Agitation Scores Research Articles

Delirium and delirium severity screening in the intensive care—correspondence of screenings tools

BackgroundDelirium severity scores are gaining acceptance for measuring delirium in the intensive care unit (ICU). ObjectiveThe aim of this study was to evaluate the concordance between the Confusion Assessment Method for the intensive care unit (CAM-ICU)-7 and the Intensive Care Delirium Screening Checklist (ICDSC) as delirium severity measurement tools. MethodsThis was a prospective, comparative, observational multicentre study. This study was conducted in 18 Danish ICUs. Delirium was assessed in adult critically ill patients admitted to an ICU with a Richmond Agitation and Sedation Score (RASS) of −2 or above. ICU nurses assessed delirium with randomised paired delirium screening instruments, using the CAM-ICU, the ICDSC, and the CAM-ICU-7. The correlation between the CAM-ICU-7 and the ICDSC severity scores was evaluated for all predefined patient subgroups. ResultsA total of 1126 paired screenings were conducted by 127 ICU nurses in 850 patients. The patients' median age was 70 years (interquartile range: 61–77), 40% (339/850) were female, and 54% (457/850) had at least one positive delirium score. Delirium severity ranges (CAM-ICU-7: 0–7; and ICDSC: 0–8) were positively correlated (Pearson's correlation coefficient, r = 0.83; p < 0.0001). The overall agreement between the CAM-ICU-7 and the ICDSC for delirium measurement (CAM-ICU-7: >2, and ICDSC: >3) was substantial (kappa = 0.74), but the agreement decreased to fair (kappa = 0.38) if a patient had a RASS less than 0. ConclusionsThe agreement between the CAM-ICU-7 and the ICDSC for delirium severity measurement was substantial but might be affected by the patient's sedation and agitation level at the time of assessment. Implications for practiceBoth CAM-ICU-7 and ICDSC can be implemented for delirium severity measurement. Attention is warranted in both scores if a patient has a RASS of −2.

Clinician perception of care at the end of life in a quaternary neonatal intensive care unit.

Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process. We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool. Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers. These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).

A Prospective, Randomized, Double-blinded Study on the Comparison of Propofol and Ketofol (Combination of Ketamine and Propofol) for Modified Electroconvulsive Therapy

ABSTRACT Background and Aims: Modified electroconvulsive therapy is routinely used to treat complicated psychiatric disorders. Its therapeutic effect is directly proportional to induced seizure duration but it is associated with hemodynamic disturbances. The aim of this study was to evaluate the effect of a ketamine + propofol combination (“ketofol”) for electroconvulsive therapy and to compare these with the effects of propofol alone. Methods: In this prospective study, 60 patients aged 18–60 years with American Society of Anesthesiologists (ASA) Ι and ΙΙ for psychiatric disorders were included. Patients were divided into two groups (30 each). Group P received propofol at 10 mg/ml and group K received ketofo at 10 mg/ml (ketamine 5 mg/ml and propofol 5 mg/ml in a 1:1 ratio). Motor/electroencephalography (EEG) seizure duration, induction time, hemodynamic variables, recovery time, agitation score, and complications were recorded. Standard qualitative and quantitative tests were used to compare the data (e.g., unpaired student t-test, Chi-squared test, etc). A P value of &lt; 0.05 was considered to be significant. Results: The mean duration of (motor/EEG) seizure was statistically significantly high in the ketofol group compared to the propofol group (P = 0.0001/0.0001). The mean induction time was significantly less in the ketofol group compared to propofol group (P = 0.0001). The recovery time was significantly early in group K patients compared to group P (P = 0.004). The ketofol group was more hemodynamically stable with comparable agitation score and side effects than patients in the propofol group. Conclusion: In modified ECT, ketofol was associated with longer seizure duration, lesser induction time, better hemodynamic stability, early recovery with comparable post ECT agitation and adverse effects compared to propofol alone.

A retrospective analysis of the incidence and determinants of self-extubation in a tertiary care surgical intensive care unit

Background &amp; Objective: Self-extubation is reported as one of the most common adverse events in the adult intensive care units worldwide. We aimed to find out the incidence and determinants of self-extubation in surgical intensive care unit of our tertiary care hospital. Methodology: It was retrospective analysis of the data acquired from the hospital databases, about the patients who self-extubated during admission to surgical intensive care unit (SICU) of Aga Khan University Hospital, Karachi, Pakistan, during six calendar years, from January 01, 2010, through December 31, 2016. Data collection form was used to collect personal details, drugs used for sedation, sedation agitation score, pain score, nurse-patient ratio and the use of any restraint at the time of extubation. SPSS was used to analyze data applying the central limit theorem to calculate the mean and standard deviation for quantitative variables and the Chi-square test was conducted using a P &lt; 0.05 for qualitative variables. Multivariate logistic regression analysis was performed to identify the independent risk factors for self-extubation Results: A total of 618 patients were admitted to the SICU who required mechanical ventilation during the study period. An overall 2.1% incidence of self-extubation was calculated with a documented thirteen self-extubation episodes. The mean age of patients was 38.46 ± 16.97 y with majority of them being males. Most, 9 (69.2%), of the patients were not restrained at the time of self-extubation. Nurse to patient ratio was 1:1. Majority of patients 7 (53.8%) were not on any sedative drug infusion and the mean sedation agitation score at that time was 4.46 ± 2.02 while mean pain score was 5.31 ± 2.72. Reintubation was performed in 10 (76.9%) of the patients, who had self-extubated. Conclusion: This study revealed that the incidence of self-extubation was 2.1% in SICU and there was strong correlation between absent physical restraint and self-extubation incidence during the weaning period. Key words: Mechanical ventilation; Reintubation; Self-extubation; Sedation; Surgical Intensive Care Unit; Tertiary Care Hospital Ali MA, Rashid S, Siddiqui KM, Yousuf MS. A retrospective analysis of the incidence and determinants of self-extubation in a tertiary care surgical intensive care unit. Anaesth. pain intensive care 2023;27(3):260−263; DOI: 10.35975/apic.v27i3.2231 Received: October 03, 2022; Reviewed: April 04, 2023; Accepted: April 19, 2023

Effect of agitation and aggression on quality of life in patients with dementia

AbstractBackgroundBehavioral and psychological symptoms of dementia (BPSD) are highly prevalent in patients with dementia during the course of the disease. Among BPSD symptoms, agitation and aggression are a source of distress for both the patients and their caregivers. In this study, we investigated the impact of agitation and aggression on Quality of Life (QoL) of patients with dementia living in long‐term care homes or admitted to psychiatric inpatient units.MethodData were obtained from the Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study, a multisite trial conducted in Canada. Agitation and aggression were assessed with the Cohen‐Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory Clinician rating scale (NPI‐C); QoL with the informant‐rated Alzheimer’s Disease Related Quality of Life (ADRQL) tool; stage of dementia with the Functional Assessment Staging Tool (FAST); and burden of physical illness with the Cumulative Illness Rating Scale‐Geriatric (CIRS‐G). Regressions were performed to investigate the associations between agitation or aggression and QoL controlling for demographic factors, FAST score, and CIRS‐G score.Result179 participants were included (52.5% female; mean (SD) age = 80.79 (9.45) years. The ADRQL score was correlated with: (1) CMAI total frequency score (Pearson’s r = ‐.333, p&lt;.001); (2) NPI‐C agitation score (Pearson’s r = ‐.209, p = .005); and (3) NPI‐C aggression score (Pearson’s r = ‐.300, p&lt;.001). The associations remained significant for the CMAI total frequency score (β = ‐.235, SE B = 0.054, p&lt;.001), and NPI‐C agitation and aggression composite score (β = ‐.288, SE B = 1.254, p&lt;.001) after controlling for age, sex, current residence, FAST score and CIRS‐G score.ConclusionQoL is related to agitation and aggression in patients with dementia. The relationship is independent of demographic factors, stage of dementia, and burden of comorbid physical illness. This suggests that better management of agitation and aggression may be an important factor in improving QoL in patients with dementia.

Neuropathological correlates of neuropsychiatric symptoms in dementia

AbstractBackgroundNeuropsychiatric symptoms (NPS) are very common in Lewy body dementias (LBD), but their aetiology is poorly understood. In a post‐mortem study we aimed to characterise the contribution of neuropathological substrates to some of the most common NPS in dementia.MethodParticipants who passed away between 2004 and 2021 underwent comprehensive neuropathologic evaluation at the Biobank for Aging Studies. Neuropathological data was collected for Lewy body neuropathology (LBD Braak score), neurofibrillary tangles (NFT Braak score), amyloid‐β burden (CERAD‐NP), TDP‐43, lacunar infarcts, cerebral amyloid angiopathy and hyaline atherosclerosis. Post‐mortem interviews were used to collect information regarding neuropsychiatric and cognitive status using the Neuropsychiatric Inventory (NPI) and Clinical Dementia Rating (CDR). A total of 948 cases were classified according to neuropathological assessment: (1) No pathology (NP) (n = 678); (2) Alzheimer’s Disease (AD) (n = 183); (3) LBD (n = 57); (4) AD+LBD (n = 30).ResultMultinomial logistic regression models comparing LBD, AD and AD+LBD to NP, adjusted for age, ethnicity, sex, and education level, showed significantly higher odds of hallucination and delusions across all groups compared to NP with the relative risk of hallucinations most elevated in AD+LBD cases (RRR = 19.3,[95%CI = 8.00‐46.3], p&lt;0.001). All groups had increased risk of higher NPI scores relative to NP, but the greatest increase was for AD+LBD (RRR = 1.04, [95%CI = 1.02‐1.06], p&lt;0.001). There were significantly greater risk of agitation and apathy in AD and AD+LBD groups relative to NP. (Table 1) Additionally, hallucinations were associated with higher Lewy body Braak scores (OR = 1.30, 95%CI = 1.13‐1.49, p&lt;0.001). Higher NFT Braak scores were associated with depression (OR = 1.28, 95%CI = 1.09‐1.50, p&lt;0.001), agitation (OR = 1.30, 95% CI = 1.07‐1.57, p = 0.009) and overall NPI score (IRR = 1.15, 95%CI = 1.05‐1.27, p = 0.004). Lacunar infarcts were associated with delusions (OR = 4.68, 95%CI = 1.12‐19.5, p = 0.03). More frequent neuritic plaques was inversely associated with apathy (OR = 0.70, 95%CI = 0.52‐0.93, p = 0.01). Cerebral amyloid angiopathy, hyaline atherosclerosis, and TDP‐43 did not associate with any of the neuropsychiatric symptoms in the multivariable logistic models. (Table 2)ConclusionLewy body pathology was the most significant contributor to the aetiology of hallucinations, while NFT were important contributors to depression and agitation in dementia. Supporting the dual importance of these pathologies, subjects with AD and LBD co‐pathology showed the greatest burden of NPS.

FEWER KNOTS IN CIRCUMCISION ARE ASSOCIATED WITH LESS POSTOPERATIVE PAIN: A RETROSPECTIVE COMPARATIVE STUDY

Male circumcision is the most frequently performed surgical procedure among Muslim and Jewish communities, mainly for medical, religious, and traditional reasons (1-4). In the USA, circumcision is frequently performed for cosmetic purposes. Although it is seen as a simple procedure, it is quite prone to complications like other surgical procedures. The early and long-term complications of circumcision are well known and the overall complication rate has been reported between 0.2% and 3.9%. Common complications associated with circumcision are acute bleeding, pain, edema, wound infection, and unnecessary foreskin. Rare complications include meatal stenosis, urethral fistula, partial and total glandular amputations, glandular necrosis, penile curvature, and penile rotation. In addition, keloid formation and scar hypertrophy are some rare complications that cause poor cosmetic appearance.The aim of paper: Our aim in this study was to investigate the effect of the number of sutures placed during circumcision on postoperative pain, infection, bleeding amount, and analgesic need in children.Materials and methods: A total of 715 patients who applied to our hospital for circumcision requests between November 2019 and January 2022 were retrospectively analyzed. The patients were randomly divided into three groups according to the number of knots used during the surgical procedure: Group 1 (8 sutures), group 2 (6 sutures), and group 3 (4 sutures). The patients were evaluated in terms of whether they needed analgesics in the postoperative period (1-hour), bleeding status, and whether this bleeding needed re-intervention.Results: The average age of the participants in the study was 4.06±2.51 years, and the average weight was 18.66±7.07 kg. The operation was completed using 8 sutures (group 1) in 47.5%, 6 sutures (group 2) in 27.7%, and 4 sutures (group 3) in 24.9% of the patients. Postoperative infection developed in 2.8% of the participants, and bleeding was observed in 25.1%. The number of participants who needed analgesia for the first hour after the operation was 66.8%. The median value of the postoperative pain scale was 5 (range: 1-9), and those with a pain scale of 5-9 were 65.5%. There was no significant difference between the groups in terms of age, weight, development of infection, and bleeding (p&gt;0.05). Analgesia was needed in 88.7% of those in group 1, 69.9% of those in group 2, and 21.6% of those in group 3 (p&lt;0.001). A score (MPOS) of 5 or higher was found in 86.8% of those in group 1, 71% of those in group 2, and 18.6% of those in group 3 (p&lt;0.001).Conclusions: our study showed that group 3 (4 sutures) achieved lower pain scores, less analgesic consumption, and lower agitation scores after circumcision compared to other groups.

Effects of aromatherapy on agitation in patients with dementia in the community: A quasi-experimental study

The behavioral and psychological symptoms of dementia (BPSD) are experienced by up to 90% of patients with dementia throughout dementia. This study aims to investigate the effect of aromatherapy on agitation in patients with dementia in the community. This prospective cohort study was conducted at a single day-care center for patients with dementia located in northern Taiwan with 2-week and 4-week follow-ups, comparing the severity of agitation between 3 measure points as the primary outcome. The aromatherapy was performed over 5 consecutive days for 4 weeks. Throughout the four-week observation were analyzed by GEE. Significant differences were found in the Chinese version of Cohen-Mansfield Agitation Inventory (CCMAI) total agitation score (ß=-3.622, p=0.037) and physically non-aggressive behavior subscale (ß=-4.005, p=0.004) between aromatherapy group and control group. The severity of dementia-related agitation, especially the severity of physically non-aggressive behavior in demented patients, could be significantly reduced by a four-week intervention of aromatherapy.

Scopolamine Induced Non-cognitive Effects in the Radial-arm maze: Alleviation by Physostigmine

Purpose: Scopolamine has frequently been reported to induce a “memory deficit” in animals and humans. However, the possible role of the non-cognitive effects of the drug in these impairments is often ignored. In the present study, the effects of scopolamine on various behaviors in the radial arm maze were recorded and the ability of physostigmine to reverse them was examined.&#x0D; Methods: Male Long-Evans hooded rats were trained on an 8-arm radial maze to consume drops of 0.1 ml of sweetened milk from the end of each arm. Once the asymptomatic performance was achieved, the effects of scopolamine (0.25 mg/kg i.p. 20 min before testing) on(1) the number of errors (re-entries into the arms), (2) the number of rewards drops not consumed, and (3) agitation were examined.&#x0D; Results: The number of errors, the number of drops left, and agitation scores were increased significantly compared to saline-treated rats. Concomitant administration of scopolamine and physostigmine (0.25 i.p. 15 min before testing) significantly reduced the agitation scores and revealed a trend toward a decrease in the number of drops left compared to scop-treated rats. However, in this experiment, scopolamine did not significantly increase the number of errors compared to the saline-treated rats.&#x0D; Conclusion: Taken together, scopolamine induced a small but inconsistent increase in the number of errors. In contrast, there were significant effects of scopolamine on agitation and milk consumption in both experiments. These non-cognitive effects of scopolamine (which were attenuated by physostigmine) may indirectly lead to an increase in errors.

Effect of ice popsicle treatment on emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia: A prospective randomized controlled study

Emergence agitation is a common postoperative complication during recovery in children. The purpose of this study is to explore whether the use of ice popsicle could prevent emergence agitation in children undergoing oral surgery with sevoflurane anaesthesia. In this prospective randomized controlled study, 100 children undergoing oral surgery were randomly assigned to Group 1 which received ice popsicle after emergence (intervention, n=50) or Group 2 which received verbal encouragement from their parents (control, n=50). The primary outcome was the 2-hour postoperative incidence of EA. Group 1 had a significant lower incidence of emergence agitation (22% vs 58%, P<0.001) compared with Group 2. The mean agitation score was significantly lower in Group 1 vs Group 2 at 10 minutes (1.64 vs 2.12, P=0.024) and 20min (1.60 vs 2.14, P=0.004) after emergence. The peak agitation and pain scores were significantly lower in Group 1 than in Group 2 (P<0.001). Findings from this study suggest that ice popsicle is an effective, cheap, pleasurable, and easily administered method for alleviating emergence agitation in paediatric patients after oral surgery under general anaesthesia. These results are worthy of confirmation in other surgeries. This approach is highly accepted by both children and their parents, and our findings support the effectiveness of ice popsicle in relieving emergence agitation and pain after oral surgery in children. Chinese Clinical Trial Registry, ChiCTR1800015634.

Measuring Performance on the ABCDEF Bundle During Interprofessional Rounds via a Nurse-Based Assessment Tool

Nurse-led rounding checklists are a common strategy for facilitating evidence-based practice in the intensive care unit (ICU). To streamline checklist workflow, some ICUs have the nurse or another individual listen to the conversation and customize the checklist for each patient. Such customizations assume that individuals can reliably assess whether checklist items have been addressed. To evaluate whether 1 critical care nurse can reliably assess checklist items on rounds. Two nurses performed in-person observation of multidisciplinary ICU rounds. Using a standardized paper-based assessment tool, each nurse indicated whether 17 items related to the ABCDEF bundle were discussed during rounds. For each item, generalizability coefficients were used as a measure of reliability, with a single-rater value of 0.70 or greater considered sufficient to support its assessment by 1 nurse. The nurse observers assessed 118 patient discussions across 15 observation days. For 11 of 17 items (65%), the generalizability coefficient for a single rater met or exceeded the 0.70 threshold. The generalizability coefficients (95% CIs) of a single rater for key items were as follows: pain, 0.86 (0.74-0.97); delirium score, 0.74 (0.64-0.83); agitation score, 0.72 (0.33-1.00); spontaneous awakening trial, 0.67 (0.49-0.83); spontaneous breathing trial, 0.80 (0.70-0.89); mobility, 0.79 (0.69-0.87); and family (future/past) engagement, 0.82 (0.73-0.90). Using a paper-based assessment tool, a single trained critical care nurse can reliably assess the discussion of elements of the ABCDEF bundle during multidisciplinary rounds.

Intramuscular Ketamine Effect on Postnasal Surgery Agitation: A Prospective Double-Blinded Randomized Controlled Trial.

This study investigates the effect of intramuscular ketamine on emergence agitation (EA) following septoplasty and open septorhinoplasty (OSRP) when administered at subanesthetic doses at the end of surgery. A random sample of 160 ASA I-II adult patients who underwent septoplasty or OSRP between May and October, 2022, was divided into two groups of eighty patients each: ketamine (Group K) and saline (Group S) with the latter serving as the control group. At the end of surgery immediately after turning off the inhalational agent, Group K was administered with intramuscular 2 ml of normal saline containing 0.7 mg/kg ketamine and Group S with 2 ml of intramuscular normal saline. Sedation and agitation scores at emergence from anesthesia were recorded after extubation using the Richmond Agitation-Sedation Scale (RASS). The incidence of EA was higher in the saline group than in the ketamine group (56.3% vs. 5%; odds ratio (OR): 0.033; 95% confidence interval (CI): 0.010-0.103; p < 0.001). Variables associated with a higher incidence of agitation were ASA II classification (OR: 3.286; 95% (CI): 1.359-7.944; p=0.008), longer duration of surgery (OR: 1.010; 95% CI: 1.001-1.020; p=0.031), and OSRP surgery (OR: 2.157; CI: 1.056-5.999; p=0.037). The study concluded that the administration of intramuscular ketamine at a dose of 0.7 mg/kg at the end of surgery effectively reduced the incidence of EA in septoplasty and OSRP surgery.

Ultrasonography Causes Agitation and Pain Leading to Hemodynamic Disturbance in Neonates: A Prospective Observational Study

Ultrasonography is widely used in neonatological practice and studies investigating the hemodynamic effects of various treatment protocols or clinical situations. On the other hand, pain causes changes in the cardiovascular system; so, in the case of ultrasonography leading to pain in neonates, it may cause hemodynamic alterations. In this prospective study, we evaluate whether ultrasonographic application causes pain and changes in the hemodynamic system. Newborns undergoing ultrasonographic examination were enrolled in the study. Vital signs, cerebral and mesenteric tissue oxygenation (StO2) levels, and middle cerebral artery (MCA) Doppler measurements were recorded, and NPASS scores were calculated before and after ultrasonography. We enrolled 39 patients in the study. After ultrasonography, Neonatal Pain, Agitation, and Sedation Scale (NPASS) scores were significantly higher (p < 0.01), and all vital signs (heart rate, respiratory rate, SpO2, diastolic and systolic blood pressure; p = 0.03; p < 0.01, p < 0.01, p < 0.01, p = 0.02, p = 0.03, respectively) were altered. Cerebral (p = 0.008) and mesenteric (p = 0.039) StO2 levels were significantly lower in the whole study group, MCA end-diastolic velocity decreased (p = 0.02), and the resistive index (p = 0.03) increased in patients whose NPASS score was >7 after ultrasonography. This study is the first to show that ultrasonography may cause pain in newborn patients, and alters vital signs and hemodynamic parameters. Therefore, precautions should be taken to protect newborn babies from pain during ultrasound applications, as they are already exposed to many noxious stimuli. Furthermore, pain scores should be considered in studies using ultrasonography and evaluating hemodynamic parameters to increase the reliability of the studies.

Effect of two different doses of oral midazolam premedication on separation anxiety in children scheduled for herniotomy

Background: Peri-operative separation anxiety in children adversely impacts on their cognitive function and behavioural outcome. The aim of the study was to assess the effect of two different doses of oral midazolam premedication on separation anxiety in paediatric patients scheduled for herniotomy. Methods: Eighty-four eligible children aged 1-6 years, of American Society of Anesthesiologists (ASA) class I or II, scheduled for herniotomy, were randomized into two groups, A and B, of 42 each after ethical clearance and written parental consent. Children in group A and group B received 0.5 mg/kg and 0.75 mg/kg respectively of oral midazolam flavoured with paracetamol syrup, were observed, and later separated from parents at 30 min post-premedication. Premedicant acceptability was noted, and separation anxiety was assessed using the Richmond agitation sedation scale (RASS). Statistical significance was set at p&lt;0.05. Results: All 84 children completed the study. At 30 min post-premedication, 47.6% in group A and 19.1% in group B had light sedation, while 52.4% in group A and 80.9% in group B were moderately sedated, p=0.0001. Premedicant acceptability and agitation scores between the groups were comparable, p&gt;0.05. Conclusions: Oral 0.5 mg/kg and 0.75 mg/kg midazolam induced desirable sedation in children at the 30th min with comparable lower agitation scores; however, the 0.75 mg/kg dose achieved significantly faster onset and higher level of sedation in a greater proportion of the subjects.

Dexmedetomidine versus Clonidine for Improved Quality of Emergence from General Anaesthesia: A Randomised Placebo-Controlled Study

Introduction: Extubation of the trachea upon emergence from General Anaesthesia (GA) is often accompanied by potentially dangerous events, like coughing, hypertension, tachycardia, and agitation. The centrally acting a -2 agonist, dexmedetomidine, has been evaluated to attenuate the emergence/extubation response. However, there is insufficient evidence regarding the effectiveness of clonidine for the same purpose. Aim: This study aimed to evaluate the quality of emergence from GA in patients receiving clonidine infusion versus dexmedetomidine infusion. Materials and Methods: In this randomised, double-blinded trial conducted over a period of 5 months, 105 patients aged 18-70 years, of either sex, with American Society of Anaesthesiologists (ASA) grade I-III, scheduled for elective laparotomies with an estimated duration of 1-4 hours, were randomly assigned to groups D, C, and P. Group D received inj. dexmedetomidine 1 μg/kg, group C received clonidine 3 μg/kg, and group P received placebo (normal saline) via intravenous (i.v.) route over 10 minutes using a syringe pump, 10 minutes prior to the anticipated end of surgery. Haemodynamic parameters, cough, agitation, shivering, time to extubation, sedation, Visual Analogue Score (VAS), and Postoperative Nausea and Vomiting (PONV) scores were recorded before, during, and after extubation. The incidence of complications (hypotension, bradycardia, or others) was also recorded. Categorical data were expressed as proportions, while numerical data were presented as mean±Standard Deviation (SD) or median±Interquartile Range (IQR). Appropriate data were compared using Statistical Package for Social Sciences (SPSS) version 16.0. Results: A total of 105 patients were included, with 53 males and 52 females. There was no difference in the demographic characteristics, such as age, gender, and Body Mass Index (BMI), amongst the three groups. Haemodynamic parameters (Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP)) were significantly lower in patients of group D and group C compared to the placebo group at 5, 10, 10, and 15 minutes, respectively, after the beginning of drug infusion (p-value &lt;0.05). Patients in groups D and C had significantly lower median cough scores at 20-25 minutes compared to the placebo group (p-value at 20 and 25 minutes was 0.012 and &lt;0.001, respectively). There was a significant reduction in postoperative pain, as measured by VAS score, and an increase in sedation, as measured by Ramsay sedation score, in groups D and C compared to the placebo group. There was no statistical difference in agitation score, shivering score, PONV score, time to extubation, and incidence of complications among the three groups (p-value &gt;0.05). Conclusion: Administration of 1 μg/kg of dexmedetomidine or 3 μg/kg of clonidine over 10 minutes prior to recovery from General Endotracheal Tube Anaesthesia (GETA) results in a better quality of recovery, as evidenced by a statistically significant reduction in cough scores in patients undergoing elective laparotomies when compared to patients of placebo group.

A prospective observational single center study evaluating emergence agitation in the early postoperative period in adult patients undergoing elective craniotomies under general anesthesia.

Emergence agitation is a significant clinical issue during recovery from general anesthesia. Patients after intracranial operations are even more vulnerable to the stress resulting from emergence agitation. Due to the limited data available in neurosurgical patients, we evaluated the incidence, risk factors, and complications of emergence agitation. 317 consenting eligible patients undergoing elective craniotomies were recruited. The preoperative Glasgow Coma Scale (GCS)) and pain score were recorded. Bispectral Index (BIS) guided balanced general anesthesia was administered and reversed. Immediate postoperatively, the GCS and the pain score were noted. The patients were observed for 24 hours following extubation. The levels of agitation and sedation were evaluated by the Riker's Agitation-Sedation Scale. Emergence Agitation was defined as Riker's Agitation score of 5 to 7. In our subset of the patient population, the incidence was 5.4%, mildly agitated in the first 24 hours and none required sedative medication as therapy. The sole risk factor identified was prolonged surgery beyond 4 hours. None of the patients in the agitated group had any complications. Early objective assessment of risk factors in the preoperative period with objective validated tests and shorter duration of surgery maybe the way forward in patients at high risk for emergence agitation, to reduce the incidence and mitigate the undesirable consequences.

Effect of Preoperative Preconditioning of Patients with External Nasal Compression for Different Time Intervals on Emergence Agitation After Nasal Surgeries: A Randomised Controlled Trial

Introduction: Emergence agitation is a commonly experienced phenomenon in the waking period of general anaesthesia, which can adversely affect the recovery of patients in the postoperative period. Patients undergoing nasal surgeries under general anaesthesia, involving postoperative nasal packing, tend to have a higher rate of emergence agitation after extubation. Non pharmacological methods like nasal clips, can be safe and costeffective alternatives to pharmacological agents for controlling emergence agitation. Aim: To evaluate the efficacy of preoperatively applying nasal clips for various durations in patients scheduled for nasal surgeries under general anaesthesia, which require nasal packing in the postoperative period, in reducing emergence agitation after extubation. Materials and Methods: The present randomised controlled trial was conducted at department of Anesthesia, Shrimati Bhikhiben Kanjibhai Shah Medical Institute and Research Centre (SBKS MIRC) in Piparia, Vadodara, Gujarat, India. A total of 75 patients with ASA I and II, aged 18-65 years, posted for elective nasal surgeries under general anaesthesia with postoperative bilateral nasal packing, were randomly divided into three groups. Group A (25 patients) wore nasal clips for 30 minutes preoperatively, Group B (25 patients) wore the clip for 40 minutes preoperatively, and Group C (25 patients) served as the control group without nasal clips. At the time of extubation, the emergence agitation score, ability to cough, time to verbal response, respiratory rate, incidences of desaturation, laryngospasm, or any other complications were observed and noted by an anaesthetist who was unaware of the application of nasal clips preoperatively. All data statistically analysis were performed using Statistical Package for Social Sciences (SPSS) for Windows (version 21.0; IBM Corporation). Results: All three groups were comparable (p&gt;0.05) in terms of demographic profile, type and duration of surgery, and baseline haemodynamic parameters like Heart Rate (HR), Mean Arterial Pressure (MAP), Oxygen Saturation (SpO2 ), and baseline Electrocardiography (ECG). Emergence agitation was significantly lower in Group A and B as compared to Group C (p-value=0.02). On comparing Groups A and B, Group B had a significantly lower incidence of emergence agitation (p-value=0.02). There were two cases of dangerous emergence agitation in the control group and one case in Group A while no cases were reported in Group B. Other parameters at extubation were comparable among all groups. Patient satisfaction was significantly higher in Groups A and B in comparison to Group C. Conclusion: The present study suggests that preoperative preconditioning with nasal clips for 40 minutes in patients undergoing elective nasal surgeries can be a useful and safe method to reduce postoperative emergence agitation.

Efficacy of Sacral Plexus Block Combined with Dexmedetomidine for Prevention of Catheter-Related Bladder Discomfort in Patients with TURP

This work focused on investigating therapeutic efficacy of sacral plexus block combined with dexmedetomidine in preventing catheter-related bladder discomfort in patients receiving transurethral resection of the prostate. Sixty patients undergoing elective prostatectomy were randomized as group D or group M (n=30 each). Both groups were given dexmedetomidine 0.5 μg/kg 10 min before induction of general anesthesia. The severity score of catheter-related bladder discomfort, Richmond agitation sedation scale, visual analog scale score and adverse events at 30 min (T1), 2 h (T2) and 6 h (T3) postoperatively were recorded. 1 d preoperatively, as well as 1 and 3 d postoperatively, the neuropsychiatric function of patients was tested by mini-mental state examination and the incidence of postoperative cognitive dysfunction was observed. Compared with group D, group M had significantly decreased catheter-related bladder discomfort incidence at T1 and T2 (p<0.05), but with the passage of time, difference in the incidence of catheter-related bladder discomfort of both groups at T3 was of no statistical significance (p>0.05). Compared with group D, the visual analog scale scores of group M at T1, T2 and T3 remarkably decreased (p<0.05). Relative to group D, group M had remarkably reduced agitation scores at T1, T2 and T3 (p<0.05). Differences in the side effects rate and postoperative cognitive dysfunction incidence were not significantly different between both groups (p>0.05). Sacral plexus block combined with dexmedetomidine decreases postoperative catheter-related bladder discomfort rate among transurethral resection of the prostate patients and has good comfort and safety.

488: DELIRIUM PREDICTS MORTALITY AND LENGTH OF STAY BUT NOT FUNCTIONAL INDEPENDENCE POST-ICU DISCHARGE

Introduction: Delirium is common in the intensive care unit (ICU) and can complicate the existing critical illness. Yet, there is a paucity of information about delirium incidence and its effect on patient’s outcomes in the developing countries where it can be misdiagnosed or undetected. The aim of this study was to determine the incidence, predictors, and the association of delirium with short-term (ICU length of stay, hospital length of stay, and in-hospital mortality) and long-term (activities of daily living and mortality at 4 months after discharge) outcomes among ICU patients. Methods: This was a prospective cohort study of 111 patients who were conscious, > 18 years old, and admitted to the ICU for ≥ 8 hours. Untestable patients (Richmond agitation score of -4 or -5, mental disability, receptive aphasia, and/or visual or auditory impairment) were excluded. The Confusion Assessment Method for the ICU (CAM-ICU) was utilized to assess delirium while Katz Activities of Daily Living index was used to assess functional independence at 4 months after discharge. Delirium was assessed daily during ICU stay and continued until death or ICU discharge. Multivariable logistic regression and student’s t-test were used in the analyses. Results: Delirium was found in 32% of patients. The severity of illness measured by APACHE II (OR 1.28, p<.001) score was an independent predictor of delirium in multivariable analysis controlling age, sex, and sedation. Patients with delirium had significantly longer ICU and hospital stay (12.4±11.9 and 22.2±19.4 respectively) compared to those without delirium (6.4±5.8 and 14.7±17.4, respectively), p<.05. Delirium was associated with increased in-hospital and 4-month mortality (OR 12.1 and 7.1, p<.05) but not with activities of daily living (OR=1.4, p=.69). Conclusions: Delirium has a substantial effect on ICU and hospital length of stay and both in-hospital and post discharge mortality. The mechanistic link between delirium and mortality remains unclear. This warrants further investigation to better understand how delirium contributes to mortality, and to determine whether the current interventions to manage delirium affect mortality among ICU patients.

Involvement of inflammation in the medial temporal region in the development of agitation in Alzheimer's disease: an in vivo positron emission tomography study.

The evaluation of 11 C-DPA-713 binding using positron emission tomography for quantifying the translocator protein can be a sensitive approach in determining the level of glial activation induced by neuroinflammation. Herein, we aimed to investigate the relationship between regional 11 C-DPA713-binding potential (BPND ) and neuropsychiatric symptoms (NPS) in amyloid-positive Alzheimer's disease (AD) patients. Fifteen AD patients were enrolled in this study. Correlations were evaluated between the 11 C-DPA713-BPND and Neuropsychiatric Inventory Questionnaire (NPI-Q) scores, including scores in its four domains: agitation, psychosis, affective, and apathy. 11 C-DPA713-BPND values were compared between groups with and without the neuropsychiatric symptoms for which a relationship was observed in the abovementioned correlation analysis. A positive correlation was found between the severity of agitation and 11 C-DPA713-BPND in the Braak 1-3 area, including the amygdala, hippocampal and parahippocampal regions, and lingual and fusiform areas. An increase in the 11 C-DPA713-BPND was observed in AD patients with agitation. We did not find any significant effects of possible confounding factors, such as age, duration of illness, education, gender, Mini-Mental State Examination score, cerebrospinal fluid amyloid β 42/40 ratio, and apolipoprotein E4 positivity, on either the 11 C-DPA713-BPND or agitation score. Neuroinflammation in the medial temporal region and its neighbouring area was shown to be associated with the development of agitation symptoms in AD patients. Our findings extend those of previous studies showing an association between some NPS and inflammation, suggesting that immunologically based interventions for agitation can serve as an alternative treatment for dementia.