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Objectives: To summarize the effectiveness of implementation strategies for ICU execution of recommendations from the 2013 Pain, Agitation/Sedation, Delirium (PAD) or 2018 PAD, Immobility, Sleep Disruption (PADIS) guidelines., Data Sources: PubMed, CINAHL, Scopus, and Web of Science were searched from January 2012 to August 2023. The protocol was registered with PROSPERO (CRD42020175268)., Study Selection: Articles were included if: 1) design was randomized or cohort, 2) adult population evaluated, 3) employed recommendations from greater than or equal to two PAD/PADIS domains, and 4) evaluated greater than or equal to 1 of the following outcome(s): short-term mortality, delirium occurrence, mechanical ventilation (MV) duration, or ICU length of stay (LOS)., Data Extraction: Two authors independently reviewed articles for eligibility, number of PAD/PADIS domains, quality according to National Heart, Lung, and Blood Institute assessment tools, implementation strategy use (including Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment [ABCDEF] bundle) by Cochrane Effective Practice and Organization of Care (EPOC) category, and clinical outcomes. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation., Data Synthesis: Among the 25 of 243 (10.3%) full-text articles included ( n = 23,215 patients), risk of bias was high in 13 (52%). Most studies were cohort ( n = 22, 88%). A median of 5 (interquartile range [IQR] 4-7) EPOC strategies were used to implement recommendations from two (IQR 2-3) PAD/PADIS domains. Cohort and randomized studies were pooled separately. In the cohort studies, use of EPOC strategies was not associated with a change in mortality (risk ratio [RR] 1.01; 95% CI, 0.9-1.12), or delirium (RR 0.92; 95% CI, 0.82-1.03), but was associated with a reduction in MV duration (weighted mean difference [WMD] -0.84 d; 95% CI, -1.25 to -0.43) and ICU LOS (WMD -0.77 d; 95% CI, -1.51 to 0.04). For randomized studies, EPOC strategy use was associated with reduced mortality and MV duration but not delirium or ICU LOS., Conclusions: Using multiple implementation strategies to adopt PAD/PADIS guideline recommendations may reduce mortality, duration of MV, and ICU LOS. Further prospective, controlled studies are needed to identify the most effective strategies to implement PAD/PADIS recommendations., Competing Interests: Dr. Devlin disclosed he has received research funding from BioExcel, Sedana Medical, and the National Institute of Aging (R13185760, R33HL23452, and R21/R33 AG05797) and that he serves as a consultant to BioExcel, La Jolla Pharmaceuticals, and Ceribell. Dr. Kane-Gill received funding from the Society of Critical Care Medicine. The remaining authors have disclosed that they do not have any potential conflict of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Purpose: Conflicting data exists on the pharmacologic management of intensive care unit (ICU) delirium. This review appraises the current evidence of pharmacologic management of ICU delirium., Materials and Methods: A systematic literature search of MEDLINE and Embase was conducted to answer the population, intervention, comparison, and outcome (PICO) question of: "Does the use of a pharmacologic agent compared to standard of care or placebo improve ICU delirium in a critically ill patient population?", Results: After application of the PICO question and the inclusion and exclusion criteria, 13 articles were included. Of these articles, 7 were prospective randomized controlled trials, 1 was a prospective nonrandomized controlled trial, and 5 were retrospective investigations. The included articles differed in the agents evaluated, primary outcome, and method of identifying delirium., Conclusion: The variability of outcomes illustrates the need for a large-scale investigation to further evaluate the role of pharmacologic management of ICU delirium.

Introduction: There is an increased risk of potential drug-drug interactions (pDDIs) in critically ill patients based on the number of drugs received. The occurrence of pDDIs and clinical significance is not well described., Objective: The aim was to provide insight into important clinical issues and offer guidance on drug-drug interaction (DDI) surveillance through the performance of a systematic review., Methods: Five targeted objectives were developed, a priori, which guided study selection and data abstraction. Two independent reviewers extracted the definition, frequency, type, and clinical significance of pDDIs. A meta-analysis was performed to evaluate the proportion of patients exposed to a pDDI. Three data sources (PubMed, Embase, and Scopus) were utilized for the search to include studies that evaluated pDDIs in adult critically ill patients. Included studies in the systematic review and meta-analysis were required to be full text., Results: A total of 39 studies met inclusion criteria. Definitions of pDDIs were diverse. Frequency of pDDIs varied by study, but was most commonly between one and five pDDIs per patient. Fifty-eight percent of patients were exposed to at least one pDDI during their intensive care unit admission. Types of pDDIs identified were numerous, with aspirin being the most common drug involved. As expected, not all pDDIs were clinically significant. Clinical significance was determined by varied definitions and sources., Conclusions: Improving the understanding of clinically significant pDDIs and alerts that clinicians encounter may guide better development of surveillance through clinical decision support and decrease alert fatigue.

Objective: To assess the impact of telepharmacy services in the acute care setting., Data Sources: EMBase, MEDLINE, and SCOPUS database searches were performed through April 2018., Study Selection and Data Extraction: PRISMA guidelines were applied for this systematic review. All English-language studies meeting the criteria of the following population, intervention, comparison, and outcome question were included: What impact does the provision of inpatient clinical pharmacy services delivered via telemedicine have on patient outcomes compared with standard of care?, Data Synthesis: A total of 11 studies were identified for the acute care setting, including 3 for critically ill patients. All studies demonstrated a positive impact on patient outcomes, nursing satisfaction, and disease management. Varying modes of telepharmacy technology were used, such as remote access to electronic medical records, faxing or scanning documents, pictures or webcams. For communication purposes, telepharmacists used email or electronic communication, facsimile, video review, or telephone to speak directly with hospital personnel and patients. Relevance to Patient Care and Clinical Practice: Inpatient telepharmacy is feasible and should be leveraged to further enhance patient care by complementing existing service models., Conclusions: Telepharmacy services enhanced patient outcomes, improved nursing satisfaction, and expanded services within inpatient settings. Similar technologies were leveraged in non-intensive care units (ICUs) and ICUs, but the goals of telepharmacy appeared to differ. ICUs focused on an expansion of services in the ICU and non-ICUs addressed improved patient outreach in rural areas.

Background: Non-Food and Drug Administration (FDA) or off-label medication prescribing occurs commonly in the intensive care unit (ICU). Off-label medication use creates a concern for untoward adverse effects; however, this worry may be alleviated by supportive literature., Objective: To evaluate the evidence behind off-label medication use by determining the presence of guideline support and compare graded recommendations to an online tertiary resource, DRUGDEX., Methods: Off-label medication use was identified prospectively over 3 months in medical ICUs in 3 academic medical centers. Literature searches were conducted in PubMed and the national guideline clearinghouse website to determine the presence of guideline support. DRUGDEX was also searched for strength-of-evidence ratings to serve as a comparator., Results: A total of 287 off-label medication indication searches resulted in 44% (126/287) without identified evidence; 253 guidelines were identified for 56% (161/287) of indications. Of the published guidelines, 89% (226/253) supported the off-label indication. In the DRUGDEX comparison, 67% (97/144) of guideline gradings disagree with DRUGDEX, whereas 33% (47/144) of the gradings matched the online database., Conclusion: Because more than half of off-label medication use has the benefit of supportive guidelines recommendations and a majority of gradings are inconsistent with DRUGDEX, clinicians should consider utilizing guidelines to inform off-label medication use in the ICU. Still, there is a considerable amount of off-label medication use in the ICU that lacks supporting evidence, and use remains concerning because it may lead to inappropriate treatment and adverse events.

Purpose: This investigation evaluated the incidence, severity, and harm of adverse drug reactions (ADRs) associated with antipsychotic use for intensive care unit (ICU) delirium., Methods: In this prospective, observational study patients were screened for development of delirium with the Intensive Care Delirium Screening Checklist (ICDSC). An ICDSC score of ≥4 was considered delirious. Patients with delirium were screened daily for ADRs. Suspected ADRs were evaluated for drug causality using 3 published, objective assessment tools. Suspected ADRs were considered positive when 2 of 3 instruments had an agreement rating of "possible" or greater. ADR severity was defined as "mild/moderate" or "severe" using the National Cancer Institute's Common Terminology Criteria for Adverse Events scale. A modified National Coordinating Council Medication Error Reporting Index for Categorizing Errors categorized ADRs into "no harm" or "harmful.", Results: Of 90 patients with delirium, 56 received antipsychotics. Ten suspected ADRs occurred attributed to antipsychotic use. QTc prolongation was the most observed ADR (50%). Patients with ADRs had higher mean Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (P = .038). Patients who received haloperidol experienced more severe (P = .048) ADRs., Conclusions: ADRs were observed in 18% of patients having delirium treated with antipsychotics with about half considered severe or harmful. A risk versus benefit assessment is needed before initiating antipsychotic therapy in ICU patients., (© The Author(s) 2015.)

Purpose: To evaluate the performance of using trigger words (e.g. clues to an adverse drug reaction) in unstructured, narrative text to detect adverse drug reactions (ADRs) and compare the use of these trigger words to a targeted chart review for ADR detection within the intensive care unit (ICU) discharge summary note., Materials: A retrospective medical record review was conducted. Evaluation of ADRs occurred in two phases - targeted chart review of the ICU discharge summary notes in Phase 1 and targeted chart review using specific words and phrases as triggers for ADRs in Phase 2., Results: Four hundred ADRs were documented in 223 patients for Phase 1. For Phase 2, there were 219 ADRs identified in 120 patients. 138 real or accurate ADRs were identified from Phase 1 and 47 duplicate events. 34 ADRs from Phase 2 were not identified in Phase 1. Fifteen of the ADRs were inaccurately presumed in Phase 2. Fifty-eight of 127 text triggers identified at least one ADR. Low and moderate frequency trigger words were more likely to have PPVs > 5%., Conclusions: Targeted chart review using specific words and phrases as triggers for ADRs is a reasonable approach to identify ADRs and may save time compared to other methods after further refinement leads to a more accurately performing trigger word list.

Objective: Prior research indicates that off-label use is common in the ICU; however, the safety of off-label use has not been assessed. The study objective was to determine the prevalence of adverse drug reactions associated with off-label use and evaluate off-label use as a risk factor for the development of adverse drug reactions in an adult ICU population., Design: Multicenter, observational study, Setting: : Medical ICUs at three academic medical centers., Patients: Adult patients (age ≥ 18 yr old) receiving medication therapy., Interventions: All administered medications were evaluated for Food and Drug Administration-approved or off-label use. Patients were assessed daily for the development of an adverse drug reaction through active surveillance. Three adverse drug reaction assessment instruments were used to determine the probability of an adverse drug reaction resulting from drug therapy. Severity and harm of the adverse drug reaction were also assessed. Cox proportional hazard regression was used to identify a set of covariates that influenced the rate of adverse drug reactions., Measurements and Main Results: Overall, 1,654 patient-days (327 patients) and 16,391 medications were evaluated, with 43% of medications being used off-label. One hundred and sixteen adverse drug reactions were categorized dichotomously (Food and Drug Administration or off-label), with 56% and 44% being associated with Food and Drug Administration-approved and off-label use, respectively. The number of adverse drug reactions for medications administered and the number of harmful and severe adverse drug reactions did not differ for medications used for Food and Drug Administration-approved or off-label use (0.74% vs 0.67%; p = 0.336; 33 vs 31 events, p = 0.567; 24 vs 24 events, p = 0.276). Age, sex, number of high-risk medications, number of off-label medications, and severity of illness score were included in the Cox proportional hazard regression. It was found that the rate of adverse drug reactions increases by 8% for every one additional off-label medication (hazard ratio = 1.08; 95% CI, 1.018-1.154)., Conclusion: Although adverse drug reactions do not occur more frequently with off-label use, adverse drug reaction risk increases with each additional off-label medication used.

Purpose: To determine the most common drug-drug interaction (DDI) pairs contributing to QTc prolongation in cardiac intensive care units (ICUs)., Materials and Methods: This retrospective evaluation included patients who were admitted to the cardiac ICUs between January 2009 and July 2009 aged ≥ 18 years with electrocardiographic evidence of a QTc ≥ 500 ms. Patients receiving at least two concomitant drugs known to prolong the QT interval were considered to experience a pharmacodynamic DDI. Drugs causing CYP450 inhibition of the metabolism of QT prolonging medications were considered to cause pharmacokinetic DDIs. The causality between drug and QTc prolongation was evaluated with an objective scale., Results: One hundred eighty-seven patients experienced QT prolongation out of a total of 501 patients (37%) admitted during the study period. Forty-three percent and 47% of patients experienced 133 and 179 temporally-related pharmacodynamic and pharmacokinetic interactions, respectively. The most common medications related to these DDIs were ondansetron, amiodarone, metronidazole, and haloperidol., Conclusion: DDIs may be a significant cause of QT prolongation in cardiac ICUs. These data can be used to educate clinicians on safe medication use. Computerized clinical decision support could be applied to aid in the detection of these events., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine the frequency and type of adverse drug events (ADEs) identified in intensive care unit (ICU) transfer summaries and in the hospital discharge summaries to demonstrate the effectiveness of ICU transfer summary surveillance in the identification of ADEs., Methods: A retrospective electronic medical record review was conducted for medical ICU patients admitted between January 2009 and April 2009 to a large, academic medical center. The Harvard Practice Scale and the modified Leonard Assessment Scale were used to evaluate the presence of an ADE from the ICU transfer and hospital discharge summaries., Results: Two hundred and fifty-four patients were identified for inclusion with a median medical ICU length of stay of 4.5 days and hospital length of stay of 13 days. The ICU transfer summary review revealed 173 ADEs among 124 unique patients with a rate of 33.9 ADEs per 1000 hospital patient days. Sixty-nine ADEs among 63 unique patients were identified through the hospital discharge summary with a rate of 13.5 ADEs per 1000 hospital patient days. Only 23.1% of ADEs discussed in the ICU transfer summary were also discussed in the hospital discharge summary., Conclusions: The use of ICU transfer summaries is an effective tool to increase ADE detection. The use of an ICU transfer summary should be considered as an adjunct method to an existing ADE surveillance system for heightened pharmacovigilance., (Copyright © 2013 John Wiley & Sons, Ltd.)

Objectives: Mortality and morbidity are increased in patients experiencing drug-drug interactions (DDIs). Critically ill patients are at an increased risk of adverse events from DDIs due to the large number of medications that they take and their changes in organ function. Currently, there is a lack of literature describing DDIs in the intensive care unit (ICU). The purpose of this study is to evaluate frequency, severity and drug combinations involved in DDIs occurring in a medical ICU (MICU)., Methods: This was a 4-week, prospective, observational study that was conducted in the MICU of an academic medical centre. Lexi-Interact and Micromedex interaction databases were utilized daily to screen patients' medication profiles for DDIs, and severity was assessed using each database's severity rating scale., Key Findings: Of 240 patient medication profiles evaluated, 457 DDIs were identified. The rate of DDIs was 190.4 DDIs/100 patient days with 297 of these interactions being unique drug pairs. About 25% (114/457) were considered major DDIs. The most commonly involved medications were antihypertensive medications (106/457) and anticoagulants/antiplatelet agents (80/457)., Conclusions: DDIs occur frequently in the MICU. Severity and drug combinations related to DDIs in the MICU differ from DDIs published in other ICU settings. When developing a DDI alerting system, patient characteristics and location should be considered., (© 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society.)

Background: Mortality and morbidity are increased in patients experiencing drug-drug interactions. Unfortunately, there is a paucity of literature describing clinically significant drug-drug interactions occurring in the intensive care unit (ICU). Knowing the clinically significant drug-drug interactions allows the opportunity for prevention through knowledge and computer-assisted programmes., Objective: To identify significant potential drug-drug interactions occurring in the cardiovascular ICU (CCU) and the cardiothoracic ICU (CTICU)., Study Design: Prospective, observational study conducted over a total of 8 weeks in February and March 2009., Setting: CCU and CTICU in a major academic medical centre (Presbyterian Hospital, University of Pittsburgh Medical Centre)., Patients: All adult patients (>or=18 years of age) admitted during 1 month in each ICU., Intervention: Micromedex and Lexi-Interact interaction databases were used to screen each patient's medication profile daily for the presence of potentially interacting drug pairs that would be considered a potential drug-drug interaction. A severity assessment using these databases was completed after a potential drug-drug interaction was identified., Primary Outcome Measure: The frequency of significant drug-drug interactions, including those that were considered major or contraindicated, according to two commercially available interaction databases., Results: Evaluations of 400 patient medication profiles were conducted, resulting in 225 profiles possessing one or more potential drug-drug interactions. A total of 1150 potential interactions were identified, resulting in 287.5 potential interactions per 100 patient-days. Of the 1150 potential drug-drug interactions, 458 were unique interacting drug pairs; 5-9% of the potential interactions were considered major or contraindicated. Many of the significant and frequent potential interactions involved blood coagulation modifiers, potential interactions that could result in QTc prolongation, and cytochrome P450 inhibition. Micromedex and Lexi-Interact agreed on the severity ratings in 20.5% of the potential interactions., Conclusions: Significant potential drug-drug interactions occur in the CCU and CTICU, highlighting the need for active surveillance to potentially prevent patient harm. Clinicians should also consider using two references for identifying interactions, due to the lack of congruence between sources.

Importance of the Field: Critically ill patients are at an increased risk to develop drug-drug interactions (DDIs). DDIs that increase the risk of QT prolongation, and ultimately torsades de pointes, can result in a medical emergency. Many clinicians are unaware of the risk of certain drug combinations that may precipitate QT prolongation in the intensive care unit (ICU). Additional DDI education and a review of management strategies could assist with prevention of future adverse outcomes., Areas Covered in This Review: This review focuses on some commonly used medications in the ICU that may be involved in pharmacokinetic and/or pharmacodynamic DDIs leading to the development of QT prolongation and possibly torsades de pointes. Also, appropriate management strategies are discussed., What the Reader Will Gain: The ICU clinician will gain a better understanding of common medications used in the ICU and DDIs that put patients at risk for the development of QT prolongation and torsades de pointes., Take Home Message: Medications that may cause QT prolongation are common in the ICU and DDIs need to be identified and prevented by the clinician to avoid a potentially life-threatening dysrrhythmia.

Critically ill patients are predisposed to drug interactions because of the complexity of the drug regimens they receive in the intensive care setting. Drugs may affect the absorption, distribution, metabolism, and/or elimination of an object drug and consequently alter the intended pharmacologic response and potentially lead to an adverse event. Certain disease states that afflict critically ill patients may also amplify an intended pharmacologic response and potentially result in an unintended effect. A team approach is important to identify, prevent, and address drug interactions in the intensive care setting and optimize patient outcomes.

Background: Damage biomarkers are helpful in early identification of patients who are at risk of developing acute kidney injury (AKI). Investigations are ongoing to identify the optimal role of stress/damage biomarkers in clinical practice regarding AKI risk prediction, surveillance, diagnosis, and prognosis. Objective: To determine the impact of utilizing a clinical decision support system (CDSS) to guide stress biomarker testing in intensive care unit (ICU) patients at risk for drug-induced acute kidney injury (D-AKI). Methods: A protocol was designed utilizing a clinical decision support system (CDSS) alert to identify patients that were ordered 3 or more potentially nephrotoxic medications, suggesting risk for progressing to AKI from nephrotoxic burden. Once alerted to these high-risk patients, the pharmacist determined if action was needed by ordering a stress biomarker test, tissue inhibitor of metalloproteinase-2-insulin-like growth factor-binding protein 7 (TIMP-2•IGFBP7). If the biomarker test result was elevated, the pharmacist provided nephrotoxin stewardship recommendations to the team. Pharmacists recorded the response to the clinical decision support alert, ordering, and interpreting the TIMP-2•IGFBP7, and information regarding clinical interventions. An alert in conjunction with TIMP-2•IGFBP7 as a strategy for AKI risk prediction and stimulant for patient care management was assessed. In addition, barriers and solutions to protocol implementation were evaluated. Results: There were 394 total activities recorded by pharmacists for 345 unique patients. Ninety-three (93/394; 23.6%) actionable alerts resulted in a TIMP-2•IGFBP7 test being ordered. Thirty-one TIMP-2•IGFBP7 results were >0.3 (31/81; 38.3%), suggesting a high-risk of progression to AKI, which prompted 191 pharmacist/team interventions. On average, there were 1.64 interventions per patient in the low-risk patients, 3.43 in high-risk patients, and 3.75 in the highest-risk patients. Conclusion and Relevance: Stress biomarkers can be used in conjunction with CDSS alerts to affect therapeutic decisions in ICU patients at high-risk for D-AKI. [ABSTRACT FROM AUTHOR]

Background: Agitation and delirium are common in mechanically ventilated adult intensive care unit (ICU) patients and may contribute to delayed extubation times. Difficult-to-wean ICU patients have been associated with an increased risk of longer ICU length of stays and mortality. The purpose of this systematic review and meta-analysis is to evaluate the evidence of dexmedetomidine facilitating successful mechanical ventilation extubation in difficult-to-wean ICU patients and clinical outcomes. Methods: A literature search was conducted using MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Cochrane Central Register of Controlled Trials, Clinical Trial Registries, and the Health Technology Assessment Database from inception to December 5, 2019. Randomized controlled trials evaluating dexmedetomidine with the intended purpose to facilitate mechanical ventilation liberation in adult ICU patients (≥18 years) experiencing extubation failure were included. The primary outcome of time to extubation was evaluated using the weighted mean difference (WMD), with a random effects model. Secondary analyses included hospital and ICU length of stay, in-hospital mortality, hypotension, and bradycardia. Results: A total of 6 trials (n = 306 patients) were included. Dexmedetomidine significantly reduced the time to extubation (WMD: -11.61 hours, 95% CI: -16.5 to -6.7, P = .005) and ICU length of stay (WMD: -3.04 days; 95% CI: -4.66 to -1.43). Hypotension risk was increased with dexmedetomidine (risk ratio [RR]: 1.62, 95% CI: 1.05-2.51), but there was no difference in bradycardia risk (RR: 3.98, 95% CI: 0.70-22.78). No differences were observed in mortality rates (RR: 1.30, 95% CI: 0.45-3.75) or hospital length of stay (WMD: -2.67 days; 95% CI: -7.73 to 2.39). Conclusions: Dexmedetomidine was associated with a significant reduction in the time to extubation and shorter ICU stay in difficult-to-wean ICU patients. Although hypotension risk was increased with dexmedetomidine, no differences in other clinical outcomes were observed. [ABSTRACT FROM AUTHOR]

Objective: Do pharmacy personnel- (ie, pharmacist or pharmacy technician) driven interventions at transitions of care into or out of the intensive care unit (ICU) improve medication safety measures compared to interventions made by other health-care team members or no intervention? Data Sources: A literature search of MEDLINE and Embase limited to English language and humans was performed (from 1969 until January 2019). Bibliographies of included investigations were reviewed for additional citations. Methods: Investigations were selected if they described a pharmacy-driven intervention at any point of transfer into or out of an ICU setting. Ten investigations were included. Five described interventions relevant to the entire ICU population, and 5 described interventions targeted to specific medications or disease. Results: A variety of interventions were utilized in the 10 included investigations. A significant improvement was demonstrated with pharmacy-driven intervention in all 4 studies that evaluated the entire ICU patient population. Interventions specific to certain medication and disease improved medication safety measures but were not always statistically significant. Medication error rates are high in patients transferred into and out of the ICU, and limited data exist to address this concern. This review compares and evaluates the current literature to guide future interventions and research in this area. Conclusions: Although pharmacy-driven interventions demonstrated some benefit in various medication safety measures in the majority of studies, additional randomized and prospective trials with patient-centered outcomes that assess morbidity and mortality are needed. [ABSTRACT FROM AUTHOR]

Introduction: Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research. Objective: To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management. Methods: The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review. Results: Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep. Conclusion: A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Shock syndromes are associated with unacceptably high rates of mortality in critically ill patients despite advances in therapeutic options. Vasodilatory shock is the most common type encountered in the intensive care unit. It is manifested by cardiovascular failure, peripheral vasodilatation, and arterial hypotension leading to tissue hypoperfusion and organ failure. Hemodynamic support is typically initiated with fluid resuscitation strategies and administration of adrenergic vasopressor agents in nonresponsive patients to restore arterial pressure with subsequent adequate organ reperfusion. Unfortunately, high catecholamine dosing requirements may be necessary to achieve targeted hemodynamic goals that may increase the risk of vasopressor‐induced adverse events. The purpose of this article is to review the clinical efficacy and safety data and potential role in therapy for catecholamine‐sparing agents in vasodilatory shock. Adjunctive therapeutic options to reduce vasoactive support requirements without compromising arterial pressure include arginine vasopressin and analogs, corticosteroids, midodrine, methylene blue, and angiotensin II. Although concomitant vasopressin and corticosteroids have a more defined role in evidence‐based guidelines for managing shock, clinicians may consider other potential catecholamine‐sparing agents. [ABSTRACT FROM AUTHOR]

Background Nonpharmacologic delirium-prevention strategies are commonly used in the intensive care unit by bedside nurses. With up to 80% of intensive care unit patients becoming delirious, and lacking treatment options, prevention is key. However, with increasing nurse workloads, innovative deliriumprevention strategies such as involving the patient's family are needed. Objective To gain insight into opinions of patients' families regarding active participation in deliriumprevention activities to inform specific recommendations for involving patients' families in such activities. Methods Purposeful sampling was used. Patients' families were contacted to be interviewed about their opinions and attitudes on participation in nonpharmacologic delirium prevention activities while visiting the intensive care unit. An interview guide was created and used to facilitate discussion. Interviews were conducted, transcribed verbatim, and coded by 2 independent coders. Themes were identified, defined, and compared between independent coders; disagreements were resolved by the study team. Results After 10 interviews were conducted, thematic saturation occurred. Three major themes emerged: (1) consistent family presence and participation in care, (2) improving ease of interactions between family and patient, and (3) delirium education for families. Conclusion Family members want to be involved with care and delirium prevention; however, many times they do not know what to do without the direction of a health care provider. Family members would benefit from open dialogue with the bedside nurse to increase family comfort and involvement in care. [ABSTRACT FROM AUTHOR]

Background Delirium occurs in up to 80% of patients admitted to an intensive care unit. Nonpharmacologic delirium-prevention strategies, which are commonly used by the bedside nurse, have reduced the incidence and duration of delirium in patients in the intensive care unit. With increasing demands on the nurse, strategies such as including the patient's family in delirium prevention activities should be investigated. Objective To determine opinions and willingness of health care providers to involve patients' families in nonpharmacologic delirium-prevention activities in the intensive care unit, and of patients' families to be involved. Methods Two surveys, one for intensive care unit nurses and physicians and one for patients' families, were developed and administered. The provider survey focused on current delirium-prevention practices and opinions about family involvement. The family survey concentrated on barriers and willingness to participate in prevention activities. Results Sixty nurses and 58 physicians completed the survey. Most physicians (93%) and all nurses believed families could assist with delirium prevention. Only 50% reported speaking with family members about delirium and delirium prevention. The family survey was completed by 60 family members; 38% reported a provider spoke with them about delirium. Family members reported high levels of comfort in participating in delirium-prevention activities. Conclusions Health care providers and family members are supportive of the latter performing deliriumprevention activities. Family of patients in the intensive care unit may work collaboratively with nurses to reduce the incidence and duration of delirium in these patients. [ABSTRACT FROM AUTHOR]

Development of delirium in critical care patients is associated with increased length of stay, hospital costs, and mortality. Delirium occurs across all inpatient settings, although critically ill patients who require mechanical ventilation are at the highest risk. Overall, evidence to support the use of antipsychotics to either prevent or treat delirium is lacking, and these medications can have adverse effects. The pain, agitation, and delirium guidelines of the American College of Critical Care Medicine provide the strongest level of recommendation for the use of nonpharmacological approaches to prevent delirium, but questions remain about which nonpharmacological interventions are beneficial. [ABSTRACT FROM AUTHOR]

Background Dexmedetomidine, a selective α² -adrenergic receptor agonist, is increasingly used as a sedative in intensive care despite variations in patients' responses. Objectives To determine the effectiveness of dexmedetomidine as a sedative and specific patient characteristics that play a role in adequate sedation with dexmedetomidine. Methods A 6-month, pilot, prospective observational study was performed in a medical intensive care unit at an academic medical center. Patients receiving dexmedetomidine were followed up until use of the drug was stopped and they were classified as nonresponders or responders. Effective sedation was defined as a score of 3 to 4 on the Sedation Agitation Scale after the administration of dexmedetomidine. Patient characteristics, laboratory values, home and inpatient medications, and dexmedetomidine dosing information were collected to identify predictors of clinical response. Results During the 6-month study period, 38 patients received dexmedetomidine. The drug was ineffective as a sedative in 19 patients (50%) and effective in 11 (29%). Effectiveness could not be assessed in 8 patients because of clinical confounders. According to standard multiple logistic regression analysis, successful sedation was more likely in patients with a lower score on the Acute Physiology and Chronic Health Evaluation II (Odds Ratio [OR] 0.81; 95% CI, -0.39 to -0.03) and patients who took antidepressants at home (OR 10.27; 95% CI, 0.23 to 4.43) than in patients who had a higher score or did not take antidepressants at home. Conclusions Effective sedation with dexmedetomidine is variable. [ABSTRACT FROM AUTHOR]

Acute pulmonary embolism accounts for 50 000 to 100000 deaths each year in the United States. Because of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small peripheral emboli, stratifying and treating patients according to their signs and symptoms is important when an acute embolism is suspected. Patients' clinical findings can range from no signs or symptoms to unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60% in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli, explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care unit also are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to assess the performance of a commercially available clinical decision support system (CDSS) drug-laboratory result alert in detecting drug-induced thrombocytopenia in critically ill patients. Materials and Methods: Adult patients admitted to the medical and cardiac intensive care unit during an 8-week period and identified by 1 of 3 signals in the CDSS, TheraDoc, were eligible. Alerts were generated when the patient had a low platelet count and was ordered a potentially causal drug. Patients were evaluated in real time for the occurrence of an adverse drug reaction using 3 causality instruments. Positive predictive values were calculated for the alert. Results: Sixty-four patients with a mean age of 54 years met the inclusion criteria, generating 350 alerts. Positive predictive values were 0.36, 0.83, and 0.40 for signals 1, 2, and 3, respectively. Overall, there were 137 adverse drug reactions identified in the 350 alerts, with heparin, vancomycin, and famotidine as the 3 most common potential causes. Conclusions: A commercial CDSS drug-laboratory alert is effective at identifying drug-induced thrombocytopenia in the intensive care unit and may improve patient safety. Compared with previous studies, the combination alert performs better than alerts based exclusively on laboratory values and should be considered to reduce alert fatigue. [Copyright &y& Elsevier]

Objectives: To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care.Data Sources: Semistructured narrative literature review and quantitative survey assessments.Study Selection: English language publications that examined critical care practices in relation to reducing cost or waste.Data Extraction: Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking.Data Synthesis: Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices.Conclusions: Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign. [ABSTRACT FROM AUTHOR]

Objective: The objective of this article is to provide a summary of the perceptions of healthcare providers and family members toward their role in active patient care in the ICU and compare the views of healthcare providers with those of relatives of critically ill patients.Data Sources: The search was conducted using PubMed as the primary search engine and EMBASE as a secondary search engine.Study Selection: Studies were included if they were conducted in the ICU, had an adult patient population, and contained a discussion of active patient care, including perspective or actions of family members or healthcare providers about the active participation.Data Extraction: Titles and abstracts of articles identified through PubMed and EMBASE were assessed for relevancy of family involvement. The full article was reviewed of titles and abstracts involving family involvement of care in the ICU to assess if the topic was active care and if the article involved perceptions of healthcare providers or family members. The references of all selected articles were then evaluated for the inclusion of additional studies.Data Synthesis: Articles including perceptions of healthcare providers were grouped separately from articles including attitudes of family members. Articles that contained the perceptions of both healthcare providers and family members were considered in both groups but were evaluated with each perspective separately. Examples of specific patient care tasks that were mentioned in each article were identified.Conclusions: A positive attitude exists among both family members and providers toward the involvement of family members in active care tasks. Providers and family members share the attitude that a partnership is necessary and that encouragement for family members to participate is essential. The findings in this review support the need for more objective research regarding how families are caring for their loved ones and how family involvement in care is affecting patient and family outcomes. [ABSTRACT FROM AUTHOR]