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      Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.

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          Abstract

          The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice.

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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.

          Timothy Girard, John Kress, Barry Fuchs … (2008)
          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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            The impact of delirium in the intensive care unit on hospital length of stay

            E. ELY, S Gautam, R. Margolin … (2001)
            Abstract. Study objective: To determine the relationship between delirium in the intensive care unit (ICU) and outcomes including length of stay in the hospital. Design: A prospective cohort study. Setting: The adult medical ICU of a tertiary care, university-based medical center. Participants: The study population consisted of 48 patients admitted to the ICU, 24 of whom received mechanical ventilation. Measurements: All patients were evaluated for the development and persistence of delirium on a daily basis by a geriatric or psychiatric specialist with expertise in delirium assessment using the Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric Association, the reference standard for delirium ratings. Primary outcomes measured were length of stay in the ICU and hospital. Results: The mean onset of delirium was 2.6 days (S.D.±1.7), and the mean duration was 3.4±1.9 days. Of the 48 patients, 39 (81.3%) developed delirium, and of these 29 (60.4%) developed the complication while still in the ICU. The duration of delirium was associated with length of stay in the ICU (r=0.65, P=0.0001) and in the hospital (r=0.68, P<0.0001). Using multivariate analysis, delirium was the strongest predictor of length of stay in the hospital (P=0.006) even after adjusting for severity of illness, age, gender, race, and days of benzodiazepine and narcotic drug administration. Conclusions: In this patient cohort, the majority of patients developed delirium in the ICU, and delirium was the strongest independent determinant of length of stay in the hospital. Further study and monitoring of delirium in the ICU and the risk factors for its development are warranted.
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              Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients.

              , Wayne Wisemandle, Richard R Riker … (2010)
              To determine the relationship between the number of delirium days experienced by intensive care patients and mortality, ventilation time, and intensive care unit stay. Prospective cohort analysis. Patients from 68 intensive care units in five countries. Three hundred fifty-four medical and surgical intensive care patients enrolled in the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared with Midazolam) trial received a sedative study drug and completed at least one delirium assessment. Sedative drug interruption and/or titration to maintain light sedation with daily arousal and delirium assessments up to 30 days of mechanical ventilation. The primary outcome was all-cause 30-day mortality. Multivariable analysis using Cox regression incorporating delirium duration as a time-dependent variable and adjusting for eight relevant baseline covariates was conducted to quantify the relationship between number of delirium days and the three main outcomes. Overall, delirium was diagnosed in 228 of 354 patients (64.4%). Mortality was significantly lower in patients without delirium compared to those with delirium (15 of 126 [11.9%] vs. 69 of 228 [30.3%]; p<.001). Similarly, the median time to extubation and intensive care unit discharge were significantly shorter among nondelirious patients (3.6 vs. 10.7 days [p<.001] and 4 vs. 16 days [p<.001], respectively). In multivariable analysis, the duration of delirium exhibited a nonlinear relationship with mortality (p=.02), with the strongest association observed in the early days of delirium. In comparison to 0 days of delirium, an independent dose-response increase in mortality was observed, which increased from 1 day of delirium (hazard ratio, 1.70; 95% confidence interval, 1.27-2.29; p<.001), 2 days of delirium (hazard ratio, 2.69; confidence interval, 1.58-4.57; p<.001), and ≥3 days of delirium (hazard ratio, 3.37; confidence interval, 1.92-7.23; p<.001). Similar independent relationships were observed between delirium duration and ventilation time and intensive care length of stay. In ventilated and lightly sedated intensive care unit patients, the duration of delirium was the strongest independent predictor of death, ventilation time, and intensive care unit stay after adjusting for relevant covariates.
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                Author and article information

                Journal
                Journal ID (iso-abbrev): Crit. Care Med.
                Title: Critical care medicine
                ISSN (Electronic): 1530-0293
                ISSN (Print): 0090-3493
                Publication date (Electronic): May 2014
                Volume: 42
                Issue: 5
                Affiliations
                [1 ] 1Center for Critical and Complex Care, The Ohio State University, College of Nursing, Columbus, OH. 2Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University, Nashville, TN. 3Center for Health Services Research, Vanderbilt University, Nashville, TN. 4Geriatric Research, Education, and Clinical Center, Tennessee Valley VA, Nashville, TN. 5Department of Pharmacy Practice, University of Nebraska Medical Center, College of Pharmacy, Omaha, NE. 6Department of Pharmaceutical and Nutrition Care, The Nebraska Medical Center, Omaha, NE. 7Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Omaha, NE. 8Department of Adult Health and Illness, University of Nebraska Medical Center, College of Nursing, Omaha, NE. 9Division of Pulmonary, Critical Care, Sleep, and Allergy, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE. 10Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE. 11Department of Surgery, University of Nebraska Medical Center, Omaha, NE. 12Department of Adult Critical Care Services, The Nebraska Medical Center, Omaha, NE. 13Department of Nursing Research and Quality Outcomes, The Nebraska Medical Center, Omaha, NE. 14Department of Respiratory Care, The Nebraska Medical Center, Omaha, NE. 15Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville, TN. 16Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE.
                Article
                Mid ID: NIHMS594879
                DOI: 10.1097/CCM.0000000000000129
                PubMed ID: 24394627
                SO-VID: 9bbac8d2-fc3b-4114-b9cf-86d28f056492
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