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

Critical Care Medicine, Journal Year: 2012, Volume and Issue: 41(1), P. 263 - 306

Published: Dec. 24, 2012

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

Language: Английский

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Interventions for preventing delirium in hospitalised non-ICU patients

Cochrane library, Journal Year: 2016, Volume and Issue: 2016(3)

Published: March 11, 2016

Language: Английский

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Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure

International Journal of Geriatric Psychiatry, Journal Year: 2017, Volume and Issue: 33(11), P. 1428 - 1457

Published: Dec. 26, 2017

Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and medically ill best characterized 5 core domains: cognitive deficits, attentional circadian rhythm dysregulation, emotional alteration in psychomotor functioning.An extensive literature review consolidation of published data into a novel interpretation known pathophysiological causes delirium.Available suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On basis an search, newly proposed theory, systems integration failure hypothesis, was developed to bring together salient previously described theories, describing various contributions from complex web pathways-highlighting areas intersection commonalities explaining how variable contribution these lead development behavioral dysfunctions characteristic delirium. The specific manifestations delirium picture result combination neurotransmitter function availability, variability processing sensory information, motor responses both external internal cues, degree breakdown neuronal network connectivity, hence term acute brain failure.The hypothesis attempts explain pathophysiologic theories interact other, causing clinically observed phenotypes. A better understanding underlying pathophysiology eventually assist designing prevention management approaches.

Language: Английский

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Sleep Deprivation in Critical Illness

Journal of Intensive Care Medicine, Journal Year: 2011, Volume and Issue: 27(2), P. 97 - 111

Published: Jan. 10, 2011

Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity time spent in restorative sleep stages. Factors that are associated with disruption the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient interactions, environmental noise light. As field critical increasingly focuses on patients’ physical psychological outcomes following illness, understanding potential contribution ICU-related recovery is an important area investigation. This review article summarizes literature regarding architecture measurement critically ill, causes ICU fragmentation, implications from illness. With this background information, strategies to optimize also discussed.

Language: Английский

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The Effect of a Quality Improvement Intervention on Perceived Sleep Quality and Cognition in a Medical ICU*

Critical Care Medicine, Journal Year: 2013, Volume and Issue: 41(3), P. 800 - 809

Published: Jan. 11, 2013

Objectives: To determine if a quality improvement intervention improves sleep and delirium/cognition. Design: Observational, pre–post design. Setting: A tertiary academic hospital in the United States. Patients: 300 medical ICU patients. Interventions: This ICU-wide project involved “usual care” baseline stage, followed by stage incorporating multifaceted sleep-promoting interventions implemented with aid of daily reminder checklists for staff. Measurements Main Results: Primary outcomes were perceived noise ratings (measured on 0–100 scale using valid reliable Richards–Campbell Sleep Questionnaire) delirium/coma-free days. Secondary included length stay mortality. Post-ICU measures cognition evaluated an patient subset. During stages, there 122 178 patients, respectively, more than one night ICU, accounting 634 826 patient-days. Within groups, 78 (63.9%) 83 (46.6%) patients received mechanical ventilation. Over patient-day period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis vs. improvements overall Richards-Campbell Questionnaire did not reach statistical significance, but significant (mean ± SD: 65.9±26.6 60.5±26.3, p = 0.001), incidence delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23–0.89; 0.02), status 1.64; 1.04–2.58; 0.03). Improvements secondary post-ICU significance. Conclusions: An improve delirium is feasible associated nighttime noise, delirium/coma, status. Improvement

Language: Английский

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Symptoms experienced by intensive care unit patients at high risk of dying*

Critical Care Medicine, Journal Year: 2010, Volume and Issue: 38(11), P. 2155 - 2160

Published: Aug. 13, 2010

To provide a focused, detailed assessment of the symptom experiences intensive care unit patients at high risk dying and to evaluate relationship between delirium patients' reports.Prospective, observational study symptoms.Two units in tertiary medical center western United States.One hundred seventy-one dying.None.Patients were interviewed every other day for up 14 days. Patients rated presence, intensity (1 = mild; 2 moderate; 3 severe), distress not very distressing; moderately distressing) ten symptoms (that is, pain, tired, short breath, restless, anxious, sad, hungry, scared, thirsty, confused). The Confusion Assessment Method-Intensive Care Unit was used ascertain presence delirium. A total 405 assessments completed by 171 patients. Patients' average age 58 ± 15 yrs; 64% males. mechanically ventilated during 34% assessments, 22% died hospital. Symptom prevalence ranged from 75% (tired) 27% (confused). Thirst intense, shortness confusion, pain distressful. Delirium found 34.2% 152 who could be evaluated. Delirious more acutely ill received significantly higher doses opioids. likely report feeling confused (43% vs. 22%, p .004) sad (46% 31%, .04) less being tired (57% 77%, .006) than nondelirious patients.Study findings suggest that unrelieved distressing are present majority patients, including those with high-risk may lead focused interventions avoid or minimize unnecessary suffering.

Language: Английский

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Melatonin decreases delirium in elderly patients: A randomized, placebo‐controlled trial

International Journal of Geriatric Psychiatry, Journal Year: 2010, Volume and Issue: 26(7), P. 687 - 694

Published: Sept. 15, 2010

Abstract Background Disturbance in the metabolism of tryptophan and tryptophan‐derived compounds (e.g., melatonin) may have a role pathogenesis delirium. Objective To evaluate efficacy low dose exogenous melatonin decreasing Design A randomized, double‐blinded, placebo‐controlled study. Setting An Internal Medicine service tertiary care centre London, Ontario, Canada. Participants 145 individuals aged 65 years or over admitted through emergency department to medical unit hospital. Intervention Patients were randomized receive either 0.5 mg placebo every night for 14 days until discharge. Measurements The primary outcome was occurrence delirium as determined by Confusion Assessment Method (CAM) criteria. Results Of total (mean age (standard deviation): 84.5 (6.1) years) 72 randomly assigned group 73 group. Melatonin associated with lower risk (12.0% vs . 31.0%, p = 0.014), an odds ratio (OR), adjusted dementia co‐morbidities 0.19 (95% confidence intervals (CI): 0.06–0.62). not different when patients prevalent excluded. Limitation intention treat analysis possible due loss follow‐up. Conclusion Exogenous administered nightly elderly acute represent potential protective agent against Copyright © 2010 John Wiley & Sons, Ltd.

Language: Английский

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Dexmedetomidine: new insights

European Journal of Anaesthesiology, Journal Year: 2010, Volume and Issue: 28(1), P. 3 - 6

Published: Sept. 25, 2010

Dexmedetomidine is a potent alpha-2-adrenergic agonist, more selective than clonidine, with widespread actions on the mammalian brain that include sedation, anaesthetic-sparing, analgesia and sympatholytic properties. A large body of recent work supports its favourable profile in improving outcome long-term function critically ill. The source these benefits may lie neuroprotective properties are seen experimental models clinical setting, which it can attenuate delirium, preserve sleep architecture, ventilatory drive decrease sympathetic tone inflammatory response. also be valuable adjuvant when regional anaesthesia used. Future research should aim at establishing risk/benefit ratio used bedside.

Language: Английский

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Protecting the Melatonin Rhythm through Circadian Healthy Light Exposure

International Journal of Molecular Sciences, Journal Year: 2014, Volume and Issue: 15(12), P. 23448 - 23500

Published: Dec. 17, 2014

Currently, in developed countries, nights are excessively illuminated (light at night), whereas daytime is mainly spent indoors, and thus people exposed to much lower light intensities than under natural conditions. In spite of the positive impact artificial light, we pay a price for easy access during night: disorganization our circadian system or chronodisruption (CD), including perturbations melatonin rhythm. Epidemiological studies show that CD associated with an increased incidence diabetes, obesity, heart disease, cognitive affective impairment, premature aging some types cancer. Knowledge retinal photoreceptors discovery melanopsin ganglion cells demonstrate intensity, timing spectrum must be considered keep biological clock properly entrained. Importantly, not all wavelengths equally chronodisrupting. Blue which particularly beneficial daytime, seems more disruptive night, induces strongest inhibition. Nocturnal blue exposure currently increasing, due proliferation energy-efficient lighting (LEDs) electronic devices. Thus, development systems preserve rhythm could reduce health risks induced by chronodisruption. This review addresses state art regarding crosstalk between system.

Language: Английский

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Prevention and Management of Delirium in the Intensive Care Unit

Seminars in Respiratory and Critical Care Medicine, Journal Year: 2020, Volume and Issue: 42(01), P. 112 - 126

Published: Aug. 3, 2020

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It associated with increased morbidity and mortality, longer lengths stay, higher hospital costs, cognitive impairment that persists long after discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, premorbid dementia. Precipitating respiratory failure shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, sedatives adverse environmental conditions impairing vision, hearing, sleep. Historically, antipsychotic medications were mainstay delirium treatment critically ill. Based on more recent literature, current Society Critical Care Medicine (SCCM) guidelines suggest against routine use antipsychotics for ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation their impact not yet clear. Nonpharmacologic thus remain cornerstone management. This approach summarized ABCDEF bundle (Assess, prevent, manage pain; Both SAT SBT; Choice analgesia sedation; Delirium: assess, manage; Early mobility exercise; Family engagement empowerment). The implementation this reduces odds developing chances needing there challenges to its implementation. There an urgent need ongoing studies effectively mitigate risk better understand pathobiology underlying ICU so as identify additional potential treatments. Further refinements therapeutic options, from drugs rehabilitation, areas ripe study improve short- long-term outcomes patients delirium.

Language: Английский

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