Micronutrient intake from enteral nutrition in critically ill adults: A systematic review of randomised controlled trials

ObjectivesThe primary objective was to compare the intake of important micronutrients provided from enteral nutrition to critically ill patients with the Australia and New Zealand recommended dietary intakes. A secondary objective was to compare the upper levels of intake and investigate prespecified subgroups.Review method usedA systematic literature review was performed.Data sourcesMEDLINE, EMBASE, CINAHL, and CENTRAL were used.Review methodsDatabases were searched for randomised controlled trials that investigated an enteral nutrition intervention as the sole source of nutrition, were published in English between January 2000 and January 8th, 2021, and provided data to calculate micronutrient intake. The primary outcome was the % recommended dietary intake. The quality of individual trials was assessed using the Cochrane Risk of Bias Tool. Outcomes are presented as either mean ± standard deviation or median [interquartile range], with a p < 0.05 considered statistically significant.ResultsThirteen trials were included (n = 1538 patients). Trials investigating hypocaloric nutrition were excluded from the primary outcome assessment (conducted in nine trials (n = 1220)). All nine trials delivered ≥104% of the recommended dietary intakes and <100% of the upper level of intakes of all micronutrients. In subgroup analyses, trials with ≥80% target energy delivered a higher % of the recommended dietary intake of vitamin B12, thiamine, zinc, and vitamin C. Acute Physiology and Chronic Health Evaluation scores ≥20 delivered a higher % of the recommended dietary intake of vitamin B12 and vitamin A. Antioxidant formulas compared with standard formulas delivered a higher % recommended dietary intake of vitamin C and thiamine. In the four trials that investigated hypocaloric feeding compared with control, there was no difference in micronutrient intake. The quality was low.ConclusionsEnteral nutrition delivery frequently met the recommended dietary intakes for all micronutrients investigated and did not exceed the upper levels of intake set for health.PROSPERO RegistrationCRD42020178333.     

Selenium supplementation in critically ill patients: A systematic review and meta-analysis

Purpose

The oxidative stress is recognized as a constant feature in critical illness. Nevertheless, the use of antioxidant therapy remains controversial. We tried to demonstrate that intravenous selenium supplementation could promote antioxidant status and help protect against infection and organ failure, improving outcome in critically ill patients.

Materials and Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the exogenous supplementation of selenium versus standard therapy without any adjuvant in critically ill adults.

Results

Nine RCTs met inclusion criteria. Selenium supplementation was associated with a reduction in 28-day mortality of borderline statistical significance (risk ratio = 0.84, 95% confidence interval 0.71–0.99, P = .04). The analysis of pre-defined subgroups detected no significant effects regarding the supplementation with doses of selenium ≤ 500 μg/d, administration of a load dose with a bolus and duration of treatment. Only 2 studies analyzed 6-month mortality and could not show a difference. No effects could be demonstrated on hospital length of stay, pulmonary infections, or renal failure.

Conclusions

The use of high-dose selenium might be associated with a beneficial effect on 28-day mortality in critically ill patients. Nevertheless, the use of selenium as adjuvant therapy needs further evaluations.     

Clinical tools for the assessment of pain in sedated critically ill adults

Aim: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. Background: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. Search strategy: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: ‘pain assessment’ and ‘sedated’ or ‘unconscious’ or ‘critically ill’ or ‘critical illness’ or ‘critical care’. Conclusions: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical‐Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non‐verbal Pain Scale (NVPS). Implications for practice: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.     

Antipyretic therapy in febrile critically ill adults: A systematic review and meta-analysis

Purpose

To determine whether fever control with antipyretic therapy effects the mortality of febrile critically ill adults.

Methods

Systematic review using MEDLINE, EMBASE, Cochrane Central Register for Controlled Trials, CINAHL, Google Scholar, and 2 clinical trial registries from inception to April 2012. Randomized clinical trials comparing treatment of fever with no treatment or comparing different thresholds for fever control in adults without acute neurological injury admitted to intensive care units (ICUs) were selected for review. The effect of fever control on all-cause ICU-mortality was determined using a random effects meta-analysis.

Results

Five randomized clinical trials in 399 patients were included. The temperature threshold for treatment in the intervention group was commonly 38.3°C to 38.5°C, whereas it was typically 40.0°C for controls. Four studies used physical measures and 3 used pharmacologic measures for temperature control. There was no significant heterogeneity among the included studies (I² = 12.5%, P = .3). Fever control did not significantly effect ICU mortality with a pooled risk ratio of 0.98 (95% confidence interval 0.58-1.63, P = .9).

Conclusions

This meta-analysis found no evidence that fever treatment influences mortality in critically ill adults without acute neurological injury. However, studies were underpowered to detect clinically important differences.     

Reliability and validity of the Chinese version of the behavioral pain scale in intubated and non-intubated critically ill patients: Two cross-sectional studies

BackgroundSelf-report pain assessment scales may be inappropriate when critically ill patients are incapable of adequate communication because of sedation or mechanical ventilation. The Behavioral Pain Scale (BPS, for intubated patients) and the BPS-non intubated (BPS-NI, for non-intubated patients) measure objective behavioral indicators of pain in non-communicating critically ill patients.ObjectivesTo develop a Chinese version of the BPS combining the original version of the BPS and BPS-NI suitable for pain assessment among critically ill patients and to determine its reliability and validity.DesignTwo cross-sectional studies.SettingsA 15-bed surgical intensive care unit (ICU) in a teaching hospital in Beijing, China.ParticipantsIn the first study, 129 patients (53 intubated and 76 non-intubated) were recruited; in the second study, 83 (43 intubated and 40 non-intubated) were recruited.MethodsThe Chinese version of the BPS (BPS-C) was developed via rigorous translation methods, including double back-translation and content validation involving 13 clinical experts. Internal consistency, discriminative validity, and criterion-related validity were established using the BPS-C and the Numeric Rating Scale (NRS). The BPS-C and NRS were used to assess pain in 53 intubated and 76 non-intubated post-abdominal surgery patients during low pain exposure and increased pain exposure in the first study. To establish interrater reliability, a researcher and a bedside nurse independently performed 172 paired assessments in 43 intubated patients and 160 paired assessments in 40 non-intubated patients with the BPS-C under the same conditions in the second study.ResultsThe BPS-C achieved conceptual and semantic equivalence with the original tool. Internal consistency was established through Cronbach's alpha (α = 0.724–0.743 in intubated patients, α = 0.701–0.762 in non-intubated patients). Interrater reliability was confirmed through the intraclass correlation coefficients (ICCs), which ranged from 0.962 to 1.000 in both intubated and non-intubated patients with high agreement percentages (95.3–100.0% in intubated and 95.0–100.0% in non-intubated patients). BPS-C scores during increased exposure to pain were significantly higher than those obtained during low exposure to pain, indicating discriminative validity. Criterion-related validity was confirmed by strong positive correlations between BPS-C and NRS scores (Pearson's correlations r = 0.815–0.937 for intubated patients, Pearson's correlations r = 0.755–0.899 for non-intubated patients).ConclusionsThe Chinese version of the BPS (BPS-C) is appropriate for pain assessment among intubated and non-intubated ICU patients.     

Millimetre wave therapy for pain relief after total knee arthroplasty: A randomised controlled trial

Millimetre wave therapy (MWT) is a promising complementary method for pain relief, however rigorous investigations of its effectiveness are needed. The purpose of this study was to examine if MWT can reduce opioid requirement compared to sham procedure applied for relief of acute pain in patients after total knee arthroplasty (TKA). Eighty patients undergoing TKA were randomly assigned to receive MWT or sham procedure. Patients and evaluators were blinded to the group allocation. MWT consisted of six sessions, each session of 30min duration. During each session the knee wound was exposed to electromagnetic waves with frequency 50–75GHz and power density 4.2mW/cm². Postoperative analgesia with piritramide, a weak opioid with 0.7 potency of morphine delivered via patient‐controlled analgesia pump, was directed to achieve pain intensity of less than 40 on a 100mm visual analogue scale (VAS). The primary outcome measure was postoperative piritramide requirement for three days after surgery. Secondary outcome measures were: total ibuprofen requirement from the fourth postoperative day to discharge; success of patients’ blinding; patients’ satisfaction with pain relief; incidence of analgesia‐related side effects; heart rate and blood pressure. Piritramide requirement was similar in both groups whereby all patients reported adequate pain relief measured on a VAS. Secondary outcome measures were also comparable in both groups. The majority of patients in both groups believed they had received true MWT and wanted to repeat it in future. Millimetre waves applied to surfaces of surgical wounds did not reduce opioid requirement compared to the sham procedure after TKA.     

Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients:A systematic review

AIM: To investigate the diagnostic yield, therapeutic efficacy, and rate of adverse events related to flexible fiberoptic bronchoscopy(FFB) in critically ill children. METHODS: We searched Pub Med, SCOPUS, OVID, and EMBASE databases through July 2014 for English language publications studying FFB performed in the intensive care unit in children 18 years old. We identified 666 studies, of which 89 full-text studies were screened for further review. Two reviewers independently determined that 27 of these studies met inclusion criteria and extracted data. We examined the diagnostic yield of FFB among upper and lower airway evaluations, as well as the utility of bronchoalveolar lavage(BAL). RESULTS: We found that FFB led to a change in medical management in 28.9%(range 21.9%-69.2%) of critically ill children. The diagnostic yield of FFB was 82%(range 45.2%-100%). Infectious organisms were identified in 25.7%(17.6%-75%) of BALs performed, resulting in a change of antimicrobial management in 19.1%(range: 12.2%-75%). FFB successfully reexpanded atelectasis or removed mucus plugs in 60.3%(range: 23.8%-100%) of patients with atelectasis. Adverse events were reported in 12.9%(range: 0.5%-71.4%) of patients. The most common adverse effects of FFB were transient hypotension, hypoxia and/or bradycardia that resolved with minimal intervention, such as oxygen supplementation or removal of the bronchoscope. Serious adverse events were uncommon; 2.1% of adverse events required intervention such as bag-mask ventilation or intubation and atropine for hypoxia and bradycardia, normal saline boluses for hypotension, or lavage and suctioning for hemorrhage. CONCLUSION: FFB is safe and effective for diagnostic and therapeutic use in critically ill pediatric patients.     

Video education for critical care nurses to assess pain with a behavioural pain assessment tool: A descriptive comparative study

AimTo evaluate the impact of video education on critical care nurses’ knowledge and skills in using a behavioural pain assessment tool for intensive care patients and to explore the nurses’ experiences with video education.MethodsForty-eight nurses in one intensive care unit watched an educational video on the use of the Critical-Care Pain Observation Tool, then assessed pain in two patients with the tool and took a knowledge test. The researcher made parallel pain assessments. Interrater reliability of patients’ pain assessment between nurses and the researcher was determined to examine nurses’ skills in using the tool after education. Twenty nurses were interviewed about their experiences with the video education. Interviews were analysed with deductive thematic analysis.ResultsThe knowledge test scores indicated that the nurses learned the principles of how to use the tool. The interrater reliability of pain assessments reached a moderate level of agreement during the painful procedure, with a weighted kappa coefficient value of 0.48, CL [0.37, 0.58]. The nurses perceived video education positively, but requested additional interaction.ConclusionsVideo education is useful in teaching the principles of using a pain assessment tool. Additional clinical training is required for nurses to reach adequate skills in using the tool.     

Acquired neuromuscular disorders in critically ill patients: a systematic review

Objective: To summarize the prospective clinical studies of neuromuscular abnormalities in intensive care unit (ICU) patients. Study identification and selection: Studies were identified through MEDLINE, EMBASE, references in primary and review articles, personal files, and contact with authors. Through duplicate independent review, we selected prospective cohort studies evaluating ICU-acquired neuromuscular disorders. Data abstraction: In duplicate, independently, we abstracted key data regarding design features, the population, clinical and laboratory diagnostic tests, and clinical outcomes. Results: We identified eight studies that enrolled 242 patients. Inception cohorts varied; some were mechanically ventilated patients for ≥ 5 days, others were based on a diagnosis of sepsis, organ failure, or severe asthma while others were selected on the basis of exposure to muscle relaxants, or because of participation in muscle biochemistry studies. Weakness was systematically assessed in two of the eight studies, concerning patients with severe asthma, with a reported frequency of 36 and 70 %, respectively. Electrophysiologic and histologic abnormalities consisted of both peripheral nerve and muscle involvement and were frequently reported, even in non-selected ICU patients. In a population of patients mechanically ventilated for more than 5 days, electrophysiologic abnormalities were reported in 76 % of cases. Two studies showed a clinically important increase (5 and 9 days, respectively) in duration of mechanical ventilation and a mortality twice as high in patients with critical illness neuromuscular abnormalities, compared to those without. Conclusions: Prospective studies of ICU-acquired neuromuscular abnormalities include a small number of patients with various electrophysiologic findings but insufficiently reported clinical correlations. Evaluation of risk factors for these disorders and studies examining their contribution to weaning difficulties and long-term disability are needed. Received: 3 April 1998 Accepted: 19 June 1998     

Nurse practitioner led pain management the day after caesarean section: A randomised controlled trial and follow-up study

BackgroundPain on the day after caesarean section is often treated with controlled-release oxycodone to supplement the decline in analgesia from intrathecal opioids. Evidence suggests that caesarean birth is a biopsychosocial experience where a comprehensive approach is needed that promotes control and participation in pain management.ObjectivesThis study compared immediate-release oxycodone integrated with supportive educational strategies to controlled-release oxycodone. A follow-up phase aimed to explore pain over three months.DesignThis study was a two-group parallel randomised controlled trial.SettingA metropolitan hospital in Australia with a birthing suite, operating rooms, and a postnatal unit.ParticipantsEnglish-speaking women scheduled for elective caesarean section were mailed trial information. Exclusion criteria included contraindications to intrathecal analgesia, herpes simplex infection, a history of chronic pain, opioid tolerance, or substance abuse. A total of 131 participants were recruited and randomised out of 298 eligible participants.MethodsGroup allocation was undertaken using sequentially numbered opaque sealed envelopes. The nurse practitioner intervention commenced on the day after surgery with immediate-release oxycodone alongside supportive strategies. The control group received scheduled doses of controlled-release oxycodone. All participants could request additional oxycodone or tramadol. Primary outcomes were pain intensity and secondary outcomes included patient global impression of change, pain interference, opioid consumption, and maternal perception of control. A follow-up phase evaluated pain outcomes over three months.ResultsThe final sample size was 122, with 61 participants in each group. Pain intensity scores were analysed by linear mixed regression models. There were no statistical differences over 24 h between the control and intervention groups at rest (p = 0.40, 95% CI – 4.8 mm, 11.9 mm) or on sitting or moving (p = 0.561, 95% CI –15.2 mm, 8.3 mm). Patient global impression of change was significant over three hours (p = 0.014, OR = 2.5, 95% CI 1.2, 5.3). The intervention group reported less pain interference while consuming less oxycodone (p < 0.05). There was no difference between groups in terms of perceived control over pain management (p = 0.273, 95% CI –16.2 mm, 4.6 mm). The follow-up analysis graded 5.9% of participants as experiencing severe pain interference. Chronic pain following caesarean was associated with postnatal depression (p < 0.001).ConclusionsThe research showed that a nurse practitioner intervention can improve pain management following caesarean section. The results underscore the influence of biological, psychological, and social factors on acute pain. Hence, this study reinforces the need for a biopsychosocial approach to acute pain management following caesarean delivery.     

The effectiveness of a multidisciplinary pain management programme managing chronic pain on pain perceptions, health-related quality of life and stages of change—A non-randomized controlled study

Background

Cognitive behavioural therapy (CBT) has been useful in the treatment of chronic pain conditions for many years. Given the increasing number of persons with chronic pain and associated psychosocial problems, the development and implementation of effective interventions based on CBT is warranted.

Objectives

The aim of this study is to evaluate the effects of a multidisciplinary pain management programme on health-related quality of life (HRQL), as measured by the Short Form Health Survey (SF-36), pain perception as measured by the Brief Pain Inventory (BPI), and readiness-to-change as measured by the Pain Stages of Change Questionnaire (PSOCQ).

Design

A pretest-post-test quasi-experimental design, with waiting list controls and baseline and post-test measures, was used.

Setting

The study was conducted in the rehabilitation unit of a university hospital.

Participants

Of 117 people suffering from chronic pain, 113 completed the 8-week multidisciplinary pain management programme. The patients were consecutive referrals. Inclusion criteria were: adults (18-67 years), pain lasting over 6 months, motivation and no ongoing litigation. Exclusion criteria were affected by major mental disorders or major medical conditions requiring treatment.

Methods

The intervention was based on a cognitive behavioural approach. Therapeutic dialogues and training, combined with physical activity, were provided to a fixed plan, including homework. The programme has several features that directly address psychosocial aspects of chronic pain. Statistical and clinical significance are considered.

Results

The findings suggest that this programme has the potential to improve HRQL, reduce pain intensity and interference, and contribute to improvement in readiness-to-change. Statistically significant results are supplemented by results showing their clinical significance.

Conclusions

Improvements in HRQL, pain-related disability, and readiness-to-change suggest that the vicious cycle of chronic pain may be alleviated by our programme. As we see it, effective treatment results are about identifying and addressing the important and changeable influences maintaining pain problems such as acceptance, understanding the mind-body connection and self-management. Although further research is needed to evaluate the effectiveness of this work, such group approaches appear to represent a feasible treatment option for many patients with chronic pain.     

The effectiveness of a Chinese midwives’ antenatal clinic service on childbirth outcomes for primipare: A randomised controlled trial

Background

Antenatal care is an important component of maternity care. In many parts of the world, midwives are the primary caregivers for childbearing women, providing a high level of continuity of care during a normal pregnancy. While in China, obstetricians are the primary providers of antenatal care for all childbearing women; and midwives only provide intrapartum care to labouring women. Today midwifery as a profession in China has been marginalised. Pregnant women usually lack individualised continuity of care from midwives during the perinatal period. There have been few randomised controlled trials of midwifery care practice in mainland China.

Objective

(1) To develop and implement a model of Chinese midwives’ antenatal clinic service and (2) to explore its effect on childbirth outcomes, psychological state and satisfaction, for primiparae.

Design and methods

Two-group randomised controlled trial. One hundred and ten pregnant women were assessed for eligibility and invited to participate in either the intervention group (midwives’ antenatal clinic service) or the control group (routine antenatal care) in the Obstetrics and Gynaecology Hospital of Fudan University from September 2011 to December 2011. Baseline data were collected, and then women were randomised to individual midwives’ antenatal clinic care (intervention group) or regular antenatal clinic service by obstetricians and obstetric nurse (control group). The research hypothesis was that compared with regular obstetrician-led antenatal care, the midwives’ antenatal clinic service would decrease the caesarean section rate, produce more favourable birth outcomes and women's greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. The sample size of 110 was calculated to identify a decrease in caesarean birth from 70% to 40%. Birth outcomes, satisfaction and anxiety score in the two groups were compared.

Setting

The midwives’ antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.

Participants

55 women, attending the midwives’ antenatal clinic (the intervention group) and 55 women, entering the control group.

Results

Women in the intervention group were more likely than women in the control group to have a vaginal birth (35 [66.04%] versus 23 [43.40%]; 95% CI for difference 3.69–41.60). Women in the intervention group had a higher perinatal satisfaction but lower anxiety score than those in the control group. No differences were seen in neonatal Apgar score and in the amount of bleeding 2 h post partum.

Conclusion and implications for practice

The midwives’ antenatal clinic can decrease the rate of caesarean section and enhance women's satisfaction with midwifery care. Further research needs to be conducted to implement this model of care more widely. We will attempt to make midwifery care a true choice for Chinese women.     

Self-management intervention for chronic pain in older adults: A randomised controlled trial

This study compared an outpatient pain self-management (PSM) program, using cognitive-behavioural therapy and exercises, with 2 control conditions in 141 chronic pain patients aged > 65 years. Results immediately posttreatment indicated that relative to the Exercise-Attention Control (EAC) group, the PSM group was significantly improved on measures of pain distress, disability, mood, unhelpful pain beliefs, and functional reach. The mean effect size for these gains was 0.52 (range: 0.44–0.68). By 1-month follow-up, relative to the EAC group, the PSM group remained better on most measures. At the 1-month follow-up, relative to a Waiting List (usual care) (WL) group, the PSM group was significantly improved on measures of pain distress, disability, and unhelpful pain beliefs. The mean effect size for these variables was 0.69 (range: 0.56–0.83). Relative to the WL group, the EAC group made no significant gains on any of the measured variables. At 1-month follow-up, the mean proportion of reliably improved cases (across outcome variables) was 41% (range: 16–60%) for the PSM group, twice that of those who met this criterion in the 2 control conditions (and this difference was statistically significant). Similarly, significantly more (44%) of the PSM group (vs 22% and 20% for the control groups) achieved a clinically significant improvement on pain disability. In the short term at least, cognitive-behavioural therapy-based PSM was more effective than exercises and usual care.     

Evaluation of pain severity in critically ill patients on mechanical ventilation

ObjectivesTo elucidate how patients’ illness severity, respiratory status, or haemodynamics are associated with the pain score of critically ill patients.MethodsThis was an observational study of patients on mechanical ventilation after surgeries. At rest and on turning, patient pain was evaluated using the Behavioural Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). Related factors were collected from medical records and analysed.FindingsMultiple logistic regression analysis was performed using data on 127 scenarios. An increase of >2 in BPS score on turning was affected by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (odds ratio [OR] = 0.864), systolic blood pressure at rest (OR = 1.032), BPS at rest (OR = 0.638), heart rate difference (OR = 1.124), and tidal volume difference (OR = 0.548). An increase of >2 in CPOT on turning score was associated with the APACHE II score (OR = 0.894), Sequential Organ Failure Assessment score (OR = 1.248), systolic blood pressure at rest (OR = 1.025), heart rate difference (OR = 1.096), and tidal volume difference (OR = 0.578).ConclusionThe Behavioural Pain Scale and the Critical-Care Pain Observation Tools were associated with illness severity and haemodynamics. A reduction in tidal volume may be useful in assessing pain.