Defining Sedation-Related Adverse Events in the Pediatric Intensive Care Unit

Background Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry. Objectives To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial. Methods In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates. Results We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy. Conclusions Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety

Outcomes Associated With Delirium in Older Patients in Surgical ICUs

BACKGROUND: We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients. METHODS: Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patients \u3eor= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument). RESULTS: Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p \u3c 0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82). CONCLUSIONS: Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home

An Exploration of Critical Care Professionals\u27 Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

OBJECTIVES: The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN: Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING: Sixty-eight academic, community, and federal ICUs. PARTICIPANTS: A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient\u27s) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS: In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation

A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes

Introduction: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. Method: We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described. Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies suc

Impact of a Multifaceted Early Mobility Intervention for Critically Ill Children - the PICU Up! Trial: Study Protocol for a Multicenter Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND: Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery. METHODS: The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial\u27s primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery. DISCUSSION: This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04989790. Registered on August 4, 2021

Improving a Mother to Child HIV Transmission Programme through Health System Redesign: Quality Improvement, Protocol Adjustment and Resource Addition

Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.All primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved (antenatal AZT increased from 74% to 86%, PMTCT clients on HAART at the time of labour increased from 10% to 25%, intrapartum AZT increased from 43% to 84%, and postnatal HIV testing from 79% to 95%) compared to baseline.System improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa

To which world regions does the valence–dominance model of social perception apply?

Over the past 10 years, Oosterhof and Todorov’s valence–dominance model has emerged as the most prominent account of how people evaluate faces on social dimensions. In this model, two dimensions (valence and dominance) underpin social judgements of faces. Because this model has primarily been developed and tested in Western regions, it is unclear whether these findings apply to other regions. We addressed this question by replicating Oosterhof and Todorov’s methodology across 11 world regions, 41 countries and 11,570 participants. When we used Oosterhof and Todorov’s original analysis strategy, the valence–dominance model generalized across regions. When we used an alternative methodology to allow for correlated dimensions, we observed much less generalization. Collectively, these results suggest that, while the valence–dominance model generalizes very well across regions when dimensions are forced to be orthogonal, regional differences are revealed when we use different extraction methods and correlate and rotate the dimension reduction solution.C.L. was supported by the Vienna Science and Technology Fund (WWTF VRG13-007); L.M.D. was supported by ERC 647910 (KINSHIP); D.I.B. and N.I. received funding from CONICET, Argentina; L.K., F.K. and Á. Putz were supported by the European Social Fund (EFOP-3.6.1.-16-2016-00004; ‘Comprehensive Development for Implementing Smart Specialization Strategies at the University of Pécs’). K.U. and E. Vergauwe were supported by a grant from the Swiss National Science Foundation (PZ00P1_154911 to E. Vergauwe). T.G. is supported by the Social Sciences and Humanities Research Council of Canada (SSHRC). M.A.V. was supported by grants 2016-T1/SOC-1395 (Comunidad de Madrid) and PSI2017-85159-P (AEI/FEDER UE). K.B. was supported by a grant from the National Science Centre, Poland (number 2015/19/D/HS6/00641). J. Bonick and J.W.L. were supported by the Joep Lange Institute. G.B. was supported by the Slovak Research and Development Agency (APVV-17-0418). H.I.J. and E.S. were supported by a French National Research Agency ‘Investissements d’Avenir’ programme grant (ANR-15-IDEX-02). T.D.G. was supported by an Australian Government Research Training Program Scholarship. The Raipur Group is thankful to: (1) the University Grants Commission, New Delhi, India for the research grants received through its SAP-DRS (Phase-III) scheme sanctioned to the School of Studies in Life Science; and (2) the Center for Translational Chronobiology at the School of Studies in Life Science, PRSU, Raipur, India for providing logistical support. K. Ask was supported by a small grant from the Department of Psychology, University of Gothenburg. Y.Q. was supported by grants from the Beijing Natural Science Foundation (5184035) and CAS Key Laboratory of Behavioral Science, Institute of Psychology. N.A.C. was supported by the National Science Foundation Graduate Research Fellowship (R010138018). We acknowledge the following research assistants: J. Muriithi and J. Ngugi (United States International University Africa); E. Adamo, D. Cafaro, V. Ciambrone, F. Dolce and E. Tolomeo (Magna Græcia University of Catanzaro); E. De Stefano (University of Padova); S. A. Escobar Abadia (University of Lincoln); L. E. Grimstad (Norwegian School of Economics (NHH)); L. C. Zamora (Franklin and Marshall College); R. E. Liang and R. C. Lo (Universiti Tunku Abdul Rahman); A. Short and L. Allen (Massey University, New Zealand), A. Ateş, E. Güneş and S. Can Özdemir (Boğaziçi University); I. Pedersen and T. Roos (Åbo Akademi University); N. Paetz (Escuela de Comunicación Mónica Herrera); J. Green (University of Gothenburg); M. Krainz (University of Vienna, Austria); and B. Todorova (University of Vienna, Austria). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.https://www.nature.com/nathumbehav/am2023BiochemistryGeneticsMicrobiology and Plant Patholog

A multi-country test of brief reappraisal interventions on emotions during the COVID-19 pandemic.

The COVID-19 pandemic has increased negative emotions and decreased positive emotions globally. Left unchecked, these emotional changes might have a wide array of adverse impacts. To reduce negative emotions and increase positive emotions, we tested the effectiveness of reappraisal, an emotion-regulation strategy that modifies how one thinks about a situation. Participants from 87 countries and regions (n = 21,644) were randomly assigned to one of two brief reappraisal interventions (reconstrual or repurposing) or one of two control conditions (active or passive). Results revealed that both reappraisal interventions (vesus both control conditions) consistently reduced negative emotions and increased positive emotions across different measures. Reconstrual and repurposing interventions had similar effects. Importantly, planned exploratory analyses indicated that reappraisal interventions did not reduce intentions to practice preventive health behaviours. The findings demonstrate the viability of creating scalable, low-cost interventions for use around the world

The course of delirium in older surgical intensive care unit patients

Delirium is one of the most frequent, dangerous, and costly complications associated with hospitalization in the older adult population. Prior studies on delirium, however, lacked data on the course of delirium in older adults admitted to Surgical Intensive Care Units (SICUs). Therefore, the objectives of this prospective, cohort study were to: (1) determine the frequency with which older adults admitted to SICUs have evidence of pre-existing delirium; (2) determine the frequency with which older adults develop delirium during their SICU stay and (3) examine the course, duration and characteristics of delirium throughout hospitalization. A secondary objective of this study was to compare delirious and nondelirious subjects with respect to hospital and SICU length of stay (LOS), mortality rates, post discharge institutionalization rates, and discharge functional and cognitive ability. The convenience sample included 114 subjects aged 65 and older admitted to the SICUs of a 672 bed university teaching hospital. Baseline characteristics were obtained through surrogate interviews and medical chart reviews. Subjects were screened for evidence of dementia and impairment in activities of daily living by using validated surrogate-rated instruments. Subjects were screened for delirium daily throughout their hospitalization. The subjects\u27 functional and cognitive ability and post-discharge institutionalization placement was assessed within 24 hours of hospital discharge. A considerable number (18.42%) of older adults were found to have evidence of dementia on admission to the SICU. This diagnosis was frequently unrecognized by both healthcare providers and the elders\u27 surrogates. While few elders were admitted to the SICU with evidence of pre-existing delirium (2.63%), a substantial number of older adults newly developed delirium during either their SICU (28.29%) or Post SICU (22.67%)stay. Episodes of deep sedation/unarousal occurred in 9.65% of the sample overall. Finally, older adults who experienced delirium in the SICU had significantly longer hospital and SICU LOS, more frequent discharge to institutional care, and decreased functional ability at hospital discharge than nondelirious elders. This study will serve as the first step in a program of research aimed at decreasing the morbidity associated with critical illness in the older adult population