Bashar, Farshid R.

Khan, Abbas M.

Miller, Andrew C.

Vahedianâ€‘Azimi, Amir

English

ScholarShip

Vahedian‑Azimi et al. Ann. Intensive Care           (2020) 10:15  https://doi.org/10.1186/s13613‑020‑0630‑8LETTER TO THE EDITORNatural versus artificial light exposure on delirium incidence in ARDS patientsAmir Vahedian‑Azimi1 , Farshid R. Bashar2 , Abbas M. Khan3  and Andrew C. Miller3,4* Keywords: Natural light, Delirium, Intensive care unit, ARDS© The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.We read with interest the study by Smonig et al. on the impact of natural light (NL) exposure on delirium-asso-ciated outcomes in mechanically ventilated (MV) inten-sive care unit (ICU) patients [1]. In this single-center, prospective, observational study, the authors report an improvement in the secondary outcomes of hallucina-tion incidence and haloperidol administration for agita-tion. No difference in delirium incidence or duration, MV duration, self-extubation, ICU or hospital length-of-stay (LOS), or mortality was observed [1]. We request clari-fication on whether the cumulative doses of haloperidol differed.Smonig’s findings differ from our observations. We have conducted a longitudinal cohort study of 16,000 ICU patients with acute respiratory distress syndrome (ARDS) on MV from 21 ICUs (10 mixed, 5 surgical, 6 medical) from 6 academic medical centers [2, 3]. Here, we report the results of a retrospective secondary anal-ysis of 4200 patients from the mixed medical–surgical ICUs of two academic hospitals to assess the impact of NL exposure on delirium incidence. Each ICU had the same layout including 10 beds; 5 with adjacent windows allowing for NL (circadian pattern), and 5 positioned 13 m from the nearest window (artificial light: AL). Delir-ium was defined according to the DSM-IV-TR [4], and was assessed three times daily by the bedside nurse and researcher (kappa agreement coefficient 0.801–0.902) using the Confusion Assessment Method for the ICU (CAM-ICU) [5]. We performed both unadjusted and adjusted logistic regression accounting for: year, diag-nosis, age, sex, vital signs, illness severity (APACHE-II score), development of ventilator-associated pneumonia, microbiology results, presence of an multiple drug resist-ant pathogens, MV duration, LOS (ICU, hospital), and survival. We found that AL patients had a 2.35- and 2.39-times greater incidence of delirium by unadjusted and adjusted logistic regression, respectively.Methodological differences in delirium definition, screening method and frequency, criteria for NL group, and population studied may contribute to the outcome heterogeneity across studies (Table 1) [1, 6–9]. Six stud-ies utilized a validated delirium screening tool (Table 1), whereas one did not [8], and one included (as a posi-tive) any patient treated with haloperidol (regardless of screen result) [6]. Furthermore, two studies required a positive delirium screen on ≥ 2 consecutive days to be classified as delirium [1, 7]. Moreover, the light expo-sure definitions vary considerably across studies. Three studies compare patients in rooms with or without win-dows [1, 7, 8], whereas in two studies, all patients have NL exposure to differing degrees [6, 9]. The assessed patient populations differ as well. Whereas we found improved delirium outcomes in ARDS patients, who often have greater illness severity and longer ICU LOS than the general ICU patient population, no difference was observed in other ICU populations [1, 6–8]. Our data suggest that further investigation in defined ICU sub-populations may provide an opportunity to bet-ter identify those likely to benefit from NL exposure. Such studies should capitalize on transparency using clear and reproducible of key variables including the definitions of delirium and NL exposure. Based on the Open Access*Correspondence:  Taqwa1@gmail.com; MillerAndr17@ecu.edu4 Department of Emergency Medicine, East Carolina University Brody School of Medicine, 600 Moye Blvd, Mailstop 625, Greenville, NC 27834, USAFull list of author information is available at the end of the articlePage 2 of 3Vahedian‑Azimi et al. Ann. Intensive Care           (2020) 10:15 current level of evidence, it would be premature to dis-card a therapeutic role for NL exposure in critically ill patients.AbbreviationsAL: Artificial light; ARDS: Acute respiratory distress syndrome; CAM‑ICU: Confu‑sion Assessment Method for the ICU; ICU: Intensive care unit; LOS: Length‑of‑stay; MV: Mechanical ventilation; NL: Natural light.AcknowledgementsNone.Authors’ contributionsThe authors that contributed to study design were AVA, FRB and ACM. Study implementation and data abstraction was performed by AVA and FRB. Data analysis was performed by AVA and ACM. Manuscript writing and revision were performed by ACM AMK, and AVA. All authors read and approved the final manuscript.Authors’ informationDr. Miller is trained in Emergency Medicine, Internal Medicine, Pulmonary Medicine and Critical Care. He is an Associate Professor of Emergency Medi‑cine at East Carolina University and founder of the MORZAK Collaborative, a platform through which he mentors and facilitates international clinical investigations. He is on the Board of Directors for the American College of Academic International Medicine, and a founding Board Member of the Accreditation Council for International Medical Programs.FundingThe authors have received no specific funding for this work.Availability of data and materialsAll data generated or analyzed during this study are included in this article.Ethics approval and consent to participateThe parent study was approved by the Investigational Review Board at Baqi‑yatallah University of Medical Sciences (IR.BMSU.REC.1394.451). For the parent study, surrogate consent from the patient’s legal guardian or designated health proxy was permitted in cases where the patient did not have decision‑making capacity. All patients that survived and regained their faculties were informed of the project.Consent for publicationThe informed consent included permission to present and publish de‑identi‑fied results.Competing interestsThe authors declare that they have no competing interests.Author details1 Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran. 2 Anesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran. 3 The MORZAK Collaborative, Greenville, NC, USA. 4 Department of Emergency Medicine, East Carolina University Brody School of Medicine, 600 Moye Blvd, Mailstop 625, Greenville, NC 27834, USA. Received: 12 December 2019   Accepted: 23 January 2020References 1. Smonig R, Magalhaes E, Bouadma L, et al. Impact of natural light expo‑sure on delirium burden in adult patients receiving invasive mechanical ventilation in the ICU: a prospective study. Ann Intensive Care. 2019;9:120. 2. Bashar FR, Vahedian‑Azimi A, Hajiesmaeili M, et al. Post‑ICU psychological morbidity in patients with ARDS and delirium. J Crit Care. 2018;43(2):88–94. https ://doi.org/10.1016/j.jcrc.2017.08.034.Table 1 Design heterogeneity in studies on the effects of natural light exposure on patients in the intensive care unitARDS acute respiratory distress syndrome, CAM-ICU confusion assessment method for the ICU, DSM Diagnostic and Statistical Manual of Mental Disorders, ICDSC Intensive Care Delirium Screening Checklist, MV mechanical ventilationa To achieve a power of power 80% to detect a decrease of delirium from 80 to 60% (two‑sided test, alpha = 0.05), the necessary sample size is 180 patients [1] would be necessaryb Delirium categorization included any patient treated with haloperidol, regardless of CAM‑ICU screenc Required a positive screen for at least 2 consecutive days to be considered positived Less haloperidol administration; less hallucinationsAuthor (reference)Design (N) Sample size calculationDelirium definitionScreening tool Screen frequency (no./day)ICU patient populationDelirium incidence or severity with NL exposureOur study Retrospective analysis of pro‑spective study (181)Yesa DSM‑IV‑TR CAM‑ICU 3 Long stay medical and surgical with ARDSDecreasedArenson [6] Retrospective (1010)No Not reported CAM‑ICU 3 Post‑operative No changeEstrup [5] Retrospective (183)No Not reported CAM‑ICUb 2 Unspecified No changeKohn [7] Retrospective (6631)No Not reported Nonec 1 Medical ICU patientsNo changeSmonig [1] Prospective, obser‑vational (195)Yesa Not reported ICDSCc 2 On MV of any eti‑ology/durationNo  changedZaal [8] Prospective, before–after (130)No Not reported CAM‑ICU 1 Medical and surgicalNo changePage 3 of 3Vahedian‑Azimi et al. Ann. Intensive Care           (2020) 10:15   3. Farzanegan B, Elkhatib THM, Elgazzar AE, et al. Impact of religiosity on delirium severity among critically ill Shi’a muslims: a prospective multi‑center observational study. J Relig Health. 2019. https ://doi.org/10.1007/s1094 3‑019‑00895 ‑7 (Epub ahead of print). 4. Diagnostic and statistical manual of mental disorders (DSM‑IV‑TR) fourth edition (text revision). 4th ed. Washington, D.C.: American Psychiatry Association Publishing, 2000. 5. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the confusion assessment method for the intensive care unit (CAM‑ICU). Crit Care Med. 2001;29:1370–9. 6. Estrup S, Kjer CKW, Poulsen LM, et al. Delirium and effect of circadian light in the intensive care unit: a retrospective cohort study. Acta Anaesthesiol Scand. 2018;62:367–75. 7. Arenson BG, MacDonald LA, Grocott HP, et al. Effect of intensive care unit environment on in‑hospital delirium after cardiac surgery. J Thorac Cardiovasc Surg. 2013;146:172–8. 8. Kohn R, Harhay MO, Cooney E, et al. Do windows or natural views affect outcomes or costs among patients in ICUs? Crit Care Med. 2013;41:1645–55. 9. Zaal IJ, Spruyt CF, Peelen LM, et al. Intensive care unit environment may affect the course of delirium. Intensive Care Med. 2013;39:481–8.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in pub‑lished maps and institutional affiliations.Reproduced with permission of copyright owner. Further reproductionprohibited without permission.

Natural versus artifcial light exposure on delirium incidence in ARDS patients

https://thescholarship.ecu.edu/bitstream/10342/7807/1/out.pdf

Natural versus artifcial light exposure on delirium incidence in ARDS patients

Abstract

Similar works

Full text

Available Versions

ScholarShip

ScholarShip