Neuromonitoring of Delirium with Quantitative Pupillometry in Sedated Mechanically Ventilated Critically Ill Patients

Abstract Background. Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods. This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 hours. Starting at day 3, automated infrared pupillometry – blinded to ICU caregivers – was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/sec). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results. A total of 59/100 patients had ICU delirium, diagnosed at a median 8 days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/sec) at day 3, and at all additional time-points tested (p<0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p=0.03). Conclusions. Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

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Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

10.21203/rs.2.19734/v2 ◽

2020 ◽

Author(s):

Eva Favre ◽

Adriano Bernini ◽

Paola Morelli ◽

Jerôme Pasquier ◽

John-Paul Miroz ◽

...

Keyword(s):

Mechanical Ventilation ◽

Brain Injury ◽

Critically Ill ◽

Critically Ill Patients ◽

Potential Utility ◽

Icu Patients ◽

Mechanically Ventilated ◽

Increased Risk ◽

Infrared Pupillometry ◽

Icu Delirium

Abstract Background. Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods. This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 hours. Starting at day 3, automated infrared pupillometry – blinded to ICU caregivers – was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/sec). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results. A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/sec) at day 3, and at all additional time-points tested ( p <0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p =0.03). Conclusions. Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

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Etiology, incidence, and outcomes of patient–ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation

Scientific Reports ◽

10.1038/s41598-021-90013-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Yongfang Zhou ◽

Steven R. Holets ◽

Man Li ◽

Gustavo A. Cortes-Puentes ◽

Todd J. Meyer ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Surgical Intensive Care ◽

Mechanically Ventilated ◽

History Of ◽

Training Background ◽

The Relationship

AbstractPatient–ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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Selection strategy for sedation depth in critically ill patients on mechanical ventilation

BMC Medical Informatics and Decision Making ◽

10.1186/s12911-021-01452-7 ◽

2021 ◽

Vol 21 (S2) ◽

Author(s):

Longxiang Su ◽

Chun Liu ◽

Fengxiang Chang ◽

Bo Tang ◽

Lin Han ◽

...

Keyword(s):

Mechanical Ventilation ◽

Dimensionality Reduction ◽

Critically Ill ◽

Critically Ill Patients ◽

Latent Profile Analysis ◽

Profile Analysis ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Sedation And Analgesia ◽

Ventilated Patients

Abstract Background Analgesia and sedation therapy are commonly used for critically ill patients, especially mechanically ventilated patients. From the initial nonsedation programs to deep sedation and then to on-demand sedation, the understanding of sedation therapy continues to deepen. However, according to different patient’s condition, understanding the individual patient’s depth of sedation needs remains unclear. Methods The public open source critical illness database Medical Information Mart for Intensive Care III was used in this study. Latent profile analysis was used as a clustering method to classify mechanically ventilated patients based on 36 variables. Principal component analysis dimensionality reduction was used to select the most influential variables. The ROC curve was used to evaluate the classification accuracy of the model. Results Based on 36 characteristic variables, we divided patients undergoing mechanical ventilation and sedation and analgesia into two categories with different mortality rates, then further reduced the dimensionality of the data and obtained the 9 variables that had the greatest impact on classification, most of which were ventilator parameters. According to the Richmond-ASS scores, the two phenotypes of patients had different degrees of sedation and analgesia, and the corresponding ventilator parameters were also significantly different. We divided the validation cohort into three different levels of sedation, revealing that patients with high ventilator conditions needed a deeper level of sedation, while patients with low ventilator conditions required reduction in the depth of sedation as soon as possible to promote recovery and avoid reinjury. Conclusion Through latent profile analysis and dimensionality reduction, we divided patients treated with mechanical ventilation and sedation and analgesia into two categories with different mortalities and obtained 9 variables that had the greatest impact on classification, which revealed that the depth of sedation was limited by the condition of the respiratory system.

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Intra-Abdominal Pressure as a Marker of Enteral Nutrition Intolerance in Critically Ill Patients. The PIANE Study

Nutrients ◽

10.3390/nu11112616 ◽

2019 ◽

Vol 11 (11) ◽

pp. 2616

Author(s):

M Bordejé ◽

Juan Montejo ◽

M Mateu ◽

Manuel Solera ◽

Jose Acosta ◽

...

Keyword(s):

Mechanical Ventilation ◽

Enteral Nutrition ◽

Critically Ill ◽

Critically Ill Patients ◽

Urinary Catheter ◽

Abdominal Pressure ◽

Icu Patients ◽

Group A ◽

Group B ◽

Low Sensitivity

To determine whether elevated intra-abdominal pressure (IAP) is associated with a higher rate of enteral nutrition-related gastrointestinal (GI) complications; to assess the value of IAP as a predictor of enteral nutrition (EN) intolerance. Intensive Care Unit (ICU) patients on mechanical ventilation requiring at least 5 days of EN were recruited for a prospective, observational, non-interventional, multicenter study. EN was performed and GI complications were managed with an established protocol. IAP was determined via a urinary catheter. Patients who developed any GI complications were considered as presenting EN intolerance. Variables related to EN, IAP and GI complications were monitored daily. Statistical analysis compared patients without GI complications (group A) vs. GI complications (group B). 247 patients were recruited from 28 participating ICUs (group A: 119, group B: 128). No differences between groups were recorded. Patients in group B (p < 0.001) spent more days on EN (8.1 ± 8.4 vs. 18.1 ± 13.7), on mechanical ventilation (8.0 ± 7.7 vs. 19.3 ± 14.9) and in the ICU (12.3 ± 11.4 vs. 24.8 ± 17.5). IAP prior to the GI complication was (14.3 ± 3.1 vs. 15.8 ± 4.8) (p < 0.003). The best IAP value identified for EN intolerance was 14 mmHg but it had low sensitivity and specificity. Although a higher IAP was associated with EN intolerance, IAP alone did not emerge as a good predictor of EN intolerance in critically ill patients.

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Effect of sedatives on in-hospital and long-term mortality of critically ill patients requiring extended mechanical ventilation for more than 48 hours

10.21203/rs.2.19879/v1 ◽

2020 ◽

Author(s):

Hannah Lee ◽

Seongmi Choi ◽

Eun Jin Jang ◽

Juhee Lee ◽

Dalho Kim ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Significant Risk ◽

Population Based ◽

Case Volume ◽

Increased Risk ◽

Benzodiazepine Use ◽

Comorbidity Index ◽

One Year

Abstract Background The purpose of this study was to assess the correlation between sedatives and mortality in critically ill patients who required mechanical ventilation (MV) for ≥48 hours from 2007 to 2016.Methods We conducted a nationwide retrospective cohort study using population-based healthcare reimbursement claims database. : Data from adult patients (aged ≥18) who underwent MV for ≥48 hours between 2008 and 2016 were identified and extracted from the National Health Insurance Service database. The benzodiazepine group consisted of patients who were administered benzodiazepines for sedation during MV. All other patients were assigned to the non-benzodiazepine group.Results A total of 158,712 patients requiring MV for ≥48 hours were admitted in 55 centers in Korea from 2007 to 2016. The benzodiazepine group had significantly higher in-hospital and one-year mortality compared to the non-benzodiazepine group (37.0% vs. 34.3%, 55.0% vs. 54.4%, respectively). Benzodiazepine use decreased from 2008 to 2016, after adjusting for age, sex, and mean Elixhauser comorbidity index in the Poisson regression analysis (incidence rate ratio, 0.968; 95% CI 0.954–0.983; p < 0.001) whereas dexmedetomidine sales have continuously increased since the second half of 2010. Benzodiazepine use, older age, lower case volume (≤500 cases/year), chronic kidney disease, and higher Elixhauser comorbidity index were common significant risk factors for in-hospital and one-year mortality.Conclusion In critically ill patients undergoing MV for >48 hours, the use of benzodiazepines for sedation was associated with an increased risk of in-hospital mortality and one-year mortality.

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EEG characteristics of mechanically ventilated critically ill patients at high risk of delirium

10.21203/rs.3.rs-133536/v1 ◽

2020 ◽

Author(s):

E. Eskioglou ◽

C. Iaquaniello ◽

V. Alvarez ◽

S. Rüegg ◽

K. Schindler ◽

...

Keyword(s):

High Risk ◽

Critically Ill ◽

Critically Ill Patients ◽

Epileptiform Activity ◽

Burst Suppression ◽

Altered Consciousness ◽

Periodic Patterns ◽

Mechanically Ventilated ◽

Icu Delirium ◽

New Onset

Abstract Background Neurophysiological exploration of ICU delirium is limited. Here, we examined EEG characteristics of medical-surgical critically ill patients with new onset altered consciousness state at high risk for ICU delirium. Methods Pre-planned analysis of non-neurological mechanically ventilated medical-surgical ICU subjects, who underwent a prospective multicenter randomized, controlled EEG study (NCT03129438, April 2017-November 2018). EEG characteristics, according to the 2012 ACNS nomenclature, included background activity, rhythmic periodic patterns/epileptic activity, amplitude, frequency, stimulus-induced discharges, triphasic waves, reactivity and NREM sleep. We explored EEG findings in delirious vs. non-delirious patients, specifically focusing on presence of burst-suppression and rhythmic periodic patterns (ictal-interictal continuum), and epileptiform activity (ictal EEG). Results We analyzed 91 patients (median age, 66 years) who underwent EEG because of new onset altered consciousness state at a median 5 days from admission; 42 patients developed delirium (46%). Burst-suppression (10 vs. 0%, p = 0.02), rhythmic/periodic patterns (43% vs. 22%, p = 0.03) and epileptiform activity (7 vs. 0%, p = 0.05) were more frequent in delirious vs. non-delirious patients. The presence of at least one of these abnormal EEG findings (32/91 patients; 35%) was associated with a significant increase in the likelihood of delirium (42 vs. 15%, p = 0.006). Cumulative dose of sedatives and analgesics, as well as all other EEG characteristics, did not differ significantly between the two groups. Conclusion In mechanically ventilated non-neurological critically ill patients with new onset alteration of consciousness, EEG showing burst-suppression and/or ictal-interictal continuum findings indicates a higher risk of ICU delirium, independently of sedation and analgesia.

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Non-cardio respiratory monitoring of mechanically ventilated critically ill patients

Anaesthesia, Pain & Intensive Care ◽

10.35975/apic.v22i1.1108 ◽

2019 ◽

pp. S150-S159

Author(s):

Chinmaya Kumar Panda ◽

Habib Mohammad Reazaul Karim ◽

Subrata Kumar Singha

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Well Being ◽

Multiple Organ ◽

Respiratory Monitoring ◽

Arterial Oxygen ◽

Mechanically Ventilated

Critically ill patients often require multiple organ supports; respiratory support in terms of mechanical ventilation (MV) is one of the commonest. But, only providing an organ support contributes less to the complete well being of the patients. Moreover, MV itself can affect various physiological systems, metabolic response, and cause side effects. A very close temporal relationship exists between patients, monitoring and management decision too, and therefore, appropriate information from monitoring can lead to better outcomes. The present review is intended to briefly highlight the current opinions and strategies for non cardio-respiratory monitoring in such critically ill patients.Abbreviations: AKI-Acute Kidney Injury; APACHE-Acute Physiology and Chronic Health Evaluation; BPS-Behavioral Pain Scale; CAM-ICU-Confusion Assessment Method for the Intensive Care Unit; CPOT–Critical Care Pain Observation Tool; EVLWI-Extra vascular lung water index; FDA-Food and Drug Administration; ISO-International Organization for Standardization; ICU-Intensive Care Unit; LOS-Length of stay; MODS-Multiple Organ Dysfunction Score; MV-Mechanical Ventilation; PaO2-Partial pressure of arterial oxygen; FiO2-Fraction of inspired oxygen; SAPS-Simplified Acute Physiologic Score; RASS-Richmond Agitation Sedation Scale; SOFA-Sequential Organ Failure Assessment; SAS-Sedation Agitation Scale; UO-Urine outputCitation: Panda CK, Karim HMR, Singha SK. Non-cardio respiratory monitoring of mechanically ventilated critically ill patients. Anaesth Pain & Intensive Care 2018;22 Suppl 1:S150-S159Received: 9 Jul 2018 Reviewed: 1 Oct 2018 Corrected & Accepted: 9 Oct 2018

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

50 Studies Every Intensivist Should Know ◽

10.1093/med/9780190467654.003.0003 ◽

2018 ◽

pp. 15-20

Author(s):

David Stahl

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Controlled Trial ◽

Mechanically Ventilated ◽

Daily Interruption ◽

Relevant Context ◽

Study Intervention ◽

Daily Sedation Interruption

This chapter provides a summary of a landmark study in critical care medicine. Does the daily interruption of continuous sedative infusions in critically ill patients receiving mechanical ventilation decrease the duration of mechanical ventilation and the duration of stay in the intensive care unit (ICU)? This chapter describes the study designed to answer that question including funding, study location, patient population, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant context and studies, discusses implications, and concludes with a relevant clinical case. This was the first randomized-controlled trial to demonstrate that daily sedation interruption for mechanically ventilated medical ICU patients is safe and may reduce the duration of mechanical ventilation and length of stay in the ICU.

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An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab202 ◽

2021 ◽

Author(s):

Aditi Balakrishna ◽

Elisa C Walsh ◽

Arzo Hamidi ◽

Sheri Berg ◽

Daniel Austin ◽

...

Keyword(s):

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Massachusetts General Hospital ◽

Academic Medical Center ◽

Clinical Impression ◽

Study Cohort ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Ventilated Patients

Abstract Purpose Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non–mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. Methods A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. Results Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. Conclusion Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.

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Patient-Ventilator Asynchrony in Critically-Ill Adult Patients Undergoing Invasive Mechanical Ventilation: Incidence, Risk Factors and Outcomes

10.21203/rs.3.rs-129357/v1 ◽

2020 ◽

Author(s):

Yongfang Zhou ◽

Steven R Holets ◽

Man Li ◽

Gustavo A Cortes Puentes ◽

Todd J Meyer ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Adult Patients ◽

Surgical Intensive Care ◽

Mechanically Ventilated ◽

Incidence Risk ◽

History Of

Abstract Background: Patient-ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background.Methods: A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥12 hours.Results: A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P<0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P<0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P<0.01).Conclusion: Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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