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Critical Care Medicine Apr 2024To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD,... (Meta-Analysis)
Meta-Analysis
Clinical Impact of the Implementation Strategies Used to Apply the 2013 Pain, Agitation/Sedation, Delirium or 2018 Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption Guideline Recommendations: A Systematic Review and Meta-Analysis.
OBJECTIVES
To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines.
DATA SOURCES
PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268).
STUDY SELECTION
Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS).
DATA EXTRACTION
Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation.
DATA SYNTHESIS
Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS.
CONCLUSIONS
Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations.
Topics: Adult; Humans; Critical Care; Intensive Care Units; Pain; Pain Management; Delirium
PubMed: 38193764
DOI: 10.1097/CCM.0000000000006178 -
Heart Views : the Official Journal of... 2023Although respiratory support is necessary to maintain hemodynamic stability in patients undergoing major surgeries, prolonging the time of mechanical ventilation is... (Review)
Review
BACKGROUND
Although respiratory support is necessary to maintain hemodynamic stability in patients undergoing major surgeries, prolonging the time of mechanical ventilation is considered a major complication following these procedures. The identification of potential factors related to this phenomenon should be identified. In the present systematic review, we first assess the pooled prevalence of prolonged mechanical ventilation (PMV) in patients undergoing coronary artery bypass grafting (CABG) surgery and also determine the main predictors for PMV by deeply reviewing the literature.
MATERIALS AND METHODS
The manuscript databases including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane were deeply searched by the two blinded investigators for all eligible studies based on the relevant keywords. Based on the titles and abstracts, 88 records were initially included and of those, 15 articles were eligible for the final analysis.
RESULTS
The pooled prevalence of PMV in the studies that defined PMV as ventilation >24 h was 6.5% (95% confidence interval [CI]: 4.1%-10.2%) and in the studies, PMV as ventilation >48 h was 2.8% (95% CI: 1.7%-4.7%). Demographics (gender and advanced age), obesity, underlying comorbidities (hypertension, chronic kidney disease, cerebrovascular accident, high New York Heart Association class, history of chronic obstructive pulmonary disease, and history of acute coronary syndrome), emergency surgery, intraoperative characteristics (needing intra-aortic balloon pump, increased peak airway pressure, using cardiopulmonary bypass, the type of dose of anesthetics, cross-clamp time, increased units of blood transfusion, occurring cardiac ischemic events within an operation, fluid imbalance, and some anastomoses), and some postoperative outcome such as lowering O saturation, sequential organ failure assessment score, inotrope use, pleural effusion, delirium, and prolonged intensive care unit stay were found to be the main determinants for PMV.
CONCLUSION
Depending on the definition of PMV, the prevalence of PMV varied from 1.7% to 10.2%. Various factors before, during, and after surgery are the predictors of PMV in these patients, which can be used to design new scoring systems to predict it.
PubMed: 38188710
DOI: 10.4103/heartviews.heartviews_71_23 -
Archives of Academic Emergency Medicine 2024Considering the importance of delirium disorder in burn patients and its complications, the present systematic review and meta-analysis aimed to determine the prevalence... (Review)
Review
INTRODUCTION
Considering the importance of delirium disorder in burn patients and its complications, the present systematic review and meta-analysis aimed to determine the prevalence of delirium and its related factors in burn patients.
METHODS
A comprehensive, systematic search was performed in different international electronic databases, such as Scopus, PubMed, and Web of Science, as well as Persian electronic databases such as Iranmedex, and Scientific Information Database (SID) using keywords extracted from Medical Subject Headings such as "Prevalence", "Delirium", and "Burns" from the earliest to the 17th of July, 2023.
RESULTS
In total, 2,710 burn patients participated in ten original studies. Among the participants, 64.6% were male. In the ten studies, the reported pooled prevalence of delirium among burn patients was 20.5% (95% CI: 10.9% to 35.0%; I=96.889%; P<0.001). Also, factors such as total body surface area, duration of hospitalization, mortality, days on ventilator, alcoholism, benzodiazepine dose, methadone dose, age, male gender, ICU days, operation days, wound care under anesthesia, and opioid dose had a significant correlation with the prevalence of delirium in burn patients.
CONCLUSION
Health managers and policymakers can reduce the prevalence of delirium in burn patients by eliminating or reducing factors associated with it.
PubMed: 38162381
DOI: 10.22037/aaem.v12i1.2136 -
Indian Journal of Orthopaedics Jan 2024The aim of this systematic review was to assess the impact of time to surgery on patient mortality, peri-operative complication rates and length of stay following a hip... (Review)
Review
Accelerated Care of Patients with Hip Fractures is Associated with Lower Risk of Delirium and Infection, and a Shorter Length of Hospital Stay: Systematic Review and Meta-analysis of Level One Evidence.
OBJECTIVES
The aim of this systematic review was to assess the impact of time to surgery on patient mortality, peri-operative complication rates and length of stay following a hip fracture using level one data.
DATA SOURCES
Multiple databases (PubMed, Embase, Medline (Ovid), and Cochrane Library) were searched using terms for "hip fracture" and the intervention "early surgery". Results were filtered to only included randomised controlled trials in the English language published from the year 2000.
STUDY SELECTION
All results were imported into Covidence and screened by two separate reviewers with conflicts resolved by a third reviewer. Studies were included if they reported data on the relationship between time to theatre and at least one of the outcome measures (mortality, peri-operative complications, and length of stay in hospital). Three papers were finalised to include in this review.
DATA EXTRACTION
Once selected, each paper had a bias assessment completed by two separate reviewers using the Cochrane RoB2 tool. Any conflicts were resolved by a third reviewer.
DATA SYNTHESIS
Data from each paper were inputted into RevMan5 for analysis. Approximated sample mean and standard deviation were collected from each paper and included for analysis. RevMan5 was then used to generate forest plots and report data on relative risk and mean difference.
CONCLUSIONS
This review has shown that accelerated care of patients with hip fractures was associated with lower risks of delirium and infection, and a shorter length of hospital stay. However, the effect of time to surgery on patient mortality is not clear, as the standard care group had a lower mortality than expected for the population at risk and had surgery on average within 24-h of presentation.
PubMed: 38161403
DOI: 10.1007/s43465-023-01026-x -
Journal of Clinical Medicine Dec 2023Regional nerve blocks (NBs) mitigate the occurrence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) in adult patients undergoing thoracic... (Review)
Review
Regional nerve blocks (NBs) mitigate the occurrence of postoperative cognitive dysfunction (POCD) and postoperative delirium (POD) in adult patients undergoing thoracic surgery. This study aimed to determine the exact effect of NBs on POCD and POD. Electronic databases, including PubMed, EMBASE, CINAHL, Scopus, and Web of Science, were searched for studies. The primary outcome was the incidence of POD or POCD. The secondary outcome was pain scores assessed 24 and 48 h postoperatively. We calculated the log odds ratio (LOR) and standardized mean difference (SMD) with 95% confidence intervals (CIs). The LOR was converted to an odds ratio (OR). In the analysis of 1010 patients from seven randomized controlled trials, POD and POCD rates were 14.1% and 16.7%, respectively, in the NB group, and higher, at 27.3% and 35.2%, in the control group. NBs reduced the incidence of POD (OR, 0.44; 95%CI 0.30 to 0.64; < 0.001; I = 0.00%) and POCD (OR, 0.43; 95%CI 0.24 to 0.76; < 0.001; I = 0.00%). NBs reduced pain scores at 24 h (SMD, -2.60; 95%CI -3.90 to -1.30, < 0.001; I = 97.68%) and 48 h (SMD, -1.80; 95%CI -3.18 to -0.41, = 0.01; I = 98.14%) postoperatively. NBs mitigated the occurrence of POD and POCD in adult patients after thoracic surgery.
PubMed: 38137648
DOI: 10.3390/jcm12247576 -
BMC Anesthesiology Dec 2023The effects of intravenous glucocorticoids on postoperative delirium (POD) in adult patients undergoing major surgery remain controversial. Therefore, we conducted this... (Meta-Analysis)
Meta-Analysis
Effects of intravenous glucocorticoids on postoperative delirium in adult patients undergoing major surgery: a systematic review and meta-analysis with trial sequential analysis.
BACKGROUND
The effects of intravenous glucocorticoids on postoperative delirium (POD) in adult patients undergoing major surgery remain controversial. Therefore, we conducted this meta-analysis to assess whether intravenous glucocorticoids can decrease POD incidence in the entire adult population undergoing major surgery and its association with patients age, type of surgery, and type of glucocorticoid.
METHODS
We searched the relevant literature published before November 3, 2023, through Cochrane Library, PubMed, Embase, and Web of Science. The primary outcome was POD incidence. The risk ratio for the primary outcome was calculated using the Mantel-Haenszel method. The secondary outcomes included 30-day mortality, length of hospital stay, ICU duration, mechanical ventilation duration, and occurrence of glucocorticoid-related adverse effects (e.g., infection and hyperglycemia). This meta-analysis was registered in PROSPERO: CRD42022345997.
RESULTS
We included eight randomized controlled studies involving 8972 patients. For the entire adult population undergoing major surgery, intravenous glucocorticoids reduced the POD incidence (risk ratio = 0.704, 95% confidence interval, 0.519-0.955; P = 0.024). However, subgroups defined by type of surgery showed differential effects of glucocorticoids on POD. Intravenous glucocorticoids can not reduce POD incidence in adult patients undergoing cardiac surgery (risk ratio = 0.961, 95% confidence interval, 0.769-1.202; P = 0.728), with firm evidence from trial sequential analysis. However, in major non-cardiac surgery, perioperative intravenous glucocorticoid reduced the incidence of POD (risk ratio = 0.491, 95% confidence interval, 0.338-0.714; P < 0.001), which warrants further studies due to inconclusive evidence by trial sequence analysis. In addition, the use of glucocorticoids may reduce the mechanical ventilation time (weighted mean difference, -1.350; 95% confidence interval, -1.846 to -0.854; P < 0.001) and ICU duration (weighted mean difference = -7.866; 95% confidence interval, -15.620 to -0.112; P = 0.047).
CONCLUSIONS
For the entire adult population undergoing major surgery, glucocorticoids reduced the POD incidence. However, the effects of glucocorticoids on POD appear to vary according to the type of surgery. In patients receiving major non-cardiac surgery, glucocorticoid may be an attractive drug in the prevention of POD, and further studies are needed to draw a definitive conclusion. In cardiac surgery, intravenous glucocorticoids have no such effect.
Topics: Adult; Humans; Glucocorticoids; Emergence Delirium; Cardiac Surgical Procedures; Administration, Intravenous; Length of Stay; Postoperative Complications
PubMed: 38057700
DOI: 10.1186/s12871-023-02359-8 -
The Journal of Clinical Endocrinology... May 2024Synthetic glucocorticoids are widely used to treat patients with a broad range of diseases. While efficacious, glucocorticoids can be accompanied by neuropsychiatric... (Meta-Analysis)
Meta-Analysis
CONTEXT
Synthetic glucocorticoids are widely used to treat patients with a broad range of diseases. While efficacious, glucocorticoids can be accompanied by neuropsychiatric adverse effects.
OBJECTIVE
This systematic review and meta-analysis assesses and quantifies the proportion of different neuropsychiatric adverse effects in patients using synthetic glucocorticoids.
METHODS
Six electronic databases were searched to identify potentially relevant studies. Randomized controlled trials, cohort studies, and cross-sectional studies assessing psychiatric side effects of glucocorticoids measured with validated questionnaires were eligible. Risk of bias was assessed with RoB 2, ROBINS-I, and AXIS appraisal tool. For proportions of neuropsychiatric outcomes, we pooled proportions, and when possible, differences in questionnaire scores between glucocorticoid users and nonusers were expressed as standardized mean differences (SMD). Data were pooled in a random-effects logistic regression model.
RESULTS
We included 49 studies with heterogeneity in study populations, type, dose, and duration of glucocorticoids. For glucocorticoid users, meta-analysis showed a proportion of 22% for depression (95% CI, 14%-33%), 11% for mania (2%-46%), 8% for anxiety (2%-25%), 16% for delirium (6%-36%), and 52% for behavioral changes (42%-61%). Questionnaire scores for depression (SMD of 0.80 [95% CI 0.35-1.26]), and mania (0.78 [0.14-1.42]) were higher than in controls, indicating more depressive and manic symptoms following glucocorticoid use.
CONCLUSION
The heterogeneity of glucocorticoid use is reflected in the available studies. Despite this heterogeneity, the proportion of neuropsychiatric adverse effects in glucocorticoid users is high. The most substantial associations with glucocorticoid use were found for depression and mania. Upon starting glucocorticoid treatment, awareness of possible psychiatric side effects is essential. More structured studies on incidence and potential pathways of neuropsychiatric side effects of prescribed glucocorticoids are clearly needed.
Topics: Humans; Glucocorticoids; Mental Disorders
PubMed: 38038629
DOI: 10.1210/clinem/dgad701 -
Critical Care (London, England) Nov 2023Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within... (Review)
Review
BACKGROUND
Despite the extensive volume of research published on checklists in the intensive care unit (ICU), no review has been published on the broader role of checklists within the intensive care unit, their implementation and validation, and the recommended clinical context for their use. Accordingly, a scoping review was necessary to map the current literature and to guide future research on intensive care checklists. This review focuses on what checklists are currently used, how they are used, process of checklist development and implementation, and outcomes associated with checklist use.
METHODS
A systematic search of MEDLINE (Ovid), Embase, Scopus, and Google Scholar databases was conducted, followed by a grey literature search. The abstracts of the identified studies were screened. Full texts of relevant articles were reviewed, and the references of included studies were subsequently screened for additional relevant articles. Details of the study characteristics, study design, checklist intervention, and outcomes were extracted.
RESULTS
Our search yielded 2046 studies, of which 167 were selected for further analysis. Checklists identified in these studies were categorised into the following types: rounding checklists; delirium screening checklists; transfer and handover checklists; central line-associated bloodstream infection (CLABSI) prevention checklists; airway management checklists; and other. Of 72 significant clinical outcomes reported, 65 were positive, five were negative, and two were mixed. Of 122 significant process of care outcomes reported, 114 were positive and eight were negative.
CONCLUSIONS
Checklists are commonly used in the intensive care unit and appear in many clinical guidelines. Delirium screening checklists and rounding checklists are well implemented and validated in the literature. Clinical and process of care outcomes associated with checklist use are predominantly positive. Future research on checklists in the intensive care unit should focus on establishing clinical guidelines for checklist types and processes for ongoing modification and improvements using post-intervention data.
Topics: Humans; Checklist; Critical Care; Delirium; Intensive Care Units
PubMed: 38037056
DOI: 10.1186/s13054-023-04758-2 -
BMC Anesthesiology Nov 2023Emergence agitation (EA) is a prevalent complication in children following general anesthesia. Several studies have assessed the relationship between melatonin or its... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Emergence agitation (EA) is a prevalent complication in children following general anesthesia. Several studies have assessed the relationship between melatonin or its analogs and the incidence of pediatric EA, yielding conflicting results. This meta-analysis aims to assess the effects of premedication with melatonin or its analogs on preventing EA in children after general anesthesia.
METHODS
PubMed, EMBASE, the Cochrane Library, ProQuest Dissertations & Theses Global, Web of Science, CNKI, Wanfang Data, clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched until 25 November 2022. We included randomized controlled trials that assessed EA in patients less than 18 years old who underwent general anesthesia. We excluded studies that did not use a specific evaluation to assess EA.
RESULTS
Nine studies (951 participants) were included in this systematic review. Melatonin significantly reduced the incidence of EA compared with placebos (risk ratio 0.40, 95% CI 0.26 to 0.61, P < 0.01) and midazolam (risk ratio 0.48, 95% CI 0.32 to 0.73, P < 0.01). Dexmedetomidine remarkably decreased the incidence of EA compared with melatonin (risk ratio 2.04, 95% CI 1.11 to 3.73, P = 0.02).
CONCLUSIONS
Melatonin premedication significantly decreases the incidence of EA compared with placebos and midazolam. Dexmedetomidine premedication has a stronger effect than melatonin in preventing EA. Nevertheless, further studies are warranted to reinforce and validate the conclusion on the efficacy of melatonin premedication in mitigating EA in pediatric patients.
Topics: Child; Humans; Adolescent; Midazolam; Dexmedetomidine; Emergence Delirium; Melatonin; Sevoflurane; Methyl Ethers; Premedication
PubMed: 38037000
DOI: 10.1186/s12871-023-02356-x -
Frontiers in Neuroscience 2023Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional... (Review)
Review
OBJECTIVE
Delirium is an acute alteration of consciousness marked by confusion, inattention, and changes in cognition. Some speculate that delirium may be a disorder of functional connectivity, but the requirement to lay still may limit measurement with existing functional imaging modalities in this population. Electroencephalography (EEG) may allow for a more feasible approach to the study of potential connectivity disturbances in delirium. We conducted a systematic review to investigate whether there are EEG-measurable differences in brain functional connectivity in the resting state associated with delirium.
METHODS
Medline, PubMed, PsychInfo, Embase and CINAHL were searched for relevant articles containing original data studying EEG functional connectivity measures in delirium.
RESULTS
The search yielded 1,516 records. Following strict inclusion criteria, four studies were included in the review. The studies used a variety of EEG measures including phase lag index, coherence, entropy, shortest path length, minimum spanning tree, and network clustering coefficients to study functional connectivity between scalp electrodes. Across connectivity measures, delirium was associated with decreased brain functional connectivity. All four studies found decreased alpha band connectivity for patients with delirium. None of the studies directly compared the different motor subtypes of delirium.
SIGNIFICANCE
This systematic review provides converging evidence for disturbances in oscillatory-based functional connectivity in delirium.
PubMed: 38033553
DOI: 10.3389/fnins.2023.1274837