Clinical Voices May 2021

May 03, 2021

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This month we explore six clinical topics, including sedation in mechanically ventilated adults with sepsis and the year's top 10 medical technology hazards, plus the latest President’s Column and an uplifting Nurse Story.

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Light Sedative Options Similarly Effective in Sepsis Trial

The outcomes did not differ with either dexmedetomidine or propofol.

A randomized trial finds no difference in outcomes for mechanically ventilated adults with sepsis who are given dexmedetomidine or propofol for light sedation.

According to "Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis," in The New England Journal of Medicine,patients achieved similar outcomes for days without delirium or coma, ventilator-free days, cognitive scores and mortality rates. Patients also scored similarly in safety measures.

The double-blind trial included 422 patients at 13 medical centers, with 214 receiving dexmedetomidine and 208 receiving propofol, for a median duration of three days. The median score on the Richmond Agitation-Sedation Scale was -2.0, with -5 being unresponsive and +4 being combative.

The trial confirms "Society of Critical Care Medicine guidance," in Critical Care Medicine, that either sedative is recommended based on practice at an individual unit and factors such as cost and availability.

Noted differences in the trial included lower rates of acute respiratory distress syndrome in the dexmedetomidine group and lower rates of self-extubation for patients receiving propofol, adds a related report in Medscape Medical News.

Among safety outcomes, the report also notes similar proportions of patients with organ dysfunction, hypotension, severe lactic acidosis or symptomatic bradycardia.

Decision-Making Authority During TeleICU Care

The review confirms the need for ICU telemedicine guidelines, including level of authority.

A review of 20 observational studies indicates that during teleICU care, decision-making authority rather than expert teleconsultations is associated with reduced ICU mortality and shorter ICU length of stay.

"Decision-Making Authority During Tele-ICU Care Reduces Mortality and Length of Stay A Systemic Review of Meta-Analysis," in Critical Care Medicine, notes that studies reveal gaps in care based on authority levels. "This work confirms the urgent need for evidence-based ICU telemedicine guidelines and reveals potential benefits of uniform regulations regarding the level of authority when providing tele-ICU care," the review adds.

The review included 20 studies and 477,637 critical care patients. In the six studies where teleICU providers had decision-making authority, there was a significant reduction in ICU mortality (0.77 risk ratio). In contrast, in the nine studies where teleICU providers' level of authority was expert teleconsultation, there was no advantage for ICU mortality. Similar differences were noted in the analysis of eight studies that collected data on ICU length of stay.

The review notes, however, that without a unified vocabulary about authority levels, all data cannot necessarily be classified correctly. Limitations to the review also include inconsistency in implementation, cultural differences across countries, ICU management factors, a lack of parallel design and possible discharge of dying ICU patients to other settings for terminal care.

"It became apparent that due to the great impact of the technical equipment of the ICUs, an even more intensive analysis with regard to ICU technology will be needed in the future," the review notes. "Furthermore, that variability of approach with regard to decisional authority provides the opportunity to investigate associations of alternative levels of decisional authority with outcomes."

Deeper Sedation and NMBA Infusions

The study involved 3,419 ICU patients with ARDS treated in a Boston hospital.

Prolonged deep sedation is associated with increased mortality among patients with ARDS who are treated with neuromuscular blocking agent (NMBA) infusions.

"Optimal Sedation in Patients Who Receive Neuromuscular Blocking Agent Infusions for Treatment of Acute Respiratory Distress Syndrome - A Retrospective Cohort Study From a New England Health Care Network," in Critical Care Medicine, finds that a high proportion of deeper sedation mediates the negative effects of NMBA infusions on inpatient mortality, ventilator-free and ICU-free days.

The retrospective cohort study involved 3,419 patients with ARDS who were treated in seven ICUs in Boston's Beth Israel Deaconess Medical Center network from January 2008 to June 2019. Of those patients, 577 (16.9%) received NMBA infusions for a mean duration of 1.8 days.

The duration of deeper sedation was prolonged for patients receiving NMBA infusions, (4.6 +/- 2.2 days) compared with patients without infusions (2.4 +/- 2.2 days). The study defines a deeper sedation day as one in which a patient's mean assessment score is equal to or less than -2 on the Richmond Agitation and Sedation Scale or equal to or less than 2 on the Riker Sedation Agitation Scale.

Results show that while NMBA infusions are associated with increased mortality, the effect "strongly depends" on the duration of deeper sedation.

"The proportion of deeper sedation completely mediated the negative effect of neuromuscular blocking agent infusions on in-hospital mortality (p <0.001), the study adds. Likewise, the effects ventilator-free and ICU-free days were mediated more than 50%.

"Our data support the use of NMBA infusions in patients who need deeper sedation to achieve lung-protective ventilation," the study concludes. It also suggests that "clinicians should minimize the duration of deeper sedation after recovery from NMBA infusions" due to the overall increased mortality associated with NMBA infusions and prolonged, deep sedation.

Insights Into Recovery From Moderate and Severe TBI

Most patients with persistent DOC recovered functional independence during rehabilitation.

Two studies involving thousands of patients with traumatic brain injury (TBI) offer new information about recovery after prolonged unconsciousness and the risk of sleep disorders.

"Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury," in JAMA Neurology, finds that most patients with persistent disorder of consciousness (DOC) recover functional independence while in rehabilitation.

Of the nearly 17,500 survivors of moderate or severe TBI in the study, initial loss of consciousness occurred in 7,547 patients (57%), and DOC persisted to rehabilitation for 2,050 patients (12%). "However, 98% of these patients recovered consciousness by the end of subsequent inpatient rehabilitation, and their trajectory of functional improvement mirrored that of patients with TBI who did not lose consciousness," the study notes.

The findings may inform treatment decisions in acute and rehabilitation settings, the study suggests, adding that "caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC."

In a related article in Medscape Medical News, lead study author Robert Kowalski, University of Colorado School of Medicine, says that for patients with TBI, the results support pursuing inpatient rehabilitation after initial hospital care "both in terms of recovery of consciousness and to aid a return to independence in daily life."

Another study, "Traumatic Brain Injury and Incidence Risk of Sleep Disorders in Nearly 200,000 US Veterans," in Neurology, finds that TBI increases the risk of developing sleep disorders, including sleep apnea, insomnia and hypersomnia.

The analysis of 98,709 veterans with TBI and an equal number without it finds that 23,127 veterans (19.6%) developed sleep disorders after an average follow-up of five years (one to 14 years). Following adjustments for demographics and other factors, veterans with TBI were 41% more likely to develop sleep disorders, the study adds.

Top Medical Technology Hazards

The first hazard is the complexity of managing medical devices that have EUAs.

The top hazards created by medical technology include fatal medication errors from ordering and delivery systems, and the dangers from remotely operated devices.

According to "Top 10 Medical Technology Hazards of 2021 Show Impact of Pandemic" in PSQH: Patient Safety & Quality Healthcare, COVID-19-related emergency use authorization (EUA) adds risk from medical devices that may be consumer-grade products or were hastily deployed. As detailed in the "ECRI Institute's executive brief," the hazards also can be mitigated with solutions available to clinicians as well as technology manufacturers.

Fatal medication errors can occur because systems for storage, ordering or delivery might require input of only the first few letters of a medication name, and then the system generates a selection list. The risk of an error could be "significantly reduced if systems are designed or configured to require entry of, at minimum, the first five letters of a drug name before populating search fields," the article adds.

Risks associated with remote operation of devices such as ventilators and infusion pumps can develop due to less frequent visual assessment of patients, longer tubing sets, tripping due to placement in hallways and unauthorized access. "ECRI recommends such remote operation only during public health emergencies, only for as long as necessary, and after assessing and mitigating risks."

ECRI identifies other risks ranging from medical devices receiving emergency regulatory clearance, ineffective protective equipment such as imported N95-style masks, and software vulnerabilities. Consumer-grade products may lead to inaccurate measurements and should not be relied on when making critical decisions.

Fruit and Vegetable Regimen Offers Benefits

The review supports dietary recommendations to increase consumption.

Consuming certain amounts of most fruits and vegetables is associated with lower mortality, but risk reduction plateaus, a review notes.

In "Fruit and Vegetable Intake and Mortality: Results From 2 Prospective Cohort Studies of US Men and Women and a Meta-Analysis of 26 Cohort Studies" in Circulation, a review of nearly 2 million Americans' diets in regularly updated studies finds that two daily servings of fruit and three daily servings of vegetables were associated with the lowest mortality over 30 years. Fruit juices and starchy vegetables such as potatoes, corn and peas were not associated with lower risk.

A related article from CNN notes that "only 9% of US adults eat the suggested servings of vegetables, and only 12% eat the recommended amount of fruit." The review adds that the findings "support current dietary recommendations to increase intake."

"The biggest gains may come from encouraging those who rarely eat fruit or vegetables since diets rich in even modestly higher fruit and vegetable consumption are beneficial," add Naveed Sattar, University of Glasgow, and Nita Forouhi, University of Cambridge, in the related article from CNN. They were not involved in the review.

The review included 66,719 women from the Nurses' Health Study (1984-2014) and 42,016 men from the Health Professionals Follow-up Study (1986-2014) as well as cohorts for a total of nearly 1.9 million participants. Those reporting "five-a-day" intake had a lower risk of total mortality (0.87 hazard ratio), cardiovascular disease mortality (0.88), cancer mortality (0.90) and respiratory disease mortality (0.65).

Limitations include self-reporting, the possibility of changed diets and other behaviors of individuals with better diets (e.g., less smoking, more physical activity). The related article also notes the need to study differences in raw, cooked, frozen and canned produce.

President's Column: Olympic-sized Lessons

In her latest column, AACN President Elizabeth Bridges explores the lessons one Olympian teaches about teamwork, and she reflects on how this month we will come together virtually at NTI to celebrate ourselves, our teams and our profession.

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Nurse Story: A Passion for Pet Therapy - A Conversation With Kaylee Browning

A Texas CVICU nurse combines her love for animals and nursing while volunteering for a pet therapy group that helps promote health and healing for patients in ICUs, rehab facilities and more. "The benefit that pets bring to patients is an incredible treatment in itself," she says.

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