Richmond Agitation-Sedation Scale Score Research Articles

Tocilizumab is associated with reduced delirium and coma in critically ill patients with COVID-19

Recent preclinical studies demonstrate a direct pathological role for the interleukin-6 (IL-6) pathway in mediating structural and functional delirium-like phenotypes in animal models of acute lung injury. Tocilizumab, an IL-6 pathway inhibitor, has shown reduced duration of ventilator dependency and mortality in critically ill patients with COVID-19. In this study, we test the hypothesis that tocilizumab is associated with reduced delirium/coma prevalence in critically ill patients with COVID-19. 253 patients were included in the study cohort, 69 in the tocilizumab group and 184 in the historical control group who did not receive tocilizumab. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) with a positive score indicating delirium. Coma was defined as a Richmond Agitation-Sedation Scale score of − 4 or − 5. Tocilizumab was associated with significantly greater number of days alive without delirium/coma (tocilizumab [7 days (IQR: 3–9 days)] vs control [3 days (IQR: 1–8 days)]; p < 0.001). These results remained significant after adjusting for age, sex, sepsis, Charlson Comorbidity Index, Sequential Organ Failure Assessment score, and median daily dose of analgesics/sedatives (β^\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\hat{\\upbeta }$$\\end{document} = 0.671, p = 0.010). There were no significant differences in mortality (β^\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\hat{\\upbeta }$$\\end{document} = − 0.204, p = 0.561), ventilator duration (β^\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\hat{\\upbeta }$$\\end{document} = 0.016, p = 0.956), and ICU or hospital length of stay (β^\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\hat{\\upbeta }$$\\end{document} = − 0.134, p = 0.603; β^\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\hat{\\upbeta }$$\\end{document} = 0.003, p = 0.991, respectively). Tocilizumab use was associated with significantly increased number of days without delirium/coma. Confirmation of these findings in randomized prospective studies may inform a novel paradigm of pharmacological amelioration of delirium/coma during critical illness.

The effect of deep and awake extubation on emergence agitation after nasal surgery: a randomized controlled trial

BackgroundPost-anesthetic emergence agitation is common after general anesthesia and may cause adverse consequences, such as injury as well as respiratory and circulatory complications. Emergence agitation after general anesthesia occurs more frequently in nasal surgery than in other surgical procedures. This study aimed to assess the occurrence of emergence agitation in patients undergoing nasal surgery who were extubated under deep anesthesia or when fully awake.MethodsA total of 202 patients (18–60 years, American Society of Anesthesiologists classification: I–II) undergoing nasal surgery under general anesthesia were randomized 1:1 into two groups: a deep extubation group (group D) and an awake extubation group (group A). The primary outcome was the incidence of emergence agitation. The secondary outcomes included number of emergence agitations, sedation score, vital signs, and incidence of adverse events.ResultsThe incidence of emergence agitation was lower in group D than in group A (34.7% vs. 72.8%; p < 0.001). Compared to group A, patients in group D had lower Richmond Agitation-Sedation Scale scores, higher Ramsay sedation scores, fewer agitation episodes, and lower mean arterial pressure when extubated and 30 min after surgery, whereas these indicators did not differ 90 min after surgery. There was no difference in the incidence of adverse events between the two groups.ConclusionsExtubation under deep anesthesia can significantly reduce emergence agitation after nasal surgery under general anesthesia without increasing the incidence of adverse events.Trial registrationRegistered in Clinicaltrials.gov (NCT04844333) on 14/04/2021.

Benefits of dexmedetomidine during noninvasive mechanical ventilation in major abdominal surgery patients with postoperative respiratory failure.

The efficacy of non-invasive mechanical ventilation (NIMV) on the postoperative ARF is conflicting and the failure rate of NIMV in this patient population is high. In our study, we hypothesized that the use of dexmedetomidine during NIMV in major abdominal surgical patients can reduce NIMV failure without significant side affect. Medical records of patients who underwent major abdominal surgery, admitted to our general surgery intensive care unit (ICU), developed postoperative ARF, received NIMV (with oro-nasal mask) and dexmedetomidine infusion were enrolled in this study. The infusion rate was adjusted to maintain a target sedation level of a Richmond Agitation-Sedation Scale (RASS) (-2)-(-3). The sedation was stopped when NIMV was discontinued. A total of 60 patients, 42 (70.0%) male, and 18 (30.0%) female, with a mean age of 68 ± 11 years were included in the study. The mean APACHE II score was 20 ± 6. Dexmedetomidine was infused for a median of 25 h (loading dose of 0.2 mcg/kg for 10 min, maintained at 0.2-0.7 mcg/kg/h, titrated every 30 min). RASS score of all study group significantly improved at the 2 h of dexmedetomidine initiation (+3 vs. -2, p = 0.01). A targeted sedation level was achieved in 92.5% of patients. Six (10.0%) patients developed bradycardia and 5 (8.3%) patients had hypotension. The mean NIMV application time was 23.4 ± 6.1 h. Seven (11.6%) patients experienced NIMV failure, all due to worsening pulmonary conditions, and required intubation and invasive ventilation. Fifty-three (88.3%) patients were successfully weaned from NIMV with dexmedetomidine sedation and discharged from ICU. The duration of NIMV application and ICU stay was shorter in NIMV succeded group (21.4 ± 3.2 vs. 29.9 ± 6.4; p = 0.012). Our study suggests that dexmedetomidine demonstrates effective sedation in patients with postoperative ARF during NIMV application after abdominal surgery. Dexmedetomidine can be considered safe and capable of improving NIMV success.

A novel objective measure for terminal delirium: Activity scores measured by a sheet-type sensor

Context: Delirium is a significant concern in end-of-life care. Continuous monitoring of agitation levels using objective methods may have advantages over existing measurement scales. Objectives: To examine whether an objective measure of activity scores measured using a sheet-type non-wearable sensor (Nemuri SCAN [NSCAN]) was correlated with agitation levels measured using the modified Richmond Agitation-Sedation Scale (RASS) in terminally ill patients with cancer. Methods: We conducted a single-center, prospective, observational study in a palliative care unit using the NSCAN to measure activity scores and the RASS to assess agitation levels. RASS scores were prospectively measured by ward nurses blinded to the NSCAN variables. A database was created to pair the RASS scores and activity scores at night on the same day. Results: During the observation period, 1209 patients were hospitalized, and 3028 pairs of assessments of 971 patients were analyzed. The NSCAN activity scores significantly increased with increasing RASS scores (Jonckheere–Terpstra test, p < 0.001). The mean values of the activity scores for each RASS score were RASS −5, 28.9; RASS −4, 36.4; RASS −3, 41.7; RASS −2, 57.4; RASS −1, 58.8; RASS 0, 62.6; RASS 1, 79.6; RASS 2, 106.5; and RASS 3, 118.7. Conclusion: The NSCAN activity significantly correlated with modified RASS agitation scores. Real-time NSCAN data on agitation may aid timely interventions for optimal symptom control. To improve outcomes for patients suffering from terminal delirium, more research on monitoring tools is warranted.

Comparison of Remimazolam Tosilate and Propofol Sedation on the Early Postoperative Quality of Recovery in Patients Undergoing Day Surgery: A Prospective Randomized Controlled Trial.

Remimazolam tosilate is a novel ultrafast-acting benzodiazepine that has a rapid emergence even after continuous infusion when using flumazenil. So far, relatively few articles are still focusing on the quality of recovery after general anesthesia with remimazolam, especially in day surgery. This study aimed to compare the early postoperative quality of recovery of remimazolam tosilate with flumazenil and propofol in patients undergoing day surgery. 137 patients scheduled for day surgery were randomly divided into the remimazolam tosilate or propofol group. The primary endpoint was the incidence of overall recovery assessed with the early postoperative quality of recovery scale (PostopQRS) on postoperative day 1 (POD 1). The Richmond Agitation-Sedation Scale (RASS) scores in the post-anesthesia care unit (PACU), extubation time, postoperative recovery profiles, and perioperative data were documented. Any adverse events were recorded. The incidence of overall recovery on POD1 was 47.7% in the remimazolam tosilate group and 65.1% in the propofol group (odds ratio, 0.52; 95% confidence interval (CI) 0.26 to 1.06; P = 0.072). In general, the overall recovery of the PostopQRS increased over time, and its interaction between time and group was significant (P = 0.003). Among the five dimensions of PostopQRS, there exist statistical differences between groups including emotional state and cognitive recovery. Upon arrival at the PACU, the remimazolam group was more sedated and took longer to recover to a RASS score similar to propofol. The frequency of application of vasoactive drugs during anesthesia was similar in both groups (P = 0.119). Despite rapid emergence with remimazolam after flumazenil reversal, re-sedation (10.8%) or somnolence (60%) in the PACU was observed, and the length of PACU stay in patients treated with remimazolam tosilate was longer than that of the propofol (35 min vs 30 min, P<0.001). General anesthesia with remimazolam tosilate in conjunction with flumazenil reversal permits rapid recovery of consciousness in day surgery, but there was a notable occurrence of re-sedation or somnolence observed in PACU.

Dexmedetomidine versus ketamine in improving tolerance to noninvasive ventilation after blunt chest trauma: A randomized, double-blinded, placebo-controlled trial

Abstract Background and Aims: Even though patient tolerance is critical to the success of noninvasive ventilation (NIV), research on using sedation to improve tolerance to NIV after traumatic chest injuries is limited. We hypothesized that dexmedetomidine would be superior to ketamine in terms of patient tolerance and lengthening the NIV sessions after blunt chest trauma. Material and Methods: This randomized, double-blinded, placebo-controlled trial included 45 patients of both genders aged 18–60 who needed NIV after blunt chest trauma. The patients were randomly assigned to one of three groups (n = 15) for receiving dexmedetomidine, ketamine, or placebo (0.9% sodium chloride solution) infusion to maintain a Richmond Agitation Sedation Scale (RASS) score between 0 and − 3 during two successive NIV sessions. Patients were evaluated for the duration of the NIV sessions, RASS, Visual Analog Scale (VAS), and the total amount of rescue analgesia consumed. Results: The mean duration of the NIV sessions was significantly longer in patients who received dexmedetomidine (P &lt; 0.001) or ketamine (P &lt; 0.001) compared to placebo. However, the NIV durations did not differ significantly between the dexmedetomidine and ketamine groups (P &gt; 0.05). The dexmedetomidine group had a significantly lower RASS score compared to the ketamine (P &lt; 0.001) and placebo (P &lt; 0.001) groups, whereas the ketamine group had a significantly lower VAS compared to the dexmedetomidine (P = 0.005) and placebo (P = 0.022) groups and required significantly less total morphine (P = 0.001) compared to the other groups. Conclusion: The duration of the NIV sessions for patients with blunt chest trauma did not differ significantly between the dexmedetomidine and ketamine groups.

Awake venovenous extracorporeal membrane oxygenation and survival.

ObjectivesDeep sedation on the ICU is linked to poor outcome. This study investigated the link between Richmond Agitation-Sedation Scale (RASS) and outcome in venovenous extracorporeal membrane oxygenation (V-V ECMO).MethodsWe performed a secondary analysis of a single-center V-V ECMO cohort. RASS was used as a surrogate measure of sedation depth, patients with a score ≥ −1 were considered awake. V-V ECMO durations below 24 h were excluded. Primary endpoint was 30-day survival. Secondary endpoints were hospital survival and weaning from both ventilator and ECMO therapy.ResultsA total of 343 patients were reanalyzed. The median age was 55 years and 52.2% (179/343) survived for 30 days after ECMO cannulation. Median duration of ECMO was 7.9 (4.7–15.0) days and the median duration of mechanical ventilation after ECMO cannulation was 11.8 (6.7–23.8) days.In the whole cohort, median RASS on day one and seven after ECMO were − 4 (−4 to −1) and − 3 (−4 to 0), respectively. ECMO survivors consistently had significantly higher RASS scores during the first 7 days of ECMO compared to non-surviving patients (p &amp;lt; 0.01). On day two after ECMO, survival of awake patients (i.e., RASS ≥-1) was significantly better compared to sedated [i.e., RASS −4 to −2; OR 2.20 (1.28–3.71), p &amp;lt; 0.01] or unresponsive patients [i.e., RASS -5; OR 2.27 (1.15–4.64), p = 0.02]. The survival benefit of awake ECMO was consistent from day two to seven. Patients awake at least once during ECMO showed higher 30-day survival rates [64.4% vs. 39.6%, OR 2.75 (1.77–4.24), p &amp;lt; 0.01].ConclusionIn this retrospective study, awake patients on V-V ECMO showed higher 30-day survival rates compared to sedated or unresponsive patients. These data should encourage further research on awake V-V ECMO.

Do Patients With Mental Illness Undergoing Office-Based Sedation Require an Increased Propofol Dosage?

Providers report needing higher sedative doses to achieve adequate sedation in patients with mental illnesses. These claims, however, have not been thoroughly assessed. The purpose of the study was to measure the association between mental illness and the propofol dosage necessary to achieve a satisfactory level of anesthesia. The study consisted of a single-center, retrospective cohort consisting of patients treated by oral and maxillofacial surgery at the University of Cincinnati Medical Center in 2020. The study was comprised of subjects 15 or older who were American Society of Anesthesiologists (ASA) classification I or II. Subjects under 15 or ASA III or higher were excluded from the study. The predictor variable was the presence or absence of mental illness. The primary outcome was the total dose of propofol, measured as the total amount of propofol administered divided by the patient's weight in kilograms divided by the length of the procedure in minutes (mg/kg/min). The secondary outcome was the Richmond Agitation-Sedation Scale (RASS) score achieved during sedation. Sex, race, ethnicity, age, weight, body mass index, ASA score, prior tobacco use, marijuana use, use of adjunct midazolam, fentanyl, and ketamine during the procedure, and type of procedure served as covariates. Test statistics were calculated using the Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, and χ2 test for bivariate analyses. Linear and logistic regression models were used to estimate association while controlling for confounding. P values ≤ .05 were considered statistically significant. The study sample was 409 subjects (36.92% male, mean age 28.27±12.20years). In bivariate analysis, mental illness did not show any association with propofol dose (mean dose with mental illness 150.85±143.97mg/kg/min, mean dose without mental illness 116.54±104.16, P=.08) or RASS score (sufficiently sedated with mental illness 63.38%, sufficiently sedated without mental illness 58.80%, P=.36). After adjusting for all previously mentioned covariates, mental illness was statistically associated with propofol dose (P<.01). Adjusting for covariates, only sex had a statistically significant association with the RASS score (P<.05). The findings suggest that a patient's mental illness may influence the amount of sedative required to achieve satisfactory anesthesia.

Nebulized dexmedetomidine prior to flexible bronchoscopy in reducing procedural cough episodes a randomized double blind clinical trial. (NCT: CTRI/2022/07/044389, NICOBAR group of investigators)

BackgroundFlexible bronchoscopy (FOB) or video bronchoscopy is a day-care procedure indicated in the diagnosis of various pulmonary disorders. FOB is done under conscious sedation with the use of local lignocaine to reduce cough episodes. Nebulized dexmedetomidine has been shown to have local anaesthetic as well as systemic action. This study investigated the role of Nebulized dexmedetomidine delivered prior to FOB to reduce cough episodes. MethodsIt was a double blind, randomized controlled trial conduced on subject undergoing diagnostic FOB. Subjects with recent history of myocardial infarction or cerebrovascular accidents were excluded. Subjects undergoing therapeutic bronchoscopy or endobronchial ultrasound were also excluded. Subjects in intervention arm received Nebulized dexmedetomidine at a dose of 2 μg/kg whereas control arm subjects were nebulized with normal saline. Primary outcome of the study was to compare the proportion of subjects with moderate-to-severe cough among the two groups. ResultsOver a period of 6 months, 128 cases were screened and 100 were randomized in a ratio of 1:1. Mean age of study population was 49.5 ± 15.6 years with majority being males (64%). Baseline characteristics were similar in the two groups. A higher number of cases in Nebulized dexmedetomidine arm underwent bronchoalveolar lavage (50% versus 24%) whereas a higher number of subjects in control groups underwent “bronchoscopy for airway inspection” (42% versus 20%). The difference in the proportion of subjects with moderate to severe cough in the two groups was not statistically significant (22% versus 18% in Nebulized dexmedetomidine group and control group, respectively, p > 0.05). Doses of anaesthetic drugs (fentanyl, midazolam, locally instilled lignocaine) were also similar in the two groups. However, the discomfort level experienced by the patient as well as ease of doing procedure for the operator, as measure by VAS score, were significantly lower in the intervention arm as compared to the control arm (51 ± 20.6 versus 72.2 ± 13.1, for patient reported discomfort and 12.5 ± 9.8 versus 36.6 ± 27.2, for operator ease of doing procedure). Mean Richmond Agitation Sedation Scale score was significantly lower in the Nebulized dexmedetomidine arm (−0.22 ± 0.1 versus 0.12 ± 0.1). Dexmedetomidine as well as normal saline were equally well tolerated in nebulized form. None of the study subjects reported any intervention related adverse events. ConclusionThis study demonstrated that Nebulized dexmedetomidine has insignificant topical action to reduce cough episodes as compared to normal saline in diagnostic FOB, but systemic effects remain to be investigated.

Safety and Efficacy of Butorphanol as an Analgesic for Patients on Mechanical Ventilation after Cardiac Surgery: An Exploratory Prospective Observational Study

Purpose: This study assessed the safety and analgesic efficacy of butorphanol in patients receiving mechanical ventilation after cardiac surgery. Methods: This was a prospective study. A consecutive cohort of patients from our medical center who underwent cardiac surgery followed by mechanical ventilation between January 2021 and April 2022 were divided into two groups and received either butorphanol or morphine for analgesia, and all patients also received propofol for sedation. Statistical analysis was performed using the t-test or chi-square test, and the pain levels of the two groups were compared based on the Critical-Care Pain Observation Tool (CPOT), as well as sedation based on the Richmond Agitation-Sedation Scale (RASS), and incidences of adverse events. Results: The two groups, each of which contained 70 patients, reported similar analgesic efficacy; the CPOT score was almost 0 and the RASS score was between 0 and –3. The butorphanol group experienced significantly lower rates of nausea, respiratory depression, and drowsiness. However, the two groups experienced similar rates of vomiting, pruritus, drowsiness, constipation, and delirium, durations of mechanical ventilation, use of sedative drugs, and lengths of stay in the intensive care unit. Conclusions: For patients on mechanical ventilation after cardiac surgery, butorphanol can provide analgesic effects similar to those of morphine with a potentially lower risk of certain adverse events.

Prospective Observational Study of Volatile Sedation with Sevoflurane After Aneurysmal Subarachnoid Hemorrhage Using the Sedaconda Anesthetic Conserving Device.

Volatile sedation is still used with caution in patients with acute brain injury because of safety concerns. We analyzed the effects of sevoflurane sedation on systemic and cerebral parameters measured by multimodal neuromonitoring in patients after aneurysmal subarachnoid hemorrhage (aSAH) with normal baseline intracranial pressure (ICP). In this prospective observational study, we analyzed a 12-h period before and after the switch from intravenous to volatile sedation with sevoflurane using the Sedaconda Anesthetic Conserving Device with a target Richmond Agitation Sedation Scale score of - 5 to - 4. ICP, cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), metabolic values of cerebral microdialysis, systemic cardiopulmonary parameters, and the administered drugs before and after the sedation switch were analyzed. We included 19 patients with a median age of 61years (range 46-78years), 74% of whom presented with World Federation of Neurosurgical Societies grade 4 or 5 aSAH. We observed no significant changes in the mean ICP (9.3 ± 4.2 vs. 9.7 ± 4.2mm Hg), PBrO2 (31.0 ± 13.2 vs. 32.2 ± 12.4mm Hg), cerebral lactate (5.0 ± 2.2 vs. 5.0 ± 1.9mmol/L), pyruvate (136.6 ± 55.9 vs. 134.1 ± 53.6µmol/L), and lactate/pyruvate ratio (37.4 ± 8.7 vs. 39.8 ± 9.2) after the sedation switch to sevoflurane. We found a significant decrease in mean arterial pressure (MAP) (88.6 ± 7.6 vs. 86.3 ± 5.8mm Hg) and CPP (78.8 ± 8.5 vs. 76.6 ± 6.6mm Hg) after the initiation of sevoflurane, but the decrease was still within the physiological range requiring no additional hemodynamic support. Sevoflurane appears to be a feasible alternative to intravenous sedation in patients with aSAH without intracranial hypertension, as our study did not show negative effects on ICP, cerebral oxygenation, or brain metabolism. Nevertheless, the risk of a decrease of MAP leading to a consecutive CPP decrease should be considered.

Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation

ObjectiveVariable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation. MethodsThis retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission. ResultsOne hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was −3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission. ConclusionNMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.

Bringing Delirium to Light: Impact of CAM-ICU Tool to Improve Care Coordination.

Delirium is a serious complication in patients in the critical care unit (CCU) that may lead to prolonged hospitalization if left undetected. The CCU at our hospital does not have a framework for determining delirium that could affect patient outcomes and discharge planning. CCU in a community hospital. A posttest-only design was used for this study. We established a framework for the early assessment of delirium, educated and trained nurses to detect delirium, collaborated with the informatics department, intensivist, nursing, respiratory therapy and worked with case management to deploy the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We used a one-tailed independent t test to determine the impact of CAM-ICU on length of stay (LOS). Cross-tabulation and chi-square tests were used to examine the impact of CAM-ICU tool on home care utilization between the intervention and comparison groups. There was a 3.12% reduction in LOS after implementing the CAM-ICU tool. Also, a reduction in home care service utilization demonstrated statistical significance (p= .001) between the intervention group (62.5%; n= 177) and the comparison group (37.5%; n= 106). Case managers are essential in improving care transitions. Case managers need to become competent in understanding the implications of the CAM-ICU tool because of their relevant role in the multidisciplinary rounds as advocates to improve care transitions across the continuum of care. Case managers need to have an understanding on how to escalate when changes in the Richmond Agitation-Sedation Scale scores occur during the multidisciplinary rounds because it can affect care coordination throughout the hospital. Implementing the CAM-ICU decreased LOS, and reduced health care utilization. The early identification of patients with delirium can affect the outcomes of critically ill patients and entails multidisciplinary collaboration.

Ketamine for Primary Analgosedation in Critically Ill Surgery and Trauma Patients Requiring Mechanical Ventilation.

Evaluate effectiveness and safety outcomes associated with the use of ketamine for primary analgosedation in the surgical/trauma ICU setting. Retrospective cohort study. Academic medical center in Minnesota. Patients admitted to the surgical ICU between 2015 and 2019 requiring mechanical ventilation and meeting one of three definitions for ketamine primary analgosedation were included: 1) no concomitant opioid infusion, 2) ketamine monotherapy for greater than or equal to 6 hours with subsequent opioid infusion, or 3) ketamine initiated concomitantly or within 4 hours of opioid and total opioid duration less than 4 hours. None. Use of ketamine, analgesics, and sedatives were evaluated. Pain, sedation, and delirium assessments immediately before and during ketamine infusion were collected and compared with reported goals. Concomitant analgesics, sedatives, and psychotropics were recorded. Reported failures due to ineffectiveness and toxicity were collected. Of 164 included patients, 88% never received a concomitant opioid infusion (primary analgosedation definition 1), 12% met alternative criteria for primary analgosedation (definitions 2 and 3). A majority, 68%, were surgical admissions and mean Acute Physiology and Chronic Health Evaluation III score was 90 (± 30). Median mechanical ventilation duration was 2.5 days (1.1-4.5) and ICU length of stay of 4.9 days (3-8). The median ketamine infusion dose and duration were 0.18 mg/kg/hr (0.1-0.3) and 30 hours (15.1-51.8). Concomitant infusions of propofol and dexmedetomidine were administered in 49% and 29% of patients, respectively. During ketamine infusion, the median percent of total pain scores at goal was 62% (33-96%), while 64% (37-91%) of Richmond Agitation Sedation Scale scores were at goal, and 47% of patients were Confusion Assessment Method-ICU positive during the ketamine infusion. Hallucinations were documented in 14% of patients and ketamine failure occurred in 11% of patients. Ketamine may be an effective primary analgosedation option in intubated surgical ICU patients, but prospective randomized studies are needed to evaluate this strategy.

Comparison of intravenous ketamine and fentanyl sedation in duration of mechanical ventilation in intensive care unit

Background and aims: To compare the duration of mechanical ventilation in patients receiving ketamine compared to fentanyl for sedation in mechanically ventilated patients in intensive care unit. Methods: One hundred and six patients requiring mechanical ventilation were randomized to receive continuous intravenous infusion of either ketamine (1 mg/kg bolus followed by 0.4 to 0.8 mg/kg/h) or fentanyl (1mcg/kg bolus followed by 0.3-0.5 mcg/kg/min) with the dose titrated to achieve Richmond Agitation Sedation Scale (RASS) score of 0 to -1 and Behavioral Pain Scale (BPS) score of 3 to 7. The primary outcome was the duration of mechanical ventilation. Secondary outcomes were sedation score, analgesia score and need of vasopressors. Results: The mean duration of ventilation was 2.5±0.6 days and 2.2±1.0 days (p=0.1) in patients receiving ketamine and fentanyl respectively. More patients required vasopressors: 27 (50.9%) vs 9 (17%) in patients receiving fentanyl compared to ketamine (p&lt;0.05). There were no significant changes in hemodynamic variables after the initiation of the study drug in both the groups. Infusion was discontinued for adverse effects in seven (13%) patients in both the groups. Conclusion: When compared with fentanyl, continuous ketamine infusion was tolerated similarly by critically ill adults, with similar duration of mechanical ventilation. Ketamine sedation was associated with decreased requirement for vasopressors.

Antipsychotic initiation in mechanically ventilated patients in a medical intensive care unit

Objectives: Guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients (PADIS) in the intensive care unit (ICU) promote use of analgosedation to minimize pain, reduce anxiety, and facilitate care. They also suggest against routine use of antipsychotics (APs) for delirium. Our institution’s adaptation incorporates assessment-driven, protocol-based pain, and sedation management and suggests a short course of APs in patients with agitated delirium, defined as Confusion Assessment Method for the ICU (CAM-ICU) positive with Richmond Agitation Sedation Scale (RASS) ≥ +2. While the use of APs in the ICU is typically for delirium, a recent study assessed whether quetiapine reduced sedative requirements among non-delirious patients. The purpose of this study was to assess adherence to our institutional guideline for AP use and to describe sedative and opioid use in relation to AP initiation. Materials and Methods: This retrospective study included patients who were mechanically ventilated and received ≥ 3 new start AP doses. The primary outcome was adherence to our guideline for use of APs in agitated delirium. The secondary outcomes were CAM-ICU and RASS scores in relation to AP initiation and change in sedative and analgesic infusion rates following AP initiation. Results: Thirty-eight patients were included in the study. Five had APs initiated appropriately per our guideline. There was no clinically significant change in continuous infusion rates in the 24 h before and after AP initiation. Conclusion: Overall, AP use was liberal with patients being started on APs who did not have agitated delirium, thus indicating potential alternative indications for initiation. APs did not result in a clinically significant change in continuous infusion requirements in the 24 h following initiation.

Предикторы развития двигательных нарушений при пробуждении после общей анестезии у пациентов травматологического профиля (проспективное когортное исследование)

Analysis of published studies shows that information on patients' hyperactivity on awakening is ambiguous, both regarding the definition of this condition itself and the causes of its occurrence. In the field of neurology and neurophysiology, there is a lack of data on the mechanisms of development of early cognitive impairment after surgery, as well as on the definition of vulnerable patients before surgery and anesthesia. Objective. To determine the prognostic value of predictors of different values on the RASS scale in trauma patients to assess the development of major clinical outcomes. Material and methods. A two-center prospective cohort study of patients aged 45–74 years after planned traumatologic surgeries under general anesthesia was conducted. Demographics, comorbidities, background therapy, preoperative laboratory examinations and testing (ASA, MoCA, AUDIT, CFS, HADS-A, RASS) were analyzed as part of the study. After extubation in the operating room, patients were evaluated using the RASS, CAM-ICU, CAM-ICU-7, NRS, and BPS scales. Statistical analysis was performed using SPSS Statistics 27.0.1.0 software. Results. Two hundred subjects were included in the study between March 2021 and June 2022. An independent predictor of positive Richmond Agitation-Sedation Scale (RASS) values after extubation in the operating room was adherence to alcohol (AUDIT test, optimal cut-off point ≥2 points, Se=59.2%, Sp=72.2%, estimate=0.440; 95% confidence interval (CI) 0.158-0.723, p=0.002). Risk factors of zero and negative RASS scores were found to be predictors of satisfactory quality by ROC analysis. When assessing the impact on clinical outcomes, differences were observed between the groups of patients with positive and zero values on the RASS scale. Conclusion. Patients with positive values on the RASS scale were statistically significantly more likely to have postoperative delirium - 12 (24.5%) patients, p=0.002.

Continuous visualization and validation of pain in critically ill patients using artificial intelligence: a retrospective observational study

Machine learning tools have demonstrated viability in visualizing pain accurately using vital sign data; however, it remains uncertain whether incorporating individual patient baselines could enhance accuracy. This study aimed to investigate improving the accuracy by incorporating deviations from baseline patient vital signs and the concurrence of the predicted artificial intelligence values with the probability of critical care pain observation tool (CPOT) ≥ 3 after fentanyl administration. The study included adult patients in intensive care who underwent multiple pain-related assessments. We employed a random forest model, utilizing arterial pressure, heart rate, respiratory rate, gender, age, and Richmond Agitation–Sedation Scale score as explanatory variables. Pain was measured as the probability of CPOT scores of ≥ 3, and subsequently adjusted based on each patient's baseline. The study included 10,299 patients with 117,190 CPOT assessments. Of these, 3.3% had CPOT scores of ≥ 3. The random forest model demonstrated strong accuracy with an area under the receiver operating characteristic curve of 0.903. Patients treated with fentanyl were grouped based on CPOT score improvement. Those with ≥ 1-h of improvement after fentanyl administration had a significantly lower pain index (P = 0.020). Therefore, incorporating deviations from baseline patient vital signs improved the accuracy of pain visualization using machine learning techniques.

Postanesthesia Care Unit Recovery Time According to Volatile Anesthetic Used in Clinical Practice.

Whether volatile anesthetic solubility affects postanesthesia recovery time in clinical practice is unclear. We investigated the association among 3 volatile agents and 2 clinically relevant outcomes-postanesthesia care unit (PACU) recovery time (time from PACU admission to fulfillment of discharge criteria) and oversedation (Richmond Agitation-Sedation Scale score ≤-3)-as a potential contributor to delaying PACU discharge. The volatile agents studied were isoflurane, desflurane, and sevoflurane. We hypothesized that increased solubility of the volatile agent (isoflurane versus desflurane or sevoflurane) would be associated with longer PACU recovery time and higher rates of oversedation. This retrospective observational study included adults (≥18 years) who underwent surgical procedures under general anesthesia with a volatile agent and were admitted to the PACU from May 5, 2018, to December 31, 2020. The primary outcome was PACU recovery time, and the secondary outcome was oversedation. PACU recovery time was log-transformed and analyzed with linear regression. Oversedation was analyzed by using logistic regression. To account for potential confounding, inverse probability of treatment weighting (IPTW) was used. Pairwise comparisons of the 3 agents were performed, with P < .017 (Bonferroni-adjusted) considered significant. Of 47,847 patients included, 11,817 (24.7%) received isoflurane, 11,286 (23.6%) received desflurane, and 24,744 (51.7%) received sevoflurane. Sevoflurane had an estimated 4% shorter PACU recovery time (IPTW-adjusted median [interquartile range {IQR}], 61 [42-89] minutes) than isoflurane (64 [44-92] minutes) (ratio of geometric means [98.3% confidence interval {CI}], 0.96 [0.95-0.98]; P < .001). Differences in PACU recovery time between desflurane and the other agents were not significant. The IPTW-adjusted frequency of oversedation was 8.8% for desflurane, 12.2% for sevoflurane, and 16.7% for isoflurane; all pairwise comparisons were observed to be significant (odds ratio [98.3% CI], 0.70 [0.62-0.79] for desflurane versus sevoflurane, 0.48 [0.42-0.55] for desflurane vs isoflurane, and 0.69 [0.63-0.76] for sevoflurane versus isoflurane; all P < .001). Although oversedated patients had longer PACU recovery time, differences in the oversedation rate across agents did not result in meaningful differences in time to PACU recovery. In clinical practice, only small, clinically unimportant differences in PACU recovery time were observed between the volatile anesthetics. Although oversedation was associated with increased PACU recovery time, differences in the rate of oversedation among agents were insufficient to produce meaningful differences in overall PACU recovery time across the 3 volatile agents. Practical attempts to decrease PACU recovery time should address factors other than volatile agent selection.

Delirium is associated with failure to rescue after cardiac surgery

ObjectivePostoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. MethodsWe studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. ResultsAny episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. ConclusionsA single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.