Validity and Reliability of the Richmond Agitation-Sedation Scale in Pediatric Intensive Care Patients: A Multicenter Study

Background: There is limited data about the psychometric properties of the Richmond Agitation-Sedation Scale (RASS) in children. This study aims to analyze the validity and reliability of the RASS in assessing sedation and agitation in critically ill children.Methods: A multicenter prospective study in children admitted to pediatric intensive care, aged between 1 month and 18 years. Twenty-eight observers from 14 PICUs (pediatric intensive care units) participated. Every observation was assessed by 4 observers: 2 nurses and 2 pediatric intensivists. We analyzed RASS inter-rater reliability, construct validity by comparing RASS to the COMFORT behavior (COMFORT-B) scale and the numeric rating scale (NRS), and by its ability to distinguish between levels of sedation, and responsiveness to changes in sedative dose levels.Results: 139 episodes in 55 patients were analyzed, with a median age 3.6 years (interquartile range 0.7–7.8). Inter-rater reliability was excellent, weighted kappa (κw) 0.946 (95% CI, 0.93–0.96; p < 0.001). RASS correlation with COMFORT-B scale, rho = 0.935 (p < 0.001) and NRS, rho = 0.958 (p < 0.001) was excellent. The RASS scores were significantly different (p < 0.001) for the 3 sedation categories (over-sedation, optimum and under-sedation) of the COMFORT-B scale, with a good agreement between both scales, κw 0.827 (95% CI, 0.789–0.865; p < 0.001), κ 0.762 (95% CI, 0.713–0.811, p < 0.001). A significant change in RASS scores (p < 0.001) was recorded with the variance of sedative doses.Conclusions: The RASS showed good measurement properties in PICU, in terms of inter-rater reliability, construct validity, and responsiveness. These properties, including its ability to categorize the patients into deep sedation, moderate-light sedation, and agitation, makes the RASS a useful instrument for monitoring sedation in PICU.

Naloxone Alleviate the Severity of Delirium in Hospitalized Patients With Parkinsonism: Three Case Reports

Purpose: Delirium is common in geriatric with Parkinson's disease (PD). Treatments for delirium have generally been neuroleptics; however, antipsychotics have potential effect to block striatal dopamine D2 receptors and worsen symptom of parkinsonism. We explored whether naloxone can alleviate delirium in PD and other forms of parkinsonism.Patients and Methods: Patients with parkinsonism who met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) received naloxone infusions once or twice daily. Treatment effects were evaluated by the delirium rating scale–revised 98 (DRS-R98), including non-cognitive and cognitive subscales; the Richmond agitation–sedation scale (RASS); and the mini mental status examination (MMSE).Results: Two patients with primary parkinsonism, one with vascular PD were observed. The daily dose of naloxone was 2.08 ± 0.64 mg (range: 1–4 mg). Medication time last from 1 h to 7 days without side effects observed. Following with naloxone infusions, DRS-R98 scores decreased within 12 h and MMSE scores increased. The psychotic symptoms, disorientation, and attention deficits were alleviated significantly, while RASS scores decreased with naloxone treatment.Conclusion: Naloxone alleviated psychotic symptoms, improved cognitive dysfunction, and irritability in patients with delirium in the context of PD. The preliminary findings point out that the opioid system may be involved in the pathophysiology of delirium, which may be one of potential treat targets for delirium of PD.

Comparison of the Effect of Ketamine, Ketamine-Midazolam and Ketamine-Propofol on Post-Tonsillectomy Agitation in Children

Background: Emergence agitation (EA) in children is one of the most common complications following anaesthesia. We aimed to compare the effect of ketamine, ketaminemidazolam and ketamine-propofol on EA after tonsillectomy. Methods: This study was a randomised, double-blind clinical trial conducted on 162 children undergoing adenotonsillectomy surgery. The participants were randomly divided into three groups of receiving ketamine (0.5 mg/kg) (N = 54), ketamine (0.5 mg/kg) + propofol (1 mg/kg) (N = 54) and ketamine (0.5 mg/kg) + midazolam (0.01 mg/kg) (N = 54) 10 min before the end of the operation. At the time of the patients’ entry into the post-anaesthesia care unit (PACU) and at intervals of 5 min, 10 min and 20 min after that, consciousness, mobility, breathing, circulation and SpO2 were recorded. Modified Aldrete recovery score (MARS), the objective pain score (OPS) and Richmond agitation-sedation scale (RASS) were also evaluated. Results: At the time of entrance to the PACU and 5 min later, the ketamine-midazolam and ketamine-propofol groups had lower RASS scores than the ketamine group (P < 0.001); after 10 min and 20 min, the ketamine-propofol group showed the lowest RASS score (P < 0.001). Ketamine-propofol group had a significantly lower MARS score at all-time points (P < 0.001). Recovery time was the longest for the ketamine-propofol group (P = 0.008). Conclusion: The ketamine-midazolam group had lower RASS, greater haemodynamic stability and MARS values without delayed awakening.

Responsiveness Index versus the RASS-Based Method for Adjusting Sedation in Critically Ill Patients

Background. Sedation of intensive care patients is needed for patient safety, but deep sedation is associated with adverse outcomes. Frontal electromyogram-based Responsiveness Index (RI) aims to quantify the level of sedation and is scaled 0–100 (low index indicates deep sedation). We compared RI-based sedation to Richmond Agitation-Sedation Scale- (RASS-) based sedation. Our hypothesis was that RI-controlled sedation would be associated with increased total time alive without mechanical ventilation at 30 days without an increased number of adverse events. Methods. 32 critically ill adult patients with mechanical ventilation and administration of sedation were randomized to either RI- or RASS-guided sedation. Patients received propofol and oxycodone, if possible. The following standardized sedation protocol was utilized in both groups to achieve the predetermined target sedation level: either RI 40–80 (RI group) or RASS −3 to 0 (RASS group). RI measurement was blinded in the RASS group, and the RI group was blinded to RASS assessments. State Entropy (SE) values were registered in both groups. Results. RI and RASS groups did not differ in total time alive in 30 days without mechanical ventilation ( p = 0.72 ). The incidence of at least one sedation-related adverse event did not differ between the groups. Hypertension was more common in the RI group ( p = 0.01 ). RI group patients were in the target RI level 22% of the time and RASS group patients had 57% of scores within the target RASS level. The RI group spent significantly more time in their target sedation level than the RASS group spent in the corresponding RI level ( p = 0.03 ). No difference was observed between the groups ( p = 0.13 ) in the corresponding analysis for RASS. Propofol and oxycodone were administered at higher RI and SE values and lower RASS values in the RI group than in the RASS group. Conclusion. Further studies with a larger sample size are warranted to scrutinize the optimal RI level during different phases of critical illness.

Monitoring the depth of palliative sedation by video-pupillometry: A case report

Background: Palliative sedation is sometimes interrupted by undesired arousals. Pupillometry has been used in anesthesiology to monitor pain and sedation but has never been used during palliative sedation. Actual case: A 48 years-old patient, with multi-metastatic cancer, underwent palliative sedation to manage global suffering. On the second day, the patient experienced arousal which required medication adjustments to ensure pain relief and increased sedation. Possible course of action: Depth of sedation is monitored with clinical scales, such as the Richmond Agitation-Sedation Scale. But these scales do not measure brain stem activity and are poor at predicting arousal. Formulation of a plan: During palliative sedation, an infrared pupillometer was used to monitor pupil size and pupillary reactivity (Neurolight®, IDMed®, Marseille, France). Outcome: The pupillary light reflex was depressed during deep sedation. In our case, we observed a low-normal reflex along with dilated pupil before arousal. Lessons from the case: Our case suggests that reflex intensity and pupil size might predict arousals during palliative sedation. View on research problems, objectives, or questions generated by the case: Prospective studies are needed to confirm our findings. Pupillometry’s acceptability should also be questioned from patient’s, families’, and caregivers’ perspectives.

Influence of Patient-Specific Covariates on Test Validity of Two Delirium Screening Instruments in Neurocritical Care Patients (DEMON-ICU)

Background Delirium screening instruments (DSIs) should be used to detect delirium, but they only show moderate sensitivity in patients with neurocritical illness. We explored whether, for these patients, DSI validity is impacted by patient-specific covariates. Methods Data were prospectively collected in a single-center quality improvement project. Patients were screened for delirium once daily using the Intensive Care Delirium Screening Checklist (ICDSC) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Reference was the daily assessment using criteria from the Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR). In a two-step receiver operating characteristics regression analysis adjusting for repeated measurements, the impact of acute diagnosis of stroke or transient ischemic attack (TIA), neurosurgical intervention, Richmond Agitation Sedation Scale, and ventilation status on test validity was determined. Results Of 181 patients screened, 101 went into final analysis. Delirium incidence according to DSM-IV-TR was 29.7%. For the first complete assessment series (CAM-ICU, ICDSC, and DSM-IV-TR), sensitivity for the CAM-ICU and the ICDSC was 73.3% and 66.7%, and specificity was 91.8% and 94.1%, respectively. Consideration of daily repeated measurements increased sensitivity for the CAM-ICU and ICDSC to 75.7% and 73.4%, and specificity to 97.3% and 98.9%, respectively. Receiver operating characteristics regression revealed that lower Richmond Agitation Sedation Scale levels significantly impaired validity of the ICDSC (p = 0.029) and the CAM-ICU in its severity scale version (p = 0.004). Neither acute diagnosis of stroke or TIA nor neurosurgical intervention or mechanical ventilation significantly influenced DSI validity. Conclusions The CAM-ICU and ICDSC perform well in patients requiring neurocritical care, regardless of the presence of acute stroke, TIA, or neurosurgical interventions. Yet, even very light or moderate sedation can significantly impair DSI performance.

Hubungan Pengukuran Richmond Agitation Sedation Scale (RASS) dengan Keberhasilan Weaning Ventilator di Ruang Intensif UPTD. RSUD Bali Mandara Provinsi Bali

Latar Belakang: Penyapihan dari ventilator mekanik dapat didefinisikan sebagai proses pelepasan ventilator baik secara langsung maupun bertahap. Salah satu cara untuk mengurangi kebutuhan ventilator adalah sedasi dan agitasi yang terukur dengan menggunakan skor Richmond Agitation and Sedation Scale (RASS). Tujuan Penelitian: Tujuan penelitian ini untuk mengetahui hubungan pengukuran Richmond Agitation Sedation Scale (RASS) dengan keberhasilan weaning ventilator di Ruang Intensif UPTD. RSUD Bali Mandara. Metedologi: Jenis penelitian ini observasional analitik dengan desain case control. Sampel penelitian ini berjumlah 48 responden dengan teknik consecutive sampling. Data dianalisis dengan uji Lambda untuk mengetahui hubungan antara pengukuran RASS dengan keberhasilan weaning ventilator dengan tingkat kemaknaan α=0,05. Hasil: Hasil penelitian ini menunjukkan rata-rata usia responden > 65 tahun yaitu 17 responden (35,4 %), sebagaian besar berjenis kelamin laki-laki yaitu 48 responden (62,5 %) sedangkan perempuan yaitu sebanyak 18 responden (37,5 %). Dengan skor RASS yaitu sedang sadar (0) dengan 22 responden (45,8%), dengan tingkat keberhasilan weaning sebesar sebanyak 30 responden (62,5 %) dengan mode SPN CPAP dengan 16 responden (88,9%) sementara kegagalan terjadi pada 18 responden (37,5 %). Analiss bivariat dengan uji Lambda menunjukkan bahwa nilai p sebesar 0.001 (p ≤ 0,05). Kesimpulan: Hal ini menunjukkan ada hubungan antara pengukuran Richmond Agitation and Sedation Scale (RASS) dengan keberhasilan weaning ventilator.

Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

Reactive Oxygen Species Scavenger in Acute Intracerebral Hemorrhage Patients

Background and Purpose: Patients with intracerebral hemorrhage (ICH) have oxidative stress. Oxidative stress contributes to the development and progression of perihematomal edema (PHE) in brain hemorrhage patients. We hypothesized that reactive oxygen species (ROS) scavengers might have a neuroprotective role in the acute period of patients with ICH. Methods: This prospective, multicenter, single-blind, randomized study was conducted between June 2017 and October 2019. Intracranial bleeding, including spontaneous ICH, secondary ICH due to vascular anomalies, venous thrombosis, neoplasms, or hemorrhagic infarction, were included in our study. These ROS scavengers were given for 14 days with a dose of N-acetylcysteine 2000 mg/d and selenium 1600 µg/d intravenously. Other patients received a placebo. The primary outcome was hemorrhage and PHE volume changes in 2-week follow-up computed tomography between ROS scavenger versus placebo groups. Results: In total, 448 patients were enrolled with 123 patients remaining after applying the inclusion and exclusion criteria. There were no significant differences in baseline characteristics between the ROS scavenger (n=57) and placebo (n=66) groups. No significant differences in baseline hematoma and PHE volumes were observed but 2 weeks follow-up computed tomography showed significant differences in PHE volume (21.90±17.63 versus 30.66±32.35, P <0.01) and PHE ratio (1.19±0.73 versus 2.05±1.27, P <0.01). Among clinical factors, time to reach target Richmond Agitation Sedation Scale (5.98 hours [95% CI, 4.82–7.241 versus 8.42 hours], [95% CI, 6.57–10.77], P <0.01) and the length of intensive care unit stays (6.46 days [95% CI, 2.38–10.55 versus 12.66 days], [95% CI, 8.47–16.85], P <0.01) were significantly shortened among patients who received ROS scavengers than among patients who did not receive ROS scavenger. Conclusions: ROS scavenger showed a significantly reduced PHE volume, time to reach target Richmond Agitation Sedation Scale, and shortened length of intensive care unit stay in patients with acute ICH. Early and high doses of ROS scavengers in a combination regimen may have played a key role in obtaining a favorable outcome in our study. Registration: URL: https://cris.nih.go.kr/cris/en ; Unique identifier: KCT0004628.

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