The Impact of Nursing Delirium Preventive Interventions in the Intensive Care Unit: A Multicenter Cluster Randomized Controlled Trial

Rationale Delirium is common in critically ill patients and associated with deleterious outcomes. Non-pharmacologic interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objective To determine the effects of a multicomponent nursing intervention program on delirium in the Intensive Care Unit. Methods Stepped wedge cluster randomized controlled trial, conducted in Intensive care units of 10 centers. Adult critically ill surgical, medical or trauma patients at high risk to develop delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. Primary outcome was the number of delirium-free and coma-free days alive in 28 days after Intensive Care Unit admission. Measurements and main results A total of 1749 patients were included. Time spent per 8 hours shift on interventions was median [IQR] 38 [14-116] in the intervention period and median 32 [13-73] minutes in the control period (p=0.44). Patients in the intervention period had median 23 [4-27] delirium-free and coma-free days alive, compared to median 23 [5-27] days for patients in the control group (mean difference -1.21 days, 95%CI -2.84 to 0.42 days; p=0.15). Also, the number of delirium days was similar: median 2 [1-4] days (ratio of medians 0.90, 95%CI 0.75 to 1.09; p=0.27). Conclusion In this large randomized controlled trial in adult ICU patients, a limited increase was achieved of the use of nursing interventions, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT03002701.

Noise in the intensive care unit and its influence on sleep quality: a multicenter observational study in Dutch intensive care units

BACKGROUND

High noise levels in the intensive care unit (ICU) are a well-known problem. Little is known about the effect of noise on sleep quality in ICU patients. The study aim is to determine the effect of noise on subjective sleep quality.

METHODS

This was a multicenter observational study in six Dutch ICUs. Noise recording equipment was installed in 2-4 rooms per ICU. Adult patients were eligible for the study 48 h after ICU admission and were followed up to maximum of five nights in the ICU. Exclusion criteria were presence of delirium and/or inability to be assessed for sleep quality. Sleep was evaluated using the Richards Campbell Sleep Questionnaire (range 0-100 mm). Noise recordings were used for analysis of various auditory parameters, including the number and duration of restorative periods. Hierarchical mixed model regression analysis was used to determine associations between noise and sleep.

RESULTS

In total, 64 patients (68% male), mean age 63.9 (± 11.7) years and mean Acute Physiology And Chronic Health Evaluation (APACHE) II score 21.1 (± 7.1) were included. Average sleep quality score was 56 ± 24 mm. The mean of the 24-h average sound pressure levels (L_{Aeq, 24h}) was 54.0 dBA (± 2.4). Mixed-effects regression analyses showed that background noise (β = - 0.51, p < 0.05) had a negative impact on sleep quality, whereas number of restorative periods (β = 0.53, p < 0.01) and female sex (β = 1.25, p < 0.01) were weakly but significantly correlated with sleep.

CONCLUSIONS

Noise levels are negatively associated and restorative periods and female gender are positively associated with subjective sleep quality in ICU patients.

TRIAL REGISTRATION

www.ClinicalTrials.gov, NCT01826799 . Registered on 9 April 2013.

Phlebitis as a consequence of peripheral intravenous administration of cisatracurium besylate in critically ill patients

This case report series describes 3 cases of cisatracurium besylate associated phlebitis after an infusion period of 14-20 hours. No similar cases have been reported in the literature. Association of phlebitis with another neuromuscular blocking agent, atracurium, has been described in the literature. The acidity of atracurium is thought to be the main cause. It is recommended that atracurium is administered only via central venous catheters when indicated to infuse over prolonged periods of time due to the acidity. Cisatracurium is a stereoisomer of atracurium and as such has the same molecular weight. Although cisatracurium also has a similar acidity as atracurium, a recommendation concerning infusion via a central venous catheter is lacking. We suggest prolonged administration of cisatracurium besylate only via centrally placed venous catheters or if not possible to careful monitor relevant peripheral intravenous sites to diminish the risks of phlebitis and associated complications or other cutaneous reactions.

[Acute liver failure in a young adult]

Acute liver failure is a rare but mostly severe disorder in previously healthy patients. Viral infections and drugs are the most common causes in the Western world. A small percentage of acute liver failure is caused by Wilson's disease. We describe a previously healthy 23-year-old female with acute haemolytic anemia and liver failure as the first manifestations of Wilson's disease. There was rapid deterioration to multi-organ failure and the patient died less than 24 hours after initial presentation. Relatively simple laboratory tests can be used for initial screening of acute liver failure due to Wilson's disease. Liver transplantation is the only way to ensure survival of the patient. Rapid transfer to a specialised centre is, therefore, of the utmost concern.

The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta-analysis

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre-existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P = 0.06) and 0.8 (95% C.I. 0.5-1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.

Reproducibility of the ambulatory arterial stiffness index in hypertensive patients

BACKGROUND

We studied the repeatability of the ambulatory arterial stiffness index (AASI), which can be computed from 24-h blood pressure (BP) recordings as unity minus the regression slope of diastolic on systolic BP.

METHODS

One hundred and fifty-two hypertensive outpatients recruited in Nijmegen (mean age = 46.2 years; 76.3% with systolic and diastolic hypertension) and 145 patients enrolled in the Systolic Hypertension in Europe (Syst-Eur) trial (71.0 years) underwent 24-h BP monitoring at a median interval of 8 and 31 days, respectively. We used the repeatability coefficient, which is twice the SD of the within-participant differences between repeat recordings, and expressed it as a percentage of four times the SD of the mean of the paired measurements.

RESULTS

Mean AASI (crude or derived by time-weighted or robust regression) and 24-h pulse pressure (PP) were similar on repeat recordings in both cohorts. In Nijmegen patients, repeatability coefficients of AASI and PP were approximately 50%. In Syst-Eur trial patients, repeatability coefficient was approximately 60% for AASI and approximately 40% for PP. For comparison, repeatability coefficients for 24-h systolic and diastolic BP were approximately 30%. Differences in AASI between paired recordings were correlated with differences in the goodness of fit (r2) of the AASI regression line as well as with differences in the night-to-day BP ratio. However, in sensitivity analyses stratified for type of hypertension, r2, or dipping status, repeatability coefficients for AASI did not widely depart from 50 to 60% range.

CONCLUSION

Estimates of mean AASI were not different between repeat recordings, and repeatability coefficients were within the 50-60% range.

Side effects of ambulatory blood pressure monitoring

OBJECTIVE

To study the experiences and complaints of patients who underwent 24 h blood pressure monitoring.

METHODS

Two groups of hypertensive patients of a tertiary outpatient clinic were asked to fill in a nine-item questionnaire about the side effects of ambulatory blood pressure monitoring (ABPM). The first group (n=75) used the auscultatory Oxford Medilog device (OM) and the second group (n=110) the oscillometric Spacelabs 90207 (SL).

RESULTS

The OM showed significantly less error readings (OM versus SL, 9 versus 19%; P=0.005) but was also less tolerated by the subjects. Sleep disturbance was noted in 53% of the OM patients group in comparison with 18% in the SL group (P<0.0001). Adjustment of daily activities occurred more often in the OM group (OM versus SL, 37 versus 19%; P=0.013) as did complaints of pain in the cuffed arm (OM versus SL, 31 versus 11 %; P=0.007). There was no difference in the proportion of patients that refused a second ABPM (OM versus SL, 11 versus 10%). Linear regression analyses showed that differences in side effects between the two devices were not due to differences in blood pressure, heart rate, age or sex.

CONCLUSIONS

This study demonstrates that side effects of ABPM are not negligible and that there are differences between devices.