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Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.

Although proning is beneficial to acute respiratory distress syndrome, impressions vary about its efficacy. Some providers believe that paralysis is required to facilitate proning. We studied impact of paralysis on prone-induced gas exchange improvements and provider attitudes regarding paralytics.DesignObservational.SettingUniversity of California San Diego.PatientsIntubated COVID acute respiratory distress syndrome patients.InterventionsNone.Measurements and main results1) Changes in Pao2:Fio2 and Spo2:Fio2 ratios before and after proning with and without paralytics, 2) adverse events during proning with and without paralytics, and 3) nurse and physician attitudes about efficacy/safety of proning with and without paralytics. Gas-exchange improvement with proning was similar with and without paralytics (with no serious adverse events). Survey results showed similar attitudes between nurses and physicians about proning efficacy but differing attitudes about the need for paralytics with proning.ConclusionsFindings support use of proning and may help in design of randomized trials to assess paralytics in acute respiratory distress syndrome management.

Delirium, a disorder characterized by altered consciousness, inattention, and global disturbance in cognition, is a common syndrome in the intensive care unit (ICU), affecting up to 90% of critically ill patients. Over the past 20 years, ICU delirium has gained substantial attention as a major health problem, due to its high prevalence and association with adverse patient outcomes including prolonged length of stay, long-term cognitive, physical, and mental health impairments, and early death. The pathophysiology of delirium is complex and poorly understood, with a number of potential mechanisms and pathways. Prevention and early identification of delirium, using multicomponent strategies and validated bedside tools, respectively, are vital for management efforts. Clinical practice guidelines for delirium prevention and treatment recommend the emphasis on routine screening for delirium, protocol-driven assessment and management of analgesia and sedation, sleep promotion, minimization of provoking factors, and the importance of early rehabilitation and mobility. As the topic of ICU delirium is extensive, this chapter will focus specifically on (1) pathophysiology; (2) presentation; and (3) prevention and management strategies of delirium.

In cardiorenal syndrome (CRS), cardiac and renal dysfunction coexist, creating a complex clinical picture. This commonly encountered scenario is associated with increased morbidity and mortality. Cardiorenal biomarkers are emerging as a tool to help define CRS pathophysiology and direct patient care. Emerging novel biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL), cystatin C (CysC), kidney injury molecule-1 (KIM-1), and proenkephalin (pro-ENK) can help identify renal impairment earlier, further delineate etiology and potentially guide treatment in the future. In this chapter, we will discuss cardio-renal syndrome, definitions of renal injury, the limitations of creatinine as a biomarker, and new biomarkers for cardio-renal dysfunction.

Aim Investigate the relationship of initial PetCO2 values of patients during inpatient pulseless electrical activity (PEA) cardiopulmonary arrest with return of spontaneous circulation (ROSC) and survival to discharge. Methods This study was performed in two urban, academic inpatient hospitals. Patients were enrolled from July 2009 to July 2013. A comprehensive database of all inpatient resuscitative events is maintained at these institutions, including demographic, clinical, and outcomes data. Arrests are stratified by primary etiology of arrest using a priori criteria. Inpatients with PEA arrest for whom recorded PetCO2 was available were included in the analysis. Capnography data obtained after ROSC and/or more than 10min after initiation of CPR were excluded. Multivariable logistic regression was used to explore the association between initial PetCO2 >20mmHg and both ROSC and survival-to-discharge. Results A total of 50 patients with PEA arrest and pre-ROSC capnography were analyzed. CPR continued an average of 11.8min after initial PetCO2 was recorded confirming absence of ROSC at time of measurement. Initial PetCO2 was higher in patients with versus without eventual ROSC (25.3±14.4mmHg versus 13.4±6.9mmHg, P =0.003). After adjusting for age, gender, and arrest location (ICU versus non-ICU), initial PetCO2 >20mmHg was associated with increased likelihood of ROSC (adjusted OR 4.8, 95% CI 1.2–19.2, P =0.028). Initial PetCO2 was not significantly associated with survival-to-discharge ( P =0.251). Conclusions Initial PetCO2 >20mmHg during CPR was associated with ROSC but not survival-to-discharge among inpatient PEA arrest victims. This analysis is limited by relatively small sample size.