To identify patient characteristics and clinical factors during ICU hospitalization potentially associated with chronic pain occurrence, and to determine its relationship with symptoms of post-traumatic stress disorder (PTSD) and health-related quality of life (HRQoL) at three time points after ICU discharge.

Adult ICU survivors were enrolled in a prospective, repeated measures study. The study was carried out in two phases. Phase I was conducted during the first 5 days of survivors' ICU hospitalization where patient characteristics and clinical data were collected. Phase II was conducted via telephone interviews after 3 (T1), 6 (T2) and 12 (T3) months post-ICU discharge, where pain, PTSD-related symptoms, and HRQoL were assessed with the Numeric Rating Scale (NRS), Davidson Trauma Scale (DTS), and 36-Item Short Form Survey version 2 (SF-36v2), respectively.

Data from 59 survivors were analysed, 69.5% of whom were males. The sample's mean age was 52.7 (SD 18.9) years and 62.7% of them reported NRS>3 at T1, indicating chronic pain. After adjusting for sex, age, and APACHE II score, chronic pain was significantly associated with: (a) length of stay in the ICU (OR=1.42; 95%CI: 1.03-1.95; p=0.030) and (b) clinically relevant symptoms of PTSD at T1 (OR=10.04; 95%CI: 2.44-41.24; p=0.001) and T2 (OR=11.90; 95%CI: 1.28-110.49; p=0.029). Lower SF-36v2 scores in all domains at T1, several domains at T2, and two domains at T3 were significantly associated with CP occurrence.

Of the patient characteristics and clinical factors analysed, only longer length of stay in ICU was significantly associated with higher odds of chronic pain occurrence, which in turn was linked to PTSD-related symptoms and lower HRQoL after ICU discharge.

Clinical interventions aimed at optimizing ICU length of stay, such as the implementation of early mobility programs and multidisciplinary rehabilitation, may support prevention of chronic pain occurrence and improve long-term outcomes.

A reduced initial dose of injectable haloperidol is recommended in older patients for treatment of acute agitation based on limited studies.

Assess the effectiveness and safety of higher-dose versus low-dose injectable haloperidol in older patients presenting to the emergency department (ED).

This was a retrospective, propensity-score matched, cohort analysis conducted at a two-campus healthcare system. Patients ≥65 years old administered injectable haloperidol in the ED were classified as receiving low-dose (≤ 0.5 mg) or higher-dose (> 0.5 mg) haloperidol. Exclusion criteria included acute alcohol withdrawal; ED or hospital stay shorter than four hours; and any of the following before injectable haloperidol administration: safety watch, physical restraint requirement, and administration of oral haloperidol, other acute antipsychotics, or benzodiazepines. The primary outcome was composite treatment failure, defined as need for repeat injectable haloperidol, alternative sedative, restraints, or safety watch within four hours of haloperidol administration. Secondary safety outcomes included escalation of respiratory support, extrapyramidal symptoms, falls, and hospital admission.

Sixty-nine patients per group were matched. There was no statistically significant difference in composite treatment failure (P = 0.087). However, patients in the higher-dose group were more likely to require alternative sedatives (P = 0.035). There were no significant differences between groups for any safety outcomes.

This study suggests low-dose (≤ 0.5 mg) injectable haloperidol may be at least as safe and effective as higher doses (> 0.5 mg) in agitated older adults. Low-dose injectable haloperidol may be preferred in mild to moderately agitated older adults, reserving higher doses for severe agitation.

Delirium is a common complication in elderly patients after major surgeries and can lead to poor outcomes such as neurocognitive decline. Acetaminophen is one of the most widely used adjuvants for perioperative multimodal analgesia. Previous studies showed that it can effectively alleviate postoperative pain, promote opioid sparing and exert anti-neuroinflammatory response, showing strong potential for preventing postoperative delirium. We, thus, propose to test the primary hypothesis that postoperative intravenous acetaminophen would reduce delirium over 5 postoperative days in older patients following major non-cardiac surgery.

We propose a multicentre, randomised, placebo-controlled, parallel-group trial in patients aged>65 years old scheduled for non-cardiac major surgery with general anaesthesia expected to last at least 2 hours. A total of 1930 elderly patients will be enrolled and randomised at 1:1 ratio to acetaminophen or saline placebo groups, stratified by age, education level and trial site with randomsised blocking. Acetaminophen or saline will be given when the surgical suture begins at the end of surgery and, thereafter, a total of seven doses within 48 hours after surgery. Our primary outcome will be the incidence of delirium, assessed two times per day, through the fifth postoperative day. Secondary and exploratory outcomes will include pain scores with movement, total opioid consumption, severity of delirium, intensive care unit and hospital lengths of stay.

This study has been approved by the Ethics Committee of Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine (LY2023-239-C) and approved by each participating centre. This report follows the Consolidated Standards of Reporting Trials reporting guideline for randomised studies. The findings will be shared in academic meetings and peer-reviewed academic journals.

NCT06653465.

Whether the use of inhaled or intravenous sedation affects outcomes differentially in mechanically ventilated adults with acute respiratory distress syndrome (ARDS) is unknown.

To determine the efficacy and safety of inhaled sevoflurane compared with intravenous propofol for sedation in patients with ARDS.

Phase 3 randomized, open-label, assessor-blinded clinical trial conducted from May 2020 to October 2023 with 90-day follow-up. Adults with early moderate to severe ARDS (defined by a ratio of Pao2 to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure of ≥8 cm H2O) were enrolled in 37 French intensive care units.

Patients were randomized to a strategy of inhaled sedation with sevoflurane (intervention group) or to a strategy of intravenous sedation with propofol (control group) for up to 7 days.

The primary end point was the number of ventilator-free days at 28 days; the key secondary end point was 90-day survival.

Of 687 patients enrolled (mean [SD] age, 65 [12] years; 30% female), 346 were randomized to sevoflurane and 341 to propofol. The median total duration of sedation was 7 days (IQR, 4 to 7) in both groups. The number of ventilator-free days through day 28 was 0.0 days (IQR, 0.0 to 11.9) in the sevoflurane group and 0.0 days (IQR, 0.0 to 18.7) in the propofol group (median difference, -2.1 [95% CI, -3.6 to -0.7]; standardized hazard ratio, 0.76 [95% CI, 0.50 to 0.97]). The 90-day survival rates were 47.1% and 55.7% in the sevoflurane and propofol groups, respectively (hazard ratio, 1.31 [95% CI, 1.05 to 1.62]). Among 4 secondary outcomes, sevoflurane was associated with higher 7-day mortality (19.4% vs 13.5%, respectively; relative risk, 1.44 [95% CI, 1.02 to 2.03]) and fewer intensive care unit-free days through day 28 (median, 0.0 [IQR, 0.0 to 6.0] vs 0.0 [IQR, 0.0 to 15.0]; median difference, -2.5 [95% CI, -3.7 to -1.4]) compared with propofol.

Among patients with moderate to severe ARDS, inhaled sedation with sevoflurane resulted in fewer ventilator-free days at day 28 and lower 90-day survival than sedation with propofol.

ClinicalTrials.gov Identifier: NCT04235608.

Perioperative psychological stress and pharmacological anxiolysis can negatively affect the quality of recovery after total knee arthroplasty. We aimed to assess whether hypnosis combined with virtual reality could reduce intraoperative pharmacological sedation and improve quality of recovery after total knee arthroplasty surgery.

In this prospective randomized clinical trial, 60 patients scheduled for total knee arthroplasty with spinal anesthesia were randomly divided into 2 groups of 30 patients each. Intraoperatively, intermittent boluses of midazolam 1 mg were administered at 5 min intervals at the patient's request, with a maximum driven by the clinical assessment of sedation depth. During surgery, patients received standard care (group control) or virtual reality hypnosis (group VRH). An unblinded observer recorded the total dose of midazolam administered during surgery, and changes in the Quality-of-Recovery 15-item score, comfort, fatigue, pain and anxiety before and 1, 3 and 7 days after surgery.

Patients in the VRH group required a lower dose of midazolam (mg; median (range)) intraoperatively (group VRH: 0 (0-4) and group control: 2 (0-9), p<0.001). Quality-of-Recovery 15-item, anxiety, and pain were similar between groups.

In total knee arthroplasty with spinal anesthesia, VRH reduces the requirement for intraoperative pharmacological sedation, without a change in the quality of recovery.

NCT05707234.

Sepsis-associated encephalopathy (SAE) represents a severe neurological complication in sepsis, characterized by high mortality and cognitive impairment. Although clinical significance, SAE lacks effective diagnostic and prognostic tools. This study evaluates the predictive value of neuron-specific enolase (NSE) and regional cerebral oxygen saturation variability (rSO₂%) as indicators for diagnosing and prognosing SAE. A prospective observational study enrolled 70 sepsis patients, classified into SAE and non-SAE groups. Serum NSE levels and rSO₂% were measured alongside clinical data and 28-day mortality outcomes. NSE and rSO₂% were identified as independent indicators of SAE (P < 0.05). Combined analysis achieved a higher diagnostic accuracy, with an area under the ROC curve of 0.749, compared to single indicators. Kaplan-Meier survival analysis reveals that elevated NSE levels and increased rSO₂% are associated with significantly reduced 28-day survival (P < 0.001). These findings suggest that NSE and rSO₂%are valuable indicators for the diagnosis and prognosticating SAE. Their combined application significantly improves diagnostic efficacy, providing a basis for personalized early intervention strategies.

Dementia often goes undetected in hospital settings, where cognitive assessments are challenging due to illness severity and delirium. This study aimed to (1) evaluate the accuracy of the Clinical Dementia Rating (CDR), based solely on knowledgeable informant reports, for detecting preexisting dementia and cognitive impairment in hospitalized patients compared to a gold-standard diagnosis, (2) and compare its performance to the 16-item Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-16).

This cross-sectional study assessed consecutive patients aged ≥ 65 admitted to inpatient units from five hospitals in Brazil. The informant-based CDR was administered to knowledgeable informants within 48 h of admission, capturing patients' cognitive status 3 months before hospitalization to avoid the influence of acute cognitive impairments. Blinded experts provided a gold standard clinical diagnosis of dementia or cognitive impairment no dementia (CIND) based on a 90-min comprehensive assessment, including a standardized neuropsychology battery. Areas under the curve (AUC) examined diagnostic accuracy.

Of 65 participants (mean age = 79.4 years; women = 54%), 34% had dementia and 32% had CIND. Compared to the gold standard, the informant-based CDR showed excellent diagnostic accuracy for detecting dementia (AUC = 0.92; 95% confidence interval [CI] = 0.86-0.98) and cognitive impairment (AUC = 0.93; 95% CI = 0.88-0.98), with a cutoff of ≥ 1 showing 98% specificity for dementia and a cutoff of ≥ 0.5 showing 98% sensitivity for cognitive impairment. Compared to the IQCODE-16, the informant-based CDR had similar performance in detecting dementia and a nonsignificant slight advantage in identifying cognitive impairment (AUC = 0.93 vs. 0.84, p = 0.069), reducing unrecognized cognitive impairment based on medical record documentation from 70% to 2%.

Informant-based CDR is a valid and efficient tool for detecting dementia and cognitive impairment in hospitalized older adults, supporting early diagnosis and guiding multidisciplinary interventions in acute care. Its use in routine hospitals may help clinicians reduce undetected cognitive impairment, enhance decision making, and improve patient care.

Sedation is often provided to resuscitated out-of-hospital cardiac arrest (OHCA) patients to tolerate post-cardiac arrest care, including temperature management. However, the evidence of benefit or harm from routinely administered deep sedation after cardiac arrest is limited. The aim of this trial is to investigate the effects of continuous deep sedation compared to minimal sedation on patient-important outcomes in resuscitated OHCA patients in a large clinical trial.

The SED-CARE trial is part of the 2 × 2 × 2 factorial Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, a randomized international, multicentre, parallel-group, investigator-initiated, superiority trial with three simultaneous intervention arms. In the SED-CARE trial, adults with sustained return of spontaneous circulation (ROSC) who are comatose following resuscitation from OHCA will be randomized within 4 hours to continuous deep sedation (Richmond agitation and sedation scale (RASS) -4/-5) (intervention) or minimal sedation (RASS 0 to -2) (comparator), for 36 h after ROSC. The primary outcome will be all-cause mortality at 6 months after randomization. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to the allocation group. To detect an absolute risk reduction of 5.6% with an alpha of 0.05, 90% power, 3500 participants will be enrolled. The secondary outcomes will be the proportion of participants with poor functional outcomes 6 months after randomization, serious adverse events in the intensive care unit, and patient-reported overall health status 6 months after randomization.

The SED-CARE trial will investigate if continuous deep sedation (RASS -4/-5) for 36 h confers a mortality benefit compared to minimal sedation (RASS 0 to -2) after cardiac arrest.

Anxiety and cognitive dysfunction are common concerns in neurological intensive care units (ICUs) and are associated with adverse outcomes, including delirium. Addressing these issues effectively is crucial for improving patient outcomes and quality of care.

To develop an anxiety-focused nursing intervention programme and investigate the effects of this programme on anxiety levels, cognitive function and the incidence of delirium among patients in a neurological ICU.

A non-randomized controlled design was employed.

The outcome variables of experimental and control groups were compared. Sixty patients in a 1235-bed tertiary general hospital ICU in South Korea were assigned to the experimental (n = 30) or control group (n = 30), which were administered the anxiety nursing intervention and standard care, respectively. Anxiety and cognitive function were measured before and after the intervention, while the incidence of delirium was monitored throughout the study period.

The results showed that the experimental group exhibited significantly lower anxiety levels (t = 6.83, p < 0.001) and improved cognitive function (t = 2.56, p = 0.013) compared to that of the control group. Additionally, the incidence of delirium in the experimental group was significantly reduced (χ2 = 11.28, p = 0.001) post-intervention.

The anxiety nursing intervention programme effectively reduces anxiety, improves cognitive function and decreases the incidence of delirium in patients with neurocritical conditions.

These findings highlight the essential role of comprehensive nursing interventions in addressing the psychological and cognitive needs of patients with neurocritical conditions. Training nurses to implement the developed protocol is vital to improve patient outcomes in neurological intensive care settings.

To investigate the effect of canine-assisted intervention (CAI) on anxiety symptoms among intensive care patients and their family members.

Prospective, single-center, single-arm, nonrandomized, within-subject study design.

Tertiary hospital ICU.

Adult (≥ 16 yr) ICU patients and their family members.

Individual CAI (therapy dog) sessions, lasting at least 15 minutes.

Primary outcome: change in Visual Analog Scale for Anxiety (VAS-A) among patients and family members; secondary outcomes (patient cohort): change in: 1) Numeric Pain Rating Scale, 2) physiologic vital signs, and 3) intervention-related adverse events. A total of 141 participants (70 patients and 71 family members) were recruited. The median (interquartile range [IQR]) age (yr) was 63 (49-71) for patients, and 51 (36-61) for family members. There was a significant reduction in anxiety scores after the intervention, with median (IQR) VAS-A scores changing from 5 (1-7) to 0 (0-4 [p < 0.001]) for the patient cohort and from 6 (5-8) to 3 (1-5 [p < 0.001]) for the family cohort. Majority of patients (56/70 [62%]) and family members (63/68 [93%]) demonstrated a greater than or equal to 2-point reduction in VAS-A scores. In terms of pain, median (IQR) scores among the patient cohort were also lower post-intervention (0 [0-5] vs. 0 [0-2]; p < 0.001). There were no statistically significant changes in physiologic vital signs (heart rate, respiratory rate, and systolic blood pressure) among patients following the intervention. Additionally, there were no reported dog bites, scratches, or other adverse events during CAI.

CAI offers immediate therapeutic benefits in reducing anxiety symptoms in ICU patients and their family members with no observed adverse effects. It may also have a potential role as an adjunctive therapy for pain management in ICU patients. Further research should explore the influence on longer-term psychologic outcomes for ICU patients and family members.

To document the experience with ECMO therapy in healthcare institutions across Latin America between 2016 and 2020.

Cross-sectional study.

Private and public health institutions from 7 countries.

ECMO Intensive Care Units.

None.

General characteristics of the center (country, ELSO center, year of first cannulation, public or private network, ECMO devices available, mobile ECMO), professional category (nurses, physicians, specialists and other professionals), nurse-to-patient ratio, interventions applied(support indications, scores, mechanical ventilation at ECMO commencement, anticoagulation and hemolysis, circuit monitoring and patient perfusion, antibiotic prophylaxis), and patient outcomes (complications and survival) in ECMO centers.

Thirteen ECMO units were included. These units reported 133 consoles and 1629 ECMO cannulations. Of these, 1018 corresponded to adult patients, 468 to pediatric patients, and 143 to newborn infants. A total of 310 medical specialists were involved in ECMO care, of whom 70.3% had received ECMO training. The nurse-to-patient ratio was 1:1 in most centers (76.9%, n = 10). Amongst adult patients, the most common indication for initiating ECMO support was refractory hypoxemia, whereas in pediatric patients, it was a post-cardiotomy shock. The mean overall survival rate of the patients at the time of decannulation was 55.7% (95%CI 53.0-58.3).

The ICUs with ECMO in Latin America participating in this study have demonstrated operational capabilities enabling them to achieve outcomes comparable to those of other ECMO units across the world.

To date, studies assessing the relationship between intensive care unit acquired weakness (ICU-AW) and postoperative delirium (POD), two of the most common complications in the intensive care unit (ICU), are lacking.

To explore the association of the occurrence of POD, POD subtypes and POD duration with ICU-AW in a surgical intensive care unit (SICU).

This study was a prospective observational study. Four hundred and two postoperative patients in a SICU at a tertiary hospital in Shanghai, China, participated in the study. Data were collected through the electronic medical record system of the hospital between October 2022 and July 2023. POD was assessed using the Richmond agitation-sedation scale (RASS) and the Confusion Assessment Method for the intensive care unit (CAM-ICU). The Medical Research Council score (MRC score) was used to measure ICU-AW. The bivariate logistic regression analysis was used to analyse the relationship between ICU-AW and POD, and further, the influencing factors of ICU-AW.

Of the 402 analysed patients (mean age: 69.2 ± 14.84, 59.7% male), 121 (30.10%) patients developed ICU-AW, and 92 (22.89%) patients developed POD. Of the ICU-AW group, 53 (43.80%) patients screened positive for POD. The occurrence of POD (odds ratio (OR), 0.227 95% CI: 0.052-0.981), hypoactive POD (OR, 4.241 95% CI: 1.490-12.072) and POD duration (OR, 2.649; 95% CI: 1.422-4.935) were independently associated with ICU-AW. Moreover, diabetes (OR, 1.710; 95% CI: 1.036-2.823) and Interleukin-6 (IL-6) (OR, 1.001; 95% CI: 1.000-1.001) were also significantly correlated with ICU-AW.

ICU-AW was associated with POD, POD subtypes and POD duration in the SICU patients. Screening for hypoactive POD should be used as part of routine risk assessment in the SICU focused on identifying ICU-AW and specifying a timely and targeted plan during the early stages of the postoperative period.

While closely monitoring ICU patients with high IL-6 levels and diabetes, nurses should assess the type and duration of POD in patients and implement care interventions to prevent the development of ICU-AW.

Diurnal variation of analgosedation may worsen patient outcomes. However, there is no data reporting diurnal variation in patients receiving extracorporeal membrane oxygenation (ECMO).

To compare diurnal variation of analgosedation doses in mechanically ventilated adult patients and those receiving ECMO.

Five ICUs (65 beds) including an ECMO unit, with patient recruitment from July 2021 to July 2023.

Retrospective single-centre cohort study including patients aged ≥ 16 years receiving continuous intravenous (IV) opioid (fentanyl) and/or sedative (midazolam and/or propofol), receiving mechanical ventilation with or without ECMO. We collected data on all intravenous analgosedation doses (excluding boluses) from 07:00 to 18:59 (day) or from 19:00 to 06:59 (nighttime) for 48 h.

We identified 1277 patients; of whom 166 (13.0 %) received ECMO and 1111 (87.0 %) received no ECMO. Most were male 815 (63.8 %), median (interquartile range (IQR)) age 58 (42-70) years. We found no diurnal variation of analgosedation doses in ECMO patients. However, we found higher doses of fentanyl (mean difference 1.7 µg/kg, 95 % Confidence Interval (CI): 1.0, 2.4 μg/kg, p < 0.001) and propofol (mean difference 2.3 mg/kg, 95 % CI: 1.7, 2.9 mg/kg, p < 0.001) at nighttime compared to daytime in non-ECMO patients. A higher proportion of ECMO patients received neuromuscular blocking drugs compared to non-ECMO group 120 (72.3 %) vs 138 (12.4 %); p < 0.001.

We found higher doses of fentanyl and propofol IV infusion doses at nighttime in non-ECMO patients. However, we found no diurnal variation of analgosedation doses in ECMO patients, most likely due to deep sedation and use of neuromuscular blocking medicines.

Patient factors, critical illness factors and type of ICU admission are likely contributory factors to differences in diurnal variation of analgosedation doses in ECMO and non-ECMO populations.

Sepsis often codevelops with brain damage, and the mechanisms underlying sepsis-related brain damage have been elucidated. However, only a few studies have reported the diagnostic imaging assessments for brain damage in sepsis. Therefore, in this study, we analyzed the brain magnetic resonance (MR) imaging (MRI) findings of patients with sepsis.

This single-center prospective observational study included 71 patients with sepsis who underwent brain MRI, regardless of the presence or absence of shocks and acute neurological abnormalities. The MR images were classified according to the presence or absence of acute cerebral ischemia and leukoencephalopathy, with normal findings indicating neither condition.

The MR images of 18 patients (25.3%) showed acute cerebral ischemia and leukoencephalopathy. Furthermore, 44 patients (62.0%) had only leukoencephalopathy. In terms of patient demographic characteristics and neurological outcomes, significant differences were noted among patients with acute cerebral ischemia findings, those with leukoencephalopathy findings, and those with neither. There were significant differences in age (P = 0.0296), neurological findings (P = 0.0057), number of days in the intensive care unit (P = 0.0239), acute disseminated intravascular coagulation score during hospitalization (P = 0.0363), and the Katz index at discharge or transfer (P = 0.0020) among these groups.

Among patients with sepsis, 25.3% showed acute cerebral ischemia findings on brain MRI, regardless of illness severity, including hypoxia and hypotension, and presence of shock. Abnormal MRI findings were also observed in patients without acute brain dysfunction. Importantly, abnormal brain MRI findings were associated with worse neurological outcomes.

Exploring the concept of patient agitation in the intensive care unit.

Patient agitation in the intensive care unit is of widespread concern and linked to negative outcomes for patients, staff, and family members. There is currently no consensus on what constitutes agitation in the intensive care context, hindering effective and tailored prevention and management.

Concept Analysis.

Walker and Avant's eight-step concept analysis approach.

A comprehensive search was carried out in the databases MEDLINE, PsychINFO and CINAHL. A total of 32 papers published between 1992 and 2023 were included, reviewed, and analysed to explore definitions, attributes, antecedents and consequences of patient agitation.

Patient agitation in the intensive care unit is characterised by excessive motor activity, emotional tension, cognitive impairment, and disruption of care, often accompanied by aggression and changes in vital signs. Antecedents encompass critical illness, pharmacological agents and other drugs, physical and emotional discomfort, patient-specific characteristics and uncaring staff behaviours. Consequences of agitation range from treatment interruptions and poor patient outcomes to the psychological impact on patients, families, and staff.

Agitation in the intensive care unit is a complex issue which significantly impacts patient treatment and clinical outcomes. For healthcare professionals, patient agitation can contribute to high workloads and job dissatisfaction. Due to the complex nature of agitation, clinicians must consider multifaceted strategies and not rely on medication alone. Further research is needed to fully understand patient agitation in the ICU. Such understanding will support the development of improved strategies for preventing and managing the behaviours.

A clearer understanding of patient agitation supports the development of tailored interventions that improve patient care, guide ICU training, and inform future research.

This concept analysis was developed with input from a patient representative.

Violence is a common hazard for those working in emergency departments (EDs), yet it remains understudied. We describe a prospectively derived estimate of the prevalence of violence against health care workers among agitated patients in an ED.

This was a secondary analysis of two prospective, observational studies of patients receiving care in a dedicated portion of the ED meant primarily to observe patients with intoxication. We collected detailed data for patients with agitation, defined as a score of +1 or higher using the altered mental status scale, an ordinal agitation scale from -4 (coma) to 0 (normal) to +4 (most agitated). Trained observers present in the ED 24/7 recorded whether each encounter involved verbal abuse, threat of violence, or a violent act against a health care worker. The primary outcome was the occurrence of assault as defined by state statute (threat of violence or violent act). We compare observed events to those formally reported to the hospital.

From 17,873 encounters screened there were 4609 (25.8%) in which the patient had agitation. Alcohol or drug intoxication was present in 4108 (89.1%) encounters. The number of encounters with assault was 937 (20.3%, 95% confidence interval [CI] 19.1%-21.5%), which included 802 encounters (17.4%, 95% CI 16.3%-18.5%) with a threat of violence and 362 encounters (7.9%, 95% CI 7.1%-8.7%) with a violent act. Verbal abuse occurred in 1786 encounters (38.8%, 95% CI 37.3%-40.2%). Events were formally reported to the hospital in 9/1786 (0.5%) instances of verbal abuse and in 224/362 (61.9%) instances of a violent act.

Verbal abuse, threats of assault, and violent acts occurred frequently in ED patients with agitation and were underreported.

Background: The purpose of this study is to assess how the socio-family demographic status of patients is related to the onset of delirium in a large cohort of older adults aged ≥65 years evaluated in the emergency department (ED) using a comprehensive geriatric assessment (CGA). Methods: This is a cross-sectional, observational, retrospective study conducted in the ED of a teaching hospital. We enrolled 2770 geriatric patients admitted to the ED from January 2019 to December 2023 and evaluated them using CGA. Clinical variables assessed in the ED were evaluated for associations with delirium onset and in-hospital mortality. Results: Delirium was statistically related to frailty statuses as measured via the Clinical Frailty Scale (CFS) (OR 1.47 [1.39-1.56]; p < 0.001). The occurrence of delirium was also associated with living arrangements: "living with other relatives" condition (OR 1.43 [1.12-1.83]; p = 0.004) and residence in a nursing home (OR 1.72 [1.30-2.31]; p < 0.001). In addition, compared to patients in emergency conditions (NEWS > 5), it emerges that patients with better clinical stability have a lower risk of developing delirium (NEWS 3-5 OR 0.604 [0.48-0.75]; p < 0.001-NEWS < 3 OR 0.42 [0.34-0.53]; p < 0.001). In-hospital mortality was associated with age, male sex, frailty status, clinical instability, and the onset of delirium in the ED. Conclusions: Delirium is a multifactorial and acute syndrome representing a negative prognostic factor of in-hospital mortality, especially in elderly patients. Independent of the clinical condition, the patient's living arrangement could be of relevance to the onset of delirium in the ED. Early comprehensive geriatric assessments in the ED could allow the early detection of all predisposing risk factors, resulting in the timely implementation of supportive strategies to prevent the onset of delirium in EDs.

Bariatric surgeries are increasingly used to manage obesity, presenting significant perioperative challenges, especially with opioid use. Opioid-Free Anesthesia (OFA) is a multimodal technique to address these issues. This study aims to compare the effects of OFA and traditional Opioid-Based Anesthesia (OBA) on postoperative morphine consumption, hemodynamics, pain, postoperative nausea and vomiting (PONV), sedation, and patient satisfaction in bariatric surgery.

A prospective controlled study was conducted in the operating room of a tertiary university hospital. It included patients aged between 18 and 65 years undergoing bariatric surgery. 58 obese patients were divided into two groups: 32 received OBA and 26 received OFA. The OFA regimen included lidocaine, ketamine, magnesium sulfate, dexmedetomidine, and dexamethasone. Main outcome measures included postoperative morphine consumption in the Post-Anesthesia Care Unit (PACU), 24 and 48 h after surgery. Secondary outcomes included hemodynamic parameters, sedation score, pain score, presence of nausea and/or vomiting, and overall patient satisfaction evaluated at 48 h postoperatively or before hospital discharge were recorded.

OFA significantly reduced postoperative morphine consumption (median dose of 8 mg vs.19 mg, p = 0.000). Visual analogue scale (VAS) scores for pain at rest, during movement, and during coughing were significantly lower in the OFA group. Both groups were hemodynamically stable perioperatively. There was no significant difference in PONV incidence or sedation levels between the groups in the PACU, 24 and 48 h after surgery. Patient satisfaction was higher in the OFA group, with 65% reporting a satisfaction score of ≥ 8/10 compared to 28% in the OBA group.

OFA reduces postoperative morphine consumption and improves pain management without compromising hemodynamic stability or increasing sedation. Furthermore, the incidence of PONV was not significantly different and overall patient satisfaction was higher with OFA. These findings support the use of OFA in bariatric surgery, despite the need for further studies with larger sample sizes.

Delirium is a frequent complication in critically ill patients, often leading to worse clinical outcomes, prolonged ICU stays, and an increased healthcare burden. Its identification has become more consistent with the adoption of validated diagnostic tools, allowing clinicians to recognize and address this condition more effectively. Although delirium can arise from direct neurological dysfunction, it is frequently a consequence of systemic conditions such as sepsis or organ failure. Therefore, a comprehensive evaluation of underlying causes is essential before initiating pharmacological treatment. Among the pharmacological options, quetiapine has gained attention for its use in ICU patients with delirium. Compared to first-generation antipsychotics, it is often preferred due to its sedative effects and more favorable safety. However, current clinical guidelines remain inconclusive regarding its routine use, as evidence supporting its efficacy is limited. One of the main challenges is the heterogeneity of patient populations included in randomized trials, making it difficult to determine whether specific subgroups may benefit more from treatment. This narrative review explores the pharmacological properties of quetiapine, its potential role in managing ICU delirium, and the current state of evidence regarding its safety and effectiveness.

Multimodal analgesia, through combining different classes of analgesia that target pain pathways with different mechanisms reduces opioid consumption. This study aimed to determine the impact of adjunct nefopam infusion on opiate consumption when added to standard-of-care analgesia and sedation in mechanically ventilated critically ill patients.

This was a prospective, randomized, active control, double-blind study. Patients admitted to the ICU, being mechanically ventilated and candidates for analgesia and sedation protocols were randomized to the intervention group (n = 30) or to the control group (n = 30). The primary outcome was the cumulative dose of fentanyl in the first 24 h after inclusion. The secondary outcomes were the proportion of patients with positive pain scores, change in mean arterial pressure (MAP), heart rate (HR), ICU mortality, and others.

A total of 60 patients were included in the final analysis; median (Q1, Q3) cumulative fentanyl consumption mcg/24 h was significantly (p = 0.001) lower in the intervention group compared to the control group 1300 (575, 2087.5) vs. 2400 (1612.5, 2665) mcg/24 h respectively. Pain and sedation scores were comparable between the two study groups. ICU mortality was 25 (83.3%) in the intervention group vs. 20 (66.7%) in the control group (P = 0.136).

Nefopam was found to be an effective non-opioid option for analgesia in mechanically ventilated surgical and trauma critically ill patients, and more studies are needed to evaluate its safety.

ClinicalTrials.gov (identifier: NCT05071352).

Prognostic markers of good neurological outcome after cardiac arrest (CA) remain limited. We aimed to evaluate the prognostic value of neuron-specific enolase (NSE), electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) in predicting good outcome, assessed separately and in combination.

A retrospective study was conducted in a tertiary CA center, using a prospective registry. We included all patients comatose after discontinuation of sedation and with one EEG and NSE blood measurement at 24, 48 or/and 72 h after CA. The primary outcome was favorable neurological outcome at three months, a Cerebral Performance Categories (CPC) scale 1-2 defining a good outcome.

Between January 2017 and April 2024, 215 patients were included. Participants were 63 years old (IQR [52-73]), and 73% were male. At 3 months, 54 patients (25.1%) had a good outcome. Compared to the poor outcome group, NSE blood levels were significantly lower in the good outcome group at 24 h (39 IQR[27-45] vs 54 IQR[37-82]µg/L, p < 0.001), 48 h (26 [18-43] vs 107 [54-227]µg/L, p < 0.001) and 72 h (20 µg/L IQR [15-30] vs 184 µg/l IQR [60-300], p < 0,001). Normal NSE (i.e., < 17 µg/L) at 24 h was highly predictive of good outcome, with a predictive positive value (PPV) of 71% despite a sensitivity (Se) of 9%. The best cut-off values for NSE at 24, 48 and 72 h were below 45.5, 51.5 and 41.5 µg/L, yielding PPV of 64%, 80% and 83% and sensitivities of 74%, 93% and 90%, respectively. A decreasing trend in NSE levels between 24 and 72 h was also highly predictive of good outcome (PPV 82%, Se 81%). A benign EEG pattern was more frequently observed in the good outcome group (87.1 vs 14.9%, p < 0.001) and predicted a good outcome with a PPV of 72% and a Se of 94%. Regarding SSEPs, a bilateral N20-baseline amplitude > 0.85 µV was predictive of good outcome (PPV 75%, Se 100%). The combination of NSE < 51.5 µg/l at 48 h, a decreasing NSE trend between 24 and 72 h and a benign EEG showed the best predictive value (PPV 96%, Se 76%).

In comatose patients after CA, a low NSE levels at 24, 48 h or 72 h, a decreasing trend in NSE over time, a benign EEG and a high N20 amplitude are robust markers of favorable outcome, reducing prognosis uncertainty.

An increasing number of patients receive end-of-life care in the intensive care unit (ICU). Death often occurs in the ICU after a decision has been made to withdraw life-sustaining therapies. In 2016, Downar et al. published Canadian consensus guidelines to standardize practices for withdrawal of life-sustaining therapy in the ICU. In this study, we sought to understand the feasibility and acceptability of implementing an order set, nursing flowsheet, and nursing care plan based on these guidelines in two ICUs in Saskatchewan, Canada.

We used a hybrid effectiveness-implementation design, engaging a steering committee of ICU health care providers and leadership to guide implementation. We conducted a six-month pilot implementation. We collected data in the three months pre-implementation, during the six-month implementation period, and for three months post-implementation. To evaluate implementation outcomes, we used the Consolidated Framework for Implementation Research to develop semi-structured interviews and feasibility surveys. To measure effectiveness outcomes, bedside nurses completed Quality of Death and Dying surveys, and we performed a patient chart review.

The intervention materials added to the burden of paperwork of bedside health care providers but helped them provide quality end-of-life care, meet the needs of patients and their families, and lessen ethical tensions between symptom control and hastening death. There was no difference in cumulative sedative dosing and time to death after extubation in the pre-implementation, implementation, or post-implementation periods. A significant increase in symptom assessment (pain, dyspnea, and agitation) using standardized tools was observed during the implementation and post-implementation periods. There was an improvement in holistic care outcomes post-implementation.

We implemented current Canadian best-practice guidelines for providing end-of-life care in the ICU using a multidisciplinary approach. This study offers insight into how standardized symptom assessment and medication titration can be incorporated into the complex ICU environment.

Sedatives are often used to facilitate mechanical ventilation in patients with sepsis. Ciprofol is a new promising sedated candidate with a higher binding activity to the gamma-aminobutyric acid-A receptor than propofol. This study aimed to compare the efficacy and safety of ciprofol and propofol for long-term sedation in mechanically ventilated patients with sepsis.

In this single-center randomized clinical trial, mechanically ventilated adults with sepsis in the intensive care unit (ICU) who anticipated to require long-term sedation ≥ 24 h were randomly assigned to receive intravenous ciprofol or propofol. The target sedation goal was - 3 to 0 according to the Richmond Agitation-Sedation Scale. The primary outcome was weaning time. Secondary outcomes included the percentage of time within the target sedation range, successful sedation (the percentage of time within the target sedation range ≥ 70% without rescue sedation), ICU and in-hospital mortality, length of ICU and hospital stay, hypotension, and bradycardia.

A total of 60 patients were randomized, 4 were excluded because of withdrawing treatment, 28 were assigned to ciprofol group and 28 to propofol group. Weaning time in ciprofol group was shorter than propofol group (median [interquartile range (IQR)], 104.0 [40.8-147.3] hours vs 132.5 [69.8-207.8] hours), but not reached significant difference between groups (P = 0.123). Ciprofol had significantly higher percentage of time within the target sedation range (median [IQR], 72.2% [14.3-92.7%] vs 22.6% [0.0-45.4%]) and successful sedation (53.6% [15/28] vs 14.3% [4/28]) than propofol. No significant differences were observed in ICU mortality, in-hospital mortality, length of ICU stay, length of hospital stay, hypotension, and bradycardia between groups.

Ciprofol is an effective and safe agent among mechanically ventilated patients with sepsis who anticipated to require long-term sedation.

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200066835) on December 19, 2022.

In this study, Pinto et al. identified significantly higher levels of neuron-specific enolase and Tau protein in older patients with sepsis-associated delirium in the emergency department, suggesting the potential of these biomarkers as diagnostic tools in this population.

Sepsis-associated delirium is a common cerebral manifestation in patients with sepsis, potentially caused by a combination of neuroinflammation and other neurophysiological disorders. This study investigated the expression of neuron-specific enolase and Tau protein as biomarkers in patients with sepsis-associated delirium. While neuron-specific enolase and Tau protein are known to be associated with brain injury, their diagnostic potential in patients with sepsis-associated delirium is not well understood.

This cross-sectional pilot study evaluated plasma levels of neuron-specific enolase and Tau protein in patients with delirium and sepsis to explore their potential for identifying sepsis in patients admitted to the emergency department.

A total of 25 patients with delirium were analyzed, 56% of whom had sepsis. Patients with sepsis exhibited significantly higher neuron-specific enolase levels (2.7ng/mL [95%CI= 2.2-3.2] versus 1.3 ng/mL [95%CI= 0.8-2.5], p<0.003) and Tau protein levels (96.1pg/mL [95%CI= 77.0-111.3] versus 43.0pg/mL [95%CI= 31.2-84.5], p<0.003) compared to patients without sepsis. Neuron-specific enolase and Tau protein thresholds of >2.08ng/mL and >59.27pg/mL, respectively, demonstrated 90% specificity for identifying sepsis in patients.

Neuron-specific enolase and Tau protein levels were significantly higher in patients with sepsis than in those without, underscoring their potential ability to identify the infectious etiology of delirium in older patients admitted to emergency departments. Clinical Trials #RBR-233bct.

■ Biomarkers of brain injury, such as neuron-specific enolase and Tau proteins, are higher in older patients with sepsis and delirium.

■ Diagnosing sepsis in patients with delirium can be challenging.

■ Early identification of sepsis is key to managing sepsisassociated delirium.

Appropriate sedative and analgesic selection is essential to reduce patient discomfort and body movement to safely conduct endoscopic ultrasonography (EUS). However, few cases have examined sedation with propofol in EUS, and few studies the need for combined analgesia. In this study, we retrospectively evaluated the usefulness and safety of propofol without analgesics for sedation in biliopancreatic observational EUS.

This single-center retrospective study included 516 observational biliopancreatic EUS procedures using propofol alone performed between April 2021 and March 2023. The primary and secondary endpoints were the observational biliopancreatic EUS results obtained with propofol alone and adverse event occurrence, respectively.

The median examination time and total propofol dose were 22 (range: 10-67) min and 186.5 (range: 50-501) mg, respectively. The median starting Richmond Agitation-Sedation Scale and Visual Analog Scale scores were -5 (range: -5-1) and 0 (range: 0-10), respectively. The median recovery time was 22 (range: 5-80) min. Adverse events occurred in 60 (11.6%) patients. Trainee-performed examination (odds ratio [OR] 3.52, 95% confidence interval [CI]: 1.63-7.60, p = 0.0014) and examination length (>22 min; OR 1.67, 95% CI: 0.95-2.92, p = 0.07) were risk factors for adverse events.High body mass index (OR 1.87, 95% CI: 1.10-3.16, p = 0.02) and extended examination time (OR 4.23, 95% CI: 2.08-8. 57, p < 0.001) were risk factors for delayed recovery.

During observational biliopancreatic EUS, propofol is useful as a single sedative and offers high patient satisfaction and relative safety.

The aim of this study is to assess the neuroprotective efficacy of early goal-directed sedation (EGDS) primarily governed by dexmedetomidine in patients experiencing severe traumatic brain injury, and to elucidate its potential underlying mechanisms.

All participants were randomly allocated into two groups: the experimental group-dexmedetomidine-dominated EGDS group (group D, n = 30) and the control group-the standard propofol sedation group (group P, n = 30). Patients in the experimental group received sedation primarily with dexmedetomidine, while those in the control group received propofol sedation. Subsequently, retrograde catheterization of the internal jugular vein on the affected side was performed, blood gas analysis samples were collected, cerebral oxygen extraction rates were computed, and levels of interleukin 6 (IL-6) and interleukin 1β (IL-1β) were assessed. One-way ANOVA and Chi-square tests were used for statistical analysis.

In group D, significant reductions were observed in the duration of ventilator dependency (p < 0.05).Compared to those documented in group P, tracheostomy incidence, and pulmonary infection rates were no different (p > 0.05). On the second, third and the seventh day, the SjvO2 levels in group D exhibited a statistically significant elevation compared to group P, while the CERO2 levels were notably lower in group D than in group P (p < 0.05). The GCS scores of patients in group D was significantly higher than that of the patients in group P and the baseline value on the seventh day and the time of discharge (p < 0.05). Additionally, the IL-6 levels in group D were significantly lower than those in group P and their corresponding baseline levels on the third and seventh days (p < 0.05). The IL-1β levels were no significant difference between the two groups.

A predominance of dexmedetomidine in EGDS demonstrates efficacy in reducing the duration of ICU stay and ventilator dependency, enhancing cerebral oxygen metabolism, and attenuating the infiltration of inflammatory factors.

Critical care nurses provide bedside care around the clock, which offers a unique opportunity to integrate rehabilitative activities into routine care. How nurses perform such activities is underinvestigated.

To explore how competencies related to early rehabilitation emerged in the clinical practice of critical care nurses, and to explore their reflections on this aspect of their clinical practice.

A qualitative study with a phenomenological-hermeneutic approach was conducted in two Norwegian ICUs from January 2022 to January 2023. Observations and video recordings of eight nurse-patient dyads were conducted, followed by post-observation nurse interviews. Data were analysed using Heath and Luff's video analysis and Malterud's systematic text condensation, with additional insights drawn from Benner's work on clinical knowledge.

Three categories emerged: 1) range in clinical assessments, displaying adequate assessments and actions related to major organ systems but lacking attention towards the assessment and facilitation of movement; 2) nurses' and physiotherapists' cooperation in terms of roles and responsibilities, revealing established roles within their professions and sparse sharing of situated considerations; and 3) grounding the patient, how the nurses used a verbal and attentive approach that appeared to ground their patients in the present, potentially enhancing participation.

Nurses were familiar with essential assessments and interventions connected to major organ systems, both independently and with physiotherapists, as well as in verbal communication. However, they were less familiar with assessing and facilitating movements, sharing professional knowledge, and using bodily communication skills.

This study highlights competencies that can be further explored and developed in CCNs clinical practice and education to improve care for critically ill patients. Future research should further investigate CCNs' roles in early rehabilitation and identify independent nursing interventions, especially where resources and multidisciplinary support are limited.

Survivors of critical illness may present physical, psychological, or cognitive symptoms after hospital discharge, encompassed within what is known as post-intensive care syndrome. These alterations result from both the critical illness itself and the medical interventions surrounding it. For its prevention, the implementation of the ABCDEF bundle (Assess/treat pain, Breathing/awakening trials, Choice of sedatives, Delirium reduction, Early mobility and exercise, Family) has been proposed, along with additional strategies grouped under the acronym GHIRN (Good communication, Handout materials, Redefined ICU architectural design, Respirator, Nutrition). In addition to these preventive measures during the ICU stay, high-risk patients should be identified for subsequent follow-up through multidisciplinary teams coordinated by Intensive Care Medicine Departments.

The efficacy and safety of a sedation regimen combining dexmedetomidine and midazolam during endoscopic submucosal dissection for upper gastrointestinal tumors remains unclear. In this study, we aimed to evaluate the efficacy and safety of this sedation regimen, where non-anesthesiologists performed sedation.

Sixty-eight patients who underwent endoscopic submucosal dissection for upper gastrointestinal tumors, sedated by non-anesthesiologists, were retrospectively evaluated. The sedation was performed by non-anesthesiologists as part of on-the-job training (OJT) under anesthesiologists' supervision. Each non-anesthesiologist received OJT at least thrice. Proficiency levels were assessed during the third OJT session. The target sedation depth was a Richmond Agitation-Sedation Scale of -2 to -4, with 2 L/min of oxygen delivered via a nasal cannula at sedation initiation. The treatment completion rates, which measured efficacy and safety, were assessed by the frequencies of respiratory depression, hypotension, and bradycardia.

The study included 14, 52, and two patients with superficial esophageal cancer, early gastric cancer, and gastric adenoma, respectively. The median treatment time was 68 and 84 min for superficial esophageal cancer, early gastric cancer, and adenoma, respectively. Endoscopic submucosal dissection was completed in all patients. No severe sedation-related adverse events were reported; however, peripheral arterial oxygen saturation <90%, hypotension, and bradycardia occurred in 1 (1.5%), 30 (44.1%), and 30 patients (44.1%), respectively. All 22 non-anesthesiologists who underwent the proficiency evaluation passed the test.

A sedation regimen combining dexmedetomidine and midazolam can be feasibly administered by non-anesthesiologists. Further studies are needed to verify the effectiveness of OJT.

The Johns Hopkins Activity and Mobility Program is a systematic approach to measure and improve patient mobility.

The purpose of this study was to evaluate the relationship between mobility loss and quality outcomes.

A retrospective cohort study design was used. Patients were categorized into 3 groups (gain, loss, no change in mobility) using the Johns Hopkins Highest Level of Mobility (JH-HLM) scores. The association between mobility loss and falls risk, in-hospital mortality, delirium, discharge to a facility, length of stay, and 30 day readmissions were assessed.

Those who lost mobility were more at risk of being a high fall risk, in-hospital mortality, delirium, discharging to a facility, and had 48% longer lengths of stay. There was no association between mobility loss and 30-day readmissions.

Loss of mobility assessed using JH-HLM scores is associated with worse patient outcomes.