Management of Pain and Agitation for Patients in the Intensive Care Unit

Factors affecting the occurrence of pressure injuries among patients receiving targeted temperature management after cardiac arrest

BACKGROUND

Pressure injuries (PIs) are a well-known complication of critically ill patients admitted to the intensive care unit with targeted temperature management (TTM) after cardiac arrest (CA). However, little is known about the factors that impact the occurrence of PIs among these patients.

OBJECTIVES

This study aimed to examine factors related to the occurrence of PIs among patients after CA treated with TTM.

METHODS

This retrospective observational study collected data from 126 patients after CA aged 18 years or older from a single tertiary hospital admitted between January 2017 and December 2019. Demographic, clinical, and medical device-related characteristics were collected by patient chart review. Multivariable logistic regression analysis was performed to identify factors related to the occurrence of PIs.

RESULTS

The study showed that the incidence of PIs was 31.8%. Patients who were male (odds ratio [OR], 4.80; 95% confidence interval [CI], 1.21-19.08), developed diarrhoea (OR, 4.90, 95% CI, 1.31-18.41), or were subjected to physical restraint (OR, 6.03; 95% CI, 1.52-23.96) were at a higher risk of developing PIs. A lower risk of developing PIs was associated with the Glasgow Coma Scale score greater than 13 on the third day of admission (OR, 0.08; 95% CI, 0.01-0.52), higher haemoglobin level (OR, 0.65; 95% CI, 0.49-0.86), or low nutritional risk index (≤100) (OR, 0.10; 95% CI, 0.02-0.57).

CONCLUSIONS

Nurses should be aware that patients treated with TTM after CA are at a high risk of developing PIs from the moment of admission and should be closely monitored.

Magnetic Resonance Imaging in Neurocritically Ill Patients: Who Fails and How?

OBJECTIVES

Performing magnetic resonance imaging (MRI) in neurocritically ill patients is challenging because it often requires sedation and withholding care in the neurological intensive care unit. This study investigated the incidence of and reasons for failed or complicated MRI (MRI-FC) in such patients.

METHODS

A consecutive series of 218 neurocritically ill patients who underwent brain MRI were retrospectively evaluated. Failed or complicated MRI included failure to obtain all ordered sequences, unscheduled sedative administration, decrease in oxygen saturation to less than 90%, hypotension (≥40-mm Hg decrease and/or use of inotropic agents), and cardiac or respiratory arrest.

RESULTS

Failed or complicated MRI occurred in 66 patients (30.3%) and included failure to obtain MRI sequences (n = 13), unscheduled use of sedatives (n = 62), oxygen desaturation (n = 9), and hypotension (n = 6). Cardiac or respiratory arrest did not occur. Use of sedative agents while in intensive care (P < 0.01), high Acute Physiology and Chronic Health Evaluation II score (P = 0.031), and low Glasgow Coma Scale score on admission (P = 0.047) were associated with MRI-FC. Scan times were longer (P = 0.004) and Glasgow Coma Scale (P < 0.001) and Richmond Agitation Sedation Scale (P = 0.003) scores were lower (P = 0.004) after imaging in patients with MRI-FC. Previous use of sedative agents was independently associated with MRI-FC (adjusted odds ratio = 3.57, 95% confidence interval = 1.78 to 7.24, P < 0.001).

CONCLUSIONS

Failed or complicated MRI was common and was associated with the use of sedative agents, severity of illness, and lower level of consciousness. Studies to ensure effective and safe performance of MRI in neurocritically ill patients are needed.

Newly developed stroke in patients admitted to non-neurological intensive care units

BACKGROUND

Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU).

OBJECTIVE

This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS).

METHODS

A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS.

RESULTS

Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03-1.06, P < 0.001), prothrombin time (AOR = 0.99, 95% CI = 0.98-0.99, P = 0.013), cardiovascular surgery (AOR = 1.84, 95% CI = 1.34-2.50, P < 0.001), mechanical ventilation (AOR = 6.75, 95% CI = 4.87-9.45, P < 0.001), and extracorporeal membrane oxygenation (AOR = 2.77, 95% CI = 1.62-4.55, P < 0.001) were related to the development of IOS. Stroke was associated with increased 3-month mortality after hospital discharge (AOR, 2.20; 95% CI, 1.58-3.05; P < 0.001), after adjustment for APACHE II and comorbidities.

CONCLUSIONS

Patients who developed IOS had characteristics of initial critical illness and managements performed in the ICU as well as neurological presentations. The occurrence of IOS was related to high morbidity and mortality.

Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation

Objectives: The use of dexmedetomidine and ketamine (DEX-KET) combination for magnetic resonance imaging (MRI) sedation has not been evaluated. We investigated the efficacy and safety of DEX-KET for sedation of patients undergoing MRI of the brain. Methods: This quasi-experimental study was conducted to compare the DEX-KET combination and midazolam for MRI sedation. We included 72 patients undergoing brain MRI following bolus injection of midazolam or DEX-KET. In August 1, 2016 a new MRI sedation protocol was implemented. After protocol implementation, bolus doses of DEX-KET were administered (DEX-KET group). Thirty-six patients from the MIDA group and 36 patients from the DEX-KET group underwent MRI sequences and were compared regarding the MRI scan time and sedation-related complications (desaturation, hypotension, cardiorespiratory arrest, and aspiration pneumonia). Results: All MRI sequences were completed for 30 patients (83.3%) from the MIDA group and for 33 patients (91.7%) from the DEX-KET group (P = 0.476). The median MRI scan time was 100.0 min (interquartile range, 87.0-111.5 min) in the MIDA group and 53.5 min (interquartile range, 45.0-60.5 min) in the DEX-KET group (P < 0.001). Complications occurred in 24 (66.7%) and 8 (22.2%) patients of the MIDA and DEX-KET group, respectively (P < 0.001). Conclusions: The efficacy of DEX-KET sedation was comparable to that of midazolam for MRI examination. DEX-KET was related to shorter scan time and lower occurrence of complications compared to midazolam.