Medicine › Critical Care and Intensive Care Medicine

Intensive Care Unit Cognitive Disorders

Works Count: 52848

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Description

This cluster of papers focuses on the management and impact of delirium in adult patients in the intensive care unit, particularly those undergoing mechanical ventilation. It covers topics such as sedation protocols, cognitive impairment, ICU-acquired weakness, rehabilitation, and long-term outcomes after critical illness.

Keywords

Delirium; Intensive Care Unit; Mechanically Ventilated Patients; Sedation; Cognitive Dysfunction; ICU-Acquired Weakness; Postoperative; Elderly Patients; Rehabilitation; Neuromuscular Dysfunction

Delirium in Older Persons

2006-03-15

Sharon K. Inouye

The prevalence of delirium increases sharply with age, and about 20 percent of older patients have delirium at the time of hospital admission for any reason. This review summarizes the … The prevalence of delirium increases sharply with age, and about 20 percent of older patients have delirium at the time of hospital admission for any reason. This review summarizes the clinical manifestations of and risk factors for delirium and the evaluation of patients with this condition. It includes an update on the current understanding of the pathogenesis of delirium and provides guidance regarding practical measures to prevent this common complication.

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Early intensive care unit mobility therapy in the treatment of acute respiratory failure*

2008-08-01

Peter E. Morris , Amanda Goad , C. Thompson +7 more

Objective: Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated … Objective: Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. Design and Setting: Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. Patients: Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165. Interventions: An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. Measurements and Main Results: The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p ≤ .001). Protocol patients were out of bed earlier (5 vs. 11 days, p ≤ .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p ≤ .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs. Conclusions: A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.

Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

2001-07-01

E. Wesley Ely , Richard Margolin , Joseph Francis +7 more

Objective To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation. … Objective To develop and validate an instrument for use in the intensive care unit to accurately diagnose delirium in critically ill patients who are often nonverbal because of mechanical ventilation. Design Prospective cohort study. Setting The adult medical and coronary intensive care units of a tertiary care, university-based medical center. Patients Thirty-eight patients admitted to the intensive care units. Measurements and Main Results We designed and tested a modified version of the Confusion Assessment Method for use in intensive care unit patients and called it the CAM-ICU. Daily ratings from intensive care unit admission to hospital discharge by two study nurses and an intensivist who used the CAM-ICU were compared against the reference standard, a delirium expert who used delirium criteria from the Diagnostic and Statistical Manual of Mental Disorders (fourth edition). A total of 293 daily, paired evaluations were completed, with reference standard diagnoses of delirium in 42% and coma in 27% of all observations. To include only interactive patient evaluations and avoid repeat-observer bias for patients studied on multiple days, we used only the first-alert or lethargic comparison evaluation in each patient. Thirty-three of 38 patients (87%) developed delirium during their intensive care unit stay, mean duration of 4.2 ± 1.7 days. Excluding evaluations of comatose patients because of lack of characteristic delirium features, the two critical care study nurses and intensivist demonstrated high interrater reliability for their CAM-ICU ratings with kappa statistics of 0.84, 0.79, and 0.95, respectively (p < .001). The two nurses' and intensivist's sensitivities when using the CAM-ICU compared with the reference standard were 95%, 96%, and 100%, respectively, whereas their specificities were 93%, 93%, and 89%, respectively. Conclusions The CAM-ICU demonstrated excellent reliability and validity when used by nurses and physicians to identify delirium in intensive care unit patients. The CAM-ICU may be a useful instrument for both clinical and research purposes to monitor delirium in this challenging patient population.

Assessing pain in critically ill sedated patients by using a behavioral pain scale

2001-12-01

Jean‐François Payen , Olivier Bru , Jean‐Luc Bosson +5 more

To establish the validity and reliability of a new behavioral pain scale (BPS) for critically ill sedated adult patients.Prospective evaluation.Ten-bed trauma and surgical intensive care unit in a university teaching … To establish the validity and reliability of a new behavioral pain scale (BPS) for critically ill sedated adult patients.Prospective evaluation.Ten-bed trauma and surgical intensive care unit in a university teaching hospital.Thirty mechanically ventilated patients who were receiving analgesia and sedation.Assessments with the BPS were completed consecutively at standardized times (morning, afternoon, night) by pairs of evaluators (nurse and nurse's aide). They collected physiologic parameters and BPS results before and during care procedures: non-nociceptive (group 1, compression stockings application and central venous catheter dressing change), nociceptive (group 2, endotracheal suctioning and mobilization), and retested nociceptive (group 3). The BPS score was the sum of three items that had a range score of 1-4: facial expression, movements of upper limbs, and compliance with mechanical ventilation.Two hundred and sixty nine assessments were completed, including 104, 134, and 31 measurements in groups 1, 2 and 3, respectively. There was no difference in Ramsay scale scores between the three groups (Ramsay 4-6). Nociceptive stimulations (group 2) resulted in significantly higher BPS values than non-nociceptive ones (group 1, 4.9 vs. 3.5, p <.01), whereas the two groups had comparable BPS values before stimulation (3.1 vs. 3.0). A trend was found in group 2 between the dosage of sedation/analgesia and BPS: the higher the dosage, the lower BPS values and BPS changes to nociceptive stimulation. Group 3 had BPS values similar to group 2 at rest (3.2 vs. 3.2) and during the procedure (4.4 vs. 4.5), with good interrater correlations (r(2) =.71 and.50, respectively).These results indicate that the expression of pain can be scored validly and reliably by using the BPS in sedated, mechanically ventilated patients. Further studies are warranted regarding the utility of the BPS in making clinical decisions about the use of analgesic drugs in the intensive care unit.

Precipitating Factors for Delirium in Hospitalized Elderly Persons

1996-03-20

Sharon K. Inouye

To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability.Two prospective cohort studies, … To prospectively develop and validate a predictive model for delirium based on precipitating factors during hospitalization, and to examine the interrelationship of precipitating factors and baseline vulnerability.Two prospective cohort studies, in tandem.General medical wards, university teaching hospital.For the development cohort, 196 patients aged 70 years and older with no delirium at baseline, and for the validation cohort, 312 comparable patients.New-onset delirium by hospital day 9, defined by the Confusion Assessment Method diagnostic criteria.Delirium developed in 35 patients (18%) in the development cohort. Five independent precipitating factors for delirium were identified; use of physical restraints (adjusted relative risk [RR], 4.4; 95% confidence interval [CI], 2.5 to 7.9), malnutrition (RR, 4.0; 95% CI, 2.2 to 7.4), more than three medications added (RR, 2.9; 95% CI, 1.6 to 5.4), use of bladder catheter (RR, 2.4; 95% CI, 1.2 to 4.7), and any iatrogenic event (RR, 1.9; 95% CI, 1.1 to 3.2). Each precipitating factor preceded the onset of delirium by more than 24 hours. A risk stratification system was developed by adding 1 point for each factor present. Rates of delirium for low-risk (0 points), intermediate-risk (1 to 2 points), and high-risk groups (> or equal to 3 points) were 3%, 20%, and 59%, respectively (P < .001). The corresponding rates in the validation cohort, in which 47 patients (15%) developed delirium, were 4%, 20%, and 35%, respectively (P < .001). When precipitating and baseline factors were analyzed in cross-stratified format, delirium rates increased progressively from low-risk to high-risk groups in all directions (double-gradient phenomenon). The contributions of baseline and precipitating factors were documented to be independent and statistically significant.A simple predictive model based on the presence of five precipitating factors can be used to identify elderly medical patients at high risk for delirium. Precipitating and baseline vulnerability factors are highly interrelated and contribute to delirium in independent substantive, and cumulative ways.

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Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care Unit

2004-04-14

E. Wesley Ely

ContextIn the intensive care unit (ICU), delirium is a common yet underdiagnosed form of organ dysfunction, and its contribution to patient outcomes is unclear.ObjectiveTo determine if delirium is an independent … ContextIn the intensive care unit (ICU), delirium is a common yet underdiagnosed form of organ dysfunction, and its contribution to patient outcomes is unclear.ObjectiveTo determine if delirium is an independent predictor of clinical outcomes, including 6-month mortality and length of stay among ICU patients receiving mechanical ventilation.Design, Setting, and ParticipantsProspective cohort study enrolling 275 consecutive mechanically ventilated patients admitted to adult medical and coronary ICUs of a US university-based medical center between February 2000 and May 2001. Patients were followed up for development of delirium over 2158 ICU days using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale.Main Outcome MeasuresPrimary outcomes included 6-month mortality, overall hospital length of stay, and length of stay in the post-ICU period. Secondary outcomes were ventilator-free days and cognitive impairment at hospital discharge.ResultsOf 275 patients, 51 (18.5%) had persistent coma and died in the hospital. Among the remaining 224 patients, 183 (81.7%) developed delirium at some point during the ICU stay. Baseline demographics including age, comorbidity scores, dementia scores, activities of daily living, severity of illness, and admission diagnoses were similar between those with and without delirium (P>.05 for all). Patients who developed delirium had higher 6-month mortality rates (34% vs 15%, P = .03) and spent 10 days longer in the hospital than those who never developed delirium (P<.001). After adjusting for covariates (including age, severity of illness, comorbid conditions, coma, and use of sedatives or analgesic medications), delirium was independently associated with higher 6-month mortality (adjusted hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.4-7.7; P = .008), and longer hospital stay (adjusted HR, 2.0; 95% CI, 1.4-3.0; P<.001). Delirium in the ICU was also independently associated with a longer post-ICU stay (adjusted HR, 1.6; 95% CI, 1.2-2.3; P = .009), fewer median days alive and without mechanical ventilation (19 [interquartile range, 4-23] vs 24 [19-26]; adjusted P = .03), and a higher incidence of cognitive impairment at hospital discharge (adjusted HR, 9.1; 95% CI, 2.3-35.3; P = .002).ConclusionDelirium was an independent predictor of higher 6-month mortality and longer hospital stay even after adjusting for relevant covariates including coma, sedatives, and analgesics in patients receiving mechanical ventilation.

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Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia

2010-07-28

Joost Witlox , Lisa S. M. Eurelings , Jos F. M. de Jonghe +3 more

<h3>Context</h3>Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying … <h3>Context</h3>Delirium is a common and serious complication in elderly patients. Evidence suggests that delirium is associated with long-term poor outcome but delirium often occurs in individuals with more severe underlying disease.<h3>Objective</h3>To assess the association between delirium in elderly patients and long-term poor outcome, defined as mortality, institutionalization, or dementia, while controlling for important confounders.<h3>Data Sources</h3>A systematic search of studies published between January 1981 and April 2010 was conducted using the databases of MEDLINE, EMBASE, PsycINFO, and CINAHL.<h3>Study Selection</h3>Observational studies of elderly patients with delirium as a study variable and data on mortality, institutionalization, or dementia after a minimum follow-up of 3 months, and published in the English or Dutch language. Titles, abstracts, and articles were reviewed independently by 2 of the authors. Of 2939 references in the original search, 51 relevant articles were identified.<h3>Data Extraction</h3>Information on study design, characteristics of the study population, and outcome were extracted. Quality of studies was assessed based on elements of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies.<h3>Data Synthesis</h3>The primary analyses included only high-quality studies with statistical control for age, sex, comorbid illness or illness severity, and baseline dementia. Pooled-effect estimates were calculated with random-effects models. The primary analysis with adjusted hazard ratios (HRs) showed that delirium is associated with an increased risk of death compared with controls after an average follow-up of 22.7 months (7 studies; 271/714 patients [38.0%] with delirium, 616/2243 controls [27.5%]; HR, 1.95 [95% confidence interval {CI}, 1.51-2.52]; I<sup>2</sup>, 44.0%). Moreover, patients who had experienced delirium were also at increased risk of institutionalization (7 studies; average follow-up, 14.6 months; 176/527 patients [33.4%] with delirium and 219/2052 controls [10.7%]; odds ratio [OR], 2.41 [95% CI, 1.77-3.29]; I<sup>2</sup>, 0%) and dementia (2 studies; average follow-up, 4.1 years; 35/56 patients [62.5%] with delirium and 15/185 controls [8.1%]; OR, 12.52 [95% CI, 1.86-84.21]; I<sup>2</sup>, 52.4%). The sensitivity, trim-and-fill, and secondary analyses with unadjusted high-quality risk estimates stratified according to the study characteristics confirmed the robustness of these results.<h3>Conclusion</h3>This meta-analysis provides evidence that delirium in elderly patients is associated with poor outcome independent of important confounders, such as age, sex, comorbid illness or illness severity, and baseline dementia.

Lorazepam Is an Independent Risk Factor for Transitioning to Delirium in Intensive Care Unit Patients

2005-12-22

Pratik P. Pandharipande , Ayumi Shintani , Josh F. Peterson +5 more

Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may … Delirium has recently been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients. Sedative and analgesic medications relieve anxiety and pain but may contribute to patients' transitioning into delirium.In this cohort study, the authors designed a priori an investigation to determine whether sedative and analgesic medications independently increased the probability of daily transition to delirium. Markov regression modeling (adjusting for 11 covariates) was used in the evaluation of 198 mechanically ventilated patients to determine the probability of daily transition to delirium as a function of sedative and analgesic dose administration during the previous 24 h.Lorazepam was an independent risk factor for daily transition to delirium (odds ratio, 1.2 [95% confidence interval, 1.1-1.4]; P = 0.003), whereas fentanyl, morphine, and propofol were associated with higher but not statistically significant odds ratios. Increasing age and Acute Physiology and Chronic Health Evaluation II scores were also independent predictors of transitioning to delirium (multivariable P values < 0.05).Lorazepam administration is an important and potentially modifiable risk factor for transitioning into delirium even after adjusting for relevant covariates.

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Advancing the science of symptom management

2001-03-13

Marylin J. Dodd , Susan Janson , Noreen C. Facione +7 more

Advancing the science of symptom management Abstract. Since the publication of the original Symptom Management Model ( Larson et al . 1994 ), faculty and students at the University of … Advancing the science of symptom management Abstract. Since the publication of the original Symptom Management Model ( Larson et al . 1994 ), faculty and students at the University of California, San Francisco (UCSF) School of Nursing Centre for System Management have tested this model in research studies and expanded the model through collegial discussions and seminars. Aim. In this paper, we describe the evidence‐based revised conceptual model, the three dimensions of the model, and the areas where further research is needed. Background/Rationale. The experience of symptoms, minor to severe, prompts millions of patients to visit their healthcare providers each year. Symptoms not only create distress, but also disrupt social functioning. The management of symptoms and their resulting outcomes often become the responsibility of the patient and his or her family members. Healthcare providers have difficulty developing symptom management strategies that can be applied across acute and home‐care settings because few models of symptom management have been tested empirically. To date, the majority of research on symptoms was directed toward studying a single symptom, such as pain or fatigue, or toward evaluating associated symptoms, such as depression and sleep disturbance. While this approach has advanced our understanding of some symptoms, we offer a generic symptom management model to provide direction for selecting clinical interventions, informing research, and bridging an array of symptoms associated with a variety of diseases and conditions. Finally, a broadly‐based symptom management model allows the integration of science from other fields.

Delirium in elderly adults: diagnosis, prevention and treatment

2009-04-01

Tamara G. Fong , Samir Tulebaev , Sharon K. Inouye

Clarifying Confusion: The Confusion Assessment Method

1990-12-15

Sharon K. Inouye

Objective: To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Design: Prospective validation study. Setting: Conducted in … Objective: To develop and validate a new standardized confusion assessment method (CAM) that enables nonpsychiatric clinicians to detect delirium quickly in high-risk settings. Design: Prospective validation study. Setting: Conducted in general medicine wards and in an outpatient geriatric assessment center at Yale University (site 1) and in general medicine wards at the University of Chicago (site 2). Patients: The study included 56 subjects, ranging in age from 65 to 98 years. At site 1, 10 patients with and 20 without delirium participated; at site 2, 16 patients with and 10 without delirium participated. Measurements and Main Results: An expert panel developed the CAM through a consensus building process. The CAM instrument, which can be completed in less than 5 minutes, consists of nine operationalized criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). An a priori hypothesis was established for the diagnostic value of four criteria: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The CAM algorithm for diagnosis of delirium required the presence of both the first and the second criteria and of either the third or the fourth criterion. At both sites, the diagnoses made by the CAM were concurrently validated against the diagnoses made by psychiatrists. At sites 1 and 2 values for sensitivity were 100% and 94%, respectively; values for specificity were 95% and 90%; values for positive predictive accuracy were 91% and 94%; and values for negative predictive accuracy were 100% and 90%. The CAM algorithm had the highest predictive accuracy for all possible combinations of the nine features of delirium. The CAM was shown to have convergent agreement with four other mental status tests, including the Mini-Mental State Examination. The interobserver reliability of the CAM was high (kappa = 0.81 - 1.0). Conclusions: The CAM is sensitive, specific, reliable, and easy to use for identification of delirium.

Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients

2007-12-11

Pratik P. Pandharipande , Brenda T. Pun , Daniel Herr +7 more

4][5][6] Because delirium is an independent risk factor for prolonged length of stay, greater neuropsychological dysfunction, and increased mortality, 7-10 efforts must be made to reduce this manifestation of organ … 4][5][6] Because delirium is an independent risk factor for prolonged length of stay, greater neuropsychological dysfunction, and increased mortality, 7-10 efforts must be made to reduce this manifestation of organ dysfunction within the context of providing adequate sedation for patients.Lorazepam is currently recommended by the Society of Critical Care Medicine (SCCM) in its clinical prac-tice guidelines 1 for the sustained sedation of mechanically ventilated ICU patients.Although recent trials have shown that protocols with patient-targeted se-

Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients

1999-07-01

Richard R. Riker , Jean T. Picard , Gilles L. Fraser

Objective Subjective scales to assess agitation and sedation in adult intensive care unit (ICU) patients have rarely been tested for validity or reliability. We revised and prospectively tested the Sedation-Agitation … Objective Subjective scales to assess agitation and sedation in adult intensive care unit (ICU) patients have rarely been tested for validity or reliability. We revised and prospectively tested the Sedation-Agitation Scale (SAS) for interrater reliability and compared it with the Ramsay scale and the Harris scale to test construct validity. Design A convenience sample of ICU patients was simultaneously and independently examined by pairs of trained evaluators by using the revised SAS, Ramsay, and Harris Scales. Setting Multidisciplinary 34-bed ICU in a nonuniversity, academic medical center. Patients Forty-five ICU patients (surgical and medical) were examined a total of 69 times by evaluator pairs. Measurements and Main Results The mean patient age was 63.2 yrs, 36% were female, and 71% were intubated. When classified by using SAS, 45% were anxious or agitated (SAS 5 to 7), 26% were calm (SAS 4), and 29% were sedated (SAS 1 to 3). Interrater correlation was high for SAS (r2 = .83; p < .001) and the weighted kappa score for interrater agreement was 0.92 (p < .001). Of 41 assessments scored as Ramsay 1, 49% scored SAS 6, 41% were SAS 5, 5% were SAS 4, and 2% each were SAS 3 or 7. SAS was highly correlated with the Ramsay (r2 = .83; p < .001) and Harris (r2 = .86; p < .001) scales. Conclusions SAS is both reliable (high interrater agreement) and valid (high correlation with the Harris and Ramsay scales) in assessing agitation and sedation in adult ICU patients. SAS provides additional information by stratifying agitation into three categories (compared with one for the Ramsay scale) without sacrificing validity or reliability. (Crit Care Med 1999; 27:1325-1329)

Cognitive Trajectories after Postoperative Delirium

2012-07-05

Jane S. Saczynski , Edward R. Marcantonio , Lien Quach +4 more

Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac … Delirium is common after cardiac surgery and may be associated with long-term changes in cognitive function. We examined postoperative delirium and the cognitive trajectory during the first year after cardiac surgery.We enrolled 225 patients 60 years of age or older who were planning to undergo coronary-artery bypass grafting or valve replacement. Patients were assessed preoperatively, daily during hospitalization beginning on postoperative day 2, and at 1, 6, and 12 months after surgery. Cognitive function was assessed with the use of the Mini-Mental State Examination (MMSE; score range, 0 to 30, with lower scores indicating poorer performance). Delirium was diagnosed with the use of the Confusion Assessment Method. We examined performance on the MMSE in the first year after surgery, controlling for demographic characteristics, coexisting conditions, hospital, and surgery type.The 103 participants (46%) in whom delirium developed postoperatively had lower preoperative mean MMSE scores than those in whom delirium did not develop (25.8 vs. 26.9, P<0.001). In adjusted models, those with delirium had a larger drop in cognitive function (as measured by the MMSE score) 2 days after surgery than did those without delirium (7.7 points vs. 2.1, P<0.001) and had significantly lower postoperative cognitive function than those without delirium, both at 1 month (mean MMSE score, 24.1 vs. 27.4; P<0.001) and at 1 year (25.2 vs. 27.2, P<0.001) after surgery. With adjustment for baseline differences, the between-group difference in mean MMSE scores was significant 30 days after surgery (P<0.001) but not at 6 or 12 months (P=0.056 for both). A higher percentage of patients with delirium than those without delirium had not returned to their preoperative baseline level at 6 months (40% vs. 24%, P=0.01), but the difference was not significant at 12 months (31% vs. 20%, P=0.055).Delirium is associated with a significant decline in cognitive ability during the first year after cardiac surgery, with a trajectory characterized by an initial decline and prolonged impairment. (Funded by the Harvard Older Americans Independence Center and others.).

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Long-term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis

2010-10-26

Theodore J. Iwashyna , E. Wesley Ely , Dylan M. Smith +1 more

Context-Cognitive impairment and functional disability are major determinants of caregiving needs and societal healthcare costs.Although the incidence of severe sepsis is high and rising, especially among older adults, the magnitude … Context-Cognitive impairment and functional disability are major determinants of caregiving needs and societal healthcare costs.Although the incidence of severe sepsis is high and rising, especially among older adults, the magnitude of patients' long-term cognitive and functional limitations after sepsis is unknown.Objective-Determine the change in cognitive impairment and physical functioning among patients who survive severe sepsis, controlling for their pre-sepsis functioning. Design-Prospective cohort.Setting-The Health and Retirement Study (HRS) conducted interviews with a nationally representative cohort of older Americans every 2 years during 1998-2006.There were 9,223 HRS respondents with linked Medicare claims who had a baseline cognitive and functional assessment 1998-2004.Patients-1,520 hospitalizations for severe sepsis occurred in 1,194 patients, as ascertained from Medicare claims linked to the HRS.Of this group, 516 individuals survived 623 episodes of severe sepsis and had at least 1 follow-up survey, and were analyzed here.A comparison group included 5,574 respondents who experienced a non-sepsis general hospitalization in the study period, of whom 4,517 survived to at least 1 follow-up survey for analysis here. Interventions-NoneMain Outcomes Measures-Personal interviews with respondents and proxies were used to assess cognitive impairment using the validated modified-TICS and IQCODE questionnaires.Disability was measured by the number of ADLs and IADLs for which patients needed assistance.We used within-person regression to identify the association of sepsis with changes in the trajectory of disability with up to 8 years of post-sepsis follow-up.

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Monitoring Sedation Status Over Time in ICU Patients

2003-06-10

E. Wesley Ely , Brenda Truman , Ayumi Shintani +7 more

ContextGoal-directed delivery of sedative and analgesic medications is recommended as standard care in intensive care units (ICUs) because of the impact these medications have on ventilator weaning and ICU length … ContextGoal-directed delivery of sedative and analgesic medications is recommended as standard care in intensive care units (ICUs) because of the impact these medications have on ventilator weaning and ICU length of stay, but few of the available sedation scales have been appropriately tested for reliability and validity.ObjectiveTo test the reliability and validity of the Richmond Agitation-Sedation Scale (RASS).DesignProspective cohort study.SettingAdult medical and coronary ICUs of a university-based medical center.ParticipantsThirty-eight medical ICU patients enrolled for reliability testing (46% receiving mechanical ventilation) from July 21, 1999, to September 7, 1999, and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1, 2000, to May 3, 2001.Main Outcome MeasuresInterrater reliability of the RASS, Glasgow Coma Scale (GCS), and Ramsay Scale (RS); validity of the RASS correlated with reference standard ratings, assessments of content of consciousness, GCS scores, doses of sedatives and analgesics, and bispectral electroencephalography.ResultsIn 290-paired observations by nurses, results of both the RASS and RS demonstrated excellent interrater reliability (weighted κ, 0.91 and 0.94, respectively), which were both superior to the GCS (weighted κ, 0.64; P<.001 for both comparisons). Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort, in whom the RASS showed significant differences between levels of consciousness (P<.001 for all) and correctly identified fluctuations within patients over time (P<.001). In addition, 5 methods were used to test the construct validity of the RASS, including correlation with an attention screening examination (r = 0.78, P<.001), GCS scores (r = 0.91, P<.001), quantity of different psychoactive medication dosages 8 hours prior to assessment (eg, lorazepam: r = − 0.31, P<.001), successful extubation (P = .07), and bispectral electroencephalography (r = 0.63, P<.001). Face validity was demonstrated via a survey of 26 critical care nurses, which the results showed that 92% agreed or strongly agreed with the RASS scoring scheme, and 81% agreed or strongly agreed that the instrument provided a consensus for goal-directed delivery of medications.ConclusionsThe RASS demonstrated excellent interrater reliability and criterion, construct, and face validity. This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications.

Long-Term Cognitive Impairment after Critical Illness

2013-10-02

Pratik P. Pandharipande , Timothy D. Girard , J.C. Jackson +7 more

Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized.We enrolled adults with respiratory failure or shock in the medical or surgical … Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized.We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders.Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months.Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. (Funded by the National Institutes of Health and others; BRAIN-ICU ClinicalTrials.gov number, NCT00392795.).

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Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

2009-05-01

William D. Schweickert , Mark Pohlman , Anne S. Pohlman +7 more

Functional Disability 5 Years after Acute Respiratory Distress Syndrome

2011-04-07

Margaret S. Herridge , Catherine M. Tansey , Andrea Matté +7 more

There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS). There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS).

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Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial

2008-01-01

Timothy D. Girard , John P. Kress , Barry D. Fuchs +7 more

Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome

2010-09-15

Laurent Papazian , Jean-Marie Forel , Arnaud Gacouin +7 more

In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We … In patients undergoing mechanical ventilation for the acute respiratory distress syndrome (ARDS), neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness. We evaluated clinical outcomes after 2 days of therapy with neuromuscular blocking agents in patients with early, severe ARDS.

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Delirium as a predictor of long-term cognitive impairment in survivors of critical illness

2010-05-14

Timothy D. Girard , James C. Jackson , Pratik P. Pandharipande +7 more

To test the hypothesis that duration of delirium in the intensive care unit is an independent predictor of long-term cognitive impairment after critical illness requiring mechanical ventilation.Prospective cohort study.Medical intensive … To test the hypothesis that duration of delirium in the intensive care unit is an independent predictor of long-term cognitive impairment after critical illness requiring mechanical ventilation.Prospective cohort study.Medical intensive care unit in a large community hospital in the United States.Mechanically ventilated medical intensive care unit patients who were assessed daily for delirium while in the intensive care unit and who underwent comprehensive cognitive assessments 3 and 12 mos after discharge.Of 126 eligible patients, 99 survived>or=3 months after critical illness; long-term cognitive outcomes were obtained for 77 (78%) patients. Median age was 61 yrs, 51% were admitted with sepsis/acute respiratory distress syndrome, and median duration of delirium was 2 days. At 3-mo and 12-mo follow-up, 79% and 71% of survivors had cognitive impairment, respectively (with 62% and 36% being severely impaired). After adjusting for age, education, preexisting cognitive function, severity of illness, severe sepsis, and exposure to sedative medications in the intensive care unit, increasing duration of delirium was an independent predictor of worse cognitive performance-determined by averaging age-adjusted and education-adjusted T-scores from nine tests measuring seven domains of cognition-at 3-mo (p=.02) and 12-mo follow-up (p=.03). Duration of mechanical ventilation, alternatively, was not associated with long-term cognitive impairment (p=.20 and .58).In this study of mechanically ventilated medical intensive care unit patients, duration of delirium (which is potentially modifiable) was independently associated with long-term cognitive impairment, a common public health problem among intensive care unit survivors.

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Acute Skeletal Muscle Wasting in Critical Illness

2013-10-10

Zudin Puthucheary , Jaikitry Rawal , Mark McPhail +7 more

Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment.To perform a comprehensive prospective characterization of skeletal muscle wasting, defining the pathogenic roles of altered protein synthesis and … Survivors of critical illness demonstrate skeletal muscle wasting with associated functional impairment.To perform a comprehensive prospective characterization of skeletal muscle wasting, defining the pathogenic roles of altered protein synthesis and breakdown.Sixty-three critically ill patients (59% male; mean age: 54.7 years [95% CI, 50.0-59.6 years]) with an Acute Physiology and Chronic Health Evaluation II score of 23.5 (95% CI, 21.9-25.2) were prospectively recruited within 24 hours following intensive care unit (ICU) admission from August 2009 to April 2011 at a university teaching and a community hospital in England. Patients were recruited if older than 18 years and were anticipated to be intubated for longer than 48 hours, to spend more than 7 days in critical care, and to survive ICU stay.Muscle loss was determined through serial ultrasound measurement of the rectus femoris cross-sectional area (CSA) on days 1, 3, 7, and 10. In a subset of patients, the fiber CSA area was quantified along with the ratio of protein to DNA on days 1 and 7. Histopathological analysis was performed. In addition, muscle protein synthesis, breakdown rates, and respective signaling pathways were characterized.There were significant reductions in the rectus femoris CSA observed at day 10 (−17.7% [95% CI, −25.9% to 8.1%]; P < .001). In the 28 patients assessed by all 3 measurement methods on days 1 and 7, the rectus femoris CSA decreased by 10.3% (95% CI, 6.1% to 14.5%), the fiber CSA by 17.5% (95% CI, 5.8% to 29.3%), and the ratio of protein to DNA by 29.5% (95% CI, 13.4% to 45.6%). Decrease in the rectus femoris CSA was greater in patients who experienced multiorgan failure by day 7 (−15.7%; 95% CI, −27.7% to 11.4%) compared with single organ failure (−3.0%; 95% CI, −5.3% to 2.1%) (P < .001), even by day 3 (−8.7% [95% CI, −59.3% to 50.6%] vs −1.8% [95% CI, −12.3% to 10.5%], respectively; P = .03). Myofiber necrosis occurred in 20 of 37 patients (54.1%). Protein synthesis measured by the muscle protein fractional synthetic rate was depressed in patients on day 1 (0.035%/hour; 95% CI, 0.023% to 0.047%/hour) compared with rates observed in fasted healthy controls (0.039%/hour; 95% CI, 0.029% to 0.048%/hour) (P = .57) and increased by day 7 (0.076% [95% CI, 0.032%-0.120%/hour]; P = .03) to rates associated with fed controls (0.065%/hour [95% CI, 0.049% to 0.080%/hour]; P = .30), independent of nutritional load. Leg protein breakdown remained elevated throughout the study (8.5 [95% CI, 4.7 to 12.3] to 10.6 [95% CI, 6.8 to 14.4] μmol of phenylalanine/min/ideal body weight × 100; P = .40). The pattern of intracellular signaling supported increased breakdown (n = 9, r = −0.83, P = .005) and decreased synthesis (n = 9, r = −0.69, P = .04).Among these critically ill patients, muscle wasting occurred early and rapidly during the first week of critical illness and was more severe among those with multiorgan failure compared with single organ failure. These findings may provide insights into skeletal muscle wasting in critical illness.

Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept

2007-04-11

Sharon K. Inouye , Stephanie A. Studenski , Mary E. Tinetti +1 more

Geriatricians have embraced the term “geriatric syndrome,” using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and … Geriatricians have embraced the term “geriatric syndrome,” using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer‐reviewed evidence. Based on a review of the literature, four shared risk factors—older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility—were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more‐complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.

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The Richmond Agitation–Sedation Scale

2002-11-15

Curtis N. Sessler , Mark S. Gosnell , Mary Jo Grap +5 more

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing … Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 “combative” to −5 “unarousable”) scale, the Richmond Agitation–Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; κ = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922–0.983) (κ = 0.64–0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by “combative” and “unresponsive,” including all patient subgroups (r = 0.84–0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; κ = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773–0.970, κ = 0.66–0.89). Correlations between RASS and the Ramsay sedation scale (r = −0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.

One-Year Health Care Costs Associated With Delirium in the Elderly Population

2008-01-14

Douglas Leslie

Background: While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood.This study determined the total 1-year health care costs associated … Background: While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood.This study determined the total 1-year health care costs associated with delirium.Methods: Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge.Total inflationadjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry.Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics.Results: During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not.Patients with delirium had significantly higher unadjusted health care costs and survived fewer days.After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2 1 ⁄2 times the costs among patients without delirium.Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. Conclusions:The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus.These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder.

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Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

2012-12-24

Juliana Barr , Gilles L. Fraser , Kathleen Puntillo +7 more

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.The American College of Critical … To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult

2002-01-01

Judith Jacobi , Gilles L. Fraser , Douglas B. Coursin +7 more

Jacobi, Judith PharmD, FCCM, BCPS; Fraser, Gilles L. PharmD, FCCM; Coursin, Douglas B. MD; Riker, Richard R. MD; Fontaine, Dorrie RN, DNSc, FAAN; Wittbrodt, Eric T. PharmD; Chalfin, Donald B. … Jacobi, Judith PharmD, FCCM, BCPS; Fraser, Gilles L. PharmD, FCCM; Coursin, Douglas B. MD; Riker, Richard R. MD; Fontaine, Dorrie RN, DNSc, FAAN; Wittbrodt, Eric T. PharmD; Chalfin, Donald B. MD, MS, FCCM; Masica, Michael F. MD, MPH; Bjerke, H. Scott MD; Coplin, William M. MD; Crippen, David W. MD, FCCM; Fuchs, Barry D. MD; Kelleher, Ruth M. RN; Marik, Paul E. MDBCh, FCCM; Nasraway, Stanley A. Jr MD, FCCM; Murray, Michael J. MD, PhD, FCCM; Peruzzi, William T. MD, FCCM; Lumb, Philip D. MB, BS, FCCM. Author Information

Occurrence and outcome of delirium in medical in-patients: a systematic literature review

2006-04-28

Najma Siddiqi , Allan House , John D. Holmes

Background: Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how … Background: Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting. Objective: To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature. Method: We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols. Results: Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months. Conclusion: Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.

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Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients<subtitle>A Randomized Trial</subtitle>

2009-02-03

Richard R. Riker

<h3>Context</h3>γ-Aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the α<sub>2</sub> agonist dexmedetomidine may have distinct advantages.<h3>Objective</h3>To … <h3>Context</h3>γ-Aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the α<sub>2</sub> agonist dexmedetomidine may have distinct advantages.<h3>Objective</h3>To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients.<h3>Design, Setting, and Patients</h3>Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU.<h3>Interventions</h3>Dexmedetomidine (0.2-1.4 μg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between −2 and +1) from enrollment until extubation or 30 days.<h3>Main Outcome Measures</h3>Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events.<h3>Results</h3>There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group; difference, 2.2% [95% confidence interval {CI}, −3.2% to 7.5%]; P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%]; P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9]; P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6]; P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122]; P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122]; P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122]; P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122]; P = .02).<h3>Conclusions</h3>There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia.<h3>Trial Registration</h3>clinicaltrials.gov Identifier: NCT00216190Published online February 2, 2009 (doi:10.1001/jama.2009.56).

Incidence, risk factors and consequences of ICU delirium

2006-11-10

Sébastien Ouimet , Brian P. Kavanagh , Stewart B. Gottfried +1 more

Delirium in Mechanically Ventilated Patients

2001-12-05

E. Wesley Ely , Sharon K. Inouye , Gordon R. Bernard +7 more

OF consciousness characterized by an acute onset and fluctuating course of impaired cognitive functioning so that a patient's ability to receive, process, store, and recall information is strikingly impaired.7][18][19][20] In … OF consciousness characterized by an acute onset and fluctuating course of impaired cognitive functioning so that a patient's ability to receive, process, store, and recall information is strikingly impaired.7][18][19][20] In this population, cogni-

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Delirium in elderly people

2013-08-28

Sharon K. Inouye , Rudi GJ Westendorp , Jane S. Saczynski

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Intensive Care Delirium Screening Checklist: evaluation of a new screening tool

2001-04-20

Nicolas Bergeron , M. J. Dubois , M Dumont +2 more

A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients

1999-03-04

Sharon K. Inouye , Sidney T. Bogardus , Peter Charpentier +4 more

Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium.

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Early exercise in critically ill patients enhances short-term functional recovery*

2009-08-13

Chris Burtin , Béatrix Clerckx , Christophe Robbeets +6 more

Objectives: To investigate whether a daily exercise session, using a bedside cycle ergometer, is a safe and effective intervention in preventing or attenuating the decrease in functional exercise capacity, functional … Objectives: To investigate whether a daily exercise session, using a bedside cycle ergometer, is a safe and effective intervention in preventing or attenuating the decrease in functional exercise capacity, functional status, and quadriceps force that is associated with prolonged intensive care unit stay. A prolonged stay in the intensive care unit is associated with muscle dysfunction, which may contribute to an impaired functional status up to 1 yr after hospital discharge. No evidence is available concerning the effectiveness of an early exercise training intervention to prevent these detrimental complications. Design: Randomized controlled trial. Setting: Medical and surgical intensive care unit at University Hospital Gasthuisberg. Patients: Ninety critically ill patients were included as soon as their cardiorespiratory condition allowed bedside cycling exercise (starting from day 5), given they still had an expected prolonged intensive care unit stay of at least 7 more days. Interventions: Both groups received respiratory physiotherapy and a daily standardized passive or active motion session of upper and lower limbs. In addition, the treatment group performed a passive or active exercise training session for 20 mins/day, using a bedside ergometer. Measurements and Main Results: All outcome data are reflective for survivors. Quadriceps force and functional status were assessed at intensive care unit discharge and hospital discharge. Six-minute walking distance was measured at hospital discharge. No adverse events were identified during and immediately after the exercise training. At intensive care unit discharge, quadriceps force and functional status were not different between groups. At hospital discharge, 6-min walking distance, isometric quadriceps force, and the subjective feeling of functional well-being (as measured with “Physical Functioning” item of the Short Form 36 Health Survey questionnaire) were significantly higher in the treatment group (p < .05). Conclusions: Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity, self-perceived functional status, and muscle force at hospital discharge.

The impact of delirium in the intensive care unit on hospital length of stay

2001-11-08

E. Wesley Ely , Shiva Gautam , Richard Margolin +7 more

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Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation

1999-12-01

Alan D. Brook , Thomas S. Ahrens , Robyn Schaiff +4 more

Objective: To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. Design: Randomized, controlled clinical trial. Setting: Medical intensive care unit (19 … Objective: To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. Design: Randomized, controlled clinical trial. Setting: Medical intensive care unit (19 beds) in an urban teaching hospital. Patients: Patients requiring mechanical ventilation (n = 321). Interventions: Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). Measurements and Main Results: The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxon's test; chi-square = 9.18, p = .003, −2 log test). Lengths of stay in the intensive care unit (5.7 ± 5.9 days vs. 7.5 ± 6.5 days; p = .013) and hospital (14.0 ± 17.3 days vs. 19.9 ± 24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5 ± 4.0 days vs. 5.6 ± 6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). Conclusions: The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

Reducing Delirium After Hip Fracture: A Randomized Trial

2001-05-01

Edward R. Marcantonio , Jonathan M. Flacker , R. John Wright +1 more

Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an … Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture.Prospective, randomized, blinded.Inpatient academic tertiary medical center.126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture.Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm.The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment.Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients.

Paresis Acquired in the Intensive Care Unit<SUBTITLE>A Prospective Multicenter Study</SUBTITLE>

2002-12-11

Bernard De Jonghe , Tarek Sharshar , Jean‐Pascal Lefaucheur +7 more

ContextAlthough electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit (ICU) patients, the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown.ObjectivesTo assess … ContextAlthough electrophysiologic and histologic neuromuscular abnormalities are common in intensive care unit (ICU) patients, the clinical incidence of ICU-acquired neuromuscular disorders in patients recovering from severe illness remains unknown.ObjectivesTo assess the clinical incidence, risk factors, and outcomes of ICU-acquired paresis (ICUAP) during recovery from critical illness in the ICU and to determine the electrophysiologic and histologic patterns in patients with ICUAP.DesignProspective cohort study conducted from March 1999 to June 2000.SettingThree medical and 2 surgical ICUs in 4 hospitals in France.ParticipantsAll consecutive ICU patients without preexisting neuromuscular disease who underwent mechanical ventilation for 7 or more days were screened daily for awakening. The first day a patient was considered awake was day 1. Patients with severe muscle weakness on day 7 were considered to have ICUAP.Main Outcome MeasuresIncidence and duration of ICUAP, risk factors for ICUAP, and comparative duration of mechanical ventilation between ICUAP and control patients.ResultsAmong the 95 patients who achieved satisfactory awakening, the incidence of ICUAP was 25.3% (95% confidence interval [CI], 16.9%-35.2%). All ICUAP patients had a sensorimotor axonopathy, and all patients who underwent a muscle biopsy had specific muscle involvement not related to nerve involvement. The median duration of ICUAP after day 1 was 21 days. Mean (SD) duration of mechanical ventilation after day 1 was significantly longer in patients with ICUAP compared with those without (18.2 [36.3] vs 7.6 [19.2] days; P = .03). Independent predictors of ICUAP were female sex (odds ratio [OR], 4.66; 95% CI, 1.19-18.30), the number of days with dysfunction of 2 or more organs (OR, 1.28; 95% CI, 1.11-1.49), duration of mechanical ventilation (OR, 1.10; 95% CI, 1.00-1.22), and administration of corticosteroids (OR, 14.90; 95% CI, 3.20-69.80) before day 1.ConclusionsIdentified using simple bedside clinical criteria, ICUAP was frequent during recovery from critical illness and was associated with a prolonged duration of mechanical ventilation. Our findings suggest an important role of corticosteroids in the development of ICUAP.

Improving long-term outcomes after discharge from intensive care unit

2011-10-04

Dale M. Needham , Judy E. Davidson , Henry Cohen +7 more

Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may … Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge.To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families.Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge.Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems.Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member.Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Long-Term Cognitive Impairment After Critical Illness

2014-09-23

Pratik P. Pandharipande , Timothy D. Girard , James C. Jackson +7 more

Pandharipande, Pratik P.; Girard, Timothy D.; Jackson, James C.; Morandi, Alessandro; Thompson, Jennifer L.; Pun, Brenda T.; Brummel, Nathan E.; Hughes, Christopher G.; Vasilevskis, Eduard E.; Shintani, Ayumi K.; Moons, … Pandharipande, Pratik P.; Girard, Timothy D.; Jackson, James C.; Morandi, Alessandro; Thompson, Jennifer L.; Pun, Brenda T.; Brummel, Nathan E.; Hughes, Christopher G.; Vasilevskis, Eduard E.; Shintani, Ayumi K.; Moons, Karel G.; Geevarghese, Sunil K.; Canonico, Angelo; Hopkins, Ramona O.; Bernard, Gordon R.; Dittus, Robert S.; Ely, E. W. for the BRAIN-ICU (Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors) Study Investigators Author Information

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Daily Interruption of Sedative Infusions in Critically Ill Patients Undergoing Mechanical Ventilation

2000-05-18

John P. Kress , Anne S. Pohlman , Michael O’Connor +1 more

Continuous infusions of sedative drugs in the intensive care unit may prolong the duration of mechanical ventilation, prolong the length of stay in the intensive care unit and the hospital, … Continuous infusions of sedative drugs in the intensive care unit may prolong the duration of mechanical ventilation, prolong the length of stay in the intensive care unit and the hospital, impede efforts to perform daily neurologic examinations, and increase the need for tests to assess alterations in mental status. Whether regular interruption of such infusions might accelerate recovery is not known.

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Post-Traumatic Stress Disorder in the General Population

1987-12-24

John E. Helzer , Lee N. Robins , Larry McEvoy

There have been numerous studies of post-traumatic stress disorder in trauma victims, war veterans, and residents of communities exposed to disaster. Epidemiologic studies of this syndrome in the general population … There have been numerous studies of post-traumatic stress disorder in trauma victims, war veterans, and residents of communities exposed to disaster. Epidemiologic studies of this syndrome in the general population are rare but add an important perspective to our understanding of it. We report findings on the epidemiology of post-traumatic stress disorder in 2493 participants examined as part of a nationwide general-population survey of psychiatric disorders. The prevalence of a history of post-traumatic stress disorder was 1 percent in the total population, about 3.5 percent in civilians exposed to physical attack and in Vietnam veterans who were not wounded, and 20 percent in veterans wounded in Vietnam. Post-traumatic stress disorder was associated with a variety of other adult psychiatric disorders. Behavioral problems before the age of 15 predicted adult exposure to physical attack and (among Vietnam veterans) to combat, as well as the development of post-traumatic stress disorder among those so exposed. Although some symptoms of post-traumatic stress disorder, such as hyperalertness and sleep disturbances, occurred commonly in the general population, the full syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition, was common only among veterans wounded in Vietnam. (N Engl J Med 1987;317:1630–4.)

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

2018-08-16

John W. Devlin , Yoanna Skrobik , Céline Gélinas +7 more

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.Thirty-two international experts, four methodologists, and four critical … To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

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Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

2020-03-25

Waleed Alhazzani , Morten Hylander Møller , Yaseen M. Arabi +7 more

Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent … Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. Methods: We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. Results: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy. Conclusion: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.

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Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

2020-03-28

Waleed Alhazzani , Morten Hylander Møller , Yaseen M. Arabi +7 more

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance … The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed. We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations. The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy. The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.

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Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy

2020-07-15

Giacomo Grasselli , Massimiliano Greco , Alberto Zanella +7 more

<h3>Importance</h3> Many patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU). <h3>Objective</h3> To evaluate the independent risk factors associated with mortality … <h3>Importance</h3> Many patients with coronavirus disease 2019 (COVID-19) are critically ill and require care in the intensive care unit (ICU). <h3>Objective</h3> To evaluate the independent risk factors associated with mortality of patients with COVID-19 requiring treatment in ICUs in the Lombardy region of Italy. <h3>Design, Setting, and Participants</h3> This retrospective, observational cohort study included 3988 consecutive critically ill patients with laboratory-confirmed COVID-19 referred for ICU admission to the coordinating center (Fondazione IRCCS [Istituto di Ricovero e Cura a Carattere Scientifico] Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy) of the COVID-19 Lombardy ICU Network from February 20 to April 22, 2020. Infection with severe acute respiratory syndrome coronavirus 2 was confirmed by real-time reverse transcriptase–polymerase chain reaction assay of nasopharyngeal swabs. Follow-up was completed on May 30, 2020. <h3>Exposures</h3> Baseline characteristics, comorbidities, long-term medications, and ventilatory support at ICU admission. <h3>Main Outcomes and Measures</h3> Time to death in days from ICU admission to hospital discharge. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional hazards regression. <h3>Results</h3> Of the 3988 patients included in this cohort study, the median age was 63 (interquartile range [IQR] 56-69) years; 3188 (79.9%; 95% CI, 78.7%-81.1%) were men, and 1998 of 3300 (60.5%; 95% CI, 58.9%-62.2%) had at least 1 comorbidity. At ICU admission, 2929 patients (87.3%; 95% CI, 86.1%-88.4%) required invasive mechanical ventilation (IMV). The median follow-up was 44 (95% CI, 40-47; IQR, 11-69; range, 0-100) days; median time from symptoms onset to ICU admission was 10 (95% CI, 9-10; IQR, 6-14) days; median length of ICU stay was 12 (95% CI, 12-13; IQR, 6-21) days; and median length of IMV was 10 (95% CI, 10-11; IQR, 6-17) days. Cumulative observation time was 164 305 patient-days. Hospital and ICU mortality rates were 12 (95% CI, 11-12) and 27 (95% CI, 26-29) per 1000 patients-days, respectively. In the subgroup of the first 1715 patients, as of May 30, 2020, 865 (50.4%) had been discharged from the ICU, 836 (48.7%) had died in the ICU, and 14 (0.8%) were still in the ICU; overall, 915 patients (53.4%) died in the hospital. Independent risk factors associated with mortality included older age (hazard ratio [HR], 1.75; 95% CI, 1.60-1.92), male sex (HR, 1.57; 95% CI, 1.31-1.88), high fraction of inspired oxygen (Fio<sub>2</sub>) (HR, 1.14; 95% CI, 1.10-1.19), high positive end-expiratory pressure (HR, 1.04; 95% CI, 1.01-1.06) or low Pao<sub>2</sub>:Fio<sub>2</sub>ratio (HR, 0.80; 95% CI, 0.74-0.87) on ICU admission, and history of chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.28-2.19), hypercholesterolemia (HR, 1.25; 95% CI, 1.02-1.52), and type 2 diabetes (HR, 1.18; 95% CI, 1.01-1.39). No medication was independently associated with mortality (angiotensin-converting enzyme inhibitors HR, 1.17; 95% CI, 0.97-1.42; angiotensin receptor blockers HR, 1.05; 95% CI, 0.85-1.29). <h3>Conclusions and Relevance</h3> In this retrospective cohort study of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed COVID-19, most patients required IMV. The mortality rate and absolute mortality were high.

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Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19

2020-08-25

Eve Garrigues , Paul Janvier , Yousra Kherabi +7 more

Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19

2020-09-02

Jonathan A C Sterne , Srinivas Murthy , Janet Dı́az +7 more

<h3>Importance</h3> Effective therapies for patients with coronavirus disease 2019 (COVID-19) are needed, and clinical trial data have demonstrated that low-dose dexamethasone reduced mortality in hospitalized patients with COVID-19 who required … <h3>Importance</h3> Effective therapies for patients with coronavirus disease 2019 (COVID-19) are needed, and clinical trial data have demonstrated that low-dose dexamethasone reduced mortality in hospitalized patients with COVID-19 who required respiratory support. <h3>Objective</h3> To estimate the association between administration of corticosteroids compared with usual care or placebo and 28-day all-cause mortality. <h3>Design, Setting, and Participants</h3> Prospective meta-analysis that pooled data from 7 randomized clinical trials that evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The trials were conducted in 12 countries from February 26, 2020, to June 9, 2020, and the date of final follow-up was July 6, 2020. Pooled data were aggregated from the individual trials, overall, and in predefined subgroups. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the<i>I2</i>statistic. The primary analysis was an inverse variance–weighted fixed-effect meta-analysis of overall mortality, with the association between the intervention and mortality quantified using odds ratios (ORs). Random-effects meta-analyses also were conducted (with the Paule-Mandel estimate of heterogeneity and the Hartung-Knapp adjustment) and an inverse variance–weighted fixed-effect analysis using risk ratios. <h3>Exposures</h3> Patients had been randomized to receive systemic dexamethasone, hydrocortisone, or methylprednisolone (678 patients) or to receive usual care or placebo (1025 patients). <h3>Main Outcomes and Measures</h3> The primary outcome measure was all-cause mortality at 28 days after randomization. A secondary outcome was investigator-defined serious adverse events. <h3>Results</h3> A total of 1703 patients (median age, 60 years [interquartile range, 52-68 years]; 488 [29%] women) were included in the analysis. Risk of bias was assessed as "low" for 6 of the 7 mortality results and as "some concerns" in 1 trial because of the randomization method. Five trials reported mortality at 28 days, 1 trial at 21 days, and 1 trial at 30 days. There were 222 deaths among the 678 patients randomized to corticosteroids and 425 deaths among the 1025 patients randomized to usual care or placebo (summary OR, 0.66 [95% CI, 0.53-0.82];<i>P</i> < .001 based on a fixed-effect meta-analysis). There was little inconsistency between the trial results (<i>I2</i> = 15.6%;<i>P</i> = .31 for heterogeneity) and the summary OR was 0.70 (95% CI, 0.48-1.01;<i>P</i> = .053) based on the random-effects meta-analysis. The fixed-effect summary OR for the association with mortality was 0.64 (95% CI, 0.50-0.82;<i>P</i> < .001) for dexamethasone compared with usual care or placebo (3 trials, 1282 patients, and 527 deaths), the OR was 0.69 (95% CI, 0.43-1.12;<i>P</i> = .13) for hydrocortisone (3 trials, 374 patients, and 94 deaths), and the OR was 0.91 (95% CI, 0.29-2.87;<i>P</i> = .87) for methylprednisolone (1 trial, 47 patients, and 26 deaths). Among the 6 trials that reported serious adverse events, 64 events occurred among 354 patients randomized to corticosteroids and 80 events occurred among 342 patients randomized to usual care or placebo. <h3>Conclusions and Relevance</h3> In this prospective meta-analysis of clinical trials of critically ill patients with COVID-19, administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality.

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Preventing Delirium in Hospitalized Patients: No Magic Bullets

2025-06-25

Jessica Spence , Roxane Fournier , Emilie P. Belley‐Côté | Critical Care Medicine

Gaps in Personalizing Anesthetic Drug Delivery During Cardiopulmonary Bypass

2025-06-25

Markus M. Luedi , Ken B. Johnson | Anesthesia & Analgesia

Correction to ‘Patients' and Family Members' Dyadic Experience of Post‐Operative Delirium in the Intensive Care Unit: A Qualitative Study’

2025-06-25

| Nursing in Critical Care

Screening for post-intensive care syndrome

2025-06-24

Brian C. Peach , Tracye Proffitt | The Nurse Practitioner

Intra- and early postoperative predictors of delirium risk in cardiac surgery

2025-06-24

Yanyan Song , Xiaojing Bao , Bo Jiang | International Journal of Surgery

Development of a Nomogram Model to Predict the Risk of Postoperative Delirium in Cardiac Surgery Patients

2025-06-24

Zikomo Gaudence Kipanga , Z.L. Bao , Marvel Gyeyock Tella +7 more | Journal of Cardiovascular Translational Research

Assessing Preoperative Cognition to Predict Postoperative Delirium in OMFS Patients

2025-06-24

Eman Alhammadi , Majeed Rana , Helmut Frohnhofen +1 more | International Journal of Oral and Maxillofacial Surgery

Sequestration of Remimazolam and Midazolam in an In-Vitro Extracorporeal Membrane Oxygenation Circuit

2025-06-24

Casper Nørholt , Søren Nielsen Skov , Peter Fast Nielsen +3 more | ASAIO Journal

Midazolam is a commonly used sedative for patients on extracorporeal membrane oxygenation (ECMO). However, its long context-sensitive half-life is of concern. Remimazolam may be a suitable alternative. This study compares … Midazolam is a commonly used sedative for patients on extracorporeal membrane oxygenation (ECMO). However, its long context-sensitive half-life is of concern. Remimazolam may be a suitable alternative. This study compares the sequestration of remimazolam and midazolam in an in-vitro ECMO circuit. Sixteen in-vitro ECMO circuits were prepared with either Ringer lactate or a combination of red blood cells and fresh frozen plasma. Each circuit operated at a flow of 3 L/min at 37°C for 24 hours. Remimazolam (1 mg) or midazolam (1 mg) was injected, creating four experimental groups. Blood samples for measurement of drug concentrations were collected at predefined time points. The percentage of drug remaining at 24 hours was comparable for remimazolam and midazolam (mean [standard deviation {SD}]: 3.7% [0.9] and 2.9% [0.5]) in Ringer lactate-perfused circuits and higher for midazolam compared with remimazolam (mean [SD] 52% [13] and 15% [2]) in blood-perfused circuits. The concentration of the remimazolam metabolite CNS7054 increased from 29 (8) ng/ml at 5 minutes to 173 (31) ng/ml at 24 hours. Drug sequestration of remimazolam in in-vitro ECMO circuit is comparable to midazolam in circuits perfused with Ringer lactate. In circuits perfused with blood, the percentage of drug remaining at 24 hours is lower for remimazolam.

Health-related quality of life and functional recovery after intensive care for sepsis in a national cohort

2025-06-23

Peter Halvorsen , Michael Hultström , Ewa Wallin +2 more | Intensive Care Medicine

Functional recovery after intensive care is an important patient-centered outcome. In this study, we investigated risk factors for poor outcome after intensive care for sepsis using serial health-related quality of … Functional recovery after intensive care is an important patient-centered outcome. In this study, we investigated risk factors for poor outcome after intensive care for sepsis using serial health-related quality of life (HRQoL) assessments and the burden of work incapacity as an objective proxy for functional recovery. We acquired data on all adult intensive care unit (ICU) patients with sepsis in Sweden between 2008 and 2020. Primary outcome was HRQoL assessed with RAND-36 at follow-up after ICU discharge. Sick-leave information was acquired on the working-age subpopulation to assess the burden of work incapacity. RAND-36 data were available for 14,006 individuals and was lower than Swedish population reference levels. Males had higher RAND-36. Age had varying associations. Pre-ICU comorbidities were associated with lower RAND-36, whereas severity of illness was associated with lower general health. Invasive ventilation was associated with higher RAND-36, while continuous renal replacement therapy and length of stay (LoS) were associated with lower RAND-36. RAND-36 increased with time after ICU. Sick-leave length was associated with lower RAND-36. High levels of sick leave were seen in patients before intensive care for sepsis, suggesting pre-existing vulnerability. Sick leave increased further after sepsis and did not return to baseline, suggesting incomplete functional recovery, with lower education, female sex, and comorbidities as risk factors. In conclusion, in a Swedish national cohort of ICU patients surviving sepsis, HRQoL was low but improved over time. Severity of illness had minimal impact on HRQoL, while LoS and comorbidities were negative factors. Functional recovery in the form of days on sick leave showed a similar pattern. The study was registered with clinicaltrials.gov: NCT06368336, on the 15th of April 2024.

A pilot study to explore children’s experiences of intensive care post-cardiac arrest using art-based participatory methods

2025-06-23

Donna Thomas , Graeme O’Connor | Journal of Child Health Care

Children who have survived a cardiac arrest are at the highest risk of long-term impairment, collectively termed Post Intensive Care Syndrome (PICS). This study aimed to explore through participatory and … Children who have survived a cardiac arrest are at the highest risk of long-term impairment, collectively termed Post Intensive Care Syndrome (PICS). This study aimed to explore through participatory and creative methods, children and young people’s (CYP) experiences post-cardiac arrest intensive care. Participatory research includes drawing, painting and small-world play. CYPs were recruited who had been admitted to intensive care post-cardiac arrest and had the cognitive and physical ability to talk, draw, paint or play out their experiences. Seven CYPs and families consented to participate. The median number of interviews was two (IQR2,3), with a median interview length of 24 minutes (IQR15,65 minutes). Themes that emerged: gratitude, distrust and extrasensory experiences. Four of the seven (57%) participants opted to paint or draw to convey their experiences. Two (28%) participants had no memories of their cardiac arrest or time in intensive care but used creative methods to express gratitude to the care team. Participatory research methods may be an effective way for CYPs to convey their experiences of post-cardiac arrest intensive care. CYPs who have been critically ill have expressed a need to make sense of their experiences in intensive care. Healthcare professionals should be aware that these experiences may be deemed as extrasensory and require sensitive exploration.

Does pneumonia increase the risk of dementia and cognitive decline? A systematic review and meta-analysis

2025-06-23

Zhen Yan , Min Zhang , Li-Fang Yu +1 more | Annals of Medicine

The link between pneumonia and elevated risk of dementia and cognitive decline is still unclear. This study aims to evaluate the link between pneumonia and the subsequent risk of developing … The link between pneumonia and elevated risk of dementia and cognitive decline is still unclear. This study aims to evaluate the link between pneumonia and the subsequent risk of developing dementia. MEDLINE (via PubMed), EMBASE (Excerpta Medica Database), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) databases were searched for studies, published up to 29 February 2024. Eligible studies provided data on adult patients diagnosed with pneumonia and reported outcomes related to dementia or cognitive decline. Quality of observational studies was assessed by the Newcastle-Ottawa Scale. Pooled hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CI) were calculated using random-effects models. Subgroup analyses were done based on age, geography, study design and pneumonia type. Ten studies were included, encompassing a diverse population sample. Pooled analysis demonstrated a significant correlation between pneumonia and increased risk of dementia (HR = 1.738; 95% CI: 1.358 to 2.225), with substantial heterogeneity across the studies (I2 = 97.1%). Subgroup analysis indicated that the association was more pronounced in older adults and varied slightly by region and study design. The risk did not significantly differ between bacterial and non-specific pneumonia types. This meta-analysis suggests that pneumonia is associated with a significantly higher risk of developing dementia. These findings underscore the need for diligent monitoring and preventive strategies for patients recovering from pneumonia, particularly among the elderly, to mitigate potential cognitive decline.PROSPERO registration number: CRD42024520631.

Commentary on “Intra- and early postoperative predictors of delirium risk in cardiac surgery”

2025-06-23

Shimeng Cui , Chao Wu , Xiaoxi Wang | International Journal of Surgery

Quetiapine Use Is Associated with Longer ICU Stay Compared to Control and Haloperidol: A Propensity Score–Matched Analysis Using the MIMIC-IV Database

2025-06-23

Ajna Hamidovic | Journal of Clinical Medicine

Background: Due to the low certainty of existing evidence, no formal recommendation can be made for or against the use of antipsychotics over usual care in ICU patients with delirium. … Background: Due to the low certainty of existing evidence, no formal recommendation can be made for or against the use of antipsychotics over usual care in ICU patients with delirium. To advance evidence-based practice, we used observational data from the Medical Information Mart for Intensive Care (MIMIC) to estimate the effect of pre-ICU quetiapine treatment (vs. control) on the length of ICU stay. In a second, head-to-head comparison, we assessed quetiapine vs. haloperidol on the same outcome. Methods: We conducted two propensity score-matched procedures: 518 patients were matched based on receipt of quetiapine versus no antipsychotic (i.e., control), and 336 patients based on quetiapine versus haloperidol prior to ICU admission. After matching, we performed Bayesian generalized additive modeling (GAM) and Bayesian sensitivity analyses within a nonlinear modeling framework. Results: In the quetiapine versus no quetiapine analysis, the original overall covariate distance of 0.48 was reduced to 0.01 post-matching. All covariates achieved an acceptable balance, with absolute standardized mean differences below 0.1. Quetiapine use was associated with a 1.31-day longer ICU stay (posterior mean = 0.36; 95% credible interval: 0.14 to 0.59). Sensitivity analyses indicated that this effect remained robust after accounting for plausible levels of unmeasured confounding. In the quetiapine versus haloperidol analysis, the initial overall distance of 0.40 was reduced to 0.09 after matching, with all covariates similarly balanced. Compared to haloperidol, quetiapine treatment was associated with a 1.46-day longer ICU stay (posterior mean = 0.48; 95% credible interval: 0.09 to 0.88). Bayesian sensitivity analyses again indicated the robustness of the effect estimate. Conclusions: In these emulated clinical trials, pre-ICU treatment with quetiapine was associated with a prolonged ICU stay compared to both untreated and haloperidol conditions. Though more research in this field is needed, these findings do not support the use of quetiapine in ICU patients with delirium.

Early acetaminophen use is associated with the reduced mortality risk in patients with sepsis-associated encephalopathy: a retrospective study

2025-06-23

Fengzhen Huang , Jiping Yi , Tieqiao Zhou +1 more | European journal of medical research

Sepsis-associated encephalopathy (SAE), a severe neurological complication of systemic infection, carries substantial morbidity and mortality risks. This study aims to examine the relationship between early acetaminophen use and survival rates … Sepsis-associated encephalopathy (SAE), a severe neurological complication of systemic infection, carries substantial morbidity and mortality risks. This study aims to examine the relationship between early acetaminophen use and survival rates in critically ill SAE patients. Using data from the MIMIC-IV database, we conducted a retrospective cohort study on patients with SAE, stratified by acetaminophen exposure within 48 h of ICU admission. Among the 4111 eligible patients (1689 acetaminophen recipients versus 2422 non-recipients), propensity score matching resulted in 3124 matched subjects (1562 per cohort). The primary outcome was 90-day mortality, while secondary outcomes included mortality rates at 30, 60, 180, and 365 days. Survival analyses utilized Cox proportional hazards regression and Kaplan-Meier curves, supplemented by subgroup analyses for 90-day mortality. Acetaminophen exposure was correlated with reduced 30-day mortality rate (HR = 0.78, 95%CI [0.65-0.94], p < 0.05), as well as decreased 60-day (HR = 0.71, 95%CI [0.60-0.83], p < 0.001), 90-day (HR = 0.70, 95%CI [0.60-0.81], p < 0.001), 180-day (HR = 0.70, 95%CI [0.60-0.80], p < 0.001) and 365-day (HR = 0.69, 95%CI [0.61-0.79], p < 0.001) mortality rate after PSM. The Kaplan-Meier analysis demonstrated significantly higher survival rates in the acetaminophen group compared to the non-acetaminophen group, with a persistent trend at 30, 90, 180, and 365 days (log-rank p < 0.05). The protective effect was consistent across subgroups except acetaminophen dosage ≥ 650 mg. Early administration of acetaminophen is associated with reduced short- and long-term mortality in SAE patients. These findings support a potential therapeutic role for acetaminophen in SAE and warrant further mechanistic and prospective validation.

Nurses’ experiences of fundamental care delivery in the intensive care unit: A qualitative systematic review

2025-06-22

Krystle Waltrovitz , Tiffany Conroy , Rebecca Feo | Australian Critical Care

Fundamental care is relationship-based care delivered by nurses in an integrated manner to meet patients' essential physical, relational, and psychosocial needs. Research on patients' and families' experiences in the intensive … Fundamental care is relationship-based care delivered by nurses in an integrated manner to meet patients' essential physical, relational, and psychosocial needs. Research on patients' and families' experiences in the intensive care unit (ICU) has reported deficits in fundamental care delivery, leading to poor patient experiences and suboptimal recovery. Understanding nurses' experience of delivering fundamental care in this context can shed light on these poor experiences. This review sought to answer the following question: "What are nurses' experiences of fundamental care delivery in the ICU?" A qualitative systematic review was conducted following JBI methods. A systematic search of five electronic databases was undertaken on January 31, 2025: MEDLINE, Cumulative Index for Nursing and Allied Health (CINAHL), APA PsycINFO, Scopus, and Emcare. A total of 5498 papers were retrieved. A total of 3750 papers were screened after duplicate removal, with 25 papers meeting eligibility criteria. All were independently critically appraised by two authors. Twenty-five papers representing 785 participants were included. Relationship development between nurses and patients was important for nurses to deliver fundamental care. When nurses were unable to develop these relationships, they felt unable to optimally meet patients' fundamental care needs, resulting in nurses experiencing feelings of frustration and failure. Several strategies were utilised by nurses to develop relationships and deliver fundamental care: getting to know patients, empathy, reassurance, touch, comfort, and informing and involving patients and families. However, nurses also articulated challenges in developing relationships and delivering fundamental care, including patient-specific, nurse-specific, and contextual factors. This review provides insights into nurses' experiences of fundamental care delivery in the ICU. Given the negative emotions nurses experience when they encounter challenges in delivering fundamental care, research is required to explore ways in which nurses can be better supported to deliver fundamental care in the ICU. The identified strategies might be helpful for nurses to utilise; however, research on their feasibility and effectiveness is warranted. The systematic review followed an a priori protocol, registered with in the International Prospective Register of Systematic Reviews (PROSPERO [CRD42023428325]).

Comparative efficacy of remifentanil and fentanyl in mechanically ventilated ICU patients: a systematic review and meta-analysis on ventilation duration and delirium incidence

2025-06-22

Hiromu Okano , Eriya Imai , Hiroshi Okamoto +6 more | Journal of Anesthesia Analgesia and Critical Care

The ultrashort-acting properties and organ-independent metabolism of remifentanil may be advantageous in mechanical ventilation management. Unlike fentanyl, which accumulates over time and may prolong sedation, remifentanil enables more predictable titration … The ultrashort-acting properties and organ-independent metabolism of remifentanil may be advantageous in mechanical ventilation management. Unlike fentanyl, which accumulates over time and may prolong sedation, remifentanil enables more predictable titration and rapid weaning. This study aimed to determine the effect of remifentanil on shortening the duration of mechanical ventilation in comparison with fentanyl in adult intensive care unit (ICU) patients. A systematic review and meta-analysis was conducted, including randomised controlled trials (RCTs) and observational studies from MEDLINE, Cochrane, EMBASE, ICTRP, and ClinicalTrials.gov, from inception to July 2024. Studies comparing remifentanil with fentanyl in mechanically ventilated ICU patients were included, whereas those that used only remifentanil or fentanyl intraoperatively were excluded. The primary outcome was ventilation duration, with a minimal important difference (MID) of 90 min. A random-effects meta-analysis was performed and the certainty of evidence was assessed using the GRADE approach. The risk of bias was evaluated using RoB 2.0 and ROBINS-I tools. We included 18 studies (14 RCTs and 4 observational studies). Ten studies (8 RCTs and 2 observational studies; 901 patients) were analysed. Remifentanil may reduce ventilation duration compared to fentanyl (8 RCTs: MD -6.70 h, 95% CI -14.36 to 0.97; low certainty; 2 observational studies: MD -21.26 h, 95% CI -37.29 to -5.24; low certainty). Remifentanil may reduce the duration of mechanical ventilation, potentially improving patient outcomes. However, owing to the low certainty of the evidence and study heterogeneity, further high-quality RCTs are required to validate these findings. PROSPERO 2024 and CRD42024557414.

Corrigendum to “Effects of DELIMA education programme on nurses’ knowledge, confidence, attitude, and screening accuracy for delirium in paediatric intensive care units” [Intensive Crit Care Nurs 2025;87:103938

2025-06-21

Iftitakhur Rohmah , Diah Sukmawati Pangarsih , Sri Puji Rahayu +5 more | Intensive and Critical Care Nursing

Prevalence, timing and characteristics of delirium preceding dementia with Lewy bodies: a retrospective case series

2025-06-21

Janice A. Taylor , Chaminda Gunawardana , Simon J.G. Lewis +1 more | Journal of Neurology

Abstract Background Consensus diagnostic criteria for delirium-onset dementia with Lewy bodies are lacking. This retrospective study aimed to identify delirium occurring in the prodrome of dementia with Lewy bodies (DLB), … Abstract Background Consensus diagnostic criteria for delirium-onset dementia with Lewy bodies are lacking. This retrospective study aimed to identify delirium occurring in the prodrome of dementia with Lewy bodies (DLB), exploring delirium-onset DLB as an entity and its natural history. Methods Thirty-four participants with an established diagnosis of probable DLB from an outpatient neurology clinic in Sydney underwent a structured telephone interview to identify episodes of delirium. The timing, precipitants, and phenomenology of each episode were documented. Core and supportive features from the proposed diagnostic criteria for DLB were evaluated. Results 26% of the participants experienced delirium prior to diagnosis of DLB, with one participant experiencing multiple episodes in the 24 months before diagnosis. Of these cases, 66% demonstrated some core and supportive features of DLB at the time of their delirium. In addition to expected triggers (e.g. surgery), international (long-haul) air flight was identified as one of the commonest precipitants for delirium in this group. Those DLB cases who fulfilled the proposed research criteria for a delirium-onset prodrome experienced a shorter time from symptom onset to dementia than those DLB patients with no history of pre-diagnosis delirium (26 vs 40 months). Conclusions These findings support delirium as a marker of prodromal DLB and suggest delirium-onset cases exhibit a more rapid progression to dementia, offering a focus for future studies. Identifying delirium as a potential early feature of DLB could aid in earlier recognition and improve diagnostic accuracy, particularly in individuals presenting with precipitants such as international air travel.

Clonidine for Management of Agitation in Delirious Patients

2025-06-21

D. Rowland , Nicholas J. Waldvogel | Current Psychiatry Reports

Fluvoxamine Attenuates Liver Injury in Lipopolysaccharide‐Induced Sepsis: Via Nrf2/HO‐1 Pathway

2025-06-20

Rahime Aslankoç , Özlem Özmen , Pınar Karabacak +3 more | Fundamental and Clinical Pharmacology

ABSTRACT The search for new treatments for sepsis is a pivotal subject of survey owing to the high mortality of sepsis. Sepsis can cause serious injury to many vital organs, … ABSTRACT The search for new treatments for sepsis is a pivotal subject of survey owing to the high mortality of sepsis. Sepsis can cause serious injury to many vital organs, including the liver. This study investigated the potential therapeutic impacts of fluvoxamine (FLV) against liver injury in a lipopolysaccharide (LPS)‐induced sepsis model. Thirty‐two female Wistar Albino rats were divided into four equal groups: control, LPS (5 mg/kg, i.p., single dose), LPS + FLV(5 mg/kg, i.p., single dose+50 mg/kg, i.p., single dose, 30 min before LPS application) and FLV(50 mg/kg, i.p., single dose). Six hours after LPS application, blood and liver tissues were gathered under anesthesia for biochemical, histopathological, and immunohistochemical analyses. The RT‐qPCR analyzed the mRNA expression of nuclear factor erythroid 2–related factor 2 (Nrf2), glycogen synthase kinase‐3 (GSK3ß), kelch‐like ECH–associated protein 1 (Keap1), and heme oxygenase‐1 (HO‐1). LPS administration caused significant histopathological changes in the liver and increased oxidative stress. It increased the number of TNF‐α, osteopontin (OPN), and serum amyloid A (SAA) immune positive cells associated with inflammation and decreased Nrf2, GSK3ß, Keap1, and HO‐1 gene expressions associated with antioxidant defense. Additionally, serum alanine aminotransferase (ALT) level significantly increased. In the LPS + FLV and FLV groups, improvement in histopathological findings and a significant decrease in oxidative stress were detected. TNF‐α, OPN, and SAA expression decreased, and Nrf2, GSK3ß, Keap1, and HO‐1 gene expressions increased. The decrease in serum aspartate aminotransferase (AST) and ALT was found to be significant only in the FLV group. Our findings therefore provide new evidence that FLV reduces LPS‐induced liver injury.

Improving Delirium Detection in Hospitalized Older Adults

2025-06-20

Pablo Richly , Chis Giedt , John McLeod | Delirium Communications

This study evaluated the effectiveness of implementing the 4AT (Rapid Assessment Test for Delirium) as a default screening tool for delirium in patients aged 65 and above upon hospital admission. … This study evaluated the effectiveness of implementing the 4AT (Rapid Assessment Test for Delirium) as a default screening tool for delirium in patients aged 65 and above upon hospital admission. An internal audit of retrospective data was conducted across two inpatient wards at Waikato Hospital, New Zealand, over four weeks in March 2024. The audit encompassed 144 consecutively admitted patients. Initial review using CHART-DEL identified 23% of patients meeting delirium criteria at admission. After implementing 4AT, the delirium detection rate significantly increased to 42%. Additionally, 25% of assessed patients exhibited signs of cognitive impairment without meeting delirium criteria. These findings demonstrate that implementing systematic delirium screening tools like 4AT can significantly improve detection rates and risk stratification among hospitalized older adults. The study underscores the importance of integrating evidence-based screening tools into routine clinical practice to enhance patient outcomes and quality of care for this vulnerable population.

Synergistic effects of commonly used ICU drugs and high temperature on skeletal muscle at the cellular and tissue levels

2025-06-20

Kei Sugiki , Hironobu Takahashi , Tatsuya Shimizu | Anesthesiology

Background: Several drugs are commonly administered to patients with high body temperature in intensive care units (ICUs). However, previous in vitro studies have investigated only the independent effects of high … Background: Several drugs are commonly administered to patients with high body temperature in intensive care units (ICUs). However, previous in vitro studies have investigated only the independent effects of high temperatures or drugs on various cultured cells. We explored the hypothesis that pharmacological treatment with representative ICU drugs induces lethal effects on cultured skeletal muscle and engineered muscle tissue at high temperatures. Methods: Human skeletal muscle cultures were treated with the representative drugs propofol, dexmedetomidine, and acetaminophen at 37, 39, and 41 °C for various exposure times. To investigate the effects of the drug treatments, cell viability, lactate dehydrogenase (LDH) activity, caspase activity, and endoplasmic reticulum (ER) stress were analyzed. Conformational changes in myotubes and functional changes in contractile muscle tissue were also assessed. All experiments were repeated at least 3 times. Results: Dexmedetomidine and acetaminophen had no observable adverse effects at high temperatures, whereas propofol treatment at > 200 µM resulted in increased LDH activity and myotube detachment. Furthermore, this cellular injury was associated with intracellular calcium overload and upregulation of the ER stress-related genes CHOP, GRP78/Bip, and GRP94. Propofol treatment also decreased the contractile ability of muscle tissues at 39 °C (vs. 37 °C propofol, 95% CI, 30.72 to 114.87%; P < 0.001). Additionally, although tauroursodeoxycholic acid (TUDCA), an ER stress inhibitor, alleviated the increase in caspase 3/7 activity at 39 °C (95% CI, 38.10 to 145.22%; P < 0.001) and mitigated myotube detachment, it did not result in notable functional improvement in muscle contraction. Conclusions: These results demonstrate that propofol had harmful effects on skeletal muscle cells and tissues at high temperatures in vitro . As these synergistic effects were closely associated with ER stress, TUDCA could mitigate propofol-induced apoptosis at high temperatures. These findings could help improve drug treatment for patients, including their functional prognosis in the clinical setting.

A commentary on “Intra- and early postoperative predictors of delirium risk in cardiac surgery results from the prospective observational FINDERI study”

2025-06-20

Jian He , Xiaoming Bian , Qing‐Li Zhao | International Journal of Surgery

Impact of tourniquet application on postoperative delirium in elderly patients undergoing total knee arthroplasty: a randomized clinical trial

2025-06-20

Xiaoyi Chen , Xinghe Wang , Yucheng Liu +7 more | International Journal of Surgery

Background: Tourniquet is widely used in total knee arthroplasty (TKA), but its impact on postoperative delirium (POD) remains unclear. The purposes of this study were to investigate the impact of … Background: Tourniquet is widely used in total knee arthroplasty (TKA), but its impact on postoperative delirium (POD) remains unclear. The purposes of this study were to investigate the impact of tourniquet application on POD in elderly patients TKA and to explore the possible mechanisms associated with POD. Materials and methods: In this prospective, single-center randomized clinical trial study, 313 patients scheduled for single TKA under general anesthesia were randomly assigned to groups with or without a limb tourniquet. The primary outcome was the incidence of POD within postoperative 7 days. Secondary outcomes were the levels of hypoxia-inducible factor-1α (HIF-1α), tumor necrosis factor-alpha (TNF-α), superoxide dismutase (SOD), and S100β protein (S100β) measured postoperative 30 min and 24 h, blood loss, pain score, the time to first postoperative ambulation, postoperative hospitalization, postoperative complications, and adverse events. Results: The incidence of POD in tourniquet group was significantly higher than that in no tourniquet group [19.1% vs. 9.6 %, relative risk (RR) 1.12, 95% confidence interval (CI): 1.02 to 1.23, P = 0.018]. The serum level of HIF-1α was higher at postoperative 30 min and 24 h and SOD was lower at postoperative 24 h in tourniquet group compared with no tourniquet group. The incidence of postoperative complications and adverse events were comparable in both groups. Conclusion: We concluded that tourniquet application during TKA increased the incidence of POD within postoperative 7 days in older patients, and increased serum level of HIF-1α and decreased level of SOD, which indicated that they may be potential targets for preventing and treating POD.

Disease entity impacts muscle wasting in the ICU with COVID-19 patients losing muscle nearly twice as fast

2025-06-20

Johannes Kolck , Clarissa Hosse , Uli Fehrenbach +4 more | Scientific Reports

Abstract Muscle loss in critically ill patients, particularly during prolonged ICU stays, poses significant challenges to recovery and long-term outcomes. ICU-acquired weakness (ICUAW) manifests as severe muscle depletion, correlating with … Abstract Muscle loss in critically ill patients, particularly during prolonged ICU stays, poses significant challenges to recovery and long-term outcomes. ICU-acquired weakness (ICUAW) manifests as severe muscle depletion, correlating with illness severity and hospitalization duration. This study aims to characterize long-term muscle loss trajectories in ICU patients with acute respiratory distress syndrome (ARDS) due to COVID-19 and severe acute pancreatitis (AP) and to explore contributing factors to elevated muscle decay. Retrospective cohort study including 154 ICU patients, 100 individuals suffering from AP and 54 from COVID-19 ARDS, who underwent a minimum of three CT scans during hospitalization, totaling 988 assessments. Sequential segmentation of psoas muscle area (PMA) was performed, and relative muscle loss per day for the entire monitoring period, as well as for the interval between each consecutive scan, was calculated. Bivariate and multivariate linear regression analyses were conducted to identify and evaluate the factors contributing to muscle loss. ICU patients experienced an average PMA decline of 46.0%, with a reduction of 41.8% observed in COVID-19 patients and 48.2% in AP patients. Notably, the long-term daily PMA loss was significantly greater in COVID-19 patients (1.88%) compared to AP patients (0.98%; p < 0.001). Linear regression analysis identified disease entity ( p < 0.001), length of hospitalization ( p < 0.001), and obesity as significant contributors to daily muscle deterioration. Patients admitted to the ICU for COVID-19 and severe AP can experience extreme muscle decay, reaching up to 48.2%. While decay rates vary considerably, COVID-19 patients experienced nearly twice the daily muscle loss compared to AP patients. Key factors contributing to muscle decay included disease entity, hospitalization duration, and obesity. These findings highlight the distinct impact of the underlying disease on muscle deterioration and emphasize the heightened risk for obese patients and those undergoing extended hospitalization.

Prevalence of and risk factors for postoperative delirium among children after cardiac surgery in a Single-Centre retrospective study

2025-06-20

Stefan Schumann , Gerhard Schön , Ida Hüners +7 more | Scientific Reports

Abstract Due to the increasing focus on neurodevelopment in children with congenital heart disease (CHD), early predictive markers are crucial for implementing interventions and improving neurodevelopmental outcomes. As postoperative delirium … Abstract Due to the increasing focus on neurodevelopment in children with congenital heart disease (CHD), early predictive markers are crucial for implementing interventions and improving neurodevelopmental outcomes. As postoperative delirium (PD) is known to have a long-term impact on neurocognitive function in adults, studies on the prevalence of and modifiable risk factors for PD offer new perspectives. We conducted a retrospective, single-centre study screening for PD using the Cornell Assessment of Pediatric Delirium (CAPD). We distinguished PD from iatrogenic withdrawal syndrome (IWS) by using the Withdrawal Assessment Tool 1 (WAT-1). A confirmatory, multivariate regression analysis was performed and included various pre-, intra-, and postoperative variables. The screening compliance rate was 95% among the 311 patients. The prevalence of PD was 40.2%, and 46.4% of the patients developed IWS. Infants were at the highest risk for PD (OR 2.9, p = 0.05). Prolonged mechanical ventilation > 100 h (OR 7.4, p = 0.003), infusion therapy with ketamine (OR 3.3, p = 0.009), IWS (mild: OR 7.7, p = < 0.001, severe: OR 17.0, p = < 0.001) and low cardiac output syndrome (LCOS) (OR 3.9, p = 0.02) were significant predictive risk factors for PD. Overall, PD and IWS are highly prevalent in paediatric cardiac intensive care units (pCICUs), especially in infants and children with prolonged ventilation durations who require multiple sedatives. This is one of the most extensive single-centre studies in the pCICU population, and the results revealed that IWS and lactatemia in the context of LCOS are novel predictors of PD.

Fentanyl-Induced Respiratory Depression in an Intensive Care Unit Patient

2025-06-20

A. Jayaram , Kumar Ganesan | Indian Journal of Pharmacy Practice

Effect of the Preoperative Application of Esketamine on Stress Indicators in Paediatric Patients Undergoing Bronchoalveolar Lavage Under General Anaesthesia

2025-06-18

Jizheng Zhang , Jiaming Zheng , Xiaohua Sun +2 more | British Journal of Hospital Medicine

Aims/Background To explore the effect of the preoperative administration of esketamine on stress indices in paediatric patients undergoing bronchoalveolar lavage (BAL) under general anaesthesia. Methods A retrospective cohort study was … Aims/Background To explore the effect of the preoperative administration of esketamine on stress indices in paediatric patients undergoing bronchoalveolar lavage (BAL) under general anaesthesia. Methods A retrospective cohort study was conducted to collect clinical data from children undergoing BAL under general anaesthesia in Tianjin Hospital of Tianjin University between February 2021 and January 2024. The patients were divided into two groups: the reference group (taking no preoperative medications) and the study group (receiving preoperative esketamine). The baseline variables of the two groups were balanced using the 1:1 nearest neighbour matching method of propensity score matching (PSM), and the outcome indicators of the matched cohorts were compared. Results A total of 168 patients were included, including 86 in the reference group and 82 in the study group. After PSM, 46 cases in each group were successfully matched. Results showed that all postoperative stress indicators in the study group were significantly lower than those in the reference group (p < 0.001). The Paediatric Anaesthesia Emergence Delirium (PAED) scores and Face, Legs, Arms, Crying, Consolability (FLACC) scale scores of the children in the study group were significantly lower than those in the reference group (p < 0.01). There was no significant difference in the overall incidence of perioperative adverse reactions between the two groups (p > 0.05). Conclusion The preoperative application of esketamine can reduce the stress response in paediatric patients undergoing BAL under general anaesthesia. This effect is beneficial for enhancing the outcome of surgical treatment.

Translation, Adaptation, and Criterion Validation of the Family Caregiver Assessment Tool for French-Speaking Cardiovascular Patients in Canada (FAM-CAM-Fr)

2025-06-18

Tanya Mailhot , Zineb Bouaouina , Imène Khetir +5 more | Canadian Journal of Nursing Research

Background Delirium is a common yet underdiagnosed condition in hospitalized older adults, particularly challenging to detect early in cardiology settings. Although delirium assessment tools improve detection rates, observations by family … Background Delirium is a common yet underdiagnosed condition in hospitalized older adults, particularly challenging to detect early in cardiology settings. Although delirium assessment tools improve detection rates, observations by family caregivers of patients’ cognitive changes can offer valuable insights, supplementing assessments by healthcare professionals. However, validated French-language tools for family caregivers to assess delirium in acute care settings in Canada are lacking. Purpose Translate, culturally adapt, and validate the Family Confusion Assessment Method for French-speaking cardiovascular patients and their caregivers (FAM-CAM-Fr). Methods The translation and cultural adaptation of the FAM-CAM were conducted following the guidelines of Sousa and Rojjanasrirat (2011) . Criterion validation involved 100 dyads of family caregivers and hospitalized cardiovascular patients. The FAM-CAM-Fr's performance was assessed by comparing it to the Confusion Assessment Method (CAM) and the DSM-5 diagnostic criteria for delirium. Measures of sensitivity, specificity, and agreement with the CAM were calculated. Results The FAM-CAM-Fr showed high specificity (92.6%) but low sensitivity (58%) in detecting delirium. Cohen's Kappa indicated a moderate agreement (>0.50) between the FAM-CAM-Fr and the CAM. Despite family caregivers using the tool without prior training, indicating its usability in real-world settings, sensitivity was lower compared to studies that included caregiver training, though specificity was similar. Conclusion The FAM-CAM-Fr is promising as a specific tool for screening delirium in cardiovascular patients. Despite its low sensitivity, its high specificity indicates that it is effective at ruling out delirium. Future research should focus on further validation across various settings.

Efficacy and Safety of Haloperidol in the Prevention and Management of Delirium in Medical Inpatients: An Umbrella Review of Systematic Reviews

2025-06-18

Vijaykumar Harbishettar , Vijayakumar M Heggeri , Saraswathi Tenagi +5 more | Indian Journal of Psychological Medicine

Delirium occurs in up to 31% of general hospital patients in the medical, surgical, or critical care wards. Agitation is common during hyperactive delirium, which poses a risk to themselves, … Delirium occurs in up to 31% of general hospital patients in the medical, surgical, or critical care wards. Agitation is common during hyperactive delirium, which poses a risk to themselves, other patients, or staff. Evidence for using oral or parenteral haloperidol from randomized controlled trials and published systematic reviews shows divergent findings, ranging from good response to no difference compared to placebo, despite its popularity in routine clinical use. We decided to perform an umbrella review of systematic reviews on the efficacy and safety of haloperidol in delirium. This protocol was registered with PROSPERO CRD42024502020. We searched PubMed, Ovid MEDLINE, and PsychINFO for systematic reviews with meta-analyses published in English only over the previous 20 years. These were searched under title, abstract, and Medical Subject Headings (MeSH) terms as applicable. We used Assessing the Methodological Quality of Systematic Reviews 2 to assess the quality of the articles. Ten systematic reviews were finally selected for review that focused on either preventing or treating delirium. The summary of results did not find that haloperidol is effective in preventing or treating delirium, though all included reviews found it a safe drug to use. Heterogeneity from I 2 statistics varied from a moderate to a high degree and may be attributable to population, outcomes, and setting variations. The authors conclude that there is limited evidence for haloperidol in preventing or treating delirium. Future studies must not aim to assess the resolution of delirium; instead, they must modify outcome measures, to mainly behavioral and psychiatric symptoms such as agitation, hallucinations, and persecutory delusions in delirium.

Delirium and Nursing in adults and older adults. Review of the literature

2025-06-18

Lucía Ruiz Rubio | Enfermería Cuidándote

Introduction: Delirium or confusional syndrome is a neurocognitive disorder with different symptomatology oriented towards cognitive alterations in consciousness and attention. New research is scarce, so there is a need for … Introduction: Delirium or confusional syndrome is a neurocognitive disorder with different symptomatology oriented towards cognitive alterations in consciousness and attention. New research is scarce, so there is a need for the present study, an update of knowledge on a relevant syndrome from the perspective of the nursing profession. General objective: To compile scientific knowledge on delirium applied to adults and the elderly from the nursing perspective, specifically seeking to study the triggering factors and the level of knowledge of nursing professionals. Methodology: A literature review study of the current scientific literature (last 5 years), divided into three stages. The literature search was conducted from December 2023 to February 2024. The databases used were Web of Science, ProQuest, Scopus and Cochrane Library Plus, with terms such as ‘Delirium AND aged’, among others. Results: 14 highly relevant articles were selected. The results show that the level of nurses' knowledge of delirium is insufficient in most of the studies. Triggering factors were found to vary greatly from study to study, with advanced age being repeatedly emphasised. Conclusion: The skills and knowledge of the nursing teams are scarce and at moderate or low levels, requiring specific educational reinforcement. Triggering factors include advanced age, dementia, systemic diseases and organ dysfunction, among many others.

Comparison of Propofol and Dexmedetomidine Infused Overnight to Treat Hyperactive and Mixed ICU Delirium: A Prospective Randomised Controlled Clinical Trial

2025-06-18

Stefan Zimmermann , Alexa Hollinger , Rita Achermann +7 more | Journal of Clinical Medicine

Delirium is a frequent yet pathophysiologically still poorly understood complication in the intensive care unit (ICU) and is associated with adverse outcomes for the patients. Currently, guidelines give several recommendations … Delirium is a frequent yet pathophysiologically still poorly understood complication in the intensive care unit (ICU) and is associated with adverse outcomes for the patients. Currently, guidelines give several recommendations for treating delirium in the ICU, but to date no sufficient drug treatment exists. Dexmedetomidine, primarily used for anesthesia and sedation in ICUs has shown a preventive effect of delirium compared to other sedatives, such as propofol. We hypothesize that overnight administration of dexmedetomidine may prevent and/or shorten the duration of delirium in ICU patients. The Basel propofol dexmedetomidine (BaProDex) Study was a single-center, prospective, randomized controlled trial. We included adult ICU patients with hyperactive or mixed delirium. Patients with delirium prior to ICU admission, advanced heart block, uncontrolled hypotension, or status epilepticus were excluded. The participants were randomly assigned 1:1 to either receive dexmedetomidine (study group) or propofol (control group) as a continuous infusion overnight. The Intensive Care Delirium Screening Checklist (ICDSC) was applied at least three times per day. Delirium was defined as an ICDSC ≥ 4. The study drug was administered until the end of delirium or ICU discharge. The primary endpoint was the time to delirium episode end, which was analyzed using cumulative incidence curves and a cause specific Cox proportional hazards regression with death as a competing risk. Secondary endpoints included recurrence of delirium until 28 days after ICU discharge, death until day 28, severity of ICU delirium, number of ventilation days, ICU length of stay (LOS) in hours, hospital length of stay in days and survival after three and twelve months after ICU discharge. Due to insufficient recruitment the trial needed to be stopped prematurely. In total, 38 patients were enrolled and randomized in the two groups. The median duration of delirium was shorter in the dexmedetomidine group as compared to the propofol group (ITT: 34 vs. 66 h; PP: 31 vs. 66 h), resulting in a hazard ratio of 1.92 (95% CI 0.89-4.15, p = 0.097) in the ITT and 2.95 (95% CI 1.27-6.86, p = 0.012) in the PP analysis. In the PP analysis, the 28-day mortality was lower in the dexmedetomidine group (1 vs. 5 deaths) and fewer patients needed ventilation (7 vs. 15 patients). Both ICU and hospital LOS were shorter in the dexmedetomidine group (ICU LOS: median 43 vs. 128 h; hospital LOS: median 12 vs. 22 days). Further, mortality up to three and twelve months was lower in the dexmedetomidine group compared to the propofol group (PP: 2 vs. 8 patients died within twelve months, 2 vs. 7 patients died within three months). The recurrence of delirium until 28 days after ICU discharge and severity of delirium were similar in both groups. Despite premature termination, BaProDex provides preliminary evidence for a reduction in the duration of delirium by nocturnal infusion of dexmedetomidine compared to propofol. Therefore, dexmedetomidine may be considered an option to treat hyperactive or mixed delirium in ICU patients. However, due to the small sample size, the study is rather of exploratory nature due to the premature termination, and we cannot rule out that the observed treatment effect is overly optimistic or by chance.

A Randomized Controlled Trial of a Post-ICU Telehealth Care Model (WFIT)

2025-06-18

Rita N. Bakhru , Lori Flores , Joanna M. Cain +7 more | American Journal of Respiratory and Critical Care Medicine

Survivors of critical illness are at high risk for poor long-term outcomes including readmissions, reduced quality of life, and mortality. A post-ICU telehealth care model may improve outcomes. We sought … Survivors of critical illness are at high risk for poor long-term outcomes including readmissions, reduced quality of life, and mortality. A post-ICU telehealth care model may improve outcomes. We sought to evaluate the cost-effectiveness and clinical efficacy of a post-ICU telehealth care model. We performed a single center randomized controlled trial of 400 ICU patients with sepsis and/or acute respiratory failure, who had ≤2 hospital admissions in the past year, and who were not admitted from or discharged to hospice, a skilled nursing facility or a long-term acute care hospital. The intervention group had scheduled telehealth visits at 1- and 2- weeks post-ICU discharge and as needed for six months with a clinician trained in post-ICU recovery. The primary outcome is cost-effectiveness of the intervention. Overall healthcare spending on ER visits and hospitalizations were a mean (SD, in USD) $7,801.10 (15,461.03) in the attention control group vs 8,086.50 (17,464.87) in the intervention group, with a calculated incremental net benefit of $1,958.29 (-$5,779.56, $9,696.14). ER visits to our health care system were the same between groups, but patient-reported ER visits to outside hospitals were different (0.97 per 100 patients per month in the attention control group vs 2.43 in the intervention group, p=0.03). Readmissions, mortality, quality of life scores and overall patient satisfaction scores were similar between groups. This randomized controlled trial of a post-ICU telehealth intervention demonstrated wide variation, but no clear incremental net benefit compared to standard care.

Handgrip and inspiratory muscle strength as surrogates for intensive care unit–acquired weakness: A prospective cohort study in Taiwan

2025-06-18

Meng‐Shan Wu , Shih-Chi Ku , Tyng‐Guey Wang +5 more | Australian Critical Care

The objective of this prospective cohort study was to investigate the incidence of intensive care unit (ICU)-acquired weakness (ICUAW) and compare handgrip strength (HGS) and inspiratory muscle strength, measured by … The objective of this prospective cohort study was to investigate the incidence of intensive care unit (ICU)-acquired weakness (ICUAW) and compare handgrip strength (HGS) and inspiratory muscle strength, measured by maximum inspiratory pressure (MIP), between critical illness survivors with and without ICUAW. Additionally, we examined whether HGS and MIP could serve as surrogate measures for ICUAW and establish reference cut-off values for both HGS and MIP in Taiwanese ICU survivors. A total of 274 ICU survivors aged ≥20 yrs without prior systemic weakness from six medical ICUs at a tertiary care hospital in Taiwan were consecutively enrolled. ICUAW was identified at the time of ICU discharge using standardised manual muscle testing based on the Medical Research Council scale. Simultaneously, HGS and MIP were assessed. A receiver operating characteristic curve analysis was performed to evaluate whether HGS and MIP could serve as surrogate markers for ICUAW and to establish their cut-off values. Among the 406 enrolled participants, 310 survived their ICU stay, and 274 completed the Medical Research Council test upon ICU discharge. The survivors were predominantly male (65.7%), with a median age of 70 years (interquartile range: 59-80). Acute respiratory failure was the leading cause of ICU admission (52.9%), and 60.2% of patients required mechanical ventilation during their ICU stay, with a median duration of 8 days (interquartile range: 3-8). ICUAW was identified in 23.0% of survivors. Fewer participants in the ICUAW group were able to complete HGS (87.1%) and MIP (45.2%) assessments, likely due to physical limitations. Compared with those without ICUAW, the ICUAW group was significantly older, had higher Acute Physiology and Chronic Health Evaluation scores at admission, required longer mechanical ventilation, had longer ICU stays, and displayed weaker HGS and lower MIP at ICU discharge. The receiver operating characteristic curve analysis demonstrated that both HGS and MIP served as promising surrogate markers with areas under the curve of 0.842 and 0.822, respectively, and optimal cut-offs of 10.9 kg-force for HGS and 22.5 cmH2O for MIP. Additionally, sex-specific cut-offs were also identified. HGS and MIP show promise as surrogate markers for ICUAW, with our ICU survivor cohort revealing comparable HGS and lower MIP cut-off values compared to previous recommendations. These results emphasise the importance of tailored cut-offs and screening approaches for different ethnic and geographic regions. Additionally, they provide preliminary reference values for ICU survivors in Taiwan and highlight the need for further studies in the region.

Incidence of delirium post cardiac surgery: Discrepancy between clinical observation, DOS scores, and single‑lead EEG

2025-06-18

Sophie Adelaars , Mariska te Pas , Steffy W. M. Jansen +5 more | Journal of Clinical Anesthesia

Postoperative delirium (POD) is a common complication after cardiac surgery, associated with increased morbidity, mortality, prolonged hospitalization, and cognitive decline. Early and accurate diagnosis is crucial, but current methods like … Postoperative delirium (POD) is a common complication after cardiac surgery, associated with increased morbidity, mortality, prolonged hospitalization, and cognitive decline. Early and accurate diagnosis is crucial, but current methods like the Delirium Observation Screening (DOS) scale rely on subjective assessments. Single‑lead EEG (sl-EEG), particularly the DeltaScan Brainstate Monitor, offers a more objective approach. This study compares the incidence of delirium detected by clinical observation, DOS scores, and single‑lead EEG scores in patients undergoing aortic valve replacement (AVR) surgery. This prospective cohort study included 50 patients aged 65 or older scheduled for AVR surgery. Delirium was assessed preoperatively and on postoperative days 1, 3, and 7 using clinical observation, DOS, and single‑lead EEG. Incidence rates were calculated, and the McNemar's Chi-squared test was used to assess differences between methods. Delirium incidence varied widely by method: 32 % by clinical assessment, 28 % by DOS, and 76 % by single‑lead EEG. Clinical assessment and DOS had an 80 % concordance, while single‑lead EEG detected significantly more cases (p < 0.001). Incidence declined across all methods over seven postoperative days. Our findings reveal significant discrepancies in POD detection rates by diagnostic methods. The high sensitivity of sl-EEG suggests a risk of false positives, while clinical assessment and DOS may risk underdiagnosis, especially in hypoactive delirium. An integrated diagnostic approach combining multiple methods may improve accuracy and capture the full spectrum of delirium symptoms. Future studies should refine these tools and explore advanced technologies to develop reliable, easily deployable diagnostics for clinical practice.

Guide til ettersamtale med tidligere intensivpasienter

2025-06-18

Sofie Lykke Herbro Gjems , Maria Wang Mikkelsen | iNSPIRA

En samtale med intensivsykepleier etter utskrivelse (ettersamtale) kan bidra til å reparere og forebygge intensivrelaterte plager for pasienten. Vi har utarbeidet en semistrukturert samtaleguide for ettersamtale med tidligere voksne intensivpasienter … En samtale med intensivsykepleier etter utskrivelse (ettersamtale) kan bidra til å reparere og forebygge intensivrelaterte plager for pasienten. Vi har utarbeidet en semistrukturert samtaleguide for ettersamtale med tidligere voksne intensivpasienter som hjelpemiddel for intensivsykepleieren. Hensikten med samtaleguiden er å møte de ulike opplevelsene pasienten sitter igjen med etter intensivoppholdet sitt, samt at intensivpersonell kan ta lærdom av pasientens opplevelser som kan føre til endring av eksisterende praksis. Samtaleguiden ble tatt i bruk av to ulike intensivavdelinger, og denne artikkelen beskriver hvordan intensivsykepleiere ved disse avdelingene opplevde å bruke samtaleguiden i ettersamtalene. ENGLISH ABSTRACT The number of patients surviving critical illness has increased with advancements in medicine. Once discharged, approximately half of the patients will be suffering from post-intensive care syndrome. Measures to address these problems are being developed. One of the measures is a conversation with intensive care personnel scheduled some time after discharge. To systematize such a conversation, this project has designed an conversation guide for this purpose. The conversation guide is experienced as a useful tool for intensive care nurses, but it requires further experience to determine whether it functions optimally.

A novel short-course, low-intensity blood-flow-restricted exercise (BFRE) regimen to study satellite cell function in critical illness survivors with sustained muscle atrophy following intensive care unit-acquired weakness (ICUAW)

2025-06-18

Sunita Mathur , Nathalia Parente de Sousa Maia , Manoela de Paula Ferreira +6 more | Frontiers in Physiology

Introduction ICU-acquired weakness (ICUAW) develops in critically ill patients and can persist after hospital discharge, resulting in physical disability. Decreased satellite cell content is reported in the atrophic muscle of … Introduction ICU-acquired weakness (ICUAW) develops in critically ill patients and can persist after hospital discharge, resulting in physical disability. Decreased satellite cell content is reported in the atrophic muscle of critical illness survivors, suggesting that the sustained muscle wasting results from satellite cell dysfunction and impaired muscle regeneration. Intense resistance exercise stimulates satellite cell proliferation and can be used to study the satellite cell role in persisting muscle atrophy following ICU discharge; however, the intensity of exercise required can be intolerable for older or frail ICU survivors. This study tested the capacity of a novel low-intensity, short-duration blood-flow-restricted exercise (BFRE) regimen, designed to accommodate the physical exercise limitations of critical illness survivors, to stimulate the satellite cell. Methods Eight healthy controls (five men, three women, ages 20–64 years) underwent five consecutive daily sessions of quadriceps BFRE consisting of eight sets of eight knee extensions at 30% isometric peak torque followed by imaging and vastus lateralis (VL) biopsy to determine the quadriceps’ size, strength, VL satellite cell content, and transcript expression levels of regulators of muscle proteolysis, autophagy, and myogenic regulatory factors pre- and post-BFRE training. The BFRE regimen was piloted in three ICUAW survivors (ages 54–62 years) 5 years post-ICU discharge. Results All study participants tolerated and completed the BFRE regimen. In controls, satellite cell content and MuRF1 transcript expression were significantly higher (1.53 ± 0.30- and 1.34 ± 0.31-fold difference, respectively) and myostatin transcript expression was significantly lower (0.58 ± 0.31-fold difference) in BFRE-trained versus untrained VL. Two survivors with low quadriceps mass compared to sex- and age-matched population-based norms and study controls showed no difference in satellite cell content in trained vs. untrained VL. In the survivor with quadriceps mass comparable to population norms and controls, satellite cell content was higher in the BFRE-trained versus untrained VL. Conclusion This study demonstrates that training with a novel short-duration, low-intensity BFRE regimen results in higher satellite cell content in healthy muscle and can be completed by ICUAW survivors. Pilot data suggest that sustained satellite cell dysfunction may impede muscle mass reconstitution after ICU discharge.

Mortality Predictors in Stroke Patients Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study

2025-06-18

В. И. Ершов , А. А. Белкин , В. И. Горбачев +7 more | Journal of Intensive Care Medicine

Background Patients with acute severe stroke requiring mechanical ventilation represent a significant clinical challenge. Identification of mortality predictors is necessary to improve outcomes. Methods Fourteen hospitals located around Russia participated … Background Patients with acute severe stroke requiring mechanical ventilation represent a significant clinical challenge. Identification of mortality predictors is necessary to improve outcomes. Methods Fourteen hospitals located around Russia participated in this prospective multicenter observational clinical study. Patients admitted to ICU between November 1, 2017, and November 1, 2019 with confirmed cerebral stroke, aged 18 to 90 years, and requiring mechanical ventilation were included. The impact of various clinical factors on mortality during the 28-day period after stroke was assessed. Results A total of 1289 patients were included in the registry, and 1144 met the study criteria. The 28-day mortality rate for stroke patients on mechanical ventilation was 64.3%. The most common indications for mechanical ventilation were impaired consciousness (75.7%) and hypoxemia (60.9%). In the cohort of strokes with NIHSS severity greater than 20 points, hypoxemia at the start of ventilation (OR 1.85 [1.21; 2.81], P = 0.004) and the use of hyperventilation mode (OR 1.46 [1.02; 2.06], P = 0.0336) were associated with increased mortality. Pressure-controlled mode as the primary ventilation method (OR 0.36 [0.21; 0.60], P < 0.001) and ICP monitoring (OR 0.23 [0.12; 0.44], P < 0.001) were associated with decreased mortality. Infectious complications were associated with longer mechanical ventilation and ICU stay (P < 0.001). The relationship between probable mortality and the severity of neurological deficit on the NIHSS scale at the start of mechanical ventilation is non-linear. A critical threshold was reached at 16 points NIHSS, where a trend of increasing probable mortality emerged. Conclusion The identified predictors of mortality in stroke patients requiring mechanical ventilation are essential for decision-making in this cohort. They include hypoxemia, hyperventilation (used to control intracranial hypertension), volume-controlled (VC) versus pressure-controlled (PC) initial ventilation, and the use of clinical methods for monitoring ICP alone versus invasive monitoring.

A Systematic Review of Transitional Care Visits After Critical Illness

2025-06-17

Johnny L. Isenberger , Dawn Carpenter , Alexander Menard +2 more | The Journal for Nurse Practitioners

Agitation control with clonidine and haloperidol in critically ill patients: A retrospective analysis

2025-06-17

Lisa Smit , Mathieu van der Jagt , Sandra M.A. Dijkstra‐Kersten +2 more | Journal of Critical Care

To investigate the effects of clonidine and haloperidol on ICU agitation control. This cohort study included mixed ICU patients with at least one agitation episode (Richmond Agitation Sedation Scale [RASS] … To investigate the effects of clonidine and haloperidol on ICU agitation control. This cohort study included mixed ICU patients with at least one agitation episode (Richmond Agitation Sedation Scale [RASS] score > 1) treated with clonidine and/or haloperidol. Primary outcome was agitation control (-2 ≤ target RASS score ≤ 1) within six hours of medication administration, using propensity score matching and Markov multinomial logistic regression. We further explored associations with concomitant medication. We analyzed 510 agitation episodes in 247 patients, with 273 (54 %) receiving clonidine only, 88 (17 %) haloperidol only, and 149 (29 %) both. Neither haloperidol only (OR 1.00, 95 %CI 0.57 to 1.76) nor administration of both medications (OR 0.83, 95 %CI 0.52 to 1.32) showed improved agitation control compared to clonidine only. Haloperidol only (adjusted difference - 44.8 mg, 95 %CI -89.1 to -0.5 mg) and both clonidine and haloperidol (adjusted difference - 48.4 mg, 95 %CI -85.6 to -11.1 mg) was associated with reduced propofol usage compared to clonidine only. Treatment with both clonidine and haloperidol was associated with lower opioid usage (adjusted difference - 52.3 mg, 95 %CI -93 to -11.7 mg). There was no difference in benzodiazepine administration. This study found no difference in agitation control among ICU patients treated with clonidine, haloperidol or both.

Muscle weakness after critical illness: unravelling biological mechanisms and clinical hurdles

2025-06-17

Alexandre Pierre , Raphaël Favory , Claire Bourel +4 more | Critical Care

Abstract Survivors of intensive care unit (ICU) are increasingly numerous because of better hospital care. However, several consequences of an ICU stay, known as post-intensive care syndrome, worsen long-term prognoses. … Abstract Survivors of intensive care unit (ICU) are increasingly numerous because of better hospital care. However, several consequences of an ICU stay, known as post-intensive care syndrome, worsen long-term prognoses. A predominant feature in survivors is reduced muscle strength, mass, and physical function. This leads to lower exercise capacity, long-lasting physical disability, higher mortality risk, and subsequent health costs. While ICU-acquired muscle weakness has been extensively studied these past decades, underlying mechanisms of post-ICU muscle weakness remain poorly understood, and there is still no evidence-based treatment for improving long-term physical outcomes. One hypothesis, among others, could be that the pathophysiology is dynamic over time, differing between the acute ICU and post-ICU recovery periods. This narrative review aims to address the clinical, physiological and biological determinants of persistent muscle dysfunction in ICU survivors, with particular attention to the molecular, cellular and systemic mechanisms involved. Specifically, pre-ICU health factors such as obesity and sarcopenia, ICU-related complications and treatments, and post-ICU management all influence recovery. Dysfunctions in the neuroendocrine, vascular, neurological, and muscle systems contribute as physiological determinants of the muscle weakness. Complex and multifaceted biological mechanisms drive the post-ICU muscle dysfunction with mitochondrial and autophagy dysfunction, epigenetic modifications, cellular senescence, muscle inflammation with altered cell–cell communication, including dysfunction of immune cells, stem cell exhaustion and extracellular matrix remodelling. The review also sheds light on new and innovative therapeutic approaches and discusses future research directions. Emphasis is placed on the potential for multi-approach treatments that integrate nutritional, physical, and biological interventions. Addressing these aspects in a holistic and dynamic manner, from ICU to post-ICU phases, may provide avenues for mitigating the long-term burden of muscle weakness and physical disability in ICU survivors.

Regional Cerebral Blood Flow Increase After Transcatheter Aortic Valve Replacement Is Related to Cardiac Output but Is Not Associated with Delirium: An Observational Cohort Study Using Transcranial Indocyanine Green Dye Dilution Technique

2025-06-17

Maximilian Oremek , P. Nowotny , Sebastian Zimmer +6 more | Journal of Clinical Medicine

Background: Despite the success of transcatheter aortic valve repair (TAVR) over the past years, its impact on global and cerebral hemodynamics remains largely unexplored. Changes in cerebral blood flow may … Background: Despite the success of transcatheter aortic valve repair (TAVR) over the past years, its impact on global and cerebral hemodynamics remains largely unexplored. Changes in cerebral blood flow may be associated with delirium, which may occur in 26 to 29% of cases. We aimed to examine the relationships between global hemodynamic parameters and cerebral parameters in patients who underwent TAVR and their impact on postinterventional delirium. Methods: Patients scheduled for TAVR were enrolled after obtaining written informed consent. Patients received light sedation according to standard procedures. Cerebral blood flow (CBF) was measured with a noninvasive near-infrared spectroscopy-based method using intravenous indocyanine green injection. CBF measurements were taken at the beginning of the TAVR procedure and after the valve was in place. Patients were screened for delirium using CAM-ICU and NuDESC tests before and after intervention. Results: A total of 52 of 60 patients remained for analysis. Thirteen patients (25%) developed delirium. Mean arterial pressure (MAP) remained unchanged, while cardiac output increased after TAVR by 44%. CBF also increased after TAVR. No significant difference was observed in CBF changes between the groups with and without delirium. A linear mixed model analysis revealed a linear relationship between CO and CBF but not between MAP and CBF. In an exploratory analysis, decreased cerebral oxygenation and increased deoxygenated hemoglobin, as measured by NIRS after TAVR, were associated with delirium. Conclusions: The results confirm that CO is an independent factor in CBF, while CBF changes per se are not linked to delirium. However, we found a mismatch between CBF and regional cerebral parameters, which may reflect cerebral metabolism and its relation to the development of delirium. This remains to be confirmed by further studies.

Die neurologisch-neurochirurgische Frührehabilitation im deutschen Gesundheitssystem

2025-06-17

Thomas Platz , Christian Dohle , Anna Gorsler +3 more | DGNeurologie

<scp>FKBP5</scp> Mediates Alveolar Fibroblast Necroptosis During Acute Respiratory Distress Syndrome

2025-06-17

Dong Zhang , Wei Liu , Ting Sun +7 more | Cell Proliferation

ABSTRACT The inflammatory storm is a hallmark of acute respiratory distress syndrome (ARDS), yet effective therapies remain unavailable. FK506‐binding protein 51 (FKBP5) has emerged as a regulator of inflammatory responses. … ABSTRACT The inflammatory storm is a hallmark of acute respiratory distress syndrome (ARDS), yet effective therapies remain unavailable. FK506‐binding protein 51 (FKBP5) has emerged as a regulator of inflammatory responses. In this study, FKBP5 expression was markedly increased in patients with sepsis and correlated with both cytokine levels and disease severity. Using sepsis‐induced ARDS models in Fkbp5 −/− and bone marrow chimeric mice, this study demonstrated that non‐haematopoietic FKBP5 mitigates inflammatory injury. Single‐cell transcriptomic analysis identified fibroblasts and epithelial cells as the primary sources of non‐haematopoietic FKBP5 in the lung injury. Conditional deletion of FKBP5 in fibroblasts ( Col1a2 ‐iCre Fkbp5 flox/flox ) confirmed the essential role of fibroblast FKBP5 in the inflammatory response during ARDS. Mechanistically, FKBP5‐mediated necroptosis of alveolar fibroblasts triggered NF‐κB activation, proinflammatory cytokine release, neutrophil recruitment, and the establishment of an inflammatory microenvironment in alveolar epithelial tissue. These findings suggest a potential therapeutic strategy targeting fibroblast FKBP5 and provide a foundation for future clinical investigation in ARDS management.

Commentary on: Catecholamines in Sepsis: Pharmacological Insights and Clinical Applications – A Narrative Review

2025-06-16

Jacopo Belfiore | Journal of Anesthesiology and Pain Therapy

The review by Belfiore et al. offers a comprehensive examination of catecholamine pharmacology and clinical application in septic shock, emphasizing their cardiovascular, metabolic, immunomodulatory, and endothelial effects. The authors highlight … The review by Belfiore et al. offers a comprehensive examination of catecholamine pharmacology and clinical application in septic shock, emphasizing their cardiovascular, metabolic, immunomodulatory, and endothelial effects. The authors highlight the dual role of catecholamines, which are essential for hemodynamic support yet capable of exacerbating sepsis through immune dysregulation and endothelial dysfunction. Key topics include catecholamine refractoriness, β2-adrenergic immunomodulation, corticosteroid synergy, and endothelial permeability. While the review provides a robust mechanistic framework and updates classical knowledge with recent immunologic and metabolic insights, future research directions are identified. These include expanding vasoactive strategies, advancing precision medicine approaches, investigating metabolic consequences, addressing catecholamine-resistant shock, and developing endothelial-targeted therapies. Overall, the review is a valuable resource for critical care clinicians, though further integration of individualized therapeutic strategies and broader exploration of emerging treatments would enhance future discourse.