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INTRODUCTION: ICU-acquired delirium results in increased LOS, duration of mechanical ventilation, and mortality. Patients with COVID are at increased risk. Current literature suggests that delirium without coma occurs in at least about 30 % of COVID patients admitted to ICU. In our ICU we use an EPIC EMR-based daily ICU checklist with ABCDEF bundle during our rounds and utilized virtual ICU during the daytime in addition to the nights with peak surges. With our study, we wanted to evaluate the incidence of Delirium during our COVID year of 2021 and its relation to Mortality rate and ICU Length of stay (LOS). METHOD(S): A retrospective evaluation of patients admitted to Houston Methodist Baytown ICU from January to December 2021. Patients with covid positive were included. Data were obtained from the EPIC and ICU dashboard. Compliance with the ABCDEF ICU checklist was reviewed by auditing 20 patient charts per month. Delirium screening compliance was evaluated on AM and PM shifts for all ICU patients. Hospital ICU acquired delirium % was defined as all patients discharged from the ICU unit in that month that didn't have a positive CAM-ICU in the first 48 hrs. and then had a positive CAM-ICU after 48 hrs. in the ICU. ICU Mortality rate is defined as the percentage of patients with ICU stays who expired during ICU stay. Descriptive statistics and linear regression were used to compare and correlate. RESULT(S): In 2021, we had 377 ICU patients with COVID positive, an Average CMI of 4.986, and a LOS index of 1.24. Compliance with the daily ABCDEF ICU Checklist was 98%. Compliance to am screening was 89.41% vs. pm screening 90.56%. Mean Incidence of ICU acquired Delirium in COVID patients was only 7.14 % (2.77- 15.22) with peaks occurring during COVID surges. Linear regression analysis predicted a strong direct relationship between Delirium % and ICU Mortality rate (P< 0.05), and ICU Length of Stay(P< 0.05). CONCLUSION(S): Our data from 2021 shows Delirium % that is significantly less than the incidence. The lower % might have been from continuing to adhere to the ABCDEF bundle, utilization of the ICU checklist, and effective use of virtual ICU. Hospital ICU acquired delirium % correlated with ICU mortality and ICU length of stay. Hence, it is important to continue to focus on ways to decrease ICU delirium.
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INTRODUCTION: Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Med device is a novel technology that delivers audio content and allows patients to interact by eye movements and could potentially allow for better communication in this setting. METHOD(S): A single-arm pilot study of patients in a mixed ICU. Patients underwent at least 3 sessions with the EyeControl-Med device administered by a speech-language pathologist. Communication and consciousness were assessed using the Lowenstein communication scale (LCS) and delirium was assessed by a computerized version of the CAM-ICU during the first and last device usage sessions. RESULT(S): 15 patients were included, 40% of whom were diagnosed with COVID-19. All patients completed three to seven usage sessions. The mean LCS score improved by 19.3 points (p < 0.0001), with each of its five components showing significant improvements as well. The mean number of errors on the CAM-ICU tool decreased from 6.5 to 2.5 (p=0.0006), indicating lower rates of delirium. No adverse effects were observed. CONCLUSION(S): The EyeControl-Med device may help enhance communication and re-orientation in this patient population while reducing the helplessness and anxiety associated with lack of communication. It may reduce the manifestations and duration of delirium in ventilated critically ill patients. Controlled studies are required to establish this effect.
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Introduction: Although guidelines recommend twice daily (BID) dosing of quetiapine for treatment of intensive care unit (ICU) delirium in most patients, once daily dosing at bedtime (HS) is commonly prescribed to reduce daytime somnolence. No studies have evaluated differences in outcomes. Research Question or Hypothesis: To determine if BID dosing of quetiapine reduces duration of delirium versus HS dosing for treatment of ICU delirium. Study Design: Retrospective analysis of ICU patients treated with BID versus HS dosing of quetiapine for ICU delirium. Method(s): Electronic health records were analyzed between January 1, 2017 and December 31, 2021 for patients prescribed quetiapine for ICU delirium. Patients were excluded for alcohol withdrawal, history of psychiatric conditions, receipt of <24 hours of therapy, alternative dosing variations, and death or transfer from the ICU <24 hours after beginning quetiapine. The primary outcome was recovery of delirium per Confusion Assessment Method (CAM-ICU) evaluated with Mann- Whitney U. Secondary outcomes included lengths of stay, mechanical ventilation duration, in-hospital death, and QTc prolongation. Unpaired t-test, chi-square with yates' correction, and Fisher's exact test were performed as appropriate using Graph-Pad Prism. Result(s): Baseline characteristics differed for sex in BID (38.9% female, n=23) versus HS (61.1% female, n=18) dosing and admission diagnosis (38.9% vs 17.4% COVID-19, respectively). No differences in time to delirium recovery [3 days (interquartile range [IQR], 2-5) vs 2.5 days (IQR, 1-5;p=0.6651)], ICU length of stay [16.9 days (standard deviation [SD], 9) versus 18.5 days (SD=13);p=0.6651)], duration of mechanical ventilation [9.6 (SD=8) vs 13.9 days (SD=12);p=0.2587)], or in-hospital death (60.9% vs 50%;p=0.7047) existed in the BID versus HS dosing group, respectively. Incidence of QTc prolongation was also similar between groups. Conclusion(s): Twice daily versus bedtime dosing of quetiapine did not significantly alter outcomes. These findings suggest similar efficacy without increased adverse events.
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Introduction: Pain, agitation, delirium, weakness, and sleep deprivation are well recognized symptoms during an ICU stay.1 In 2019, our institution set up an ICU Liberation Working Group (ILWG)2, aiming to reduce the harmful effects of these symptoms. This interprofessional working group encompassed medical, pharmacy, nursing and allied health members and utilised a multifocal approach. Objectives: To review the impact of various initiatives implemented on the outcomes of the ABCDEF (A2F) bundle in the last two years. Methods: These initiatives are based on each aspect of the A2F bundle. As shown in Table 1, the interventions were each targeted to one aspect of the A2F bundle and were grouped under four themes of teaching, operational interventions, informatics, and guidelines/policies. These interventions were audited regularly, with the results displayed on awareness boards, aiming to encourage staff engagement. An ICU Liberation week was also held to improve awareness and compliance with the A2F bundle. Results: Audit cycles were performed in April 2019, December 2019, and November 2020, assessing data representing each arm of the A2F bundle. Two-thirds of the audit standards showed a significant improvement after initial interventions were employed. The third cycle showed improvement has been maintained in half of the standards. Unfortunately, adherence did reduce in several fields. The greatest improvement was seen in sedation target documentation. A further cycle in January 2021 assessed the impact of COVID-19 on A2F application, showing a reduction across most audit criteria. There were, however, improvements in family updates and early mobilisation. Conclusion: The ongoing work of an interprofessional ILWG has shown a cohesive approach application of the A2F bundle, which has resulted in improved harm prevention and management. The impact of COVID-19 has been shown to have reduced our ability to provide improvements in A2F application. Ongoing interventions are a bespoke sleep tool and more detailed CAM-ICU assessment, designed to elucidate the underlying causes of sleep disruption and delirium. A focused quality improvement project has started, where specific interventions are to be trialed on one ICU before expectant deployment throughout other ICUs. Data will continue to be collected and presented to further assess the most effective methodology for application of the A2F bundle.
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Aim and background: Delirium is the disturbance of consciousness characterised by acute onset, rapid fluctuations in mental status, and impaired cognitive functioning. The patient's ability to receive, process, store, and recall information is impaired in delirium. Objective: To study the incidence of delirium in patients in COVID and non-COVID ICU. To also study various risk factors associated with delirium. Materials and methods: After ethical committee approval and written informed consent, this study was carried out over a period of 1 year (August 2020 to July 2021). Each patient meeting the inclusion criteria was evaluated on the RAAS score within 24 hours of admission, then screened for delirium according to CAM-ICU worksheet every 6th hourly after admission in MICU. 50 patients were studied each in COVID and non-COVID ICU. Patients found to have delirium after the first assessment were classified as new cases. Various risk factors were evaluated prospectively. Results: Incidence of delirium in non-COVID ICU was 29%, while in COVID ICU was 37%. Delirium is present in a patient who has risk factors including smoking, higher severity of illness, oversedation, and mechanical ventilation. Antipsychotics can be used for patients who develop delirium. Conclusion: Delirium is a preventable issue in ICU patients that can be managed by preventing the risk factors that will decrease overall length of stay in ICU.
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Introduction: Activity monitoring is important in the ICU where delirium, sedation, and critical illness are associated with both inactivity and agitation. Staff monitoring of motion and sleep is intermittent and resource intense. Wearable actigraphic devices are poorly tolerated and limited to limb motion. Here we demonstrate continuous AI video monitoring in the ICU to provide alwayson, unobtrusive patient activity monitoring. Methods: We conducted a pilot study of AI video monitoring in the Duke University Hospital Medical Intensive Care Unit. Video carts continuously recorded data on encrypted hard drives. Second-by-second AI analysis generated binary motion “counts” that were summed to generate our patient motion metric: counts per minute (CPM). Scene intelligence from AI object and people detectors provided room environment information. These data streams along with de-identified (blurred) video data were used to generate prototype graphical and visual summaries of patient activity patterns and the hospital room environment. Results: We enrolled 22 patients and collected 2155 hours (116 days) of video. Representative time-series data streams are shown in the Figure (top left). These data were acquired from a 76-year-old with liver failure and an escalating nasal cannula oxygen requirement who was endotracheally intubated on the subsequent day. Note 1) the declining patient activity as the patient deteriorates and 2) the significant bedside activity (high acuity) throughout the day. We developed a prototype “overnight report” that summarizes patient activity and room environment. The Figure (bottom left) shows the overnight report for a 54-year-old post-COVID-19 patient admitted to the MICU for respiratory failure with hypoactive delirium that resolved per CAM-ICU on day 5 of data collection. Notably, our report demonstrates significant overnight movement, possibly consistent with a mixed or hyperactive delirium. To visually summarize patient motion, we generated activity “heat maps” over 10-minute intervals. As a control, we showed that the intubated and sedated liver failure patient generated a still heat map (Figure upper right). Further, we visualized daytime hypoactivity/sleep in the delirious post-COVID patient (Figure lower right), suggesting disrupted circadian rhythm, giving additional context to the negative CAM assessment. Conclusions: We demonstrated the feasibility of AI to monitor patient activity in a quaternary-care MICU. Our method has advantages compared to wearable actigraphic methods for monitoring patient activity, including being unobtrusive and being able to visualize and summarize wholebody motion. The data presented here suggest that such monitoring may be able to provide clinically actionable insights in delirium care and sedation weaning.
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Rationale: The COVID-19 pandemic has renewed interest in the use of inhaled anesthetics for sedation of ventilated critically ill patients. Compared to intravenous sedatives, inhaled anesthetics reduce lung inflammation, time to extubation, and ICU length of stay. However, their impact on cognitive and psychiatric outcomes is less clear. In this systematic review we summarize the impact of inhaled sedatives on cognitive and psychiatric outcomes in ventilated critically ill patients. Methods: We searched MEDLINE, EMBASE, and PsychINFO for studies from 1970 - 2021 that assessed cognitive and psychiatric outcomes in critically ill adult patients sedated with inhaled anesthetics. We included case series, observational, cohort, and randomized controlled trials. Outcome(s) of interest included cognition, anxiety, depression, hallucinations, psychomotor recovery, and PTSD, as well as instruments for assessing these outcomes. Results: We identified a total of twelve studies that examined at least one of our outcomes of interest (16 total outcomes). Four studies were in post cardiac arrest survivors, three in post-operative (non-cardiac) patients, two in post-operative cardiac patients, and three more in mixed medical-surgical patients. Seven studies reported incidence of delirium, two assessed neurologic recovery post cardiac-arrest, and two examined ICU memories. One study reported on each of anxiety, depression, hallucinations, PTSD, psychomotor recovery, and long-term cognitive dysfunction more than 3 months following ICU discharge. Of the seven studies reporting on delirium, only one reported an increase in delirium for those sedated with intravenous sedation compared to volatile. The remaining studies did not report any difference in delirium incidence between modes of sedation. Similarly, no difference between sedation methods were observed for neurologic recovery following cardiac arrest, anxiety, depression, hallucinations, PTSD, psychomotor recovery, or long-term cognitive dysfunction. The most commonly used tool used was the CAM-ICU tool (delirium outcome;3 studies). Five studies used subjective chart review to assess their outcome of interest, or did not report their method of assessment. Conclusions: Few studies examined cognitive and psychiatric outcomes in critically ill adults sedated with volatile anesthetics. As volatile anesthetics offer a promising alternative mode of sedation in the ICU, future studies should incorporate assessment of these important patientcentered outcomes using validated objective tools during and following hospital stay.
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Purpose of Study Describe possible iatrogenic opioid withdrawal syndrome in a mechanically ventilated and sedated COVID-19 patient. Methods Used Case study Summary of Results A 41-year-old man presented with acute hypoxic respiratory failure due to COVID-19 requiring mechanical ventilation and high dose sedation with fentanyl over several days. Past medical history included type 2 diabetes, hypertension, rheumatoid arthritis on immunosuppressive medications, gout, and morbid obesity. The patient received an IV fentanyl infusion over fifteen days of approximately 50,000 mcg of fentanyl IV. The patient had frequent episodes of hypertension, delirium, and agitation while weaning from this sedation protocol. The CAM-ICU score and vital signs were used to assess for possible opioid withdrawal. Post-extubation, he received fentanyl at 10 micrograms per hour for three days to limit withdrawal symptoms. Discussion Approximately one-fourth of mechanically ventilated patients who received opioid infusions experience iatrogenic opioid withdrawal syndrome. Opioid withdrawal syndrome in an intubated and sedated patient can be challenging to identify. Classical diagnostic criteria outlined in the DSM-V include three or more of the following: dysphoric mood, nausea, vomiting, muscle aches, lacrimation, rhinorrhea, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, and insomnia. Relying on these symptoms in intubated and sedated patients with complex medical pathologies can confound the results of identifying and adequately treating Iatrogenic Opioid Withdrawal Syndrome. This case emphasizes the importance of judicious sedation in the intensive care setting and using bedside scales, such as the CAM-ICU score and autonomic changes in vital signs, to assess patients for withdrawal.