Sedation and Delirium in the Intensive Care Unit

Reade, Michael C.; Finfer, Simon

doi:10.1056/nejmra1208705

Cited by 486 publications

(392 citation statements)

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“…In the past decade significant advances have been made increasing our knowledge on the epidemiology, clinical phenotype, diagnosis, prevention, treatment, and risk assessment of delirium [1]. As clinicians in the intensive care unit (ICU), being able to predict the occurrence of delirium early in the course of critical illness may be extremely useful for the implementation of preventive measures or to design interventions for preemptive treatment of high-risk individuals.…”

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Making advances in delirium research: coupling delirium outcomes research and data sharing

Salluh

Latronico

2015

Intensive Care Med

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Understanding and improving the current management of delirium in critically ill patients has become a major challenge for clinicians at the bedside and researchers. In the past decade significant advances have been made increasing our knowledge on the epidemiology, clinical phenotype, diagnosis, prevention, treatment, and risk assessment of delirium [1]. As clinicians in the intensive care unit (ICU), being able to predict the occurrence of delirium early in the course of critical illness may be extremely useful for the implementation of preventive measures or to design interventions for preemptive treatment of high-risk individuals. In a recent study Wassenaar et al. [2] demonstrated the ability to predict delirium with a relatively straightforward model for implementation at ICU admission.Before publishing the E-PRE-DELIRIC, the authors planned and realized a series of rigorous studies. In their first study, the authors developed the PREdiction of DELIRium for Intensive Care patients (PRE-DELIRIC) model for prediction of delirium based on variables readily available in the first 24 h after ICU admission. The authors then temporally validated it in a second prospective cohort in the same hospital and finally validated it externally in four other Dutch hospitals. Prevalence of delirium varied between 25.5 and 36.8 %. Risk factors were selected on the basis of a systematic review [3]. Of the 25 potential risk factors, ten were retained (Table 1). The area under receiver operating characteristics curve (AUROC) of pooled data varied for development (AUROC = 0.86), temporal validation (AUROC = 0.89), and external validation (AUROC = 0.84), resulting in an AUROC of 0.85.In a second study [4], the PRE-DELIRIC was recalibrated in eight ICUs from six countries; the median delirium incidence was 22.5 % (IQR 12.8-36.6 %). The incidence of the ten predictors differed significantly between centers, but the AUROC of the eight participating centers remained good at 0.77 [95 % confidence interval (CI) 0.74-0.79].In this third prospective cohort study in 13 ICUs from seven countries [2], the authors enrolled 2914 patients to develop and validate a predictive model for ICU delirium based on data available at ICU admission. Multiple logistic regression analysis was used to develop the model on data of the first two-thirds and validated on data of the last one-third of the patients from every participating ICU. The incidence of delirium was 24.5 % in the development cohort (1962 patients), 21.8 % in the validation cohort (952 patients), and 23.6 % in the entire study population. The AUROC was 0.76 (95 % CI

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Making advances in delirium research: coupling delirium outcomes research and data sharing

Salluh

Latronico

2015

Intensive Care Med

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“…Similar to the concept of the ''triad of anesthesia'' (analgesia, sedation, and muscle relaxation), the concept of the ''triad of intensive care'', which consists of addressing pain, agitation, and delirium, has been proposed for critically ill patients. 1 The most recently published guidelines for the management of pain, agitation, and delirium in the intensive care unit (ICU) 2 recommend: 1) regularly assessing levels of pain, sedation, and delirium using validated scales; 2) prioritizing the treatment of pain using both non-pharmacologic and pharmacologic means; 3) prioritizing non-pharmacologic means to prevent and treat delirium; and 4) using sedatives to maintain only light rather than deep levels of sedation.…”

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“…1 Although clinicians may have previously considered deeper sedation necessary to improve patientventilator synchrony (especially when ICU ventilators were less capable of synchronizing with patients' respiratory efforts) and to minimize perceived psychological trauma, recent trials have shown that the use of lighter sedation results in no worse 3 or actually decreased adverse psychological outcomes. 4,5 Thus, investigators involved in this important field of research are pursuing the best way to approach this ICU triad while minimizing potential detrimental effects of the pharmacologic agents employed and optimizing important patient outcomes, such as minimizing the duration of ventilation and length of ICU stay.…”

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confidence: 99%

“…Semblable au concept de la « triade anesthésique » (analgésie, sédation et relâchement musculaire), le concept de « triade des soins intensifs » qui consiste à répondre à la douleur, l'agitation et au délirium, a été proposé pour les patients dans un état critique. 1 Les recommandations les plus récentes publiées pour la gestion de la douleur, de l'agitation et du déirium en unité de soins intensifs (USI) sont les suivantes 2 : 1) évaluer régulièrement le niveau de douleur, de sédation et de délirium en utilisant des échelles validées; 2) donner la priorité au traitement de la douleur en utilisant des moyens à la fois non pharmacologiques et pharmacologiques; 3) donner la priorité aux moyens non pharmacologiques pour prévenir et traiter le délirium; et 4) utiliser des sédatifs pour maintenir des niveaux de sédation légers plutôt que profonds.…”

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“…1 Bien que des cliniciens aient pu considérer par le passé qu'une sédation plus profonde était nécessaire pour améliorer la synchronisation patient-ventilateur (en particulier quand les ventilateurs d'USI avaient une moins grande capacité à se synchroniser avec les efforts respiratoires des patients) et pour minimiser le traumatisme psychologique perçu, les études récentes ont montré que le recours à une sédation plus légère n'étaient pas pires 3 ou, en fait, diminuait les effets psychologiques indésirables. 4,5 Les investigateurs travaillant dans cet important domaine d'étude recherchent donc la meilleure façon d'aborder cette triade d'USI, tout en minimisant les effets nuisibles éventuels des agents pharmacologiques utilisés et en optimisant les aboutissements importants pour les patients, telle que la réduction de la durée de la ventilation et de la durée de séjour en USI.…”

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Optimizing the approach to pain, agitation, and delirium in critical care

Friedrich

Baker

2014

Can J Anesth/J Can Anesth

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Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

Curley

Wypij

Watson

et al. 2015

JAMA

356

246

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Importance Protocolized sedation improves clinical outcomes in critically-ill adults, but its effect in children is unknown. Objective To determine whether critically-ill children managed with a nurse-implemented, goal-directed sedation protocol (RESTORE) would experience fewer days of mechanical ventilation than patients receiving usual care. Design, Setting, and Participants Cluster-randomized trial conducted in 31 U.S. Pediatric Intensive Care Units (PICUs). Children (n=2449; mean age 4.7 years, range 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled 2009–2013 and followed until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Interventions Intervention PICUs (17 sites, n=1225 patients) managed sedation using a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites, n=1224 patients) managed sedation per usual care without a protocol. Main Outcome and Measures The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, sedative exposure including measures of wakefulness, pain, and agitation, and occurrence of iatrogenic withdrawal. Results Duration of mechanical ventilation was not statistically significantly different between the two groups (median; interquartile range: intervention: 6.5 days; 4.1–11.2 vs. control: 6.5; 3.7–12.1). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not statistically significantly different between the two groups. Intervention patients experienced more post-extubation stridor (7% vs. 4%; P=0.03) and fewer stage 2+ immobility-related pressure ulcers (<1% vs. 2%; P=0.001). In exploratory analyses, intervention patients had fewer days of opioid administration (median; interquartile range: 9; 5–15 vs. 10; 4–21; P=0.01), were exposed to fewer sedative classes (2; 2–3 vs. 3; 2–4; P<0.001), and were awake and calm for a greater percentage of study days while intubated (86%; 67–100% vs. 75%; 50–100%; P=0.004), than control patients. However, patients in the intervention group had a greater percentage of days with any report of a pain score ≥4 (50%; 27%-67% vs. 23%; 0–46%; P<0.001) and any report of agitation with a State Behavior Scale score of +1/+2 (60%; 33–80% vs. 40%; 13–67%, P=0.003), than control patients. Conclusions and Relevance Among children undergoing mechanical ventilation for acute respiratory failure, the use of a nurse-implemented, goal-directed sedation protocol compared with usual care did not reduce the duration of mechanical ventilation. Exploratory analyses of secondary outcomes suggest a complex relatio...

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Sedation and Delirium in the Intensive Care Unit

Cited by 486 publications

References 55 publications

Making advances in delirium research: coupling delirium outcomes research and data sharing

Making advances in delirium research: coupling delirium outcomes research and data sharing

Optimizing the approach to pain, agitation, and delirium in critical care

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

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