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      Executive Summary : Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

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      Critical Care Medicine

      Ovid Technologies (Wolters Kluwer Health)

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          Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial.

          Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)-ie, daily interruption of sedatives-with spontaneous breathing trials (SBTs). In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630. One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14.7 days vs 11.6 days; mean difference 3.1 days, 95% CI 0.7 to 5.6; p=0.02) and were discharged from intensive care (median time in intensive care 9.1 days vs 12.9 days; p=0.01) and the hospital earlier (median time in the hospital 14.9 days vs 19.2 days; p=0.04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6.0% difference, 95% CI 0.6% to 11.8%; p=0.03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1.2% difference, 95% CI -5.2% to 2.5%; p=0.47), as were total reintubation rates (13.8%vs 12.5%; 1.3% difference, 95% CI -8.6% to 6.1%; p=0.73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0.68, 95% CI 0.50 to 0.92; p=0.01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7.4, 95% CI 4.2 to 35.5). Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.
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            Early intensive care unit mobility therapy in the treatment of acute respiratory failure.

            Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission: Protocol, n = 165; Usual Care, n = 165. An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < or = .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < or = .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < or = .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p = .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p = .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost difference (survivors + nonsurvivors) between the two arms, including Mobility Team costs. A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care.
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              Incidence, risk factors and consequences of ICU delirium.

              Delirium in the critically ill is reported in 11-80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Prospective study in a 16-bed medical-surgical intensive care unit (ICU). 820 consecutive patients admitted to ICU for more than 24 h. Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3-2.6), alcoholism (2.03, 1.2-3.2), and severity of illness (1.25, 1.03-1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5-6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5+/-11.5 vs. 4.4+/-3.9 days), longer hospital stay (18.2+/-15.7 vs. 13.2+/-19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs.
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                Author and article information

                Journal
                Critical Care Medicine
                Critical Care Medicine
                Ovid Technologies (Wolters Kluwer Health)
                0090-3493
                2018
                September 2018
                : 46
                : 9
                : 1532-1548
                Article
                10.1097/CCM.0000000000003259
                30113371
                © 2018

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