Dexmedetomidine infusion for more than 24 hours in critically ill patients: sedative and cardiovascular effects

Objective To assess the potential of dexmedetomidine for targeted sedation in complex Intensive Care (ICU) patients for >24 h.Design Prospective, open label, clinical trial.Setting Tertiary general ICU.Patients Twenty critically ill patients, mean APACHE II 23(±9).Interventions A continuous infusion of dexmedetomidine, median infusion time 71.5 (35–168) h, starting at 0.4g·kg·h without a loading dose and adjusted (0.2–0.7g·kg·h) to a target Ramsay Sedation Score (RSS) of 2–4. Rescue midazolam and/or morphine/fentanyl were given as clinically indicated.Measurements and results Haemodynamic parameters and RSSs were collected until 24 h after cessation. An RSS 2–5 was achieved in 1,147 (83%) of observations with a reduction in RSS of 6 from 13% in the first 6 h to 3% between 18 h and 24 h. Sixteen patients needed minimal or no additional midazolam, median 4 mg/day (0.5–10) and ten required minimal or no additional analgesia, median 2 mg/day (0.5–4.5), 55g/day (14–63) of morphine/fentanyl.Results A 16% reduction in mean systolic blood pressure (SBP) and 21% reduction in heart rate (HR) occurred over the first 4 h followed by minimal (± 10%) changes throughout the infusion. A rise in SBP was observed in two patients. After abrupt cessation, SBP and HR monitored for 24 h rose by 7% and 11%, respectively.Conclusions Dexmedetomidine was an effective sedative and analgesic sparing drug in critically ill patients when used without a loading dose for longer than 24 h with predictable falls in blood pressure and HR. There was no evidence of cardiovascular rebound 24 h after abrupt cessation of infusion.The study was performed in the Intensive Care Units of the Prince of Wales hospital, a principal teaching hospital of the University of New South Wales and the Prince of Wales private hospital. Abbott Australia provided the study drug free of charge     

Erythropoietin in the critically ill - is it more than just blood?

Erythropoietin (EPO) has been in clinical use for the treatment of anemia for over 15 years. Recently it has been demonstrated that EPO has actions other than stimulating the bone marrow. It has been suggested that due to its tissue protecting effect, EPO may be effective in improving outcome in the critically ill.     

Does improving sleep for the critically ill reduce the incidence and duration of delirium? An evidence-based review

Delirium is associated with poor patient outcome. Critical-care nurses maintain that patients with disrupted sleep appear to develop delirium. We sought to explore whether improving sleep in the critically ill patients reduced the incidence and duration of delirium. Our review of five relevant studies suggests that there is low-quality evidence that improving sleep may reduce the incidence of delirium. The bidirectional association between delirium and sleep stymies research in this area, and thus, establishing cause and effect, is difficult. Research exploring other patient-centred outcomes, such as pain intensity, suggests that enhancing sleep may improve these outcomes.     

Comparison of 1,3-β-d-glucan with galactomannan in serum and bronchoalveolar fluid for the detection of Aspergillus species in immunosuppressed mechanical ventilated critically ill patients

PurposeInvasive pulmonary aspergillosis (IPA) is an important cause of morbidity/mortality in immunocompromised critically ill patients. New diagnostic strategies for early detection of IPA include the noninvasive biomarkers 1,3-β-d-glucan (BDG), serum, and bronchoalveolar (BAL) fluid galactomannan (GM). The aim of this study was to compare these markers for early detection of IPA in immunosuppressed critically ill patients.MethodsBetween December 2014 and December 2015, 49 immunosuppressed patients with respiratory failure were treated at our intensive care unit (ICU). We compared the BDG Fungitell assay with GM Platelia assay in serum and BAL for early detection of IPA. All tests were performed initially after admission at the ICU.ResultsIn our study with 49 patients, 13 (26%) had probable IPA. These patients had a higher Acute Physiology And Chronic Health Evaluation II score (28 vs 23, P < .001), Sequential Organ Failure Assessment score (16 vs 14, P < .001), more neutropenia (77% vs 30%, P < .001), worse Horowitz Index (99 vs 73 P < .020), a longer ICU stay (26 vs 17 days, P < .044), and a higher mortality rate (77% vs 58%, P < .001) as compared with patients without probable IPA.The used biomarker BDG presented in patients with probable IPA showed significantly higher levels as compared with patients without probable IPA (375 [103-1000 pg/mL; P < .001] vs 64 [30-105 pg/mL; P < .001]).Comparison of BDG with GM showed that positive serum GM could be detected in only 4 (30%), whereas positive BAL GM could be detected in 12 (92%; mean optical density index, 3.7) of 13 probable IPA cases.These results can be expressed as an overall sensitivity of 88% and a specificity of 82% for probable IPA using the BDG Fungitell assay, a sensitivity of 35% and a specificity of 70% using the serum GM Platelia assay, and a sensitivity of 70% and a specificity of 94% using the BAL GM Platelia assay. The negative predictive values of the used tests were 94% for the BDG Fungitell assay, 94% for the serum GM Platelia assay, and 90% for the BAL GM Platelia assay.Conclusion1,3-β-d-Glucan may be a useful marker for patients under surveillance at risk for IPA. In critically ill patients with immunosuppression, early diagnosis of IPA may be improved by BDG as compared with serum GM. However, diagnostic performance and accuracy increase when BDG is run in parallel with GM from BAL; moreover, the association of the 2 parameters has also the advantage of detecting early and reliable IPA.     

An assessment of the validity of spectral entropy as a measure of sedation statein mechanically ventilated critically ill patients

Objective To assess whether the Entropy Module (GE Healthcare, Helsinki, Finland), a device to measure hypnosis in anesthesia, is a valid measure of sedation state in critically ill patients by comparing clinically assessed sedation state with Spectral Entropy Design Prospective observational study. Setting Teaching hospital general ICU. Patients and participants 30 intubated, mechanically ventilated patients without primary neurological diagnoses or drug overdose receiving continuous sedation. Interventions Monitoring of EEG and fEMG activity via forehead electrodes for up to 72 h and assessments of conscious level using a modified Ramsay Sedation Scale. Measurements and results 475 trained observer assessments were made and compared with concurrent Entropy numbers. Median State (SE) and Response (RE) Entropy values decreased as Ramsay score increased, but wide variation occurred, especially in Ramsay 4–6 categories. Discrimination between different sedation scores [mean (SEM) P_K value: RE 0.713 (0.019); SE 0.710 (0.019)] and between lighter (Ramsay 1–3) vs.deeper (Ramsay 4–6) sedation ranges was inadequate [P_K: RE 0.750 (0.025); SE 0.748 (0.025)]. fEMG power decreased with increasing Ramsay score but was often significant even at Ramsay 4–6 states. Frequent “on–off” effects occurred for both RE and SE, which were associated with fEMG activity.Values switched from low to high values even in deeply sedated patients. High Entropy values during deeper sedation were strongly associated with simultaneous high relative fEMG powers. Conclusions Entropy of the frontal EEG does not discriminate sedation state adequately for clinical use in ICU patients. Facial EMG is a major confounder in clinical sedation ranges.     

Changing use of noninvasive ventilation in critically ill patients: trends over 15 years in francophone countries

Purpose

Over the last two decades, noninvasive ventilation (NIV) has been proposed in various causes of acute respiratory failure (ARF) but some indications are debated. Current trends in NIV use are unknown.

Methods

Comparison of three multicenter prospective audits including all patients receiving mechanical ventilation and conducted in 1997, 2002, and 2011 in francophone countries.

Results

Among the 4132 patients enrolled, 2094 (51 %) required ventilatory support for ARF and 2038 (49 %) for non-respiratory conditions. Overall NIV use was markedly increased in 2010/11 compared to 1997 and 2002 (37 % of mechanically ventilated patients vs. 16 % and 28 %, P < 0.05). In 2010/11, the use of first-line NIV for ARF had reached a plateau (24 % vs. 16 % and 23 %, P < 0.05) whereas pre-ICU and post-extubation NIV had substantially increased (11 % vs. 4 % and 11 % vs. 7 %, respectively, P < 0.05). First-line NIV remained stable in acute-on-chronic RF, continued to increase in cardiogenic pulmonary edema, but decreased in de novo ARF (16 % in 2010/11 vs. 23 % in 2002, P < 0.05). The NIV success rate increased from 56 % in 2002 to 70 % in 2010/11 and remained the lowest in de novo ARF. NIV failure in de novo ARF was associated with increased mortality in 2002 but not in 2010/11. Mortality decreased over time, and overall, NIV use was associated with a lower mortality.

Conclusion

Increases in NIV use and success rate, an overall decrease in mortality, and a decrease of the adverse impact NIV failure has in de novo ARF suggest better patient selection and greater proficiency of staff in administering NIV.

Trial registration

Clinicaltrials.gov Identifier NCT01449331.

     

De-implementing low value care in critically ill patients: a call for action—less is more

Intensive Care Medicine -