DELIRIUM IN THE MECHANICALLY-VENTILATED ICU PATIENT
It's a significant independent predictor of death.
A new study has demonstrated that delirium in patients in the ICU is an independent predictor of mortality.
Researchers used the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale to assess the development of delirium in 275 patients consecutively admitted to and mechanically ventilated in the ICUs of a single hospital during a total of 2,158 ICU days. The primary outcomes included mortality rate at six months and hospital length of stay post-ICU.
Because nearly 19% of patients were in a persistent coma and died while hospitalized, only the remaining 224 patients were assessed for the development of delirium. The results showed that the majority of them developed delirium while in the ICU (81.7%) and spent most of the time there in delirium (43.1%) rather than in either normal (21.6%) or comatose (35.3%) states. The mortality rate at six months was significantly higher in those who developed delirium than in those who did not, 34% and 15%, respectively, as was the length of stay (longer by 10 days). After adjusting for confounding variables, such as the presence of coma and the use of sedatives or analgesics, those who developed delirium had, as a group, a three times greater risk of death within six months, a doubled length of hospital stay, significantly fewer days without mechanical ventilation, and a nine times greater incidence of cognitive impairment at hospital discharge than those who did not.
Although the relationship between delirium and clinical outcomes was not studied, the unfavorable associations found suggest that perhaps nurses should be aware of the prevalence of delirium in critically ill patients and should assess for it throughout the day. According to the authors, clinicians should avoid interventions that increase risk, such as the administration of certain psychoactive medications.
Ely EW, et al. JAMA 2004;291(14): 1753-62.
EPINEPHRINE ADMINISTERED TO CHILDREN
High doses can be harmful to children in cardiac arrest.
Although the American Heart Association's guidelines on pediatric advanced life support recommend that children in cardiac arrest who don't respond to an initial standard dose of epinephrine (0.01 mg/kg) can receive either additional standard doses or higher ones (0.1 mg/kg), a recent prospective, randomized, double-blind study revealed that they don't benefit from receiving high-dose epinephrine as the second, or "rescue," dose.
From 1999 to 2001 researchers randomly assigned 68 children in in-hospital cardiac arrest to receive additional doses of either standard-dose (n = 34) or high-dose (n = 34) epinephrine after failure to respond to the initial standard dose. Survival at 24 hours was assessed.
The results showed a significantly lower rate of survival at 24 hours among patients in the high-dose group (3%), compared with that among patients in the standard-dose group (21%), and a still lower one if cardiac arrest had been caused by asphyxia. But the groups didn't differ significantly in survival rate up to the point of discharge. Although there were 18 protocol violations, the 24-hour survival rate in the high-dose group still was significantly lower than that in the low-dose group after exclusion of the affected cases.
Because of its small sample size, the 24-hour survival rate serving as the primary outcome, and the numerous protocol violations, the study's results have limited generalizability. But in pediatric patients in cardiac arrest caused by asphyxia, this study's findings seem to indicate that it's safer to administer standard-dose epinephrine rather than high-dose epinephrine as the rescue dose.
Perondi MB, et al. N Engl J Med 2004;350 (17):1722-30.
IN THE ICU, NO REST FOR THE WEARY
Night shift activities leave patients little time to sleep.
Patients in the ICU often have no more than a three-hour uninterrupted period during which to sleep each night, according to a recent study.
Through a random, retrospective review of the medical records of 50 adults admitted to the medical, coronary care, neurosurgical, or surgical-trauma units of an academic hospital, researchers documented the hourly care of each patient between 7:00 pm and 7:00 am on two or three consecutive nights. The activities that necessitated interaction between providers and patients included measuring vital signs, administering medication, bathing, suctioning, and taking blood samples. Other data collected included age, sex, diagnosis, and patient acuity.
The review revealed 147 "nights of data" in patients who needed "continuous care," the second highest level of acuity. There was a mean of 42.6 interactions per night, most of them occurring at 8:00 pm, midnight, and 6:00 am, and least often at 3:00 am, leaving nine uninterrupted periods of two to three hours each. The majority of the baths (62%) were given between 9:00 pm and 6:00 am, and although baths can induce sleep in some people, the one intervention documented that did so was a back rub.
Patients might have greater opportunity to sleep if the period near 3:00 am, when care interactions are least frequent, were extended. Additionally, giving the daily bath earlier could help to create longer uninterrupted periods during which patients might sleep.
Tamburri LM, et al. Am J Crit Care 2004; 13(2):102-12; quiz 14-5.
CHILDREN AT RISK FOR POST-ICU PTSD
Longer ICU stays heighten the risk in children undergoing cardiac surgery.
An ICU stay of 48 or more hours can significantly heighten the risk of the development of posttraumatic stress disorder (PTSD) in children.
Researchers at two major medical centers studied 43 schoolchildren (mean age, 8.2 years) to evaluate the associations between baseline cognitive level, temperament, family support, and length of ICU stay and the development of PTSD after cardiac surgery. Preoperatively, the Diagnostic Interview Schedule for Children, Raven's Coloured Progressive Matrices, the School-Age Temperament Inventory, and the Family Apgar were used to assess PTSD, cognitive level, temperament, and family support, respectively, and medical, psychiatric, and social histories also were obtained at that time. Postoperatively, patients were assessed again.
Although PTSD wasn't present in any of the children at baseline, 12% of them suffered from it postoperatively. Additionally, the number of PTSD symptoms increased significantly in those who spent 48 hours or longer in the ICU. In fact, the length of stay there was found to be the only significant predictor of the development of postoperative PTSD symptoms. The study's results suggest that nurses caring for these patients assess them for post-ICU PTSD.
Connolly D, et al. J Pediatr 2004;144 (4):480-4.