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Hu Q, Liu X, Xiang Y, Lei X, Yu H, Liu L, Feng J. Comparing different postoperative sedation strategies for patients in the intensive care unit after cardiac surgery: A systematic review of randomized controlled trials and network meta-analysis. Basic Clin Pharmacol Toxicol 2024; 135:180-194. [PMID: 39004790 DOI: 10.1111/bcpt.14043] [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: 12/25/2023] [Revised: 05/12/2024] [Accepted: 05/30/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Various postoperative sedation protocols with different anaesthetics lead to profound effects on the outcomes for post-cardiac surgery patients. However, a comprehensive analysis of optimal postoperative sedation strategies for patients in the intensive care unit (ICU) after cardiac surgery is lacking. METHODS We systematically searched for randomized controlled trials (RCTs) in databases including PubMed and Embase. The primary outcome measured the duration of mechanical ventilation (MV) in the ICU, and the secondary outcome encompassed the length of stay (LOS) in the ICU and hospital and the monitoring adverse events. RESULTS The literature included 18 RCTs (1652 patients) with 13 sedation regimens. Dexmedetomidine plus ketamine and sevoflurane were associated with a significantly reduced duration of MV when compared with propofol. Our results also suggested that dexmedetomidine plus ketamine may associated with a shorter LOS in ICU, and sevoflurane associated with a shorter LOS in the hospital, respectively. CONCLUSIONS The combination of dexmedetomidine and ketamine seems to be a better option for adult patients needing sedation after cardiac surgery, and the incidence of side effects is lower with dexmedetomidine. These findings have potential implications for medication management in the perioperative pharmacotherapy of cardiac surgery patients.
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Affiliation(s)
- Qinxue Hu
- Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Xing Liu
- The Third Central Clinical College, Tianjin Medical University, Tianjin, China
- Department of Anesthesiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Yuancai Xiang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Xianying Lei
- Department of Critical Care Medicine, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Hong Yu
- Department of Anesthesiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Jianguo Feng
- Department of Anesthesiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, The Affiliated Hospital, Southwest Medical University, Luzhou, China
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Chen XH, Zhao JJ, Chen C, Yao L. Establishment and validation of a predictive model for tracheotomy in critically ill patients and analysis of the impact of different tracheotomy timing on patient prognosis. BMC Anesthesiol 2024; 24:175. [PMID: 38760700 PMCID: PMC11100231 DOI: 10.1186/s12871-024-02558-x] [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: 03/11/2024] [Accepted: 05/14/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In critically ill patients receiving invasive mechanical ventilation (IMV), it is unable to determine early which patients require tracheotomy and whether early tracheotomy is beneficial. METHODS Clinical data of patients who were first admitted to the ICU and underwent invasive ventilation for more than 24 h in the Medical Information Marketplace in Intensive Care (MIMIC)-IV database were retrospectively collected. Patients were categorized into successful extubation and tracheotomy groups according to whether they were subsequently successfully extubated or underwent tracheotomy. The patients were randomly divided into model training set and validation set in a ratio of 7:3. Constructing predictive models and evaluating and validating the models. The tracheotomized patients were divided into the early tracheotomy group (< = 7 days) and the late tracheotomy group (> 7 days), and the prognosis of the two groups was analyzed. RESULTS A total of 7 key variables were screened: Glasgow coma scale (GCS) score, pneumonia, traumatic intracerebral hemorrhage, hemorrhagic stroke, left and right pupil responses to light, and parenteral nutrition. The area under the receiver operator characteristic (ROC) curve of the prediction model constructed through these seven variables was 0.897 (95% CI: 0.876-0.919), and 0.896 (95% CI: 0.866-0.926) for the training and validation sets, respectively. Patients in the early tracheotomy group had a shorter length of hospital stay, IMV duration, and sedation duration compared to the late tracheotomy group (p < 0.05), but there was no statistically significant difference in survival outcomes between the two groups. CONCLUSION The prediction model constructed and validated based on the MIMIC-IV database can accurately predict the outcome of tracheotomy in critically ill patients. Meanwhile, early tracheotomy in critically ill patients does not improve survival outcomes but has potential advantages in shortening the duration of hospitalization, IMV, and sedation.
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Affiliation(s)
- Xing-Hua Chen
- Department of Intensive Care Unit, Hefei Hospital Affiliated to Anhui Medical University, The Second People's Hospital of Hefei, Hefei, Anhui, 230011, China
| | - Jing-Jing Zhao
- Department of Intensive Care Unit, Hefei Hospital Affiliated to Anhui Medical University, The Second People's Hospital of Hefei, Hefei, Anhui, 230011, China
| | - Cheng Chen
- Department of Intensive Care Unit, Hefei Hospital Affiliated to Anhui Medical University, The Second People's Hospital of Hefei, Hefei, Anhui, 230011, China
| | - Li Yao
- Department of Intensive Care Unit, Hefei Hospital Affiliated to Anhui Medical University, The Second People's Hospital of Hefei, Hefei, Anhui, 230011, China.
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Bhat AA, Kukreti N, Afzal M, Goyal A, Thapa R, Ali H, Shahwan M, Almalki WH, Kazmi I, Alzarea SI, Singh SK, Dua K, Gupta G. Ferroptosis and circular RNAs: new horizons in cancer therapy. EXCLI JOURNAL 2024; 23:570-599. [PMID: 38887390 PMCID: PMC11180955 DOI: 10.17179/excli2024-7005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/09/2024] [Indexed: 06/20/2024]
Abstract
Cancer poses intricate challenges to treatment due to its complexity and diversity. Ferroptosis and circular RNAs (circRNAs) are emerging as innovative therapeutic avenues amid the evolving landscape of cancer therapy. Extensive investigations into circRNAs reveal their diverse roles, ranging from molecular regulators to pivotal influencers of ferroptosis in cancer cell lines. The results underscore the significance of circRNAs in modulating molecular pathways that impact crucial aspects of cancer development, including cell survival, proliferation, and metastasis. A detailed analysis delineates these pathways, shedding light on the molecular mechanisms through which circRNAs influence ferroptosis. Building upon recent experimental findings, the study evaluates the therapeutic potential of targeting circRNAs to induce ferroptosis. By identifying specific circRNAs associated with the etiology of cancer, this analysis paves the way for the development of targeted therapeutics that exploit vulnerabilities in cancer cells. This review consolidates the existing understanding of ferroptosis and circRNAs, emphasizing their role in cancer therapy and providing impetus for ongoing research in this dynamic field. See also the graphical abstract(Fig. 1).
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Affiliation(s)
- Asif Ahmad Bhat
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Mahal Road, Jaipur, India
| | - Neelima Kukreti
- School of Pharmacy, Graphic Era Hill University, Dehradun 248007, India
| | - Muhammad Afzal
- Department of Pharmaceutical Sciences, Pharmacy Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia
| | - Ahsas Goyal
- Institute of Pharmaceutical Research, GLA University, Mathura, U. P., India
| | - Riya Thapa
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Mahal Road, Jaipur, India
| | - Haider Ali
- Center for Global Health Research, Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, India
- Department of Pharmacology, Kyrgyz State Medical College, Bishkek, Kyrgyzstan
| | - Moyad Shahwan
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, 346, United Arab Emirates
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, Ajman, 346, United Arab Emirates
| | - Waleed Hassan Almalki
- Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Imran Kazmi
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, 21589, Jeddah, Saudi Arabia
| | - Sami I. Alzarea
- Department of Pharmacology, College of Pharmacy, Jouf University, 72341, Sakaka, Al-Jouf, Saudi Arabia
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara 144411, India
- Faculty of Health, Australian Research Center in Complementary and Integrative Medicine, University of Technology, Sydney, Ultimo-NSW 2007, Australia
- School of Medical and Life Sciences, Sunway University, Sunway, Malaysia
| | - Kamal Dua
- Faculty of Health, Australian Research Center in Complementary and Integrative Medicine, University of Technology, Sydney, Ultimo-NSW 2007, Australia
- Discipline of Pharmacy, Graduate School of Health, University of Technology, Sydney, Ultimo-NSW 2007, Australia
- Uttaranchal Institute of Pharmaceutical Sciences, Uttaranchal University, Dehradun, India
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Mahal Road, Jaipur, India
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, Ajman, 346, United Arab Emirates
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Widing H, Pellegrini M, Chiodaroli E, Persson P, Hallén K, Perchiazzi G. Positive end-expiratory pressure limits inspiratory effort through modulation of the effort-to-drive ratio: an experimental crossover study. Intensive Care Med Exp 2024; 12:10. [PMID: 38311676 PMCID: PMC10838888 DOI: 10.1186/s40635-024-00597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/11/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND How assisted spontaneous breathing should be used during acute respiratory distress syndrome is questioned. Recent evidence suggests that high positive end-expiratory pressure (PEEP) may limit the risk of patient self-inflicted lung injury (P-SILI). The aim of this study was to assess the effects of PEEP on esophageal pressure swings, inspiratory drive, and the neuromuscular efficiency of ventilation. We hypothesized that high PEEP would reduce esophageal pressure swings, regardless of inspiratory drive changes, by modulating the effort-to-drive ratio (EDR). This was tested retrospectively in an experimental animal crossover study. Anesthetized pigs (n = 15) were subjected to mild to moderate lung injury and different PEEP levels were applied, changing PEEP from 0 to 15 cmH2O and back to 0 cmH2O in steps of 3 cmH2O. Airway pressure, esophageal pressure (Pes), and electric activity of the diaphragm (Edi) were collected. The EDR was calculated as the tidal change in Pes divided by the tidal change in Edi. Statistical differences were tested using the Wilcoxon signed-rank test. RESULTS Inspiratory esophageal pressure swings decreased from - 4.2 ± 3.1 cmH2O to - 1.9 ± 1.5 cmH2O (p < 0.01), and the mean EDR fell from - 1.12 ± 1.05 cmH2O/µV to - 0.24 ± 0.20 (p < 0.01) as PEEP was increased from 0 to 15 cmH2O. The EDR was significantly correlated to the PEEP level (rs = 0.35, p < 0.01). CONCLUSIONS Higher PEEP limits inspiratory effort by modulating the EDR of the respiratory system. These findings indicate that PEEP may be used in titration of the spontaneous impact on ventilation and in P-SILI risk reduction, potentially facilitating safe assisted spontaneous breathing. Similarly, ventilation may be shifted from highly spontaneous to predominantly controlled ventilation using PEEP. These findings need to be confirmed in clinical settings.
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Affiliation(s)
- Hannes Widing
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden.
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Elena Chiodaroli
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Anesthesia and Intensive Care Medicine, Polo Universitario San Paolo, University of Milan, Milan, Italy
| | - Per Persson
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Hallén
- Department of Anesthesiology and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Akademiska sjukhuset, Ing 40, 3 tr, 751 85, Uppsala, Sweden
- Department of Anesthesia, Operation, and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
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Sharif S, Munshi L, Burry L, Mehta S, Gray S, Chaudhuri D, Duffett M, Siemieniuk RA, Rochwerg B. Ketamine sedation in the intensive care unit: a survey of Canadian intensivists. Can J Anaesth 2024; 71:118-126. [PMID: 37884773 DOI: 10.1007/s12630-023-02608-x] [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: 02/19/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE We sought to understand the beliefs and practices of Canadian intensivists regarding their use of ketamine as a sedative in critically ill patients and to gauge their interest in a randomized controlled trial (RCT) examining its use in the intensive care unit (ICU). METHODS We designed and validated an electronic self-administered survey examining the use of ketamine as a sedative infusion for ICU patients. We surveyed 400 physician members of the Canadian Critical Care Society (CCCS) via email between February and April 2022 and sent three reminders at two-week intervals. The survey was redistributed in January 2023 to improve the response rate. RESULTS We received 87/400 (22%) completed questionnaires. Most respondents reported they rarely use ketamine as a continuous infusion for sedation or analgesia in the ICU (52/87, 58%). Physicians reported the following conditions would make them more likely to use ketamine: asthma exacerbation (73/87, 82%), tolerance to opioids (68/87, 77%), status epilepticus (44/87, 50%), and severe acute respiratory distress syndrome (33/87, 38%). Concern for side-effects that limited respondents' use of ketamine include adverse psychotropic effects (61/87, 69%) and delirium (47/87, 53%). The majority of respondents agreed there is need for an RCT to evaluate ketamine as a sedative infusion in the ICU (62/87, 71%). CONCLUSION This survey of Canadian intensivists illustrates that use of ketamine as a continuous infusion for sedation is limited, and is at least partly driven by concerns of adverse psychotropic effects. Canadian physicians endorse the need for a trial investigating the safety and efficacy of ketamine as a sedative for critically ill patients.
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Affiliation(s)
- Sameer Sharif
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Hamilton General Hospital, 237 Barton St East, 2nd Floor McMaster Wing, Room 252, Hamilton, ON, L8L 2X2, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Sara Gray
- Division of Emergency Medicine, and the Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Network, University of Toronto, Toronto, ON, Canada
| | - Dipayan Chaudhuri
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Duffett
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Reed A Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Schoene D, Hartmann C, Winzer S, Moustafa H, Günther A, Puetz V, Barlinn K. [Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]. DER NERVENARZT 2023; 94:934-943. [PMID: 37140605 PMCID: PMC10157548 DOI: 10.1007/s00115-023-01486-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. OBJECTIVE This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. MATERIAL AND METHODS From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed. RESULTS Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation. CONCLUSION The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.
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Affiliation(s)
- D Schoene
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland.
| | - C Hartmann
- Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - S Winzer
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - H Moustafa
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - A Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - V Puetz
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - K Barlinn
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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Blume ED, Kirsch R, Cousino MK, Walter JK, Steiner JM, Miller TA, Machado D, Peyton C, Bacha E, Morell E. Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000114. [PMID: 36633003 PMCID: PMC10472747 DOI: 10.1161/hcq.0000000000000114] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease. METHODS A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.
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Prin M, Pattee J, Douin DJ, Scott BK, Ginde AA, Eckle T. Time-of-day dependent effects of midazolam administration on myocardial injury in non-cardiac surgery. Front Cardiovasc Med 2022; 9:982209. [PMID: 36386382 PMCID: PMC9650651 DOI: 10.3389/fcvm.2022.982209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/10/2022] [Indexed: 01/22/2023] Open
Abstract
Background Animal studies have shown that midazolam can increase vulnerability to cardiac ischemia, potentially via circadian-mediated mechanisms. We hypothesized that perioperative midazolam administration is associated with an increased incidence of myocardial injury in patients undergoing non-cardiac surgery (MINS) and that circadian biology may underlie this relationship. Methods We analyzed intraoperative data from the Multicenter Perioperative Outcomes Group for the occurrence of MINS across 50 institutions from 2014 to 2019. The primary outcome was the occurrence of MINS. MINS was defined as having at least one troponin-I lab value ≥0.03 ng/ml from anesthesia start to 72 h after anesthesia end. To account for bias, propensity scores and inverse probability of treatment weighting were applied. Results A total of 1,773,118 cases were available for analysis. Of these subjects, 951,345 (53.7%) received midazolam perioperatively, and 16,404 (0.93%) met criteria for perioperative MINS. There was no association between perioperative midazolam administration and risk of MINS in the study population as a whole (odds ratio (OR) 0.98, confidence interval (CI) [0.94, 1.01]). However, we found a strong association between midazolam administration and risk of MINS when surgery occurred overnight (OR 3.52, CI [3.10, 4.00]) or when surgery occurred in ASA 1 or 2 patients (OR 1.25, CI [1.13, 1.39]). Conclusion Perioperative midazolam administration may not pose a significant risk for MINS occurrence. However, midazolam administration at night and in healthier patients could increase MINS, which warrants further clinical investigation with an emphasis on circadian biology.
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Mahmud TI, Imran SA, Shahnaz C. Res-SE-ConvNet: A Deep Neural Network for Hypoxemia Severity Prediction for Hospital In-Patients Using Photoplethysmograph Signal. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2022; 10:4901409. [PMID: 36457893 PMCID: PMC9704746 DOI: 10.1109/jtehm.2022.3217428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
Determining the severity level of hypoxemia, the scarcity of saturated oxygen (SpO2) in the human body, is very important for the patients, a matter which has become even more significant during the outbreak of Covid-19 variants. Although the widespread usage of Pulse Oximeter has helped the doctors aware of the current level of SpO2 and thereby determine the hypoxemia severity of a particular patient, the high sensitivity of the device can lead to the desensitization of the care-givers, resulting in slower response to actual hypoxemia event. There has been research conducted for the detection of severity level using various parameters and bio-signals and feeding them in a machine learning algorithm. However, in this paper, we have proposed a new residual-squeeze-excitation-attention based convolutional network (Res-SE-ConvNet) using only Photoplethysmography (PPG) signal for the comfortability of the patient. Unlike the other methods, the proposed method has outperformed the standard state-of-art methods as the result shows 96.5% accuracy in determining 3 class severity problems with 0.79 Cohen Kappa score. This method has the potential to aid the patients in receiving the benefit of an automatic and faster clinical decision support system, thus handling the severity of hypoxemia.
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Affiliation(s)
- Talha Ibn Mahmud
- Department of Electrical and Electronic EngineeringBangladesh University of Engineering and Technology (BUET) Dhaka 1205 Bangladesh
| | - Sheikh Asif Imran
- Department of Electrical and Electronic EngineeringBangladesh University of Engineering and Technology (BUET) Dhaka 1205 Bangladesh
| | - Celia Shahnaz
- Department of Electrical and Electronic EngineeringBangladesh University of Engineering and Technology (BUET) Dhaka 1205 Bangladesh
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Wojnar-Gruszka K, Sega A, Płaszewska-Żywko L, Wojtan S, Potocka M, Kózka M. Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10894. [PMID: 36078609 PMCID: PMC9517797 DOI: 10.3390/ijerph191710894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation. METHODS In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment. RESULTS It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907). CONCLUSIONS Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.
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Affiliation(s)
- Katarzyna Wojnar-Gruszka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Aurelia Sega
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Lucyna Płaszewska-Żywko
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Stanisław Wojtan
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
- Department of Anaesthesiology and Intensive Therapy, University Hospital in Kraków, 30-688 Kraków, Poland
| | - Marcelina Potocka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
| | - Maria Kózka
- Department of Clinical Nursing, Faculty of Health Sciences, Collegium Medicum, Jagiellonian University, 31-501 Kraków, Poland
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11
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Heavner MS, Gorman EF, Linn DD, Yeung SYA, Miano TA. Systematic review and meta‐analysis of the correlation between bispectral index (
BIS
) and clinical sedation scales: Toward defining the role of
BIS
in critically ill patients. Pharmacotherapy 2022; 42:667-676. [PMID: 35707961 PMCID: PMC9671609 DOI: 10.1002/phar.2712] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/13/2022] [Accepted: 05/21/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The bispectral index (BIS) is an attractive approach for monitoring level of consciousness in critically ill patients, particularly during paralysis, when commonly used sedation scales cannot be used. OBJECTIVES As a first step toward establishing the utility of BIS during paralysis, this review examines the strength of correlation between BIS and clinical sedation scales in a broad population of non-paralyzed, critically ill adults. METHODS We included studies evaluating the strength of correlation between concurrent assessments of BIS and Richmond Agitation Sedation Scale (RASS), Ramsay Sedation Scale (RSS), or Sedation Agitation Scale (SAS) in critically ill adult patients. Studies involving assessment of depth sedation periperative or procedural time periods, and those reporting BIS and sedation scale assessments conducted >5 min apart or while neuromuscular blocking agents (NMBA) were administered, were excluded. Data were abstracted on sedation scale, correlation coefficients, setting, patient characteristics, and BIS assessment characteristics that could impact the quality of the studies. RESULTS Twenty-four studies which enrolled 1235 patients met inclusion criteria. The correlation between BIS and RASS, RSS, and SAS overall was 0.68 (95% confidence interval, 0.61-0.74, Ƭ2 = 0.06 I2 = 71.26%). Subgroup analysis by sedation scale indicated that the correlation between BIS and RASS, RSS, and SAS were 0.66 (95% confidence interval 0.58-0.73, Ƭ2 = 0.01 I2 = 30.20%), 0.76 (95% confidence interval 0.69-0.82, Ƭ2 = 0.04 I2 = 67.15%), and 0.53 (95% confidence interval 0.42-0.63, Ƭ2 = 0.01 I2 = 26.59%), respectively. Factors associated with significant heterogeneity included comparator clinical sedation scale, neurologic injury, and the type of intensive care unit (ICU) population. CONCLUSIONS BIS demonstrated moderate to strong correlation with clinical sedation scales in adult ICU patients, providing preliminary evidence for the validity of BIS as a measure of sedation intensity when clinical scales cannot be used. Future studies should determine whether BIS monitoring is safe and effective in improving outcomes in patients receiving NMBA treatment.
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Affiliation(s)
- Mojdeh S. Heavner
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Emily F. Gorman
- Health Sciences and Human Services Library University of Maryland Baltimore Maryland USA
| | - Dustin D. Linn
- Medical Science Liaison Philips North America Cambridge Massachusetts USA
| | - Siu Yan Amy Yeung
- Medical Intensive Care Unit, Department of Pharmacy Services University of Maryland Medical Center Baltimore Maryland USA
| | - Todd A. Miano
- Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia Pennsylvania USA
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12
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Rasulo FA, Hopkins P, Lobo FA, Pandin P, Matta B, Carozzi C, Romagnoli S, Absalom A, Badenes R, Bleck T, Caricato A, Claassen J, Denault A, Honorato C, Motta S, Meyfroidt G, Radtke FM, Ricci Z, Robba C, Taccone FS, Vespa P, Nardiello I, Lamperti M. Processed Electroencephalogram-Based Monitoring to Guide Sedation in Critically Ill Adult Patients: Recommendations from an International Expert Panel-Based Consensus. Neurocrit Care 2022; 38:296-311. [PMID: 35896766 PMCID: PMC10090014 DOI: 10.1007/s12028-022-01565-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/20/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
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Affiliation(s)
- Frank A Rasulo
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy. .,Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Philip Hopkins
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Pierre Pandin
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Basil Matta
- Department of Anaesthesia and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carla Carozzi
- Department of Anesthesia and Intensive Care, Istituto Neurologico C. Besta, Milan, Italy
| | - Stefano Romagnoli
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Anthony Absalom
- Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, University of Valencia, Valencia, Spain
| | - Thomas Bleck
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Evanston, IL, USA
| | - Anselmo Caricato
- Department of Anesthesia and Intensive Care, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jan Claassen
- Department of Neurocritical Care, Columbia University Irving Medical Center, New York, NY, USA
| | - André Denault
- Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Cristina Honorato
- Department of Anesthesiology and Critical Care, Universidad de Navarra, Pamplona, Spain
| | - Saba Motta
- Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Finn Michael Radtke
- Department of Anesthesiology IRS, Nykøbing F. Hospital, Nykøbing Falster, Denmark
| | - Zaccaria Ricci
- Department of Pediatric Anesthesia, Meyer University Hospital of Florence, University of Florence, Florence, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Policlinico San Martino and University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium
| | - Paul Vespa
- Department of Neurosurgery and Neurocritical Care, Los Angeles Medical Center, Ronald Reagan University of California, Los Angeles, CA, USA
| | - Ida Nardiello
- Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Massimo Lamperti
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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13
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Lewis K, Alshamsi F, Carayannopoulos KL, Granholm A, Piticaru J, Al Duhailib Z, Chaudhuri D, Spatafora L, Yuan Y, Centofanti J, Spence J, Rochwerg B, Perri D, Needham DM, Holbrook A, Devlin JW, Nishida O, Honarmand K, Ergan B, Khorochkov E, Pandharipande P, Alshahrani M, Karachi T, Soth M, Shehabi Y, Møller MH, Alhazzani W. Dexmedetomidine vs other sedatives in critically ill mechanically ventilated adults: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2022; 48:811-840. [PMID: 35648198 DOI: 10.1007/s00134-022-06712-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/18/2022] [Indexed: 12/17/2022]
Abstract
Conventional gabaminergic sedatives such as benzodiazepines and propofol are commonly used in mechanically ventilated patients in the intensive care unit (ICU). Dexmedetomidine is an alternative sedative that may achieve lighter sedation, reduce delirium, and provide analgesia. Our objective was to perform a comprehensive systematic review summarizing the large body of evidence, determining if dexmedetomidine reduces delirium compared to conventional sedatives. We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov and the WHO ICTRP from inception to October 2021. Independent pairs of reviewers identified randomized clinical trials comparing dexmedetomidine to other sedatives for mechanically ventilated adults in the ICU. We conducted meta-analyses using random-effects models. The results were reported as relative risks (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes, with corresponding 95% confidence intervals (CIs). In total, 77 randomized trials (n = 11,997) were included. Compared to other sedatives, dexmedetomidine reduced the risk of delirium (RR 0.67, 95% CI 0.55 to 0.81; moderate certainty), the duration of mechanical ventilation (MD - 1.8 h, 95% CI - 2.89 to - 0.71; low certainty), and ICU length of stay (MD - 0.32 days, 95% CI - 0.42 to - 0.22; low certainty). Dexmedetomidine use increased the risk of bradycardia (RR 2.39, 95% CI 1.82 to 3.13; moderate certainty) and hypotension (RR 1.32, 95% CI 1.07 to 1.63; low certainty). In mechanically ventilated adults, the use of dexmedetomidine compared to other sedatives, resulted in a lower risk of delirium, and a modest reduction in duration of mechanical ventilation and ICU stay, but increased the risks of bradycardia and hypotension.
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Affiliation(s)
- Kimberley Lewis
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Alain, United Arab Emirates
| | - Kallirroi Laiya Carayannopoulos
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Joshua Piticaru
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Zainab Al Duhailib
- Department of Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Dipayan Chaudhuri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Laura Spatafora
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yuhong Yuan
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Canada
| | - John Centofanti
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Jessica Spence
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Department of Anesthesia, McMaster University, Hamilton, Canada.,Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Bram Rochwerg
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Dan Perri
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, USA.,Armstrong Institute for Patient Safety and Quality, John Hopkins University, Baltimore, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Canada
| | - John W Devlin
- School of Pharmacy, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Northeastern University, Boston, MA, USA
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Kimia Honarmand
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Eugenia Khorochkov
- Department of Medical Imaging, Memorial University of Newfoundland, St. John's, Canada
| | - Pratik Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, USA
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, College of Medicine, Imam Abdulrahman Ben Faisal University, Al Khobar, Kingdom of Saudi Arabia
| | - Tim Karachi
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Mark Soth
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada
| | - Yahya Shehabi
- Department of Intensive Care, Monash Health School of Clinical Sciences, The School of Clinical Medicine, University of New South Wales, Clayton, VIC 3168, Randwick, 2031, Australia
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Division of Critical Care, Intensive Care Unit, Department of Medicine, McMaster University, St Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON, L8N 4A, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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14
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Davoudi A, Shickel B, Tighe PJ, Bihorac A, Rashidi P. Potentials and Challenges of Pervasive Sensing in the Intensive Care Unit. Front Digit Health 2022; 4:773387. [PMID: 35656333 PMCID: PMC9152012 DOI: 10.3389/fdgth.2022.773387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Patients in critical care settings often require continuous and multifaceted monitoring. However, current clinical monitoring practices fail to capture important functional and behavioral indices such as mobility or agitation. Recent advances in non-invasive sensing technology, high throughput computing, and deep learning techniques are expected to transform the existing patient monitoring paradigm by enabling and streamlining granular and continuous monitoring of these crucial critical care measures. In this review, we highlight current approaches to pervasive sensing in critical care and identify limitations, future challenges, and opportunities in this emerging field.
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Affiliation(s)
- Anis Davoudi
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States,*Correspondence: Anis Davoudi
| | - Benjamin Shickel
- Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Patrick James Tighe
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, United States
| | - Parisa Rashidi
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, United States
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15
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Tarwade P, Smischney NJ. Endotracheal intubation sedation in the intensive care unit. World J Crit Care Med 2022; 11:33-39. [PMID: 35433310 PMCID: PMC8788207 DOI: 10.5492/wjccm.v11.i1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/21/2021] [Accepted: 11/04/2021] [Indexed: 02/06/2023] Open
Abstract
Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.
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Affiliation(s)
- Pritee Tarwade
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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16
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Sousa GC, Fernandes MV, Cruz FF, Antunes MA, da Silva CM, Takyia C, Battaglini D, Samary CS, Robba C, Pelosi P, Rocco PRM, Silva PL. Comparative effects of dexmedetomidine and propofol on brain and lung damage in experimental acute ischemic stroke. Sci Rep 2021; 11:23133. [PMID: 34848804 PMCID: PMC8633001 DOI: 10.1038/s41598-021-02608-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/17/2021] [Indexed: 11/09/2022] Open
Abstract
Acute ischemic stroke is associated with pulmonary complications, and often dexmedetomidine and propofol are used to decrease cerebral metabolic rate. However, it is unknown the immunomodulatory actions of dexmedetomidine and propofol on brain and lungs during acute ischemic stroke. The effects of dexmedetomidine and propofol were compared on perilesional brain tissue and lung damage after acute ischemic stroke in rats. Further, the mean amount of both sedatives was directly evaluated on alveolar macrophages and lung endothelial cells primarily extracted 24-h after acute ischemic stroke. In twenty-five Wistar rats, ischemic stroke was induced and after 24-h treated with sodium thiopental (STROKE), dexmedetomidine and propofol. Dexmedetomidine, compared to STROKE, reduced diffuse alveolar damage score [median(interquartile range); 12(7.8–15.3) vs. 19.5(18–24), p = 0.007)], bronchoconstriction index [2.28(2.08–2.36) vs. 2.64(2.53–2.77), p = 0.006], and TNF-α expression (p = 0.0003), while propofol increased VCAM-1 expression compared to STROKE (p = 0.0004). In perilesional brain tissue, dexmedetomidine, compared to STROKE, decreased TNF-α (p = 0.010), while propofol increased VCAM-1 compared to STROKE (p = 0.024). In alveolar macrophages and endothelial cells, dexmedetomidine decreased IL-6 and IL-1β compared to STROKE (p = 0.002, and p = 0.040, respectively), and reduced IL-1β compared to propofol (p = 0.014). Dexmedetomidine, but not propofol, induced brain and lung protection in experimental acute ischemic stroke.
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Affiliation(s)
- Giselle C Sousa
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Department of Anesthesiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos Vinicius Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Mariana A Antunes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Carla M da Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Laboratory of Imunopathology, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Christina Takyia
- Laboratory of Imunopathology, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Denise Battaglini
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Genoa, Italy
| | - Cynthia S Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Chiara Robba
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil. .,Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.
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17
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Lee H, Choi S, Jang EJ, Lee J, Kim D, Yoo S, Oh SY, Ryu HG. Effect of Sedatives on In-hospital and Long-term Mortality of Critically Ill Patients Requiring Extended Mechanical Ventilation for ≥ 48 Hours. J Korean Med Sci 2021; 36:e221. [PMID: 34463064 PMCID: PMC8405403 DOI: 10.3346/jkms.2021.36.e221] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/22/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥ 48 hours from 2008 to 2016. METHODS We conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. Data from adult patients (aged ≥ 18) who underwent MV for ≥ 48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group. RESULTS A total of 158,712 patients requiring MV for ≥ 48 hours were admitted in 55 centers in Korea from 2008 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% confident interval, 0.954-0.983; P < 0.001). Benzodiazepine use, older age, lower case volume (≤ 500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality. CONCLUSION In critically ill patients undergoing MV for ≥ 48 hour, the use of benzodiazepines for sedation, older age, and chronic kidney disease were associated with higher in-hospital mortality and one-year mortality. Further studies are needed to evaluate the impact of benzodiazepines on the mortality in elderly patients with chronic kidney disease requiring MV for ≥ 48 hours.
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Affiliation(s)
- Hannah Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seongmi Choi
- Health Insurance Policy Research Institute, National Health Insurance Service, Wonju, Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Korea
| | - Juhee Lee
- Department of Statistics, Kyungpook National University, Daegu, Korea
| | - Dalho Kim
- Department of Statistics, Kyungpook National University, Daegu, Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Young Oh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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18
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Comparative Safety Profiles of Sedatives Commonly Used in Clinical Practice: A 10-Year Nationwide Pharmacovigilance Study in Korea. Pharmaceuticals (Basel) 2021; 14:ph14080783. [PMID: 34451882 PMCID: PMC8399659 DOI: 10.3390/ph14080783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/29/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022] Open
Abstract
This study aims to compare the prevalence and seriousness of adverse events (AEs) among sedatives used in critically ill patients or patients undergoing invasive procedures and to identify factors associated with serious AEs. Retrospective cross-sectional analysis of sedative-related AEs voluntarily reported to the Korea Adverse Event Reporting System from 2008 to 2017 was performed. All AEs were grouped using preferred terms and System Organ Classes per the World Health Organization-Adverse Reaction Terminology. Logistic regression was performed to identify factors associated with serious events. Among 95,188 AEs, including 3132 (3.3%) serious events, the most common etiologic sedative was fentanyl (58.8%), followed by pethidine (25.9%). Gastrointestinal disorders (54.2%) were the most frequent AEs. The most common serious AE was heart rate/rhythm disorders (33.1%). Serious AEs were significantly associated with male sex; pediatrics; etiologic sedative with etomidate at the highest risk, followed by dexmedetomidine, ketamine, and propofol; polypharmacy; combined sedative use; and concurrent use of corticosteroids, aspirin, neuromuscular blockers, and antihistamines (reporting odds ratio > 1, p < 0.001 for all). Sedative-induced AEs are most frequently reported with fentanyl, primarily manifesting as gastrointestinal disorders. Etomidate is associated with the highest risk of serious AEs, with the most common serious events being heart rate/rhythm disorders.
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19
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Sionis A, Sans-Rosello J. Dexmedetomidine in the cardiac intensive care unit: still no simple answers to a complex problem. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:369-371. [PMID: 33855350 PMCID: PMC8264028 DOI: 10.1093/ehjacc/zuab017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alessandro Sionis
- Acute and Intensive Cardiovascular Care Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau Barcelona, Spain
| | - Jordi Sans-Rosello
- Acute and Intensive Cardiovascular Care Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau Barcelona, Spain
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20
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Egbuta C, Mason KP. Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit. J Clin Med 2021; 10:1847. [PMID: 33922824 PMCID: PMC8122992 DOI: 10.3390/jcm10091847] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.
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Affiliation(s)
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
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21
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Eghbali N, Alhanai T, Ghassemi MM. Patient-Specific Sedation Management via Deep Reinforcement Learning. Front Digit Health 2021; 3:608893. [PMID: 34713090 PMCID: PMC8521809 DOI: 10.3389/fdgth.2021.608893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/04/2021] [Indexed: 02/04/2023] Open
Abstract
Introduction: Developing reliable medication dosing guidelines is challenging because individual dose-response relationships are mitigated by both static (e. g., demographic) and dynamic factors (e.g., kidney function). In recent years, several data-driven medication dosing models have been proposed for sedatives, but these approaches have been limited in their ability to assess interindividual differences and compute individualized doses. Objective: The primary objective of this study is to develop an individualized framework for sedative-hypnotics dosing. Method: Using publicly available data (1,757 patients) from the MIMIC IV intensive care unit database, we developed a sedation management agent using deep reinforcement learning. More specifically, we modeled the sedative dosing problem as a Markov Decision Process and developed an RL agent based on a deep deterministic policy gradient approach with a prioritized experience replay buffer to find the optimal policy. We assessed our method's ability to jointly learn an optimal personalized policy for propofol and fentanyl, which are among commonly prescribed sedative-hypnotics for intensive care unit sedation. We compared our model's medication performance against the recorded behavior of clinicians on unseen data. Results: Experimental results demonstrate that our proposed model would assist clinicians in making the right decision based on patients' evolving clinical phenotype. The RL agent was 8% better at managing sedation and 26% better at managing mean arterial compared to the clinicians' policy; a two-sample t-test validated that these performance improvements were statistically significant (p < 0.05). Conclusion: The results validate that our model had better performance in maintaining control variables within their target range, thereby jointly maintaining patients' health conditions and managing their sedation.
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Affiliation(s)
- Niloufar Eghbali
- Human Augmentation and Artificial Intelligence Laboratory, Department of Computer Science, Michigan State University, East Lansing, MI, United States
| | - Tuka Alhanai
- Laboratory for Computer-Human Intelligence, Division of Engineering, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Mohammad M. Ghassemi
- Human Augmentation and Artificial Intelligence Laboratory, Department of Computer Science, Michigan State University, East Lansing, MI, United States
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22
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Karamchandani K, Dalal R, Patel J, Modgil P, Quintili A. Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:107-115. [PMID: 33654458 PMCID: PMC7907309 DOI: 10.1007/s40140-021-00440-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
Purpose of Review To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients. Recent Findings A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages. Summary With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.
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Affiliation(s)
- Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Rajeev Dalal
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Jina Patel
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
| | - Puneet Modgil
- Penn State University College of Medicine, 500 University Drive, Hershey, PA 17033 USA
| | - Ashley Quintili
- Department of Pharmacy, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA
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23
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Cheng MH, Tan TK. Sedating critically ill patients. Singapore Med J 2021; 61:2-3. [PMID: 32043157 DOI: 10.11622/smedj.2020002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ming Hua Cheng
- Department of Intensive Care, Singapore General Hospital, Singapore
| | - Tong Khee Tan
- Department of Intensive Care, Singapore General Hospital, Singapore
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24
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Decker EP, Vasauskas AA. Lung Epithelial Protein Expression and the Use of Volatile Anesthetics in Acute Respiratory Distress Syndrome. Cureus 2020; 12:e10196. [PMID: 33033674 PMCID: PMC7532868 DOI: 10.7759/cureus.10196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a potentially fatal lung injury that can present with divergent underlying cause across cases. Current treatment options are limited by an incomplete understanding of the disease sequelae, undefined unifying pathology, and lack of reliable diagnostic tools. ARDS is defined as respiratory failure not caused by fluid overload or cardiac failure within one week of a known clinical insult with bilateral opacities on chest imaging, and diagnosis is based on these parameters. Increased understanding of the inflammatory cascade associated with ARDS progression shows promise for identifying potential diagnostic biomarkers and additional treatment options. Here, we review recent studies that point to the unifying inflammatory element(s) of the disease process and the use of agents that decrease inflammation as potentially powerful treatments for ARDS patients.
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Affiliation(s)
- Eric P Decker
- Anesthesiology, Alabama College of Osteopathic Medicine, Dothan, USA
| | - Audrey A Vasauskas
- Molecular Medicine, Alabama College of Osteopathic Medicine, Dothan, USA
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25
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Aggarwal J, Lustrino J, Stephens J, Morgenstern D, Tang WY. <p>Cost-Minimization Analysis of Dexmedetomidine Compared to Other Sedatives for Short-Term Sedation During Mechanical Ventilation in the United States</p>. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:389-397. [PMID: 32801809 PMCID: PMC7395701 DOI: 10.2147/ceor.s242994] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/02/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Mechanical ventilation (MV) remains a substantial cost driver in intensive care units (ICU) in the United States (US). Evaluations of standard sedation treatments used to relieve pain and discomfort in this setting have found varying impacts on ICU length of stay. This cost analysis examines both length-of=stay costs and the total cost implications among MV patients receiving common sedative treatments (dexmedetomidine, propofol, or midazolam) in short-term sedation settings (<24 hours). Methods A cost-minimization model was conducted from the hospital provider perspective. Clinical outcomes were obtained from published literature and included ICU length of stay, MV duration, prescription of sedatives and pain medication, and the occurrence of adverse events. Outcomes costs were obtained from previously conducted ICU cost studies and Medicare payment fee schedules. All costs were estimated in 2018 US Dollars. Results The per patient costs associated with dexmedetomidine, propofol, and midazolam were estimated to be $21,115, $27,073, and $27,603, respectively. Dexmedetomidine was associated with a savings of $5958 per patient compared to propofol and a saving of $6487 compared to midazolam. These savings were primarily driven by a reduction in ICU length of stay and the degree of monitoring and management. Conclusion Dexmedetomidine was associated with reduced costs when compared to propofol or midazolam used for short-term sedation during MV in the ICU, suggesting sedative choice can have a potential impact on overall cost per episode.
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Affiliation(s)
| | | | | | | | - Wing Yu Tang
- Pfizer, New York, NY, USA
- Correspondence: Wing Yu Tang Pfizer, 235 E. 42nd St, New York, NY10017, USA Email
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26
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Abstract
Objectives: To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade. Design: Retrospective cohort study. Setting: Tertiary care teaching hospital in Boston, MA. Patients: All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours. Interventions: We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration. Measurements and Main Results: Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12–2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001). Conclusions: Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.
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27
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Zheng WL, Sun H, Akeju O, Westover MB. Adaptive Sedation Monitoring From EEG in ICU Patients With Online Learning. IEEE Trans Biomed Eng 2020; 67:1696-1706. [PMID: 31545708 PMCID: PMC7085963 DOI: 10.1109/tbme.2019.2943062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sedative medications are routinely administered to provide comfort and facilitate clinical care in critically ill ICU patients. Prior work shows that brain monitoring using electroencephalography (EEG) to track sedation levels may help medical personnel to optimize drug dosing and avoid the adverse effects of oversedation and undersedation. However, the performance of sedation monitoring methods proposed to date deal poorly with individual variability across patients, leading to inconsistent performance. To address this challenge we develop an online learning approach based on Adaptive Regularization of Weight Vectors (AROW). Our approach adaptively updates a sedation level prediction algorithm under a continuously evolving data distribution. The prediction model is gradually calibrated for individual patients in response to EEG observations and routine clinical assessments over time. The evaluations are performed on a population of 172 sedated ICU patients whose sedation levels were assessed using the Richmond Agitation-Sedation Scale (scores between -5 = comatose and 0 = awake). The proposed adaptive model achieves better performance than the same model without adaptation (average accuracies with tolerance of one level difference: 68.76% vs. 61.10%). Moreover, our approach is shown to be robust to sudden changes caused by label noise. Medication administrations have different effects on model performance. We find that the model performs best in patients receiving only propofol, compared to patients receiving no sedation or multiple simultaneous sedative medications.
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28
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Automated tracking of level of consciousness and delirium in critical illness using deep learning. NPJ Digit Med 2019; 2:89. [PMID: 31508499 PMCID: PMC6733797 DOI: 10.1038/s41746-019-0167-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/20/2019] [Indexed: 01/02/2023] Open
Abstract
Over- and under-sedation are common in the ICU, and contribute to poor ICU outcomes including delirium. Behavioral assessments, such as Richmond Agitation-Sedation Scale (RASS) for monitoring levels of sedation and Confusion Assessment Method for the ICU (CAM-ICU) for detecting signs of delirium, are often used. As an alternative, brain monitoring with electroencephalography (EEG) has been proposed in the operating room, but is challenging to implement in ICU due to the differences between critical illness and elective surgery, as well as the duration of sedation. Here we present a deep learning model based on a combination of convolutional and recurrent neural networks that automatically tracks both the level of consciousness and delirium using frontal EEG signals in the ICU. For level of consciousness, the system achieves a median accuracy of 70% when allowing prediction to be within one RASS level difference across all patients, which is comparable or higher than the median technician–nurse agreement at 59%. For delirium, the system achieves an AUC of 0.80 with 69% sensitivity and 83% specificity at the optimal operating point. The results show it is feasible to continuously track level of consciousness and delirium in the ICU.
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29
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Morley G, Ives J, Bradbury-Jones C. Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare. HEALTH CARE ANALYSIS 2019; 27:185-201. [PMID: 31317374 PMCID: PMC6667688 DOI: 10.1007/s10728-019-00376-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect-moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians' moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times.
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Affiliation(s)
- Georgina Morley
- Department of Bioethics, Heart and Vascular Institute, Cleveland Clinic, Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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30
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Sun H, Nagaraj SB, Akeju O, Purdon PL, Westover BM. Brain Monitoring of Sedation in the Intensive Care Unit Using a Recurrent Neural Network. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:1-4. [PMID: 30440304 DOI: 10.1109/embc.2018.8513185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Over and under-sedation are common in critically ill patients admitted to the Intensive Care Unit. Clinical assessments provide limited time resolution and are based on behavior rather than the brain itself. Existing brain monitors have been developed primarily for non-ICU settings. Here, we use a clinical dataset from 154 ICU patients in whom the Richmond Agitation-Sedation Score is assessed about every 2 hours. We develop a recurrent neural network (RNN) model to discriminate between deep vs. no sedation, trained end-to-end from raw EEG spectrograms without any feature extraction. We obtain an average area under the ROC of 0.8 on 10-fold cross validation across patients. Our RNN is able to provide reliable estimates of sedation levels consistently better compared to a feed-forward model with simple smoothing. Decomposing the prediction error in terms of sedatives reveals that patient-specific calibration for sedatives is expected to further improve sedation monitoring.
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31
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Liu L, Wu AP, Yang Y, Liu SQ, Huang YZ, Xie JF, Pan C, Yang CS, Qiu HB. Effects of Propofol on Respiratory Drive and Patient-ventilator Synchrony during Pressure Support Ventilation in Postoperative Patients: A Prospective Study. Chin Med J (Engl) 2018; 130:1155-1160. [PMID: 28485314 PMCID: PMC5443020 DOI: 10.4103/0366-6999.205864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Propofol is increasingly used during partial support mechanical ventilation such as pressure support ventilation (PSV) in postoperative patients. However, breathing pattern, respiratory drive, and patient-ventilator synchrony are affected by the sedative used and the sedation depth. The present study aimed to evaluate the physiologic effects of varying depths of propofol sedation on respiratory drive and patient-ventilator synchrony during PSV in postoperative patients. METHODS Eight postoperative patients receiving PSV for <24 h were enrolled. Propofol was administered to achieve and maintain a Ramsay score of 4, and the inspiratory pressure support was titrated to obtain a tidal volume (VT) of 6-8 ml/kg. Then, the propofol dose was reduced to achieve and maintain a Ramsay score of 3 and then 2. At each Ramsay level, the patient underwent 30-min trials of PSV. We measured the electrical activity of the diaphragm, flow, airway pressure, neuro-ventilatory efficiency (NVE), and patient-ventilator synchrony. RESULTS Increasing the depth of sedation reduced the peak and mean electrical activity of the diaphragm, which suggested a decrease in respiratory drive, while VT remained unchanged. The NVE increased with an increase in the depth of sedation. Minute ventilation and inspiratory duty cycle decreased with an increase in the depth of sedation, but this only achieved statistical significance between Ramsay 2 and both Ramsay 4 and 3 (P < 0.05). The ineffective triggering index increased with increasing sedation depth (9.5 ± 4.0%, 6.7 ± 2.0%, and 4.2 ± 2.1% for Ramsay 4, 3, and 2, respectively) and achieved statistical significance between each pair of depth of sedation (P < 0.05). The depth of sedation did not affect gas exchange. CONCLUSIONS Propofol inhibits respiratory drive and deteriorates patient-ventilator synchrony to the extent that varies with the depth of sedation. Propofol has less effect on breathing pattern and has no effect on VT and gas exchange in postoperative patients with PSV.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ai-Ping Wu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Song-Qiao Liu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Ying-Zi Huang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Jian-Feng Xie
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Chun Pan
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Cong-Shan Yang
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
| | - Hai-Bo Qiu
- Department of Critical Care Medicine, School of Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, Jiangsu 210009, China
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Feasibility of continuous sedation monitoring in critically ill intensive care unit patients using the NeuroSENSE WAV CNS index. J Clin Monit Comput 2018; 32:1081-1091. [PMID: 29464512 DOI: 10.1007/s10877-018-0115-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/16/2018] [Indexed: 10/18/2022]
Abstract
Sedation in the intensive care unit (ICU) is challenging, as both over- and under-sedation are detrimental. Current methods of assessment, such as the Richmond Agitation Sedation Scale (RASS), are measured intermittently and rely on patients' behavioral response to stimulation, which may interrupt sleep/rest. A non-stimulating method for continuous sedation monitoring may be beneficial and allow more frequent assessment. Processed electroencephalography (EEG) monitors have not been routinely adopted in the ICU. The aim of this observational study was to assess the feasibility of using the NeuroSENSE™ monitor for EEG-based continuous sedation assessment. With ethical approval, ICU patients on continuous propofol sedation were recruited. Depth-of-hypnosis index (WAVCNS) values were obtained from the NeuroSENSE. Bedside nurses, blinded to the NeuroSENSE, performed regular RASS assessments and maintained the sedation regimen as per standard of care. Participants were monitored throughout the duration of their propofol infusion, up to 24 h. Fifteen patients, with median [interquartile range] age of 57 [52-62.5] years were each monitored for a duration of 9.0 [5.7-20.1] h. Valid WAVCNS values were obtained for 89% [66-99] of monitoring time and were widely distributed within and between individuals, with 6% [1-31] spent < 40 (very deep), and 3% [1-15] spent > 90 (awake). Significant EEG suppression was detected in 3/15 (20%) participants. Observed RASS matched RASS goals in 36/89 (40%) assessments. The WAVCNS variability, and incidence of EEG suppression, highlight the limitations of using RASS as a standalone sedation measure, and suggests potential benefit of adjunct continuous brain monitoring.
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Oyama Y, Bartman CM, Gile J, Sehrt D, Eckle T. The Circadian PER2 Enhancer Nobiletin Reverses the Deleterious Effects of Midazolam in Myocardial Ischemia and Reperfusion Injury. Curr Pharm Des 2018; 24:3376-3383. [PMID: 30246635 PMCID: PMC6318050 DOI: 10.2174/1381612824666180924102530] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/10/2018] [Accepted: 09/16/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Recently, we identified the circadian rhythm protein Period 2 (PER2) in robust cardioprotection from myocardial ischemia (MI). Based on findings that perioperative MI is the most common major cardiovascular complication and that anesthetics can alter the expression of PER2, we hypothesized that an anesthesia mediated downregulation of PER2 could be detrimental if myocardial ischemia and reperfusion (IR) would occur. METHODS AND RESULTS We exposed mice to pentobarbital, fentanyl, ketamine, propofol, midazolam or isoflurane and determined cardiac Per2 mRNA levels. Unexpectedly, only midazolam treatment resulted in an immediate and significant downregulation of Per2 transcript levels. Subsequent studies in mice pretreated with midazolam using an in-situ mouse model for myocardial (IR)-injury revealed a significant and dramatic increase in infarct sizes or Troponin-I serum levels in the midazolam treated group when compared to controls. Using the recently identified flavonoid, nobiletin, as a PER2 enhancer completely abolished the deleterious effects of midazolam during myocardial IR-injury. Moreover, nobiletin treatment alone significantly reduced infarct sizes or Troponin I levels in wildtype but not in Per2-/- mice. Pharmacological studies on nobiletin like flavonoids revealed that only nobiletin and tangeritin, both found to enhance PER2, were cardioprotective in our murine model for myocardial IR-injury. CONCLUSION We identified midazolam mediated downregulation of cardiac PER2 as an underlying mechanism for a deleterious effect of midazolam pretreatment in myocardial IR-injury. These findings highlight PER2 as a cardioprotective mechanism and suggest the PER2 enhancers nobiletin or tangeritin as a preventative therapy for myocardial IR-injury in the perioperative setting where midazolam pretreatment occurs frequently.
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Affiliation(s)
- Yoshimasa Oyama
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, United States
| | - Colleen Marie Bartman
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, United States
| | - Jennifer Gile
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, United States
| | - Daniel Sehrt
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, United States
| | - Tobias Eckle
- Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO 80045, United States
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Design and Rationale of the Reevaluation of Systemic Early Neuromuscular Blockade Trial for Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2017; 14:124-133. [PMID: 27779896 DOI: 10.1513/annalsats.201608-629ot] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The Reevaluation of Systemic Early Neuromuscular Blockade (ROSE) trial is a multicenter, randomized trial designed to assess the efficacy and safety of early neuromuscular blockade in patients with moderate to severe acute respiratory distress syndrome. This document provides background for interpretation of the trial results, and highlights unique design approaches that may inform future trials of acute illness. We describe the process by which ROSE was chosen as the inaugural trial of the multidisciplinary Prevention and Early Treatment of Acute Lung Injury Network, provide the trial methodology using the Consolidated Standards of Reporting Trials framework, and discuss key design challenges and their resolution. Four key design issues proved challenging-feasibility, choice of sedation depth in the control group, impact of emphasizing early treatment on enrollment criteria and protocol execution, and choice of positive end-expiratory pressure strategy. We used literature, an iterative consensus model, and internal surveys of current practice to inform design choice. ROSE will provide definitive, Consolidated Standards of Reporting Trials adherent data on early neuromuscular blockade for future patients with acute respiratory distress syndrome. Our multidisciplinary approach to trial design may be of use to other trials of acute illness. Clinical trial registered with www.clinicaltrials.gov (NCT02509078).
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Hetland B, Bailey T, Prince-Paul M. Animal Assisted Interactions to Alleviate Psychological Symptoms in Patients on Mechanical Ventilation. J Hosp Palliat Nurs 2017; 19:516-523. [PMID: 29276432 PMCID: PMC5739326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Mechanical ventilation is a common life support intervention for critically ill patients that can cause stressful psychological symptoms. Animal assisted interactions have been used in variety of inpatient settings to reduce symptom burden and promote overall well-being. Due to the severity of illness associated with critical care, use of highly technological equipment, and heightened concern for infection control and patient safety, animal-assisted interaction has not been widely adopted in the intensive care unit. This case study of the therapeutic interaction between a canine and a mechanically ventilated patient provides support for the promotion of animal-assisted interactions as an innovative symptom management strategy in the intensive care unit.
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Affiliation(s)
- Breanna Hetland
- Assistant Professor, University of Nebraska Medical Center College of Nursing
| | - Tanya Bailey
- Animal-Assisted Interaction Program Specialist, Center for Spirituality & Healing, University of Minnesota
| | - Maryjo Prince-Paul
- Associate Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University
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Spatio-temporal dynamics of multimodal EEG-fNIRS signals in the loss and recovery of consciousness under sedation using midazolam and propofol. PLoS One 2017; 12:e0187743. [PMID: 29121108 PMCID: PMC5679575 DOI: 10.1371/journal.pone.0187743] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/25/2017] [Indexed: 12/29/2022] Open
Abstract
On sedation motivated by the clinical needs for safety and reliability, recent studies have attempted to identify brain-specific signatures for tracking patient transition into and out of consciousness, but the differences in neurophysiological effects between 1) the sedative types and 2) the presence/absence of surgical stimulations still remain unclear. Here we used multimodal electroencephalography–functional near-infrared spectroscopy (EEG–fNIRS) measurements to observe electrical and hemodynamic responses during sedation simultaneously. Forty healthy volunteers were instructed to push the button to administer sedatives in response to auditory stimuli every 9–11 s. To generally illustrate brain activity at repetitive transition points at the loss of consciousness (LOC) and the recovery of consciousness (ROC), patient-controlled sedation was performed using two different sedatives (midazolam (MDZ) and propofol (PPF)) under two surgical conditions. Once consciousness was lost via sedatives, we observed gradually increasing EEG power at lower frequencies (<15 Hz) and decreasing power at higher frequencies (>15 Hz), as well as spatially increased EEG powers in the delta and lower alpha bands, and particularly also in the upper alpha rhythm, at the frontal and parieto-occipital areas over time. During ROC from unconsciousness, these spatio-temporal changes were reversed. Interestingly, the level of consciousness was switched on/off at significantly higher effect-site concentrations of sedatives in the brain according to the use of surgical stimuli, but the spatio-temporal EEG patterns were similar, regardless of the sedative used. We also observed sudden phase shifts in fronto-parietal connectivity at the LOC and the ROC as critical points. fNIRS measurement also revealed mild hemodynamic fluctuations. Compared with general anesthesia, our results provide insights into critical hallmarks of sedative-induced (un)consciousness, which have similar spatio-temporal EEG-fNIRS patterns regardless of the stage and the sedative used.
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Schneider R, Puetz A, Vassiliou T, Wiesmann T, Lewan U, Wulf H, Bartsch DK, Rolfes C. The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care. Indian J Crit Care Med 2017; 21:274-280. [PMID: 28584430 PMCID: PMC5455020 DOI: 10.4103/ijccm.ijccm_67_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aims: Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation. Methods: In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed. Results: Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128). Conclusions: The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.
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Affiliation(s)
- Ralph Schneider
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Andreas Puetz
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Timon Vassiliou
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Ulrike Lewan
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Germany
| | - Caroline Rolfes
- Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Germany.,Clinic of Anesthesiology and Intensive Care Medicine, University of Cologne, Germany
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Paliwal B, Rai P, Kamal M, Singariya G, Singhal M, Gupta P, Trivedi T, Chouhan DS. Comparison Between Dexmedetomidine and Propofol with Validation of Bispectral Index For Sedation in Mechanically Ventilated Intensive Care Patients. J Clin Diagn Res 2015; 9:UC01-5. [PMID: 26393184 PMCID: PMC4573016 DOI: 10.7860/jcdr/2015/14474.6258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/24/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIM Sedation plays a pivotal role in the care of the critically ill patient. It is equally important to assess depth of sedation. The present study had been designed to compare dexmedetomidine and propofol for sedation in mechanically ventilated intensive care patients. It also intended to verify the clinical validity, reliability and applicability of objective assessment tool bispectral index (BIS) for monitoring sedation and observe for correlation with the commonly used subjective scale, Ramsay sedation score (RSS). MATERIALS AND METHODS This prospective randomized study was carried out in 60 haemodynamically stable patients, aged between 18 to 80 years, requiring sedation and mechanical ventilation. These were divided equally into two groups. Group A received dexmedetomidine loading dose (1μg/kg) over 10 min followed by maintenance infusion of 0.5μg/kg/hr (0.2-0.7 μg/kg/hr). Group B received propofol loading dose (1mg/kg) over 5 min followed by infusion of 2mg/kg/hr (1-3mg/kg/hr). All patients received fentanyl 1 μg/kg prior to the study drugs. Vital parameters and sedation levels (using RSS and BIS) were monitored for the study period of 12 hours with level 4 or 5 of RSS as target for sedation. Ramsay score was compared with the average of BIS values. Statistical analysis was done using SPSS VERSION 17 software. RESULTS The study revealed statistically significant lower heart rates during sedation in dexmedetomidine group whereas fall in mean arterial pressure (MAP) following loading dose in propofol group. Patients sedated with dexmedetomidine were easily arousable. Need for rescue drug for achieving the desired RSS as well as incidence of bradycardia was more in dexmedetomidine group than other. Good correlation exists between Ramsay score and BIS values. CONCLUSION Dexmedetomidine reduces heart rate while propofol transiently affects MAP. However, adequate sedation is achieved with both the drugs. The data obtained from the study validate BIS monitoring for ICU sedation.
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Affiliation(s)
- Bharat Paliwal
- Assistant Professor, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Pyush Rai
- Final Year Resident, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Manoj Kamal
- Associate Professor, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Geeta Singariya
- Associate Professor, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Madhu Singhal
- Former Professor and Head, Department of Anesthesiology and Critical care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Priyanka Gupta
- Final Year Resident, Department of Pathology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Tanuja Trivedi
- Senior Resident, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
| | - Dilip Singh Chouhan
- Professor and Head, Department of Anesthesiology and Critical Care, Dr.S.N.Medical College, Jodhpur, Rajasthan, India
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Dias DDS, Resende MV, Diniz GDCLM. Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit. Rev Bras Ter Intensiva 2015; 27:18-25. [PMID: 25909309 PMCID: PMC4396893 DOI: 10.5935/0103-507x.20150005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/20/2015] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To evaluate and compare stressors identified by patients of a coronary intensive care unit with those perceived by patients of a general postoperative intensive care unit. METHODS This cross-sectional and descriptive study was conducted in the coronary intensive care and general postoperative intensive care units of a private hospital. In total, 60 patients participated in the study, 30 in each intensive care unit. The stressor scale was used in the intensive care units to identify the stressors. The mean score of each item of the scale was calculated followed by the total stress score. The differences between groups were considered significant when p < 0.05. RESULTS The mean ages of patients were 55.63 ± 13.58 years in the coronary intensive care unit and 53.60 ± 17.47 years in the general postoperative intensive care unit. For patients in the coronary intensive care unit, the main stressors were "being in pain", "being unable to fulfill family roles" and "being bored". For patients in the general postoperative intensive care unit, the main stressors were "being in pain", "being unable to fulfill family roles" and "not being able to communicate". The mean total stress scores were 104.20 ± 30.95 in the coronary intensive care unit and 116.66 ± 23.72 (p = 0.085) in the general postoperative intensive care unit. When each stressor was compared separately, significant differences were noted only between three items. "Having nurses constantly doing things around your bed" was more stressful to the patients in the general postoperative intensive care unit than to those in the coronary intensive care unit (p = 0.013). Conversely, "hearing unfamiliar sounds and noises" and "hearing people talk about you" were the most stressful items for the patients in the coronary intensive care unit (p = 0.046 and 0.005, respectively). CONCLUSION The perception of major stressors and the total stress score were similar between patients in the coronary intensive care and general postoperative intensive care units.
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Srivastava VK, Agrawal S, Kumar S, Mishra A, Sharma S, Kumar R. Comparison of dexmedetomidine, propofol and midazolam for short-term sedation in postoperatively mechanically ventilated neurosurgical patients. J Clin Diagn Res 2014; 8:GC04-7. [PMID: 25386451 DOI: 10.7860/jcdr/2014/8797.4817] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 05/12/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Effective management of analgesia and sedation in the intensive care unit depends on the needs of the patient, subjective and/or objective measurement and drug titration to achieve specific endpoints. AIM The present study compared the efficacy of dexmedetomidine, propofol and midazolam for sedation in neurosurgical patients for postoperative mechanical ventilation. MATERIALS AND METHODS Ninety patients aged 20-65 years, ASA physical status I to III, undergoing neurosurgery and requiring postoperative ventilation were included. The patients were randomly divided into three groups of 30 each. Group D received dexmedetomidine 1 mcg/kg over 15 minutes as a loading dose, followed by 0.4-0.7 mcg/kg/h. Group P received propofol 1 mg/kg over 15 minutes as a loading dose, followed by 1-3 mg/kg/h. Group M received midazolam 0.04 mg/kg over 15 minutes as a loading dose, followed by 0.08 mg/kg/h. MEASUREMENTS Heart rate, mean arterial pressure, sedation level, fentanyl requirement, ventilation and extubation time were recorded. RESULTS Adequate sedation level was achieved with all three agents. Dexmedetomidine group required less fentanyl for postoperative analgesia. In group D there was a decrease in HR after dexmedetomidine infusion (p<0.05), but there was no significant difference in HR between group P and group M. After administration of study drug there was a significant decrease in MAP comparison to baseline value in all groups at all time intervals (p<0.05), except postextubation period (p>0.05). Extubation time was lowest in group P (p<0.05). CONCLUSION Dexmedetomidine is safer and equally effective agent compared to propofol and midazolam for sedation of neurosurgical mechanically ventilated patients with good hemodynamic stability and extubation time as rapid as propofol. Dexmedetomidine also reduced postoperative fentanyl requirements.
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Affiliation(s)
- Vinit K Srivastava
- Consultant, Department of Anaesthesiology, Apollo Hospitals Bilaspur , Chhattisgarh, India
| | - Sanjay Agrawal
- Professor, Department of Anaesthesiology, Himalayan Institute of Medical Sciences , Dehradun, India
| | - Sanjay Kumar
- Assistant Professor, Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences , Lucknow, India
| | - Abhishek Mishra
- Postgraduate trainee, Department of Anaesthesiology, Apollo Hospitals Bilaspur , Chhattisgarh, India
| | - Sunil Sharma
- Senior Consultant, Department of Neurosurgery, Apollo Hospitals Bilaspur , Chhattisgarh, India
| | - Raj Kumar
- Senior Consultant, Department of Neurosurgery, Apollo Hospitals Bilaspur , Chhattisgarh, India
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Tanaka LMS, Azevedo LCP, Park M, Schettino G, Nassar AP, Réa-Neto A, Tannous L, de Souza-Dantas VC, Torelly A, Lisboa T, Piras C, Carvalho FB, Maia MDO, Giannini FP, Machado FR, Dal-Pizzol F, de Carvalho AGR, dos Santos RB, Tierno PFGMM, Soares M, Salluh JIF. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R156. [PMID: 25047960 PMCID: PMC4223597 DOI: 10.1186/cc13995] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 06/23/2014] [Indexed: 12/13/2022]
Abstract
Introduction Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). Methods A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. Results A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. Conclusions Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.
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