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Hamadeh S, Lambert GW, Willetts G, Garvey L. Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses. Intensive Crit Care Nurs 2024; 84:103770. [PMID: 39032213 DOI: 10.1016/j.iccn.2024.103770] [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: 11/30/2023] [Revised: 06/25/2024] [Accepted: 07/08/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Pain management of sedated and ventilated patients in intensive care units lacks consistency. OBJECTIVES To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives. METHODS A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to. OUTCOME MEASURES Demographics, training, governance, clinical practice, knowledge, and attitudes. RESULTS/FINDINGS 108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness." CONCLUSION The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management. IMPLICATIONS FOR CLINICAL PRACTICE Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.
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Affiliation(s)
- Samira Hamadeh
- Institute of Health and Wellbeing, Federation University, Australia. https://federation.edu.au/
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, Victoria, Australia. https://twitter.com/glamb30004
| | - Georgina Willetts
- Institute of Health and Wellbeing, Federation University, Australia. https://twitter.com/GeorgiWilletts
| | - Loretta Garvey
- Assessment Transformation, Federation University, Australia. https://twitter.com/LorettaGarvey
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Nydahl P, Liu K, Bellelli G, Benbenishty J, van den Boogaard M, Caplan G, Chung CR, Elhadi M, Gurjar M, Heras-La Calle G, Hoffmann M, Jeitziner MM, Krewulak K, Mailhot T, Morandi A, Nawa RK, Oh ES, Collet MO, Paulino MC, Lindroth H, von Haken R. A world-wide study on delirium assessments and presence of protocols. Age Ageing 2024; 53:afae129. [PMID: 38952186 DOI: 10.1093/ageing/afae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105 Kiel, Germany
- Institute of Nursing Science and Development, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Rd, Chermside QLD 4032, Australia
- Institute for Molecular Bioscience (IMB), The University of Queensland, 306 Carmody Rd, St Lucia QLD, 4067, Queensland, Australia
- Non-Profit Organization ICU Collaboration Network (ICON), 2-15-13 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
- Acute Geriatric Unit, IRCCS San Gerardo Foundation, Via Pergolesi 33, 20900 Monza, Italy
| | - Julie Benbenishty
- Hebrew University Faculty of Medicine School of Nursing, PO Box 12272, Jerusalem 91120, Israel
| | - Mark van den Boogaard
- Department Intensive Care, Radboud University Medical Center, 10 Geert Grooteplein Zuid, 6525 GA, Nijmegen, The Netherlands
| | - Gideon Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital Sydney, 320-346 Barker St, Randwick NSW 2031, Sydney, Australia
- University of New South Wales, Gate 9, High St, The Chancellery Kensington, 2052, NSW Sydney, Australia
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro Gangnam-gu. Seoul, Korea 06351, South Korea
| | - Muhammed Elhadi
- Faculty of Medicine, University of Tripoli, University Road, Al-Furnaje Tripoli, PO Box 13932, Tripoli, Libya
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Rae Bareli Road, Lucknow-226014, Uttar Pradesh, India
| | - Gabi Heras-La Calle
- Director of the International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI), Madrid, Spain
- Intensive Care Unit, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Magdalena Hoffmann
- Research Unit for Safety and Sustainability in Healthcare, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Marie-Madlen Jeitziner
- Department of Intensive Care Medicine, University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
- Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 1, Postfach, 4001 Basel, Switzerland
| | - Karla Krewulak
- Department of Critical Care Medicine, Alberta Health Services and University of Calgary, 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1, Canada
| | - Tanya Mailhot
- Montreal Heart Institute Research Center, Faculty of Nursing, Université de Montréal, 680 Sherbrooke West, Montreal QC, H3A 2M7, Canada
| | - Alessandro Morandi
- Intermediate Care and Rehabilitation, Azienda Speciale Cremona Solidale, Via Brescia 207, 26100 Cremona, Italy
- Parc Sanitari Per Vergili, Val d'Hebron Institute of Research, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Ricardo Kenji Nawa
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627, São Paulo, SP 05652-900, Brazil
| | - Esther S Oh
- Departments of Medicine, Psychiatry and Behavioral Sciences, and Pathology, Johns Hopkins University School of Medicine, 733 N. Broadway, MD 21205 Baltimore, ML, USA
| | - Marie O Collet
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Maria Carolina Paulino
- Department of Intensive Care, Hospital da Luz Lisboa, 1150-082 Lisbon, Portugal
- NOVA Medical School, New University of Lisbon, 1150-199 Lisbon, Portugal
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1500-650 Lisbon, Portugal
| | - Heidi Lindroth
- Division of Nursing Research, Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
- Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, 1101 W 10th St, Indianapolis, IN 46202, USA
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Paul N, Grunow JJ, Rosenthal M, Spies CD, Page VJ, Hanison J, Patel B, Rosenberg A, von Haken R, Pietsch U, Schrag C, Waydhas C, Schellongowski P, Lobmeyr E, Sander M, Piper SK, Conway D, Totzeck A, Weiss B. Enhancing European Management of Analgesia, Sedation, and Delirium: A Multinational, Prospective, Interventional Before-After Trial. Neurocrit Care 2024; 40:898-908. [PMID: 37697129 PMCID: PMC11147880 DOI: 10.1007/s12028-023-01837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND The objective of this study was to analyze the impact of a structured educational intervention on the implementation of guideline-recommended pain, agitation, and delirium (PAD) assessment. METHODS This was a prospective, multinational, interventional before-after trial conducted at 12 intensive care units from 10 centers in Germany, Austria, Switzerland, and the UK. Intensive care units underwent a 6-week structured educational program, comprising online lectures, instructional videos, educational handouts, and bedside teaching. Patient-level PAD assessment data were collected in three 1-day point-prevalence assessments before (T1), 6 weeks after (T2), and 1 year after (T3) the educational program. RESULTS A total of 430 patients were included. The rate of patients who received all three PAD assessments changed from 55% (107/195) at T1 to 53% (68/129) at T2, but increased to 73% (77/106) at T3 (p = 0.003). The delirium screening rate increased from 64% (124/195) at T1 to 65% (84/129) at T2 and 77% (82/106) at T3 (p = 0.041). The pain assessment rate increased from 87% (170/195) at T1 to 92% (119/129) at T2 and 98% (104/106) at T3 (p = 0.005). The rate of sedation assessment showed no signficiant change. The proportion of patients who received nonpharmacological delirium prevention measures increased from 58% (114/195) at T1 to 80% (103/129) at T2 and 91% (96/106) at T3 (p < 0.001). Multivariable regression revealed that at T3, patients were more likely to receive a delirium assessment (odds ratio [OR] 2.138, 95% confidence interval [CI] 1.206-3.790; p = 0.009), sedation assessment (OR 4.131, 95% CI 1.372-12.438; p = 0.012), or all three PAD assessments (OR 2.295, 95% CI 1.349-3.903; p = 0.002) compared with T1. CONCLUSIONS In routine care, many patients were not assessed for PAD. Assessment rates increased significantly 1 year after the intervention. Clinical trial registration ClinicalTrials.gov: NCT03553719.
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Affiliation(s)
- Nicolas Paul
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Max Rosenthal
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Valerie J Page
- Department of Anaesthesia, Watford General Hospital, Watford, Hertfordshire, UK
| | - James Hanison
- Manchester Royal Infirmary, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Brijesh Patel
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Alex Rosenberg
- Royal Brompton and Harefield National Health Service Foundation Trust, London, UK
| | - Rebecca von Haken
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Urs Pietsch
- Department of Anesthesiology and Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Claudia Schrag
- Clinic of Intensive Care Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
- Medical Faculty, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Elisabeth Lobmeyr
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Sophie K Piper
- Berlin Institute of Health, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Conway
- Manchester Royal Infirmary, Manchester University National Health Service Foundation Trust, Manchester, UK
| | - Andreas Totzeck
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, Germany
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
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Bhattacharyya A, Laycock H, Brett SJ, Beatty F, Kemp HI. Health care professionals' experiences of pain management in the intensive care unit: a qualitative study. Anaesthesia 2024; 79:611-626. [PMID: 38153304 DOI: 10.1111/anae.16209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2023] [Indexed: 12/29/2023]
Abstract
Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.
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Affiliation(s)
| | - H Laycock
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - S J Brett
- Division of Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Directorate of Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - F Beatty
- Guy's and St Thomas' NHS Trust, London, UK
| | - H I Kemp
- The Pain Research Group, Imperial College London, London, UK
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Balsalobre-Martínez P, Montosa-García R, Marín-Yago A, Baeza-Mirete M, Muñoz-Rubio GM, Rojo-Rojo A. Challenges of the Implementation of a Delirium Rate Scale in a Pediatric Intensive Care Unit: A Qualitative Approach. Healthcare (Basel) 2023; 12:52. [PMID: 38200958 PMCID: PMC10779040 DOI: 10.3390/healthcare12010052] [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: 10/31/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
INTRODUCTION Delirium in the pediatric population admitted to intensive care is a worrying reality due to its potential complications and the increase in associated costs. This study aims to explore the experiences of nursing staff of a Pediatric Intensive Care Unit after 15 months of starting a program to fight against childhood delirium in their unit. METHODOLOGY A qualitative study was conducted through semi-structured interviews with Pediatric Intensive Care Unit (PICU) Key Informants. The Standards for Reporting Qualitative Research (SRQR) and the consolidated criteria for Reporting Qualitative Research (COREQ) were followed as quality measures for the study. Seven nurses (33% of the eligible population) from the PICU of a referral hospital were interviewed. Text transcripts were analyzed using the Interpretative Description and Qualitative Content Analysis method. RESULTS The interviewees indicated not identifying delirium as an important reality; with great deficiencies observed in what is related to the identification of delirium; identifying CAPD as an unreliable tool in their unit; and not sharing therapeutic objectives in this respect with the medical staff. CONCLUSIONS The nursing staff presented a series of negative attitudes towards the phenomena of delirium in their unit, with gaps in training and in clinical management, and the diagnostic tool used, and did not see it as a priority objective of the unit, partly due to a resistance to change and a latent interprofessional communication conflict. A change at the formative, attitudinal, and relational levels is urgently needed for the success of the program and the well-being of the children in the unit.
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Affiliation(s)
| | - Raquel Montosa-García
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Ana Marín-Yago
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Healthcare System, 30120 Murcia, Spain (A.M.-Y.)
| | - Manuel Baeza-Mirete
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
| | - Gloria María Muñoz-Rubio
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Public Murcian Health System, 30120 Murcia, Spain
| | - Andrés Rojo-Rojo
- Faculty of Nursing, Catholic University of Murcia (UCAM), 30107 Murcia, Spain
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Tronstad O, Patterson S, Sutt AL, Pearse I, Hay K, Liu K, Sato K, Koga Y, Matsuoka A, Hongo T, Rätsep I, Fraser JF, Flaws D. A protocol of an international validation study to assess the clinical accuracy of the eDIS-ICU delirium screening tool. Aust Crit Care 2023; 36:1043-1049. [PMID: 37003849 DOI: 10.1016/j.aucc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Delirium is a common, yet underdiagnosed neuropsychiatric complication of intensive care unit (ICU) admission, associated with significant mortality and morbidity. Delirium can be difficult to diagnose, with gold standard assessments by a trained specialist being impractical and rarely performed. To address this, various tools have been developed, enabling bedside clinicians to assess for delirium efficiently and accurately. However, the performance of these tools varies depending on factors including the assessor's training. To address the shortcomings of current tools, electronic tools have been developed. AIMS AND OBJECTIVES The aims of this validation study are to assess the feasibility, acceptability, and generalisability of a recently developed and pilot-tested electronic delirium screening tool (eDIS-ICU) and compare diagnostic concordance, sensitivity, and specificity between eDIS-ICU, Confusion Assessment Method for the ICU (CAM-ICU), and the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V) gold standard in diverse ICU settings. METHODS Seven hundred participants will be recruited across five sites in three countries. Participants will complete three assessments (eDIS-ICU, CAM-ICU, and DSM-V) twice within one 24-h period. At each time point, assessments will be completed within one hour. Assessments will be administered by three different people at any given time point, with the assessment order and assessor for eDIS-ICU and CAM-ICU randomly allocated. Assessors will be blinded to previous and concurrent assessment results. RESULTS The primary outcome is comparing diagnostic sensitivity of eDIS-ICU and CAM-ICU against the DSM-V. RELEVANCE TO CLINICAL PRACTICE This protocol describes a definitive validation study of an electronic diagnostic tool to assess for delirium in the ICU. Delirium remains a common and difficult challenge in the ICU and is linked with multiple neurocognitive sequelae. Various challenges to routine assessment mean many cases are still unrecognised or misdiagnosed. An improved ability for bedside clinicians to screen for delirium accurately and efficiently will support earlier diagnosis, identification of underlying cause(s) and timely treatments, and ultimately improved patient outcomes. CLINICAL TRIAL REGISTRATION NUMBER This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) on 8th February 2022 (ACTRN12622000220763).
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Affiliation(s)
- Oystein Tronstad
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Physiotherapy Department, The Prince Charles Hospital, Brisbane, Queensland, Australia.
| | - Sue Patterson
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; School of Dentistry, The University of Queensland, Brisbane, Queensland, Australia.
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - India Pearse
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Menzies Health Institute QLD, Griffith University, Gold Coast, Australia.
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Yuji Koga
- Kawasaki University of Medical Welfare, Kawasaki, Japan; Kawasaki Medical School Hospital, Kawasaki, Japan.
| | | | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Indrek Rätsep
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia.
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Metro North Mental Health, Caboolture Hospital, Queensland, Australia; School of Clinical Science, Queensland University of Technology, Brisbane, Queensland, Australia.
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Hyun DG, Ahn JH, Gil HY, Nam CM, Yun C, Lim CM. Longitudinal trajectories of sedation level and clinical outcomes in patients who are mechanically ventilated based on a group-based trajectory model: a prospective, multicentre, longitudinal and observational study in Korea. BMJ Open 2023; 13:e072628. [PMID: 37369420 PMCID: PMC10410862 DOI: 10.1136/bmjopen-2023-072628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES Changes in sedation levels over a long time in patients who are mechanically ventilated are unknown. Therefore, we investigated the long-term sedation levels of these patients by classifying them into different longitudinal patterns. DESIGN This was a multicentre, prospective, longitudinal, and observational study. SETTING Twenty intensive care units (ICUs) spanning several medical institutions in Korea. PARTICIPANTS Patients who received mechanical ventilation and sedatives in ICU within 48 hours of admission between April 2020 and July 2021. PRIMARY AND SECONDARY OUTCOME MEASURES The primary objective of this study was to identify the pattern of sedation practice. Additionally, we analysed the associations of trajectory groups with clinical outcomes as the secondary outcome. RESULTS Sedation depth was monitored using Richmond Agitation-Sedation Scale (RASS). A group-based trajectory model was used to classify 631 patients into four trajectories based on sedation depth: persistent suboptimal (13.2%, RASS ≤ -3 throughout the first 30 days), delayed lightening (13.9%, RASS ≥ -2 after the first 15 days), early lightening (38.4%, RASS ≥ -2 after the first 7 days) and persistent optimal (34.6%, RASS ≥ -2 during the first 30 days). 'Persistent suboptimal' trajectory was associated with delayed extubation (HR: 0.23, 95% CI: 0.16 to 0.32, p<0.001), longer ICU stay (HR: 0.36, 95% CI: 0.26 to 0.51, p<0.001) and hospital mortality (HR: 13.62, 95% CI: 5.99 to 30.95, p<0.001) compared with 'persistent optimal'. The 'delayed lightening' and 'early lightening' trajectories showed lower extubation probability (HR: 0.30, 95% CI: 0.23 to 0.41, p<0.001; HR: 0.72, 95% CI: 0.59 to 0.87, p<0.001, respectively) and ICU discharge (HR: 0.44, 95% CI: 0.33 to 0.59, p<0.001 and HR: 0.80, 95% CI: 0.65 to 0.97, p=0.024) compared with 'persistently optimal'. CONCLUSIONS Among the four trajectories, 'persistent suboptimal' trajectory was associated with higher mortality.
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Affiliation(s)
- Dong-Gon Hyun
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jee Hwan Ahn
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ha-Yeong Gil
- Medical Research Project Team, Pfizer Korea Pharmaceuticals Ltd, Seoul, Republic of Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Choa Yun
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
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Hyun DG, Ahn JH, Gil HY, Nam CM, Yun C, Lee JM, Kim JH, Lee DH, Kim KH, Kim DJ, Lee SM, Ryu HG, Hong SK, Kim JB, Choi EY, Baek J, Kim J, Kim EJ, Park TY, Kim JH, Park S, Park CM, Jung WJ, Choi NJ, Jang HJ, Lee SH, Lee YS, Suh GY, Choi WS, Lee KS, Kim HW, Min YG, Lee SJ, Lim CM. The Profile of Early Sedation Depth and Clinical Outcomes of Mechanically Ventilated Patients in Korea. J Korean Med Sci 2023; 38:e141. [PMID: 37191845 DOI: 10.3346/jkms.2023.38.e141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/31/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known. METHODS From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation-Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups. RESULTS Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death (P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.55-0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% CI, 0.56-0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79-1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65-2.17; P = 0.582). CONCLUSION In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.
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Affiliation(s)
- Dong-Gon Hyun
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jee Hwan Ahn
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha-Yeong Gil
- Medical Research Project Team, IM Medical, Pfizer Korea Pharmaceuticals Limited Company, Seoul, Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Choa Yun
- Division of Biostatistics, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Myeong Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jae Hun Kim
- Department of Trauma and Surgical Critical Care and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong-Hyun Lee
- Department of Intensive Care Medicine, Dong-A University Hospital, Busan, Korea
| | - Ki Hoon Kim
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dong Jung Kim
- Department of Thoracic & Cardiovascular Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Min Lee
- Department of Critical Care Medicine, Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho-Geol Ryu
- Department of Critical Care Medicine, Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Suk-Kyung Hong
- Department of Acute Care Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Eun Young Choi
- Division of Pulmonology and Allergy, Department of Internal Medicine, Regional Center for Respiratory Diseases, Yeungnam University Medical Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - JongHyun Baek
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University Medical Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jeoungmin Kim
- Division of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jin Kim
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Tae Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Je Hyeong Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hwaseong, Korea
| | - Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Jai Jung
- Department of Pulmonary, Allergy, and Critical Care Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Nak-Jun Choi
- Division of Acute Care Surgery, Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hang-Jea Jang
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Su Hwan Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Seok Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo-Sung Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Keu Sung Lee
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyung Won Kim
- Division of Acute Care Surgery, Department of Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Young-Gi Min
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Seok Jeong Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]. DER NERVENARZT 2023; 94:99-105. [PMID: 36269366 DOI: 10.1007/s00115-022-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.
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Kim SB, Bong SH, Lee JH, Choi TY, Yoon SY, Kim JW. The Usefulness of Quantitative Electroencephalography in Diagnosis and Severity Evaluation of Delirium: A Retrospective Study. Psychiatry Investig 2023; 20:144-151. [PMID: 36891599 PMCID: PMC9996146 DOI: 10.30773/pi.2022.0294] [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: 10/11/2022] [Accepted: 12/09/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE Incontrovertible disease markers are absent in delirium. This study investigated the usefulness of quantitative electroencephalography (qEEG) in diagnosing delirium. METHODS This retrospective case-control study reviewed medical records and qEEG data of 69 age/sex-matched patients (delirium group, n=30; control group, n=39). The first minute of artifact-free EEG data with eyes closed was selected. Nineteen electrodes' sensitivity, specificity, and correlation with delirium rating scale-revised-98 were analyzed. RESULTS On comparing the means of absolute power by frontal, central, and posterior regions, the delta and theta powers showed significant differences (p<0.001) in all regions, and the magnitude of the absolute power was higher in the delirium group than in the control group; only the posterior region showed a significant (p<0.001) difference in beta power. The spectral power of theta at the frontal region (area under the curve [AUC]=0.84) and theta at the central and posterior regions (AUC=0.83) showed 90% sensitivity and 79% specificity, respectively, in differentiating delirious patients and controls. The beta power of the central region showed a significant negative correlation with delirium severity (R=-0.457, p=0.011). CONCLUSION Power spectrum analysis of qEEG showed high accuracy in screening delirium among patients. The study suggests qEEG as a potential aid in diagnosing delirium.
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Affiliation(s)
- Seung Bhin Kim
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Su Hyun Bong
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jong Hun Lee
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Tae Young Choi
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Seo Young Yoon
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jun Won Kim
- Department of Psychiatry, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
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Waydhas C, Deffner T, Gaschler R, Häske D, Hamsen U, Herbstreit F, Hierundar A, Kumpf O, Rohe G, Spiekermann A, Vonderhagen S, Waeschle RM, Riessen R. Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey. BMC Anesthesiol 2022; 22:384. [PMID: 36503427 PMCID: PMC9743767 DOI: 10.1186/s12871-022-01887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.
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Affiliation(s)
- Christian Waydhas
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany ,Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Teresa Deffner
- grid.275559.90000 0000 8517 6224Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Jena, Bachstrasse 18, 07743 Jena, Germany
| | - Robert Gaschler
- Fakultät Für Psychologie, Lehrgebiet Allgemeine Psychologie: Lernen, Motivation, Emotion, FernUniversität in Hagen, Universitätsstrasse 33, 58084 Hagen, Germany
| | - David Häske
- grid.411544.10000 0001 0196 8249Center for Public Health and Health Services Research, University Hospital Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Uwe Hamsen
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Frank Herbstreit
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Anke Hierundar
- grid.413108.f0000 0000 9737 0454Klinik Für Anästhesiologie Und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Kumpf
- grid.7468.d0000 0001 2248 7639Klinik Für Anästhesiologie Mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte Und Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Rohe
- grid.5560.60000 0001 1009 3608University Clinic for Anaesthesiology / Intensive Care Medicine / Emergency Medicine / Pain Medicine, Klinikum Oldenburg, Medical Campus of the University Oldenburg), Rahel Straus - Str. 10, 26133 Oldenburg, Germany
| | - Aileen Spiekermann
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Sonja Vonderhagen
- Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Reiner M. Waeschle
- grid.411984.10000 0001 0482 5331Klinik Für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099 Göttingen, Germany
| | - Reimer Riessen
- grid.411544.10000 0001 0196 8249Department Für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany
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Varga S, Ryan T, Moore T, Seymour J. What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100060. [PMID: 38745639 PMCID: PMC11080319 DOI: 10.1016/j.ijnsa.2021.100060] [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: 08/18/2021] [Revised: 12/22/2021] [Accepted: 12/31/2021] [Indexed: 11/15/2022] Open
Abstract
Background Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery. Objective Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients. Design We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients. Settings General adult intensive care units. Participants Health care professionals working in adult intensive care units. Methods Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis. Results Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation. Conclusions A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence. Tweetable abstract Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.
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Affiliation(s)
- Sarah Varga
- Division of Nursing and Midwifery, Health Sciences School, Sheffield S10 2HQ, United Kingdom
| | - Tony Ryan
- Division of Nursing and Midwifery, Health Sciences School, Sheffield S10 2HQ, United Kingdom
| | - Tracey Moore
- Division of Nursing and Midwifery, Health Sciences School, Sheffield S10 2HQ, United Kingdom
| | - Jane Seymour
- Division of Nursing and Midwifery, Health Sciences School, Sheffield S10 2HQ, United Kingdom
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Hermes C, Ottens T, Knitter P, Hauss O, Bellgardt M, von Dossow V. Delir – Beurteilung, Vorbeugung und Behandlung. Med Klin Intensivmed Notfmed 2022; 117:479-488. [DOI: 10.1007/s00063-022-00943-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
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Paulino MC, Pereira IJ, Costa V, Neves A, Santos A, Teixeira CM, Coimbra I, Fernandes P, Bernardo R, Póvoa P, Granja C. Sedation, analgesia, and delirium management in Portugal: a survey and point prevalence study. Rev Bras Ter Intensiva 2022; 34:227-236. [PMID: 35946653 DOI: 10.5935/0103-507x.20220020-pt] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/19/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To establish current Portuguese critical care practices regarding analgesia, sedation, and delirium based on a comparison between the activities reported and daily clinical practice. METHODS A national survey was conducted among physicians invited to report their practice toward analgesia, sedation, and delirium in intensive care units. A point prevalence study was performed to analyze daily practices. RESULTS A total of 117 physicians answered the survey, and 192 patients were included in the point prevalence study. Survey and point prevalence studies reflect a high sedation assessment (92%; 88.5%), with the Richmond Agitated Sedation Scale being the most reported and used scale (41.7%; 58.2%) and propofol being the most reported and used medication (91.4%; 58.6%). Midazolam prescribing was reported by 68.4% of responders, but a point prevalence study revealed a use of 27.6%.Although 46.4% of responders reported oversedation, this was actually documented in 32% of the patients. The survey reports the daily assessment of pain (92%) using standardized scales (71%). The same was identified in the point prevalence study, with 91.1% of analgesia assessment mainly with the Behavioral Pain Scale. In the survey, opioids were reported as the first analgesic. In clinical practice, acetaminophen was the first option (34.6%), followed by opioids. Delirium assessment was reported by 70% of physicians but was performed in less than 10% of the patients. CONCLUSION The results from the survey did not accurately reflect the common practices in Portuguese intensive care units, as reported in the point prevalence study. Efforts should be made specifically to avoid oversedation and to promote delirium assessment.
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Affiliation(s)
- Maria Carolina Paulino
- Unidade de Terapia Intensiva Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
| | - Isabel Jesus Pereira
- Departamento de Medicina Intensiva, Centro Hospitalar de Gaia/Espinho - Vila Nova de Gaia, Portugal
| | - Vasco Costa
- Unidade de Terapia Intensiva Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
| | - Aida Neves
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário de São João - Porto, Portugal
| | - Anabela Santos
- Serviço de Medicina Intensiva/Anestesiologia, Centro Hospitalar Trás-os-Montes - Alto Douro, Portugal
| | - Carla Margarida Teixeira
- Departamento de Anestesiologia e Medicina Intensiva, Centro Hospitalar Universitário do Porto - Porto, Portugal
| | - Isabel Coimbra
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário de São João - Porto, Portugal
| | - Paula Fernandes
- Departamento de Medicina Intensiva, Centro Hospitalar de Gaia/Espinho - Vila Nova de Gaia, Portugal
| | - Ricardo Bernardo
- Departamento de Anestesiologia, Centro Hospitalar Universitário Lisboa Norte - Lisboa, Portugal
| | - Pedro Póvoa
- Unidade de Terapia Intensiva Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal
| | - Cristina Granja
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário de São João - Porto, Portugal
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Wiegand TLT, Rémi J, Dimitriadis K. Electroencephalography in delirium assessment: a scoping review. BMC Neurol 2022; 22:86. [PMID: 35277128 PMCID: PMC8915483 DOI: 10.1186/s12883-022-02557-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Background Delirium is a common disorder affecting around 31% of patients in the intensive care unit (ICU). Delirium assessment scores such as the Confusion Assessment Method (CAM) are time-consuming, they cannot differentiate between different types of delirium and their etiologies, and they may have low sensitivities in the clinical setting. While today, electroencephalography (EEG) is increasingly being applied to delirious patients in the ICU, a lack of clear cut EEG signs, leads to inconsistent assessments. Methods We therefore conducted a scoping review on EEG findings in delirium. One thousand two hundred thirty-six articles identified through database search on PubMed and Embase were reviewed. Finally, 33 original articles were included in the synthesis. Results EEG seems to offer manifold possibilities in diagnosing delirium. All 33 studies showed a certain degree of qualitative or quantitative EEG alterations in delirium. Thus, normal routine (rEEG) and continuous EEG (cEEG) make presence of delirium very unlikely. All 33 studies used different research protocols to at least some extent. These include differences in time points, duration, conditions, and recording methods of EEG, as well as different patient populations, and diagnostic methods for delirium. Thus, a quantitative synthesis and common recommendations are so far elusive. Conclusion Future studies should compare the different methods of EEG recording and evaluation to identify robust parameters for everyday use. Evidence for quantitative bi-electrode delirium detection based on increased relative delta power and decreased beta power is growing and should be further pursued. Additionally, EEG studies on the evolution of a delirium including patient outcomes are needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02557-w.
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de Souza RLP, Abrão J, Garcia LV, Vila Moutinho S, Wiggers E, Cagnoni Balestra A. Impact of a Multimodal Analgesia Protocol in an Intensive Care Unit: A Pre-post Cohort Study. Cureus 2022; 14:e22786. [PMID: 35371872 PMCID: PMC8971103 DOI: 10.7759/cureus.22786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 11/05/2022] Open
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Nydahl P, Baumgarte F, Berg D, Bergjan M, Borzikowsky C, Franke C, Green D, Hannig A, Hansen HC, Hauss A, Hansen U, Istel R, Krämer N, Krause K, Lohrmann R, Mohammadzadeh-Vazifeh M, Osterbrink J, Palm F, Petersen T, Schöller B, Stolze H, Zilezinski M, Meyne J, Margraf NG. Delirium on stroke units: a prospective, multicentric quality-improvement project. J Neurol 2022; 269:3735-3744. [PMID: 35157137 PMCID: PMC9217833 DOI: 10.1007/s00415-022-11000-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
Abstract
Background Post-stroke delirium (POD) in patients on stroke units (SU) is associated with an increased risk for complications and poorer clinical outcome. The objective was to reduce the severity of POD by implementing an interprofessional delirium-management. Methods Multicentric quality-improvement project on five SU implementing a delirium-management with pre/post-comparison. Primary outcome was severity of POD, assessed with the Nursing Delirium Screening Scale (Nu-DESC). Secondary outcome parameters were POD incidence, duration, modified Rankin Scale (mRS), length of stay in SU and hospital, mortality, and others. Results Out of a total of 799 patients, 59.4% (n = 475) could be included with 9.5% (n = 45) being delirious. Implementation of a delirium-management led to reduced POD severity; Nu-DESC median: pre: 3.5 (interquartile range 2.6–4.7) vs. post 3.0 (2.2–4.0), albeit not significant (p = 0.154). Other outcome parameters were not meaningful different. In the post-period, delirium-management could be delivered to 75% (n = 18) of delirious patients, and only 24 (53.3%) of delirious patients required pharmacological treatments. Patients with a more severe stroke and POD remained on their disability levels, compared to similar affected, non-delirious patients who improved. Conclusions Implementation of delirium-management on SU is feasible and can be delivered to most patients, but with limited effects. Nursing interventions as first choice could be delivered to the majority of patients, and only the half required pharmacological treatments. Delirium-management may lead to reduced severity of POD but had only partial effects on duration of POD or length of stay. POD hampers rehabilitation, especially in patients with more severe stroke. Registry DRKS, DRKS00021436. Registered 04/17/2020, www.drks.de/DRKS00021436. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11000-6.
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Affiliation(s)
- Peter Nydahl
- Nursing Science and development, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | | | - Daniela Berg
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Manuela Bergjan
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics und Statistics, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Christiana Franke
- Department of Neurology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Diana Green
- Christian Albrechts University Kiel, Kiel, Germany
| | - Anisa Hannig
- Department of Neurology, Friedrich-Ebert-Krankenhaus, Neumünster, Germany
| | | | - Armin Hauss
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Uta Hansen
- Department of Neurology, Diako Flensburg, Flensburg, Germany
| | - Rahel Istel
- Christian Albrechts University Kiel, Kiel, Germany
| | - Norma Krämer
- Department of Neurology, Friedrich-Ebert-Krankenhaus, Neumünster, Germany
| | | | - Renée Lohrmann
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | | | - Jürgen Osterbrink
- Institut für Pflegewissenschaft und-praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
- Brooks College of Health, University of North Florida, Jacksonville, USA
| | - Frederick Palm
- Department of Neurology, Heliosklinikum Schleswig, Schleswig, Germany
| | | | - Bernd Schöller
- Department of Neurology, Heliosklinikum Schleswig, Schleswig, Germany
| | - Henning Stolze
- Department of Neurology, Diako Flensburg, Flensburg, Germany
| | - Max Zilezinski
- Business Division Nursing Directorate, Nursing Science, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- University Medicine Halle (Saale), Health Service Research Working Group | Acute Care, Department of Internal Medicine, Faculty of Medicine, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Johannes Meyne
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Nils G. Margraf
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
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18
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Ishii K, Kuroda K, Tokura C, Michida M, Sugimoto K, Sato T, Ishikawa T, Hagioka S, Manabe N, Kurasako T, Goto T, Kimura M, Sunami K, Inoue K, Tsukiji T, Yasukawa T, Nogami S, Tsukioki M, Okabe D, Tanino M, Morimatsu H. Current status of delirium assessment tools in the intensive care unit: a prospective multicenter observational survey. Sci Rep 2022; 12:2185. [PMID: 35140285 PMCID: PMC8828828 DOI: 10.1038/s41598-022-06106-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/24/2022] [Indexed: 01/01/2023] Open
Abstract
Delirium is a critical challenge in the intensive care unit (ICU) or high care unit (HCU) setting and is associated with poor outcomes. There is not much literature on how many patients in this setting are assessed for delirium and what tools are used. This study investigated the status of delirium assessment tools of patients in the ICU/HCU. We conducted a multicenter prospective observational study among 20 institutions. Data for patients who were admitted to and discharged from the ICU/HCU during a 1-month study period were collected from each institution using a survey sheet. The primary outcome was the usage rate of delirium assessment tools on an institution- and patient-basis. Secondary outcomes were the delirium prevalence assessed by each institution’s assessment tool, comparison of delirium prevalence between delirium assessment tools, delirium prevalence at the end of ICH/HCU stay, and the relationship between potential factors related to delirium and the development of delirium. Result showed that 95% of institutions used the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU) to assess delirium in their ICU/HCU, and the remaining one used another assessment scale. The usage rate (at least once during the ICU/HCU stay) of the ICDSC and the CAM-ICU among individual patients were 64.5% and 25.1%, and only 8.2% of enrolled patients were not assessed by any delirium assessment tool. The prevalence of delirium during ICU/HCU stay was 17.9%, and the prevalence of delirium at the end of the ICU/HCU stay was 5.9%. In conclusion, all institutions used delirium assessment tools in the ICU/HCU, and most patients received delirium assessment. The prevalence of delirium was 17.9%, and two-thirds of patients had recovered at discharge from ICU/HCU. Trial registration number: UMIN000037834.
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Affiliation(s)
- Kenzo Ishii
- Department of Anesthesiology, Intensive Care Unit, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan. .,Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Kosuke Kuroda
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Chika Tokura
- Department of Anesthesia, Kagawa Rosai Hospital, Marugame, Kagawa, Japan
| | - Masaaki Michida
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | | | - Tetsufumi Sato
- Department of Anesthesia and Intensive Care, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoki Ishikawa
- Department of Anesthesia, Okayama Red Cross General Hospital, Okayama, Japan
| | - Shingo Hagioka
- Department of Anesthesia, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | - Nobuki Manabe
- Department of Anesthesia, Saiseikai Imabari Hospital, Imabari, Ehime, Japan
| | - Toshiaki Kurasako
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Takashi Goto
- Department of Anesthesia, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Masakazu Kimura
- Department of Anesthesia, Okayama City Hospital, Okayama, Japan
| | - Kazuharu Sunami
- Department of Internal Medicine, Okayama Kyoritsu Hospital, Okayama, Japan
| | - Kazuyoshi Inoue
- Department of Anesthesia, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Takashi Tsukiji
- Department of Anesthesia, Takasago Municipal Hospital, Takasago, Hyogo, Japan
| | - Takeshi Yasukawa
- Department of Anesthesia, Okayama Kyokuto Hospital, Okayama, Japan
| | - Satoshi Nogami
- Department of Anesthesia, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Mitsunori Tsukioki
- Department of Anesthesia, Onomichi Municipal Hospital, Onomichi, Hiroshima, Japan
| | - Daisuke Okabe
- Department of Anesthesia, Himeji St. Mary's Hospital, Himeji, Hyogo, Japan
| | - Masaaki Tanino
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School Hospital, Kurashiki, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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19
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Luz M, Brandão Barreto B, de Castro REV, Salluh J, Dal-Pizzol F, Araujo C, De Jong A, Chanques G, Myatra SN, Tobar E, Gimenez-Esparza Vich C, Carini F, Ely EW, Stollings JL, Drumright K, Kress J, Povoa P, Shehabi Y, Mphandi W, Gusmao-Flores D. Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic. Ann Intensive Care 2022; 12:9. [PMID: 35122204 PMCID: PMC8815719 DOI: 10.1186/s13613-022-00985-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/16/2022] [Indexed: 12/16/2022] Open
Abstract
Background Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. Methods This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. Results We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. Conclusions Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00985-y.
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Affiliation(s)
- Mariana Luz
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil. .,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil. .,Intensive Care Unit, Hospital Universitário Professor Edgard Santos, Salvador, Brazil.
| | - Bruna Brandão Barreto
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Roberta Esteves Vieira de Castro
- Departamento de Pediatria, Hospital Universitário Pedro Ernesto, Universidade Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jorge Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil.,Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Caio Araujo
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, BA, Brazil
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Gérald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Eduardo Tobar
- Internal Medicine Department, Critical Care Unit, Hospital Clínico Universidad de Chile, Santiago, Chile
| | | | - Federico Carini
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eugene Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly Drumright
- Tennessee Valley Healthcare System VA Medical Center, Nashville, TN, USA
| | - John Kress
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | - Pedro Povoa
- Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal.,CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Yahya Shehabi
- Department of Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Wilson Mphandi
- Intensive Care Unit, Hospital Américo Boavida, Luanda, Angola
| | - Dimitri Gusmao-Flores
- Intensive Care Unit of the Hospital da Mulher, Rua Barão de Cotegipe, 1153, Roma, Salvador, BA, CEP: 40411-900, Brazil.,Programa de Pós-Graduação em Medicina e Saúde, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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20
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Frade-Mera MJ, Arias-Rivera S, Zaragoza-García I, Martí JD, Gallart E, San José-Arribas A, Velasco-Sanz TR, Blazquez-Martínez E, Raurell-Torredà M. The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nurs Crit Care 2022; 27:772-783. [PMID: 34994034 DOI: 10.1111/nicc.12740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ABCDE bundle is a set of evidence-based practices to systematically reduce the risks of sedation, delirium, and immobility in intensive care patients. Implementing the bundle improves clinical outcome. AIMS AND OBJECTIVES To investigate the association between patient outcomes and compliance with bundle components ABC (analgosedation algorithms), D (delirium protocol), and E (early mobilization protocol). DESIGN A Spanish multicentre cohort study of adult patients receiving invasive mechanical ventilation (IMV) for ≥48 h until extubation. METHODS The primary outcome was pain level, cooperation to permit Medical Research Council Scale administration, patient days of delirium, and mobility. The secondary outcome was cumulative drug dosing by IMV days. Tertiary outcomes (ICU days, IMV days, bed rest days, ICU mortality, ICUAW) and independent variables (analgosedation, delirium, early mobilization protocols) were also studied. RESULTS Data were collected from 605 patients in 80 ICUs and 5214 patient days with IMV. Two-thirds of the ICUs studied applied no protocols. Pain was not assessed on 83.6% of patient days. Patient cooperation made scale administration feasible on 20.7% of days. Delirium and immobility were found on 4.2% and 69.9% of days, respectively. Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03, respectively). Analgosedation protocols were associated with more opioid dosing (P = 0.02), and delirium and early mobilization protocols with more propofol (P = 0.001), dexmedetomidine (P = 0.001), and lower benzodiazepine dosing (P = 0.008). CONCLUSIONS The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. RELEVANCE TO CLINICAL PRACTICE Applying some but not all the bundle components, there is increased analgesia and light sedation drug use, decreased benzodiazepines, and increased patient cooperation and mobility, resulting in a shorter ICU stay and fewer days of IMV.
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Affiliation(s)
- María Jesús Frade-Mera
- Critical Care Department, 12 Octubre University Hospital, Madrid, Spain.,Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
| | - Susana Arias-Rivera
- Department of Nursing Management, University Hospital of Getafe, Madrid, Spain.,Research Department, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Ignacio Zaragoza-García
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Research department (Invecuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Centro de Actividades Ambulatorias, Madrid, Spain
| | - Joan Daniel Martí
- Cardiovascular Surgery Intensive Care Department, Instituto Clínico Cardiovascular, Clinic University Hospital, Barcelona, Spain
| | - Elisabet Gallart
- Critical Care Department, Vall Hebron University Hospital, Barcelona, Spain
| | - Alicia San José-Arribas
- Department of Nursing, Escola Universitaria d'Infermeria Sant Pau (Hospital de la Santa Creu i Sant Pau), Barcelona, Spain
| | - Tamara Raquel Velasco-Sanz
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Critical Care Department, San Carlos University Hospital, Madrid, Spain
| | | | - Marta Raurell-Torredà
- Department of Fundamental and Medical Surgical Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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21
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Jäckel M, Zotzmann V, Wengenmayer T, Duerschmied D, Biever PM, Spieler D, von Zur Mühlen C, Stachon P, Bode C, Staudacher DL. Incidence and predictors of delirium on the intensive care unit after acute myocardial infarction, insight from a retrospective registry. Catheter Cardiovasc Interv 2021; 98:1072-1081. [PMID: 32926556 DOI: 10.1002/ccd.29275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study aimed to identify the incidence and potential risk factors for delirium after myocardial infarction (MI). BACKGROUND Delirium is a common complication on intensive care units. Data on incidence and especially on predictors of delirium in patients after acute MI are rare. METHODS In this retrospective study, all patients hospitalized for MI treated with coronary angiography in an university hospital in 2018 were included and analyzed. Onset of delirium within the first 5 days after MI was attributed to the MI and was defined by a Nursing Delirium screening scale (NuDesc) ≥2. This score is taken as part of daily care in every patient on intensive care unit three times a day by especially trained nurses. RESULTS A total of 624 patients with MI (age 68.5 ± 13.2 years, ST-elevation MI 41.6%, hospital mortality 3.2%) were included in the study. Delirium was detected in 10.9% of all patients. In the subgroup of patients with a stay on the intensive care unit (ICU) for more than 24 hr (n = 229), delirium was detected in 29.7%. Hospital and ICU stay were significantly longer in patients with delirium (p < .001). Delirium was an independent predictor of prolonged ICU-stay. Independent predictors of delirium were age, dementia, alcohol abuse, cardiac arrest, hypotension, and leucocytosis. Infarct size or presentation with ST-elevation were not associated with incidence of delirium. CONCLUSION Development of delirium is frequent after acute MI and prolongs hospitalization. Incidence of delirium is associated with clinical instability, preexisting comorbidity, and age rather than MI type or size.
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Affiliation(s)
- Markus Jäckel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M Biever
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Derek Spieler
- Department of Psychosomatic Medicine and Psychotherapy, Center for Mental Health, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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22
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Palakshappa JA, Hough CL. How We Prevent and Treat Delirium in the ICU. Chest 2021; 160:1326-1334. [PMID: 34102141 PMCID: PMC8727852 DOI: 10.1016/j.chest.2021.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022] Open
Abstract
Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.
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23
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Nydahl P, Günther U, Hansen HC, Meyne J, Osterbrink J, Margraf NG. [Pitfalls in the diagnosis of delirium]. Med Klin Intensivmed Notfmed 2021; 117:615-622. [PMID: 34383103 DOI: 10.1007/s00063-021-00846-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/09/2021] [Accepted: 07/03/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis of delirium is challenging and requires precise definitions in both clinical routine and in studies. AIM To point out various pitfalls in the clinical diagnosis of delirium and discuss solutions. METHODS Review. RESULTS Common problems include (a) clinical judgment of staff vs. the use of valid assessment tools, (b) different lists of criteria for delirium that may consider the symptoms of delirium differently and thus lead to inclusion or exclusion of patients, (c) different assessment tools that test the symptoms of delirium to different extents and thus have different accuracy, (d) patients with limited communication abilities, such as aphasia, where common tests often fail and alternative procedures may be more effective; (e) the decision whether to test delirium once, twice, three times, or more frequently in 24 h has consequences on the incidence and duration of delirium, (f) the end of delirium, often defined retrospectively as a delirium-free interval or prospectively as the time of transfer or occurrence of an exclusion criterion, can lead to considerable measurement inaccuracies. CONCLUSIONS Although not all problems can be definitively answered, transparent definition, performance, and documentation of diagnostic procedures are recommended.
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Affiliation(s)
- Peter Nydahl
- Pflegeforschung, Abteilung für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Brunswiker Str. 10, 24105, Kiel, Deutschland.
| | - Ulf Günther
- Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie, Klinikum Oldenburg AöR, Oldenburg, Deutschland.,Oldenburger Forschungsnetzwerk Notfall- und Intensivmedizin, Fakultät VI - Medizin und Gesundheitswissenschaften, Carl von Ossietzky Universität, Oldenburg, Deutschland
| | - Hans-Christian Hansen
- Klinik für Neurologie, Friedrich-Ebert-Krankenhaus GmbH Neumünster/Universität Hamburg, Neumünster, Deutschland
| | - Johannes Meyne
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Jürgen Osterbrink
- Institut für Pflegewissenschaft und -praxis, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich.,Brooks College of Health, University of North Florida, Jacksonville, FL, USA
| | - Nils G Margraf
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
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Dominguini D, Steckert AV, Michels M, Spies MB, Ritter C, Barichello T, Thompson J, Dal-Pizzol F. The effects of anaesthetics and sedatives on brain inflammation. Neurosci Biobehav Rev 2021; 127:504-513. [PMID: 33992694 DOI: 10.1016/j.neubiorev.2021.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 04/27/2021] [Accepted: 05/09/2021] [Indexed: 12/17/2022]
Abstract
Microglia are involved in many dynamic processes in the central nervous system (CNS) including the development of inflammatory processes and neuromodulation. Several sedative, analgesic or anaesthetic drugs, such as opioids, ∝2-adrenergic agonists, ketamine, benzodiazepines and propofol can cause both neuroprotective and harmful effects on the brain. The purpose of this review is to present the main findings on the use of these drugs and the mechanisms involved in microglial activation. Alpha 2-adrenergic agonists, propofol and benzodiazepines have several pro- or anti-inflammatory effects on microglia. Long-term use of benzodiazepines and propofol causes neuroapoptotic effects and α2-adrenergic agonists may attenuate these effects. Conversely, morphine and fentanyl may have proinflammatory effects, causing behavioural changes in patients and changes in cell viability in vitro. Conversely, chronic administration of morphine induces CCL5 chemokine expression in microglial cells that promotes their survival.
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Affiliation(s)
- Diogo Dominguini
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Amanda V Steckert
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Monique Michels
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Mariana B Spies
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Cristiane Ritter
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Tatiana Barichello
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil; Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Center of Excellence on Mood Disorders, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA; Neuroscience Graduate Program, The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA
| | - Jonathan Thompson
- Department of Cardiovascular Sciences, Anaesthesia Critical Care and Pain Management Group, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil.
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Kerbage SH, Garvey L, Lambert GW, Willetts G. Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review. Int J Nurs Stud 2021; 122:104044. [PMID: 34399307 DOI: 10.1016/j.ijnurstu.2021.104044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/23/2021] [Accepted: 07/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment. OBJECTIVE To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting. DESIGN A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR). METHODS The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting. RESULTS The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency. CONCLUSION Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.
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Affiliation(s)
| | - Loretta Garvey
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design
| | - Gavin W Lambert
- Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Georgina Willetts
- Department of Nursing and Allied Health; Faculty of Health, Arts and Design; Iverson Health Innovation Research Institute, Swinburne University of Technology, Hawthorn, VIC, Australia
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Reeve BK, Dennis BB, Dechert W, Longo B, Heels-Ansdell D, Scholes A, Clarke FJ, Arthur JRK, Cook DJ. Community implementation of the 3 Wishes Project: an observational study of a compassionate end-of-life care initiative for critically ill patients. CMAJ Open 2021; 9:E757-E764. [PMID: 34285055 PMCID: PMC8313093 DOI: 10.9778/cmajo.20200273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The 3 Wishes Project (3WP) promotes a personalized dying experience by eliciting and facilitating individualized terminal wishes for patients, families and the clinicians caring for them. We aimed to evaluate the adaptability of the 3WP to a community intensive care unit (ICU), and to describe the patients cared for with this palliative approach, as well as local implementation strategies. METHODS The 3WP was implemented in a 15-bed community hospital ICU in southern Ontario from 2017 to 2019. In this observational, descriptive study, we invited adult patients (≥ 18 yr) whose risk of death was deemed to be 95% or greater by the attending physician, or patients undergoing withdrawal of life-support to participate. We abstracted patient data from medical records, as well as the type, timing and cost of each wish, which person or service made and facilitated each wish, and if and why wishes were completed or not. We summarized data both narratively and quantitatively. RESULTS The 3WP helped to realize 479 (99.2%) of 483 terminal wishes for 101 dying patients. This initiative was introduced as an interprofessional intervention and championed by nursing staff who were responsible for most patient enrolment and wish facilitation. Wishes included humanizing the ICU environment for the patient with belongings and blankets, musical performances, smudging and bathing ceremonies, and keepsakes. The cost was $5.39 per patient (standard deviation $22.40), with 430 (89.8%) wishes incurring no cost. Wishes made directly by patients accounted for 30 (6.2%) of wishes; those from family members and ICU staff accounted for 236 (48.9%) and 238 (49.3%) of wishes, respectively. The program comforted patients and their loved ones, motivating clinicians to sustain this end-of-life intervention. INTERPRETATION We documented successful implementation of the 3WP in a community hospital, showing program adaptability and uptake outside of academic centres at relatively low cost. The lack of strict protocolization and personalized design of this intervention underscores its inherent flexibility, with potential to promote individualized end-of-life care in nonacademic hospital wards, homes or hospice.
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Affiliation(s)
- Brenda K Reeve
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - Brittany B Dennis
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - William Dechert
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - Barbara Longo
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - Diane Heels-Ansdell
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - Alison Scholes
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - France J Clarke
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - John R K Arthur
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont
| | - Deborah J Cook
- Department of Critical Care (Reeve, Dechert, Longo, Scholes, Arthur), Brantford General Hospital, Brantford, Ont.; Department of Medicine (Dennis, Cook), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evaluation, and Impact (Dennis, Heels-Ansdell, Clarke, Cook), McMaster University, Hamilton, Ont.; Department of Critical Care (Dechert, Clarke, Cook), St. Joseph's Healthcare Hamilton, Ont.
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Screening for delirium in the intensive care unit using eDIS-ICU - A purpose-designed app: A pilot study. Aust Crit Care 2021; 34:547-551. [PMID: 33766486 DOI: 10.1016/j.aucc.2020.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Delirium, a common complication of an intensive care unit (ICU) admission, is inconsistently diagnosed by clinicians. Current screening tools require specialist expertise and/or training. Some are time-consuming to administer, and reliability in routine clinical practice is questionable. An innovative app designed to enable efficient and sensitive screening for delirium without specialist training (eDIS-ICU) has recently been described. This pilot study compared the eDIS-ICU against the reference standard expert assessment using DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria and the Confusion Assessment Method for the ICU (CAM-ICU). METHODS In this prospective, single-centre pilot study, a convenience sample of 29 ICU patients were recruited at a tertiary referral hospital between November 2018 and August 2019. After obtaining written consent, demographic and clinical data were collected, and the patients were screened for delirium using eDIS-ICU and CAM-ICU by two clinician researchers in random order. The patients were also assessed for presence of delirium independently by an expert clinician using a structured interview to diagnose as per DSM-V criteria. The results of screening and diagnosis were tabulated to allow comparison of screening tools against diagnosis; sensitivity and specificity of the tools were calculated. RESULTS Seven participants were diagnosed with delirium as per DSM-V criteria. The eDIS-ICU tool correctly identified six of these participants compared with two identified by CAM-ICU. The sensitivity of the eDIS-ICU tool was 86% (95% confidence interval [CI] = 81.5-100.0) compared with 29% (95% CI = 5.1-69.7) for CAM-ICU (p < 0.05), and the specificity was 73% (95% CI = 81.5-100.0) versus 96% (95% CI = 75.1-99.8), respectively. CONCLUSION The simple and novel eDIS-ICU delirium screening tool was noninferior to the CAM-ICU in detecting delirium as per DSM-V criteria. A definitive validation study is warranted.
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Chen K, Yang YL, Li HL, Xiao D, Wang Y, Zhang L, Zhou JX. A gap existed between physicians' perceptions and performance of pain, agitation-sedation and delirium assessments in Chinese intensive care units. BMC Anesthesiol 2021; 21:61. [PMID: 33627067 PMCID: PMC7905610 DOI: 10.1186/s12871-021-01286-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain, agitation-sedation and delirium management are crucial elements in the care of critically ill patients. In the present study, we aimed to present the current practice of pain, agitation-sedation and delirium assessments in Chinese intensive care units (ICUs) and investigate the gap between physicians' perception and actual clinical performance. METHODS We sent invitations to the 33 members of the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians. Finally, 24 ICUs (14 general-, 5 neuroscience-, 3 surgical-, and 2 emergency-ICUs) from 20 hospitals participated in this one-day point prevalence study combined with an on-site questionnaire survey. We enrolled adult ICU admitted patients with a length of stay ≥24 h, who were divided into the brain-injured group or non-brain-injured group. The hospital records and nursing records during the 24-h period prior to enrollment were reviewed. Actual evaluations of pain, agitation-sedation and delirium were documented. We invited physicians on-duty during the 24 h prior to the patients' enrollment to complete a survey questionnaire, which contained attitude for importance of pain, agitation-sedation and delirium assessments. RESULTS We enrolled 387 patients including 261 (67.4%) brain-injured and 126 (32.6%) non-brain-injured patients. There were 19.9% (95% confidence interval [CI]: 15.9-23.9%) and 25.6% (95% CI: 21.2-29.9%) patients receiving the pain and agitation-sedation scale assessment, respectively. The rates of these two types of assessments were significantly lower in brain-injured patients than non-brain-injured patients (p = 0.003 and < 0.001). Delirium assessment was only performed in three patients (0.8, 95% CI: 0.1-1.7%). In questionnaires collected from 91 physicians, 70.3% (95% CI: 60.8-79.9%) and 82.4% (95% CI: 74.4-90.4%) reported routine use of pain and agitation-sedation scale assessments, respectively. More than half of the physicians (52.7, 95% CI: 42.3-63.2%) reported daily screening for delirium using an assessment scale. CONCLUSIONS The actual prevalence of pain, agitation-sedation and delirium assessment, especially delirium screening, was suboptimal in Chinese ICUs. There is a gap between physicians' perceptions and actual clinical practice in pain, agitation-sedation and delirium assessments. Our results will prompt further quality improvement projects to optimize the practice of pain, agitation-sedation and delirium management in China. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT03975751 . Retrospectively registered on 2 June 2019.
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Affiliation(s)
- Kai Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Dan Xiao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Adrion C, Weiss B, Paul N, Berger E, Busse R, Marschall U, Caumanns J, Rosseau S, Mansmann U, Spies C. Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes. BMJ Open 2020; 10:e036096. [PMID: 32978185 PMCID: PMC7520839 DOI: 10.1136/bmjopen-2019-036096] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to. METHODS AND ANALYSIS The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated. ETHICS AND DISSEMINATION This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net). TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03671447).
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Affiliation(s)
- Christine Adrion
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nicolas Paul
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Elke Berger
- Department of Health Care Management, Technical University of Berlin, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technical University of Berlin, Berlin, Germany
| | | | - Jörg Caumanns
- Fraunhofer Institute for Open Communication Systems, Berlin, Germany
| | - Simone Rosseau
- Weaning and Ventilation Centre, Ernst von Bergmann Klinikum, Bad Belzig, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Deffland M, Spies C, Weiss B, Keller N, Jenny M, Kruppa J, Balzer F. Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study. PLoS One 2020; 15:e0234801. [PMID: 32877411 PMCID: PMC7467321 DOI: 10.1371/journal.pone.0234801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/02/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION clinicaltrials.gov NCT02265263, Registered 15 October 2014.
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Affiliation(s)
- Marc Deffland
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- * E-mail:
| | - Bjoern Weiss
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Niklas Keller
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mirjam Jenny
- Science Communication Unit, Robert Koch Institute, Berlin, Germany
- Harding Center for Risk Literacy, Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Jochen Kruppa
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Felix Balzer
- Department of Anaesthesiology and Intensive Care Medicine (CCM, CVK), Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
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Besen BAMP, Nassar Júnior AP, Lacerda FH, Silva CMDD, Souza VTD, Martins EVDN, Lopes ATA, Brandão CE, Oliveira LFD. Pain management protocol implementation and opioid consumption in critical care: an interrupted time series analysis. Rev Bras Ter Intensiva 2020; 31:447-455. [PMID: 31967218 PMCID: PMC7009002 DOI: 10.5935/0103-507x.20190085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the impact of an opioid-sparing pain management protocol on overall opioid consumption and clinical outcomes. METHODS This was a single-center, quasi-experimental, retrospective, before and after cohort study. We used an interrupted time series to analyze changes in the levels and trends of the utilization of different analgesics. We used bivariate comparisons in the before and after cohorts as well as logistic regression and quantile regression for adjusted estimates. RESULTS We included 988 patients in the preintervention period and 1,838 in the postintervention period. Fentanyl consumption was slightly increasing before the intervention (β = 16; 95%CI 7 - 25; p = 0.002) but substantially decreased in level with the intervention (β = - 128; 95%CI -195 - -62; p = 0.001) and then progressively decreased (β = - 24; 95%CI -35 - -13; p < 0.001). There was an increasing trend in the utilization of dipyrone. The mechanical ventilation duration was significantly lower (median difference: - 1 day; 95%CI -1 - 0; p < 0.001), especially for patients who were mechanically ventilated for a longer time (50th percentile difference: -0.78; 95%CI -1.51 - -0.05; p = 0.036; 75th percentile difference: -2.23; 95%CI -3.47 - -0.98; p < 0.001). CONCLUSION A pain management protocol could reduce the intensive care unit consumption of fentanyl. This strategy was associated with a shorter mechanical ventilation duration.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Fábio Holanda Lacerda
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Clínica, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Carla Marchini Dias da Silva
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | | | | | | | - Carlos Eduardo Brandão
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Lucas Fernandes de Oliveira
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital AC Camargo Cancer Center - São Paulo (SP), Brasil
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Gencer M, Sezen O. A study comparing the effect of premedication with intravenous midazolam or dexmedetomidine on ketamine-fentanyl sedoanalgesia in burn patients: A randomized clinical trial. Burns 2020; 47:101-109. [PMID: 33277091 DOI: 10.1016/j.burns.2020.05.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Dressing changes and wound care-debridement procedures often cause fear and anxiety in burn patients, as these processes are quite painful. In order to determine the best method for alleviating pain during these procedures, the current study compared the efficacy and safety of intravenous dexmedetomidine and midazolam for premedication prior to these painful burn care procedures. METHODS This comparative and randomized study included patients who had a burn size of 1563%, were aged 1870 years, were diagnosed with the American Society of Anesthesiologists physical status (ASA I-II), and who underwent painful burn care procedures. Patients were intravenously administered either 1 mcg/kg dexmedetomidine (Group 1) or 0.03 mg/kg midazolam (Group 2) prior to the burn care procedure. Recorded at predetermined time points for each patient were heart rhythm (HR), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), standard bispectral index (BIS), and Ramsay Sedation Scale (RSS). RESULTS In the dexmedetomidine group, HR and MAP measurements of patients at the 3rd, 5th, and 10th mins during sedation were significantly lower than the baseline values (p < 0.05). A significant decrease in SpO2 was observed in both groups at the 10th min during sedation, but the decline was higher in the midazolam group (p < 0.05). BIS measurements of the patients in both groups were significantly lower at 10 min. during sedation and at 15th and 60th mins during the procedure (p < 0.05). However, there was no significant difference between the group (p > 0.05). The RSS scales of both groups in during the sedation were higher in the 3rd, 5th and 10th mins than the baseline values (p < 0.05), but there was no significant difference between the groups (p > 0.05). The RSS scales of groups in during the burn procedure were significantly higher at 15 th min than the 0 th values, while the RSS scales of both groups were significantly lower in the 45th and 60th mins (p < 0.05). CONCLUSION Results of this study indicate that dexmedetomidine causes hemodynamic alterations while midazolam causes respiratory depression. However, these effects are not severe, and we conclude that both agents are safe and effective to ensure sedation prior to painful burn-care procedures.
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Affiliation(s)
- Muzaffer Gencer
- Department of Anesthesia, Istinye University Medical Faculty, Istanbul, Turkey.
| | - Ozlem Sezen
- Department of Anesthesia, Dr. Lutfi Kirdar Research and Education Hospital, Istanbul, Turkey.
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Delp S, Mei W, Spies CD, Neuner B, Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Kramer S, Weiss B. Clinical practice in the management of postoperative delirium by Chinese anesthesiologists: a cross-sectional survey designed by the European Society of Anaesthesiology. J Int Med Res 2020; 48:300060520927207. [PMID: 32493149 PMCID: PMC7273774 DOI: 10.1177/0300060520927207] [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] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/27/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE In this survey, we assessed the current clinical management of postoperative delirium (POD) among Chinese anesthesiologists, after publishing the European POD guideline. METHODS We administered an electronic survey, designed according to the European POD guideline. The survey was completed using mobile devices. RESULTS In total, 1,514 respondents from China participated in the survey. Overall, 74.4% of participants reported that delirium is very important. More than 95% of participants stated that they routinely assessed POD. In total, 61.4% screened for POD using clinical observation and 37.6% used a delirium screening tool. Although the depth of anesthesia (a POD risk factor) was monitored, electroencephalogram monitoring was unavailable to 30.6% of respondents. Regarding treatment, only 24.1% of respondents used a standard algorithm; 58.5% used individualized treatment. CONCLUSION Our survey showed that there are high awareness levels among Chinese anesthesiologists regarding the importance of POD. However, routine assessment and monitoring of all patients, including perioperative anesthesia depth monitoring, and a treatment algorithm need to be implemented on a larger scale. According to the results, efforts should be made to improve the knowledge of POD among Chinese anesthesiologists.
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Affiliation(s)
- Simon Delp
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Wei Mei
- Department of Anaesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Claudia D. Spies
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Bruno Neuner
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - César Aldecoa
- Department of Anesthesiology, Facultad de Medicina de Valladolid, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery; Department of Anaesthesia, Analgesia and Intensive Care, Italian National Research Centres on Aging/IRCCS, Ancona, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, ‘Sapienza’ University of Rome, Rome, Italy
| | - Robert D. Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, USA
| | - Sylvia Kramer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
| | - Bjoern Weiss
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin, Germany
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Gehrke P, Binnie A, Chan SPT, Cook DJ, Burns KEA, Rewa OG, Herridge M, Tsang JLY. Fostering community hospital research. CMAJ 2020; 191:E962-E966. [PMID: 31481424 DOI: 10.1503/cmaj.190055] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Paige Gehrke
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Alexandra Binnie
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Stephanie P T Chan
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Deborah J Cook
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Karen E A Burns
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Oleksa G Rewa
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Margaret Herridge
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont
| | - Jennifer L Y Tsang
- Niagara Health (Gehrke, Tsang), St. Catharines, Ont.; Niagara Regional Campus (Chan, Tsang), Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ont.; William Osler Health System (Binnie), Brampton, Ont.; Sturgeon Community Hospital (Rewa), St. Albert, Alta.; University of Alberta Hospital (Rewa), Edmonton, Alta.; Department of Critical Care Medicine (Rewa), University of Alberta, Edmonton, Alta.; University Health Network (Herridge); Department of Medicine (Herridge, Burns), University of Toronto, Toronto, Ont.; St. Joseph's Health Care (Cook), Hamilton, Ont.; Departments of Medicine (Cook, Tsang), and Clinical Epidemiology & Biostatistics (Cook), McMaster University, Hamilton, Ont.; St. Michael's Hospital (Burns), Toronto, Ont.
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[Study protocol to improve the quality of delirium management in intensive care]. Med Klin Intensivmed Notfmed 2020; 115:428-436. [PMID: 32248245 DOI: 10.1007/s00063-020-00676-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 12/31/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far. HYPOTHESIS In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration. METHODS Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients. INCLUSION CRITERIA (a) ≥18 years, (b) consent for research with their data. EXCLUSION CRITERIA (a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics. OBJECTIVES The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.
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Bilotta F, Weiss B, Neuner B, Kramer S, Aldecoa C, Bettelli G, Sanders RD, Delp SM, Spies CD. Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists. Acta Anaesthesiol Scand 2020; 64:494-500. [PMID: 31883373 DOI: 10.1111/aas.13535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology Critical Care and Pain Medicine, "Sapienza" University of Rome Rome Italy
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sylvia Kramer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - César Aldecoa
- Department of Anaesthesiology & Intensive Care Hospital Universitario Rio Hortega Valladolid Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery Italian National Research Centres on Aging/IRCCS Ancona Italy
- Department of Anaesthesia, Analgesia and Intensive Care Italian National Research Centres on Aging/IRCCS Ancona Italy
| | | | - Simon M. Delp
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Sepsis-Associated Encephalopathy: From Delirium to Dementia? J Clin Med 2020; 9:jcm9030703. [PMID: 32150970 PMCID: PMC7141293 DOI: 10.3390/jcm9030703] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/20/2020] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a major cause of death in intensive care units worldwide. The acute phase of sepsis is often accompanied by sepsis-associated encephalopathy, which is highly associated with increased mortality. Moreover, in the chronic phase, more than 50% of surviving patients suffer from severe and long-term cognitive deficits compromising their daily quality of life and placing an immense burden on primary caregivers. Due to a growing number of sepsis survivors, these long-lasting deficits are increasingly relevant. Despite the high incidence and clinical relevance, the pathomechanisms of acute and chronic stages in sepsis-associated encephalopathy are only incompletely understood, and no specific therapeutic options are yet available. Here, we review the emergence of sepsis-associated encephalopathy from initial clinical presentation to long-term cognitive impairment in sepsis survivors and summarize pathomechanisms potentially contributing to the development of sepsis-associated encephalopathy.
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Chiu JA, Shergill M, Dhingra V, Ronco JJ, LeBlanc A, Pamplin C, McKeown S, Dodek PM. Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia. Am J Crit Care 2020; 29:122-129. [PMID: 32114614 DOI: 10.4037/ajcc2020396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.
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Affiliation(s)
- Judy A. Chiu
- Judy A. Chiu is a project manager at the Centre for Health Evaluation & Outcome Sciences, Vancouver, British Columbia, Canada
| | - Meher Shergill
- Meher Shergill was a consultant at the BC Patient Safety and Quality Council, Vancouver
| | - Vinay Dhingra
- Vinay Dhingra was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Juan J. Ronco
- Juan J. Ronco was a physician consultant at the BC Patient Safety and Quality Council and are physicians at the Division of Critical Care Medicine, University of British Columbia, Vancouver
| | - Allana LeBlanc
- Allana LeBlanc is a nurse educator at the Vancouver Coastal Health Authority, Vancouver
| | - Chantale Pamplin
- Chantale Pamplin was a consultant at the BC Patient Safety and Quality Council
| | - Shari McKeown
- Shari McKeown was a leader at the BC Patient Safety and Quality Council and a faculty member at Thompson Rivers University, Kamloops, British Columbia
| | - Peter M. Dodek
- Peter M. Dodek is a scientist at the Centre for Health Evaluation and Outcome Sciences and a physician at the Division of Critical Care Medicine, University of British Columbia
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Zoremba N, Coburn M, Schälte G. [Delirium in intensive care patients : A multiprofessional challenge]. Anaesthesist 2019; 67:811-820. [PMID: 30298270 DOI: 10.1007/s00101-018-0497-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. Due to the close connection between delirium, agitation and pain, sedation and analgesia must be evaluated at least every 8 h analogous to delirium screening. According to current knowledge, a multifactorial and multiprofessional approach is favored in the prevention and treatment of delirium. Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.
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Affiliation(s)
- N Zoremba
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Sankt Elisabeth Hospital Gütersloh, Stadtring Kattenstroth 130, 33332, Gütersloh, Deutschland.
| | - M Coburn
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
| | - G Schälte
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Aachen, Deutschland
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Gong Y, Yang H, Xie J, Liu J, Zhou J, Ma P. ICU Physicians' Perception of Patients' Tolerance Levels in Light Sedation Impacts Sedation Practice for Mechanically Ventilated Patients. Front Med (Lausanne) 2019; 6:226. [PMID: 31681782 PMCID: PMC6813223 DOI: 10.3389/fmed.2019.00226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022] Open
Abstract
Purpose: To investigate physicians' perception of patients' tolerance levels regarding sedation, which could affect sedation practice for mechanically ventilated (MV) patients. Methods: This is a questionnaire survey combined with a 24 h cross-sectional study. The physician's propensity score for light sedation (PS-LS) was estimated by his/her response to the given answers for each item of the questionnaire, which tested the levels of interviewee's desire to manage MV patient with light sedation. Thereby, the mean physicians' PS-LS of each participating ICU (ICU-meanPS-LS) was calculated. The practical measurements of all variables listed on the questionnaire were used to semi-quantitatively assess stimulus intensity of what the recruited patients suffered (i.e., semi-quantitative stimulus intensity, SSI). Sedation depth was assessed by Richmond Agitation Sedation Scale (RASS). Results: 555 of 558 (99.5%) physicians from 102 ICUs were concerned with patients' tolerance levels regarding sedation while titrating sedation depth. The physician's PS-LS was non-normally distributed with median (IQR) of 3 (0–5). ICU-meanPS-LS was calculated in 92 out of 102 ICUs participating in the cross-sectional study, which was ranged from −5 to 7 with a median (IQR) of 2.37 (0.16–4.33). A significant increasing trend in prevalence of light sedation was observed over increasing ICU-meanPS-LS quartiles (from Q1 to Q4, χ2-test for trend, p = 0.002). Moreover, odds ratio for probability of light sedation remained significant in MV patients from Q4 ICUs vs. Q1 ICUs, adjusted by APACHE II score (OR, 2.332; 95% CI: 1.463–3.717; p < 0.001) or SSI score (OR, 2.445; 95% CI: 1.468–4.074; p = 0.001). Notably, adjusted OR for mortality was significant in deeply sedated MV patients (OR, 2.034; 95% CI: 1.435–2.884; p < 0.001). Conclusions: ICU physician's individualized perception for patients' tolerance levels regarding sedation, in light sedation affected sedation practice for MV patients.
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Affiliation(s)
- Yichun Gong
- Medical School of Chinese PLA, Beijing, China.,SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | | | - Junqing Xie
- Feng Tai District Center for Disease Control and Prevention, Beijing, China
| | - Jingtao Liu
- SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Jianxin Zhou
- NICU, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Penglin Ma
- Medical School of Chinese PLA, Beijing, China.,SICU, The Eighth Medical Center of PLA General Hospital, Beijing, China
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42
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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA. Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients. PUERTO RICO HEALTH SCIENCES JOURNAL 2019; 38:156-162. [PMID: 31536628 PMCID: PMC6906604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Our study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines. METHODS A descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records. RESULTS Eighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation. CONCLUSION Although pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.
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Tan CM, Camargo M, Miller F, Ross K, Maximous R, Yung P, Marshall C, Fleming D, Law M, Tsang JL. Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit. BMJ Open Qual 2019; 8:e000421. [PMID: 31428703 PMCID: PMC6683107 DOI: 10.1136/bmjoq-2018-000421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/06/2019] [Accepted: 07/06/2019] [Indexed: 11/25/2022] Open
Abstract
Background In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). Methods All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. Results There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). Conclusion The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.
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Affiliation(s)
- Carolyn M Tan
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Mercedes Camargo
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada.,Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Franziska Miller
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Katie Ross
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Ramez Maximous
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Priscilla Yung
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Carl Marshall
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Dimitra Fleming
- Pharmacy, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Madelyn Law
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Jennifer Ly Tsang
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada.,Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Geriatrische Rehabilitation herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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45
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Kemp HI, Laycock H, Costello A, Brett SJ. Chronic pain in critical care survivors: a narrative review. Br J Anaesth 2019; 123:e372-e384. [PMID: 31126622 DOI: 10.1016/j.bja.2019.03.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/19/2019] [Indexed: 01/28/2023] Open
Abstract
Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.
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Affiliation(s)
- Harriet I Kemp
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Helen Laycock
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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García-Sánchez M, Caballero-López J, Ceniceros-Rozalén I, Giménez-Esparza Vich C, Romera-Ortega M, Pardo-Rey C, Muñoz-Martínez T, Escudero D, Torrado H, Chamorro-Jambrina C, Palencia-Herrejón E. Prácticas de analgosedación y delirium en Unidades de Cuidados Intensivos españolas: Encuesta 2013-2014. Med Intensiva 2019; 43:225-233. [DOI: 10.1016/j.medin.2018.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/02/2018] [Accepted: 12/04/2018] [Indexed: 01/17/2023]
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Owen GD, Stollings JL, Rakhit S, Wang L, Yu C, Hosay MA, Stewart JW, Frutos-Vivar F, Peñuelas O, Esteban A, Anzueto AR, Raymondos K, Rios F, Thille AW, González M, Du B, Maggiore SM, Matamis D, Abroug F, Amin P, Zeggwagh AA, Patel MB. International Analgesia, Sedation, and Delirium Practices: a prospective cohort study. J Intensive Care 2019; 7:25. [PMID: 31049203 PMCID: PMC6480848 DOI: 10.1186/s40560-019-0379-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background While understanding of critical illness and delirium continue to evolve, the impact on clinical practice is often unknown and delayed. Our purpose was to provide insight into practice changes by characterizing analgesia and sedation usage and occurrence of delirium in different years and international regions. Methods We performed a retrospective analysis of two multicenter, international, prospective cohort studies. Mechanically ventilated adults were followed for up to 28 days in 2010 and 2016. Proportion of days utilizing sedation, analgesia, and performance of a spontaneous awakening trial (SAT), and occurrence of delirium were described for each year and region and compared between years. Results A total of 14,281 patients from 6 international regions were analyzed. Proportion of days utilizing analgesia and sedation increased from 2010 to 2016 (p < 0.001 for each). Benzodiazepine use decreased in every region but remained the most common sedative in Africa, Asia, and Latin America. Performance of SATs increased overall, driven mostly by the US/Canada region (24 to 35% of days with sedation, p < 0.001). Any delirium during admission increased from 7 to 8% of patients overall and doubled in the US/Canada region (17 to 36%, p < 0.001). Conclusions Analgesia and sedation practices varied widely across international regions and significantly changed over time. Opportunities for improvement in care include increasing delirium monitoring, performing SATs, and decreasing use of sedation, particularly benzodiazepines. Electronic supplementary material The online version of this article (10.1186/s40560-019-0379-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gary D Owen
- 1Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN USA
| | - Joanna L Stollings
- 1Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN USA.,2Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt University Medical Center, Nashville, TN USA
| | - Shayan Rakhit
- 2Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt University Medical Center, Nashville, TN USA.,3Vanderbilt University School of Medicine, Nashville, TN USA.,4Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| | - Li Wang
- 5Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Chang Yu
- 5Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Morgan A Hosay
- 2Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt University Medical Center, Nashville, TN USA.,6Baylor University, Waco, TX USA
| | - James W Stewart
- 2Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt University Medical Center, Nashville, TN USA.,7Meharry Medical College, Nashville, TN USA
| | - Fernando Frutos-Vivar
- 8Hospital Universitario de Getafe, Madrid, Spain.,9Centro de Investigación Biomédica en red de Enfermedades Respiratorias, Madrid, Spain
| | - Oscar Peñuelas
- 8Hospital Universitario de Getafe, Madrid, Spain.,9Centro de Investigación Biomédica en red de Enfermedades Respiratorias, Madrid, Spain
| | - Andres Esteban
- 8Hospital Universitario de Getafe, Madrid, Spain.,9Centro de Investigación Biomédica en red de Enfermedades Respiratorias, Madrid, Spain
| | - Antonio R Anzueto
- 10Department of Medicine, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX USA
| | | | - Fernando Rios
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | | | - Marco González
- 14Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Bin Du
- 15Peking Union Medical College Hospital, Beijing, People's Republic of China
| | | | | | | | - Pravin Amin
- 19Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Amine Ali Zeggwagh
- 20Centre Hospitalier Universitaire Ibn Sina - Mohammed V University, Rabat, Morocco
| | - Mayur B Patel
- 2Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt University Medical Center, Nashville, TN USA.,3Vanderbilt University School of Medicine, Nashville, TN USA.,4Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN USA.,21Center for Health Services Research and Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN USA.,22Surgery Service and Geriatric Research, Education and Clinical Center (GRECC) at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN USA
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Abstract
RATIONALE Intensive care unit (ICU) delirium is highly prevalent and a potentially avoidable hospital complication. The current cost of ICU delirium is unknown. OBJECTIVES To specify the association between the daily occurrence of delirium in the ICU with costs of ICU care accounting for time-varying illness severity and death. RESEARCH DESIGN We performed a prospective cohort study within medical and surgical ICUs in a large academic medical center. SUBJECTS We analyzed critically ill patients (N=479) with respiratory failure and/or shock. MEASURES Covariates included baseline factors (age, insurance, cognitive impairment, comorbidities, Acute Physiology and Chronic Health Evaluation II Score) and time-varying factors (sequential organ failure assessment score, mechanical ventilation, and severe sepsis). The primary analysis used a novel 3-stage regression method: first, estimation of the cumulative cost of delirium over 30 ICU days and then costs separated into those attributable to increased resource utilization among survivors and those that were avoided on the account of delirium's association with early mortality in the ICU. RESULTS The patient-level 30-day cumulative cost of ICU delirium attributable to increased resource utilization was $17,838 (95% confidence interval, $11,132-$23,497). A combination of professional, dialysis, and bed costs accounted for the largest percentage of the incremental costs associated with ICU delirium. The 30-day cumulative incremental costs of ICU delirium that were avoided due to delirium-associated early mortality was $4654 (95% confidence interval, $2056-7869). CONCLUSIONS Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.
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Arias-Rivera S, López-López C, Frade-Mera MJ, Via-Clavero G, Rodríguez-Mondéjar JJ, Sánchez-Sánchez MM, Acevedo-Nuevo M, Gil-Castillejos D, Robleda G, Cachón-Pérez M, Latorre-Marco I. Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. ENFERMERIA INTENSIVA 2019; 31:3-18. [PMID: 31003871 DOI: 10.1016/j.enfi.2018.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 01/25/2023]
Abstract
AIMS Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).
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Affiliation(s)
- S Arias-Rivera
- Hospital Universitario de Getafe, Getafe, Madrid, España; CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España.
| | - C López-López
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario 12 de Octubre, Madrid, España; Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas12), Madrid, España; Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Madrid, España
| | - M J Frade-Mera
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario 12 de Octubre, Madrid, España; Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense, Madrid, España
| | - G Via-Clavero
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitari de Bellvitge (GRIN-IDIBELL), Hospitalet de Llobregat, Barcelona, España
| | - J J Rodríguez-Mondéjar
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Gerencia de Urgencias y Emergencias 061, Servicio Murciano de Salud, Murcia, España; Universidad de Murcia, Instituto Murciano de Investigación Biomédica del HCU Virgen de la Arrixaca (IMIB-Arrixaca), Murcia, España
| | - M M Sánchez-Sánchez
- Hospital Universitario de Getafe, Getafe, Madrid, España; Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España
| | - M Acevedo-Nuevo
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), Majadahonda, Madrid, España; Facultad de Ciencias de la Salud, Universidad Autónoma de Madrid, Madrid, España
| | - D Gil-Castillejos
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Juan XXIII, Tarragona, España
| | - G Robleda
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Escuela Superior de Enfermería Mar (ESIMar), Universidad Pompeu Fabra, Barcelona, España; Centro Cochrane Iberoamericano, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M Cachón-Pérez
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, España
| | - I Latorre-Marco
- Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), España; Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España; Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana (IDIPHISA), Majadahonda, Madrid, España
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50
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Fleischmann R, Tränkner S, Bathe-Peters R, Rönnefarth M, Schmidt S, Schreiber SJ, Brandt SA. Diagnostic Performance and Utility of Quantitative EEG Analyses in Delirium: Confirmatory Results From a Large Retrospective Case-Control Study. Clin EEG Neurosci 2019; 50:111-120. [PMID: 29631447 DOI: 10.1177/1550059418767584] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The lack of objective disease markers is a major cause of misdiagnosis and nonstandardized approaches in delirium. Recent studies conducted in well-selected patients and confined study environments suggest that quantitative electroencephalography (qEEG) can provide such markers. We hypothesize that qEEG helps remedy diagnostic uncertainty not only in well-defined study cohorts but also in a heterogeneous hospital population. Methods. In this retrospective case-control study, EEG power spectra of delirious patients and age-/gender-matched controls (n = 31 and n = 345, respectively) were fitted in a linear model to test their performance as binary classifiers. We subsequently evaluated the diagnostic performance of the best classifiers in control samples with normal EEGs (n = 534) and real-world samples including pathologic findings (n = 4294). Test reliability was estimated through split-half analyses. Results. We found that the combination of spectral power at F3-P4 at 2 Hz (area under the curve [AUC] = .994) and C3-O1 at 19 Hz (AUC = .993) provided a sensitivity of 100% and a specificity of 99% to identify delirious patients among normal controls. These classifiers also yielded a false positive rate as low as 5% and increased the pretest probability of being delirious by 57% in an unselected real-world sample. Split-half reliabilities were .98 and .99, respectively. Conclusion. This retrospective study yielded preliminary evidence that qEEG provides excellent diagnostic performance to identify delirious patients even outside confined study environments. It furthermore revealed reduced beta power as a novel specific finding in delirium and that a normal EEG excludes delirium. Prospective studies including parameters of pretest probability and delirium severity are required to elaborate on these promising findings.
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Affiliation(s)
- Robert Fleischmann
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Neurointensive Care Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Steffi Tränkner
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rouven Bathe-Peters
- St. Hedwig Hospital, Department of Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maria Rönnefarth
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sein Schmidt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan J Schreiber
- Department of Neurology, Asklepios Fachklinikum Brandenburg, Brandenburg, Germany
| | - Stephan A Brandt
- Vision and Motor System Research Group, Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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