCID: PMC11019221 DOI: 10.5664/jcsm.10880] [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: 08/22/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Abstract
STUDY OBJECTIVES Although sleep is frequently disrupted in the pediatric intensive care unit, it is currently not possible to perform real-time sleep monitoring at the bedside. In this study, spectral band powers of electroencephalography data are used to derive a simple index for sleep classification. METHODS Retrospective study at Erasmus MC Sophia Children's Hospital, using hospital-based polysomnography recordings obtained in non-critically ill children between 2017 and 2021. Six age categories were defined: 6-12 months, 1-3 years, 3-5 years, 5-9 years, 9-13 years, and 13-18 years. Candidate index measures were derived by calculating spectral band powers in different frequent frequency bands of smoothed electroencephalography. With the best performing index, sleep classification models were developed for two, three, and four states via decision tree and five-fold nested cross-validation. Model performance was assessed across age categories and electroencephalography channels. RESULTS In total 90 patients with polysomnography were included, with a mean (standard deviation) recording length of 10.3 (1.1) hours. The best performance was obtained with the gamma to delta spectral power ratio of the F4-A1 and F3-A1 channels with smoothing. Balanced accuracy was 0.88, 0.74, and 0.57 for two-, three-, and four-state classification. Across age categories, balanced accuracy ranged between 0.83 and 0.92 and 0.72 and 0.77 for two- and three-state classification, respectively. CONCLUSIONS We propose an interpretable and generalizable sleep index derived from single-channel electroencephalography for automated sleep monitoring at the bedside in non-critically ill children ages 6 months to 18 years, with good performance for two- and three-state classification. CITATION van Twist E, Hiemstra FW, Cramer ABG, et al. An electroencephalography-based sleep index and supervised machine learning as a suitable tool for automated sleep classification in children. J Clin Sleep Med. 2024;20(3):389-397.
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Affiliation(s)
- Eris van Twist
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Floor W. Hiemstra
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Laboratory for Neurophysiology, Department of Cellular and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnout B.G. Cramer
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Sascha C.A.T. Verbruggen
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - David M.J. Tax
- Pattern Recognition Laboratory, Delft University of Technology, Delft, The Netherlands
| | - Koen Joosten
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Maartje Louter
- Division of Clinical Neurophysiology, Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | - Dirk C.G. Straver
- Division of Clinical Neurophysiology, Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Rogier C.J. de Jonge
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
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Niyogi SG, Naskar C, Singh A, Kumar B, Grover S. Melatonin and Melatonin Agonists for Prevention of Delirium in the Cardiac Surgical ICU: A Meta-analysis. Indian J Crit Care Med 2023; 27:837-844. [PMID: 37936806 PMCID: PMC10626232 DOI: 10.5005/jp-journals-10071-24571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Aim and Background Delirium is highly prevalent in the immediate postoperative period following cardiac surgery and adversely impacts outcomes. Melatonin has been increasingly used in pharmacological prevention of delirium. We aimed to synthesize the available evidence concerning the role of melatonin and melatonin agonists in preventing delirium in patients after cardiac surgery. Materials and methods PubMed, Google Scholar, and Web of Science databases were searched for relevant randomized and non-randomized trials in adults undergoing cardiac surgery investigating melatonin agonists to prevent delirium. Studies incorporating transplants, preoperative organ support, prophylactic antipsychotics, or children were excluded. Risk-of-bias was assessed using Cochrane ROB 2.0 and ROBINS-I tools. A systematic review and meta-analysis were conducted, calculating pooled odds ratio (OR) for the incidence of postoperative delirium using a random effects model with the Mantel-Haenszel method with restricted maximum-likelihood estimator. Trial sequential analysis was also carried out for the primary outcome. Results Six randomized trials and one non-randomized trial involving 1,179 patients were included. Incidence of delirium was 16.7 and 29.6% in the intervention and comparator groups respectively, indicating a pooled OR of 0.44 [95% confidence interval (CI) 0.27 - 0.71, p = 0.04] favoring melatonin. Two studies had a high risk of bias, and I2 statistics indicated significant heterogeneity. However, publication bias was insignificant, and trial sequential analysis indicated the significance of the attained effect size. Conclusion Based on available studies, perioperative melatonin use significantly decreases postoperative incidence of delirium after adult cardiac surgery. However, the available quality of evidence is low, and larger trials with standardization of nonpharmacological delirium prevention interventions, in high-risk cohorts, and exploring various dosages and regimens should be carried out. How to cite this article Niyogi SG, Naskar C, Singh A, Kumar B, Grover S. Melatonin and Melatonin Agonists for Prevention of Delirium in the Cardiac Surgical ICU: A Meta-analysis. Indian J Crit Care Med 2023;27(11):837-844.
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Affiliation(s)
- Subhrashis Guha Niyogi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chandrima Naskar
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avneet Singh
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Dulko E, Jedrusiak M, Osuru HP, Atluri N, Illendula M, Davis EM, Beenhakker MP, Lunardi N. Sleep Fragmentation, Electroencephalographic Slowing, and Circadian Disarray in a Mouse Model for Intensive Care Unit Delirium. Anesth Analg 2023; 137:209-220. [PMID: 37192134 DOI: 10.1213/ane.0000000000006524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND We aimed to further validate our previously published animal model for delirium by testing the hypothesis that in aged mice, Anesthesia, Surgery and simulated ICU conditions (ASI) induce sleep fragmentation, electroencephalographic (EEG) slowing, and circadian disarray consistent with intensive care unit (ICU) patients with delirium. METHODS A total of 41 mice were used. Mice were implanted with EEG electrodes and randomized to ASI or control groups. ASI mice received laparotomy, anesthesia, and simulated ICU conditions. Controls did not receive ASI. Sleep was recorded at the end of ICU conditions, and hippocampal tissue was collected on EEG recording. Arousals, EEG dynamics, and circadian gene expression were compared with t tests. Two-way repeated measures analysis of variance (RM ANOVA) was used to assess sleep according to light. RESULTS ASI mice experienced frequent arousals (36.6 ± 3.2 vs 26.5 ± 3.4; P = .044; 95% confidence interval [CI], 0.29-19.79; difference in mean ± SEM, 10.04 ± 4.62) and EEG slowing (frontal theta ratio, 0.223 ± 0.010 vs 0.272 ± 0.019; P = .026; 95% CI, -0.091 to -0.007; difference in mean ± SEM, -0.05 ± 0.02) relative to controls. In ASI mice with low theta ratio, EEG slowing was associated with a higher percentage of quiet wakefulness (38.2 ± 3.6 vs 13.4 ± 3.8; P = .0002; 95% CI, -35.87 to -13.84; difference in mean ± SEM, -24.86 ± 5.19). ASI mice slept longer during the dark phases of the circadian cycle (nonrapid eye movement [NREM], dark phase 1 [D1]: 138.9 ± 8.1 minutes vs 79.6 ± 9.6 minutes, P = .0003, 95% CI, -95.87 to -22.69, predicted mean difference ± SE: -59.28 ± 13.89; NREM, dark phase 2 (D2): 159.3 ± 7.3 minutes vs 112.6 ± 15.5 minutes, P = .006, 95% CI, -83.25 to -10.07, mean difference ± SE, -46.66 ± 13.89; rapid eye movement (REM), D1: 20.5 ± 2.1 minutes vs 5.8 ± 0.8 minutes, P = .001, 95% CI, -24.60 to -4.71, mean difference ± SE, -14. 65 ± 3.77; REM, D2: 21.0 ± 2.2 minutes vs 10.3 ± 1.4 minutes, P = .029, 95% CI, -20.64 to -0.76, mean difference ± SE, -10.70 ± 3.77). The expression of essential circadian genes was also lower in ASI mice (basic helix-loop-helix ARNT like [BMAL1] : -1.3 fold change; circadian locomotor output cycles protein kaput [CLOCK] : -1.2). CONCLUSIONS ASI mice experienced EEG and circadian changes mimicking those of delirious ICU patients. These findings support further exploration of this mouse approach to characterize the neurobiology of delirium.
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Affiliation(s)
| | | | | | | | | | | | - Mark P Beenhakker
- Pharmacology, University of Virginia Health, Charlottesville, Virginia
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Beaucage-Charron J, Rinfret J, Coveney R, Williamson D. Melatonin and Ramelteon for the treatment of delirium: A systematic review and meta-analysis. J Psychosom Res 2023; 170:111345. [PMID: 37150157 DOI: 10.1016/j.jpsychores.2023.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
OBJECTIVE To assess the efficacy of melatonin and melatonergic agonist for the treatment of delirium in hospitalized patients. METHODS Embase, MEDLINE, PsycINFO, PubMed, CENTRAL, Cochrane Database of Systematic Reviews, TRIP Medical Database, ClinicalTrials.gov and Google were searched from inception to October 2022. Randomized controlled trials (RCT) and observational studies with any type of comparator evaluating melatonin or melatonergic agonist (ramelteon) enrolling any populations (ICU, surgery, geriatric) were included. Two reviewers independently selected and extracted data using the Cochrane risk of bias tools (RoB2 and ROBINSI). RESULTS Out of the 650 screened publications, three RCTs and six observational studies were included (n = 1211). All three RCTs compared melatonin to placebo, as the majority of observational studies compared melatonin or ramelteon to antipsychotics. Two RCTs reported the duration of delirium and a meta-analysis provided a statistical difference between melatonin and placebo (-1.72 days, 95% CI -2.66 to -0.77, p = 0.0004). Five observational studies reported the duration of delirium but only one reported a statistical reduction in the duration of delirium. CONCLUSION Although melatonin and ramelteon may be effective treatments for delirium, particularly to shorten the duration of delirium and to limit the use of rescue medication, current data is limited in number and in its quality. Clinicians should wait until higher quality data from ongoing RCTs are available before prescribing melatonin to delirious patients.
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Affiliation(s)
- Johannie Beaucage-Charron
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada.
| | - Justine Rinfret
- Department of Pharmacy, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - Richard Coveney
- Direction of Education, Research and Innovation, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est-de-l'Île-de-Montréal, Montréal, Canada
| | - David Williamson
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montréal, Canada; Faculty of Pharmacy, Université de Montréal, Montréal, Canada
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Wei W, Huang X, Zhu J. Effect of Acupoint Therapies on Postoperative Sleep Quality: A Narrative Review. Med Sci Monit 2023; 29:e938920. [PMID: 36760099 PMCID: PMC9926797 DOI: 10.12659/msm.938920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Several studies have reported that sleep quality often decreases in patients after surgery, especially in elderly patients, which seriously affects postoperative prognosis and outcomes, inducing diseases such as postoperative delirium, long-term chronic pain, and potentially fatal cardiovascular events. With the popularization of comfortable medicine, medical workers pay more attention to the postoperative sleep quality of patients. The causes underlying the decrease in postoperative sleep quality may include postoperative pain, the severity of surgical trauma and stress, perioperative anxiety and depression, and postoperative complications. Patients with insomnia often use acupoint therapies as a safe and effective alternative to drugs. Acupoint therapies are among the oldest medical therapies of Traditional Chinese Medicine and are gradually gaining recognition among medical workers worldwide. Various types of acupoint stimulation methods such as transcutaneous electrical acupoint simulation (TEAS), acupressure, acupuncture, and electroacupuncture can change the brain's local electrical activity, inhibit the central nervous system, and achieve deep sedation through stimulating the related acupoints, which provides a novel idea and basis for improvement in factors affecting postoperative sleep quality. This review explores the mechanism of acupoint therapies from several aspects of affecting the sleep quality of patients after surgery and its clinical results. We found that acupoint therapies effectively improve sleep quality and alleviate the postoperative complications of patients, and we emphasize the importance of acupoint therapies to guide future research and clinical practice. Large-scale, multicenter studies are needed to determine the optimal duration, frequency, and timing of acupoint stimulation for improving postoperative sleep quality.
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Affiliation(s)
- Wenxin Wei
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
| | - Xin Huang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Junchao Zhu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, PR China
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11
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Rault C, Heraud Q, Ragot S, Frat JP, Thille AW, Drouot X. A real-time automated sleep scoring algorithm to detect refreshing sleep in conscious ventilated critically ill patients. Neurophysiol Clin 2023; 53:102856. [DOI: 10.1016/j.neucli.2023.102856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
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Actigraphy-based sleep and activity measurements in intensive care unit patients randomized to ramelteon or placebo for delirium prevention. Sci Rep 2023; 13:1450. [PMID: 36702822 PMCID: PMC9879948 DOI: 10.1038/s41598-023-28095-0] [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: 06/25/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Patients in the ICU often sleep poorly for various reasons, which may predispose to delirium. We previously conducted a clinical trial in which we tested the efficacy of ramelteon, a melatonin-receptor agonist used to treat insomnia, versus placebo, in preventing ICU delirium in patients who underwent elective pulmonary thromboendarterectomy (PTE) surgery. Here we examine sleep, activity, and circadian patterns, measured with actigraphy, to understand changes in these metrics with our intervention and in those with and without delirium. Participants wore wrist actigraphy devices while recovering post-operatively in the ICU. For sleep analysis, we extracted total sleep time and sleep fragmentation metrics over the 22:00 to 06:00 period nightly, and daytime nap duration from the daytime period (0:600 to 22:00) for each participant. For activity analyses, we extracted the following metrics: total daytime activity count (AC), maximum daytime AC, total nighttime AC, and maximum nighttime AC. Next, we performed a nonparametric circadian analysis on ACs over each 24-h day and extracted the following: interdaily stability (IS), intra-daily variability (IV), relative amplitude (RA), and low and high periods of activity (L5 and M10) as well as their start times. These metrics were compared between patients who received ramelteon versus placebo, and between patients who became delirious versus those who did not develop delirium. We additionally made comparisons between groups for daytime and nighttime light levels. No differences in sleep, activity, circadian metrics or light levels were found between drug groups. Delirious patients, when compared to those who were never delirious, had a lower IS (0.35 ± 0.16 vs. 0.47 ± 0.23; P = 0.006). Otherewise, no differences in IV, L5, M10, or RA were found between groups. L5 and M10 activity values increased significantly over the post-extubation for the whole cohort. No differences were found for daytime or nighttime light levels between groups. Overall, ramelteon did not impact sleep or circadian metrics in this cohort. Consistent with clinical experience, delirious patients had less inter-daily stability in their rest-activity rhythms. These data suggest that actigraphy might have value for individual assessment of sleep in the ICU, and for determining and detecting the impact of interventions directed at improving sleep and circadian activity rhythms in the ICU.Trial registration: REGISTERED at CLINICALTRIALS.GOV: NCT02691013. Registered on February 24, 2016 by principal investigator, Dr. Robert L. Owens.
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Allen RW, Shaw RD, Burney CP, Newton LE, Lee AY, Judd BG, Ivatury SJ. Deep sleep and beeps II: Sleep quality improvement project in general surgery patients. Surgery 2022; 172:1697-1703. [PMID: 38375787 DOI: 10.1016/j.surg.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poor sleep leads to poor health outcomes. Phase I of our sleep quality improvement project showed severe sleep disturbance in the ward setting. We implemented a novel PostOp Pack to improve sleep quality. METHODS Patients underwent elective, general surgery procedures. Fitbit trackers measured total sleep time. Patients completed the inpatient Richards-Campbell Sleep Questionnaire, which combines 5 domains into a cumulative score (0-100). Patients completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. Patients received the PostOp Pack, which included physical items and a sleep-protective order set to reduce nighttime awakenings. Patients from phase I served as the historical control. The primary outcome was the percentage of patients with Richards-Campbell Sleep Questionnaire total sleep score ≥50. The secondary outcomes included the mean Richards-Campbell Sleep Questionnaire domain scores and Fitbit total sleep time. RESULTS A total of 49 patients were compared with 64 historical controls. The percentage of patients with a total sleep score ≥50 was significantly higher in patients receiving a PostOp Pack versus historical control (69% vs. 44%, difference 26%, 95% confidence interval 6.1-45%, P = .01). The mean Richards-Campbell Sleep Questionnaire Total Sleep Score was significantly higher in patients with a PostOp Pack (62 vs 49, mean difference 13, 95% confidence interval 6-21, P ≤ .01). The PostOp Pack Richards-Campbell Sleep Questionnaire domain scores were significantly higher in various areas: Sleep Latency (68 vs 49, P ≤ .01), Awakenings (56 vs 40, P = .01), Sleep Quality (61 vs 49, P = .02), and Noise Disturbance (70 vs 59, P = .04). Of all patients, 92% would use PostOp Pack again in a future hospitalization. No patients had a failure to rescue event with PostOp Pack. The mean total sleep time was significantly improved with PostOp Pack on night 1 (6.4 vs 4.7 hours, P = .03). CONCLUSION The PostOp Pack improves inpatient sleep quality and is safe.
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Affiliation(s)
- Robert W Allen
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Robert D Shaw
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Laura E Newton
- Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | - Andrew Y Lee
- Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | - Brooke G Judd
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth College, Lebanon, NH; Sleep Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Srinivas Joga Ivatury
- Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin TX
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Sui X, Wang Y, Jin M, Li K, Jiang G, Song A, He Z, Yin C, Zhao J, Wang L, Han F. The effects of dexmedetomidine for patient-controlled analgesia on postoperative sleep quality and gastrointestinal motility function after surgery: A prospective, randomized, double-blind, and controlled trial. Front Pharmacol 2022; 13:990358. [PMID: 36299885 PMCID: PMC9588938 DOI: 10.3389/fphar.2022.990358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Postoperative poor sleep quality and decreased gastrointestinal motility function are common clinical problems. This study investigated the effects of dexmedetomidine (DEX) combined with sufentanil for patient-controlled analgesia (PCA) on postoperative sleep quality and gastrointestinal motility function after surgery in patients with colorectal cancer. Methods: Patients undergoing colorectal cancer surgery were randomly divided into three groups, DEX 0, 200, or 400 μg, each combined with sufentanil 150 μg for PCA immediately after surgery. The primary outcome was sleep quality in the first 7 days after surgery based on the Athens Insomnia Scale (AIS) score. The secondary outcome was postoperative gastrointestinal motility recovery evaluated by the time of first flatus, first feces and first diet. Postoperative pain intensity, side effects and the length of postoperative hospital stay were also compared among groups. The study was registered with the Chinese Clinical Trial Registry (https://www.chictr.org.cn/enIndex.aspx, ChiCTR2000032601). Results: Ultimately, 210 cases were included. Sleep quality was better in the DEX 200 μg group and DEX 400 μg group than in the DEX 0 μg group. Overall, in the DEX 200 μg group and DEX 400 μg group, the AIS score (p < 0.05) and the incidence of sleep disturbance (7.3%, 4.5% vs. 19.6%, p < 0.001) were lower than those in the DEX 0 μg group in the first 7 days after surgery. There were no significant differences in postoperative gastrointestinal motility among the three groups in the total surgical categories (p > 0.05). In the laparoscopic surgery patients of each group, the time of postoperative first flatus (p = 0.02) and first feces (p = 0.01) was significantly longer in the DEX 400 μg group than in the DEX 0 μg group. There were no differences in postoperative pain intensity, side effects or length of postoperative hospital stay (p > 0.05). Conclusion: The continuous infusion of DEX (200 or 400 μg) for PCA significantly improved postoperative sleep quality after colorectal cancer surgery. DEX (200 μg) was better at improving postoperative sleep quality without affecting gastrointestinal motility function than DEX (400 μg) in patients who underwent laparoscopic colorectal cancer surgery.
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Affiliation(s)
- Xin Sui
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Yue Wang
- Department of Pain Medicine, Shanghai Fourth People’s Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Mingxin Jin
- Department of Anesthesiology, Cancer Hospital Chinese Academy of Medical Science, Shenzhen Center, Shenzhen, China
| | - Kun Li
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Ge Jiang
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Ailing Song
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Zhaoyi He
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Chengke Yin
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Jingshun Zhao
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Liping Wang
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
| | - Fei Han
- Department of Anesthesiology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, China
- *Correspondence: Fei Han,
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An Automated Algorithm for Determining Sleep Using Single-Channel Electroencephalography to Detect Delirium: A Prospective Observational Study in Intensive Care Units. Healthcare (Basel) 2022; 10:healthcare10091776. [PMID: 36141389 PMCID: PMC9498606 DOI: 10.3390/healthcare10091776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
The relationship between polysomnography-based objective sleep and delirium in the intensive care unit (ICU) is inconsistent across studies, suggesting limitations in manually determining the sleep stage of critically ill patients. We objectively measured 24-h sleep using a single-channel electroencephalogram (SleepScope [SS]) and an under-mattress sleep monitor (Nemuri SCAN [NSCAN]), both of which have independent algorithms that automatically determine sleep and wakefulness. Eighteen patients (median age, 68 years) admitted to the ICU after valvular surgery or coronary artery bypass grafting were included, and their sleep time was measured one day after extubation. The median total sleep times (TSTs) measured by SS (TST-SS) and NSCAN were 548 (48−1050) and 1024 (462−1257) min, respectively. Two patients with delirium during the 24-h sleep measurement had very short TST-SS of 48 and 125 min, and the percentage of daytime sleep accounted for >80% in both SS and NSCAN. This preliminary case series showed marked sleep deprivation and increased rates of daytime sleeping in ICU patients with delirium. Although data accuracy from under-mattress sleep monitors is contentious, automated algorithmic sleep/wakefulness determination using a single-channel electroencephalogram may be useful in detecting delirium in ICU patients and could even be superior to polysomnography.
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Lerman SF, Owens MA, Liu T, Puthumana J, Hultman CS, Caffrey JA, Smith MT. Sleep after burn injuries: A systematic review and meta-analysis. Sleep Med Rev 2022; 65:101662. [DOI: 10.1016/j.smrv.2022.101662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/26/2022]
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Golubovic J, Neerland BE, Aune D, Baker FA. Music Interventions and Delirium in Adults: A Systematic Literature Review and Meta-Analysis. Brain Sci 2022; 12:brainsci12050568. [PMID: 35624955 PMCID: PMC9138821 DOI: 10.3390/brainsci12050568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
Delirium is a neuropsychiatric syndrome represented by an acute disturbance in attention, awareness and cognition, highly prevalent in older, and critically ill patients, and associated with poor outcomes. This review synthesized existing evidence on the effectiveness of music interventions on delirium in adults, and music interventions (MIs), psychometric assessments and outcome measures used. We searched MEDLINE, PsychINFO, SCOPUS, Clinical Trials and CENTRAL for quantitative designs comparing any MIs to standard care or another intervention. From 1150 studies 12 met the inclusion criteria, and 6 were included in the meta-analysis. Narrative synthesis showed that most studies focused on prevention, few assessed delirium severity, with the majority of studies reporting beneficial effects. The summary relative risk for incident delirium comparing music vs. no music in postsurgical and critically ill older patients was 0.52 (95% confidential interval (CI): 0.20−1.35, I2 = 79.1%, heterogeneity <0.0001) for the random effects model and 0.47 (95% CI: 0.34−0.66) using the fixed effects model. Music listening interventions were more commonly applied than music therapy delivered by credentialed music therapists, and delirium assessments methods were heterogeneous, including both standardized tools and systematic observations. Better designed studies are needed addressing effectiveness of MIs in specific patient subgroups, exploring the correlations between intervention-types/dosages and delirium symptoms.
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Affiliation(s)
- Jelena Golubovic
- Centre for Research in Music and Health, Norwegian Academy of Music, 0363 Oslo, Norway;
- Creative Arts and Music Therapy Research Unit, The University of Melbourne, Melbourne 3010, Australia
- Correspondence: ; Tel.: +47-94298662
| | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0462 Oslo, Norway;
| | - Dagfinn Aune
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London SW7 2AZ, UK;
- Department of Nutrition, Oslo New University College, 0456 Oslo, Norway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Felicity A. Baker
- Centre for Research in Music and Health, Norwegian Academy of Music, 0363 Oslo, Norway;
- Creative Arts and Music Therapy Research Unit, The University of Melbourne, Melbourne 3010, Australia
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Comparative efficacy of nonpharmacological interventions on sleep quality in people who are critically ill: A systematic review and network meta-analysis. Int J Nurs Stud 2022; 130:104220. [DOI: 10.1016/j.ijnurstu.2022.104220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 11/19/2022]
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19
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Chen TJ, Traynor V, Wang AY, Shih CY, Tu MC, Chuang CH, Chiu HY, Chang HC(R. Comparative Effectiveness of Non-Pharmacological Interventions for Preventing Delirium in Critically Ill Adults: A Systematic Review and Network Meta-Analysis. Int J Nurs Stud 2022; 131:104239. [DOI: 10.1016/j.ijnurstu.2022.104239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022]
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Wibrow B, Martinez FE, Myers E, Chapman A, Litton E, Ho KM, Regli A, Hawkins D, Ford A, van Haren FMP, Wyer S, McCaffrey J, Rashid A, Kelty E, Murray K, Anstey M. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med 2022; 48:414-425. [DOI: 10.1007/s00134-022-06638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
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Terrelonge M, LaHue SC, Tang C, Movsesyan I, Pullinger CR, Dubal DB, Leung J, Douglas VC. KIBRA, MTNR1B, and FKBP5 genotypes are associated with decreased odds of incident delirium in elderly post-surgical patients. Sci Rep 2022; 12:556. [PMID: 35017578 PMCID: PMC8752781 DOI: 10.1038/s41598-021-04416-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/10/2021] [Indexed: 12/19/2022] Open
Abstract
Despite the association between cognitive impairment and delirium, little is known about whether genetic differences that confer cognitive resilience also confer resistance to delirium. To investigate whether older adults without postoperative delirium, compared with those with postoperative delirium, are more likely to have specific single nucleotide polymorphisms (SNPs) in the FKBP5, KIBRA, KLOTHO, MTNR1B, and SIRT1 genes known to be associated with cognition or delirium. This prospective nested matched exploratory case–control study included 94 older adults who underwent orthopedic surgery and screened for postoperative delirium. Forty-seven subjects had incident delirium, and 47 age-matched controls were not delirious. The primary study outcome was genotype frequency for the five SNPs. Compared with participants with delirium, those without delirium had higher adjusted odds of KIBRA SNP rs17070145 CT/TT [vs. CC; adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.03, 7.54; p = 0.04] and MTNR1B SNP rs10830963 CG/GG (vs. CC; aOR 4.14, 95% CI 1.36, 12.59; p = 0.01). FKBP5 SNP rs1360780 CT/TT (vs. CC) demonstrated borderline increased adjusted odds of not developing delirium (aOR 2.51, 95% CI 1.00, 7.34; p = 0.05). Our results highlight the relevance of KIBRA, MTNR1B, and FKBP5 in understanding the complex relationship between delirium, cognition, and sleep, which warrant further study in larger, more diverse populations.
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Affiliation(s)
- Mark Terrelonge
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA. .,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
| | - Christopher Tang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Irina Movsesyan
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Clive R Pullinger
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Dena B Dubal
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Jacqueline Leung
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Vanja C Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA.,Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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Rizvi M, Alotaibi J, Dharmarajan B. Influence of nursing care intervention on quality of sleep in hospitalized patients at Riyadh, Saudi Arabia. SAUDI JOURNAL FOR HEALTH SCIENCES 2022. [DOI: 10.4103/sjhs.sjhs_7_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Guan HL, Liu H, Hu XY, Abdul M, Dai MS, Gao X, Chen XF, Zhou Y, Sun X, Zhou J, Li X, Zhao Q, Zhang QQ, Wang J, Han Y, Cao JL. Urinary albumin creatinine ratio associated with postoperative delirium in elderly patients undergoing elective non-cardiac surgery: A prospective observational study. CNS Neurosci Ther 2021; 28:521-530. [PMID: 34415671 PMCID: PMC8928921 DOI: 10.1111/cns.13717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction The blood‐brain barrier (BBB) disruption contributes to postoperative delirium, but cost‐effective and non‐invasive assessment of its permeability is not practicable in the clinical settings. Urine albumin to creatinine ratio (UACR), reflecting systemic vascular endothelial dysfunction, may be a prognostic and predictive factor associated with postoperative delirium. The aim was to analyze the relationship between UACR and postoperative delirium in elderly patients undergoing elective non‐cardiac surgery. Materials and methods Through stratified random sampling, a cohort of 408 individuals aged 60 years and older scheduled for elective non‐cardiac surgery were included between February and August 2019 in the single‐center, prospective, observational study. The presence of delirium was assessed using the Confusion Assessment Method (CAM) or Confusion Assessment Method for the ICU (CAM‐ICU) on the day of surgery, at 2 h after the surgery ending time and on the first 3 consecutive days with repeated twice‐daily, with at least 6‐h intervals between assessments. Urine samples were collected on one day before surgery, and 1st day and 3rd day after surgery. The primary outcome was the presence of postoperative delirium, and association of the level of UACR with postoperative delirium was evaluated with unadjusted/adjusted analyses and multivariable logistic regression. Results Postoperative delirium was observed in 26.75% (107 of 400) of patients within 3 days post‐surgery. UACR‐Pre (OR, 1.30; 95% CI, 1.14–1.49, p < 0.001), UACR‐POD1 (OR, 1.20; 95% CI, 1.13–1.27, p < 0.001), and UACR‐POD3 (OR, 1.14; 95% CI, 1.08–1.20, p < 0.001) between the delirium and non‐delirium groups show a significant difference, even after adjusting for age, education levels, and other factors. Conclusion As the marker of endothelial dysfunction, the high perioperative UACR value may be linked to the postoperative delirium in elderly patients undergoing elective non‐cardiac surgery.
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Affiliation(s)
- Hui-Lian Guan
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu City, China
| | - He Liu
- Department of Anesthesiology, The Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Huzhou City, China
| | - Xiao-Yi Hu
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Mannan Abdul
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Ming-Sheng Dai
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xing Gao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xue-Fen Chen
- School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yang Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xun Sun
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Jian Zhou
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Xiang Li
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Qiu Zhao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Qian-Qian Zhang
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Jun Wang
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
| | - Yuan Han
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology & NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou City, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou City, China
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Kishore K, Cusimano MD. The Fundamental Need for Sleep in Neurocritical Care Units: Time for a Paradigm Shift. Front Neurol 2021; 12:637250. [PMID: 34220667 PMCID: PMC8248989 DOI: 10.3389/fneur.2021.637250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/27/2021] [Indexed: 11/30/2022] Open
Abstract
Intensive neurological assessments in neurocritical care settings for unduly prolonged period result in profound sleep deprivation in those patients that confounds the true neurological status of these patients, and the mounting apprehension in providers can beget a vicious cycle of even more intensive neurological assessments resulting in further sleep deprivation from being constantly woken up to be “assessed.” This iatrogenic state drives these patients into deep sleep stages that impact spontaneous breathing trials, weaken immunity, and lead to unwarranted investigations and interventions. There is dwindling value of prolonged frequent neurochecks beyond the initial 24–48 h of an intracranial event. We insist that sleep must be considered on at least an equal par to other functions that are routinely assessed. We reason that therapeutic sleep must be allowed to these patients in suitable amounts especially beyond the first 36–48 h to achieve ideal and swift recovery. This merits a paradigm shift.
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Affiliation(s)
- Kislay Kishore
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Rasulo FA, Seghelini E. Alterations of circadian rhythms in critically ill patients: can we sleep on it? Minerva Anestesiol 2021; 87:750-751. [PMID: 34134461 DOI: 10.23736/s0375-9393.21.15777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Frank A Rasulo
- Department of Medical, Surgical, Radiological Sciences and Public Health, Institute of Anesthesia, Intensive Care and Emergency Medicine, University of Brescia, Brescia, Italy -
| | - Elisa Seghelini
- Department of Medical, Surgical, Radiological Sciences and Public Health, Institute of Anesthesia, Intensive Care and Emergency Medicine, University of Brescia, Brescia, Italy
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Giuliano K, Pozzar R. Achieving Noise Reduction With a Novel Lower Limb External Mechanical Compression System. ERGONOMICS IN DESIGN 2021. [DOI: 10.1177/10648046211016690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hospitals are one of the noisiest public environments in the United States, and hospital noise is associated with disrupted sleep. This study provides insights into the noise levels produced by three commonly used medical devices for mechanical deep vein thrombosis prophylaxis: the VenaFlow Elite System, the Kendall SCD Compression System, and the ArjoHuntleigh Flowtron. Noise levels produced were compared with a novel device, the RF Health MAC™ system, which was designed to provide improved comfort and noise reduction. Results suggest that future innovation in mechanical deep vein thrombosis prophylaxis should include efforts to reduce noise during operation.
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Sun T, Sun Y, Huang X, Liu J, Yang J, Zhang K, Kong G, Han F, Hao D, Wang X. Sleep and circadian rhythm disturbances in intensive care unit (ICU)-acquired delirium: a case-control study. J Int Med Res 2021; 49:300060521990502. [PMID: 33730927 PMCID: PMC7983249 DOI: 10.1177/0300060521990502] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The relationships among sleep, circadian rhythm, and intensive care unit (ICU)-acquired delirium are complex and remain unclear. This study aimed to examine the pathophysiological mechanisms of sleep and circadian rhythm disturbances in patients with ICU-acquired delirium. METHODS This study included critical adult patients aged 18 to 75 years who were treated in the ICU. Twenty-four-hour polysomnography was performed and serum melatonin and cortisol levels were measured six times during polysomnography. Receiver operating characteristic curves and binomial logistic regression were used to evaluate the potential of sleep, melatonin, and cortisol as indicators of delirium in the ICU. RESULTS Patients with delirium (n = 24) showed less rapid eye movement (REM) sleep compared with patients without delirium (n = 24, controls). Melatonin levels were lower and cortisol levels were higher in the delirium group than in the control group. REM sleep, melatonin, and cortisol were significantly associated with delirium. The optimal cutoff values of REM sleep and mean melatonin and cortisol levels that predicted delirium were ≤1.05%, ≤422.09 pg/mL, and ≥212.14 ng/mL, respectively. CONCLUSIONS REM sleep, and melatonin and cortisol levels are significantly associated with the risk of ICU-acquired delirium. Improved sleep and readjustment of circadian rhythmicity may be therapeutic targets of ICU-acquired delirium.
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Affiliation(s)
- Ting Sun
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Yunliang Sun
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Xiao Huang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Jianghua Liu
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Jiabin Yang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Kai Zhang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Guiqing Kong
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Fang Han
- Department of Pulmonary and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Dong Hao
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Xiaozhi Wang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
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Abstract
Sleep affects physiologic and psychological recovery throughout critical illness. Patients often describe poor sleep as a major source of distress while hospitalized in an intensive care unit. The intensive care unit environment poses unique challenges for sleep assessment and monitoring. The purpose of this literature review is to discuss methods of assessment and monitoring of sleep within the intensive care unit setting. The advantages and disadvantages of physiologic monitoring of sleep (eg, polysomnography, bispectral index, and actigraphy) are compared with those of subjective measures of sleep quality (eg, validated patient-oriented sleep questionnaires, and informal nursing assessments).
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29
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Romero N, Dube KM, Lupi KE, DeGrado JR. Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon. Ann Pharmacother 2021; 55:1347-1354. [PMID: 33715466 DOI: 10.1177/10600280211002054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. OBJECTIVE To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). METHODS This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. RESULTS No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. CONCLUSION AND RELEVANCE Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.
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Allen RW, Burney CP, Davis A, Henkin J, Kelly J, Judd BG, Ivatury SJ. Deep Sleep and Beeps: Sleep Quality Improvement Project in General Surgery Patients. J Am Coll Surg 2021; 232:882-888. [PMID: 33675989 DOI: 10.1016/j.jamcollsurg.2021.02.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Poor sleep leads to poor health outcomes. Inpatient sleep disturbance has been studied primarily in the ICU. Minimal research exists on sleep in surgical populations. METHODS We recruited patients undergoing elective, inpatient general surgery procedures. Participants wore Fitbit trackers while inpatient to measure total sleep time (CDC recommendation is 7 or more hours per night). At discharge, patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) to measure inpatient sleep quality. The RCSQ combines 5 domains into a cumulative score (0 to 100); a higher score means better sleep quality. Patients also completed the outpatient Pittsburgh Sleep Quality Index preoperatively and postoperatively. The primary end point was percentage of patients with total sleep score ≥ 50. Secondary outcomes included mean RCSQ domain scores, Fitbit total sleep time, and percentage with Pittsburgh Sleep Quality Index Score indicating poor sleep. RESULTS We included 64 patients (mean ± SD age 55.0 ± 14.1 years). Mean ± SD RCSQ total sleep score was 49 ± 20.5 and 53.1% with total sleep score < 50. Mean ± SD RCSQ domain scores were Awakenings: 40.4 ± 22.8, Sleep Quality: 49.1 ± 27.9, Sleep Latency: 49.2 ± 25.3, Sleep Depth: 50.2 ± 26.5, Returning to Sleep: 55.9 ± 28.1, and Noise Disturbance: 59.1 ± 27.9. On night one, 25 devices (40%) had recorded sleep data due to enough sleep. Mean ± SD total sleep time on night 1 was 4.7 ± 2.8 hours. Mean total sleep time for nights 2, 3, and 4 remained fewer than 7 hours. Percentages for each night that achieved the CDC goal of 7 or more hours were as follows: night one 10.9%, night two 32.8%, night three 35.3%, and night four 27.6%. Per the Pittsburgh Sleep Quality Index, 88.1% of patients were poor sleepers preoperatively and 84.5% were poor sleepers at follow-up (p = 0.6). CONCLUSIONS Elective general surgery patients experience a severe inpatient sleep disturbance, worse than in similarly studied ICU cohorts. This disturbance is driven primarily by nighttime awakenings.
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Affiliation(s)
- Robert W Allen
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Amy Davis
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jessica Henkin
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Julia Kelly
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Brooke G Judd
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Sleep Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | - Srinivas Joga Ivatury
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Geisel School of Medicine, Dartmouth College, Lebanon, NH
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31
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Abstract
Sleep is fundamental for everyday functioning, yet it is often negatively impacted in critically ill patients by the intensive care setting. With a focus on the neurological intensive care unit (NeuroICU), this narrative review summarizes methods of measuring sleep and addresses common causes of sleep disturbance in the hospital including environmental, pharmacological, and patient-related factors. The effects of sleep deprivation on the cardiovascular, pulmonary, immune, endocrine, and neuropsychological systems are discussed, with a focus on short-term deprivation in critically ill populations. Where evidence is lacking in the literature, long-term sleep deprivation studies and the effects of sleep deprivation in healthy individuals are also referenced. Lastly, strategies for the promotion of sleep in the NeuroICU are presented.
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32
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (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). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Delaney LJ, Litton E, Melehan KL, Huang HCC, Lopez V, Van Haren F. The feasibility and reliability of actigraphy to monitor sleep in intensive care patients: an observational study. Crit Care 2021; 25:42. [PMID: 33514414 PMCID: PMC7844945 DOI: 10.1186/s13054-020-03447-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sleep amongst intensive care patients is reduced and highly fragmented which may adversely impact on recovery. The current challenge for Intensive Care clinicians is identifying feasible and accurate assessments of sleep that can be widely implemented. The objective of this study was to investigate the feasibility and reliability of a minimally invasive sleep monitoring technique compared to the gold standard, polysomnography, for sleep monitoring. METHODS Prospective observational study employing a within subject design in adult patients admitted to an Intensive Care Unit. Sleep monitoring was undertaken amongst minimally sedated patients via concurrent polysomnography and actigraphy monitoring over a 24-h duration to assess agreement between the two methods; total sleep time and wake time. RESULTS We recruited 80 patients who were mechanically ventilated (24%) and non-ventilated (76%) within the intensive care unit. Sleep was found to be highly fragmented, composed of numerous sleep bouts and characterized by abnormal sleep architecture. Actigraphy was found to have a moderate level of overall agreement in identifying sleep and wake states with polysomnography (69.4%; K = 0.386, p < 0.05) in an epoch by epoch analysis, with a moderate level of sensitivity (65.5%) and specificity (76.1%). Monitoring accuracy via actigraphy was improved amongst non-ventilated patients (specificity 83.7%; sensitivity 56.7%). Actigraphy was found to have a moderate correlation with polysomnography reported total sleep time (r = 0.359, p < 0.05) and wakefulness (r = 0.371, p < 0.05). Bland-Altman plots indicated that sleep was underestimated by actigraphy, with wakeful states overestimated. CONCLUSIONS Actigraphy was easy and safe to use, provided moderate level of agreement with polysomnography in distinguishing between sleep and wakeful states, and may be a reasonable alternative to measure sleep in intensive care patients. Clinical Trial Registration number ACTRN12615000945527 (Registered 9/9/2015).
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Affiliation(s)
- L J Delaney
- School of Nursing, Queensland University of Technology, Brisbane, QLD, Australia.
- Medicine and Health Sciences, Australian National University, Canberra, ACT, Australia.
| | - E Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
- Intensive Care Unit, St John of God Hospital Subiaco, Perth, WA, Australia
| | - K L Melehan
- Sleep Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - H-C C Huang
- Medicine and Health Sciences, Australian National University, Canberra, ACT, Australia
- Respiratory and Sleep Medicine, Canberra Hospital, Woden, ACT, Australia
- Canberra Obesity Management Service, Canberra Health Services, Belconnen, ACT, Australia
| | - V Lopez
- School of Nursing, Hubei University of Medicine, Shiyan, China
- School of Nursing, University of Tasmania, Hobart, TAS, Australia
| | - F Van Haren
- Medicine and Health Sciences, Australian National University, Canberra, ACT, Australia
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia
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Munro CL, Liang Z, Ji M, Elías MN, Chen X, Calero K, Ely EW. Family automated voice reorientation (FAVoR) intervention for mechanically ventilated patients in the intensive care unit: Study protocol for a randomized controlled trial. Contemp Clin Trials 2021; 102:106277. [PMID: 33482395 DOI: 10.1016/j.cct.2021.106277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/27/2022]
Abstract
Delirium in the intensive care unit (ICU) affects up to 80% of critically ill, mechanically ventilated (MV) adults. Delirium is associated with substantial negative outcomes, including increased hospital complications and long-term effects on cognition and health status in ICU survivors. The purpose of this randomized controlled trial is to test the effectiveness of a Family Automated Voice Reorientation (FAVoR) intervention on delirium among critically ill MV patients. The FAVoR intervention uses scripted audio messages, which are recorded by the patient's family and played at hourly intervals during daytime hours. This ongoing orientation to the ICU environment through recorded messages in a voice familiar to the patient may enable the patient to more accurately interpret the environment and thus reduce risk of delirium. The study's primary aim is to test the effect of the FAVoR intervention on delirium in critically ill MV adults in the ICU. The secondary aims are to explore: (1) if the effect of FAVoR on delirium is mediated by sleep, (2) if selected biobehavioral factors moderate the effects of FAVoR on delirium, and (3) the effects of FAVoR on short-term and long-term outcomes, including cognition and health status. Subjects (n = 178) are randomly assigned to the intervention or control group within 48 h of initial ICU admission and intubation. The intervention group receives FAVoR over a 5-day period, while the control group receives usual care. Delirium-free days, sleep and activity, cognition, patient-reported health status and sleep quality, and data regarding iatrogenic/environmental and biobehavioral factors are collected.
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Affiliation(s)
- Cindy L Munro
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States.
| | - Zhan Liang
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Ming Ji
- University of South Florida College of Nursing, 12901 Bruce B. Downs Blvd, Tampa, FL, United States
| | - Maya N Elías
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Xusheng Chen
- University of Miami School of Nursing and Health Studies, 5030 Brunson Drive, Coral Gables, FL, United States
| | - Karel Calero
- Department of Pulmonary, Critical Care, and Sleep Medicine, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL, United States
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, 2525 West End Avenue Suite 450, Nashville, TN, United States; Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN, United States; Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), 1310 24th Ave S, Nashville, TN, United States
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35
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Abstract
TOPIC Sleep deprivation in the intensive care unit setting. CLINICAL RELEVANCE The Society of Critical Care Medicine has identified sleep deprivation as a significant contributor to the development of delirium in adult patients in the intensive care unit. Thus, preventing and managing sleep deprivation is important in reducing the incidence of delirium in this patient population. A multifaceted and multidisciplinary approach to promoting sleep in the intensive care unit setting that includes sleep hygiene routines, nursing care plans, and appropriate medication regimens may improve patient outcomes, including reducing delirium. PURPOSE OF ARTICLE To review the current literature on sleep deprivation in the intensive care unit setting and present care guidelines in a concise format. This information may be helpful in the development of clinical tools and may guide future quality improvement projects aimed at reducing delirium through sleep promotion in critical care patients. CONTENT COVERED A review of current literature and national organization recommendations revealed consistent themes in addressing the problem of sleep deprivation in the intensive care unit. Modifiable and nonmodifiable risk factors included frequent care interactions, light, noise, medication effects, and preexisting sleep problems.
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Affiliation(s)
- Jessica Grimm
- Jessica Grimm is an associate professor, School of Nursing, College of Health and Human Services, Touro University Nevada, Henderson, Nevada
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Nilius G, Richter M, Schroeder M. Updated Perspectives on the Management of Sleep Disorders in the Intensive Care Unit. Nat Sci Sleep 2021; 13:751-762. [PMID: 34135650 PMCID: PMC8200142 DOI: 10.2147/nss.s284846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/19/2021] [Indexed: 12/28/2022] Open
Abstract
Sleep disorders and circadian dysrhythmias are extremely prevalent in critically ill patients. Impaired sleep has a variety of etiologies, exhibits a wide range of negative effects and, moreover, might deteriorate the patient's prognosis. Despite a number of scientific findings and increased awareness, the importance of sleep optimization is still lower on the list of priories in the intensive care unit (ICU). The techniques of measuring and the evaluation of sleep quantity and quality are a great challenge in the ICU setting. The subjective and objective tools of sleep validation continue to suffer from deficiencies. Treatment approaches to improve the critically ill patient's sleep have focused on non-pharmacologic and pharmacologic strategies with some promising results. But pharmacological interventions alone could not provide sufficient patient benefit. Being aware and knowing of sleep problems and the beneficial effect of the necessary therapies in ICU patients requires greater acceptance. The application of available methods and the development of new methods to prevent sleep disorders in the ICU offer the potential to improve the critically ill patient's outcome.
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Affiliation(s)
- Georg Nilius
- Kliniken Essen Mitte, Department of Pneumology, Essen, Germany.,Witten/Herdecke University, Department of Internal Medicine, Witten, Germany
| | | | - Maik Schroeder
- Kliniken Essen Mitte, Department of Pneumology, Essen, Germany
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Li S, Song B, Li Y, Zhu J. Effects of Intravenous Anesthetics vs Inhaled Anesthetics on Early Postoperative Sleep Quality and Complications of Patients After Laparoscopic Surgery Under General Anesthesia. Nat Sci Sleep 2021; 13:375-382. [PMID: 33758567 PMCID: PMC7979340 DOI: 10.2147/nss.s300803] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/24/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Decreased postoperative sleep quality remains a serious problem in surgical settings at present. The purpose of our study was to compare the effect of propofol vs sevoflurane on early postoperative sleep quality and complications of patients receiving laparoscopic surgery after general anesthesia. METHODS Seventy-four patients undergoing selective laparoscopic surgery under general anesthesia were randomly assigned to the propofol group or sevoflurane group. The wireless portable sleep monitor (WPSM) is used to collect sleep quality on the night before surgery (sleep preop 1), the first night after surgery (sleep POD 1), and the third night after surgery (sleep POD 3). Record the subjective sleep quality and dreaming state during the operation. The perioperative hemodynamics, postoperative sleep and complications were also evaluated. RESULTS Compared with Sleep preop 1, patients showed lower sleep efficiency, Stable sleep and Unstable sleep during Sleep POD 1 and Sleep POD 3. In addition, compared with the propofol group, the proportion of REM sleep in the sevoflurane group was much higher during Sleep POD 1 and Sleep POD 3, and the incidence of dreaming was also higher in the sevoflurane group. Patients in the propofol group had better pain relief at 2, 4, and 6 hours after surgery. And the incidence of postoperative nausea and vomiting and dizziness in the sevoflurane group was significantly higher than that in the propofol group. CONCLUSION The degree of postoperative sleep efficiency was better on Sleep POD1 and Sleep POD3; the incidence of postoperative nausea and vomiting, and dizziness was lower; and postoperative pain was slighter when the operation was performed under propofol anesthesia compared with patients in the sevoflurane group. Propofol should be considered a better choice during the operation to promote the patient's postoperative sleep quality, relieve postoperative pain and improve the incidence of postoperative dizziness and nausea and vomiting.
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Affiliation(s)
- Shiyi Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Bijia Song
- Department of Anesthesiology, Beijing Friendship Hospital of Capital Medical University, Beijing, People's Republic of China
| | - Yang Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
| | - Junchao Zhu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
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Ye L, Dykes PC. Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient sleep. Mhealth 2021; 7:25. [PMID: 33898594 PMCID: PMC8063008 DOI: 10.21037/mhealth-20-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/03/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Improving sleep for hospitalized patients is an essential clinical need. Compared to the traditional "one-size-fits-all" interventions designed by clinicians for all patients, an individualized strategy engaging patients to identify salient sleep disruptors and seek their input how to address these disruptors are more likely to succeed. Followed by our work of developing the Factors Affecting Inpatient Sleep (FAIS) scale, in this report we developed a set of icons illustrating 14 common sleep disruptors on the FAIS scale, and proposed behavioral sleep promotion tips addressing each sleep disruptor. The set of icons and sleep promotion tips were built into the mobile health (mHealth) tool SLEEPKit, which was the start of our endeavor using mHealth technology to support individualized sleep promotion. METHODS A participatory iterative approach including feedbacks from patients, family members, and clinicians was used to develop and refine the icons and sleep promotion tips. Focus groups were used to inform the initial development and to brainstorm for the refinement of the icons. Individual interviews with patients and clinicians were conducted to validate each version of the icons using a standardized Content Validity Index (CVI) on a 4-point Likert scale, and offered comments and suggestions for improvement. Strategies of sleep promotion were first identified by the literature review, and then enriched by the summary of data from our previous work. Focus groups were conducted in order to learn empirically if the sleep promotion tips on the current version were acceptable to both patients and clinicians, and how they could be improved. RESULTS Six focus groups were conducted and achieved saturation in suggestions for improvement. A total of 5 patients and 3 family members who served on the Patient/ Family Advisory Council, and 42 nurses who served on the interdisciplinary professional practice committees participated in the focus groups. A total of 75 patients and 50 clinicians offered individual feedback and the CVI test for the icons. Successive two or four phases of iterative icon evaluation and refinement were carried out until the average CVI ratings for each icon achieved 3 and above. The sleep promotion tips were created to demonstrate a collaborative effort between patients and clinicians. To empower patients for bedside communication related to their sleep, examples of communication starters ("Try saying") were included in the tips for patients. CONCLUSIONS By using the participatory iterative approach, these icons for common sleep disturbing factors were understandable by both patients and clinicians, and the sleep promotion tips were perceived to be feasible and effective in the acute care hospital setting. This work moved the individualized sleep promotion forward, and supported the development of a novel mHealth tool for inpatient sleep promotion tailored to individual patient's needs.
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Affiliation(s)
- Lichuan Ye
- Bouvé College of Health Sciences School of Nursing, Northeastern University, Boston, USA
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Lis K, Sak-Dankosky N, Czarkowska-Pączek B. Nurses' autonomy in sleep management improves patients' sleep quality: A cross-sectional study. Nurs Crit Care 2020; 27:326-333. [PMID: 33295120 DOI: 10.1111/nicc.12579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/24/2020] [Accepted: 11/26/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The current literature indicates that intensive care (ICU) patients' sleep quality is generally poor, which is associated with serious physical and psychological consequences. AIMS AND OBJECTIVES To describe the practices nurses use to provide good-quality sleep to adult ICU patients and assess nurses' perceptions of patients' sleep quality and nurses' professional autonomy in sleep management. DESIGN A descriptive-correlational, cross-sectional study. METHODS A total of 232 ICU nurses from four hospitals in Poland were recruited. Data were collected between May and August 2019 using a previously developed questionnaire and analysed using descriptive statistics and non-parametric tests. RESULTS A total of 119 nurses took part in the study (response rate: 51%). On average, nurses rated patients' sleep quality as moderate (4.44 ± 2.23, scale 0-10). Most of the respondents (95.8%) said they did not use any sleep protocol. Various strategies to improve patients' sleep were used sporadically (2.64 ± 1.55, scale 1-5). The use of sleep quality assessment methods was positively correlated with patients' sleep quality (rho = 0.22, P = .02). Nurses' professional autonomy regarding sleep management was assessed as average (4.34 ± 2.43, scale 0-10) and was correlated with the patients' sleep quality (rho = 0.25, P < .01). Nurses who rated their autonomy in patients' sleep management more highly (rho = 0.29, P < .01) and more often influenced patients' sleep decisions (rho = 0.24, P < .01) used more methods to improve patients' sleep. CONCLUSIONS Strengthening the professional autonomy of ICU nurses and creating a reliable sleep assessment and improvement tool, which would describe strategies nurses can implement independently could increase sleep quality among ICU patients. RELEVANCE TO CLINICAL PRACTICE Addressing organizational problems, which hamper the patients' sleep management by ICU nurses could result in using more strategies to provide good-quality sleep to ICU patients. There is a need for clinical guidelines regarding patients' sleep management to help educate and guide nurses how to independently use sleep improvement methods.
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Affiliation(s)
- Katarzyna Lis
- Department of Clinical Nursing, Medical University of Warsaw, Warsaw, Poland
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40
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Andrews JL, Louzon PR, Torres X, Pyles E, Ali MH, Du Y, Devlin JW. Impact of a Pharmacist-Led Intensive Care Unit Sleep Improvement Protocol on Sleep Duration and Quality. Ann Pharmacother 2020; 55:863-869. [PMID: 33166192 DOI: 10.1177/1060028020973198] [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] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sleep improvement protocols are recommended for use in the intensive care unit (ICU) despite questions regarding which interventions to include, whether sleep quality or duration will improve, and the role of pharmacists in their development and implementation. OBJECTIVE To characterize the impact of a pharmacist-led, ICU sleep improvement protocol on sleep duration and quality as evaluated by a commercially available activity tracker and patient perception. METHODS Critical care pharmacists from a 40-bed, mixed ICU at a large community hospital led the development and implementation of an interprofessional sleep improvement protocol. It included daily pharmacist medication review to reduce use of medications known to disrupt sleep or increase delirium and guideline-based recommendations on both environmental and nonpharmacological sleep-focused interventions. Sleep duration and quality were compared before (December 2018 to December 2019) and after (January to June 2019) protocol implementation in non-mechanically ventilated adults using both objective (total nocturnal sleep time [TST] measured by an activity tracker (Fitbit Charge 2) and subjective (patient-perceived sleep quality using the Richards-Campbell Sleep Questionnaire [RCSQ]) measures. RESULTS Groups before (n = 48) and after (n = 29) sleep protocol implementation were well matched. After protocol implementation, patients had a longer TST (389 ± 123 vs 310 ± 147 minutes; P = 0.02) and better RCSQ-perceived sleep quality (63 ± 18 vs 42 ± 24 mm; P = 0.0003) compared with before implementation. CONCLUSION AND RELEVANCE A sleep protocol that incorporated novel elements led to objective and subjective improvements in ICU sleep duration and quality. Application of this study may result in increased utilization of sleep protocols and pharmacist involvement.
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Affiliation(s)
| | | | - Xavier Torres
- University of Chicago Medical Center, Chicago, IL, USA
| | | | | | - Yuan Du
- AdventHealth Orlando, Orlando, FL, USA
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Czempik PF, Jarosińska A, Machlowska K, Pluta MP. Impact of sound levels and patient-related factors on sleep of patients in the intensive care unit: a cross-sectional cohort study. Sci Rep 2020; 10:19207. [PMID: 33154537 PMCID: PMC7644698 DOI: 10.1038/s41598-020-76314-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 10/27/2020] [Indexed: 01/28/2023] Open
Abstract
Sleep disruption is common in patients in the intensive care unit (ICU). The aim of the study was to measure sound levels during sleep-protected time in the ICU, determine sources of sound, assess the impact of sound levels and patient-related factors on duration and quality of patients' sleep. The study was performed between 2018 and 2019. A commercially available smartphone application was used to measure ambient sound levels. Sleep duration was measured using the Patient's Sleep Behaviour Observational Tool. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ). The study population comprised 18 (58%) men and 13 (42%) women. There were numerous sources of sound. The median duration of sleep was 5 (IQR 3.5–5.7) hours. The median score on the RCSQ was 49 (IQR 28–71) out of 100 points. Sound levels were negatively correlated with sleep duration. The cut-off peak sound level, above which sleep duration was shorter than mean sleep duration in the cohort, was 57.9 dB. Simple smartphone applications can be useful to estimate sound levels in the ICU. There are numerous sources of sound in the ICU. Individual units should identify and eliminate their own sources of sound. Sources of sound producing peak sound levels above 57.9 dB may lead to shorter sleep and should be eliminated from the ICU environment. The sound levels had no effect on sleep quality.
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Affiliation(s)
- Piotr F Czempik
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 14 Medyków Str., 40-752, Katowice, Poland.
| | - Agnieszka Jarosińska
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krystyna Machlowska
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Michał P Pluta
- Students' Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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Jaiswal SJ, Kang DY, Wineinger NE, Owens RL. Objectively measured sleep fragmentation is associated with incident delirium in older hospitalized patients: Analysis of data collected from an randomized controlled trial. J Sleep Res 2020; 30:e13205. [PMID: 33051948 DOI: 10.1111/jsr.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/18/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022]
Abstract
Delirium may lead to poor outcomes in hospitalized older adults, and sleep deprivation may contribute to its pathogenesis. Thus, we sought to measure sleep duration and fragmentation using wrist-worn actigraphy in older, hospitalized patients with and without delirium, and to determine if actigraphy-based parameters could be used to predict delirium prior to clinical recognition. We conducted a secondary analysis of data from a recent, randomized clinical trial aimed at preventing inpatient delirium. Participants (n = 70) were aged ≥ 65 years admitted to an internal medicine service. Delirium was defined by the Confusion Assessment Method, or altered mental status identified by a clinician. Sleep measurements were actigraphy-based, and included total sleep time, median sleep bout duration and other measures of sleep fragmentation. We found that total sleep duration was similar between patients with (n = 17) and without (n = 53) delirium (mean 384.9 ± SD 162.7 versus mean 456.6 ± SD 135.8 min; p = .081). Mean sleep bout times were shorter in delirious versus never-delirious patients (median 6.1 [interquartile range 4.3-8.9] versus 7.9 [interquartile range 5.7-11.3] min, p = .048). Patients with delirium had more short sleep bouts (< 10 min) and fewer longer sleep bouts (> 30 min) compared with those without delirium. Increased sleep fragmentation was present prior to the clinical recognition of delirium. Overall, delirium was associated with increased sleep fragmentation detected by actigraphy, and sleep fragmentation might be useful as a biomarker for delirium prediction in the future.
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Affiliation(s)
- Stuti J Jaiswal
- The Scripps Research Institute, La Jolla, CA, USA.,Division of Hospital Medicine, Scripps Clinic, La Jolla, CA, USA
| | - Dae Y Kang
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
| | | | - Robert L Owens
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
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Kim J, Choi D, Yeo MS, Yoo GE, Kim SJ, Na S. <p>Effects of Patient-Directed Interactive Music Therapy on Sleep Quality and Melatonin Levels in Postoperative Elderly Patients: A Randomized Controlled Trial</p>. Patient Relat Outcome Meas 2020. [DOI: 10.2147/prom.s255100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kaseda ET, Levine AJ. Post-traumatic stress disorder: A differential diagnostic consideration for COVID-19 survivors. Clin Neuropsychol 2020; 34:1498-1514. [PMID: 32847484 DOI: 10.1080/13854046.2020.1811894] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: SARS-CoV-2 infection and its oft-associated illness COVID-19 may lead to neuropsychological deficits, either through direct mechanisms (i.e., neurovirulance) or indirect mechanisms, most notably complications caused by the virus (e.g., stroke) or medical procedures (e.g., intubation). The history of past human coronavirus outbreaks resulting in similar health emergencies suggests there will be a substantial prevalence of post-traumatic stress disorder (PTSD) among COVID-19 survivors. To prepare neuropsychologists for the difficult task of differentiating PTSD-related from neuropathology-related deficits in the oncoming wave of COVID-19 survivors, we integrate research across a spectrum of related areas.Methods: Several areas of literature were reviewed: psychiatric, neurologic, and neuropathological outcomes of SARS and MERS patients; neurological outcomes in COVID-19 survivors; PTSD associated with procedures common to COVID-19 patients; and differentiating neuropsychological deficits due to PTSD from those due to acquired brain injuries in other patient groups.Conclusions: Heightened risk of PTSD occurred in MERS and SARS survivors. While data concerning COVID-19 is lacking, PTSD is known to occur in patient groups who undergo similar hospital courses, including ICU survivors, patients who are intubated and mechanically ventilated, and those that experience delirium. Research with patients who develop PTSD in the context of mild traumatic brain injury further suggests that PTSD may account for some or all of a patient's subjective cognitive complaints and neuropsychological test performance. Recommendations are provided for assessing PTSD in the context of COVID-19.
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Affiliation(s)
- Erin T Kaseda
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Andrew J Levine
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Antipsychotic Drugs in Prevention of Postoperative Delirium-What Is Known in 2020? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176069. [PMID: 32825428 PMCID: PMC7503241 DOI: 10.3390/ijerph17176069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
Delirium is one of the most frequently reported neuropsychiatric complications in the perioperative period, especially in the population of elderly patients who often suffer from numerous comorbidities undergoing extensive or urgent surgery. It can affect up to 80% of patients who require hospitalization in an intensive care setting postoperatively. Delirium increases mortality, morbidity, length of hospital stay, and cost of treatment. An episode of delirium in the acute phase may lower the general quality of life and increases the risk of cognitive decline long-term. Since pharmacological treatment of delirium is not highly effective, focus of research has shifted towards developing preventive strategies. We aimed to perform a review of the topic based on the most recent literature. We conclude that, based on the available data, it seems impossible to make strong recommendations for using antipsychotic drugs in prophylaxis. Further research should answer the question what, if any, benefit patients receive from the pharmacological prevention of delirium, and which agents should be used.
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Assessing delirium with nursing care instruments: Evaluation of the cognitive and associated domains. Palliat Support Care 2020; 19:11-16. [PMID: 32729445 DOI: 10.1017/s1478951520000620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Nursing instruments have the potential for daily screening of delirium; however, they have not yet been evaluated. Therefore, after assessing the functional domains of the electronic Patient Assessment - Acute Care (ePA-AC), this study evaluates the cognitive and associated domains. METHODS In this prospective cohort study in the intensive care unit, 277 patients were assessed and 118 patients were delirious. The impacts of delirium on the cognitive domains, consciousness and cognition, communication and interaction, in addition to respiration, pain, and wounds were determined with simple logistic regressions and their respective odds ratios (ORs). RESULTS Delirium was associated with substantial impairment throughout the evaluated domains. Delirious patients were somnolent (OR 6), their orientation (OR 8.2-10.6) and ability to acquire knowledge (OR 5.5-11.6) were substantially impaired, they lost the competence to manage daily routines (OR 8.2-22.4), and their attention was compromised (OR 12.8). In addition, these patients received psychotropics (OR 3.8), were visually impaired (OR 1.8), unable to communicate their needs (OR 5.6-7.6), displayed reduced self-initiated activities (OR 6.5-6.9) and challenging behaviors (OR 6.2), as well as sleep-wake disturbances (OR 2.2-5), Furthermore, delirium was associated with mechanical ventilation, abdominal/thoracic injuries or operations (OR 4.2-4.4), and sensory perception impairment (OR 3.9-5.8). SIGNIFICANCE OF RESULTS Delirium caused substantial impairment in cognitive and associated domains. In addition to the previously described functional impairments, these findings will aid the implementation of nursing instruments in delirium screening.
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Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
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Azimaraghi O, Hammer M, Santer P, Platzbecker K, Althoff FC, Patrocinio M, Grabitz SD, Wongtangman K, Rumyantsev S, Xu X, Schaefer MS, Fuller PM, Subramaniam B, Eikermann M. Study protocol for a randomised controlled trial evaluating the effects of the orexin receptor antagonist suvorexant on sleep architecture and delirium in the intensive care unit. BMJ Open 2020; 10:e038474. [PMID: 32690536 PMCID: PMC7371384 DOI: 10.1136/bmjopen-2020-038474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Insomnia frequently occurs in patients admitted to an intensive care unit (ICU). Sleep-promoting agents may reduce rapid eye movement sleep and have deliriogenic effects. Suvorexant (Belsomra) is an orexin receptor antagonist with Food and Drug Administration (FDA) approval for the treatment of adult insomnia, which improves sleep onset and maintenance as well as subjective measures of quality of sleep. This trial will evaluate the efficacy of postoperative oral suvorexant treatment on night-time wakefulness after persistent sleep onset as well as the incidence and duration of delirium among adult cardiac surgical patients. METHODS AND ANALYSIS In this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 120 patients, aged 60 years or older, undergoing elective cardiac surgery with planned postoperative admission to the ICU. Participants will be randomised to receive oral suvorexant (20 mg) or placebo one time a day starting the night after extubation. The primary outcome will be wakefulness after persistent sleep onset. The secondary outcome will be total sleep time. Exploratory outcomes will include time to sleep onset, incidence of postoperative in-hospital delirium, number of delirium-free days and subjective sleep quality. ETHICS AND DISSEMINATION Ethics approval was obtained through the 'Committee on Clinical Investigations' at Beth Israel Deaconess Medical Center (protocol number 2019P000759). The findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER This trial has been registered at clinicaltrials.gov on 17 September 2019 (NCT04092894).
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Affiliation(s)
- Omid Azimaraghi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maximilian Hammer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Katharina Platzbecker
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Friederike C Althoff
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Patrocinio
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Karuna Wongtangman
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sandra Rumyantsev
- Pharmacy, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick M Fuller
- Department of Neurology, Program in Neuroscience and Division of Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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49
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Knauert MP, Murphy TE, Doyle MM, Pisani MA, Redeker NS, Yaggi HK. Pilot Observational Study to Detect Diurnal Variation and Misalignment in Heart Rate Among Critically Ill Patients. Front Neurol 2020; 11:637. [PMID: 32760341 PMCID: PMC7373742 DOI: 10.3389/fneur.2020.00637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/28/2020] [Indexed: 11/21/2022] Open
Abstract
Circadian disruption is common in critically ill patients admitted to the intensive care unit (ICU). Understanding and treating circadian disruption in critical illness has significant potential to improve critical illness outcomes through improved cognitive, immune, cardiovascular, and metabolic function. Measurement of circadian alignment (i.e., circadian phase) can be resource-intensive as it requires frequent blood or urine sampling over 24 or more hours. Less cumbersome methods of assessing circadian alignment would advance investigations in this field. Thus, the objective of this study is to examine the feasibility of using continuous telemetry to assess diurnal variation in heart rate (HR) among medical ICU patients as a proxy for circadian alignment. In exploratory analyses, we tested for associations between misalignment of diurnal variation in HR and death during hospital admission. This was a prospective observational cohort study embedded within a prospective medical ICU biorepository. HR data were continuously collected (every 5 s) via telemetry systems for the duration of the medical ICU admission; the first 24 h of this data was analyzed. Patients were extensively characterized via medical record chart abstraction and patient interviews. Of the 56 patients with complete HR data, 48 (86%) had a detectable diurnal variation. Of these patients with diurnal variation, 39 (81%) were characterized as having the nadir of their HR outside of the normal range of 02:00–06:00 (“misalignment”). Interestingly, no deaths occurred in the patients with normally aligned diurnal variation; in contrast, there were seven deaths (out of 39 patients) in patients who had misaligned diurnal variation in HR. In an exploratory analysis, we found that the odds ratio of death for misaligned vs. aligned patients was increased at 4.38; however, this difference was not statistically significant (95% confidence interval 0.20–97.63). We conclude that diurnal variation in HR can be detected via continuous telemetric monitoring of critically ill patients. A majority of these patients with diurnal variation exhibited misalignment in their first 24 h of medical ICU admission. Exploratory analyses suggest possible associations between misalignment and death.
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Affiliation(s)
- Melissa P Knauert
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Terrence E Murphy
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, United States
| | - Margaret M Doyle
- Section of Geriatrics, Yale School of Medicine, New Haven, CT, United States
| | - Margaret A Pisani
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, United States
| | | | - Henry K Yaggi
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, United States
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50
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Richards HS, Portal A, Absolom K, Blazeby JM, Velikova G, Avery KNL. Patient experiences of an electronic PRO tailored feedback system for symptom management following upper gastrointestinal cancer surgery. Qual Life Res 2020; 30:3229-3239. [PMID: 32535864 PMCID: PMC8528794 DOI: 10.1007/s11136-020-02539-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 11/26/2022]
Abstract
Purpose Complications following upper gastrointestinal (UGI) surgery are common. Symptom-monitoring following discharge is not standardized. An electronic patient-reported outcome (ePRO) system providing feedback to patients and clinicians could support patients and improve outcomes. Little is known about patients’ experiences of using such systems. This qualitative sub-study explored patients’ perspectives of the benefits of using a novel ePRO system, developed as part of the mixed methods eRAPID pilot study, to support recovery following discharge after UGI surgery. Methods Patients completed the online ePRO symptom-report system post-discharge. Weekly interviews explored patients’ experiences of using ePRO, the acceptability of feedback generated and its value for supporting their recovery. Interviews were audio-recorded and targeted transcriptions were thematically analysed. Results Thirty-five interviews with 16 participants (11 men, mean age 63 years) were analysed. Two main themes were identified: (1) reassurance and (2) empowerment. Feelings of isolation were common; many patients felt uninformed regarding their expectations of recovery and whether their symptoms warranted clinical investigation. Participants were reassured by tailored feedback advising them to contact their care team, alleviating their anxiety. Patients reported feeling empowered by the ePRO system and in control of their symptoms and recovery. Conclusion Patients recovering at home following major cancer surgery regarded electronic symptom-monitoring and feedback as acceptable and beneficial. Patients perceived that the system enhanced information provision and provided a direct link to their care team. Patients felt that the system provided reassurance at a time of uncertainty and isolation, enabling them to feel in control of their symptoms and recovery. Electronic supplementary material The online version of this article (10.1007/s11136-020-02539-w) contains supplementary material, which is available to authorised users.
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Affiliation(s)
- H S Richards
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - A Portal
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - K Absolom
- Leeds Institute of Medical Research at St James, St James's Hospital, University of Leeds, Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK
| | - J M Blazeby
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - G Velikova
- Leeds Institute of Medical Research at St James, St James's Hospital, University of Leeds, Bexley Wing, Beckett Street, Leeds, LS9 7TF, UK
| | - K N L Avery
- Bristol Centre for Surgical Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
- Medical Research Council ConDuCT-II Hub for Trials Methodology Research, Bristol Medical School: Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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