Methodologic Innovation in Creating Clinical Practice Guidelines: Insights From the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guideline Effort

Devlin, John W.; Skrobik, Yoanna; Rochwerg, Bram; Nunnally, Mark; Needham, Dale M.; Gélinas, Céline; Pandharipande, Pratik P.; Slooter, Arjen J. C.; Watson, Paula L.; Weinhouse, Gerald L.; Kho, Michelle E.; Centofanti, John; Price, Carrie; Harmon, Lori; Misak, Cheryl; Flood, Pamela; Alhazzani, Waleed

doi:10.1097/ccm.0000000000003298

Cited by 71 publications

(82 citation statements)

References 29 publications

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“…Both ICU-AW and delirium affect not only mortality but also health-related quality of life and increase ICU length of stay [35–39]. Deep sedation is associated with ICU-AW and delirium [40, 41]. Additionally, there is considerable evidence that early mobilization can decrease the incidence of ICU-AW and delirium [40–42].…”

Section: Discussionmentioning

confidence: 99%

Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

et al. 2019

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PurposeGait independence is one of the most important factors related to returning home from the hospital for patients treated in the intensive care unit (ICU), but the factors affecting gait independence have not been clarified. This study aimed to determine the factors affecting gait independence at hospital discharge using a standardized early mobilization protocol that was shared by participating hospitals.Materials and methodsPatients who entered the ICU from January 2017 to March 2018 were screened. The exclusion criteria were mechanical ventilation < 48 hours, age < 18, loss of gait independence before hospitalization, being treated for neurological issues, unrecoverable disease, unavailability of continuous data, and death during ICU stay. Basic attributes, such as age, ICU length of stay, information on early mobilization while in the ICU, Medical Research Council (MRC) sum-score at ICU discharge, incidence of ICU-acquired weakness (ICU-AW) and delirium, and the degree of gait independence at hospital discharge, were collected. Gait independence was determined using a mobility scale of the Barthel Index, and the factors that impaired gait independence at hospital discharge were investigated using a Cox proportional hazard regression analysis.ResultsOne hundred thirty-two patients were analyzed. In the univariate analysis, age, APACHE II score, duration of mechanical ventilation, ICU length of stay, incidence of delirium, and MRC sum-score at ICU discharge were extracted as significant. In the multivariate analysis, age (p = 0.014), MRC sum-score < 48 (p = 0.021), and delirium at discharge from ICU (p < 0.0001) were extracted as significant variables.ConclusionsWe found that age and incidence of ICU-AW and delirium were significantly related to impaired gait independence at hospital discharge.

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Section: Discussionmentioning

confidence: 99%

Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

et al. 2019

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“…Trends over time of q-PLR and CV in delirious vs. non-delirious patients are illustrated in Figure 1. In the subset of patients in whom pupillometry measurements were performed at day 6 and 7 (n=30), q-PLR remained significantly lower in patients with delirium (median 22 [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]…”

Section: Associations Between Icu Delirium and Quantitative Pupillarymentioning

confidence: 99%

“…E-PRE-DELIRIC [22] and PRE-DELIRIC [23]) may help improving delirium prediction [24], however there are currently no available quantitative tools for the monitoring of ICU delirium. The objective of this study was to examine in high-risk sedated mechanically ventilated patients, without primary acute or known brain injury, whether reduced pupillary light constriction -assessed quantitatively at the early phase of ICU using automated infrared pupillometry -was associated with delirium, assessed with the Confusion Assessment Method for the ICU (CAM-ICU) [25].…”

Section: Introductionmentioning

confidence: 99%

Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

Favre

Bernini

Morelli

et al. 2020

Preprint

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Background. Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods. This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 hours. Starting at day 3, automated infrared pupillometry – blinded to ICU caregivers – was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/sec). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results. A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/sec) at day 3, and at all additional time-points tested ( p <0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p =0.03). Conclusions. Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

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“…Continuous intravenous analgesia is an effective method for relieving pain, antagonizing stress and reducing oxygen consumption. It has become one of the preferred methods for providing postoperative analgesia [1,2]. Butorphanol is a lipid soluble opioid analgesic which can be used intravenously, intrathecally as well as for epidural analgesia.…”

Section: Introductionmentioning

confidence: 99%

Butorphanol tartrate is better than fentanyl for postoperative analgesia after intestinal surgery: A prospective cohort study

Wang

et al. 2019

Preprint

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Background Traditional opioid analgesics act on the μ2 receptors and lead to delayed gastric emptying and weakening of the peristalsis. Butorphanol is an opioid analgesic that has strong excitatory effect on κ receptors, weak μ receptor agonistic and antagonistic activity. This study aimed to compare the effects of butorphanol tartrate and fentanyl on the analgesia and the gastrointestinal motility after intestinal surgery. Method This prospective cohort study was conducted in Zhongnan Hospital of Wuhan University, Wuhan, China from May to September 2017. One hundred and forty six patients admitted to ICU after intestinal surgeries, were divided into fentanyl group and butorphanol group. The fentanyl group continually infused fentanyl with 1ug/kg/h and the butorphanol group continually infused butorphanol with 20ug/kg/h. The analgesics were used until the patients were transfer out of ICU or up to 24 hours. The primary outcome was the time required for the first passage of flatus. The second outcomes included the pain and sedation scores, the incidence of nausea and vomiting, serum motilin concentrations, and the incidence rate of adverse reactions. Results There were 69 patients in butorphanol group and 77patients in fentanyl group. Compared with the fentanyl group, the time required for the first passage of flatus was shorter (69.82 ±18.84 h vs. 79.34 ± 15.69 h, p= 0.0012) and the incidence of nausea (14.9% vs. 29.3%, P=0.013) and vomiting (11.7% vs. 27.3%, P=0.031) was significantly lower in the butorphanol group without any significant difference in analgesic score and sedation score. The serum motilin increase level was significantly higher in butorphanol group [21.36(6.17, 28.47) ng/L vs. 5.56(3.04, 9.81) ng/L, P = 0.034]. Conclusion: In patients undergoing intestinal surgery, butorphanol tartrate allows faster recovery of gastrointestinal function and similar analgesia compared to fentanyl. TRIAL REGESTRITION Chinese Clinical Trial Register (ChiCTR-INR-17011031). Registered on Mar 31th 2017.

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Methodologic Innovation in Creating Clinical Practice Guidelines: Insights From the 2018 Society of Critical Care Medicine Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Guideline Effort

Abstract: Our multifaceted, interdisciplinary approach and novel methodologic strategies can help inform the development of future critical care clinical practice guidelines.

Cited by 71 publications

References 29 publications

Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

Butorphanol tartrate is better than fentanyl for postoperative analgesia after intestinal surgery: A prospective cohort study

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