RESUMEN
BACKGROUND: Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision. METHODS: We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. DISCUSSION: This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023402365.
Asunto(s)
Metaanálisis en Red , Agitación Psicomotora , Revisiones Sistemáticas como Asunto , Humanos , Agitación Psicomotora/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto , Proyectos de Investigación , Antipsicóticos/uso terapéuticoRESUMEN
Background: Aggression, a common symptom of Alzheimer's disease (AD), can impose a significant burden on caregivers, necessitating early institutionalization. Objective: The current study examined the neural basis of aggression and its expression mechanism, to advance the development of effective treatment strategies for aggression in patients with AD. Methods: The study sample included 257 patients; 180 were diagnosed with AD and 77 with amnestic mild cognitive impairment (aMCI). Factor analysis of the neuropsychiatric inventory (NPI) aggression scores was performed, and the correlation between each factor and cerebral blood flow (CBF) was examined via diagnosis of AD or aMCI using statistical parametric mapping. Results: Refusal of care was correlated with reduced CBF in the right hippocampus of patients with AD while no specific related regions could be identified in patients with aMCI. Violent behavior was associated with decreased CBF in the right temporal pole and medial frontal lobe of patients with AD and aMCI. Conclusions: These findings suggest that aggression, measured using NPI includes two distinct symptoms, refusal of care and violent behavior, having different underlying neural bases.
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Enfermedad de Alzheimer , Amnesia , Disfunción Cognitiva , Humanos , Enfermedad de Alzheimer/psicología , Enfermedad de Alzheimer/fisiopatología , Masculino , Femenino , Disfunción Cognitiva/psicología , Anciano , Amnesia/psicología , Amnesia/fisiopatología , Pruebas Neuropsicológicas , Imagen por Resonancia Magnética , Agresión/fisiología , Agresión/psicología , Anciano de 80 o más Años , Circulación Cerebrovascular/fisiología , Agitación Psicomotora/psicología , Encéfalo/fisiopatología , Encéfalo/diagnóstico por imagenAsunto(s)
Delirio , Ketamina , Agitación Psicomotora , Ketamina/administración & dosificación , Ketamina/uso terapéutico , Humanos , Delirio/tratamiento farmacológico , Agitación Psicomotora/tratamiento farmacológico , Servicios Médicos de Urgencia/métodos , Anestésicos Disociativos/administración & dosificación , Anestésicos Disociativos/uso terapéuticoRESUMEN
BACKGROUND: Increasing evidence suggested that immune abnormalities involved in the pathophysiology of schizophrenia. However, the relationship between immunity and clinical features has not been clarified. The aim of this study was to measure the plasma levels of tumor necrosis factor alpha (TNF-α) and soluble TNF-α receptor 1 (sTNF-α R1) and to investigate their association with agitation in first episode patients with schizophrenia (FEPS). METHODS: The plasma TNF-α and sTNF-α R1 levels were measured using sandwich enzyme-linked immunosorbent assay (ELISA) in the FEPS with (n = 36) and without agitation (n = 49) symptoms, and healthy controls (HCs, n = 54). The psychopathology was assessed by the Positive and Negative Syndrome Scale (PANSS), and the agitation symptoms were evaluated by the PANSS excitatory component (PANSS-EC). RESULTS: The plasma TNF-α levels in patients with and without agitation symptoms were significantly higher than those in HCs. The patients with agitation had significantly higher plasma TNF-α levels compared to the patients without agitation. There were no significant differences in the sTNF-α R1 levels among the three groups. Furthermore, the plasma TNF-α levels were positively correlated with the PANSS total score, Positive and General psychopathological subscores, and PANSS-EC score in the FEPS, but the relationships were not found for the plasma sTNF-α R1 levels. CONCLUSIONS: These results suggested that TNF-α might play an important role in the onset and development of agitation symptoms of schizophrenia.
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Agitación Psicomotora , Receptores Tipo I de Factores de Necrosis Tumoral , Esquizofrenia , Factor de Necrosis Tumoral alfa , Humanos , Esquizofrenia/sangre , Esquizofrenia/complicaciones , Femenino , Masculino , Factor de Necrosis Tumoral alfa/sangre , Agitación Psicomotora/sangre , Adulto , Receptores Tipo I de Factores de Necrosis Tumoral/sangre , Adulto Joven , Escalas de Valoración PsiquiátricaRESUMEN
While Title VI of the Civil Rights Act of 1964 mandates use of interpreters for patients with limited English proficiency, significant disparities persist in intensive postsurgical care. We present the case of a 60-year-old Vietnamese-speaking man with a Type A aortic dissection requiring postoperative mechanical ventilation and stroke care. Despite use of a remote video interpreter, our language-discordant nursing and physician providers faced challenges in managing agitation and delirium and assessing neurological function. This case highlights the need for adequate interpretation equipment, linguistic diversity among providers, and interventions to promote and enable consistent certified and professional medical interpreter use.
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Delirio , Accidente Cerebrovascular , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/complicaciones , Agitación Psicomotora , Dominio Limitado del Inglés , Complicaciones Posoperatorias , Disección Aórtica/cirugía , Respiración ArtificialRESUMEN
Background: To investigate the effects of nalbuphine on emergency agitation (EA), which affects up to 80% of the children following otolaryngology procedures, in children undergoing cochlear implantation. Methods: A prospective double-blinded randomized controlled clinical trial was conducted between November 2020 and October 2022. Eligible children, aged 6 months to 3 years old, were randomly assigned to either 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg nalbuphine or 0.9% saline groups. EA was defined by the Pediatric Anesthesia Emergence Delirium (PAED) score ≥10. Extubation time, post-anesthesia care unit (PACU) length of stay, severe EA (PAED ≥ 15), peak PAED score, the Faces, Legs, Activity, Cry, and Consolability (FLACC) scale, Ramsay sedation score, and adverse events were also recorded. Results: A total of 104 children were enrolled, with 26 children in each group. Nalbuphine significantly reduced the EA occurrence from 73.1% in the saline group to 38.5%, 30.8%, and 26.9% in the 0.1 mg/kg, 0.15 mg/kg, and 0.2 mg/kg nalbuphine groups, respectively (P < 0.001), without affecting the extubation time and PACU length of stay. More children (34.6%) in the 0.9% saline group experienced severe EA. Higher dose nalbuphine (0.15 mg/kg, 0.2 mg/kg) showed lower peak PAED score, better analgesia and sedation effect compared with 0.1 mg/kg nalbuphine and saline groups. However, 0.2mg/kg nalbuphine caused undesired over-sedation in two (7.7%) children. No other adverse events were reported. Conclusion: Young children undergoing cochlear implantation surgery were at a high risk of EA and postoperative pain, while 0.2 mg/kg nalbuphine might be an ideal candidate for EA and pain prevention when used under close monitoring. Trial Registration: ChiCTR2000040407.
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Analgésicos Opioides , Implantación Coclear , Delirio del Despertar , Nalbufina , Humanos , Nalbufina/administración & dosificación , Nalbufina/uso terapéutico , Preescolar , Masculino , Método Doble Ciego , Femenino , Estudios Prospectivos , Lactante , Delirio del Despertar/prevención & control , Delirio del Despertar/tratamiento farmacológico , Implantación Coclear/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Relación Dosis-Respuesta a Droga , Agitación Psicomotora/tratamiento farmacológico , Agitación Psicomotora/prevención & controlRESUMEN
Agitation and psychosis are key behavioral and psychological symptoms of Alzheimer's disease (AD). For family and caregivers of patients, such symptoms are critical factors of distress and increased burden, but medication to treat them is limited. In most cases, drugs for other neuropsychiatric diseases have been used to manage these symptoms in an off-label manner. Due to the complex pathological background of AD and limited clinical data, obtaining proof of concept for the treatment of these symptoms is challenging. However, in 2023, the U.S. Food and Drug Administration approved brexpiprazole as the first and only drug to treat agitation in AD. Several other compounds have been evaluated in clinical situations. This review highlights recent pipelines being developed for agitation and psychosis for patients living with AD.
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Enfermedad de Alzheimer , Antipsicóticos , Agitación Psicomotora , Trastornos Psicóticos , Enfermedad de Alzheimer/tratamiento farmacológico , Enfermedad de Alzheimer/diagnóstico , Humanos , Trastornos Psicóticos/tratamiento farmacológico , Trastornos Psicóticos/diagnóstico , Agitación Psicomotora/tratamiento farmacológico , Antipsicóticos/uso terapéuticoAsunto(s)
Delirio , Ketamina , Agitación Psicomotora , Humanos , Ketamina/administración & dosificación , Ketamina/uso terapéutico , Delirio/tratamiento farmacológico , Agitación Psicomotora/tratamiento farmacológico , Servicios Médicos de Urgencia/métodos , Anestésicos Disociativos/administración & dosificación , Anestésicos Disociativos/uso terapéuticoRESUMEN
This cohort study examines the risk factors for developing delirium and/or agitation in patients in the emergency department waiting for an inpatient bed.
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Delirio , Servicio de Urgencia en Hospital , Agitación Psicomotora , Humanos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Pacientes Internos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Anciano de 80 o más Años , Hospitalización/estadística & datos numéricos , Factores de TiempoRESUMEN
BACKGROUND: Music therapy has been used as a complementary intervention to provide synergistic analgesia for various procedures. OBJECTIVE: To evaluate the effects of natural sound therapy on pain intensity and agitation scores in intubated adult Chinese patients who received endotracheal suctioning in a critical care unit. METHODS: A prospective, real-world, randomized, double-blind, controlled study was conducted from July 2021 through February 2022 among intubated surgical intensive care unit patients in a Chinese hospital. Patients were randomly assigned to a control group receiving conventional treatment or an intervention group receiving natural sound therapy plus conventional treatment (50 patients in each group). Patients' pain intensity and agitation levels were analyzed before, during, immediately after, 5 minutes after, and 15 minutes after completion of endotracheal suctioning. Pain intensity was assessed with the Critical-Care Pain Observation Tool (CPOT); agitation was assessed with the Richmond Agitation-Sedation Scale (RASS). RESULTS: According to CPOT scores, patients in the intervention group had significant relief of pain intensity during, immediately after, and 5 minutes after endotracheal suctioning compared with patients in the control group (all P < .001). The RASS scores showed that agitation levels were significant lower in the intervention group than in the control group during (P = .002) and immediately after (P < .001) endotracheal suctioning. CONCLUSIONS: In this real-world study, natural sound therapy was part of a holistic bundle of interventions used to reduce pain and agitation in surgical intensive care unit patients during endotracheal suctioning.
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Unidades de Cuidados Intensivos , Intubación Intratraqueal , Dimensión del Dolor , Agitación Psicomotora , Humanos , Femenino , Masculino , Persona de Mediana Edad , Succión/métodos , Estudios Prospectivos , Método Doble Ciego , Intubación Intratraqueal/efectos adversos , Agitación Psicomotora/prevención & control , Agitación Psicomotora/etiología , Anciano , Manejo del Dolor/métodos , China , AdultoRESUMEN
The aim of this short narrative review was to evaluate the existing literature regarding the clinical use of ketamine among individuals with dementia, especially those with behavioral disturbances. PubMed, Cochrane, and Ovid (Embase, APA PsycINFO, and MEDLINE) databases were searched for abstracts using the search terms "ketamine" AND "dementia." Only articles describing the use of ketamine in individuals with dementia were included. Articles that did not include individuals with dementia, did not use ketamine, were published in a non-English language, primarily described animal studies, or were reviews were excluded. Three case reports met the inclusion criteria. One described the use of subcutaneous ketamine for depression, one described the use of intramuscular ketamine for acute agitation, and one described the use of S-ketamine as anesthesia during electroconvulsive therapy for depression and catatonia. No significant adverse effects were reported in any of the cases. Although the use of ketamine in the treatment of depression and agitation associated with dementia has potential, the current evidence remains limited. High-quality prospective studies are needed to confirm the observations of these case reports before ketamine can be used to treat behavioral disturbances in individuals with dementia.
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Demencia , Ketamina , Ketamina/uso terapéutico , Ketamina/administración & dosificación , Humanos , Demencia/tratamiento farmacológico , Depresión/tratamiento farmacológico , Agitación Psicomotora/tratamiento farmacológico , Terapia Electroconvulsiva/métodosRESUMEN
OBJECTIVE: This study began as a single-blind randomized controlled trial (RCT) to investigate the efficacy and safety of electroconvulsive therapy (ECT) for severe treatment-refractory agitation in advanced dementia. The aims are to assess agitation reduction using the Cohen-Mansfield Agitation Inventory (CMAI), evaluate tolerability and safety outcomes, and explore the long-term stability of agitation reduction and global functioning. Due to challenges encountered during implementation, including recruitment obstacles and operational difficulties, the study design was modified to an open-label format and other protocol amendments were implemented. METHODS: Initially, the RCT randomized participants 1:1 to either ECT plus usual care or simulated ECT plus usual care (S-ECT) groups. As patients were enrolled, data were collected from both ECT and simulated ECT (S-ECT) patients. The study now continues in an open-label study design where all patients receive actual ECT, reducing the targeted sample size from 200 to 50 participants. RESULTS: Study is ongoing and open to enrollment. CONCLUSION: The transition of the ECT-AD study design from an RCT to open-label design exemplifies adaptive research methodologies in response to real-world challenges. Data from both the RCT and open-label phases of the study will provide a unique perspective on the role of ECT in managing severe treatment-refractory agitation in dementia, potentially influencing future clinical practices and research approaches.
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Demencia , Terapia Electroconvulsiva , Agitación Psicomotora , Humanos , Terapia Electroconvulsiva/métodos , Agitación Psicomotora/terapia , Demencia/terapia , Demencia/complicaciones , Método Simple Ciego , Femenino , Masculino , Resultado del Tratamiento , Anciano , Conducta Motora Aberrante en la DemenciaRESUMEN
OBJECTIVE: 40-60% of persons living with dementia (PLWD) experience agitation and/or aggression symptoms. There is a need to understand the best method to detect agitation and/or aggression in PLWD. We aimed to identify agitation and/or aggression tools that are validated against a reference standard within the context of PLWD. METHODS: Our study was registered on PROSPERO (CRD42020156708). We searched MEDLINE, Embase, and PsycINFO up to April 22, 2024. There were no language or date restrictions. Studies were included if they used any tools or questionnaires for detecting either agitation or aggression compared to a reference standard among PLWD, or any studies that compared two or more agitation and/or aggression tools in the population. All screening and data extraction were done in duplicates. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data extraction was completed in duplicates by two independent authors. We extracted demographic information, prevalence of agitation and/or aggression, and diagnostic accuracy measures. We also reported studies comparing the correlation between two or more agitation and/or aggression tools. RESULTS: 6961 articles were screened across databases. Six articles reporting diagnostic accuracy measures compared to a reference standard and 30 articles reporting correlation measurements between tools were included. The agitation domain of the Spanish NPI demonstrated the highest sensitivity (100%) against the agitation subsection of the Spanish CAMDEX. Single-study evidence was found for the diagnostic accuracy of commonly used agitation scales (BEHAVE-AD, NPI and CMAI). CONCLUSIONS: The agitation domain of the Spanish NPI, the NBRS, and the PAS demonstrated high sensitivities, and may be reasonable for clinical implementation. However, a limitation to this finding is that despite an extensive search, few studies with diagnostic accuracy measurements were identified. Ultimately, more research is needed to understand the diagnostic accuracy of agitation and/or aggression detection tools among PLWD.
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Agresión , Demencia , Agitación Psicomotora , Humanos , Agresión/psicología , Agitación Psicomotora/diagnóstico , Agitación Psicomotora/psicología , Demencia/diagnóstico , Demencia/psicologíaRESUMEN
BACKGROUND We aimed to assess the effect of dexmedetomidine (Dex) combined with remifentanil on emergence agitation (EA) during awakening from sevoflurane anesthesia for pediatric liver surgery. MATERIAL AND METHODS Sixty children who underwent liver surgery in our hospital were prospectively selected and randomly allocated into group A (placebo+remifentanil+sevoflurane) or group B (Dex+remifentanil+sevoflurane). Mean arterial pressure (MAP) and heart rate (HR) at different time points, agitation score during awakening, behavioral status, pain level, and the incidence of postoperative adverse effects were compared in both groups. RESULTS Children in group B had lower HR and MAP levels immediately after tracheal extubation and 5 min after tracheal extubation than those in group A. The Aono's scores, PAED agitation scores, and CHIPP scores at 15 min and 30 min of admission to the PACU were lower in group B than in group A. The incidence of agitation during postoperative anesthesia awakening was lower in group B in contrast to group A. There was no significant difference in postoperative adverse reactions between group A and group B. CONCLUSIONS In pediatric liver surgery, the use of Dex+remifentanil+sevoflurane anesthesia can reduce the incidence of EA during the awakening period, stabilize hemodynamic levels, and relieve postoperative pain, and has fewer postoperative adverse effects, which warrants clinical application.
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Anestésicos por Inhalación , Dexmedetomidina , Delirio del Despertar , Remifentanilo , Sevoflurano , Humanos , Dexmedetomidina/administración & dosificación , Dexmedetomidina/uso terapéutico , Remifentanilo/administración & dosificación , Remifentanilo/uso terapéutico , Sevoflurano/administración & dosificación , Femenino , Masculino , Anestésicos por Inhalación/administración & dosificación , Anestésicos por Inhalación/efectos adversos , Preescolar , Delirio del Despertar/prevención & control , Delirio del Despertar/etiología , Delirio del Despertar/epidemiología , Estudios Prospectivos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/uso terapéutico , Lactante , Niño , Agitación Psicomotora/prevención & control , Agitación Psicomotora/etiología , Hígado/cirugía , Periodo de Recuperación de la Anestesia , Piperidinas/administración & dosificación , Piperidinas/uso terapéutico , Piperidinas/efectos adversos , Método Doble Ciego , Quimioterapia Combinada , Éteres Metílicos/administración & dosificación , Éteres Metílicos/efectos adversos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéuticoRESUMEN
OBJECTIVES: Datura stramonium , jimsonweed, is a toxic plant with hallucinogenic properties. Although there are many studies on Datura poisoning, none reported cases in Jordan. This study offers a comprehensive review on D. stramonium ingestion, covering its epidemiology, clinical presentation, and treatment. We aimed to provide better understanding of the factors for Datura ingestion, identify prevention and management strategies, and address research challenges. METHODS: This study adopted a retrospective review design to evaluate the cases of Datura poisoning in Al Karak, province of Jordan during the spring of 2022. Data collected from medical records, toxicology databases, and consultation records were analyzed using descriptive statistics. RESULTS: The common symptoms of Datura poisoning included agitation, mydriasis, and tachycardia. The management approaches comprised supportive care, administration of Diazepam for agitation, and, in some cases, neostigmine to counteract anticholinergic effects. CONCLUSIONS: Understanding the risks associated with D. stramonium poisoning and implementing effective prevention and management strategies are crucial. This study highlights the importance of recognizing Datura poisoning as a potential diagnosis in children presenting with unexplained anticholinergic symptoms or agitation to the emergency room.
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Datura stramonium , Humanos , Estudios Retrospectivos , Jordania/epidemiología , Niño , Datura stramonium/envenenamiento , Masculino , Femenino , Preescolar , Adolescente , Lactante , Intoxicación por Plantas/epidemiología , Midriasis/inducido químicamente , Agitación Psicomotora/epidemiología , Taquicardia/inducido químicamente , Taquicardia/epidemiología , Intoxicación/epidemiología , Intoxicación/terapiaRESUMEN
BACKGROUND: Remimazolam is an ultrashort-acting benzodiazepine. Few studies have evaluated the effects of remimazolam-based total intravenous anesthesia (TIVA) on emergence agitation (EA). This study aimed to compare the incidence and severity of EA between TIVA using remimazolam and desflurane. METHODS: This prospective randomized controlled study enrolled 76 patients who underwent nasal surgery under general anesthesia. Patients were randomized into two groups of 38 each: desflurane-nitrous oxide (N2O) (DN) and remimazolam-remifentanil (RR) groups. The same protocol was used for each group from induction to emergence, except for the use of different anesthetics during maintenance of anesthesia according to the assigned group: desflurane and nitrous oxide for the DN group and remimazolam and remifentanil for the RR group. The incidence of EA as the primary outcome was evaluated using three scales: Ricker Sedation-Agitation Scale, Richmond Agitation-Sedation Scale, and Aono's four-point agitation scale. Additionally, hemodynamic changes during emergence and postoperative sense of suffocation were compared. RESULTS: The incidence of EA was significantly lower in the RR group than in the DN group in all three types of EA assessment scales (all P < 0.001). During emergence, the change in heart rate differed between the two groups (P = 0.002). The sense of suffocation was lower in the RR group than in the DN group (P = 0.027). CONCLUSIONS: RR reduced the incidence and severity of EA in patients undergoing nasal surgery under general anesthesia. In addition, RR was favorable for managing hemodynamics and postoperative sense of suffocation.
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Anestesia General , Anestésicos por Inhalación , Benzodiazepinas , Desflurano , Delirio del Despertar , Procedimientos Quírurgicos Nasales , Humanos , Masculino , Femenino , Estudios Prospectivos , Desflurano/administración & dosificación , Anestesia General/métodos , Anestesia General/efectos adversos , Adulto , Persona de Mediana Edad , Delirio del Despertar/prevención & control , Delirio del Despertar/epidemiología , Anestésicos por Inhalación/administración & dosificación , Anestésicos por Inhalación/efectos adversos , Procedimientos Quírurgicos Nasales/efectos adversos , Procedimientos Quírurgicos Nasales/métodos , Benzodiazepinas/administración & dosificación , Remifentanilo/administración & dosificación , Periodo de Recuperación de la Anestesia , Agitación Psicomotora/prevención & control , Agitación Psicomotora/etiologíaRESUMEN
CONTEXT: Delirium is a significant concern in end-of-life care. Continuous monitoring of agitation levels using objective methods may have advantages over existing measurement scales. OBJECTIVES: To examine whether an objective measure of activity scores measured using a sheet-type non-wearable sensor (Nemuri SCAN [NSCAN]) was correlated with agitation levels measured using the modified Richmond Agitation-Sedation Scale (RASS) in terminally ill patients with cancer. METHODS: We conducted a single-center, prospective, observational study in a palliative care unit using the NSCAN to measure activity scores and the RASS to assess agitation levels. RASS scores were prospectively measured by ward nurses blinded to the NSCAN variables. A database was created to pair the RASS scores and activity scores at night on the same day. RESULTS: During the observation period, 1209 patients were hospitalized, and 3028 pairs of assessments of 971 patients were analyzed. The NSCAN activity scores significantly increased with increasing RASS scores (Jonckheere-Terpstra test, p < 0.001). The mean values of the activity scores for each RASS score were RASS -5, 28.9; RASS -4, 36.4; RASS -3, 41.7; RASS -2, 57.4; RASS -1, 58.8; RASS 0, 62.6; RASS 1, 79.6; RASS 2, 106.5; and RASS 3, 118.7. CONCLUSION: The NSCAN activity significantly correlated with modified RASS agitation scores. Real-time NSCAN data on agitation may aid timely interventions for optimal symptom control. To improve outcomes for patients suffering from terminal delirium, more research on monitoring tools is warranted.
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Delirio , Cuidados Paliativos , Agitación Psicomotora , Humanos , Delirio/diagnóstico , Masculino , Femenino , Estudios Prospectivos , Anciano , Persona de Mediana Edad , Cuidados Paliativos/métodos , Cuidado Terminal , Enfermo Terminal , Neoplasias/complicaciones , Anciano de 80 o más Años , Monitoreo Fisiológico/métodos , Monitoreo Fisiológico/instrumentaciónRESUMEN
BACKGROUND AND OBJECTIVES: Patient monitoring systems provide critical information but often produce loud, frequent alarms that worsen patient agitation and stress. This may increase the use of physical and chemical restraints with implications for patient morbidity and autonomy. This study analyzes how augmenting alarm thresholds affects the proportion of alarm-free time and the frequency of medications administered to treat acute agitation. METHODS: Our emergency department's patient monitoring system was modified on June 28, 2022 to increase the tachycardia alarm threshold from 130 to 150 and to remove alarm sounds for several arrhythmias, including bigeminy and premature ventricular beats. A pre-post study was performed lasting 55 days before and 55 days after this intervention. The primary outcome was change in number of daily patient alarms. The secondary outcomes were alarm-free time per day and median number of antipsychotic and benzodiazepine medications administered per day. The safety outcome was the median number of patients transferred daily to the resuscitation area. We used quantile regression to compare outcomes between the pre- and post-intervention period and linear regression to correlate alarm-free time with the number of sedating medications administered. RESULTS: Between the pre- and post-intervention period, the median number of alarms per day decreased from 1332 to 845 (-37%). This was primarily driven by reduced low-priority arrhythmia alarms from 262 to 21 (-92%), while the median daily census was unchanged (33 vs 32). Median hours per day free from alarms increased from 1.0 to 2.4 (difference 1.4, 95% CI 0.8-2.1). The median number of sedating medications administered per day decreased from 14 to 10 (difference - 4, 95% CI -1 to -7) while the number of escalations in level of care to our resuscitation care area did not change significantly. Multivariable linear regression showed a 60-min increase of alarm-free time per day was associated with 0.8 (95% CI 0.1-1.4) fewer administrations of sedating medication while an additional patient on the behavioral health census was associated with 0.5 (95% CI 0.0-1.1) more administrations of sedating medication. CONCLUSION: A reasonable change in alarm parameter settings may increase the time patients and healthcare workers spend in the emergency department without alarm noise, which in this study was associated with fewer doses of sedating medications administered.
Asunto(s)
Alarmas Clínicas , Servicio de Urgencia en Hospital , Agitación Psicomotora , Humanos , Masculino , Agitación Psicomotora/tratamiento farmacológico , Femenino , Persona de Mediana Edad , Antipsicóticos/uso terapéutico , Antipsicóticos/administración & dosificación , Adulto , Anciano , Benzodiazepinas/uso terapéutico , Benzodiazepinas/administración & dosificación , Monitoreo Fisiológico/métodos , Hipnóticos y Sedantes/uso terapéutico , Hipnóticos y Sedantes/administración & dosificaciónRESUMEN
BACKGROUND: Agitation/delirium is commonly seen in children after anesthesia, and a proper dose of dexmedetomidine can prevent this complication. This study aimed to investigate the effects of different doses of Dexmedetomidine (DEX) on agitation/delirium and other complications in anesthetized children, providing clinical evidence for dose recommendations of DEX. METHODS: This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search was conducted in the Cochrane Library, PubMed, Web of Science, and EMBASE. Two independent researchers performed literature screening, data extraction, and assessed the methodological quality. Data analysis was conducted using R and STATA 16.0. RESULTS: In the final analysis, 20 randomized controlled trials (RCTs) involving 2521 children were included. The results showed that in comparison to normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX significantly reduced the incidence of post-anesthetic emergence agitation in children with the most effective dose being 2 µg/kg (SUCRA = 0.91). Compared with normal saline, 1 µg/kg, 1.5 µg/kg, and 2 µg/kg intranasal DEX reduced patient's need for postoperative analgesia, with the most effective dose being 1.5 µg/kg (SUCRA = 0.78). However, 1 µg/kg DEX performed the best in reducing Pediatric Anaesthesia Emergence Delirium (PAED) Scale score (SUCRA = 0.88). CONCLUSION: Compared with normal saline, intranasal administration of 2 µg/kg DEX and 1.5 µg/kg DEX are the optimal doses to reduce the incidence of agitation and the need for postoperative pain relief in children under general anesthesia. Given effectiveness and safety, intranasal use of 1 µg/kg DEX appears to be the most effective dosage for anesthetized children.
Asunto(s)
Administración Intranasal , Dexmedetomidina , Relación Dosis-Respuesta a Droga , Hipnóticos y Sedantes , Dexmedetomidina/administración & dosificación , Dexmedetomidina/efectos adversos , Humanos , Niño , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Padres , Delirio del Despertar/prevención & control , Agitación Psicomotora/prevención & control , Agitación Psicomotora/etiología , Complicaciones Posoperatorias/prevención & control , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
PURPOSE: We evaluated impact on length of stay and possible complications of replacing the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale with a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) to support managing patients admitted with alcohol withdrawal symptoms in a community hospital. Since mRASS-AW is viewed as easier and quicker to use than CIWA-Ar, provided use of mRASS-AW does not worsen outcomes, it could be a safe alternative in a busy ED environment and offer an opportunity to release nursing time to care. METHODS: Retrospective time-series analysis of mean quarterly length of stay. All analyses exclusively used our hospital's administrative discharge diagnoses database. During April 1st 2012 to December 14th 2014, the CIWA-Ar was used in the ED and in-patient units to guide benzodiazepine dosing decisions for alcohol withdrawal symptoms. After this point, CIWA-Ar was replaced with mRASS-AW. Data was evaluated until December 31st 2020. PRIMARY OUTCOME: mean quarterly length of stay. SECONDARY OUTCOMES: delirium, intensive care unit (ICU) admission, other post-admission complications, mortality. RESULTS: N = 1073 patients. No association between length of stay and scale switch (slope change 0.3 (95% CI - 0.03 to 0.6), intercept change, 0.06 (- 0.03 to 0.2). CIWA-Ar (n = 317) mean quarterly length of stay, 5.7 days (95% 4.2-7.1), mRASS-AW (n = 756) 5.0 days (95% CI 4.3-5.6). Incidence of delirium, ICU admission or mortality was not different. However, incidence of other post-admission complications was higher with CIWA-Ar (6.6%) than mRASS-AW (3.4%) (p = 0.020). CONCLUSIONS: This was the first study to compare patient outcomes associated with using mRASS-AW for alcohol withdrawal symptoms outside the ICU. Replacing CIWA-Ar with mRASS-AW did not worsen length of stay or complications. These findings provide some evidence that mRASS-AW could be considered an alternative to CIWA-Ar and potentially may provide an opportunity to release nursing time to care.
ABSTRAIT: BUT: Nous avons évalué l'impact sur la durée du séjour et les complications possibles du remplacement de l'échelle Clinical Institute Withdrawal Assessment- Alcohol Revised (CIWA-Ar) par une échelle d'agitation et de sédation de Richmond légèrement modifiée (mRASS-AW) soutenir la prise en charge des patients admis avec des symptômes de sevrage d'alcool dans un hôpital communautaire. Étant donné que le mRASS-AW est considéré comme plus facile et plus rapide à utiliser que le CIWA-Ar, à condition que l'utilisation du mRASS-AW n'aggrave pas les résultats, il pourrait s'agir d'une solution de rechange sécuritaire dans un environnement de SU occupé et offrir une occasion de libérer du temps pour les soins infirmiers. MéTHODES: Analyse rétrospective de séries chronologiques de la durée moyenne trimestrielle du séjour. Toutes les analyses utilisaient exclusivement la base de données des diagnostics de sortie administrative de notre hôpital. Entre le 1er avril 2012 et le 14 décembre 2014, le CIWA-Ar a été utilisé dans les unités de soins intensifs et de soins aux patients hospitalisés pour guider les décisions de dosage des benzodiazépines pour les symptômes de sevrage de l'alcool. Après ce point, CIWA-Ar a été remplacé par mRASS-AW. Les données ont été évaluées jusqu'au 31 décembre 2020. Résultat principal : durée moyenne trimestrielle du séjour. Résultats secondaires : délire, admission en unité de soins intensifs (USI), autres complications post-admission, mortalité. RéSULTATS: N = 1073 patients. Aucune association entre la durée de séjour et le changement d'échelle (changement de pente 0,3 (IC à 95 % -0,03 à 0,6), changement d'interception, 0,06 (-0,03 à 0,2). CIWA-Ar (n = 317) durée moyenne trimestrielle du séjour, 5,7 jours (95 % 4,2 à 7,1), mRASS-AW (n = 756) 5,0 jours (95 % IC 4,3 à 5,6). L'incidence du délire, de l'admission aux soins intensifs ou de la mortalité n'était pas différente. Cependant, l'incidence d'autres complications post-admission était plus élevée avec CIWA-Ar (6,6%) que mRASS-AW (3,4%) (p = 0,020). CONCLUSIONS: Il s'agissait de la première étude à comparer les résultats des patients associés à l'utilisation du mRASS-AW pour les symptômes de sevrage alcoolique en dehors des soins intensifs. Le remplacement de CIWA-Ar par mRASS-AW n'a pas aggravé la durée du séjour ou les complications. Ces résultats fournissent certaines preuves que le mRASS-AW pourrait être considéré comme une alternative au CIWA-Ar et pourrait potentiellement fournir une occasion de libérer du temps de soins infirmiers.