A Screening, Prevention, and Restoration model for saving the injured brain in intensive care unit survivors

Center for Health Services Research, Department of Medicine, Vanderbilt School of Medicine, Nashville, TN, USA.
Critical care medicine (Impact Factor: 6.31). 10/2010; 38(10 Suppl):S683-91. DOI: 10.1097/CCM.0b013e3181f245d3
Source: PubMed


We face a profound and emerging public health problem in the form of acute and chronic brain dysfunction. This affects both young and elderly intensive care unit survivors and is altering the landscape of society. Two-thirds of intensive care unit patients develop delirium, and this is associated with longer stays, increased costs, and excess mortality. In addition, over half of intensive care unit survivors suffer a dementia-like illness that impacts their physical and cognitive functional abilities and which appears to be related to the duration of their intensive care unit delirium. A new paradigm of how intensivists handle the brain is required. We propose a three-step approach to address this emerging epidemic, which includes Screening, Prevention, and Restoration of brain function (SPR). Screening combines risk factor identification and delirium assessment using validated instruments. Prevention of acute and chronic brain dysfunction requires implementation of a core model of care that combines evidence-based practices: awakening and breathing, coordination with target-based sedation, delirium monitoring, and exercise/early mobility (ABCDE). Restoration introduces strategies of ongoing screening and treatment for intensive care unit survivors at high risk of ongoing brain dysfunction. This practical system applying many evidence-based concepts incorporates personalized medicine, systems-based practice, and continuing research and development toward improving acute and chronic cognitive outcomes.

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Available from: Eduard E Vasilevskis, Oct 10, 2015
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    • "The utilization of dexmedetomidine for sedation, however, has been shown to decrease duration of brain organ dysfunction when compared with benzodiazepines in medical and surgical ICU populations.58,59 A liberation and animation strategy focusing on the ABCDE’s [Awakening and Breathing trials (AB), Choice of sedation (C), Delirium monitoring and management (D), and early Exercise (E)] may potentially reduce the incidence and duration of acute and long-term brain dysfunction.90 "
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    ABSTRACT: Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.
    Clinical Pharmacology: Advances and Applications 10/2012; 4(1):53-63. DOI:10.2147/CPAA.S26582
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    • "We previously published a study showing that a protocol of no sedation reduced the time patients received mechanical ventilation and reduced the intensive care and total hospital length of stay [7]. Concerns have been raised that our method with only bolus doses of morphine and no sedation carries a higher risk of psychological trauma than does standard care with sedation [8-10]. A study investigating the psychological effects of a no-sedation strategy has been warranted [8-10]. "
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    ABSTRACT: A protocol of no sedation has been shown to reduce the time patients receive mechanical ventilation and to reduce intensive care and total hospital length of stay. The long-term psychological effects of this strategy have not yet been described. The purpose of the study was to test whether a strategy of no sedation alters long-term psychological outcome compared with a standard strategy with sedation. During intensive care stay, 140 patients requiring mechanical ventilation were randomized to either no sedation or sedation with daily interruption of sedation. This study was done as a single-blinded cohort study. After discharge, patients were interviewed by a neuropsychologist assessing quality of life, depression, anxiety, and posttraumatic stress disorder. Two years after randomization, 38 patients were eligible for interview, and 26 patients were interviewed (13 from each group). No difference was found with respect to quality of life (Medical Outcome Study, 36-item short-form health survey). Both mental and physical components were nonsignificant. The Beck depression index was low in both groups (one patient in intervention group versus three patients in the control group were depressed, p = 0.32). Evaluated with the Impact of Events Scale, both groups had low stress scores (one in the intervention group versus two in the control group had scores greater than 32; p = 0.50). State anxiety scores were also low (28 in the control group versus 30 in the intervention group, p = 0.58). Our data suggest that a protocol of no sedation applied to critically ill patients undergoing mechanical ventilation does not increase the risk of long-term psychological sequelae after intensive care compared with standard treatment with sedation.
    Critical care (London, England) 12/2011; 15(6):R293. DOI:10.1186/cc10586 · 4.48 Impact Factor
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    ABSTRACT: To describe the reliability and sustainability of delirium and sedation measurements of bedside intensive care unit (ICU) nurses. Prospective cohort study. A tertiary care academic medical center. Five hundred ten ICU patients from 2007 to 2010; 627 bedside nurses. Bedside nurses and well-trained reference-rater research nurses independently measured delirium and sedation levels in routine care. Bedside nurses were instructed to use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) every 12 hours to measure delirium and the Richmond Agitation-Sedation Scale (RASS) every 4 hours to measure sedation. CAM-ICU and RASS assessment agreement were computed using weighted kappa statistics across the entire population and subgroups (e.g., ICU type). Sensitivity and specificity of bedside nurse identification of delirium were calculated to understand sources of discordance. Six thousand one hundred ninety-eight CAM-ICU and 6,880 RASS measurement pairs obtained on 3,846 patient-days. For CAM-ICU measurements, agreement between bedside and research nurses was substantial (weighted kappa = 0.67, 95% confidence interval (CI) = 0.66-0.70) and stable over 3 years of data collection. RASS measures also demonstrated substantial agreement (weighted kappa = 0.66, 95% CI = 0.64-0.68), which was stable across all years of data collection. The sensitivity of delirium nurse assessments was 0.81 (95% CI = 0.78-0.83), and the specificity was 0.81 (95% CI = 0.78-0.85). Bedside nurse measurements of delirium and sedation are sustainable and reliable sources of information. These measures can be used for clinical decision-making, quality improvement, and quality measurement activities.
    Journal of the American Geriatrics Society 11/2011; 59 Suppl 2(s2):S249-55. DOI:10.1111/j.1532-5415.2011.03673.x · 4.57 Impact Factor
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