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Stollings JL, Rumbaugh KA, Wang L, Hayhurst CJ, Ely EW, Hughes CG. Correlation of the Critical Care Pain Observation Tool and Numeric Rating Scale in Intensive Care Unit Patients. J Intensive Care Med 2024; 39:12-20. [PMID: 37455408 PMCID: PMC10666505 DOI: 10.1177/08850666231187336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/22/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments. MATERIALS AND METHODS We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors. RESULTS Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001). CONCLUSIONS The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.
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Affiliation(s)
- Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Kelli A Rumbaugh
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Quality Aging – All at Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Anesthesia Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Rengel KF, Wahl LA, Sharma A, Lee H, Hayhurst CJ. Delirium Prevention and Management in Frail Surgical Patients. Anesthesiol Clin 2023; 41:175-189. [PMID: 36871998 DOI: 10.1016/j.anclin.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Delirium, an acute, fluctuating impairment in cognition and awareness, is one of the most common causes of postoperative brain dysfunction. It is associated with increased hospital length of stay, health care costs, and mortality. There is no FDA-approved treatment of delirium, and management relies on symptomatic control. Several preventative techniques have been proposed, including the choice of anesthetic agent, preoperative testing, and intraoperative monitoring. Frailty, a state of increased vulnerability to adverse events, is an independent and potentially modifiable risk factor for the development of delirium. Diligent preoperative screening techniques and implementation of prevention strategies could help improve outcomes in high-risk patients.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Lindsay A Wahl
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Archit Sharma
- Division of Cardiothoracic Anesthesia, Solid Organ Transplant, and Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242, USA
| | - Howard Lee
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, 251 East Huron, Suite 5-704, Chicago, IL 60611, USA
| | - Christina J Hayhurst
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
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Hughes CG, Hayhurst CJ, Pandharipande PP, Shotwell MS, Feng X, Wilson JE, Brummel NE, Girard TD, Jackson JC, Ely EW, Patel MB. Association of Delirium during Critical Illness With Mortality: Multicenter Prospective Cohort Study. Anesth Analg 2021; 133:1152-1161. [PMID: 33929361 PMCID: PMC8542584 DOI: 10.1213/ane.0000000000005544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The temporal association of delirium during critical illness with mortality is unclear, along with the associations of hypoactive and hyperactive motoric subtypes of delirium with mortality. We aimed to evaluate the relationship of delirium during critical illness, including hypoactive and hyperactive motoric subtypes, with mortality in the hospital and after discharge up to 1 year. METHODS We analyzed a prospective cohort study of adults with respiratory failure and/or shock admitted to university, community, and Veterans Affairs hospitals. We assessed patients using the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the intensive care unit (ICU) and defined the motoric subtype according to the corresponding Richmond Agitation-Sedation Scale if delirium was present. We used Cox proportional hazard models, adjusted for baseline characteristics, coma, and daily hospital events, to determine whether delirium on a given day predicted mortality the following day in patients in the hospital and also to determine whether delirium presence and duration predicted mortality after discharge up to 1 year in patients who survived to hospital discharge. We performed similar analyses for hypoactive and hyperactive subtypes of delirium. RESULTS Among 1040 critically ill patients, 214 (21%) died in the hospital and 204 (20%) died out-of-hospital by 1 year. Delirium was common, occurring in 740 (71%) patients for a median (interquartile range [IQR]) of 4 (2-7) days. Hypoactive delirium occurred in 733 (70%) patients, and hyperactive occurred in 185 (18%) patients, with a median (IQR) of 3 (2-7) days and 1 (1-2) days, respectively. Delirium on a given day (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.32-6.21; P = .008), in particular the hypoactive subtype (HR, 3.35; 95% CI, 1.51-7.46; P = .003), was independently associated with an increased risk of death the following day in the hospital. Hyperactive delirium was not associated with an increased risk of death in the hospital (HR, 4.00; 95% CI, 0.49-32.51; P = .19). Among hospital survivors, neither delirium presence (HR, 1.01; 95% CI, 0.82-1.24; P = .95) nor duration (HR, 0.99; 95% CI, 0.97-1.01; P = .56), regardless of motoric subtype, was associated with mortality after hospital discharge up to 1 year. CONCLUSIONS Delirium during critical illness is associated with nearly a 3-fold increased risk of death the following day for patients in the hospital but is not associated with mortality after hospital discharge. This finding appears primarily driven by the hypoactive motoric subtype. The independent relationship between delirium and mortality occurs early during critical illness but does not persist after hospital discharge.
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Affiliation(s)
- Christopher G. Hughes
- Professor, Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Christina J. Hayhurst
- Assistant Professor, Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Pratik P. Pandharipande
- Professor, Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Matthew S. Shotwell
- Assistant Professor, Department of Biostatistics and Anesthesiology, Vanderbilt University Medical Center
| | - Xiaoke Feng
- Biostatistician, Department of Biostatistics, Vanderbilt University Medical Center
| | - Jo Ellen Wilson
- Assistant Professor, Department of Psychiatry, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center
| | - Nathan E. Brummel
- Associate Professor, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center
| | - Timothy D. Girard
- Associate Professor, Department of Critical Care Medicine and Clinical Research, Investigation, and Systems Modeling of Acute Illnesses Center, University of Pittsburgh; Critical Illness, Brain Dysfunction, and Survivorship Center; Vanderbilt University Medical Center
| | - James C. Jackson
- Research Associate Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Research Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - E. Wesley Ely
- Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Geriatric Research, Education and Clinical Center (GRECC), Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Mayur B. Patel
- Associate Professor, Section of Surgical Sciences, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt Brain Institute, Center for Health Services Research, Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center; Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
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Nordness MF, Hayhurst CJ, Pandharipande P. Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit. J Pain Res 2021; 14:1733-1744. [PMID: 34163231 PMCID: PMC8214553 DOI: 10.2147/jpr.s256406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.
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Affiliation(s)
- Mina F Nordness
- Department of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik Pandharipande
- Department of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Hayhurst CJ, Hughes CG, Pandharipande PP. The Conundrum of Pain, Opiate Use and Delirium: Analgosedation or Analgesia-first Approach? Am J Respir Crit Care Med 2021; 204:502-503. [PMID: 33956575 PMCID: PMC8491271 DOI: 10.1164/rccm.202104-0968ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Christina J Hayhurst
- Vanderbilt University Medical Center, 12328, Nashville, Tennessee, United States
| | - Christopher G Hughes
- Vanderbilt University Medical Center, 12328, Department of Anesthesiology, Nashville, Tennessee, United States
| | - Pratik P Pandharipande
- Vanderbilt University Medical Center, 12328, Department of Anesthesiology, Nashville, Tennessee, United States;
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Rengel KF, Hayhurst CJ, Jackson JC, Boncyk CS, Patel MB, Brummel NE, Shi Y, Shotwell MS, Ely EW, Pandharipande PP, Hughes CG. Motoric Subtypes of Delirium and Long-Term Functional and Mental Health Outcomes in Adults After Critical Illness. Crit Care Med 2021; 49:e521-e532. [PMID: 33729717 PMCID: PMC8634774 DOI: 10.1097/ccm.0000000000004920] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Adult ICU survivors that experience delirium are at high risk for developing new functional disabilities and mental health disorders. We sought to determine if individual motoric subtypes of delirium are associated with worse disability, depression, and/or post-traumatic stress disorder in ICU survivors. DESIGN Secondary analysis of a prospective multicenter cohort study. SETTING Academic, community, and Veteran Affairs hospitals. PATIENTS Adult ICU survivors of respiratory failure and/or shock. INTERVENTIONS We assessed delirium and level of consciousness using the Confusion Assessment Method-ICU and Richmond Agitation and Sedation Scale daily during hospitalization. We classified delirium as hypoactive (Richmond Agitation and Sedation Scale ≤ 0) or hyperactive (Richmond Agitation and Sedation Scale > 0). At 3- and 12-month postdischarge, we assessed for dependence in activities of daily living and instrumental activities of daily living, symptoms of depression, and symptoms of post-traumatic stress disorder. Adjusting for baseline and inhospital covariates, multivariable regression examined the association of exposure to delirium motoric subtype and long-term outcomes. MEASUREMENTS AND MAIN RESULTS In our cohort of 556 adults with a median age of 62 years, hypoactive delirium was more common than hyperactive (68.9% vs 16.8%). Dependence on the activities of daily living was present in 37% at 3 months and 31% at 12 months, whereas dependence on instrumental activities of daily living was present in 63% at 3 months and 56% at 12 months. At both time points, depression and post-traumatic stress disorder rates were constant at 36% and 5%, respectively. Each additional day of hypoactive delirium was associated with higher instrumental activities of daily living dependence at 3 months only (0.24 points [95% CI, 0.07-0.41; p = 0.006]). There were no associations between the motoric delirium subtype and activities of daily living dependence, depression, or post-traumatic stress disorder. CONCLUSIONS Longer duration of hypoactive delirium, but not hyperactive, was associated with a minimal increase in early instrumental activities of daily living dependence scores in adult survivors of critical illness. Motoric delirium subtype was neither associated with early or late activities of daily living functional dependence or mental health outcomes, nor late instrumental activities of daily living functional dependence.
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Affiliation(s)
- Kimberly F Rengel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Surgery, Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
- Departments of Neurosurgery, and Hearing & Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Internal Medicine, Division of Pulmonary, Allery, Critical Care, and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | | | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Pratik P Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
| | - Christopher G Hughes
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System
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Hayhurst CJ, Patel MB, McNeil JB, Girard TD, Brummel NE, Thompson JL, Chandrasekhar R, Ware LB, Pandharipande PP, Ely EW, Hughes CG. Association of neuronal repair biomarkers with delirium among survivors of critical illness. J Crit Care 2019; 56:94-99. [PMID: 31896448 DOI: 10.1016/j.jcrc.2019.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 10/02/2019] [Accepted: 12/09/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Delirium is prevalent but with unclear pathogenesis. Neuronal injury repair pathways may be protective. We hypothesized that higher concentrations of neuronal repair biomarkers would be associated with decreased delirium in critically ill patients. MATERIALS AND METHODS We performed a nested study of hospital survivors within a prospective cohort that enrolled patients within 72 h of respiratory failure or shock. We measured plasma concentrations of ubiquitin carboxyl-terminal-esterase-L1 (UCHL1) and brain-derived neurotrophic factor (BDNF) from blood collected at enrollment. Delirium was assessed twice daily using the CAM-ICU. Multivariable regression was used to examine the associations between biomarkers and delirium prevalence/duration, adjusting for covariates and interactions with age and IL-6 plasma concentration. RESULTS We included 427 patients with a median age of 59 years (IQR 48-69) and APACHE II score of 25 (IQR 19-30). Higher plasma concentration of UCHL1 on admission was independently associated with lower prevalence of delirium (p = .04) but not associated with duration of delirium (p = .06). BDNF plasma concentration was not associated with prevalence (p = .26) or duration of delirium (p = .36). CONCLUSIONS During critical illness, higher UCHL1 plasma concentration is associated with lower prevalence of delirium; BDNF plasma concentration is not associated with delirium. Clinical trial number: NCT00392795; https://clinicaltrials.gov/ct2/show/NCT00392795.
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Affiliation(s)
- Christina J Hayhurst
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Mayur B Patel
- Section of Surgical Sciences, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Division of Trauma and Surgical Critical Care, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, United States
| | - J Brennan McNeil
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy D Girard
- Department of Critical Care Medicine and Clinical Research, Investigation, and Systems Modeling of Acute Illnesses Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nathan E Brummel
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jennifer L Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Pratik P Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, United States
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States
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Affiliation(s)
- Christina J Hayhurst
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, 37232 Nashville, TN, USA
| | - Emily Farrin
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, 37232 Nashville, TN, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, 37232 Nashville, TN, USA.
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Hayhurst CJ, Jackson JC, Archer KR, Thompson JL, Chandrasekhar R, Hughes CG. Pain and Its Long-term Interference of Daily Life After Critical Illness. Anesth Analg 2019; 127:690-697. [PMID: 29649027 DOI: 10.1213/ane.0000000000003358] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Persistent pain likely interferes with quality of life in survivors of critical illness, but data are limited on its prevalence and risk factors. We sought to determine the prevalence of persistent pain after critical illness and its interference with daily life. Additionally, we sought to determine if intensive care unit (ICU) opioid exposure is a risk factor for its development. METHODS In a cohort of adult medical and surgical ICU survivors, we used the brief pain inventory (BPI) to assess pain intensity and pain interference of daily life at 3 and 12 months after hospital discharge. We used proportional odds logistic regression with Bonferroni correction to evaluate the independent association of ICU opioid exposure with BPI scores, adjusting for potential confounders including age, preadmission opioid use, frailty, surgery, severity of illness, and durations of delirium and sepsis while in the ICU. RESULTS We obtained BPI outcomes in 295 patients overall. At 3 and 12 months, 77% and 74% of patients reported persistent pain symptoms, respectively. The median (interquartile range) pain intensity score was 3 (1, 5) at both 3 and 12 months. Pain interference with daily life was reported in 59% and 62% of patients at 3 and 12 months, respectively. The median overall pain interference score was 2 (0, 5) at both 3 and 12 months. ICU opioid exposure was not associated with increased pain intensity at 3 months (odds ratio [OR; 95% confidence interval], 2.12 [0.92-4.93]; P = .18) or 12 months (OR, 2.58 [1.26-5.29]; P = .04). ICU opioid exposure was not associated with increased pain interference of daily life at 3 months (OR, 1.48 [0.65-3.38]; P = .64) or 12 months (OR, 1.46 [0.72-2.96]; P = .58). CONCLUSIONS Persistent pain is prevalent after critical illness and frequently interferes with daily life. Increased ICU opioid exposure was not associated with worse pain symptoms. Further studies are needed to identify modifiable risk factors for persistent pain in the critically ill and the effects of ICU opioids on patients with and without chronic pain.
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Affiliation(s)
- Christina J Hayhurst
- From the Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jim C Jackson
- Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University School of Medicine
| | - Kristin R Archer
- Department of Orthopedic Surgery and Physical Medicine and Rehabilitation
| | | | | | - Christopher G Hughes
- Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Vanderbilt University School of Medicine, Nashville, Tennessee
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Hayhurst CJ, Nemergut EC. Essence of Anesthesia Practice, 3rd ed. Anesth Analg 2012. [DOI: 10.1213/ane.0b013e31822cf1b8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
TNT Equivalency methods are widely used for vapour cloud explosion blast modeling. Presently, however, other types of models are available which do not have the fundamental objections TNT Equivalency models have. TNO Multi-Energy method is increasingly accepted as a more reasonable alternative to be used as a simple and practical method. Computer codes based on computational fluid dynamics (CFD) like AutoReaGas, developed by TNO and Century Dynamics, could be used also in case a more rigorous analysis is required. Application of the Multi-Energy method requires knowledge of two parameters describing the explosion: a charge size and a charge strength. During the last years, research has led to an improved determination of the charge strength (i.e., the class number or source overpressure) to be chosen to apply the blast charts. A correlation has been derived relating the charge strength to a set of parameters describing the boundary conditions of the flammable cloud and the fuel in the cloud. A simple approach may not be satisfactory in all situations. The overpressure distribution inside a vapour cloud explosion is generally not homogeneous and the presence of obstructions causes directional blast propagation in the near field. A CFD approach, in which the actual situation is modeled, supplies case-specific results. An overview of the key aspects relevant to the application of the Multi-Energy method and CFD modeling is provided. Then the application of the two methods is demonstrated for an example problem involving the calculation of the explosion blast load on a structure at some distance from the explosion in an offshore platform complex.
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Affiliation(s)
- W P Mercx
- TNO Prins Maurits Laboratory, PO Box 45, Rijswijk, Netherlands
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