Propofol for the promotion of sleep in adults in the intensive care unit

This Cochrane Systematic Review by Lewis and colleagues was published on 8th January 2018.
Background:  People in the intensive care unit (ICU) experience sleep deprivation caused by environmental disruption, such as high noise levels and 24‐hour lightcochrane-57-1ing, as well as increased patient care activities and invasive monitoring as part of their care. Sleep deprivation affects physical and psychological health, and people perceive the quality of their sleep to be poor whilst in the ICU. Propofol is an anaesthetic agent which can be used in the ICU to maintain patient sedation and some studies suggest it may be a suitable agent to replicate normal sleep.
Objectives:  To assess whether the quantity and quality of sleep may be improved by administration of propofol to adults in the ICU and to assess whether propofol given for sleep promotion improves both physical and psychological patient outcomes.
Search methods:  We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10), MEDLINE (1946 to October 2017), Embase (1974 to October 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to October 2017) and PsycINFO (1806 to October 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.
Selection criteria:  We included randomized and quasi‐randomized controlled trials with adults, over the age of 16 years, admitted to the ICU with any diagnoses, given propofol versus a comparator to promote overnight sleep. We included participants who were and were not mechanically ventilated. We included studies that compared the use of propofol, given at an appropriate clinical dose with the intention of promoting night‐time sleep, against: no agent; propofol at a different rate or dose; or another agent, administered specifically to promote sleep. We included only studies in which propofol was given during ‘normal’ sleeping hours (i.e. between 10 pm and 7 am) to promote a sleep‐like state with a diurnal rhythm.
Data collection and analysis:  Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings.
Main results:  We included four studies with 149 randomized participants. We identified two studies awaiting classification for which we were unable to assess eligibility and one ongoing study.
Participants differed in severity of illness as assessed by APACHE II scores in three studies and further differences existed between comparisons and methods. One study compared propofol versus no agent, one study compared different doses of propofol and two studies compared propofol versus a benzodiazepine (flunitrazepam, one study; midazolam, one study). All studies reported randomization and allocation concealment inadequately. We judged all studies to have high risk of performance bias from personnel who were unblinded. We noted that some study authors had blinded study outcome assessors and participants for relevant outcomes.  It was not appropriate to combine data owing to high levels of methodological heterogeneity.
One study comparing propofol with no agent (13 participants) measured quantity and quality of sleep using polysomnography; study authors reported no evidence of a difference in duration of sleep or sleep efficiency, and reported disruption to usual REM (rapid eye movement sleep) with propofol.
One study comparing different doses of propofol (30 participants) measured quantity and quality of sleep by personnel using the Ramsay Sedation Scale; study authors reported that more participants who were given a higher dose of propofol had a successful diurnal rhythm, and achieved a greater sedation rhythmicity.
Two studies comparing propofol with a different agent (106 participants) measured quantity and quality of sleep using the Pittsburgh Sleep Diary and the Hospital Anxiety and Depression Scale; one study reported fewer awakenings of reduced duration with propofol, and similar total sleep time between groups, and one study reported no evidence of a difference in sleep quality. One study comparing propofol with another agent (66 participants) measured quantity and quality of sleep with the Bispectral Index and reported longer time in deep sleep, with fewer arousals. One study comparing propofol with another agent (40 participants) reported higher levels of anxiety and depression in both groups, and no evidence of a difference when participants were given propofol.
No studies reported adverse events.
We used the GRADE approach to downgrade the certainty of the evidence for each outcome to very low. We identified sparse data with few participants, and methodological differences in study designs and comparative agents introduced inconsistency, and we noted that measurement tools were imprecise or not valid for purpose.
Authors’ conclusions:  We found insufficient evidence to determine whether administration of propofol would improve the quality and quantity of sleep in adults in the ICU. We noted differences in study designs, methodology, comparative agents and illness severity amongst study participants. We did not pool data and we used the GRADE approach to downgrade the certainty of our evidence to very low.

The full text of the review can be found via this link.

Critical Care Reviews Newsletter 330 8th April 2018

The 330th Critical Care Reviews Newsletter brings “you the best critical care research and open access articles from across the medical literature over the past seven days. The highcritcal care reviewslights of this week’s newsletter are clinical reviews on reperfusion in patients with acute coronary syndrome, hypomagnesemia in critically ill patients & lung ultrasonography and echocardiography in ICU; plus non-clinical reviews on preprints & how pragmatic are randomized controlled trials labelled as pragmatic.”

The full text of newsletter 330 can be found via this link

Organ support therapy in the intensive care unit and return to work: a nationwide, register-based cohort study

This study by Riddersholm and colleagues was published in Intensive Care Medicine in April 2018.
Purpose:  The association between severity of illness and ability to return to work is unclear. Therefore, we investigated return to work and associations with measures of illness severity in ICU survivors.
Methods:  We conducted this cohort study using Danish registry data for the period 2005-2014 on ICU patients who were discharged alive from hospital, had an ICU length of stay (LOS) of at least 72h, were not treated with dialysis before hospital admission and were working prior to admission. We assessed (1) the cumulative incidence (chance) of return to work (2005-2017) and receipt of social benefits after discharge from a hospital stay with ICU admission and (2) the association between organ support therapies (renal replacement therapy, cardiovascular support and mechanical ventilation), and during 2011-2014 SAPS II and ICU LOS, and return to work, using multi-variable Cox regression.
Results:  Among 5762 ICU survivors, 68% returned to work within 2 years after hospital discharge. Disability and sickness benefits constituted 89% of social benefits among patients not returning to work and 59% among patients withdrawing from work following an initial return to work. Mechanical ventilation (HR 0.70, 95% CI [0.65-0.77]), but not RRT (HR 0.85, 95% CI [0.71-1.02]), cardiovascular support (HR 0.93, 95% CI [0.82-1.07]) and increasing SAPS II, was associated with decreased chance of return to work. Increasing ICU LOS was also associated with a decreased chance of return to work.
Conclusions:  The majority of a nationwide cohort of ICU survivors returned to work. Sick leave and receipt of disability pension were common following ICU admission. Mechanical ventilation and longer ICU LOS were associated with reduced chances of return to work.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Intensive Care Management of Patients with Cirrhosis

This article by Olson was published in the April 2018 issue of Current Treatment Options in Gastroenterology.
Purpose of Review:  Cirrhosis is a major worldwide health problem which results in a high level of morbidity and mortality. Patients with cirrhosis who require intensive care support have high mortality rates of near 50%. The goal of this review is to address the management of common complications of cirrhosis in the ICU.
Recent Findings:  Recent epidemiological studies have shown an increase in hospitalizations due to advanced liver disease with an associated increase in intensive care utilization. Given an increasing burden on the healthcare system, it is imperative that we strive to improve our management cirrhotic patients in the intensive care unit. Large studies evaluating the management of patients in the intensive care setting are lacking. To date, most recommendations are based on extrapolation of data from studies in cirrhosis outside of the ICU or by applying general critical care principles which may or may not be appropriate for the critically ill cirrhotic patient. Future research is required to answer important management questions.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Daily routine versus on-demand chest radiograph policy and practice in adult ICU patients- clinicians’ perspective.

This paper by Al Shahrani and colleagues was published in BMC Medical imaging in April 2018.
Background:  Chest radiographs are taken daily as a part of routine investigations in Intensive care unit (ICU) patients. They are less effective and unlikely to alter the management of the majority of these patients compared to the radiographs obtained when indicated. According to the American College of Radiology (ACR) Appropriateness criteria, only selective ordering of chest radiographs is recommended, including elderly or high risk patients. The aim of this study was to identify and assess the clinician’s perspective in abandoning the current practice of daily routine chest radiograph and replacing with the on-demand radiograph in Saudi hospitals.
Methods:  This was a cross-sectional study. A valid self-administered questionnaire was distributed to all clinical staff members working in ICUs in the major tertiary hospitals in Saudi Arabia. The study population was primarily the ICU intensivists (physicians), nurses and respiratory therapists (RT). The data collected were statistically processed using SPSS version 20.0; descriptive and inferential analyses were done.
Results:  Out of 730 questionnaires sent, we received only 495 completed questionnaires with a response rate of 67.8%. Majority of them (n = 351) are working at academic hospitals. About half of the respondents (n = 247) are working in an open-format ICUs. Findings showed that the daily routine chest X-ray was performed in almost 96.8% of ICUs patients, which the majority of the clinical staff members (73%) thought that this current daily routine CXR protocol in the ICUs should be replaced with the on-demand CXR policy. Interestingly, the differences in demographic and work-related characteristics had no significant impact on the clinician’s view and supported moving to on-demand CXR policy and practice.
Conclusions:  The daily routine CXR is still a common practice in most of the Saudi hospitals ICUs although enough empirical evidence shows that it can be avoided. We observed that intensivists support the change of the current practice and recommend an on-demand CXR policy likely to be followed in intensive care management.

The full text of the article is available via this link.

Critical Care Reviews Newsletter 329 1st April 2018

The 329th Critical Care Reviews Newsletter, “bringing you the best critical care research and open access articles from across the medical literature over the past seven days. The big news this week is the impending opening of registration for #CCR19, on January 17th and 18th in Titanic, Belfast. It might seem a long way in the future, but our new two-day format will encourage delegates from further afield, so there will be more interest, and relatively fewer tickets to go around.”  “This week’s Topic of the Week is the first of two parts, based on a series of articles from the Journal of Thoracic Disease on ECMO, starting with a paper on oxygenator performance and artificial-native lung interaction in today’s Paper of the Day.”
The full text of newsletter 329 can be found via this link

August Issue of “Intensive Care Medicine” Volume 43 Number 7

intensive-care-medicine

To access Intensive Care Medicine’s latest issue’s contents page follow this link.
Articles published in this issue include “Short-course antibiotic therapy for critically ill patients treated for postoperative intra-abdominal infection: the DURAPOP randomised clinical trial”, “Biomarkers for prediction of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis” and “Relationships between markers of neurologic and endothelial injury during critical illness and long-term cognitive impairment and disability”.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.