Non-pharmacological interventions to reduce physical restraints in critical care units.

Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.

Uso de isoflurano como tratamiento del estado epiléptico superrefractario / Use of isoflurane as treatment for super-refractory status epilepticus

Introducción: El estado epiléptico superrefractario (EESR) es una entidad neurológica con una importante morbimortalidad, en la que se dispone de pocas opciones terapéuticas. La sedación inhalatoria con isoflurano es un tratamiento de uso compasivo actualmente en las unidades de cuidados intensivos españolas. Existe poca documentación sobre su utilidad en el tratamiento del estado epiléptico refractario y superrefractario, pero parece ser una alternativa terapéutica útil y segura para esta patología. Casos clínicos: Este artículo es una revisión de tres casos de EESR tratados con isoflurano. Se evaluó el control de las crisis epilépticas por isoflurano mediante monitorización electroencefalográfica. Otras variables evaluadas han sido el tiempo transcurrido hasta el control de las crisis, la supervivencia, el resultado funcional y la aparición de complicaciones secundarias al isoflurano. En los tres casos revisados, el isoflurano se mostró efectivo para el control de las crisis epilépticas en pacientes afectados por EESR. El control de las crisis epilépticas se logró rápidamente, y se pudo titular fácil y rápidamente la mínima dosis que obtenía el patrón burst-suppression. A pesar del control de la epilepsia, se objetivó una elevada mortalidad (66,66%). Esto se explica tanto por la mortalidad del EESR como por las patologías subyacentes de los pacientes fallecidos. El uso de isoflurano no presentó complicaciones. Conclusión: Con los resultados obtenidos, es factible pensar que el uso de isoflurano no se relaciona con las lesiones en el sistema nervioso central descritas en otros artículos, y se puede considerar que este tratamiento es efectivo y seguro para el control del EESR.(AU)

Introduction: Super-refractory status epilepticus (SRSE) is a neurological condition with an important morbidity and mortality rate, for which few therapeutic options are available. Inhalation sedation with isoflurane is currently a compassionate-use treatment in Spanish intensive care units. Little has been written about its usefulness in the treatment of refractory and super-refractory status epilepticus, but it appears to be a useful and safe therapeutic alternative for this condition. Case reports: This article reviews three cases of SRSE treated with isoflurane. The capacity of isoflurane to control seizures was assessed by electroencephalographic monitoring. Other variables assessed were time to seizure control, survival, functional outcome and occurrence of complications secondary to isoflurane. In the three cases reviewed, isoflurane proved to be effective for seizure control in patients affected by SRSE. Seizure control was accomplished quickly and the minimum dose required to obtain a burst-suppression pattern was titrated easily and rapidly. Despite controlling epilepsy, high mortality was observed (66.66%). This is explained by both the mortality of SRSE and the underlying pathologies of the patients who died. The use of isoflurane did not give rise to any complications. Conclusion: With the results obtained, it is feasible to think that the use of isoflurane is not related to lesions in the central nervous system reported in other articles, and this treatment can be considered effective and safe for the control of SRSE.(AU)

[Use of isoflurane as treatment for super-refractory status epilepticus]. / Uso de isoflurano como tratamiento del estado epiléptico superrefractario.

INTRODUCTION: Super-refractory status epilepticus (SRSE) is a neurological condition with an important morbidity and mortality rate, for which few therapeutic options are available. Inhalation sedation with isoflurane is currently a compassionate-use treatment in Spanish intensive care units. Little has been written about its usefulness in the treatment of refractory and super-refractory status epilepticus, but it appears to be a useful and safe therapeutic alternative for this condition. CASE REPORTS: This article reviews three cases of SRSE treated with isoflurane. The capacity of isoflurane to control seizures was assessed by electroencephalographic monitoring. Other variables assessed were time to seizure control, survival, functional outcome and occurrence of complications secondary to isoflurane. In the three cases reviewed, isoflurane proved to be effective for seizure control in patients affected by SRSE. Seizure control was accomplished quickly and the minimum dose required to obtain a burst-suppression pattern was titrated easily and rapidly. Despite controlling epilepsy, high mortality was observed (66.66%). This is explained by both the mortality of SRSE and the underlying pathologies of the patients who died. The use of isoflurane did not give rise to any complications. CONCLUSION: With the results obtained, it is feasible to think that the use of isoflurane is not related to lesions in the central nervous system reported in other articles, and this treatment can be considered effective and safe for the control of SRSE.

TITLE: Uso de isoflurano como tratamiento del estado epiléptico superrefractario.Introducción. El estado epiléptico superrefractario (EESR) es una entidad neurológica con una importante morbimortalidad, en la que se dispone de pocas opciones terapéuticas. La sedación inhalatoria con isoflurano es un tratamiento de uso compasivo actualmente en las unidades de cuidados intensivos españolas. Existe poca documentación sobre su utilidad en el tratamiento del estado epiléptico refractario y superrefractario, pero parece ser una alternativa terapéutica útil y segura para esta patología. Casos clínicos. Este artículo es una revisión de tres casos de EESR tratados con isoflurano. Se evaluó el control de las crisis epilépticas por isoflurano mediante monitorización electroencefalográfica. Otras variables evaluadas han sido el tiempo transcurrido hasta el control de las crisis, la supervivencia, el resultado funcional y la aparición de complicaciones secundarias al isoflurano. En los tres casos revisados, el isoflurano se mostró efectivo para el control de las crisis epilépticas en pacientes afectados por EESR. El control de las crisis epilépticas se logró rápidamente, y se pudo titular fácil y rápidamente la mínima dosis que obtenía el patrón burst-suppression. A pesar del control de la epilepsia, se objetivó una elevada mortalidad (66,66%). Esto se explica tanto por la mortalidad del EESR como por las patologías subyacentes de los pacientes fallecidos. El uso de isoflurano no presentó complicaciones. Conclusión. Con los resultados obtenidos, es factible pensar que el uso de isoflurano no se relaciona con las lesiones en el sistema nervioso central descritas en otros artículos, y se puede considerar que este tratamiento es efectivo y seguro para el control del EESR.

Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD / Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD

Objetivos: Objetivo principal: Conocer qué unidades de cuidados intensivos (UCI) españolas valoran y registran, de forma normalizada, niveles de dolor, sedación/agitación, delirio y uso de contenciones mecánicas (CM). Objetivos secundarios: Determinar la utilización de herramientas validadas de valoración y explorar los niveles de dolor y sedación/agitación de los pacientes, la prevalencia de deliro y el uso de CM. Método: Estudio observacional, descriptivo, transversal, prospectivo y multicéntrico mediante una encuesta ad hoc con acceso on line, de 2 bloques: bloque1, enfocado a preguntas sobre características de las unidades y práctica habitual, y bloque 2, sobre aspectos de asistencia directa y evaluaciones directas de pacientes ingresados en unidades participantes. Resultados: Participaron 158 unidades y 1.574 pacientes. La valoración normalizada y el registro del dolor de pacientes comunicativos (PC) se realizaba en 109 unidades (69%), el dolor de pacientes no comunicativos (PNC) en 84 (53%), la sedación/agitación en 111 (70%), el delirio en 39 unidades (25%). Registrado el uso de CM en 39 unidades (25%). Se utilizaban escalas validadas para valorar el dolor en PC en 139 unidades (88%), en PNC en 102 (65%), sedación/agitación en 145 (92%), delirio en 53 unidades (34%). En 33 unidades (21%) se valoraba dolor a PC y PNC, sedación/agitación y delirio, y en 8 de estas unidades existía protocolo específico de CM y registro. Entre los pacientes que pudieron ser evaluados, se reportó ausencia de dolor en el 57%, dolor moderado en el 27%; tranquilos y colaboradores el 48%, y el 10% agitados; tenían CM el 21% y delirio el 12,6% de los pacientes. Conclusiones: La valoración del dolor, sedación y delirio está acreditada, obteniéndose bajos porcentajes de pacientes con agitación y delirio. Observamos un elevado porcentaje de pacientes con dolor y moderado uso de la CM. Hay que generalizar el uso de protocolos para valorar, prevenir y tratar el dolor y el delirio mediante un adecuado manejo de la analgesia, de la sedación y un uso individual y reflexivo de las CM. (ClinicalTrials.gov Identifier: NCT03773874)

Aims: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients’ levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. Method: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. Results: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. Conclusions: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874)

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).