Pain and Its Long-term Interference of Daily Life After Critical Illness.

BACKGROUND: Persistent pain likely interferes with quality of life in survivors of critical illness, but data are limited on its prevalence and risk factors. We sought to determine the prevalence of persistent pain after critical illness and its interference with daily life. Additionally, we sought to determine if intensive care unit (ICU) opioid exposure is a risk factor for its development. METHODS: In a cohort of adult medical and surgical ICU survivors, we used the brief pain inventory (BPI) to assess pain intensity and pain interference of daily life at 3 and 12 months after hospital discharge. We used proportional odds logistic regression with Bonferroni correction to evaluate the independent association of ICU opioid exposure with BPI scores, adjusting for potential confounders including age, preadmission opioid use, frailty, surgery, severity of illness, and durations of delirium and sepsis while in the ICU. RESULTS: We obtained BPI outcomes in 295 patients overall. At 3 and 12 months, 77% and 74% of patients reported persistent pain symptoms, respectively. The median (interquartile range) pain intensity score was 3 (1, 5) at both 3 and 12 months. Pain interference with daily life was reported in 59% and 62% of patients at 3 and 12 months, respectively. The median overall pain interference score was 2 (0, 5) at both 3 and 12 months. ICU opioid exposure was not associated with increased pain intensity at 3 months (odds ratio [OR; 95% confidence interval], 2.12 [0.92-4.93]; P = .18) or 12 months (OR, 2.58 [1.26-5.29]; P = .04). ICU opioid exposure was not associated with increased pain interference of daily life at 3 months (OR, 1.48 [0.65-3.38]; P = .64) or 12 months (OR, 1.46 [0.72-2.96]; P = .58). CONCLUSIONS: Persistent pain is prevalent after critical illness and frequently interferes with daily life. Increased ICU opioid exposure was not associated with worse pain symptoms. Further studies are needed to identify modifiable risk factors for persistent pain in the critically ill and the effects of ICU opioids on patients with and without chronic pain.

Evaluating early administration of the hydroxymethylglutaryl-CoA reductase inhibitor simvastatin in the prevention and treatment of delirium in critically ill ventilated patients (MoDUS trial): study protocol for a randomized controlled trial.

BACKGROUND: The incidence of delirium in ventilated patients is estimated at up to 82%, and it is associated with longer intensive care and hospital stays, and long-term cognitive impairment and mortality. The pathophysiology of delirium has been linked with inflammation and neuronal apoptosis. Simvastatin has pleiotropic properties; it penetrates the brain and, as well as reducing cholesterol, reduces inflammation when used at clinically relevant doses over the short term. This is a single centre randomised, controlled trial which aims to test the hypothesis that treatment with simvastatin will modify delirium incidence and outcomes. METHODS/DESIGN: The ongoing study will include 142 adults admitted to the Watford General Hospital Intensive Care Unit who require mechanical ventilation in the first 72 hours of admission. The primary outcome is the number of delirium- and coma-free days in the first 14 days. Secondary outcomes include incidence of delirium, delirium- and coma-free days in the first 28 days, days in delirium and in coma at 14 and 28 days, number of ventilator-free days at 28 days, length of critical care and hospital stay, mortality, cognitive decline and healthcare resource use. Informed consent will be taken from patient's consultee before randomisation to receive either simvastatin (80 mg) or placebo once daily. Daily data will be recorded until day 28 after randomisation or until discharge from the ICU if sooner. Surviving patients will be followed up on at six months from discharge. Plasma and urine samples will be taken to investigate the biological effect of simvastatin on systemic markers of inflammation, as related to the number of delirium- and coma-free days, and the potential of cholinesterase activity and beta-amyloid as predictors of the risk of delirium and long-term cognitive impairment. DISCUSSION: This trial will test the efficacy of simvastatin on reducing delirium in the critically ill. If patients receiving the statin show a reduced number of days in delirium compared with the placebo group, the inflammatory theory implicated in the pathogenesis of delirium will be strengthened. TRIAL REGISTRATION: The trial was registered with the International Standard Randomised Controlled Trial Registry ( ISRCTN89079989 ) on 26 March 2013.

Delirium-O-Meter: a nurses' rating scale for monitoring delirium severity in geriatric patients.

BACKGROUND: Delirium is a common psychiatric disorder in general hospital elderly patients. Several delirium screening tests exist. Few nurse based delirium severity measures are available. The aim of this study was to evaluate the Delirium-O-Meter, a new nurses' behavioural rating scale that is an efficient and sensitive measure of delirium severity. METHODS: Analysis of cross sectional and repeated assessments data. Participants were 92 elderly general hospital patients; 56 with delirium, 24 with dementia or other cognitive disturbances (no delirium) and 12 with other psychiatric disorders or no mental disorder. Measures were the Delirium-O-Meter (DOM), Delirium Rating Scale-Revised version (DRS-R-98), Delirium Observation Scale (DOS), Behavioural observation scale for geriatric inpatients (GIP) and Mini Mental State Examination (MMSE). RESULTS: The majority of DOM items show a (near-) normal score distribution. Reliability of the DOM was high; Cronbach's alpha values ranged from 0.87-0.92; Intra Class Correlation (ICC) range was 0.84-0.91 for total scores and 0.40-0.97 for item scores. Factor analysis produced a 'Cognitive/Motivational' factor explaining almost half of variance and a smaller 'Psychotic/Behavioural' factor. The two-factor model results support the conceptual distinction between hyperactive and hypoactive delirium. DOM observations differentiated delirium from non delirium patients. DOM total scores were highly related to the DRS-R-98, DOS, MMSE and GIP apathy and cognitive sub scales, but less so to the GIP affective disturbances subscale, indicating convergent and divergent validity. Temporal difference scores calculated for DRS-R-98 and DOM assessments on subsequent days were also highly related (rho = 0.80-0.95). CONCLUSIONS: The newly constructed DOM is a brief and valid nurses' behavioural rating scale that can be useful for measuring different aspects of delirium and for efficiently monitoring delirium severity in elderly patients.