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Academic Emergency Medicine : Official... Dec 2022Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral... (Review)
Review
OBJECTIVE
Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings.
METHODS
A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions.
RESULTS
A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical.
CONCLUSIONS
Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
Topics: Humans; Child; Young Adult; Adult; Droperidol; Retrospective Studies; Emergency Service, Hospital; Prospective Studies; Respiratory Insufficiency; Psychomotor Agitation; Observational Studies as Topic
PubMed: 35490341
DOI: 10.1111/acem.14515 -
Critical Care (London, England) Mar 2022Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on...
BACKGROUND
Delirium is the most common cerebral dysfunction in the intensive care unit (ICU) and can be subdivided into a hypoactive, hyperactive, or mixed motor subtype based on the clinical manifestation. The aim of this review was to describe the distribution, pharmacological interventions, and outcomes of delirium motor subtypes in ICU patients.
METHODS
This systematic scoping review was performed according to the PRISMA-ScR and Cochrane guidelines. We performed a systematic search in six major databases to identify relevant studies. A meta-regression analysis was performed where pooled estimates with 95% confidence intervals were computed by a random effect model.
RESULTS
We included 131 studies comprising 13,902 delirious patients. There was a large between-study heterogeneity among studies, including differences in study design, setting, population, and outcome reporting. Hypoactive delirium was the most prevalent delirium motor subtype (50.3% [95% CI 46.0-54.7]), followed by mixed delirium (27.7% [95% CI 24.1-31.3]) and hyperactive delirium (22.7% [95% CI 19.0-26.5]). When comparing the delirium motor subtypes, patients with mixed delirium experienced the longest delirium duration, ICU and hospital length of stay, the highest ICU and hospital mortality, and more frequently received administration of specific agents (antipsychotics, α2-agonists, benzodiazepines, and propofol) during ICU stay. In studies with high average age for delirious patients (> 65 years), patients were more likely to experience hypoactive delirium.
CONCLUSIONS
Hypoactive delirium was the most prevalent motor subtype in critically ill patients. Mixed delirium had the worst outcomes in terms of delirium duration, length of stay, and mortality, and received more pharmacological interventions compared to other delirium motor subtypes. Few studies contributed to secondary outcomes; hence, these results should be interpreted with care. The large between-study heterogeneity suggests that a more standardized methodology in delirium research is warranted.
Topics: Aged; Critical Care; Critical Illness; Delirium; Humans; Intensive Care Units; Psychomotor Agitation
PubMed: 35241132
DOI: 10.1186/s13054-022-03931-3 -
Annals of Palliative Medicine Jan 2022The incidence of hyperactive brain syndrome in patients in the intensive care unit (ICU) is very high. Compared with other sedative drugs, existing research shows that... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The incidence of hyperactive brain syndrome in patients in the intensive care unit (ICU) is very high. Compared with other sedative drugs, existing research shows that dexmedetomidine can significantly reduce the incidence of hyperactive brain syndrome. This study systematically analyzed the clinical efficacy of a dexmedetomidine intravenous injection in ICU patients with hyperactive brain syndrome.
METHODS
The databases PubMed, Web of Science, Embase, and the Cochrane Library were searched from January 2000 to December 2020 to identify papers that studied the clinical efficacy of dexmedetomidine intravenous injection in ICU patients with hyperactive brain syndrome. The basic information and evaluation indexes in the literature were screened and extracted. Revman5.3 software was used for quality assessment and meta-analysis of the included studies, and forest maps were drawn.
RESULTS
A total of 255 patients were included in 5 studies. The results of the meta-analysis showed that intravenous infusion of dexmedetomidine could reduce the incidence of restless delirium in patients [odds ratio (OR) =0.14; 95% confidence interval (CI): 0.07 to 0.29; (Z test) Z=5.39, P<0.00001], total delirium after medication duration [mean difference (MD) =-15.50; 95% CI: -25.70 to -5.29; Z=2.98; P=0.003], and ICU hospitalization time (MD =-1.93; 95% CI: -3.57 to -0.29; Z=2.31; P=0.02). However, there was no significant difference in the incidence of adverse reactions (bradycardia and hypotension) in patients who were given an intravenous infusion of dexmedetomidine (OR =2.85; 95% CI: 0.21 to 38.74; Z=0.79; P=0.43).
DISCUSSION
The incidence of restlessness delirium, the duration of total delirium after medication, and the length of ICU stay in patients treated with a dexmedetomidine intravenous injection were significantly lower than those in patients treated with haloperidol, indicating that a dexmedetomidine intravenous injection had clinical efficacy in ICU patients with hyperactive brain syndrome.
Topics: Brain; Delirium; Dexmedetomidine; Humans; Injections, Intravenous; Intensive Care Units; Psychomotor Agitation; Treatment Outcome
PubMed: 35144421
DOI: 10.21037/apm-21-3762 -
Revista de Neurologia Feb 2022Neuropsychiatric symptoms are common in patients with mild cognitive impairment and dementia. This symptomatology can appear or be exacerbated with changes in routine...
INTRODUCTION
Neuropsychiatric symptoms are common in patients with mild cognitive impairment and dementia. This symptomatology can appear or be exacerbated with changes in routine and in the patient's usual environment. The lockdown situation during the COVID-19 pandemic has meant a drastic and unexpected change in the daily life of the general population, with a particular impact on the most physically and mentally vulnerable groups, including patients with cognitive impairment.
AIM
To know the impact of lockdown measures imposed due to the COVID-19 pandemic on neuropsychiatric symptomatology in people with mild cognitive impairment and dementia.
MATERIALS AND METHODS
Exploratory systematic review, in accordance with the PRISMA guidelines, of Pubmed and Psycinfo databases papers published from January 2020 to April 2021 which related confinement due to COVID-19 with the presentation or worsening of neuropsychiatric symptoms in patients with mild cognitive impairment mild or dementia.
RESULTS
Worsening of neuropsychiatric symptoms was observed in patients with dementia and mild cognitive impairment, especially agitation/aggression, anxiety, depression and apathy. Neuropsychiatric symptoms were more common in patients with dementia than in those with mild cognitive impairment, although their typology varied depending on the severity of dementia.
CONCLUSIONS
During lockdown a worsening in the psychobehavioral area has been observed in people with mild cognitive impairment or dementia. Therefore, considerations arise on the need of promoting social contact in people with mild cognitive impairment and dementia, avoiding situations of isolation and low stimulation.
Topics: Activities of Daily Living; Aggression; Anxiety; Apathy; Argentina; COVID-19; Cognitive Dysfunction; Dementia; Depression; Europe; Humans; Mental Disorders; Mood Disorders; Neuropsychological Tests; Pandemics; Psychomotor Agitation; Quarantine; Retrospective Studies; SARS-CoV-2; Sleep Initiation and Maintenance Disorders; Social Isolation; United States
PubMed: 35084733
DOI: 10.33588/rn.7403.2021356 -
The American Journal of Emergency... Jan 2022Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED).
METHODS
The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome.
RESULTS
Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety.
CONCLUSIONS
Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
Topics: Adult; Droperidol; Emergence Delirium; Emergency Service, Hospital; Humans; Ketamine; Network Meta-Analysis; Psychomotor Agitation; Randomized Controlled Trials as Topic; Severity of Illness Index; Treatment Outcome
PubMed: 34823192
DOI: 10.1016/j.ajem.2021.11.011 -
Journal of Neurotrauma Nov 2021Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages... (Meta-Analysis)
Meta-Analysis
Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behavior Type.
Agitation is a common behavioral problem following traumatic brain injury (TBI); however, the precise proportion of patients who experience agitation in the early stages of recovery is unknown. The aim of this systematic review and meta-analysis was to evaluate the prevalence of agitation in TBI patients undergoing inpatient care, and whether this prevalence differed by post-traumatic amnesia (PTA) status and setting (acute and rehabilitation). We also aimed to describe the prevalence of sub-types of agitated behavior (disinhibited, aggressive, and emotionally labile). We searched five databases and one clinical trials register, with additional review of websites and key journals to identify any relevant records up to July 2020. We included studies describing the proportion of hospitalized TBI patients age 16 years or older demonstrating agitated behavior. We included comparative studies with and without concurrent controls, randomized controlled trials, pseudo-randomized controlled trials, and case series. Methodological quality was critically appraised using a Joanna Briggs Institute checklist. Sixteen studies met eligibility criteria, with a total of 5592 participants. The pooled prevalence of agitation was 31.73% (95% confidence interval [CI], 25.25%-39.00%) during inpatient care (acute and rehabilitation), 32.23% (95% CI, 27.13%-37.80%) during rehabilitative care and 44.06% (95% CI, 36.15%-52.28%) for inpatients in PTA specifically. Disinhibited behaviors were the most common. There was substantial heterogeneity between studies. Additional high-quality research featuring large samples, frequent and long-term measurement of agitation, use of validated scales, and consideration of variables such as PTA status will further improve estimates of agitation prevalence following TBI.
Topics: Amnesia; Brain Injuries, Traumatic; Hospitalization; Humans; Prevalence; Psychomotor Agitation
PubMed: 34435884
DOI: 10.1089/neu.2021.0257 -
The American Journal of Hospice &... May 2022Antipsychotics and benzodiazepines do not improve delirium. Valproic acid (VPA) has been used recently to treat agitation in delirium.
CONTEXT
Antipsychotics and benzodiazepines do not improve delirium. Valproic acid (VPA) has been used recently to treat agitation in delirium.
OBJECTIVES
To review the evidence for VPA in the management of Delirium.
METHODS
Systematic review. English language, age 19 and above, from 1946 to January 12, 2021.
MESH TERMS
"Valproic acid", "valproate", "sodium valproate", "delirium", "acute mania with delirium" in PubMed and Ovid.
EXCLUSION
Studies of VPA used for diagnoses other than delirium.
RESULTS
21 abstracts were identified and 10 studies were included in the review (252 patients): One prospective open label study (n: 7), 2 case series (n: 22), 4 retrospective studies (n: 219) and 3 case reports (n: 4). No randomized controlled trial (RCT) evaluates the effect of VPA in delirium. 237/250 (94.8%) patients were in the ICU. Mean age was 59.7 (27-87). 153/204 (74%) were male. The mean starting dose was 733 mg/day in 148 patients and the mean dose at follow up was 1061 mg/day in 205 patients. CAM ICU was used to diagnose delirium in 6 reviews. Delirium improved in case series in 19/22 patients. Delirium improved in retrospective studies at day 3 compared to day 1. VPA levels were not consistently reported. Hyperammonemia (12-19%) and thrombocytopenia (9-13%) were the most common side effects. No deaths were attributed to VPA.
CONCLUSION
VPA is being used more frequently for delirium. The evidence is limited to retrospective studies and case series. There is a need for RCT to evaluate the effect of VPA in delirium compared to other alternatives and placebo.
Topics: Adult; Antipsychotic Agents; Benzodiazepines; Delirium; Humans; Male; Middle Aged; Psychomotor Agitation; Valproic Acid; Young Adult
PubMed: 34409869
DOI: 10.1177/10499091211038371 -
Australian Critical Care : Official... Jul 2022Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates... (Review)
Review
BACKGROUND
Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role.
OBJECTIVES
The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU.
METHODS
A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715.
RESULTS
Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues.
CONCLUSIONS
This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.
Topics: Adult; Humans; Intensive Care Units; Patient Care
PubMed: 34373173
DOI: 10.1016/j.aucc.2021.05.011 -
Clinical NeuropharmacologyIntranasal drip of dexmedetomidine in children with sevoflurane anesthesia can reduce anesthesia and restlessness. However, there is still some controversy. We conducted... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intranasal drip of dexmedetomidine in children with sevoflurane anesthesia can reduce anesthesia and restlessness. However, there is still some controversy. We conducted a meta-analysis to explore the effect of intranasal infusion of dexmedetomidine on the quality of recovery during the recovery period, to provide certain guidance for clinical application.
METHODS
Web of Science, PubMed, Embase, and the Cochrane Library were used for literature search. Systematic reviews were based on PRISMA (the Preferred Reporting Items for Systematic Reviews and Meta-Analysis).
RESULTS
A total of 14 articles and 1123 patients were included. The results of the meta-analysis showed that the incidence of emergence agitation [risk ratio (RR), 0.32; 95% confidence interval (CI), 0.20-0.50; P < 0.0001], satisfactory sedation at parent separation (RR, 1.41; 95% CI, 1.031-93; P = 0.034), incidence of nausea and vomiting (RR, 0.41; 95% CI, 0.21-0.78; P = 0.007), and incidence of laryngospasm (RR, 0.23; 95% CI, 0.08-0.65; P = 0.006) of the intranasal dexmedetomidine group were different compared with the control group. However, the satisfactory sedation at mask induction in the intranasal dexmedetomidine group (RR, 1.16; 95% CI, 0.87-1.54; P = 0.319), postanesthesia care unit (PACU) stay time (standardized mean deviation, 0.51; 95% CI, -0.11 to 1.12; P = 0.107), and extubation time (standardized mean deviation, 1.64; 95% CI, -1.07 to 4.35; P = 0.235) were not statistically significant compared with those of the control group.
CONCLUSION
Intranasal dexmedetomidine anesthesia with sevoflurane in children can reduce the incidence of emergence agitation, provide more satisfactory sedation when the parents are separated, reduce the incidence of nausea and vomiting, and reduce the incidence of laryngospasm. In addition, the 2 μg/kg dose of dexmedetomidine may be the best dose for clinical application.
Topics: Anesthesia, General; Child; Dexmedetomidine; Humans; Hypnotics and Sedatives; Psychomotor Agitation; Sevoflurane
PubMed: 34347636
DOI: 10.1097/WNF.0000000000000466 -
Trends in Psychiatry and Psychotherapy Jun 2022Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, associated with the... (Review)
Review
INTRODUCTION
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, associated with the presence of restricted and repetitive patterns of behavior, interests, or activities. Cannabis has been used to alleviate symptoms associated with ASD.
METHOD
We carried out a systematic review of studies that investigated the clinical effects of cannabis and cannabinoid use on ASD, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA checklist). The search was carried out in four databases: MEDLINE/PubMed, Scientific Electronic Library Online (SciELO), Scopus, and Web of Science. No limits were established for language during the selection process. Nine studies were selected and analyzed.
RESULTS
Some studies showed that cannabis products reduced the number and/or intensity of different symptoms, including hyperactivity, attacks of self-mutilation and anger, sleep problems, anxiety, restlessness, psychomotor agitation, irritability, aggressiveness perseverance, and depression. Moreover, they found an improvement in cognition, sensory sensitivity, attention, social interaction, and language. The most common adverse effects were sleep disorders, restlessness, nervousness and change in appetite.
CONCLUSION
Cannabis and cannabinoids may have promising effects in the treatment of symptoms related to ASD, and can be used as a therapeutic alternative in the relief of those symptoms. However, randomized, blind, placebo-controlled clinical trials are necessary to clarify findings on the effects of cannabis and its cannabinoids in individuals with ASD.
SYSTEMATIC REVIEW REGISTRATION
International Prospective Register of Systematic Reviews (PROSPERO), code 164161.
Topics: Anxiety; Anxiety Disorders; Autism Spectrum Disorder; Cannabinoids; Cannabis; Humans; Psychomotor Agitation
PubMed: 34043900
DOI: 10.47626/2237-6089-2020-0149