Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic.

BACKGROUND: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them. METHODS: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic. RESULTS: We analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently. CONCLUSIONS: Most sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Morphological analysis of vessel elements for systematic study of three Zingiberaceae tribes.

Zingiberaceae containing over 1,000 species that are divided into four subfamilies and six tribes. In recent decades, there has been an increase in the number of studies about vessel elements in families of monocotyledon. However, there are still few studies of Zingiberaceae tribes. This study aims to establish systematic significance of studying vessel elements in two subfamilies and three tribes of Zingiberaceae. The vegetative organs of 33 species processed were analysed by light and scanning electron microscopy and Principal Component Analysis was used to elucidate genera boundaries. Characteristics of vessel elements, such as the type of perforation plate, the number of bars and type of parietal thickening, are proved to be important for establishing the relationship among taxa. Scalariform perforation plate and the scalariform parietal thickening are frequent in Zingiberaceae and may be a plesiomorphic condition for this taxon. In the Principal Component Analysis, the most significant characters of the vessel elements were: simple perforation plates and partially pitted parietal thickening, found only in Alpinieae tribe, and 40 or more bars composing the plate in Elettariopsis curtisii, Renealmia chrysotricha, Zingiber spectabile, Z. officinale, Curcuma and Globba species. Vessel elements characters of 18 species of Alpinieae, Zingibereae and Globbeae were first described in this work.

Implementing early mobilization interventions in mechanically ventilated patients in the ICU.

As ICU survival continues to improve, clinicians are faced with short- and long-term consequences of critical illness. Deconditioning and weakness have become common problems in survivors of critical illness requiring mechanical ventilation. Recent literature, mostly from a medical population of patients in the ICU, has challenged the patient care model of prolonged bed rest. Instead, the feasibility, safety, and benefits of early mobilization of mechanically ventilated ICU patients have been reported in recent publications. The benefits of early mobilization include reductions in length of stay in the ICU and hospital as well as improvements in strength and functional status. Such benefits can be accomplished with a remarkably acceptable patient safety profile. The importance of interactions between mind and body are highlighted by these studies, with improvements in patient awareness and reductions in ICU delirium being noted. Future research to address the benefits of early mobilization in other patient populations is needed. In addition, the potential for early mobilization to impact long-term outcomes in ICU survivors requires further study.