Richmond Agitation-Sedation Scale Research Articles

Prevalence and Risk Factors of Delirium in Patients Admitted to Intensive Care Units: A Multicentric Cross-Sectional Study.

Background Delirium is a common and serious complication among critically ill patients in the intensive care unit. Knowledge of the risk factors of delirium can help tremendously in the diagnosis of delirium. Methods In April of 2023, a cross-sectional multicenter study was conducted in eight intensive care units (ICUs) across Pakistan. Delirium was assessed using the intensive care delirium screening checklist. Demographic and clinical data were collected, and multivariable logistic regression analysis was performed to identify predictors of delirium. A total of 256 patients were enrolled in the study. Results The mean age of participants was 56 (S.D. 12) years. The point prevalence of delirium was 39%, and the point prevalence did not vary significantly among the participating intensive care units. Advanced age, higher Acute Physiology and Chronic Health Evaluation - IV (APACHE IV) scores, and higher Richmond Agitation-Sedation Scale (RASS) scores at enrollment were identified as significant predictors of delirium. Conclusion The high prevalence of delirium, observed at 39.0%, emphasizes the importance of proactive screening and effective management strategies in the ICU setting. Healthcare providers in Pakistan should be mindful of these risk factors and implement preventive measures to minimize the occurrence of delirium in critically ill patients. Further research and implementation of targeted interventions are warranted to improve patient outcomes and enhance the overall quality of care in this population.

Nociception assessment with videopupillometry in deeply sedated intensive care patients: Discriminative and criterion validations

BackgroundNociceptive assessment in deeply sedated patients is challenging. Validated instruments are lacking for this unresponsive population. Videopupillometry is a promising tool but has not been established in intensive care settings. Aim/ObjectiveTo test the discriminate validity of pupillary dilation reflex (PDR) between non-noxious and noxious procedures for assessing nociception in non-neurological intensive care unit (ICU) patients and to test the criterion validity of pupil dilation using recommended PDR cut-off points to determine nociception. MethodsA single-centre prospective observational study was conducted in medical–surgical ICU patients. Two independent investigators performed videopupillometer measurements during a non-noxious and a noxious procedure, once a day (up to 7 days), when the patient remained deeply sedated (Richmond Agitation–Sedation Scale score: −5 or −4). The non-noxious procedures consisted of a gentle touch on each shoulder and the noxious procedures were endotracheal suctioning or turning onto the side. Bivariable and multivariable general linear mixed models were used to account for multiple measurements in same patients. Sensitivity and specificity, and areas under the curve of the receiver operating characteristic curve were calculated. ResultsSixty patients were included, and 305 sets of 3 measurements (before, during, and after), were performed. PDR was higher during noxious procedures than before (mean difference between noxious and non-noxious procedures = 31.66%). After testing all variables of patient and stimulation characteristics in bivariable models, age and noxious procedures were kept in the multivariable model. Adjusting for age, noxious procedures (coefficient = −15.14 (95% confidence interval = −20.17 to −15.52, p < 0.001) remained the only predictive factor for higher pupil change. Testing recommended cut-offs, a PDR of >12% showed a sensitivity of 65%, and a specificity of 94% for nociception prediction, with an area under the receiver operating curve of 0.828 (95% confidence interval = 0.779–0.877). ConclusionsIn conclusion, PDR is a potentially appropriate measure to assess nociception in deeply sedated ICU patients, and we suggest considering its utility in daily practices. RegistrationThis study was not preregistered in a clinical registry. Tweetable abstractPupillometry may help clinicians to assess nociception in deeply sedated ICU patients.

Erector spinae plane block versus local infiltration anaesthesia for transforaminal percutaneous endoscopic discectomy: A prospective randomised controlled trial

BackgroundAround 60%–80% of the population suffers from back pain, making it one of the most common health complaints. Transforaminal percutaneous endoscopic discectomy (TPED) is an effective treatment for low back pain that can be performed using different anaesthesia techniques. Our primary objective was to test the hypothesis that bilateral Erector spinae plane block (ESP) plus sedation is equally effective as traditional local infiltration anaesthesia plus sedation in TPED. Materials and methodsFifty-two patients undergoing TPED were randomly assigned to 2 groups: G1 – intravenous sedation with local infiltration anaesthesia; G2 – intravenous sedation with bilateral ESP. Primary outcome: volume of fentanyl and propofol administered during surgery. Secondary outcomes: adverse events during sedation reported using the World Society of Intravenous Anaesthesia (SIVA) adverse sedation event tool, level of postoperative sedation measured on the Richmond Agitation-Sedation Scale (RASS), intensity of postoperative pain on a visual analogue scale (VAS), mechanical pain threshold (MPT) measured with von Frey monofilaments on both lower extremities, patient satisfaction with analgesia on 5-point Likert scale. ResultsVolume of fentanyl, propofol, and level of postoperative sedation was significantly lower in G2 (p < 0.001). There was no difference between groups in intensity of pain, patient satisfaction with analgesia, and mechanical pain threshold after surgery. There were no adverse events in G2, but in G1 2 patients presented minimal risk descriptors, 5 presented minor risk descriptors, and 1 presented sentinel risk descriptors that required additional medication or rescue ventilation. ConclusionsThe ESP was equal to local infiltration anaesthesia in terms of intensity of pain, mechanical pain threshold after surgery, and patient satisfaction; however, ESP reduced the volume of intraoperative fentanyl and propofol, thereby reducing the adverse effects of sedation.

A Comparative Study of Intramuscular Ketamine and a Combination of Intramuscular Dexmedetomidine and Ketamine as Premedication in Paediatric Anesthesia

Introduction: Preoperative anxiety is an issue of concern in paediatric anaesthesia practice. Forceful transfer of children into the operating room can cause long-term psychological trauma. This clinical study compares intramuscular ketamine and a combination of intramuscular dexmedetomidine and ketamine as anaesthetic premedicants in terms of +anxiolysis, sedation and ease of IV cannulation.&#x0D; Objectives: To compare the level of preoperative anxiety, sedation and ease of cannulation following premedication between intramuscular ketamine and a combination of intramuscular dexmedetomidine and ketamine.&#x0D; Methods: Total of 60 patients belonging to American Society of Anaesthesiologists physical status I-II, in the age group of two to ten years, scheduled for elective surgery under general anaesthesia were included in the study; Group A patients received ketamine 3mg/kg body weight while Group B patients received ketamine 2mg/kg body weight and dexmedetomidine 1mcg/kg body weight intramuscular. The outcome variables were sedation score (Richmond Agitation Sedation Scale), IV cannula acceptance (IV cannula Acceptance Score), and parental separation (Separation Score).&#x0D; Results: The groups were comparable in patient characteristics and hemodynamic parameters between the groups. Median (IQR) sedation score at 10 min were -1 (-2—0) and 0(-1—1) (p&lt; 0.001); mean parental separation scores were 3.76± 0.43 and 3.36±0.55 (p&lt; 0.001); IV cannula acceptance score were 3.73±0.44 and 4.53±7.27 (p= 0.001) in Group A and Group B respectively.&#x0D; Conclusion: Combination of dexmedetomidine and ketamine is superior to ketamine alone in terms of sedation at 15 min and ease of IV cannulation but comparable in terms of anxiolysis.

Effect of postoperative application of esketamine on postoperative depression and postoperative analgesia in patients undergoing pancreatoduodenectomy: a randomized controlled trial protocol

BackgroundPancreatoduodenectomy (PD) is traumatic, difficult to perform, and has a high incidence of postoperative complications and perioperative mortality. Postoperative complications and pain occur frequently and seriously affect the psychological status of patients. Esketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has analgesic and antidepressant effects. In this study, we aim to investigate the effect of esketamine on postoperative depression and pain in patients undergoing PD.Methods/designThis prospective, single-center, randomized control trial will include 80 patients who will undergo elective PD. The patients will be randomly assigned to two groups: the experimental group that will receive esketamine (n = 40) and the control group (n = 40). In the esketamine group, the analgesic pump will be connected immediately after surgery. A solution of esketamine 1.5 mg/kg + sufentanil 2 µg/kg, diluted to 150 mL, will be administered continuously for 72 h at the background infusion and impact doses of 1 mL/h and 2 mL/time, respectively; the locking time will be 10 min. The control group will receive sufentanil 2 µg/kg that will be administered as per the esketamine group. The primary outcome will be the Hamilton Depression Scale (HAMD-17) score on the third day post-surgery (POD3). Secondary study indicators will include (1) visual analog scale (VAS) score and HAMD-17 score prior to surgery, immediately after entering the postanesthesia care unit (PACU) and 1, 2, 3, 4, and 5 days after surgery; (2) Richmond Agitation-Sedation Scale (RASS) score at 1, 2, 3, 4, and 5 days after surgery; (3) consumed doses of sufentanil and esketamine after surgery; (4) postoperative analgesia pump effective press times, rescue analgesia times, and rescue drug dosage, recording the number of rescue analgesia and rescue drug dosage at 6, 24, 48, and 72 h after the patient enters the PACU; (5) postoperative complications and adverse events; (6) postoperative hospital stay; (7) concentrations of brain-derived neurotrophic factor (BDNP), 5-hydroxytryptamine (5-HT), tumor necrosis factor (TNF-α) and interleukin-6, at 1, 3, and, 5 days post-surgery; and (8) the patient survival rate at 6 and 12 months post-surgery.DiscussionThe study hypothesis is that the postoperative HAMD-17 and VAS scores, incidence of postoperative adverse reactions, and concentration of serum markers BDNP, 5-HT, TNF-α, and IL-6 in the experimental group will be lower than those in the control group.Trial registrationClinicalTrials.gov ChiCTR2200066303. Registered on November 30, 2022.Protocol version: 1.0

Effect of a music intervention on anxiety in adult critically ill patients: a multicenter randomized clinical trial

BackgroundPrevious studies show positive effect of music on reducing anxiety, pain, and medication requirement. Anxiety has become a more pertinent issue in the intensive care unit (ICU) since wakefulness is preferred according to recent guidelines. Nevertheless, evidence on the effect of music in ICU patients is scarce. Therefore, we studied the effect of music intervention on anxiety in ICU patients.MethodsA multicenter randomized clinical trial was conducted between August 2020 and December 2021 in ICU’s at an academic medical centre and two regional hospitals. Adult critically ill patients were eligible when hemodynamically stable and able to communicate (Richmond agitation-sedation scale (RASS) of at least − 2). Patients in the intervention arm were offered music twice daily during three days for at least 30 min per session. Patients in the control group received standard care. The primary outcome was anxiety level assessed with the visual analogue scale for anxiety [VAS-A; range 0–10] twice daily (morning and evening). Secondary outcomes included; 6-item state-trait anxiety inventory (STAI-6), sleep quality, delirium, heart rate, mean arterial pressure, pain, RASS, medication, ICU length of stay, patients’ memory and experience of ICU stay.Results94 patients were included in the primary analysis. Music did not significantly reduce anxiety (VAS-A in the intervention group; 2.5 (IQR 1.0–4.5), 1.8 (0.0–3.6), and 2.5 (0.0–3.6) on day 1, 2, and 3 vs. 3.0 (0.6–4.0), 1.5 (0.0–4.0), and 2.0 (0.0–4.0) in the control group; p > 0.92). Overall median daily VAS-A scores ranged from 1.5 to 3.0. Fewer patients required opioids (21 vs. 29, p = 0.03) and sleep quality was lower in the music group on study day one [5.0 (4.0–6.0) vs. 4.5 (3.0–5.0), p = 0.03]. Other outcomes were similar between groups.ConclusionsAnxiety levels in this ICU population were low, and music during 3 days did not decrease anxiety. This study indicates that efficacy of music is context and intervention-dependent, given previous evidence showing decreased anxiety.Trial registration Netherlands Trial Register: NL8595, Registered, 1 April 2020. ClinicalTrials.gov ID: NCT04796389, Registered retrospectively, 12 March 2021

In-hospital catatonia, delirium, and coma and mortality: Results from the delirium and catatonia prospective cohort investigation

BackgroundCatatonia, a form of acute brain dysfunction typically linked with severe affective and psychotic disorders, occurs in critical illness with delirium and coma. Delirium and coma are associated with mortality, though catatonia's relationship with mortality is unclear. We aim to describe whether catatonia, delirium, and coma are associated with mortality. MethodsWe enrolled a convenience cohort of critically ill adults (N = 378) at an academic medical center. We assessed catatonia, delirium, and coma using the Bush-Francis Catatonia Rating Scale, the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation-Sedation Scale, respectively. We tested the associations between previous day brain dysfunction state occurrence with in-hospital and one-year mortality using multivariable time-dependent risk models. Additionally, we tested the association between brain dysfunction duration and one-year mortality. ResultsCatatonia was not associated with death on the day after diagnosis during hospitalization, and neither previous catatonia occurrence nor duration was associated with one-year mortality. Delirium was not associated with death on any day following diagnosis during hospitalization, and neither previous delirium occurrence nor duration was associated with one-year mortality. The occurrence of coma was associated with death on any day after diagnosis during hospitalization (HR 2.30,CI 1.19–4.44,p = 0.014), as well as through one year following hospital discharge (HR 1.68,CI 1.09–2.59,p = 0.02). ConclusionsComa, but neither catatonia nor delirium, was associated with future day in-hospital and one-year mortality. More research is needed to understand catatonia's clinical impact. Delirium results differ from existing literature likely due to cohort demographics and size. Coma results highlight the prognostic significance of suppressed arousal while critically ill.

The pupillary dilation reflex to a nociceptive stimulus as a tool for analgesia management: A diagnostic study

BackgroundMore than 70% of patients demonstrate pain after endotracheal aspiration. Tools are needed to objectify the need for analgesia in non-communicative critically ill patients. ObjectiveThe objective of this study was to identify the lowest intensity electrical stimulus for detecting pain before daily care interventions. MethodsStudy of diagnostic tests to assess pupillometry to detect pain through the pupillary dilation response to noxious stimuli versus the Behavioural Pain Scale. Patients older than 18 years, under analgosedation, subjected to invasive ventilation, baseline Behavioural Pain Scale of 3, and Richmond Agitation-Sedation Scale between −1 and −4 were studied. We assessed the Behavioural Pain Scale and the pupillary dilation response to 10, 20, 30, and 40 mA stimuli. We studied the diagnostic performance based on sensitivity and specificity, negative predictive value, positive predictive value, and accuracy of the selected points after the different stimulations. AlgiScan® Pupillometer measured the pupillary dilation response. The presence of pain was considered as a Behavioural Pain Scale score of ≥4. Significance was defined as p <0.05. ResultsMeasurements were performed on 31 patients. In the 20 mA stimulus, we found an area under the curve of 0.85 (0.69–1.0). The cut-off point of pupillary dilation was 11.5%, with a sensitivity of 100% (34.2–100) and a specificity of 75.9% (57.9–87.8). This point had an accuracy of 77.4 (60.2–88.6) and a Youden's Index of 0.8. ConclusionsPupillary variation measurement during a 20 mA stimulus could help assess the need for analgesia before potentially painful interventions. Further studies are needed to confirm this. RegistrationPhase 1 of the project PUPIPAIN ClinicalTrials.gov Identifier: NCT04078113.

Pain Control and Sedation in Neuro Intensive Critical Unit

Neurocritical patients who can self-report pain use the 0-10 numerical rating scale (NRS, verbal or visual form). However, critically ill patients whose nervous systems cannot express pain use the behavioral pain scale (BPS) and the critical care pain observation tool (CPOT) behavioral pain assessment tools. These tools reveal pain-related changes in movement, facial expression, posture, and physiological indicators such as heart rate, blood pressure, and respiratory rate. In pain control, it is first essential to reduce unnecessary painkillers through non-drug therapy and maximize the effect of the administered analgesics. For nonneuropathic pain, narcotic analgesics such as fentanyl, hydromorphone, morphine, and remifentanil are administered intravenously. Gabapentin, pregabalin, and carbamazepine are recommended along with narcotic analgesics for neuropathic pain control. In addition, nonnarcotic analgesics for multi-modal analgesia are used to reduce the use of narcotic analgesics or the side effects of narcotic analgesics. In the intensive care unit (ICU), the sedation-agitation scale (SAS) and the Richmond agitation-sedation scale (RASS) are used to determine the depth of sedation to be maintained during shallow or deep sedation, considering the condition of the critically ill patient. When selecting sedatives for critically ill patients, preferentially consider nonbenzodiazepines such as propofol or dexmedetomidine rather than benzodiazepines such as midazolam or lorazepam. In addition, patients use painkillers or sedatives for over a week, and neurological changes or physiological dependence may occur. Therefore, clinicians should evaluate the critically ill patient’s condition, and sedatives and painkillers should be reduced or discontinued.

Long-term sedation with remimazolam besylate versus propofol in critically ill patients during invasive mechanical ventilation: a study protocol for a multicenter randomized non-inferior trial.

Background: Remimazolam besylate is a novel ultra-short-acting benzodiazepine that can potentially be a safe and effective sedative in intensive care units. This study aims to assess whether remimazolam besylate is not inferior to propofol in maintaining mild-to-moderate sedation in critically ill patients receiving long-term mechanical ventilation. Methods and analysis: This is a multicenter, randomized, single-blind, propofol-controlled, non-inferiority study. Eligible patients are randomly assigned to receive remimazolam besylate or propofol in a 1:1 ratio to maintain a Richmond Agitation-Sedation Scale score between -3 and 0. When patients are under-sedated, rescue sedation of dexmedetomidine is added. The primary outcome is the percentage of time in the target sedation range. The secondary outcomes are hours free from the invasive ventilator in 7days, successful extubation in 7days, and weaning time, the length of intensive care unit stay, the length of hospital stay, and mortality in 28days. Modified intention-to-treat and safety analysis is performed. Clinical trial registration number: https://clinicaltrials.gov/ct2/show/NCT05555667.

Ideal Anesthetic Agent for Cardiac Electrophysiology Study and Catheter Ablation – A Pilot Study

Objectives: Patients suffering from supraventricular tachycardia (SVT) require diagnostic or therapeutic intervention in a cardiac electrophysiology (EP) laboratory. Some anesthetic medications may adversely affect cardiac EP and conduction, altering the ability to induce the arrhythmia, and may have a negative impact on the ablation treatment. This prospective, randomized, pilot study was conducted in the cardiac EP laboratory of a tertiary care hospital with the aim to identify the ideal anesthetic agent for cardiac EP study and catheter ablation of SVT. The primary objective was to compare the effects of anesthetic agents on cardiac electrophysiological parameters and arrhythmia inducibility. The secondary objective was to compare the patient, anesthesiologist, and cardiologist satisfaction scores with respect to the anesthetic agent used. Materials and Methods: Thirty adult patients with SVT for EP study and radiofrequency catheter ablation were administered either of the anesthetic agents: midazolam, fentanyl, propofol, ketamine, or sevoflurane titrated to produce conscious sedation corresponding to bispectral index (BIS) values between 71 and 90. Electrophysiological parameters were recorded before and after administering the anesthetic agent. Results: Arrhythmia could be induced in all patients. Although electrophysiological parameters remained stable with ketamine administration; higher values of the Richmond Agitation Sedation Scale score and BIS were recorded. Propofol and sevoflurane administration was associated with deviation in electrophysiological parameters more than fentanyl and midazolam. The highest values of patient, anesthesiologist, and cardiologist satisfaction scores were obtained in the fentanyl group and the lowest in the ketamine group (P &lt; 0.002). Conclusion: In doses used to provide conscious sedation, fentanyl provided ideal conditions, and midazolam, propofol, sevoflurane, and ketamine provided satisfactory conditions for conducting EP study and catheter ablation for supraventricular tachyarrhythmias. The potential of propofol to impede cardiac conduction needs to be explored further.

Comparison of propofol vs. remimazolam on emergence profiles after general anesthesia: A randomized clinical trial

Study objectiveThe emergence profiles in patients undergoing total intravenous anesthesia with either propofol or remimazolam with flumazenil reversal were compared. DesignA prospective, double-blind, randomized trial. SettingAn operating room and a post-anesthesia care unit (PACU). PatientsAdult patients (n = 100) having American Society of Anesthesiologists (ASA) physical status of I-III undergoing general anesthesia were enrolled and randomly assigned to the propofol or the remimazolam group. InterventionsThe propofol group received target-controlled infusion of propofol, and the remimazolam group received continuous infusion of remimazolam. Continuous infusion of remifentanil was used in both groups. For emergence, flumazenil was used in increments of 0.2 mg in the remimazolam group. MeasurementsThe primary outcome was the time required for the patient to obey verbal commands. The secondary outcomes included the time to bispectral index (BIS) over 80, the time to laryngeal mask airway (LMA) removal, the Richmond Agitation-Sedation Scale (RASS) scores in the PACU, and adverse events throughout the study period. Main resultsThe time taken to obey verbal commands was significantly longer in the propofol group than the remimazolam group (14 [9, 19]) vs. 5 [3, 7]) minutes, P < 0.001; median difference -9, 95% confidence interval -11 to -6). The times to BIS over 80 and to LMA removal were also significantly longer in the propofol group. In addition, the RASS score upon arrival to the PACU differed significantly between the two groups (P = 0.006). Re-sedation in the PACU was observed in 11 (22%) of the patients in the remimazolam group. ConclusionsRemimazolam-based total intravenous anesthesia with flumazenil reversal may be effective in reducing emergence time, but a significant incidence of re-sedation was observed in the PACU. Further studies are needed to determine adequate dose and timing of routine flumazenil use and minimize the risk of re-sedation.

Postoperative infusion of dexmedetomidine via intravenous patient-controlled analgesia for prevention of postoperative delirium in elderly patients undergoing surgery

BackgroundPostoperative delirium (POD) is a common clinical complication in elderly patients after surgery and predicts poor outcomes.AimWe researched whether postoperative infusion of dexmedetomidine (DEX) had prophylactic effect on POD in elderly patients.MethodsA total of 236 patients over the age of 60 years undergoing thoracoabdominal tumor surgery were enrolled in Zhejiang Cancer Hospital from November 2016 to October 2020. The patients were randomly assigned into DEX group (group D) and control group (Group C). DEX was provided via PCIA pump 1–3 days after surgery, which consisted of 3 ug/kg sufentanil and 3 ug/kg DEX in group D, and 3 ug/kg sufentanil without DEX in group C. The PCIA parameters were programmed as follows: total amount 150 ml, 2 ml bolus dose with a lock-out of 10 min and background infusion rate 2 ml/h. The primary endpoint was the incidence of POD, assessed twice daily within 7 days after surgery by Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method–Intensive Care Unit (CAM-ICU). The secondary endpoint was postoperative hospitalization days, ICU stay time, adverse events and non-delirium complications.ResultsThe incidence of POD in all patients was 7%. The incidence of POD in group C was significantly higher than that in group D (10.1% vs 3.4%, P = 0.042). There were no significant differences in length of hospital stay after operation, ICU stay time, the percentage of patients discharged within 7 days after surgery, non-delirium complications, and 30-day all-cause deaths between the two groups. The incidence of hypertension in group D was lower than that in group C (P = 0.003), and there were no differences in other adverse events.ConclusionPatients aged over 60 years received DEX in addition to intravenous patient-controlled analgesia (PCIA) for major thoracoabdominal surgery experienced less delirium.

Correlation of the Critical Care Pain Observation Tool and Numeric Rating Scale in Intensive Care Unit Patients.

We sought to determine the correlation between the Numeric Rating Scale (NRS) and Critical-Care Pain Observation Tool (CPOT) to determine whether clinical factors modified the relationship between NRS and CPOT assessments. We included nonventilated adults admitted to the MICU or SICU who could self-report pain and had at least 3 paired NRS and CPOT assessments. We performed Spearman correlation to assess overall correlation and performed proportional odds logistic regression to evaluate whether the relationship between NRS and CPOT assessments was modified by clinical factors. Nursing staff performed NRS and CPOT assessments every 4 h in 1302 patients, leading to 61,142 matched assessments. We found that the NRS and CPOT have a Spearman correlation coefficient of 0.56 and an intraclass correlation coefficient of 0.32 in intensive care unit patients. Factors that modified the relationship between the NRS and CPOT included the presence of delirium (P < .001) and lower mean daily Richmond Agitation Sedation Scale (<0.001). The correlation coefficient between the NRS and the CPOT was found to be 0.56. The presence of delirium, decreased level of arousal, modified the relationship between the NRS and CPOT. Self-reported and behavioral pain assessments cannot be used interchangeably in critically ill adults.

EEG response of dexmedetomidine during drug induced sleep endoscopy.

Dexmedetomidine is one of the anesthetics of choice for drug induced sleep endoscopy (DISE), with advantages including limited respiratory depression, analgesia, and decreased incidence of emergence delirium. However, challenges with determining sedation levels and prolonged recovery have limited its usage. An improved understanding of the effect of dexmedetomidine on the level of sedation and the corresponding electroencephalographic (EEG) changes could help overcome these barriers. Fifty-one patients received dexmedetomidine sedation with Richmond Agitation-Sedation Scale (RASS) score assessment and continuous EEG monitoring via SedLine for DISE. We constructed a pharmacokinetic model to determine continuous dexmedetomidine blood concentration. From the SedLine, we extracted the patient state index (PSI), and from the EEG we calculated the spectral edge frequency 95% (SEF95) and the correlation dimension (CD), a type of fractal dimension used to assess the complexity of a system. These metrics were subsequently compared against one another and with the dexmedetomidine concentration. Our pharmacokinetic model yielded a two-compartment model with volumes of 51.8 L and 106.2 L, with clearances of 69.5 and 168.9 L/h, respectively, and a time to effect of 9 min, similar to prior studies. Based on this model, decreasing RASS score, SEF95, CD, and PSI were all significantly associated with increasing dexmedetomidine concentration (p < 0.001, p = 0.006, p < 0.001 respectively). The CD, SEF95, and PSI better captured the effects of increasing dexmedetomidine concentration as compared to the RASS score. Simulating dexmedetomidine concentration based on titration to target levels derived from CD and PSI confirmed commonly used dexmedetomidine infusion dosages. Dexmedetomidine use for DISE confirmed previous pharmacokinetic models seen with dexmedetomidine. Complex EEG metrics such as PSI and CD, as compared to RASS score and SEF95, better captured changes in brain state from dexmedetomidine and have potential to improve the monitoring of dexmedetomidine sedation.

Monitoring delirium in the intensive care unit: Diagnostic accuracy of the CAM-ICU tool when performed by certified nursing assistants – A prospective multicenter study

BackgroundMonitoring delirium in critically ill patients is recognized as a major challenge. Although involving certified nursing assistants could be a valuable help in this field, such strategy has never been formally investigated. ObjectivesFollowing theoretical training, we conducted a prospective multicenter study assessing the diagnostic accuracy of a CAM-ICU delirium screening strategy performed by CNAs in clinical settings, compared to parallel blinded evaluations conducted by nurses and physicians. MethodsFrom October 2020 to June 2022, adult intensive care patients admitted in three French University teaching hospitals with Richmond Agitation Sedation Scale ≥−2 were independently assessed for delirium by the three members of the care team (clinical nursing assistant, nurse and physician) using CAM-ICU in a random order. Physician’s assessment served as the reference standard for comparisons. ResultsWe analyzed results from 268 triplets of CAM-ICU assessments performed sequentially on 203 patients. Prevalence of delirium was 22%. Compared to physician's assessments, clinical nursing assistants demonstrated a sensitivity (Se) of 88% CI95% [80–96] and a specificity (Sp) of 95% [92–98] in detecting delirium. There was no significant difference in the performance of clinical nursing assistants and nurses (Se = 90 % [82–97] p = 0.77, Sp = 98 % [95–100] p = 0.19). We observed high agreement between results obtained by physicians and clinical nursing assistants (ĸ = 0.82) and clinical nursing assistants performance remained consistent in the subgroups at higher risk of delirium. ConclusionEvaluation of the CAM-ICU by clinical nursing assistants is feasible and should be seen as an opportunity to increase routine monitoring of delirium in intensive care patients. Implication for Clinical PracticeDelirium is a severe and underestimated complication of intensive care unit stay. This study results demonstrate the great performance of trained clinical nursing assistants in detecting delirium using the CAM-ICU. Further research is needed to define the most effective role for clinical nursing assistants in the routine management of delirium in intensive care patients.

Evaluation of Atypical Antipsychotics for the Facilitation of Weaning Sedation in Mechanically Ventilated Critically Ill Patients.

Sedatives and analgesics are commonly utilized as continuous infusions in the ICU but have complications, including an increase in mechanical ventilation days, ICU length of stay, and delirium. Atypical antipsychotics (AAPs) affect several receptors including muscarinic, histamine, and α-1 adrenergic receptors, which may allow them to act as adjunctive agents to facilitate weaning of continuous infusions. To determine if there is a decrease in sedatives/analgesics requirements with the use of quetiapine and olanzapine in mechanically ventilated critically ill patients. A single-center, retrospective study conducted at Brigham and Women's Hospital from 1/1/2018 to 12/31/2019. Patients were included if they were mechanically ventilated for at least 48 hours before and following AAP initiation, were receiving at least one sedative/analgesic by continuous infusion and received AAP for at least 48 hours. The major endpoint was the percentage of patients with ≥20% reduction in the cumulative dose (CD) of midazolam, propofol, or opioids using morphine mg equivalent (MME), 48 hours from AAP initiation. Minor endpoints included median changes in CD at 24 and 48 hours, and Richmond Agitation-Sedation Scale (RASS), and Critical Care Pain Observation Tool (CPOT) changes at 48 hours. A total of 1177 encounters were screened and 107 were included. Within the 48 hours after AAP initiation, 77.6% had ≥20% reduction in the CD of a sedative/analgesic. There was a significant reduction in propofol, no change in MME, and significant increase in dexmedetomidine median CD at 48 hours from AAP start. No difference was found in pain scores, but patients had significantly lighter sedation scores in the 48 hours after AAP initiation. A multivariate analysis showed that earlier initiation of antipsychotics was associated with a higher likelihood of achieving a 20% reduction in a sedative/analgesic. AAP use was associated with a significant reduction in sedatives/analgesics doses. Future studies are warranted to confirm the results.

Effect of perioperative application of dexmedetomidine on post-operative stress reaction, pain and prognostic adverse effects in patients undergoing gynaecological laparoscopy.

The aim of this study was to analyse the effect of perioperative dexmedetomidine (DEX) application on stress response, post-operative pain and prognosis in patients undergoing gynaecologic laparoscopy. One hundred and sixty-eight patients admitted for gynaecologic laparoscopic surgery from May 2020 to November 2022 were included in the study. The patients were randomly divided into pre-operative DEX group (n = 56), intraoperative DEX group (n = 56) and post-operative DEX group (n = 56) according to the application of DEX in the perioperative period. The visual analogue scale (VAS), time awake, extubation time, pneumoperitoneum time, post-anaesthesia care unit (PACU) stay time and Richmond agitation-sedation scale score (RASS) were recorded. Patients in both the pre-operative and intraoperative DEX groups had substantially shorter wakeup and extubation times than those in the post-operative DEX group. Patients in the pre-operative DEX group had considerably shorter wakeup and extubation times than those in the intraoperative DEX group, and their pneumoperitoneum time was significantly shorter than that of the post-operative DEX group (P < 0.001). The RASS scores of the pre-operative DEX group and intraoperative DEX group were significantly lower than those of the post-operative DEX group at 1 h, 6 h and 12 h after surgery. Meanwhile, at all time periods, the RASS scores of patients in the pre-operative DEX group were considerably lower than those in the intraoperative DEX group (P < 0.01). The VAS scores of patients in the pre-operative DEX group and intraoperative DEX group were evidently lower than those in the post-operative DEX group at 0.5 h, 2 h and 12 h postoperatively, and the VAS scores of patients in the pre-operative DEX group were markedly lower than those in the intraoperative DEX group (P < 0.001). The incidence of nausea and vomiting was significantly lower in the pre-operative DEX group than in the intraoperative DEX group and the post-operative DEX group at 0-2 h, >2-12 h and >12-24 h postoperatively (P < 0.001). The incidence of nausea and vomiting in the intraoperative DEX group was significantly lower than that in the post-operative DEX group from 0 to 2 h after surgery (P < 0.05). The incidence of adverse reactions was not significantly different amongst the three groups of patients (P > 0.05). Pre-operative and intraoperative application of DEX can help reduce post-operative pain and stress responses, help patients recover quickly after surgery and improve patient prognosis, especially the pre-operative application of DEX.

Effect of Midazolam on the Incidence of Agitation in Patients Undergoing Electroconvulsive Therapy: A Randomized Clinical Trial

Objectives Electroconvulsive therapy (ECT) is one of the treatment methods for neuropsychiatric patients. Midazolam is a relatively short-acting benzodiazepine drug used as a pre-anesthetic drug and has sedative, anticonvulsant, and muscle relaxant effects. This study aims to investigate the effect of midazolam on agitation in patients undergoing ECT. Methods This double-blinded clinical trial was conducted on 80 patients (aged 18-75 years) diagnosed with psychotic disorders indicating the need for ECT. The patients were selected by a convenience sampling method and allocated to two placebo and intervention groups by the envelope method. In the control group, the patients were injected with 2cc of distilled water, 2 mg/kg nesdonal, 0.5 mg/kg atropine, and 0.5 mg/kg succinylcholine. In the intervention group, in addition to these drugs, 0.2 mg/kg midazolam was injected at 4 sessions. The Richmond agitation sedation scale (RASS) was used to assess agitation immediately and one hour after ECT. Data were analyzed in SPSS software, version using independent t-test, Man-Whitney U test, and chi square test. The significance level was set at 0.05. Results The data of 42 patients in the intervention group and 38 in the control group were analyzed. The mean systolic and diastolic blood pressures were significantly lower in the intervention group. Immediately after ECT, 68% and 44% of patients in the intervention and control groups, respectively, were alert and calm. The patients in the midazolam group had a better condition based on the RASS score one hour after ECT (P=0.04). Conclusion Midazolam is able to reduce agitation in patients receiving ECT and can control the changes in systolic and diastolic blood pressures in the long term.

S100B as a predictor of delirium in critically ill obstetric patients: A nested case-control study.

Delirium is a neuropsychiatric illness that lasts for a short period of time. The incidence of delirium in the intensive care unit (ICU) varies from 20% to 80%. A nested case-control study was carried out in the obstetric ICU. Individuals were divided into three groups: critically ill obstetric women who had delirium on admission (Group A), women who developed delirium within follow-up of 7 days (Group B), and women who did not develop delirium after follow-up of 7 days (Group C). The APACHE II score was used to assess critical illness severity. The Richmond Agitation-Sedation Scale was used to assess the alertness or sedation level of patients, and the Confusion Assessment Method (ICU scale) was used to assess the presence of delirium. S100B was measured by human S100B calcium-binding protein B ELISA kit (Elabscience Biotechnology, Houston, USA). Severe preeclampsia and antepartum eclampsia were significantly associated with delirium. S100B levels in Group B were found to be significantly higher than those in Group C. S100B levels were higher in patients with >2 morbidities in comparison to patients with two morbidities. At a cutoff value of >169.25 pg/ml, S100B had a sensitivity of 74% and a specificity of 87.2% to discriminate cases of delirium from nondelirium. The rise in S100B levels was approximately three times greater in those who developed delirium as compared to those who did not. It is a more specific predictor of delirium.