Sedation and Delirium in the Intensive Care Unit—A Practice-Based Approach

2020 ◽  
Vol 49 (4) ◽  
pp. 215-225
Author(s):  
Irene MJ Wong ◽  
Suhitharan Thangavelautham ◽  
Sean CH Loh ◽  
Shin Yi Ng ◽  
Brendan Murfin ◽  
...  
Keyword(s):  
Cognitive Rehabilitation ◽  
Atypical Antipsychotics ◽  
Therapeutic Interventions ◽  
Optimal Timing ◽  
Dependent Relationship ◽  
Key Words Analgesia ◽  
Light Sedation ◽  
Definition Of ◽  
Dose Dependent ◽  
Current Guidelines

Introduction: Critically ill patients often require sedation for comfort and to facilitate therapeutic interventions. Sedation practice guidelines provide an evidencebased framework with recommendations that can help improve key sedation-related outcomes. Materials and Methods: We conducted a narrative review of current guidelines and recent trials on sedation. Results: From a practice perspective, current guidelines share many limitations including lack of consensus on the definition of light sedation, optimal frequency of sedation assessment, optimal timing for light sedation and consideration of combinations of sedatives. We proposed several strategies to address these limitations and improve outcomes: 1) early light sedation within the first 48 hours with time-weighted monitoring (overall time spent in light sedation in the first 48 hours—sedation intensity—has a dose-dependent relationship with mortality risk, delirium and time to extubation); 2) provision of analgesia with minimal or no sedation where possible; 3) a goal-directed and balanced multimodal approach that combines the benefits of different agents and minimise their side effects; 4) use of dexmedetomidine and atypical antipsychotics as a sedative-sparing strategy to reduce weaning-related agitation, shorten ventilation time and accelerate physical and cognitive rehabilitation; and 5) a bundled approach to sedation that provides a framework to improve relevant clinical outcomes. Conclusion: More effort is required to develop a practical, time-weighted sedation scoring system. Emphasis on a balanced, multimodal appraoch that targets light sedation from the early phase of acute critical illness is important to achieve optimal sedation, lower mortality, shorten time on ventilator and reduce delirium. Ann Acad Med Singapore;49:215–25 Key words: Analgesia, Benzodiazepine, Critical Care, Dexmedetomidine, Propofol

scholarly journals Modelling Ecological Cognitive Rehabilitation Therapies for Building Virtual Environments in Brain Injury

2016 ◽  
Vol 55 (01) ◽  
pp. 50-59 ◽  
Author(s):  
P. Sánchez-González ◽  
M. Luna ◽  
T. Roig ◽  
J. M. Tormos ◽  
E. J. Gómez ◽  
...  
Keyword(s):  
Brain Injury ◽  
Virtual Environments ◽  
Therapeutic Intervention ◽  
Cognitive Rehabilitation ◽  
Interactive Video ◽  
Cognitive Deficit ◽  
New Technologies ◽  
Therapeutic Interventions ◽  
Definition Of

SummaryBackground: Brain Injury (BI) has become one of the most common causes of neurological disability in developed countries. Cognitive disorders result in a loss of independence and patients’ quality of life. Cognitive rehabilitation aims to promote patients’ skills to achieve their highest degree of personal autonomy. New technologies such as virtual reality or interactive video allow developing rehabilitation therapies based on reproducible Activities of Daily Living (ADLs), increasing the ecological validity of the therapy. However, the lack of frameworks to formalize and represent the definition of this kind of therapies can be a barrier for widespread use of interactive virtual environments in clinical routine. Objectives: To provide neuropsychologists with a methodology and an instrument to design and evaluate cognitive rehabilitation therapeutic interventions strategies based on ADLs performed in interactive virtual environments. Methods: The proposed methodology is used to model therapeutic interventions during virtual ADLs considering cognitive deficit, expected abnormal interactions and therapeutic hypotheses. It allows identifying abnormal behavioural patterns and designing interventions strategies in order to achieve errorless-based rehabilitation. Results: An ADL case study (’buying bread’) is defined according to the guidelines established by the ADL intervention model. This case study is developed, as a proof of principle, using interactive video technology and is used to assess the feasibility of the proposed methodology in the definition of therapeutic intervention procedures. Conclusions: The proposed methodology provides neuropsychologists with an instrument to design and evaluate ADL-based therapeutic intervention strategies, attending to solve actual limitation of virtual scenarios, to be use for ecological rehabilitation of cognitive deficit in daily clinical practice. The developed case study proves the potential of the methodology to design therapeutic interventions strategies; however our current work is devoted to designing more experiments in order to present more evidence about its values.

Cognitive Impact of Cerebellar Damage: Is There a Future for Cognitive Rehabilitation?

2018 ◽  
Vol 17 (3) ◽  
pp. 199-206 ◽  
Author(s):  
Kim van Dun ◽  
Frank V. Overwalle ◽  
Mario Manto ◽  
Peter Marien
Keyword(s):  
Affective Disorders ◽  
Cognitive Rehabilitation ◽  
Therapeutic Interventions ◽  
Posterior Fossa Surgery ◽  
Daily Life Activities ◽  
Wide Range ◽  
Affective Deficits ◽  
Cerebellar Injury ◽  
Cognitive Therapies ◽  
The Impact

Background & Objective: During the past 3 decades, numerous neurophysiological, neuroimaging, experimental and clinical studies have evidenced a crucial role for the cerebellum in cognitive, affective and behavioral functions. As a result of the acknowledged modulatory role of the cerebellum upon remote structures such as the cerebral cortex, cerebellar injury may give rise to a constellation of behavioral, affective and cognitive symptoms (Schmahmann's Syndrome). In sharp contrast to the wide range of therapeutic interventions to treat cognitive and affective disorders following cerebral cortical lesions and despite the consequences of Schmahmann’s syndrome upon daily life activities, the literature is surprisingly only scantly documented with studies investigating the impact of cognitive therapies on cerebellar induced cognitive and affective disorders. This survey aims to present an overview of the therapeutic interventions available in the literature as a possible treatment for Schmahmann’s Syndrome after cerebellar injury, after posterior fossa surgery in children, and in children with neurodevelopmental disorders. Although systematical studies are clearly warranted, available evidence suggests that cerebellar-induced cognitive and affective disorders should be treated in a specific way. Approaches where the patients are explicitly made aware of their deficits and are considered to act as an “external cerebellum” are the most promising. Conclusion: The study of the anatomical connectivity of the cerebellar microcomplexes involved in cognitive/affective deficits is likely to play a major-role in the future.

Evaluation of Dexmedetomidine Dosing in Obese Critically Ill Patients

2021 ◽  
pp. 089719002110215
Author(s):  
Sara A. Atyia ◽  
Keaton S. Smetana ◽  
Minh C. Tong ◽  
Molly J. Thompson ◽  
Kari M. Cape ◽  
...  
Keyword(s):  
Body Weight ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Statistical Difference ◽  
Ideal Body Weight ◽  
Weight Percentage ◽  
Before And After ◽  
Light Sedation ◽  
Icu Sedation ◽  
Dose Dependent

Background: Dexmedetomidine is a highly selective α2-adrenoreceptor agonist that produces dose-dependent sedation, anxiolysis, and analgesia without respiratory depression. Due to these ideal sedative properties, there has been increased interest in utilizing dexmedetomidine as a first-line sedative for critically ill patients requiring light sedation. Objective: To evaluate the ability to achieve goal intensive care unit (ICU) sedation before and after an institutional change of dosing from actual (ABW) to adjusted (AdjBW) body weight in obese patients on dexmedetomidine. Methods: This study included patients ≥ 18 years old, admitted to a surgical or medical ICU, required dexmedetomidine for at least 8 hours as a single continuous infusion sedative, and weighed ≥ 120% of ideal body weight. Percentage of RASS measurements within goal range (−1 to +1) during the first 48 hours after initiation of dexmedetomidine as the sole sedative agent or until discontinuation dosed on ABW compared to AdjBW was evaluated. Results: 100 patients were included in the ABW cohort and 100 in the AdjBW cohort. The median dosing weight was significantly higher in the ABW group (95.9 [78.9-119.5] vs 82.2 [72.1-89.8] kg; p = 0.001). There was no statistical difference in percent of RASS measurements in goal range (61.5% vs 69.6%, p = 0.267) in patients that received dexmedetomidine dosed based on ABW versus AdjBW. Conclusion: Dosing dexmedetomidine using AdjBW in obese critically ill patients for ongoing ICU sedation resulted in no statistical difference in the percent of RASS measurements within goal when compared to ABW dosing. Further studies are warranted.

scholarly journals Towards approval of autonomous ship systems by their operational envelope

2021 ◽  
Author(s):  
Ørnulf Jan Rødseth ◽  
Lars Andreas Lien Wennersberg ◽  
Håvard Nordahl
Keyword(s):  
Geographic Area ◽  
System Modelling ◽  
Modelling Language ◽  
Human Control ◽  
Operational Design ◽  
Autonomous Ship ◽  
Definition Of ◽  
Operational Envelope ◽  
Concrete Operations ◽  
Current Guidelines

AbstractCurrent guidelines for approval of autonomous ship systems are focused on the ships’ concrete operations and their geographic area. This is a natural consequence of the link between geography and the navigational complexity, but moving the ship to a new area or changing owners may require a costly re-approval. The automotive industry has introduced the Operational Design Domain (ODD) that can be used as a basis for approval. However, the ODD does not include the human control responsibilities, while most autonomous ship systems are expected to be dependent on sharing control responsibilities between humans and automation. We propose the definition of an operational envelope for autonomous ship systems that include the sharing of responsibilities between human and automation, and that is general enough to allow approval of autonomous ship systems in all geographic areas and operations that falls within the envelope. We also show how the operational envelope can be defined using a system modelling language, such as the unified modelling language (UML).

scholarly journals Neonatal Hypoglycaemia: A Never-Ending Story?

Neonatology ◽  
2021 ◽  
pp. 1-8
Author(s):  
Nestor E. Vain ◽  
Florencia Chiarelli
Keyword(s):  
At Risk ◽  
Neonatal Period ◽  
Newborn Infants ◽  
Neonatal Hypoglycaemia ◽  
Rational Decision Making ◽  
Weak Evidence ◽  
Universal Approach ◽  
Definition Of ◽  
Therapeutic Alternatives ◽  
Current Guidelines

Neonatal hypoglycaemia is a common metabolic disorder presenting in the first days of life and one potentially preventable cause of brain injury. However, a universal approach to diagnosis and management is still lacking. The rapid decrease in blood glucose (BG) after birth triggers homeostatic mechanisms. Most episodes of hypoglycaemia are asymptomatic, and symptoms, when they occur, are nonspecific. Therefore, neonatologists are presented with the challenge of identifying infants at risk who might benefit from a rapid and effective therapy while sparing others unnecessary sampling and overtreatment. There is much controversy regarding the definition of hypoglycaemia, and one level does not fit all infants since postnatal age and clinical situations trigger different accepted thresholds for therapy. The concentration and duration of BG which cause neurological damage are unclear. Recognizing which newborn infants are at risk of hypoglycaemia and establishing protocols for treatment are essential to avoid possible deleterious effects on neurodevelopment. Early breastfeeding may reduce the risk of hypoglycaemia, but in some cases, the amount of breast milk available immediately after birth is insufficient or non-existent. In these situations, other therapeutic alternatives such as oral dextrose gel may lower the risk for NICU admissions. Current guidelines continue to be based on expert opinion and weak evidence. However, malpractice litigation related to neurodevelopmental disorders is frequent in children who suffered hypoglycaemia in the neonatal period even if they had other important factors contributing to the poor outcome. This review is aimed to help the practicing paediatricians and neonatologists to comprehend neonatal hypoglycaemia from physiology to therapy, hoping it will result in a rational decision-making process in an area not sufficiently supported by evidence.

scholarly journals Alpha-Tocopherol Metabolites (The Vitamin E Metabolome) and Their Interindividual Variability during Supplementation

Antioxidants ◽  
2021 ◽  
Vol 10 (2) ◽  
pp. 173
Author(s):  
Desirée Bartolini ◽  
Rita Marinelli ◽  
Danilo Giusepponi ◽  
Roberta Galarini ◽  
Carolina Barola ◽  
...  
Keyword(s):  
Vitamin E ◽  
Target Genes ◽  
Interindividual Variability ◽  
Pregnane X Receptor ◽  
Alpha Tocopherol ◽  
Therapeutic Interventions ◽  
Intrinsic Variability ◽  
Blood Leukocytes ◽  
Definition Of ◽  
And Function

The metabolism of α-tocopherol (α-TOH, vitamin E) shows marked interindividual variability, which may influence the response to nutritional and therapeutic interventions with this vitamin. Recently, new metabolomics protocols have fostered the possibility to explore such variability for the different metabolites of α-TOH so far identified in human blood, i.e., the “vitamin E metabolome”, some of which have been reported to promote important biological functions. Such advances prompt the definition of reference values and degree of interindividual variability for these metabolites at different levels of α-TOH intake. To this end, a one-week oral administration protocol with 800 U RRR-α-TOH/day was performed in 17 healthy volunteers, and α-TOH metabolites were measured in plasma before and at the end of the intervention utilizing a recently validated LC-MS/MS procedure; the expression of two target genes of α-TOH with possible a role in the metabolism and function of this vitamin, namely pregnane X receptor (PXR) and the isoform 4F2 of cytochrome P450 (CYP4F2) was assessed by immunoblot in peripheral blood leukocytes. The levels of enzymatic metabolites showed marked interindividual variability that characteristically increased upon supplementation. With the exception of α-CEHC (carboxy-ethyl-hydroxychroman) and the long-chain metabolites M1 and α-13′OH, such variability was found to interfere with the possibility to utilize them as sensitive indicators of α-TOH intake. On the contrary, the free radical-derived metabolite α-tocopheryl quinone significantly correlated with the post-supplementation levels of α-TOH. The supplementation stimulated PXR, but not CYP4F2, expression of leucocytes, and significant correlations were observed between the baseline levels of α-TOH and both the baseline and post-supplementation levels of PXR. These findings provide original analytical and molecular information regarding the human metabolism of α-TOH and its intrinsic variability, which is worth considering in future nutrigenomics and interventions studies.

A narrative review of chronic alcohol-induced atrial fibrillation

2021 ◽  
Author(s):  
Rea Mittal ◽  
Lilly Su ◽  
Devyani Ramgobin ◽  
Ashwani Garg ◽  
Rahul Jain ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Alcohol Use ◽  
Alcohol Intake ◽  
Cardiovascular Complications ◽  
Chronic Alcohol ◽  
Higher Alcohol ◽  
Dependent Relationship ◽  
Increased Risk ◽  
Low Levels ◽  
Dose Dependent

Alcohol use disorder (AUD) is highly prevalent and can lead to many cardiovascular complications, including arrhythmias. Chronic alcohol use has a dose-dependent relationship with incidence of atrial fibrillation (AF), where higher alcohol intake (>3 drinks a day) is associated with higher risk of AF. Meanwhile, low levels of chronic alcohol intake (<1 drink a day) is not associated with increased risk of AF. Mechanistically, chronic alcohol intake alters the structural, functional and electrical integrity of the atria, predisposing to AF. Increased screening can help identify AUD patients early on and provide the opportunity to educate on chronic alcohol use related risks, such as AF. The ideal treatment to reduce risk of incident or recurrent AF in AUD populations is abstinence.

scholarly journals ISMAR-study presentation: in-hospital epidemiology and clinical management of respiratory and cardiac comorbidities in cardiac and respiratory disease units

2014 ◽  
Vol 9 ◽  
Author(s):  
Roberto Tramarin ◽  
Mario Polverino ◽  
Maurizio Volterrani ◽  
Bruna Girardi ◽  
Claudio Chimini ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Management ◽  
Real Life ◽  
Length Of Hospital Stay ◽  
Relevant Information ◽  
Hospital Epidemiology ◽  
Discharge Data ◽  
Definition Of ◽  
Current Guidelines

Background: Cardiovascular and respiratory diseases are leading causes of morbidity and their co-occurrence has important implications in mortality and other outcomes. Even the most recent guidelines do not reliably address clinical, prognostic, and therapeutic concerns due to the overlap of respiratory and cardiac diseases. Study objectives and design: In order to evaluate in the reality of clinical practice the epidemiology and the reciprocal impact of cardio-pulmonary comorbidity on the clinical management, diagnostic workup and treatment, 1,500 cardiac and 1,500 respiratory inpatients, admitted in acute and rehabilitation units, will be enrolled in a multicenter, nationwide, prospective observational study. For this purpose, each center will enroll at least 50 consecutive patients. At discharge, data analysis will be aimed at the definition of cardiac and pulmonary inpatient comorbidity prevalence, demographic characteristics, length of hospital stay, and risk factors, taking into account also procedures, pharmacological and non-pharmacological treatment, and follow up in patients with cardio-respiratory comorbidity. Conclusions: The purely observational design of the study aims to give new relevant information on the assessment and management of overlapping patients in real life clinical practice, and new insight for improvement and implementation of current guidelines on the management of individual diseases.

scholarly journals Major Depressive Disorder (MDD) and Antidepressant Medication Are Overrepresented in High-Dose Statin Treatment

2021 ◽  
Vol 8 ◽  
Author(s):  
Leutner Michael ◽  
Matzhold Caspar ◽  
Kautzky Alexander ◽  
Kaleta Michaela ◽  
Thurner Stefan ◽  
...  
Keyword(s):  
Major Depressive Disorder ◽  
Inpatient Care ◽  
Low Dose ◽  
Antidepressant Medication ◽  
Statin Treatment ◽  
High Dose ◽  
Major Depressive ◽  
Dependent Relationship ◽  
Different Types ◽  
Dose Dependent

Objective: To examine the dose-dependent relationship of different types of statins with the occurrence of major depressive disorder (MDD) and prescription of antidepressant medication.Methods: This cross-sectional study used medical claims data for the general Austrian population (n = 7,481,168) to identify all statin-treated patients. We analyzed all patients with MDD undergoing statin treatment and calculated the average defined daily dose for six different types of statins. In a sub-analysis conducted independently of inpatient care, we investigated all patients on antidepressant medication (statin-treated patients: n = 98,913; non-statin-treated patients: n = 789,683). Multivariate logistic regression analyses were conducted to calculate the risk of diagnosed MDD and prescription of antidepressant medication in patients treated with different types of statins and dosages compared to non-statin-treated patients.Results: In this study, there was an overrepresentation of MDD in statin-treated patients when compared to non-statin-treated patients (OR: 1.22, 95% CI: 1.20–1.25). However, there was a dose dependent relationship between statins and diagnosis of MDD. Compared to controls, the ORs of MDD were lower for low-dose statin-treated patients (simvastatin&gt;0– &lt; =10 mg:OR: 0.59, 95% CI: 0.54–0.64; atorvastatin&gt;0– &lt; =10 mg:OR:0.65, 95%CI: 0.59–0.70; rosuvastatin&gt;0– &lt; =10 mg:OR: 0.68, 95% CI: 0.53–0.85). In higher statin dosages there was an overrepresentation of MDD (simvastatin&gt;40– &lt; =60 mg:OR: 2.42, 95% CI: 2.18–2.70, &gt;60–80 mg:OR: 5.27, 95% CI: 4.21–6.60; atorvastatin&gt;40– &lt; =60 mg:OR: 2.71, 95% CI: 1.98–3.72, &gt;60– &lt; =80 mg:OR: 3.73, 95% CI: 2.22–6.28; rosuvastatin&gt;20– &lt; =40 mg:OR: 2.09, 95% CI: 1.31–3.34). The results were confirmed in a sex-specific analysis and in a cohort of patients taking antidepressants, prescribed independently of inpatient care.Conclusions: This study shows that it is important to carefully re-investigate the relationship between statins and MDD. High-dose statin treatment was related to an overrepresentation, low-dose statin treatment to an underrepresentation of MDD.

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