An aromatherapy massage intervention on sleep in the ICU: A randomized controlled feasibility study.

We conducted a feasibility randomized controlled trial exploring the effect of aromatherapy massage on sleep in critically ill patients. Patients were randomized to receive aromatherapy massage or usual care, and feasibility of recruitment and outcome data completion was captured. Sleep (depth) was assessed through Bispectral Index monitoring and self/nurse-reported Richards-Campbell Sleep Questionnaires, and the Sleep in the ICU Questionnaire. Thirty-four patients participated: 17 were randomized to aromatherapy massage and 17 to control. Five participants who received the intervention completed outcomes for analysis (alongside eight controls). A larger study was deemed unfeasible in this population, highlighting the value of testing feasibility of complex interventions, such as massage for sleep in ICU.

Delayed neurologic sequelae resulting from epidemic diethylene glycol poisoning.

BACKGROUND: Diethylene glycol (DEG) is a well-known metabolic and renal toxin usually ingested accidentally as an ethanol substitute or as a contaminant in various medicinals. To date, most poisonings have occurred in third-world countries where early death from renal failure is very common. We report a series of seven patients presenting with epidemic DEG poisoning from a correctional facility with varying degrees of metabolic acidemia and acute renal impairment responding to emergent hemodialysis (HD). Significantly, three patients developed delayed neurologic toxicity which has not been well characterized in the past. CASE SERIES: Seven male patients (age range 19-55) presented over a 36 h period following ingestion of varying quantities of DEG. Initially three patients, ingesting the largest quantities of DEG, presented more than 24 h postingestion with severe metabolic acidemia (pH range 6.8-7.1) and anuric acute renal failure requiring HD. All three remained dialysis-dependent and developed significant cranial neuropathies with bulbar palsy in the second week postingestion. One patient died with cerebral oedema and a progressive encephalopathy. Two further patients presented within 24 h of ingestion with normal renal function and a moderate metabolic acidemia (pH range 7.2-7.28) requiring HD. They remained well. Finally, two further patients presented with a history of trivial DEG ingestion and did not require any therapy. Neurologic signs in the two surviving initial presenters improved over 4-6 months although they remained dialysis-dependent. CONCLUSION: Unrecognized DEG poisoning may present with metabolic acidemia and anuric acute renal failure. Established renal impairment may predict subsequent delayed neurologic toxicity.

Biasing effect of the electromyogram on BIS: a controlled study during high-dose fentanyl induction.

OBJECTIVE: A biasing effect of the electromyogram (EMG) on the Bispectral Index (BIS) may explain discrepancies in previous studies assessing BIS in the presence of neuromuscular activity. Our aims were: to evaluate variations of BIS in the presence of high EMG activity associated with muscular rigidity after administration of high-dose fentanyl; to compare muscular rigidity, as measured by the EMG variable of the BIS monitor, in patients who were administered two different dosages of fentanyl at induction of cardiac anaesthesia. METHODS: 26 patients undergoing CABG surgery, after premedication with morphine 0.15 mg/kg, were randomized to receive either fentanyl 50 mcg/kg (group F) or fentanyl 10 mcg/kg plus etomidate 0.2 mg/kg (group EF). The induction dose was administered over 2 minutes. Patients were manually ventilated with O2 via face mask. Five minutes after induction was complete, patients were clinically assessed using the Responsiveness portion of the Observer's Assessment of Alertness/Sedation scale (OAAS). Haemodynamic data were recorded and arterial blood samples obtained at the time of OAAS observation. Patients were administered a neuromuscular blocking agent only after the OAAS assessment. BIS (3.4) was recorded from an A-2000 EEG monitor (Aspect Medical Systems) using disposable sensors (BIS Sensor, Aspect Medical Systems) applied per manufacturer's instructions. Data were recorded on a PC for off-line analysis. RESULTS: At the time of OAAS observation, mean (95% CI) BIS in group F was 85 (77-92) compared to 67 (56-79) in group EF (p = 0.01). Similarly, mean (95% CI) EMG was 50 dB (45-56) in F and 41 dB (35-47) in EF (p = 0.01). Correlation between BIS and EMG was very high (r2 = 0.88). OAAS scores were significantly higher in group F (p = 0.03). Non significant correlation was observed between BIS and OAAS scores (r2 = 0.32, p = 0.1). Backward stepwise multiple regression analysis including EMG, pH, CO2, O2 and OASS scores showed EMG as strong predictor of BIS (p < 0.0001, r2 = 0.7). Regression of EMG against BIS yielded the equation: BIS = 3.7 + (1.6 x EMG). CONCLUSION: During fentanyl-induced muscular rigidity BIS recordings reflect EMG variations. When assessing BIS in the absence of neuromuscular blockade, it is necessary to evaluate the effect of EMG on BIS before making conclusions about depth of sedation. Fentanyl-induced rigidity appears to be a dose-related phenomenon which the EMG variable of BIS 3.4 is able to quantify.