ABSTRACT
Introduction: Patients in the intensive care (ICU) commonly receive analgesics and sedatives to facilitate mechanical ventilation. Recommendations suggest patients are kept as lightly sedated as feasible. Studies report an inconsistent association between deep sedation, prolonged ventilation and ICU stay.1 Opinions around patients 'wakefulness' include discomfort and the potential increased prevalence of psychological morbidity.2 Alpha-2-agonists (clonidine and dexmedetomidine) are agents used in ASD management and reported to produce lighter sedation. The aim of this project was to explore ICU pharmacist's perspective on ASD practice over UK. Objectives: • Explore ICU pharmacist's views on: ASD practices, sedation research priority, importance of A2B clinical trial and the impact of Covid19. • Determine the prevalence of clonidine and dexmedetomidine prescribing. Methods: An online survey was devised on SurveyMonkey. The survey was designed in 2 sections: -1. Respondents provided responses based on a 'point prevalence' of clonidine and dexmedetomidine prescriptions, on day of completion. 2. Their local ICU sedation practice, their views on priority of sedation research, the A2B study and whether they believed ASD was more challenging during the Covid19 pandemic. The online survey was distributed via the UK Clinical Pharmacy Association Critical Care Group (UKCPA CCG), the NIHR Critical Care National Speciality Group (NSG), the UK Critical Care Research Group and Twitter. The survey remained active for 12 weeks from 30.3.2021 with reminders sent for completion every fortnight. Results: There were 121 respondents, all but 1 were ICU pharmacists. There are approximately 243 ICU pharmacist posts in the UK, this represents a response rate of approximately 50%. 37 (30%) of respondent reported clonidine (but not dexmedetomidine) was prescribed in their ICU;7 (6%) described dexmedetomidine only;and 76 (63%) reported both. In describing ASD during Covid-19 pandemic, 107 (88%) respondents reported it had become more challenging. 83 (69%) of respondents stated that clonidine usage increased during the pandemic (27 (22%) no change). 46 (39%) stated that dexmedetomidine usage increased during the pandemic (50 (42%) no change). Among the respondents 98 (81%) 'strongly agreed', and 20 (17%) 'agreed' that research involving ASD is a priority. A2B is set to compare clinical and cost effectiveness of propofol, clonidine, and dexmedetomidine as primary sedative for ICU patients. 49 (40%) of respondents reported participating in A2B. 65 (54%) respondents felt that A2B was a 'very important', and 63 (52%) said it was an 'important' research question. Conclusion: This survey reported widespread use of alpha-2-agonists in ASD practice. Almost two-thirds of ICUs report using both agents. Clonidine use is the most prevalent. Given the paucity of high quality clinical effectiveness and safety data for this drug, clinical trials which assess clinical effectiveness, including ASD are a priority. Respondents endorsed that ASD research is a priority, with ASD management much more challenging during the Covid19 pandemic. Limitations include that the design was a brief online survey;although had a high pharmacist response it did not incorporate the views of other members of the ICU team.
ABSTRACT
INTRODUCTION: Propofol has been widely used in the ICU for sedation and refractory status epilepticus. PRIS is a serious and potentially fatal condition that is characterized by a spectrum of clinical symptoms and abnormalities. Literature suggests that a longer duration of propofol ≥ 48 hours or a dose ≥ 83 mcg/kg/min is associated with a higher risk of PRIS. Many of the critically ill patients in our health system required a larger dose of propofol and prolonged duration of infusion for sedation in the ICU, especially during Covid-19. Delayed treatment of PRIS can lead to death. It is very likely that patients who develop PRIS may often go unrecognized as the manifestations of PRIS can overlap with common ICU conditions. The current prevalence of PRIS is unknown, however, a prospective study has reported a prevalence of 1.1% in critically ill patients. METHODS: Patients were identified by querying the NYU Langone Health COVID clinical data mart from March 2020 till February 2021. The inclusion criteria included patients receiving propofol infusion for ≥ 48 hours or receiving a dose ≥ 60 mcg/kg/min for more than 24 hours. Pregnant patients, children, and patients with rhabdomyolysis prior to the start of infusion were excluded. PRIS was defined by the development of metabolic acidosis and cardiac dysfunction with 2 or more minor criteria (rhabdomyolysis, hypertriglyceridemia, renal failure, and hepatic transaminitis) or developing 3 or more minor criteria. RESULTS: 424 patients were included in our study. Of the 424 patients, 21 patients were found to have developed PRIS. The occurrence of PRIS was observed at the median infusion rate of 36.1 mcg/kg/min and a median duration of infusion of 147 hours. The prevalence of PRIS was found to be 4.9%. CONCLUSIONS: The prevalence of PRIS in our study was found to be 4.9%. The occurrence of PRIS was observed at the median infusion rate of 36.1 mcg/kg/min suggesting that PRIS can be developed at a lower rate of infusion than previously reported. We suggest that patients - especially those receiving a duration ≥ 48 hours and a higher dose of 60 mcg/kg/min - should be monitored for signs and symptoms of PRIS during propofol infusion as it may be underrecognized because PRIS is characterized by multiple clinical manifestations that overlap with critical illness.
ABSTRACT
BACKGROUND: Dementia Australia's strategic direction represents a year of extensive community consultation and identifies discrimination as a leading issue for people living with dementia. An objective is to change community attitudes to dementia, creating greater community empathy so no-one with dementia feels isolated. METHOD: In 2019, Dementia Australia surveyed >5000 respondents to identify types of discrimination faced by people living with dementia. Of responding family members, friends and carers, 94% said people had not stayed connected with a relative living with dementia. Some 80% said people had deliberately avoided their friend or relative living with dementia;81% felt people in shops, cafes and restaurants treated people living with dementia differently. Traditionally anti-discrimination campaigns focus on elevating awareness and understanding to change behaviour. Dementia Australia tackled the behaviour directly: expanding people's understanding of discrimination and its impact, providing practical information and tips to do better. The 'Help Keep the World Open' campaign used the social isolation created by COVID-19 to show that once the crisis had passed, most people could resume regular social routines. However, for people with dementia, isolation can be a reality every day. The next campaign stage - 'A little support makes a lot of difference' - highlighted the capabilities of people living with dementia, given the right supports. The campaign shared tips and tools to support people living with dementia to live well. These broad-ranging national campaigns were developed collaboratively with people with a lived experience of dementia. The high-level objectives were to raise awareness of dementia and the lack of understanding that causes discrimination, to shift negative perceptions and show practical ways for people to support those living with dementia. RESULT: Exceptional levels of engagement and reach were achieved across media. From May 18 to 23 December 2020, more than 35 million impressions reached 4.6 million Australians, with engagement rates well above industry averages across all channels. CONCLUSION: Our content created increased awareness and understanding of dementia, changing misconceptions - vital to improving quality of life. This campaign demonstrated that building empathy alongside knowledge by asking the community to change behaviour and attitudes is both engaging and effective. © 2021 the Alzheimer's Association.