Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know.

ABSTRACT: Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.

Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures.

BACKGROUND: Rib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures. STUDY DESIGN: A pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs). RESULTS: Six hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006). CONCLUSION: The implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge. LEVEL OF EVIDENCE: Therapeutic/Care Management; level IV.

Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient.

Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patient's medication use and clinical status.

Evaluating pain, sedation, and delirium in the neurologically critically ill-feasibility and reliability of standardized tools: a multi-institutional study.

OBJECTIVES: To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population. DESIGN: Multicentered prospective observational study. SETTING: Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States). PATIENTS: A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012. INTERVENTIONS: Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to -4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items. MEASUREMENTS AND MAIN RESULTS: 151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay. CONCLUSIONS: Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.

Impact of a delirium screening tool and multifaceted education on nurses' knowledge of delirium and ability to evaluate it correctly.

BACKGROUND: The impact of using a validated delirium screening tool and different levels of education on surgical-trauma intensive care unit (STICU) nurses' knowledge about delirium is unclear. OBJECTIVES: To measure the impact of using the Intensive Care Delirium Screening Checklist (ICDSC), with or without a multi-faceted education program, on STICU nurses' knowledge and perceptions of delirium and their ability to evaluate it correctly. METHODS: The knowledge and perceptions of subject nurses about delirium, and agreement between the independent assessments of delirium by the subject nurse and by a validated judge (who always used the ICDSC), were compared across 3 phases. Phase 1: No delirium screening tool and no education. Phase 2: ICDSC and minimal education (ie, ICDSC validation study only). Phase 3: ICDSC and multifaceted education (ie, pharmacist-led didactic lecture, Web-based module, and nurse-led bedside training). RESULTS: Nurses' knowledge (mean [SD] score out of 10 points) was similar (P = .08) in phase 1 (6.1 [1.4]) and phase 2 (6.5 [1.4]) but was greater (P = .001) in phase 3 (8.2 [1.4]). Agreement between nurses and the validated judge in the assessment of delirium increased from phase 1 (κ = 0.40) to phase 2 (κ = 0.62) to phase 3 (κ = 0.74). Nurses perceived use of the ICDSC as improving their ability to recognize delirium. CONCLUSIONS: Use of a multifaceted education program improves both nurses' knowledge about delirium and their perceptions about its recognition. Implementation of the ICDSC improves the ability of STICU nurses to evaluate delirium correctly.

Diazepam as a component of goal-directed sedation in critically ill trauma patients.

PURPOSE: Limited information addressing the safety and efficacy of diazepam in the intensive care unit, particularly in trauma patients, is available. The purpose of this study is to evaluate the safety and efficacy of diazepam when used in routine clinical practice as a component of a goal-directed sedation regimen in critically ill trauma patients. MATERIAL AND METHODS: This is a prospective observational evaluation of adult trauma patients admitted to an intensive care unit with orders for as-needed midazolam or lorazepam followed by scheduled diazepam. Medication administration and Sedation-Agitation Scale scores were recorded. RESULTS: Twenty-four patients were evaluated. The most common diazepam dosage was 10 mg every 6 hours, and individual doses ranged from 5 to 30 mg. Sedation-Agitation Scale scores were recorded a median of 20 times per day (interquartile range, 15-24), and the majority (68%) were in the target range. No diazepam-related adverse events were observed. CONCLUSIONS: Based on this limited sample, the use of diazepam as a component of goal-directed therapy appears safe and effective in providing adequate sedation in critically ill trauma patients using an average dosage of 40 mg/d.

Skin and skin structure infections: treatment with newer generation fluoroquinolones.

Skin and skin structure infections (SSSI) are an emerging issue in healthcare. They are responsible for increasing heathcare utilization, both in hospitalizations and intravenous antibiotic use. SSSI are caused by an evolving variety of pathogens, including Gram-positive, Gram-negative, and anaerobic bacteria. In combination with mounting resistance patterns, this diverse range of bacteria mandate empiric broad-spectrum antibiotic coverage. Historically, cephalosporins and penicillins have been the mainstay of treatment, but recent data suggest newer generation fluoroquinolones are being used with increasing frequency. In 2005, moxifloxacin joined gatifloxacin and levofloxacin as newer generation fluoroquionolones with Food and Drug Administration indications for SSSIs. Even within this group there exist subtle differences that impact optimal management. This paper offers the clinician a comparative review of the antimicrobial spectrum, pharmacodynamics, pharmacokinetics, and clinical efficacy data to support the appropriate use of fluoroquinolones in SSSIs.