2021 KSCCM clinical practice guidelines for pain, agitation, delirium, immobility, and sleep disturbance in the intensive care unit

Liberation from Mechanical Ventilation in Critically Ill Patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care, because it is the first step through which a respiratory failure patient begins to transition out of the intensive care unit, and return to normal life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider scientific and systematic approaches, as well as the individual experiences of healthcare professionals. Recently, numerous studies have investigated methods and tools to identify when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians for liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. These evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved the recommendations.

RESULTS

Recommendations for nine questions on ventilator liberation about Population, Intervention, Comparator, and Outcome (PICO) are presented in this document. This guideline presents seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSION

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Translation, cultural debugging, and validation of the Chinese version of the Sour Seven Questionnaire: a cross-sectional study

Introduction

Intensive care unit delirium (ICUD) is an acute cerebral dysfunction accompanied by a change of level of consciousness, disorientation, and cognitive dysfunction, typically occurring over a short duration ranging from hours to days and resulting from underlying medical causes. Family members may sometimes detect changes in consciousness earlier than medical staff. The Sour Seven Questionnaire is a tool to assist family members in screening for delirium, but there is currently no Chinese version. This study aimed to translate and cross-culturally debug the Sour Seven Questionnaire and test the effectiveness of the Chinese version in screening for ICUD by family members.

Methods

To create the Chinese version of the questionnaire, the questionnaire was first translated and then culturally debugged through expert consultation and cognitive interviews. Patients and their family members admitted to three ICUs in a Chinese hospital were selected to test the Chinese version of the Sour Seven Questionnaire and the results were compared with those of the validated and recommended Confusion Assessment Method for the intensive care unit (CAM-ICU) assessment.

Results

A total of 190 ICU patients and their families were included in this study. Results of the CAM-ICU assessment showed that 73 (38.4%) patients developed ICUD compared to the 66 (34.7%) using the Chinese version of the Sour Seven Questionnaire, which had a Cohen's kappa coefficient of 0.853, a sensitivity of 0.863, and a specificity of 0.974. The positive predictive value was 0.954 and the negative predictive value was 0.919.

Discussion

The Chinese version of the Sour Seven Questionnaire is a valid assessment tool for helping families screen for ICUD, and it is effective in identifying altered consciousness in patients even during online visits.

Prevalence and risk factors of subsyndromal delirium in ICU: A systematic review and meta-analysis

OBJECTIVE

To systematically assess the prevalence and risk factors for subsyndromal delirium (SSD) in the intensive care unit.

DESIGN

A systematic reviewand meta-analysis.

METHODOLOGY

This systematic review and meta-analysis was conducted in eight databases, including PubMed, Web of Science, Ovid,Scopus, China Knowledge Resource Integrated Database, Wanfang Database,Weipu Database and Chinese Biomedical Database. All original observational studies of subsyndromal delirium in the ICU were included, with languages limited to English and Chinese. The methodological quality was assessed by the Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality recommendation checklist. Meta-analysis was performed using Stata software (version 18.0).

RESULT

A total of 27 studies involving 7,286 participants were included in this review. The pooled prevalence of SSD was 32.4 % (95 %CI: 27.1 %-37.7 %).Fourteen studies reported 34 independent risk factors, and the following ten factors were significantly associated with SSD: older age, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, lower Mini-mental Status Examination (MMSE) score, pain, mechanical ventilation, hypoproteinemia, blood transfusion, longer ICU stay, infection, and physical restraint.

CONCLUSION

We conducted a systematic review and meta-analysis to evaluate the prevalence of SSD in the ICU and identified 10 risk factors associated with SSD. However, the studies have significant heterogeneity, future research should be conducted in multicenter with large samples to strengthen the current evidence.

IMPLICATIONS FOR CLINICAL PRACTICE

Subsyndromal delirium is a frequently occurring adverse event in the ICU, so it is recommended that clinicians and nurses incorporate the assessment of SSD into their daily routine. In this study, we also identified ten risk factors associated with SSD, and some of which could be modified or intervened. These findings provide a basis for ICU medical staff to identify patients at high risk of SSD and then implement individualized interventions to reduce the prevalence of SSD.

A multicentre point prevalence study of nocturnal hours awake and enteral pharmacological sleep aids in patients admitted to Australian and New Zealand intensive care units

Objective

Critically ill patients suffer disrupted sleep. Hypnotic medications may improve sleep; however, local epidemiological data regarding the amount of nocturnal time awake and the use of such medications is needed.

Design

Point prevalence study.

Setting

Adult ICUs in Australia and New Zealand.

Participants

All adult patients admitted to participating Intensive Care Units (ICUs) on the study day.

Main outcome measures

Time awake overnight (22:00-06:00) was determined by structured nurse observation. The use of enterally administered sedative-hypnotic drugs prior to and during ICU admission was recorded, as was the use of a unit policy and non-pharmacological sleep promotion strategies.

Results

Data were available for 532 patients admitted to 40 ICUs (median age 60 years, 336 (63.2%) male, and 222 (41.7%) invasively ventilated). Forty-eight patients (9.0%) received an enteral pharmacological sleep aid, of which melatonin (28, 5.2%) was most frequently used. Patients not invasively ventilated were observed to be awake overnight for a median of 4.0 h (interquartile range (IQR): 2.5, 5.5), with no difference in those receiving an enteral hypnotic (p = 0.9). Non-pharmacological sleep aids were reportedly not offered or available for 52% (earplugs) and 63% of patients (eye masks). Only 7 (17.5%) participating ICUs had a policy informing sleep-optimising interventions.

Conclusions

Patients not receiving invasive ventilation appeared to spend many nocturnal hours awake. Pharmacological sleep aid administration was not associated with a greater observed time asleep. Most patients did not receive any non-pharmacological aid, and most ICUs did not have a local guideline or unit policy on sleep promotion.

Limitations of life-sustaining treatments in intensive care units in Croatia: a multicenter retrospective study

AIM

In order to gain insight into the current prevailing practices regarding the limitation of life-sustaining treatment in intensive care units (ICUs) in Croatia, we assessed the frequency of limitation and provision of certain treatment modalities, as well as the associated patient and ICU-related factors.

METHODS

A multicenter retrospective cross-sectional study was conducted in 17 ICUs in Croatia. We reviewed the medical records of patients deceased in 2017 and extracted data on demographic, clinical, and health care variables. A logistic regression analysis was conducted to determine the associations between these variables and treatment modalities.

RESULTS

The study enrolled 1095 patients (55% male; mean age 69.9±13.7). Analgesia and sedation were discontinued before the patient's death in 23% and 34% of the cases, respectively. Patients older than 71 years were less often mechanically ventilated (P<0.001), and less frequently received inotropes and vasoactive therapy (P=0.002) than younger patients. Patients hospitalized in the ICU for less than 7 days less frequently had discontinuation of mechanical ventilation and inotropes and vasoactive therapy than patients hospitalized for 8 days and longer (P<0.001). Logistic regression analysis showed that ICU type was a crucial determinant, with multidisciplinary and surgical ICUs being associated with higher odds of intubation, mechanical ventilation, vasoactive and inotropic therapy, analgesia, and sedation.

CONCLUSION

Older patients and those diagnosed with stroke and intracranial hemorrhage received fewer therapeutic modalities. All the observed treatment modalities were more frequently discontinued in patients who were hospitalized in the ICU for a prolonged time.

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis

PURPOSE

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs.

METHODS

This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status.

RESULTS

A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72 h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs.

CONCLUSION

The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Nociception level index variations in ICU: curarized vs non-curarized patients - a pilot study

PURPOSE

Pain is a major physiological stressor that can worsen critical medical conditions in many ways. Currently, there is no reliable monitoring tool which is available for pain monitoring in the deeply sedated ± curarized critically ill patients. This study aims to assess the effectiveness of the multiparameter nociception index (NOL®) in the critical care setting. We compared NOL with traditionally used neurovegetative signs and examined its correlation with sedation depth measured by bispectral index (BIS®) electroencephalographic (EEG) monitoring.

METHODS

This retrospective monocentric cohort study was conducted in a general intensive care unit, including patients who required moderate-to-deep levels of sedation with or without continuous neuromuscular blockade. The performance of NOL was evaluated both in the entire studied population, as well as in two subgroups: curarized and non-curarized patients.

RESULTS

NOL demonstrated greater accuracy than all other indicators in pain detection in the overall population. In the non-curare subgroup, all indices correctly recognized painful stimulation, while in the patients subjected to neuromuscular blocking agent's infusion, only NOL properly identified nociception. In the former group, EEG's relation to nociception was on the border of statistical significance, whereas in the latter BIS showed no correlation with NOL.

CONCLUSION

NOL emerges as a promising device for pain assessment in the critical care setting and exhibits its best performance precisely in the clinical context where reliable pain assessment methods are most lacking. Furthermore, our research confirms the distinction between sedation and analgesia, highlighting the necessity for distinct monitoring instruments to accurately assess them.

Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study

BACKGROUND

Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce.

AIM

To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making.

DESIGN

Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis.

SETTING AND PARTICIPANTS

This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate.

FINDINGS

Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation.

CONCLUSION

Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns.

IMPLICATIONS FOR CLINICAL PRACTICE

Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.

From the Intensive Care Unit to Recovery: Managing Post-intensive Care Syndrome in Critically Ill Patients

Post-intensive care syndrome (PICS) is the term used to describe the decline in the physical, cognitive, and/or mental condition of individuals who have been discharged from the intensive care unit (ICU). This complication could result in a significant reduction in quality of life, with some patients experiencing symptoms of prolonged weakness, depression, anxiety, and post-traumatic stress disorder (PTSD). Intensive care advancement over the years has resulted in an increase in ICU survival rates and a proportional increase in PICS, creating a need for more in-depth research into the prevention and management of the disease. Hence, this study aims to examine the present body of literature on PICS, encompassing its underlying physiological processes and elements that contribute to its development, methods for evaluating and diagnosing the condition, current treatment choices as well as potential new approaches, and the constraints in managing PICS and the necessity for further investigation. In this article, studies were compiled from several databases, including, but not limited to, Google Scholar, PubMed, and Cochrane Library. These studies were reviewed, and their data were used to highlight important aspects regarding the efficacy of current PICS screening tools, the optimization and limitations of both pharmacologic and non-pharmacologic treatment methods, and the feasibility and safety of emerging treatments and technologies. The major conclusions of this review were centered around the need for multidisciplinary management of PICS. From pharmacological management using analgesia to non-pharmacological management using early mobilization and exercise therapy, the effective treatment of PICS requires a multifaceted approach. Patient follow-up and its importance were touched upon, including strategies and policies to bolster proper follow-up, thereby increasing favorable outcomes. Lastly, the importance of family involvement and the increased need for research into this topic were highlighted.

Pain Management Strategies in Intensive Care Unit: Challenges and Best Practice

Pain management in the ICU (intensive care unit) is a very complex problem which involves a wide variety of conditions, lack of sufficient tools for use, and high personnel to patient ratio. In the last three decades, pain as a clinical issue has become well analyzed, and treatment protocols based on scientific evidence have been established. Besides medication, some non-pharmacological methods such as music therapy, relaxation, and massage have been proven to be very much practical and manageable in pain management of ICU. The main opioids are utilized predominantly due to their power but NSAIDs and local anesthesia are combined with opioids with the aim to reduce the pain as much as possible. Yet more research now has to prove that pain evaluation and management is effective. This article discusses on the issues and the best approaches to solving them when managing pain in ICU patients.

Content analysis of NOC outcomes related to mechanical ventilation in people with COVID-19

OBJECTIVE

To analyze the evidence of content validity of the Nursing Outcomes "Mechanical Ventilation Response: Adult" and "Mechanical Ventilation Weaning Response: Adult", for patients with severe COVID-19.

METHOD

Methodological study developed in two stages: literature review to construct the definitions of the indicators and analysis of the evidence of content validity of the nursing outcomes by a focus group.

RESULTS

All the conceptual and operational definitions developed for the 56 indicators were considered clear and precise. However, 17 indicators were excluded because they were deemed not to be relevant. The definitions of the magnitudes for 17 indicators of the Nursing Outcome "Mechanical Ventilation Response: Adult" and 22 indicators "Mechanical Ventilation Weaning Response: Adult" were thus constructed.

CONCLUSION

The development of definitions and validation by experts makes the use of these outcomes and their indicators more understandable and precise, favoring their use in clinical practice and providing greater detail in assessment and recording.

Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality

AIM OF THE STUDY

The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated.

MATERIALS AND METHODS

This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression.

RESULTS

Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070).

CONCLUSIONS

Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset.

IMPLICATIONS FOR CLINICAL PRACTICE

Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.

Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

RESULTS

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSIONS

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Psychiatric Consults Associated With Longer Length of Stay in Trauma Patients-A Retrospective Study

INTRODUCTION

Mental illness is a risk factor for intentional and unintentional injury and is associated with readmission. The impact of psychiatric consults on length of stay (LOS) of trauma patients is still undergoing study.

METHODS

Trauma registry at Ascension St. Mary's of Saginaw, a community level 2 trauma center, was queried. Further chart review was performed to demographically characterize the control and intervention groups. Univariate and multivariate regression was performed to identify the association between psychiatric consultation and LOS while considering demographic variables and Injury Severity Score.

RESULTS

A total of 661 patients were identified with trauma and a documented mental health disorder. 612 did not receive a psychiatric consultation and 49 did. The group without a psychiatric consultation had a mean and median LOS of 6 d and 4 d, respectively, compared to 12 d and 10 d for those with a psychiatric consult (P < 0.0001). Mean ISS scores comparable across all groups. Delirium was associated with the highest LOS with a mean of 17.25 d and a median of 14.5 d. All 11 patients transferred to a psychiatric facility at discharge received a consult for self-harm.

CONCLUSIONS

Psychiatric consultations were associated with lengthened stay of trauma patients independent of initial injury severity and documented mental health disorders, and more transfers to inpatient psych facilities. This represents an important prognostic factor for a patient's course of care and suggests that trauma physicians should be well-versed at identifying mental health issues which may require early intervention, as well as managing delirium.

Cross-cultural adaptation and validation of the Indonesian version of the Critical-care Pain Observation Tool

Objective

The Critical-care Pain Observation Tool (CPOT) is one of the most accurate methods for assessing pain in ICU patients with critical illness and/or a decreased level of consciousness (LOC). This study aimed to determine the validity and reliability of the Indonesian version of the CPOT.

Methods

The English version of CPOT was translated into the Indonesian version following five steps: initial translation, synthesis of instrument translation results, back translation, validation of the instrument by an expert committee, and testing of the Indonesian instrument. Between September and December 2022, a total of 52 ICU patients from four hospitals in Indonesia were evaluated for pain at rest, during body-turning procedure, and 15 minutes after the procedure using the CPOT. The researcher used the verbal Faces Pain Thermometer (FPT) instrument as a gold standard to assess the CPOT's criteria validity. Validity assessments included content and criterion validity. Reliability was evaluated using Cronbach's α coefficient and interrater reliability.

Results

Higher CPOT scores were found during the body-turning procedure than at rest and after the procedure. The instrument's item-content validity index (I-CVI) ranged from 0.75 to 1.00, and the overall instrument's average scale-level content validity index (S-CVI/Ave) was 0.93. The statistical analysis revealed a positive correlation (r) between the CPOT and the patient's FPT scores (0.877-0.983, P < 0.01). The significant agreement amongst raters (κ) revealed the inter-rater reliability of the CPOT (0.739-0.834, P < 0.01).

Conclusion

The Indonesian version of the CPOT has been proven valid and reliable in assessing pain in patients with critical illness and/or decreased LOC.

Sedation for Patients with Sepsis: Towards a Personalised Approach

This article looks at the challenges of sedoanalgesia for sepsis patients, and argues for a personalised approach. Sedation is a necessary part of treatment for patients in intensive care to reduce stress and anxiety and improve long-term prognoses. Sepsis patients present particular difficulties as they are at increased risk of a wide range of complications, such as multiple organ failure, neurological dysfunction, septic shock, ARDS, abdominal compartment syndrome, vasoplegic syndrome, and myocardial dysfunction. The development of any one of these complications can cause the patient's rapid deterioration, and each has distinct implications in terms of appropriate and safe forms of sedation. In this way, the present article reviews the sedative and analgesic drugs commonly used in the ICU and, placing special emphasis on their strategic administration in sepsis patients, develops a set of proposals for sedoanalgesia aimed at improving outcomes for this group of patients. These proposals represent a move away from simplistic approaches like avoiding benzodiazepines to more "objective-guided sedation" that accounts for a patient's principal pathology, as well as any comorbidities, and takes full advantage of the therapeutic arsenal currently available to achieve personalised, patient-centred treatment goals.

Diagnostic Value of the Bispectral Index to Assess Sleep Quality after Elective Surgery in Intensive Care Unit

Purpose

Monitoring and improving sleep quality may help recovery from major illness. Polysomnography is a gold standard for measuring sleep quality, but routine use is not practical. The goal of this study is to investigate the diagnostic accuracy of an alternative monitor, the Bispectral Index (BIS), for evaluating the quality of sleep-in postoperative patients in the intensive care unit (ICU).

Study design

An observational study.

Materials and methods

Patients admitted to postoperative ICU after elective major noncardiac surgery were monitored with both BIS and PSG during the first night. The temporally synchronized data from both monitors were obtained for measurement of the association. Clinical outcomes were compared between patients with different postoperative sleep quality.

Results

Thirty-three patients were enrolled in this study. For determining the average BIS index associated with good postoperative sleep quality, receiver operating characteristics (ROC) curve was generated. Area under the ROC curve (AUC) was 0.65. The cutoff with best discriminability was 75 with a sensitivity of 68% and a specificity of 56%. Compared with those with good and poor postoperative sleep quality, there were no differences in main postoperative outcomes including duration of mechanical ventilation and ICU stay. Although the quality of sleep after surgery of all subjects with postoperative delirium was poor, the incidence of delirium between the groups did not significantly differ (0% vs 10.3%; p = 0.184).

Conclusion

The monitoring of BIS is a viable tool for evaluating sleep quality in mechanically ventilated patients in the postoperative ICU with acceptable precision.

Trial registration

www.clinicaltrials.in.th, TCTR20200310005.

How to cite this article

Sirilaksanamanon P, Thawitsri T, Charuluxananan S, Chirakalwasan N. Diagnostic Value of the Bispectral Index to Assess Sleep Quality after Elective Surgery in Intensive Care Unit. Indian J Crit Care Med 2023;27(11):795-800.

Potentially inappropriate medications with older people in intensive care and associated factors: a historic cohort study

BACKGROUND

The epidemiology of potentially inappropriate medications (PIMs) in critical care units remains limited, especially in terms of the factors associated with their use.

OBJECTIVE

To estimate the incidence and factors associated with PIMs use in intensive care units.

DESIGN AND SETTING

Historical cohort study was conducted in a high-complexity hospital in Brazil.

METHODS

A retrospective chart review was conducted on 314 patients aged ≥ 60 years who were admitted to intensive care units (ICUs) at a high-complexity hospital in Brazil. The dates were extracted from a "Patient Safety Project" database. A Chi-square test, Student's t-test, and multivariable logistic regression analyses were performed to assess which factors were associated with PIMs. The statistical significance was set at 5%.

RESULTS

According to Beers' criteria, 12.8% of the identified drugs were considered inappropriate for the elderly population. The incidence rate of PIMs use was 45.8%. The most frequently used PIMs were metoclopramide, insulin, antipsychotics, non-steroidal anti-inflammatory drugs, and benzodiazepines. Factors associated with PIMs use were the number of medications (odds ratio [OR] = 1.17), length of hospital stay (OR = 1.07), and excessive potential drug interactions (OR = 2.43).

CONCLUSIONS

Approximately half of the older adults in ICUs received PIM. Patients taking PIMs had a longer length of stay in the ICU, higher numbers of medications, and higher numbers of potential drug interactions. In ICUs, the use of explicit methods combined with clinical judgment can contribute to the safety and quality of medication prescriptions.

Systemic Nonsteroidal Anti-Inflammatories for Analgesia in Postoperative Critical Care Patients: A Systematic Review and Meta-Analysis of Randomized Control Trials

While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients.

DATA SOURCES

We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023.

STUDY SELECTION

Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization.

DATA EXTRACTION

In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark).

DATA SYNTHESIS

We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8-31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis.

CONCLUSIONS

In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.

The Profile of Early Sedation Depth and Clinical Outcomes of Mechanically Ventilated Patients in Korea

BACKGROUND

Current international guidelines recommend against deep sedation as it is associated with worse outcomes in the intensive care unit (ICU). However, in Korea the prevalence of deep sedation and its impact on patients in the ICU are not well known.

METHODS

From April 2020 to July 2021, a multicenter, prospective, longitudinal, noninterventional cohort study was performed in 20 Korean ICUs. Sedation depth extent was divided into light and deep using a mean Richmond Agitation-Sedation Scale value within the first 48 hours. Propensity score matching was used to balance covariables; the outcomes were compared between the two groups.

RESULTS

Overall, 631 patients (418 [66.2%] and 213 [33.8%] in the deep and light sedation groups, respectively) were included. Mortality rates were 14.1% and 8.4% in the deep and light sedation groups (P = 0.039), respectively. Kaplan-Meier estimates showed that time to extubation (P < 0.001), ICU length of stay (P = 0.005), and death (P = 0.041) differed between the groups. After adjusting for confounders, early deep sedation was only associated with delayed time to extubation (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.55-0.80; P < 0.001). In the matched cohort, deep sedation remained significantly associated with delayed time to extubation (HR, 0.68; 95% CI, 0.56-0.83; P < 0.001) but was not associated with ICU length of stay (HR, 0.94; 95% CI, 0.79-1.13; P = 0.500) and in-hospital mortality (HR, 1.19; 95% CI, 0.65-2.17; P = 0.582).

CONCLUSION

In many Korean ICUs, early deep sedation was highly prevalent in mechanically ventilated patients and was associated with delayed extubation, but not prolonged ICU stay or in-hospital death.