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Desaturating Patient with Long Bone Fractures
Published in Kajal Jain, Nidhi Bhatia, Acute Trauma Care in Developing Countries, 2023
Devendra Kumar Chouhan, Narendra Chouhan
These patients need deep sedation with occasional neuromuscular blockers for ventilator synchronization and decreased O2 consumption. Using sedation scales such as the Richmond Agitation-Sedation Scale (RASS) may help clinicians meet sedation goals more effectively, decreasing the likelihood of over- or undersedation. Most patients are kept comfortable awake or under light sedation (e.g. RASS of 0 or –1), although some patients with more severe lung injury or poor tolerance of mechanical ventilation may need deeper sedation.
Alcohol Withdrawal
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Akhil Patel, Kunal Karamchandani
While a majority of individuals experience only minor, uncomplicated withdrawal symptoms, such as increased anxiety, headache, nausea, vomiting, insomnia, and mild tremors, which self-resolve, a small subgroup of these individuals experience a more complicated syndrome that includes hallucinations, seizures, delirium, and/or more severe autonomic hyperactivity. Patients with such severe symptoms usually require intensive care unit (ICU) admission. The Revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) is one of the most commonly used tools to address withdrawal severity as well as treatment effects amongst these patients. It is a 10-item scale that tracks the degree of nausea and vomiting, headache, tremor, diaphoresis, anxiety, agitation, disorientation, and auditory, visual, and tactile disturbances [3]. The CIWA-Ar scale requires patient interaction to accurately assess patient symptomology and allow active medication titration. The scale is used for its therapeutic use as it can be continued throughout the withdrawal process. Other scales such as the Riker Sedation-Agitation scale and Richmond Agitation-Sedation scale can be used for patients that require mechanical ventilation or are unable to communicate [1].
Delirium
Published in Stephen M. Cohn, Peter Rhee, 50 Landmark Papers, 2019
Anchit Mehrotra, Natasha Keric
Currently, there is no large randomized controlled trial that supports the use of pharmacologic interventions to treat and prevent delirium, and despite popular belief that benzodiazepines cause delirium there has been no single trial that has validated or disproved this. Benefits related to dexmedetomidine use when compared to benzodiazepine and propofol infusions have shown ventilator-free time and faster resolution of delirium symptoms; however, the studies with dexmedetomidine have had small sample sizes, and its use as a first-line treatment modality is not clearly indicated at this time. Similarly, there has been no proven benefit of antipsychotics for the treatment or prevention of ICU delirium. A recent small sample size comparison trial of antipsychotics and melatonin showed no difference in delirium-free days, duration of delirium, mortality, or ICU length of stay (Hayhurst et al., 2016; Daniels et al., 2018). Regardless of what pharmacologic interventions are employed, implementing a daily target sedation goal, with analgesia first treatment and titrating sedatives to maintain light sedation, is the key to success when trying to manage delirium in the ICU. Either the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS) may be used as they have been found to be the most valid, reliable, and discriminatory sedation assessment tools for measuring quality and depth of sedation in adult ICU patients.
Is a hyperosmolar pump prime for cardiopulmonary bypass a risk factor for postoperative delirium? A double blinded randomised controlled trial
Published in Scandinavian Cardiovascular Journal, 2023
Helena Claesson Lingehall, Yngve Gustafson, Staffan Svenmarker, Micael Appelblad, Fredrik Davidsson, Fredrik Holmner, Alexander Wahba, Birgitta Olofsson
Assessments were performed preoperatively and repeated after extubation on day 1 (+1) and day 3 (±1) postoperatively. Five persons blinded to group assignment were after formal training assigned to administer the test instruments. The test battery included: (1) The Mini Mental State Examination Second Edition Standard Version (MMSE-2 SV) to assess cognition [11]. (2) The Organic Brain Syndrome Scale (OBS) to assess disturbances of awareness and orientation and fluctuations of cognition and degree of emotional reactions and psychotic symptoms [12]. (3) The Nursing Delirium Screening Scale (Nu-DESC) to assess disorientation, inappropriate behaviour, inappropriate communication, illusions or hallucinations and psychomotor retardation [13]. This is a routine procedure repeated three times every day from admittance to ICU until discharge from hospital. (4) Richmond Agitation Sedation Scale (RASS) to assess degree of agitation or sedation [14]. (5) Glasgow Coma Scale (GCS) to assess level of consciousness [15]. (6) Geriatric Depression Scale (GDS-15) to assess depressive symptoms [16]. (7) Activities of Daily Living (ADL) to assess functional ability based on the Katz [17] and Barthel index [18].
Elevated sTREM2 and NFL levels in patients with sepsis associated encephalopathy
Published in International Journal of Neuroscience, 2023
Günseli Orhun, Figen Esen, Vuslat Yilmaz, Canan Ulusoy, Elif Şanlı, Elif Yıldırım, Hakan Gürvit, Perihan Ergin Özcan, Serra Sencer, Nerses Bebek, Erdem Tüzün
All participants underwent detailed neurological examination by neurologists and ICU specialists. Components of the neurologic assessment in the ICU included the level of consciousness and delirium assessment. Delirium was assessed twice daily by trained research nurses using the Confusion Assessment Method for the ICU (CAM-ICU) [22]. Patients were diagnosed with delirium when they had at least one positive CAM-ICU assessments. The sedation level was measured via the Richmond Agitation-Sedation Scale [23]. Daily interruption of sedation was performed for the level of consciousness and those patients with a Glasgow Coma Scale ≤ 8 were accepted as comatose. The presence of one of generalized or focal, tonic or clonic, short or long term and recurrent movement on the face or extremities was defined as an epileptic seizure. Any lateralized deficit was considered a focal neurological deficit.
Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies
Published in Expert Review of Neurotherapeutics, 2021
Dharmanand Ramnarain, Emily Aupers, Brenda den Oudsten, Annemarie Oldenbeuving, Jolanda de Vries, Sjaak Pouwels
Another important feature in optimizing recovery and outcome is choosing the most suitable drugs for analgesia and sedation. Sedatives are commonly used to treat agitation in ICU patients, but it is also of great importance to rule out and treat underlying causes of agitation. Common causes of agitation are pain, delirium, hypoxemia, hypoglycemia, hypotension, and substance withdrawal, and simple interventions can include optimization of patient comfort, adequate analgesia, frequent reorientation, maintenance of sleep patterns, before the administration of sedatives [115]. In line with the goal-directed approach of the Pain Agitation and Delirium guidelines, it is recommended to maintain light levels of sedation over prolonged, deep sedation. Studies have shown that light sedation is associated with shorter duration of mechanical ventilation and shorter length of stay in the ICU [115]. To monitor sedation levels in ICU patients, the use of sedation scales can be ideal for healthcare providers. The most valid and reliable scales are the Sedation–Agitation Scale (SAS) and the RASS. The SAS ranges from 1 (unarousable) to 7 (dangerous agitation). The RASS is a 10-point scale ranging from escalating agitation (RASS +1 to +4), a calm and alert state (RASS 0), sedation (RASS −1 to −3) and coma (RASS −4 and −5). As they rely on head or limb movement and eye contact, they are quick and straightforward assessment tools, requiring minimal training with high interrater reliability among a wide variety of ICU patients [119].