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Scholarly Works (7 results)

  • Thesis
  • Peer Reviewed
UC San Francisco Electronic Theses and Dissertations (2010)

Delirium and sleep deprivation are experienced by patients in intensive care units (ICUs) and have been associated with negative patient outcomes. Benzodiazepine, often used for sedation in critically ill patients, contributes to an imbalance of neurotransmitters that can influence the wake-sleep-regulatory system and the occurrence of delirium. This dissertation evaluated the effect of a sedation wake-up trial (SWT) and spontaneous breathing trial (SBT) on the occurrence of delirium, perception of sleep and other outcomes in trauma ICU (TICU) patients.

The first study was a prospective interventional trial that implemented the SWT plus SBT in TICU patients. The intervention group (IG, n = 20) experienced less delirium (OR 0.107; 95% CI: 0.025-0.459), recovered from drug-induced coma faster (RH 2.25; 95% CI: 1.08-4.65), and was liberated from the mechanical ventilator (RH 3.09; 95% CI: 1.45-6.60) and discharged from the TICU sooner (RH 4.20; 95% CI: 1.82-9.69) than the control group (CG, n = 20). Sleep perception was rated as bad and did not differ between groups.

A second report addressed the feasibility of conducting the SWT plus SBT based on the ability to implement the combined intervention, measure patients' physiological responses, and maintain patient safety. IG patients passed 67% of the 39 SWTs performed. Those who did not pass presented RASS scores of +1 and +2, tachycardia, or showed ventilator asynchrony. Eighteen patients tolerated their first SBT and after the second SBT more than half of patients were discontinued from the mechanical ventilator. Physiological responses (i.e., heart rate, respiratory rate, and systolic blood pressure) increased significantly from the beginning to the end of the SWT. However, their overall means did not increase by 20%. Opioids were not interrupted during the SWT; however, at the end of six SWTs patients reported having pain.

The findings demonstrated that those TICU patients who received the combined intervention decreased in the occurrence of delirium and improved in several outcomes. However, this conclusion is limited by the non randomized design, the small sample, and the lack of control in the type of sedative given to both groups. The combined intervention was well tolerated, safe, and clinically feasible.

    Cover page: The Effect of a Sedation Wake-up Trial and Spontaneous Breathing Trial on the Occurrence of Delirium and Perception of Sleep in Critically Ill Trauma Patients
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2019)

    Objective

    Our study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines.

    Methods

    A descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records.

    Results

    Eighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation.

    Conclusion

    Although pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.
      Cover page: Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients.
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2019)
      Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.
        Cover page: Opioid and Benzodiazepine Iatrogenic Withdrawal Syndrome in Patients in the Intensive Care Unit.
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2020)
        Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome.

        Design

        Prospective exploratory observational study.

        Setting

        Trauma ICU in large medical center in Puerto Rico.

        Participants

        Fifty patients who received opioids and/or benzodiazepines for greater than or equal to 5 days.

        Measurements and main results

        Using an opioid/benzodiazepine withdrawal syndrome checklist developed from research in adult ICU patients, the Diagnostic and Statistical Manual of Mental Disorders-5, and the International Classification of Diseases, 10th Edition, we evaluated patients at baseline and for 72 hours after drug weaning was initiated. Patients received opioid/benzodiazepine (88%), opioid (10%), or benzodiazepine (2%). Probable withdrawal syndrome occurred in 44%, questionable withdrawal syndrome in 20%, and no withdrawal syndrome in 18 (36%). Signs that were more frequent in the probable withdrawal syndrome group were agitation, diarrhea, fever, tachypnea, lacrimation, and hyperactive delirium. Patients who developed probable withdrawal syndrome spent almost double the amount of time receiving mechanical ventilation, and length of stay was higher in both ICU and hospital when compared with patients in the other two groups. Age, cumulative opioid dose amounts, and previous drug (opioid/benzodiazepine, cannabis, cocaine, or heroin) use were associated with odds of developing withdrawal syndrome. With the addition of Richmond Agitation-Sedation Scale and delirium to the multilevel analysis, older age no longer had its protective effect, whereas increase in Richmond Agitation-Sedation Scale scores, delirium presence, and increased duration of mechanical ventilation were associated with higher odds of withdrawal syndrome.

        Conclusions

        We identified probable withdrawal syndrome in a sample of trauma ICU patients through observation of several associated symptoms. Significant factors associated with withdrawal syndrome found in this study should be considered when caring for patients being weaned from opioids and/or benzodiazepines. Further validation of the opioid/benzodiazepine withdrawal syndrome checklist is recommended.
          Cover page: Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: A Prospective Exploratory Study
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2020)

          Background

          The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process.

          Objective

          To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT.

          Methods

          Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT.

          Results

          The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version.

          Conclusion

          The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.
            Cover page: Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool.
            • Article
            • Peer Reviewed
            UC San Diego Previously Published Works (2024)

            A lack of high-quality provider education hinders the delivery of standard-of-care delirium detection and prevention practices in the intensive care unit (ICU). To fill this gap, we developed and validated an e-learning ICU Delirium Playbook consisting of eight videos and a 44-question knowledge assessment quiz. Given the increasing Spanish-speaking population worldwide, we translated and cross-culturally adapted the playbook from English into Spanish.

            To translate and culturally adapt the ICU Delirium Playbook into Spanish, the second most common native language worldwide.

            The translation and cross-cultural adaptation process included double forward and back translations and harmonization by a 14-person interdisciplinary team of ICU nurses and physicians, delirium experts, methodologists, medical interpreters, and bilingual professionals representing many Spanish-speaking global regions. After a preeducation quiz, a nurse focus group completed the playbook videos and posteducation quiz, followed by a semistructured interview.

            The ICU Delirium Playbook: Spanish Version maintained conceptual equivalence to the English version. Focus group participants posted mean (standard deviation) pre- and post-playbook scores of 63% (10%) and 78% (12%), with a 15% (11%) pre-post improvement (P = 0.01). Participants reported improved perceived competency in performing the Confusion Assessment Method for the ICU and provided positive feedback regarding the playbook.

            After translation and cultural adaptation, the ICU Delirium Playbook: Spanish Version yielded significant knowledge assessment improvements and positive feedback. The Spanish playbook is now available for public dissemination.

              • Article
              • Peer Reviewed
              UC San Diego Previously Published Works (2023)
              Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention.

              Design

              Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews.

              Setting

              Online validation survey, virtual focus group, and virtual interviews.

              Subjects

              The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews.

              Interventions

              None.

              Measurements and main results

              The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs.

              Conclusions

              The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.
                Cover page: Development and Validation of an ICU Delirium Playbook for Provider Education
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