Sedation in the Intensive Care Setting

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

Sedation in the Intensive Care Setting

10.2310/anes.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

Sedation in the Intensive Care Setting

10.2310/pm.8262 ◽

2019 ◽

Author(s):

William John Wallisch IV ◽

Ata Murat Kaynar

Keyword(s):

Care Setting ◽

Assessment Method ◽

Assessment Tools ◽

Intensive Care Setting ◽

Sedation Scale ◽

Confusion Assessment ◽

The Past ◽

Sedation Program

The recent clinical trials on sedation and delirium in the ICU shifted the scales dramatically in the past 10 to 20 years and less sedation is now the accepted norm with titration goals. Now the art of sedation is in the hands of the clinicians to achieve a balance between alleviation of pain and anxiety while keeping patients calm, cooperative, and part of daily activities in the ICU. In this chapter we summarize the various assessment tools for optimal sedation in the ICU as well as the medications used to achieve sedation. However, the clinicians should not forget the nonpharmacologic approaches such as prevention of sleep interruption as part of a successful comprehensive sedation program in the ICU. This review contains 3 tables, and 22 references. Key Words: confusion assessment method, delirium, dexmedetomidine, etomidate, fentanyl, GABA, ketamine, propofol, Richmond agitation-sedation scale (RASS), sedation-agitation scale (SAS)

Ação de fármacos sedativos para o desenvolvimento de delirium e perfil funcional de pacientes internados em unidades de terapia intensiva

Research Society and Development ◽

10.33448/rsd-v10i3.13588 ◽

2021 ◽

Vol 10 (3) ◽

pp. e45410313588

Author(s):

Anne Karine Menezes Santos Batista ◽

Tais Santana Barbosa ◽

Phydel Palmeira Carvalho ◽

Natasha Cordeiro dos Santos ◽

Victor Durier Cavalcanti de Almeida ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Assessment Method ◽

Sedation Scale ◽

Confusion Assessment ◽

Status Score ◽

Terapia Intensiva

Introdução: Os sedativos são fármacos utilizados como auxiliares terapêuticos em pacientes sob cuidados intensivos. Dentre os possíveis desfechos controversos ao seu uso, as alterações cognitivas são pontuadas na literatura, com a encefalopatia aguda ou delirium, sendo a mais descrita. Objetivos: Avaliar a associação entre o uso de fármacos com ação sedativa para o desenvolvimento de delirium e caracterizar o perfil funcional dos indivíduos com delirium. Material e métodos: Estudo longitudinal, realizado em um hospital público da rede estadual, durante os meses de junho de 2019 a outubro (primeira quinzena) de 2020, com indivíduos acima de 18 anos, internados em unidades de terapia intensiva e enfermarias, por meio de escalas para avaliação de sedação, delirium e funcionalidade (Richmond Agitation Sedation Scale - RASS, Confusion Assessment Method for the Intensive Care Unit - CAM-ICU e Status Score for the Intensive Care Unit - FSS, respectivamente), com capacidade de verbalização e sem admissão via transferência externa. Resultados: Inclusos 104 pacientes com idade média de 59,7 ± 15,3 anos, sendo 53,2% do sexo masculino, com 49% sendo hipertensos e 79,8% negando tabagismo. Não houve significância estatística entre os fármacos sedativos para o desencadeamento de delirium. A maioria dos pacientes com delirium estavam no intervalo da FSS entre 0-15 no ambiente intensivo e 16-25 nas enfermarias. Considerações finais: Não há associação entre o uso de fármacos com ação sedativa e delirium. Houve alteração do perfil funcional, com os pacientes tornando-se dependentes moderados a máximos nas unidades intensivas e dependentes mínimos ou independentes nas enfermarias.

Διερεύνηση των παθοφυσιολογικών μηχανισμών εγκατάστασης μετεγχειρητικής διέγερσης σε βαριατρικούς ασθενείς μονάδων μεταναισθητικής φροντίδας

10.12681/eadd/42950 ◽

2018 ◽

Author(s):

Κωνσταντινιά Μαμούρα

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Assessment Method ◽

Pain Scale ◽

Sedation Scale ◽

Confusion Assessment ◽

Behavioral Pain Scale

Εισαγωγή: Η διέγερση είναι μια κατάσταση που μπορεί να εμφανιστεί σε μετεγχειρητικούς ασθενείς και βαρέως πάσχοντες, και συνδέεται με δυνητικά επικίνδυνες επιπλοκές. Ωστόσο, τα επίπεδα πόνου, stress, φεντανύλης, αναισθητικών φαρμάκων και άλλων διεγχειρητικών παραμέτρων, σε σχέση με τη διέγερση, δεν έχουν αξιολογηθεί εστιασμένα σε βαριατρικούς ασθενείς.Σκοπός: Η διερεύνηση της σχέσης των επιπέδων μετεγχειρητικού πόνου stress, φεντανύλης, αναισθητικών φαρμάκων και άλλων διεγχειρητικών παραμέτρων με την εγκατάσταση μετεγχειρητικής διέγερσης σε βαριατρικούς ασθενείς, με απώτερο στόχο την πρόληψή της.Μεθοδολογία: Πραγματοποιήθηκε συγχρονική κλινική μελέτη συσχέτισης, σε Μονάδα Μεταναισθητικής Φροντίδας ιδιωτικού νοσοκομείου των Αθηνών για χρονικό διάστημα δεκατεσσάρων μηνών, με δείγμα 76 βαριατρικών ασθενών. Για τη συλλογή των δεδομένων χρησιμοποιήθηκαν: α) Φύλλο δημογραφικών και κλινικών δεδομένων, β) Κλίμακες αξιολόγησης διέγερσης, CAM-ICU (Confusion Assessment Method for the Intensive Care Unit), ICDSC (Intensive Care Delirium Screening Checklist) και RASS (Richmond Agitation-Sedation Scale), γ) Εργαλεία αξιολόγησης πόνου, CPOT (Critical-Care Pain Observation Tool), BPS (Behavioral Pain Scale) και NRS (0-10). Οι μεταβλητές ελέγχθηκαν για την κανονικότητα της κατανομής τους και ανάλογα εφαρμόστηκαν είτε παραμετρικές είτε μη παραμετρικές δοκιμασίες. Πραγματοποιήθηκε περιγραφική στατιστική, μελέτη εσωτερικής συνοχής κλιμάκων (Cronbach’s α), μελέτη συσχετίσεων (Pearson, Kendall’s tau, Spearman’s rho), έλεγχος μέσων και διαμέσων (T-test, Mann Whitney U test) και μελέτη παλινδρομήσεων με το SPSS 22.0 (p≤0,05). Αποτελέσματα: Οι συμμετέχοντες ήταν 46,1% άντρες, με μέση ηλικία 37,7(±10,2) έτη. Ο Δείκτης Μάζας Σώματος (ΔΜΣ/BMI), κυμαινόταν από 24,2 έως 67,6, με μέσο 46,3(±6,1). Οι βαθμολογίες στις κλίμακες ICDSC και RASS ήταν μέτριες ωστόσο μετεγχειρητική διέγερση, με βάση την κλίμακα CAM-ICU, καταγράφηκε στο 50% των ασθενών. Ο Cronbach’s α ήταν ≥0,726για όλες της κλίμακες. Επίσης τα επίπεδα πόνου ήταν χαμηλά προς μέτρια. Οι κλίμακες πόνου συσχετίσθηκαν μεταξύ τους (0,77≤rho≤0.958, p<0,001). O μετεγχειρητικός πόνος που αξιολογήθηκε με όλες τις κλίμακες συσχετίσθηκε στατιστικά σημαντικά θετικά, με όλες τις κλίμακες διέγερσης (0,622≤rho≤0.838, p<0,001). Άλλοι παράγοντες που συσχετίσθηκαν στατιστικά σημαντικά θετικά με την εμφάνιση διέγερσης ήταν τα επίπεδα κορτιζόλης ορού το πρωί του χειρουργείου (p<0,001), οι χορηγούμενες ποσότητες μιδαζολάμης και προποφόλης (p<0,001), ο μεγαλύτερος χρόνος διασωλήνωσης (p<0,001) και χειρουργείου (p<0,001), η οξέωση (p=0,005), το ιστορικό προηγούμενων χειρουργικών επεμβάσεων (p=0,004) και ο αριθμός ατόμων που συγκατοικούν με τον ασθενή (p=0,011). Αρνητικά συσχετίσθηκαν με την εμφάνιση διέγερσης τα υψηλότερα επίπεδα φεντανύλης ούρων (p<0,001), τα επίπεδα ACTH το πρωί του χειρουργείου(p=0,023) και η μεγαλύτερη ηλικία (p=0,04). Το 77,1% της διακύμανσης της CAM-ICU επεξηγήθηκε από την συνολική ποσότητα χορηγούμενης φεντανύλης, και η αλλαγή στα επίπεδα φεντανύλης ούρων κατά 1 μονάδα (ng/ml) μείωσε την διέγερση κατά 0,927 φορές. Επίσης αλλαγή στα επίπεδα Κορτιζόλης το πρωί του χειρουργείου κατά μία μονάδα (μg/dl) αυξάνει τη διέγερση κατά 1,244 φορές, ενώ 1 μονάδα Προποφόλης αυξάνει τη διέγερση κατά 1,041φορές. Συμπέρασμα: Ο μετεγχειρητικός πόνος, το στρες, τα αναισθητικά φάρμακα και άλλοι διεγχειρητικοί παράγοντες φαίνεται να αυξάνουν την πιθανότητα εμφάνισης διέγερσης σε βαριατρικούς ασθενείς. Απαιτείται η χρήση κατάλληλων εργαλείων αξιολόγησης πόνου και διέγερσης στη μονάδα μεταναισθητικής φροντίδας, και κατάλληλη τιτλοποίηση της αναλγητικής αγωγής ώστε να μειωθεί σημαντικά η εγκατάσταση διέγερσης. Η διαχείριση του προεγχειρητικού στρες, από τον νοσηλευτή, είναι δυνατό να περιορίσει την εμφάνιση μετεγχειρητικής διέγερσης. Τέλος, προσοχή πρέπει να δίνεται στους ασθενείς που υποβάλλονται σε επέμβαση μεγαλύτερης χρονικής διάρκειας και σε αυτούς που εμφανίζουν διαταραχές της οξεοβασικής ισορροπίας.

A Systematic Review and Pooled Prevalence of Paediatric Delirium in Critically Ill Children

International Journal of Pharmacy Practice ◽

10.1093/ijpp/riab015.038 ◽

2021 ◽

Vol 29 (Supplement_1) ◽

pp. i31-i32

Author(s):

D Semple ◽

M M Howlett ◽

J D Strawbridge ◽

C V Breatnach ◽

J C Hayden

Keyword(s):

Risk Factors ◽

Critical Care ◽

Critically Ill ◽

Observational Studies ◽

Assessment Method ◽

Assessment Tools ◽

Critically Ill Children ◽

Confusion Assessment ◽

Pooled Prevalence

Abstract Introduction Paediatric Delirium (PD) is a neuropsychiatric complication that occurs during the management of children in the critical care environment (Paediatric Intensive Care (PICU) and Neonatal Intensive Care (NICU). Delirium can be classified as hypoactive (decreased responsiveness and withdrawal), hyperactive (agitation and restlessness), and mixed (combined) (1). PD can be assessed using a number of assessment tools. PD has been historically underdiagnosed or misdiagnosed, having many overlapping symptoms with other syndrome such as pain and iatrogenic withdrawal syndrome (2). An appreciation of the extent of PD would help clinicians and policy makers drive interventions to improve recognition, prevention and management of PD in clinical practice. Aim To estimate the pooled prevalence of PD using validated assessment tools, and to identify risk factors including patient-related, critical-care related and pharmacological factors. Methods A systematic search of PubMed, EMBASE and CINAHL databases was undertaken. Eligible articles included observational studies or trials that estimated a prevalence of PD in a NICU/PICU population using a validated PD assessment tool. Validated tools are the paediatric Confusion Assessment Method-ICU (pCAM-ICU), the Cornell Assessment of Pediatric Delirium (CAPD), the PreSchool Confusion Assessment Method for the ICU (psCAM-ICU), pCAM-ICU severity scale (sspCAM-ICU), and the Sophia Observation Withdrawal Symptoms scale Paediatric Delirium scale (SOS-PD) (1). Only full text studies were included. No language restrictions were applied. Two reviewers independently screened records. Data was extracted using a pre-piloted form and independently verified by another reviewer. Quality was assessed using tools from the National Institutes of Health. A pooled prevalence was calculated from the studies that estimated PD prevalence using the most commonly applied tool, the CAPD (1). Results Data from 23 observational studies describing prevalence and risk factors for PD in critically ill children were included (Figure 1). Variability in study design and outcome reporting was found. Study quality was generally good. Using the validated tools prevalence ranged from 10–66% of patients. Hypoactive delirium was the most prevalent sub-class identified. Using the 13 studies that used the CAPD tool, a pooled prevalence of 35% (27%-43% 95%CI) was calculated. Younger ages, particularly less than two years old, sicker patients, particularly those undergoing mechanical and respiratory ventilatory support were more at risk for PD. Restraints, the number of sedative medications, including the cumulative use of benzodiazepines and opioids were identified as risk factors for the development of PD. PD was associated with longer durations of mechanical ventilation, longer stays and increased costs. Data on association with increased mortality risk is limited and conflicting. Conclusion PD affects one third of critical care admissions and is resource intense. Routine assessment in clinical practice may facilitate earlier detection and management strategies. Modifiable risk factors such as the class and number of sedative and analgesic medications used may contribute to the development of PD. Early mobility and lessening use of these medications present strategies to prevent PD occurrence. Longitudinal prospective multi-institutional studies to further investigate the presentations of the different delirium subtypes and modifiable risk factors that potentially contribute to the development of PD, are required. References 1. Semple D (2020) A systematic review and pooled prevalence of PD, including identification of the risk factors for the development of delirium in critically ill children. doi: 10.17605/OSF.IO/5KFZ8 2. Ista E, te Beest H, van Rosmalen J, de Hoog M, Tibboel D, van Beusekom B, et al. Sophia Observation withdrawal Symptoms-Paediatric Delirium scale: A tool for early screening of delirium in the PICU. Australian Critical Care. 2018;31(5):266–73

Assessment of Delirium Using the Confusion Assessment Method in Older Adult Inpatients in Malaysia

Geriatrics ◽

10.3390/geriatrics4030052 ◽

2019 ◽

Vol 4 (3) ◽

pp. 52

Author(s):

Khor ◽

Ong ◽

Tan ◽

Low ◽

Saedon ◽

...

Keyword(s):

Older Patients ◽

Altered Mental Status ◽

Assessment Method ◽

Assessment Tools ◽

University Hospital ◽

Cognitive Screening ◽

Cross Sectional ◽

Confusion Assessment ◽

Severity Scores

The detection of delirium in acutely ill older patients is challenging with the lack of informants and the necessity to identify subtle and fluctuating signs. We conducted a cross-sectional study among older patients admitted to a university hospital in Malaysia to determine the presence, characteristics, and mortality outcomes of delirium. Consecutive patients aged ≥65years admitted to acute medical wards were recruited from August to September 2016. Cognitive screening was performed using the mini-mental test examination (MMSE) and the Confusion Assessment Method (CAM). The CAM-Severity (CAM-S) score was also performed in all patients. Of 161 patients recruited, 43 (26.7%) had delirium. At least one feature of delirium from the CAM-S short and long severity scores were present in 48.4% and 67.1%, respectively. Older age (OR: 1.07, 95% CI: 1.01–1.14), immobility (OR: 3.16, 95% CI: 1.18–8.50), cognitive impairment (OR: 5.04, 95% CI: 2.07–12.24), and malnutrition (OR: 3.37; 95% CI: 1.15–9.85) were significantly associated with delirium. Older patients with delirium had a higher risk of mortality (OR: 7.87, 95% CI: 2.42–25.57). Delirium is common among older patients in our setting. A large proportion of patients had altered mental status on admission to hospital although they did not fulfill the CAM criteria of delirium. This should prompt further studies on strategies to identify delirium and the use of newer, more appropriate assessment tools in this group of vulnerable individuals.

Delirium

10.2310/psych.13089 ◽

2019 ◽

Author(s):

Sarah Wagner ◽

Robert Gerstman

Keyword(s):

Health Care Cost ◽

Length Of Hospital Stay ◽

Altered Mental Status ◽

Assessment Method ◽

Medical Illness ◽

The Past ◽

Short Period ◽

Brain Failure

Delirium is a disturbance of attention and awareness, which develops over a short period of time. It is a change in a person’s baseline and fluctuates throughout the course of the day.1 Delirium can accompany almost any serious medical illness. It is an independent risk factor for increasing a person’s morbidity and mortality. Delirium is associated with an increased length of hospital stay and an increase in health care cost.2 There is growing literature to assist in the diagnosing and treatment of patients with delirium. This article dives into the recent research addressing the pharmacologic and nonpharmacologic methods to treat delirium. Various pharmacologic interventions have been studied over the past several years including the use of melatonin, ramelteon, dexmedetomidine, and antipsychotics. This review contains 2 tables and 17 references. Key Words: acute brain failure, altered mental status, Confusion Assessment Method, critical care, delirium, encephalopathy, ICU, RASS, Richmond Agitation-Sedation Scale

Using an Evidence-Based Approach for Assessing and Identifying Delirium Among Medical-Surgical Patients in the Acute Care Setting

Journal of Doctoral Nursing Practice ◽

10.1891/2380-9418.10.1.24 ◽

2017 ◽

Vol 10 (1) ◽

pp. 24-27

Author(s):

Mary Belding ◽

Erin Delaney ◽

Valeria Dworkowitz ◽

Samuel Osho

Keyword(s):

Care Setting ◽

Evidence Based Practice ◽

Assessment Method ◽

Evidence Based ◽

Doctor Of Nursing Practice ◽

Confusion Assessment ◽

Surgical Units ◽

Clinical Problems

Objective:The scholarship of the doctor of nursing practice (DNP) is crucial in the use of evidence-based practice to address clinical gaps in practice. The Confusion Assessment Method (CAM) is a literature supported tool for the assessment of delirium. Registered nurses (RNs) were educated on the application of the CAM for their patients.Method:RNs on two medical-surgical units received education about delirium and use of the CAM. The CAM tool was used for 2 weeks on all admitted patients.Result:There was an 11% increase in knowledge gained during the educational sessions. There were 15 patients identified with a suggestive diagnosis of delirium via the CAM during a 2-week period.Conclusion:Using evidence-based practice to solve clinical problems enhances quality of life. Prompt identification of delirium can help to reverse delirium and adverse sequelae.