Douleur, sédation et delirium : évaluation des patients sous sédation profonde aux soins intensifs

Introduction : Aux soins intensifs (SI), une sédation profonde peut être indiquée pour la gestion de la défaillance aiguë d’organes, mais une fois que le patient est non réactif, les cliniciens ne disposent pas d’outils validés pour évaluer la douleur, la profondeur de sédation et le delirium. La pupillométrie et l’électro-encéphalogramme (EEG) simplifié sont des nouveaux outils de mesures quantifiées prometteurs, mais très peu d’évidence est disponible quant à leur pertinence aux SI. Les objectifs étaient : 1) de valider la dilatation pupillaire comme mesure diagnostique de la douleur (mesures avant-pendant-après un soin (non-) douloureux) ; 2) d’identifier une potentielle relation entre la constriction pupillaire et la survenue de delirium ; 3) d’examiner une potentielle association entre un niveau de sédation très profonde (évalué par l’EEG simplifié) et la survenue de delirium.  Méthode : Ce projet de recherche a inclus trois études observationnelles. Les analyses principales ont été : 1) la différence de la moyenne du pourcentage de la dilatation pupillaire pendant une procédure nocive par rapport à avant ; 2) un modèle de régression logistique multivariable en entrant la constriction pupillaire au jour 3 comme variable d’intérêt, et le score SOFA jour 3, la dose cumulée de fentanyl et la dose cumulée de sédatifs comme co-variables ; 3) une analyse de régression multivariable avec le pourcentage de temps passé avec une sédation excessive comme variable d’intérêt et le fentanyl, le propofol et le midazolam cumulés comme co-variables. Résultats : Nos résultats suggèrent que les deux outils pourraient fournir des informations cliniques pertinentes. Les principaux constats sont que : 1) la dilatation pupillaire a augmenté pendant les procédures nocives par rapport à la ligne de base avec une différence moyenne de 31,66% ; 2) Après ajustement en fonction de la défaillance des organes (score SOFA) et de la dose cumulée d’analgésie et de sédation, les patients présentant une constriction pupillaire inférieure avaient un risque accru de développer un delirium des soins intensifs (OR 1,057; IC 95% 1,007-1,113) au jour 3 de la ventilation mécanique ; 3) après ajustement de la dose cumulée d’analgésie et de sédation, les patients avec une proportion de temps plus importante avec une sédation excessive entre le jour 1 et le jour 3 de la maladie critique étaient plus à risque de développer un delirium (OR 1,014; IC 95%  1,001-1,027). Discussion et conclusion : La pupillométrie et l’EEG simplifié sont des outils qui pourraient contribuer à l’amélioration de la gestion de la douleur, de la sédation et du delirium chez une population très à risque.Introduction : Aux soins intensifs (SI), une sédation profonde peut être indiquée pour la gestion de la défaillance aiguë d’organes, mais une fois que le patient est non réactif, les cliniciens ne disposent pas d’outils validés pour évaluer la douleur, la profondeur de sédation et le delirium. La pupillométrie et l’électro-encéphalogramme (EEG) simplifié sont des nouveaux outils de mesures quantifiées prometteurs, mais très peu d’évidence est disponible quant à leur pertinence aux SI. Les objectifs étaient : 1) de valider la dilatation pupillaire comme mesure diagnostique de la douleur (mesures avant-pendant-après un soin (non-) douloureux) ; 2) d’identifier une potentielle relation entre la constriction pupillaire et la survenue de delirium ; 3) d’examiner une potentielle association entre un niveau de sédation très profonde (évalué par l’EEG simplifié) et la survenue de delirium.  Méthode : Ce projet de recherche a inclus trois études observationnelles. Les analyses principales ont été : 1) la différence de la moyenne du pourcentage de la dilatation pupillaire pendant une procédure nocive par rapport à avant ; 2) un modèle de régression logistique multivariable en entrant la constriction pupillaire au jour 3 comme variable d’intérêt, et le score SOFA jour 3, la dose cumulée de fentanyl et la dose cumulée de sédatifs comme co-variables ; 3) une analyse de régression multivariable avec le pourcentage de temps passé avec une sédation excessive comme variable d’intérêt et le fentanyl, le propofol et le midazolam cumulés comme co-variables. Résultats : Nos résultats suggèrent que les deux outils pourraient fournir des informations cliniques pertinentes. Les principaux constats sont que : 1) la dilatation pupillaire a augmenté pendant les procédures nocives par rapport à la ligne de base avec une différence moyenne de 31,66% ; 2) Après ajustement en fonction de la défaillance des organes (score SOFA) et de la dose cumulée d’analgésie et de sédation, les patients présentant une constriction pupillaire inférieure avaient un risque accru de développer un delirium des soins intensifs (OR 1,057; IC 95% 1,007-1,113) au jour 3 de la ventilation mécanique ; 3) après ajustement de la dose cumulée d’analgésie et de sédation, les patients avec une proportion de temps plus importante avec une sédation excessive entre le jour 1 et le jour 3 de la maladie critique étaient plus à risque de développer un delirium (OR 1,014; IC 95%  1,001-1,027). Discussion et conclusion : La pupillométrie et l’EEG simplifié sont des outils qui pourraient contribuer à l’amélioration de la gestion de la douleur, de la sédation et du delirium chez une population très à risque

Determinants of Vaccination and Willingness to Vaccinate against COVID-19 among Pregnant and Postpartum Women during the Third Wave of the Pandemic: A European Multinational Cross-Sectional Survey.

With COVID-19 vaccination hesitancy at around 50% in the obstetric population, it is critical to identify which women should be addressed and how. Our study aimed to assess COVID-19 vaccination willingness among pregnant and postpartum women in Europe and to investigate associated determinants. This study was a cross-sectional, web-based survey conducted in Belgium, Norway, Switzerland, The Netherlands, and United Kingdom (UK) in June-August 2021. Among 3194 pregnant women, the proportions of women vaccinated or willing to be vaccinated ranged from 80.5% in Belgium to 21.5% in Norway. The associated characteristics were country of residence, chronic illness, history of flu vaccine, trimester of pregnancy, belief that COVID-19 is more severe during pregnancy, and belief that the COVID-19 vaccine is effective and safe during pregnancy. Among 1659 postpartum women, the proportions of women vaccinated or willing to be vaccinated ranged from 86.0% in the UK to 58.6% in Switzerland. The associated determinants were country of residence, chronic illness, history of flu vaccine, breastfeeding, and belief that the COVID-19 vaccine is safe during breastfeeding. Vaccine hesitancy in the obstetric population depends on medical history and especially on the opinion that the vaccine is safe and on the country of residence

Antidiabetic Medication Utilisation before and during Pregnancy in Switzerland between 2012 and 2019: An Administrative Claim Database from the MAMA Cohort.

BACKGROUND The incidence of diabetes mellitus (both pregestational and gestational) is increasing worldwide, and hyperglycemia during pregnancy is associated with adverse pregnancy outcomes. Evidence on the safety and efficacy of metformin during pregnancy has accumulated resulting in an increase in its prescription in many reports. AIMS We aimed to determine the prevalence of antidiabetic drug use (insulins and blood glucose-lowering drugs) before and during pregnancy in Switzerland and the changes therein during pregnancy and over time. METHODS We conducted a descriptive study using Swiss health insurance claims (2012-2019). We established the MAMA cohort by identifying deliveries and estimating the last menstrual period. We identified claims for any antidiabetic medication (ADM), insulins, blood glucose-lowering drugs, and individual substances within each class. We defined three groups of pattern use based on timing of dispensation: (1) dispensation of at least one ADM in the prepregnancy period and in or after trimester 2 (T2) (pregestational diabetes); (2) dispensation for the first time in or after T2 (GDM); and (3) dispensation in the prepregnancy period and no dispensation in or after T2 (discontinuers). Within the pregestational diabetes group, we further defined continuers (dispensation for the same group of ADM) and switchers (different ADM group dispensed in the prepregnancy period and in or after T2). RESULTS MAMA included 104,098 deliveries with a mean maternal age at delivery of 31.7. Antidiabetic dispensations among pregnancies with pregestational and gestational diabetes increased over time. Insulin was the most dispensed medication for both diseases. Between 2017 and 2019, less than 10% of pregnancies treated for pregestational diabetes continued metformin rather than switching to insulin. Metformin was offered to less than 2% of pregnancies to treat gestational diabetes (2017-2019). CONCLUSION Despite its position in the guidelines and the attractive alternative that metformin represents to patients who may encounter barriers with insulin therapy, there was reluctance to prescribe it

A systematic review of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal syndrome in pediatric intensive care

IntroductionThis systematic review aimed to evaluate the quality of clinical practice guidelines (CPGs) and recommendations for managing pain, sedation, delirium, and iatrogenic withdrawal syndrome in pediatric intensive care (PICU). The objectives included evaluating the quality of recommendations, synthesizing recommendations, harmonizing the strength of the recommendation (SoR) and the certainty of evidence (CoE), and assessing the relevance of supporting evidence.MethodsA comprehensive search in four electronic databases (Medline, Embase.com, CINAHL and JBI EBP Database), 9 guideline repositories, and 13 professional societies was conducted to identify CPGs published from January 2010 to the end of May 2023 in any language. The quality of CPGs and recommendations was assessed using the AGREE II and AGREE-REX instruments. Thematic analysis was used to synthesize recommendations, and the GRADE SoR and CoE harmonization method was used to interpret the credibility of summary recommendations.ResultsA total of 18 CPGs and 170 recommendations were identified. Most CPGs were of medium-quality, and three were classified as high. A total of 30 summary recommendations were synthesized across each condition, focused on common management approaches. There was inconsistency in the SoRs and CoE for summary recommendations, those for assessment showed the highest consistency, the remaining were conditional, inconsistent, inconclusive, and lacked support from evidence.ConclusionThis systematic review provides an overview of the quality of CPGs for these four conditions in the PICU. While three CPGs achieved high-quality ratings, the overall findings reveal gaps in the evidence base of recommendations, patient and family involvement, and resources for implementation. The findings highlight the need for more rigorous and evidence-based approaches in the development and reporting of CPGs to enhance their trustworthiness. Further research is necessary to enhance the quality of recommendations for this setting. The results of this review can provide a valuable foundation for future CPG development.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274364, PROSPERO (CRD42021274364)

COVID-19-related medicine utilization study in pregnancy: The COVI-PREG cohort

AIM The objective of this study was to describe the use of COVID-19-related medicines during pregnancy and their evolution between the early/late periods of the pandemic. METHODS Pregnant women who tested positive for SARS-CoV-2 from March 2020 to July 2021 were included using the COVI-PREG registry. Exposure to the following COVID-19-related medicines was recorded: antibiotics, antivirals, hydroxychloroquine, corticosteroids, anti-interleukin-6 and immunoglobulins. We described the prevalence of medicines used, by trimester of pregnancy, maternal COVID-19 severity level and early/late period of the pandemic (before and after 1 July 2020). FINDINGS We included 1964 pregnant patients who tested positive for SARS-CoV-2. Overall, 10.4% (205/1964) received at least one COVID-19-related medicine including antibiotics (8.6%; 169/1694), corticosteroids (3.2%; 62/1964), antivirals (2.0%; 39/1964), hydroxychloroquine (1.4%; 27/1964) and anti-interleukin-6 (0.3%; 5/1964). The use of at least one COVID-19-related medicine was 3.1% (12/381) in asymptomatic individuals, 4.2% (52/1233) in outpatients, 19.7% (46/233) in inpatients without oxygen, 72.1% (44/61) in those requiring standard oxygen, 95.7% (22/23) in those requiring high flow oxygen, 96.2% (25/26) in patients who required intubation and 57.1% (4/7) among patients who died. The proportion who received medicines to treat COVID-19 was higher before than after July 2020 (16.7% vs. 7.7%). Antibiotics, antivirals and hydroxychloroquine had lower rates of use during the late period. CONCLUSION Medicine use in pregnancy increased with disease severity. The trend towards increased use of corticosteroids seems to be aligned with changing guidelines. Evidence is still needed regarding the effectiveness and safety of COVID-19-related medicines in pregnancy

Datamama, bringing pregnancy research into the future: design, development, and evaluation of a citizen science pregnancy mobile application

Background: Pregnancy mobile applications (apps) have grown in popularity over the past decade, with some being used to promote study recruitment or health behaviors. However, no app serves as an all-in-one solution for collecting general data for research purposes and providing women with useful and desirable features. Aim: To create and develop a Swiss pregnancy mobile app as an innovative means to collect research data and provide users with reliable information. Methods: Determining the key features of the app involved a review of the literature and assessment of popular apps in the Swiss AppStore. A team of engineers developed the app, which includes a pregnancy timeline, questionnaires for data collection, medical and psychological articles and a checklist with appointment reminders. The content was written and reviewed by healthcare providers considered experts in the topics adressed. The questionnaires are distributed based on the user’s gestational age, by a chatbot. The project was authorized by the ethics commission in the canton of Vaud. An online survey of ten questions, advertised on Datamama’s home screen, was conducted to assess the users’ use of the app (27.11- 19.12.2022). Results: A review of 84 articles and 25 popular apps showed the need for a comprehensive pregnancy app. The development of Datamama took 2 years and included the creation of 70 medical and psychological articles and 29 questionnaires covering 300 unique variables. Six months after the launch, there were 800 users with a 73% average participation rate in the questionnaires. Sixty-five women completed the survey, with 70.8% using the app once to multiple times per week. The primary reason for using the app was to help research by answering the questionnaires, followed by access to reliable medical information. The reason most frequently ranked first for using the app was to help research by answering the questionnaires (42/65, 67% of women rated it first), followed by access to reliable medical information (34/65, 54% women rated it second). Women rated the information as clear, understandable, and interesting with a trust rating in data handling at 98.5%. The average grade for recommending the app was 8/10, with suggestions for increasing the amount of medical content and tailoring it based on gestational age. Conclusion: Datamama is the first pregnancy app to address the needs of both patients and researchers. Initial feedback from users was positive, highlighting future challenges for success. Future work will consist in improving the app, validating the data and use it to answer specific pregnancy-related research questions

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake