CASE REPORT: A 91 year old lady presented with an acute manic relapse for the past 2 weeks. She was previously on oral Sodium Valproate, and during this current admission was augmented with oral Quetiapine IR 100 mg bd. She remained unwell and was planned for right unilateral ECT with age-based dosing stimuli. After only 4 sessions, she showed complete resolution of her manic symptoms.
RESULT: In our case study, the patient showed rapid response to right unilateral ECT. Even though the Post Suppression Index (PSI) was not significant, there is some evidence that in elderly patients, burst suppression (not measured in this case) may be more accurate measure of ECT efficacy. The transient treatment emergent delirium was short lived and ECT was very tolerated in this patient.
CONCLUSION: Clinicians should not delay ECT in old-old patients who do not respond to pharmacologic treatment, as early switch to ECT results in rapid response with good safety profile.
BACKGROUND: Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools.
DESIGN: This study, performed in Malaysia, used a single-group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment.
METHODS: Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and postintervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance.
RESULTS: There were significant differences in the knowledge scores pre- and postintervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision-making" and "difficult to interpret delirium in intubated patients".
CONCLUSIONS: Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and interprofessional involvements are essential for a successful implementation of intensive care unit delirium assessment practice.
RELEVANCE TO CLINICAL PRACTICE: This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings.
AIMS: To investigate the effect of ketamine on emergence agitation in children.
METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were systematically searched from their start date until February 2019. Randomized controlled trials comparing intravenous ketamine and placebo in children were sought. The primary outcome was the incidence of emergence agitation. Secondary outcomes included postoperative pain score, duration of discharge time, and the adverse effects associated with the use of ketamine, namely postoperative nausea and vomiting, desaturation, and laryngospasm.
RESULTS: Thirteen studies (1125 patients) were included in the quantitative meta-analysis. The incidence of emergence agitation was 14.7% in the ketamine group and 33.3% in the placebo group. Children receiving ketamine had a lower incidence of emergence agitation, with an odds ratio being 0.23 (95% confidence interval: 0.11 to 0.46), certainty of evidence: low. In comparison with the placebo, ketamine group achieved a lower postoperative pain score (odds ratio: -2.42, 95% confidence interval: -4.23 to -0.62, certainty of evidence: very low) and lower pediatric anesthesia emergence delirium scale at 5 minutes after operation (odds ratio: -3.99, 95% confidence interval: -5.03 to -2.95; certainty of evidence: moderate). However, no evidence was observed in terms of incidence of postoperative nausea and vomiting, desaturation, and laryngospasm.
CONCLUSION: In this meta-analysis of 13 randomized controlled trials, high degree of heterogeneity and low certainty of evidence limit the recommendations of ketamine for the prevention of emergence agitation in children undergoing surgery or imaging procedures. However, the use of ketamine is well-tolerated without any notable adverse effects across all the included trials.
PROSPERO REGISTRATION: CRD42019131865.
DESIGN: Harmonized data from prospective multicenter international longitudinal cohort studies SETTING:: Diverse mix of ICUs.
PATIENTS: Critically ill patients expected to be ventilated for longer than 24 hours.
INTERVENTIONS: Richmond Agitation Sedation Scale and pain were assessed every 4 hours. Delirium and mobilization were assessed daily using the Confusion Assessment Method of ICU and a standardized mobility assessment, respectively.
MEASUREMENTS AND MAIN RESULTS: Sedation intensity was assessed using a Sedation Index, calculated as the sum of negative Richmond Agitation Sedation Scale measurements divided by the total number of assessments. We used multivariable Cox proportional hazard models to adjust for relevant covariates. We performed subgroup and sensitivity analysis accounting for immortal time bias using the same variables within 120 and 168 hours. The main outcome was 180-day survival. We assessed 703 patients in 42 ICUs with a mean (SD) Acute Physiology and Chronic Health Evaluation II score of 22.2 (8.5) with 180-day mortality of 32.3% (227). The median (interquartile range) ventilation time was 4.54 days (2.47-8.43 d). Delirium occurred in 273 (38.8%) of patients. Sedation intensity, in an escalating dose-dependent relationship, independently predicted increased risk of death (hazard ratio [95% CI], 1.29 [1.15-1.46]; p < 0.001, delirium hazard ratio [95% CI], 1.25 [1.10-1.43]), p value equals to 0.001 and reduced chance of early extubation hazard ratio (95% CI) 0.80 (0.73-0.87), p value of less than 0.001. Agitation level independently predicted subsequent delirium hazard ratio [95% CI], of 1.25 (1.04-1.49), p value equals to 0.02. Delirium or mobilization episodes within 168 hours, adjusted for sedation intensity, were not associated with survival.
CONCLUSIONS: Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation. These observations suggest that keeping sedation level equivalent to a Richmond Agitation Sedation Scale 0 is a clinically desirable goal.
METHODS: A retrospective review of the medical and surgical notes of 68 patients who underwent TOF repair in Hospital Serdang, from January 2013 to December 2017 was done. Univariate and multivariate analyses of demographics and perioperative clinical data were performed to determine the risk for the development of acute neurological complications (ANC) among these patients.
RESULTS: ANC was reported in 13 cases (19.1%) with delirium being the most common manifestation (10/68, 14.7%), followed by seizures in 4 (5.9%) and abnormal movements in two patients (2.9%). Univariate analyses showed that the presence of right ventricular (RV) dysfunction, prolonged duration of inotropic support (≥7 days), prolonged duration of mechanical ventilation (≥7 days), longer length of ICU stays (≥7 days), and longer length of hospital stay (≥14 days), were significantly associated with the presence of ANCs (p<0.05). However, multivariate analyses did not show any significant association between these variables and the development of ANC (p>0.05). The predictors for the development of postoperative delirium were pre-operative oxygen saturation less than 75% (Odds Ratio, OR=16.90, 95% Confidence Interval, 95%CI:1.36, 209.71) and duration of ventilation of more than 7 days (OR=13.20, 95%CI: 1.20, 144.98).
CONCLUSION: ANC following TOF repair were significantly higher in patients with RV dysfunction, in those who required a longer duration of inotropic support, mechanical ventilation, ICU and hospital stay. Low pre-operative oxygen saturation and prolonged mechanical ventilation requirement were predictors for delirium which was the commonest neurological complications observed in this study. Hence, routine screening for delirium using an objective assessment tool should be performed on these high-risk patients to enable accurate diagnosis and early intervention to improve the overall outcome of TOF surgery in this country.