37th International Symposium on Intensive Care and Emergency Medicine (part 2 of 3)

Intensive care unit interventions to promote sleep and circadian biology in reducing incident delirium: a scoping review

RATIONALE/OBJECTIVES

Despite plausible pathophysiological mechanisms, research is needed to confirm the relationship between sleep, circadian rhythm and delirium in patients admitted to the intensive care unit (ICU). The objective of this review is to summarise existing studies promoting, in whole or in part, the normalisation of sleep and circadian biology and their impact on the incidence, prevalence, duration and/or severity of delirium in ICU.

METHODS

A sensitive search of electronic databases and conference proceedings was completed in March 2023. Inclusion criteria were English-language studies of any design that evaluated in-ICU non-pharmacological, pharmacological or mixed intervention strategies for promoting sleep or circadian biology and their association with delirium, as assessed at least daily. Data were extracted and independently verified.

RESULTS

Of 7886 citations, we included 50 articles. Commonly evaluated interventions include care bundles (n=20), regulation or administration of light therapy (n=5), eye masks and/or earplugs (n=5), one nursing care-focused intervention and pharmacological intervention (eg, melatonin and ramelteon; n=19). The association between these interventions and incident delirium or severity of delirium was mixed. As multiple interventions were incorporated in included studies of care bundles and given that there was variable reporting of compliance with individual elements, identifying which components might have an impact on delirium is challenging.

CONCLUSIONS

This scoping review summarises the existing literature as it relates to ICU sleep and circadian disruption (SCD) and delirium in ICU. Further studies are needed to better understand the role of ICU SCD promotion interventions in delirium mitigation.

"Patient Comfort Can Be Sacrificed for Patient Safety"-Perception and Practice Reported by Critical Care Nurses Toward Physical Restraints: A Qualitative Descriptive Study

Aim: The aim of the study was to explore the perception and practice of physical restraints used by critical care nurses.

Design: A qualitative descriptive design was used.

Method: From December 2019 to May 2020, a one-to-one, semi-structured in-depth interview with 10 critical care nurses from two intensive care units in a tertiary general hospital with 3,200 beds in China was conducted using the method of purposeful sampling. The data were analyzed using inductive thematic analysis.

Findings: The perception of physical restraints among critical care nurses was that patient comfort can be sacrificed for patient safety. Physical restraints protected patient safety by preventing patients from unplanned extubation but influenced patient comfort. Physical restraints were common practice of critical care nurses. Relative physical restraints provided patients with more freedom of movement and rationalization of physical restraints which were the practical strategies.

Conclusion: The study identified problems in critical care nurses' perception and practice on physical restraints. Critical care nurses are confident that physical restraints can protect patient safety, and the influence of physical restraints on patient comfort is just like the side effect. Although physical restraints were common practice, critical care nurses still faced dilemmas in the implementation of physical restraints. Relative physical restraints and rationalization of physical restraints help critical care nurses cope with the “bad feelings,” which may also be the cause of unplanned extubation. It is necessary for the adaptation of clinical practice guidelines about physical restraints for critically ill patients in the Chinese context, to change the perception and practice of critical care nurses and deliver safe and high-quality patient care.

Propofol Formulation Affects Myocardial Function in Newborn Infants

This study aimed to evaluate the effects of propofol in diluted and undiluted formulations on cardiac function in infants. Infants > 30 days received propofol sedation for central line insertion. Cases were divided into two groups: those who received undiluted 1% propofol (P1%); and those who received a diluted formulation (Pd) of equal volumes propofol 1% and 0.9% NaCl. Echocardiograms were performed pre (t₀)-, immediately post (t₁)-, and 1-h post (t₂) propofol administration. Myocardial deformation was assessed with tissue Doppler imaging (TDI) analysis and peak longitudinal strain (LS). 18 cases were included: nine (50%) P1% and nine (50%) Pd. In the P1% group, TDI velocities and LS were significantly reduced at t₁ and t₂. In the Pd Group, only TDI velocities in the left ventricle were reduced at t₁, but not at t₂. Dilution of propofol may minimize myocardial dysfunction while maintaining adequate sedation in infants. Further comparative studies are needed to investigate the safety and efficacy of this approach.

Intravenous Propofol Allows Fast Intubation in Neonates and Young Infants Undergoing Major Surgery

Aim of the study: In selected surgical neonates and infants, the rapidity of induction and intubation may represent an important factor for their safety. Propofol is an anesthetic characterized by a rapid onset and fast recovery time that may reduce time of anesthetic induction and improve post-anesthetic outcome. The aim of this study was to evaluate the safety and efficacy of anesthesia induction in full-term neonates and young infants after propofol bolus administration. Methods: A retrospective case-control study including infants below 6 months of age, undergoing general anesthesia between 2011 and 2013, was carried out. Patients that received intravenous propofol bolus to induce anesthesia were compared to patients who received inhaled sevoflurane. Time to reach successful orotracheal intubation (OTI) was measured in seconds. The quality of OTI was defined as "excellent," "good," and "poor," based on established classification and was reported. Hemodynamic parameters as systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), heart rate (HR), and oxygen saturation (SaO2) were collected before OTI (t0), at OTI (t1), and at spontaneous breathing recovery (t2). Main adverse effects were recorded for both groups. Results are median (IQ range) or prevalence; p < 0.05 was considered significant. Results: 160 infants were enrolled in the study, 80 received propofol and 80 inhaled sevoflurane. Major surgery (involving organs in the thoracic, abdominal, or pelvic cavities) was performed in 64 and 54% of patients in the propofol and sevoflurane group, respectively (p = 0.07). Patients in the propofol group showed a shorter time for OTI [11.5 (4.0-65) vs. 360.0 (228.0-720.0) seconds, (p < 0.0001)]. No difference was found in the quality of OTI between the two groups. No significant complications were recorded in either group. Conclusions: Propofol is a safe and effective anesthetic in neonates and infants permitting rapid induction of anesthesia and rapid intubation, without negative impact on the quality of intubation and haemodynamic compromise.