Effect of nocturnal sound reduction on the incidence of delirium in intensive care unit patients: An interrupted time series analysis

Introduction:  Delirium in critically-ill patients is a common multifactorial disorder that is associated with various negative outcomes. It is assumed that sleep disturbances can result in an increased risk of delirium. This study hypothesized that implementing a protocol that reduces overall nocturnal sound levels improves quality of sleep and reduces the incidence of delirium in Intensive Care Unit (ICU) patients.

Methods:  This interrupted time series study was performed in an adult mixed medical and surgical 24-bed ICU. A pre-intervention group of 211 patients was compared with a post-intervention group of 210 patients after implementation of a nocturnal sound-reduction protocol. Primary outcome measures were incidence of delirium, measured by the Intensive Care Delirium Screening Checklist (ICDSC) and quality of sleep, measured by the Richards-Campbell Sleep Questionnaire (RCSQ). Secondary outcome measures were use of sleep-inducing medication, delirium treatment medication, and patient-perceived nocturnal noise.

Results:  A significant difference in slope in the percentage of delirium was observed between the pre- and post-intervention periods (-3.7% per time period, p=0.02). Quality of sleep was unaffected (0.3 per time period, p=0.85). The post-intervention group used significantly less sleep-inducing medication (p<0.001). Nocturnal noise rating improved after intervention (median: 65, IQR: 50-80 versus 70, IQR: 60-80, p=0.02).

Conclusions:  The incidence of delirium in ICU patients was significantly reduced after implementation of a nocturnal sound-reduction protocol. However, reported sleep quality did not improve.

This article by Van de Pol and colleagues was published in Intensive & critical care nursing; August 2017.  Library members can order the full text of this and other articles via the Rotherham NHS Foundation Trust Library and Knowledge Service website using the article requests online via this link.

Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit.

Background:  Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis.

Objective:  To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock.

Method:  Retrospective and exploratory study that involved collection of patients’ sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions.

Results:  Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions.

Conclusion:  Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes.

This article by Silveira and colleagues was published in Intensive & critical care nursing; August 2017.  Library members can order the full text of this and other articles via the Rotherham NHS Foundation Trust Library and Knowledge Service website using the article requests online via this link.

Stress ulcer prophylaxis in the intensive care unit trial: detailed statistical analysis plan

Background:  In this statistical analysis plan, we aim to provide details of the pre-defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. The aim of the SUP-ICU trial is to assess benefits and harms of stress ulcer prophylaxis with a proton pump inhibitor in adult patients in the intensive care unit (ICU).

Methods:  The SUP-ICU trial is an investigator-initiated, international, multicentre, randomised, blinded, parallel-group trial of intravenously pantoprazole 40 mg once daily vs. placebo in 3350 acutely ill adult ICU patients at risk of gastrointestinal bleeding. The primary outcome measure is 90-day mortality. Secondary outcomes include the proportion of patients with clinically important gastrointestinal bleeding, pneumonia, Clostridium difficile infection or myocardial ischaemia, days alive without life support, serious adverse reactions, 1-year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre-defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables comparing the two intervention groups in the intention-to-treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention-to-treat population.

Conclusion:  Stress ulcer prophylaxis is standard of care in ICUs worldwide, but has never been tested in large high-quality randomised placebo-controlled trials. The SUP-ICU trial will provide important high-quality data on the balance between the benefits and harms of stress ulcer prophylaxis in adult critically ill patients.

This article by Krag and colleagues was published in Acta anaesthesiologica Scandinavica August 2017.  Library members can order the full text of this and other articles via the Rotherham NHS Foundation Trust Library and Knowledge Service website using the article requests online via this link.

Is Admission to the Intensive Care Unit Associated With Chronic Opioid Use? A 4-Year Follow-Up of Intensive Care Unit Survivors

Purpose:  To describe opioid use before and after intensive care unit (ICU) admission and to identify factors associated with chronic opioid use upto 4 years after ICU discharge.

Methods:  Retrospective review of adult patients admitted to the ICU at a tertiary care center between January 1, 2005, to December 31, 2008. We defined “nonuser,” “intermittent,” and “chronic” opioid status by abstinence, use in 70% of days for a given time period, respectively. We assessed opioid use at 3 months prior to ICU admission, at discharge, and annually for upto 4 years following ICU discharge.

Results:  A total of 2595 ICU patients were included for surgical (48.6%), medical (38.4%), and undetermined (13%) indications. The study population included both elective (26.9%) and emergent (73.1%) admissions. Three months prior to ICU admission, 76.9% were nonusers, 16.9% used opioids intermittently, and 6.2% used opioids chronically. We found an increase in nonuser patients from 87.8% in the early post-ICU period to 95.6% at 48-month follow-up. Consequently, intermittent and chronic opioid use dropped to 8.6% and 3.6% at discharge and 2.6% and 1.8% at 48-month follow-up, respectively. Prolonged hospital length of stay was associated with chronic opioid use.

Conclusion:  Admission to ICU and duration of ICU stay were not associated with chronic opioid use.

This research was published in the August 2017 issue of “Journal of Intensive Care Medicine” by Yaffe, Green, Buttler and Witter.  Library members can order the full text of this and other articles via the Rotherham NHS Foundation Trust Library and Knowledge Service website using the article requests online via this link

NutritionDay ICU: A 7 year worldwide prevalence study of nutrition practice in intensive care

Introduction:  To determine the nutrition practice in intensive care units and the associated outcome across the world, a yearly 1 day cross sectional audit was performed from 2007 to 2013. The data of this initiative called “nutrition Day ICU” were analyzed.

Material and methods:  A questionnaire translated in 17 languages was used to determine the unit’s characteristics, patient’s condition, nutrition condition and therapy as well as outcome. All the patients present in the morning of the 1 day prevalence study were included from 2007 to 2013.

Results:  9777 patients from 46 countries and 880 units were included. Their SAPS 2 was median 38 (IQR 27-51), predicted mortality was 30.7% ± 26.9, and their SOFA score 4.5 ± 3.4 with median 4 (IQR 2-7). Administration of calories did not appear to be related to actual or ideal body weight within all BMI groups. Patients with a BMI 40 received slightly less calories than all other BMI groups. Two third of the patients were either ventilated or were in the ICU for longer than 24 h at nutrition.  Day. Routes of feeding used were the oral, enteral and parenteral routes. More than 40% of the patients were not fed during the first day. The mean energy administered using enteral route was 1286 ± 663 kcal/day and using parenteral nutrition 1440 ± 652 kcal/day. 60 days mortality was 26.0%.

Discussion:  This very large collaborative cohort study shows that most of the patients are underfed during according to actual recommendations their ICU stay. Prescribed calories appear to be ordered regardless to the ideal weight of the patient. Nutritional support is slow to start and never reaches the recommended targets. Parenteral nutrition prescription is increasing during the ICU stay but reaching only 20% of the population studied if ICU stay is one week or longer. The nutritional support worldwide does not seem to be guided by weight or disease but more to be standardized and limited to a certain level of calories. These observations are showing the poor observance to guidelines.

This research by Bendavid and colleagues was published in the Clinical Nutrition August issue.  Library members can order the full text of this and other articles via the Rotherham NHS Foundation Trust Library and Knowledge Service website using the article requests online via this link

Sixth International Fluid Academy Days Antwerp 23rd-25th November 2017

“The aim of this sixth edition is again to review recent advances in fluid management, and hemodynamic and organ function monitoring in the critical care setting in a comprehensive manner for intensivists, anaesthesiologists and emergency physicians as well as interested internists and surgeons. However the meeting will deal with any broad topic related to critical care. As always it is also a great way to promote professional interaction between faculty members, participants and delegates of the industry.

iFAD is an innovative Critical Care Educational meeting. This conference provides the highest quality of Critical Care education and is guaranteed to innovate and inspire. The iFAD Faculty is the most provocative, engaging, motivating and inspiring group of international educational speakers and as organizing committee we want to ensure we have the sponsors to match. Together, we make iFAD stand apart from other Critical Care conferences.”

Full details can be found on the conference website

Critical Care Reviews Newsletter 294 30th July 2017

The Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature from the past week.  “The highlights of this week’s edition are the TTH48 trial, comparing targeted temperature management for 48 vs 24 hours after out-of-hospital cardiac arrest, guidelines on paediatric nutrition, the management of ARDS and EEG monitoring in neurocritical care; reviews on extracorporeal membrane oxygenation and dialysis-based liver support devices, the Intensive Care Medicine research agenda on critically ill oncology and hemtology patients and antimicrobial resistance in the next 30 years.”

The full copy of newsletter 294 30th July 2017 can be accessed via this link.