Volume 28 - No 3 - May 2020
Netherlands Journal of Critical Care
Bi-monthly journal of the Dutch Society of Intensive Care
LETTER TO THE EDITOR EXPERT OPINION REVIEW
Dedicated proning teams in the ICU Lung-protective mechanical ventilation in Delirium in the ICU – A structured review T.C. Roeleveld, H.J. de Vries, A. Girbes patients with COVID-19 of promising diagnostic and therapeutic H.J. de Vries, H. Endeman, approaches: Next steps in ICU delirium J.G. van der Hoeven, L.M.A. Heunks L. Smit, M. van der Jagt Netherlands Journal of Critical Care
NETHERLANDS JOURNAL OF CRITICAL CARE
EXECUTIVE EDITORIAL BOARD D.W. Donker, editor in chief CONTENTS I. van Stijn, managing editor H. Dupuis, language editor EDITORIAL D. van Dijk, associate editor M.M.J. van Eijk, associate editor 116 Powerful spin-offs … fostering flexibility, creativity and individualised N. Kusadasi, associate editor critical care! C.L. Meuwese, associate editor D.W. Donker [email protected] LETTER TO THE EDITOR COPYRIGHT 118 Dedicated proning teams in the ICU Netherlands Journal of Critical Care ISSN: 1569-3511 T.C. Roeleveld, H.J. de Vries, A. Girbes NVIC p/a Domus Medica P.O. Box 2124, 3500 GC Utrecht T: +31-(0)30 - 282 38 38 EXPERT OPINION 120 Lung-protective mechanical ventilation in patients with COVID-19 © 2020 NVIC. All rights reserved. Except as H.J. de Vries, H. Endeman, J.G. van der Hoeven, L.M.A. Heunks outlined below, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, REVIEW electronic, mechanical, photocopying, recording 126 Delirium in the ICU – A structured review of promising diagnostic and or otherwise, without prior written permission of the publisher. Permission may be sought directly therapeutic approaches: Next steps in ICU delirium from NVIC. L. Smit, M. van der Jagt
DERIVATIVE WORKS Subscribers may reproduce tables of contents ORIGINAL ARTICLE or prepare lists of articles including abstracts 134 A Lean approach to improve the organisation of unplanned intensive care for internal circulation within their institutions. admissions: A before-after analysis Permission of the publisher is required for resale or distribution outside the institution. Permission I.T. Spaan, A.F. van der Sluijs, A.D. Boelens, J. Binnekade, E-J. van Lieshout, of the publisher is also required for all other N.P. Juffermans, R. Mudde, P. Bouter, D.A. Dongelmans, A.P.J. Vlaar derivative works, including compilations and translations. ORIGINAL ARTICLE ELECTRONIC STORAGE 139 POCUS series: E-point septal separation, a quick assessment of reduced left Permission of the publisher is required to store or ventricular ejection fraction in a POCUS setting use electronically any material contained in this journal, including any article or part of an article. S.C. Boon, J.E. López Matta, C.V. Elzo Kraemer, P.R. Tuinman, D.J. van Westerloo
SUBSCRIPTIONS CLINICAL IMAGE An annual subscription to the Netherlands Journal of Critical Care consists of 6 issues. Issues 142 Harm prevented by using ICU ultrasound prior to percutaneous dilatational within Europe are sent by standard mail and tracheostomy outside Europe by air delivery. Cancellations M.E. Seubert, M. de Mos should be made, in writing, at least two months before the end of the year. The annual subscription fee for the Netherlands 5 5 is 175, for Europe 295, for the rest of the world 144 NVIC conference and course agenda 5 390. Subscriptions are accepted on a prepaid basis only and are entered on a calendar year basis. 145 Editorial board Please transfer the fee to ABNAMRO NL55 ABNA 145 International advisory board 0524 5618 93, swift-code: ABNANL2A. Do not forget to mention the complete address for 146 Information for authors delivery of the Journal.
CLAIMS Claims for missing issues should be made within two months of the date of dispatch. Missing issues will be mailed without charge. Issues claimed beyond the two-month limit must be prepaid at back copy rates.
ADVERTISING/ BUSINESS CONTACTS For advertising, please contact Eventex.
Eventex Sint Bernulphusstraat 13D 6861GS Oosterbeek T: +31 (0)26 – 333 75 77 E: [email protected]
Netherlands Journal of Critical Care is indexed in:
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 115 Netherlands Journal of Critical Care Submitted April 2020; Accepted April 2020
EDITORIAL
Powerful spin-offs … fostering flexibility, creativity and individualised critical care!
D.W. Donker Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
Correspondence D.W. Donker - [email protected]
In recent weeks we have experienced the enormous impact of elements to maintain a high level of modern ventilatory care in the current coronavirus pandemic. Excellently guided by our these difficult times; rather, we should consider this ambition of society’s president, Diederik Gommers, we have all done our our young colleagues as a commendable example of how we can utmost as critical care professionals to respond in the best develop and implement novel elements of patient care within an possible ways to this crisis and we have succeeded in maintaining open-minded, self-improving critical care environment. a high level of patient care. Obviously, in this period, we feel the urgent need to quickly Above all, we are doing a great job by communicating effectively share our collective experience and all the latest insights on the and collaborating closely on a national and international level, coronavirus disease 2019 (COVID-19), as realised by the recent within our networks, our hospitals, units and teams. This is our webinar of the Dutch Society of Intensive Care moderated credo in the Netherlands intensive care networks, as recently by Iwan van der Horst. The link to the webinar can be found emphatically reflected by Verona Gerardu and Iwan van der at the end if this editorial. In this issue, Heder de Vries, Leo Horst in ‘In networks we trust’, as published in this journal.[1] This Heunks and collaborators have compiled a timely summary in notion sets, more than ever, the broad and solid professional order to provide us with an expert opinion on the ventilator base as also timely illustrated by Peter van der Voort and strategies advocated and likely to be pivotal in COVID-19 care collaborators in the last issue of the Netherlands Journal of as discussed in the webinar.[5] Critical Care.[2,3] In our daily practice of COVID-19 care, we are experiencing Although our intensive care units have not changed beyond a broad spectrum of disease manifestations on one side and recognition, we now encounter many ‘new’ professionals in a lack of mechanistic insights and clinical understanding on our usual workplace. Just a few examples are trauma surgeons the other side. Fortunately, as critical care physicians we are coordinating critical care logistics or clinical geneticists who used to personalising our care to the individual patient rather have taken over daily telephone updates to inform family than aiming to rely on scientific evidence that is often in great members on the status of critical care patients. Dedicated contrast with the complexity of the patients we see. anaesthesiologists are introducing the long-term use of volatile In this context, I would like to recommend a very readable and anaesthetics in our intensive care units to counterbalance important recent plea for individualised critical care by Armand the shortage of modern intravenous drugs. Numerous nurse Girbes.[6] His thoughts are gaining even more momentum anaesthetists and scrub nurses are teaming up with critical care and come to our clinical life while facing the great paucity of nurses to provide daily bedside care. Last but not least, we all scientific evidence on COVID-19 care. Although this void of appreciate the indispensable aid and fruitful exchange with our evidence is neither filled, nor are we sure that it ever will be, military colleagues and all other allied professionals involved in this notion or even a ‘renewed focus’ of critical care according managing the current crisis. to Armand Girbes should strongly remind us of the clinical In this sense, we all feel how valuable multidisciplinary care can relevance of individualised medicine. It is the continuing be and how smoothly it can be integrated into our daily routine careful and critical observation at the individual’s bedside that by fostering flexibility and creativity. will ultimately lead us to gain more clinical and ultimately In this issue, the virtue of flexibility and creativity is literally mechanistic understanding. embodied by the creation of ‘dedicated proning teams in the ICU’ authored by Timo Roeleveld, Heder de Vries and Armand In line with these thoughts on individualised care, Lisa Smit and Girbes.[4] Such initiatives are not only embraced as helpful Mathieu van der Jagt provide us with a creative and if you will a
116 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Flexibility, creativity and individualised care in the ICU
bit provocative, well-structured review on ‘promising diagnostic traits now cumulate into a multitude of powerful spin-offs while and therapeutic approaches’ on delirium care in the intensive converting this crisis into noticeable results intended to provide care unit. the best possible critical care for all our individual patients in We are all aware that delirium care is important in this the Dutch intensive care units. COVID-19 pandemic, especially when facing shortages of, for example, short-acting sedatives and critical care personnel, Let’s keep up the spirit ! and delirium in the intensive care unit is certainly a prominent example of how randomised trials have not been able to give us long-awaited answers. Again this emphasises that personalised References care can potentially make a great difference for the individual 1. Gerardu VCA, van der Horst ICC. In networks we trust. Neth J Crit Care. 2020;28:76-7. patient, be it that the underlying scientific evidence will never 2. van der Voort PHJ, de Beer AA, van Stijn I, van der Meer BJM. Network governance of Dutch intensive care units: state of affairs after implementation of the Quality Standard. reach its highest level as outlined by Smit and Van der Jagt while Neth J Crit Care. 2020;28:88-92. highlighting future perspectives of delirium care.[7] 3. van der Voort PHJ, de Beer AA, van Stijn I, van der Meer BJM. Trust in Dutch intensive care networks: the results of a survey. Neth J Crit Care. 2020;28:93-7. 4. Roeleveld T, de Vries H, Girbes A. Dedicated proning teams in the ICU. Neth J Crit Care. 2020;28:118-119. Needless to say, the contribution of Ilona Spaan, Alexander 5. De Vries H, Endeman H, van der Hoeven H, Heunks L. Lung-protective mechanical Vlaar and colleagues in this issue of our journal demonstrates ventilation in patients with COVID-19. Neth J Crit Care 2020;28:120-124. 6. Girbes ARJ, de Grooth HJ. Time to stop randomized and large pragmatic trials for the advantages of an optimised and ‘Lean approach to improve intensive care medicine syndromes: the case of sepsis and acute respiratory distress the organisation of unplanned intensive care admissions’, a syndrome. J Thorac Dis. 2020;12(Suppl 1):S101-S109. 7. Smit L, van der Jagt M. Delirium in the ICU. A structured review of promising diagnostic message that resonates even more clearly in the light of this and therapeutic approaches. Neth J Crit Care. 2020;28:126-133. crisis.[8] 8. Spaan IT, van der Sluijs AF, Boelens AD, et al. A Lean approach to improve the organisation of unplanned intensive care admissions: A before-after analysis. Neth J Crit Care. 2020;28:134-138. Finally, I am particularly grateful to all contributing authors and 9. Boon SC, López Matta JE, Elzo Kraemer CV, Tuinman PR, van Westerloo DJ. POCUS series: E-point septal separation, a quick assessment of reduced left ventricular ejection fraction the editorial team greatly supported by Femke Meijer that we have in a POCUS setting. Neth J Crit Care. 2020;28:139-141. 10. Seubert ME, de Mos M. et al. Harm prevented by using ICU ultrasound prior to got so far and been able to compile this issue of the Netherlands percutaneous dilatational tracheostomy. Neth J Crit Care. 28:142-143. Journal of Critical Care in times of crisis. It is not only the ad hoc effort of our colleagues to contribute timely to this current issue. It is also the endless drive of others to continuously advance our Webinar NVIC dinsdag 7 april knowledge, such as our echo(cardio)graphic skills as reflected Vraag hier een wachtwoord aan om de webinar te bekijken en by the POCUS series effort by David van Westerloo, Pieter Roel [9] scroll naar Webinar NVIC 7 april Tuinman and collaborators. Moreover, valuable case reports are always welcome and of interest to all of us, as represented and described in this issue by Mark Seubert.[10]
I hope in this way that we have succeeded in reflecting a bit https://www.demedischspecialist.nl/ our collective drive and nature of great flexibility and creativity webinars-wetenschappelijke-verenigingen characterising our Dutch intensive care community. These
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 117 Netherlands Journal of Critical Care Submitted April 2020; Accepted April 2020
LETTER TO THE EDITOR
Dedicated proning teams in the ICU
T.C. Roeleveld1, H.J. de Vries1,2, A. Girbes1 1Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands 2Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, the Netherlands
Correspondence T.C. Roeleveld - [email protected]
Dear editor, Human Resources department to look for suitable candidates ICU departments in our country face numerous challenges in to recruit. Since all internships for medical students and non- the current COVID-19 pandemic, including shortages of beds, urgent surgery are cancelled, we initially focused on medical ventilators and personnel. Luckily, various initiatives have students with postponed internships and surgical residents. emerged to tackle these challenges. In this letter, we would Many medical students are currently at home because like to inform our fellow colleagues how we have solved one internships have been cancelled, but they are eager to help of the major problems in our ICU: the lack of personnel and their future colleagues in these challenging times. Having an time for adequate management of prone positioning by forming abundance of medical students in our university clinic, we specialised ‘proning teams’. trained a second group of medical students to continue the proning team when surgical residents are no longer available. Ventilating patients in prone position, commonly known as We edited the hospital protocol to describe the tasks and proning (Dutch: ‘buikligging’), is a well-established intervention responsibilities of the proning team members. The ICU nurse in patients with acute hypoxic respiratory failure.[1] Prone in our new protocol has a supervisory position and assists the positioning improves ventilation in the dorsal lung fields, shifts physician at the head of the team. The medical students and perfusion away from collapsed lung regions and improves surgical residents were trained in our simulation facilities mobilisation of sputum. Current guidelines recommend proning with assessment of their adherence to protocol in emergency patients with severe hypoxic failure, defined as having a PaO2/ situations. During the training we repetitively practised the
FiO2-ratio below 150 mmHg. Proning has improved patient procedure with closed loop communication, planning and outcomes, including mortality, independently from improved identification of problems, and creating awareness of the risks oxygenation.[1] and possible emergencies.
However, there are several challenges to overcome for proning Next, we analysed the position at the head of the proning to be successful. During the proning procedure loss of airway team. ICU physicians were using multiple methods to and vascular access are looming and require immediate action. reach the proning position and the risk of loss of airway is To prevent pressure ulcers patients are positioned facing left and significant and disastrous in patients that are expected to right alternatingly. To support stable positions legs and arms benefit from proning. We reached out to the anaesthesiology are moved to support a straight back position. The procedure department, acknowledging their experience in emergency itself is labour-intensive and requires a coordinated effort of airway management and guidance in a structured standardised five trained professionals. The recent surge of patients in prone protocol. Many anaesthesiologists volunteered and appreciate position causes logistical challenges with limited capacity of the possibility to support the Intensive Care with their expertise. ICU nurses. Whilst evaluating the performance of the proning team, we found that positioning of the proned patients was diverse. Professional Proning Team Physiotherapists were included in the proning team to find the The proning procedure is best performed using a repetitive best position for each patient. standardised approach with all principles of crew resource management in mind. To reduce the workload of ICU nurses Currently ICU nurses and intensivists are supervising the we looked for aspects of the proning procedure that could be proning procedure and assist in case of emergencies, having the replaced by other healthcare providers. We reached out to our flexibility to respond to emergencies with other patients.
118 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Proning teams in the ICU
Since the professional proning team is operational and References performing the proning procedures in most patients, the 1. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory workload for ICU nurses has decreased tremendously, whilst distress syndrome. N Engl J Med. 2013;368:2159–68. adherence to protocols improved and less adverse events, such as loss of ventilator connection of dislocated lines, are Proning teams method and protocol reported. Both nurses and physicians report high satisfaction with the proning team. We feel that the involvement of a multidisciplinary team, consisting of anaesthesiologist, physical therapists and surgical residents, has improved the quality of our proning procedures. This will be beneficial even after the https://njcc.nl/sites/nvic.nl/files/ current crisis. Draaiteams_werkwijze_en_protocol.pdf Our recommendation is to analyse hospital protocols for repetitive, labour-intensive procedures, which can be performed under adequate supervision. Training is paramount to reach an Proning teams instructional video adequate quality and high-risk procedures should be performed by the most experienced available professionals. Together, we can overcome the current challenges and perhaps even improve future care.
Disclosures https://njcc.nl/draaien-ic-patient All authors declare no conflict of interest. No funding or financial support was received.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 119 Netherlands Journal of Critical Care Submitted April 2020; Accepted April 2020
EXPERT OPINION
Lung-protective mechanical ventilation in patients with COVID-19
H.J. de Vries1, H. Endeman2, J.G. van der Hoeven3, L.M.A. Heunks1 1Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands 2Department of Intensive Care, Erasmus MC, Erasmus University Rotterdam, Rotterdam, the Netherlands 3Department of Intensive Care, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
Correspondence L.M.A. Heunks - [email protected]
Keywords - mechanical ventilation, SARS-CoV-2, COVID-19, corona
Introduction COVID-19: one disease, different phenotypes Infection with the novel coronavirus (SARS-CoV-2) can cause Several publications[3,4] and personal observations by the authors corona-virus infectious disease (COVID-19), which is generally indicate that severe ‘COVID-19’ is different from typical ARDS, characterised by mild respiratory symptoms among other especially in the early phase of COVID-19. Key differences clinical features.[1,2] Some patients develop severe hypoxaemic include: respiratory failure requiring ICU admission for respiratory 1. A relatively high compliance of the respiratory system, support and ultimately mechanical ventilation. suggesting preserved lung volume; Interestingly, many of these patients exhibit markedly 2. Low recruitability with PEEP; different physiological characteristics when compared with 3. High intrapulmonary shunt fractions, disproportionate to the ‘typical’ ARDS, especially severe hypoxaemia, exceeding the loss of ventilated lung area. abnormalities in respiratory mechanics (i.e. relatively preserved compliance with severe hypoxaemia). Thus, the COVID-19 However, in some patients, the physiology appears to resemble patients might benefit from a different ventilation strategy to classical ARDS with high respiratory elastance (the inverse of ensure lung-protective ventilation. compliance, defined as change in volume divided by change The aim of the current article is to briefly summarise the in pressure (ΔVolume/ΔPressure)) and higher recruitablity. respiratory physiology of severe COVID-19 and provide Gattinoni proposed two different phenotypes[4]: L-type and recommendations for lung-protective mechanical ventilation H-type (figure 1) representing the ends of a spectrum (figures in these patients. The recommendations in this manuscript are 1 and 2). Figure 2 shows CT scans of six different COVID-19 based on small observational trials and case series, as reliable patients. The patient on the far left is a typical L-type patient data from COVID-19 patients are still scarce and large trials are and the one on the far right a typical H-type patient. lacking. Thus, these recommendations are merely expert opinion and do not meet the criteria for ‘evidence-based medicine’. However, it is clear that some patients have features of both the Moreover, understanding of this disease is developing rapidly L-type and H-type. In fact, it is possible that L-type patients and new insights may require update of the recommendations evolve into H-type, either spontaneously, or due to high published in this article. We advise readers to consult the website lung stress with non-lung-protective mechanical ventilation of the Dutch Society of Intensive Care Medicine (nvic.nl) for the (ventilator-induced lung injury, VILI) in the already-inflamed latest updates. The link can be found at the end of this article. lung.[5] Interestingly, high patient respiratory effort has been This article does not discuss the possible application of advanced proposed to result in lung injury, known as patient self-inflicted respiratory monitoring techniques and interventions such as lung injury (P-SILI).[6] High patient effort may develop before transpulmonary pressure measurements, electronic impendence intubation, or with partially supported modes.[7.8] It appears tomography, extracorporeal membrane oxygenation and that many COVID-19 patients exhibit high respiratory drive, extracorporeal carbon dioxide removal as these are not widely possibly due to stimulation of lung irritant, stretch, and available. Especially the application of extracorporeal techniques J-receptors.[7,9] The proposed role of P-SILI in the evolution should be discussed with expert centres. from H-type to L-type needs further evaluation.
120 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Mechanical ventilation in COVID-19
In conclusion, from the respiratory physiological perspective, patient exhibits persisting hypoxaemia despite low-flow oxygen COVID-19 is not a single entity but has rather different administration. Earlier studies in hypoxaemic respiratory failure appearances. This may have important implications for the have shown favourable results for HFNC compared with NIV or ventilation strategies. low flow oxygen through a face mask.[11.12] Early observations suggest that about 75% of patients that require HFNC will L-Type H-Type eventually require intubation, therefore close monitoring of Low elastance oxygenation (SpO ) and breathing effort (respiratory rate, use High elastance 2 Low lung weight High lung weight of accessory respiratory muscles, and ROX index, defined as the Low V/Q Spontaneous evolution High R-L shunt Low recruitability VILI ratio of SpO2/FiO2 to respiratory rate) is recommended. High recruitability Low hypoxic pulm. vasoc.* P-SILI* Earlier studies indicated increased risk of intubation and even mortality with NIV in community-acquired pneumonia.[11] Figure 1. Subtypes of COVID-19 pneumonia Thus, we advise against the use of NIV in COVID-19, especially Two phenotypes are hypothesised to exist in COVID-19 ARDS. The first in patients exhibiting high respiratory drive. If HFNC is not subtype, L-type, is characterised by high compliance of the respiratory available, a short trial of NIV under close monitoring (SpO2, system (and thus low elastance), relatively unaffected lung aeration, tidal volume) may be considered. and thus low lung-recruitability. The hypoxaemia often observed in these patients might be explained by loss of hypoxic pulmonary Using a helmet interface for CPAP or NIV might improve vasoconstriction, although evidence for this hypothesis is lacking. the outcome of patients with ARDS.[13] The possibility to use Due to spontaneous progression of the disease, ventilator-induced higher PEEP may improve oxygenation and reduce respiratory lung injury (VILI) and/or patient self-inflicted lung injury (P-SILI), the drive. Many centres in Italy (and a few in the Netherlands) have L-phenotype might evolve into the H-phenotype. The H-phenotype applied the helmet interface in the treatment of hypoxaemic is more comparable to ‘typical’ ARDS, characterised by extensive lung failure in COVID-19, and report good patient tolerance and consolidations, widespread lung oedema, and shunting in collapsed improved symptoms. lung regions.
Figure 2. CT scans from patients with confirmed COVID-19 pneumonia Invasive mechanical ventilation Computed tomography images from 6 patients with confirmed A. Tidal volumes COVID-19 pneumonia. The far left scan might be from a patient Although mechanical ventilation is life-saving, the pressures with the L-phenotype: apart from minor ground-glass opacities no and volumes delivered by the ventilator might contribute to the large disturbances are found. The scan on the right shows major development of further lung injury.[5] consolidations and loss of lung aeration, and might fit the H-phenotype. The cornerstone of lung-protective ventilation is adhering to a The scans in between show progressively worse deviations from normal low tidal volume, usually defined as ±6 ml/kg ideal body weight.[14] lung morphology, illustrating that COVID-19 can result in a diverse Until more evidence is available, there is no reason to divert pathophysiological spectrum. from these guidelines in COVID-19. It is important not to use a patient’s current weight, but instead to calculate the predicted body weight: Non-invasive ventilation PBWMale: 0.9 * (length-152) + 50 (Kg)
Non-invasive respiratory support, such as high flow nasal PBWFemale: 0.9 * (length-152) + 45 (Kg) cannula (HFNC), non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been applied Low tidal volumes predispose patients to develop hypercapnia to prevent endotracheal intubation. The use of HFNC, CPAP and concomitant acidosis. To limit hypercapnia, minute volume or NIV is controversial due to increased risk of contamination can be raised by setting the breathing frequency up to ±30/min. of healthcare workers. Although no data exist that demonstrate Care should be taken to avoid development of intrinsic PEEP at increased risk of contamination with appropriate personal these higher respiratory rates (and thus shorter expiratory times). protective equipment,[10] this topic is beyond the scope of Intrinsic PEEP can be suspected if expiratory flow does not this article. If available, we advise to consider HFNC when a reach 0L/sec. Persistent hypercapnia at a breathing frequency of
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 121 Netherlands Journal of Critical Care Mechanical ventilation in COVID-19
30/min can be accepted to facilitate lung-protective ventilation (‘permissive hypercapnia’). A formal lower limit to the pH that is still acceptable is unknown, but there are no known studies that suggest that a pH up to 7.20 is deleterious, unless the patient has elevated intracranial pressures or pulmonary hypertension. Thus, we advise to adhere to 6 ml/kg, especially in the early phase, and accept a pH of up to 7.20
B. End-inspiratory plateau pressure Tidal volumes is not the only parameter that contributes to ventilation-induced lung injury, as can be illustrated with figure 3.
Figure 4. Screenshot from the ventilator monitor during an end- inspiratory occlusion. The airway pressure drops from the peak pressure to a stable plateau after an inspiratory hold of 3-5 seconds. Figure 3. Two CT scans from patients with ARDS Computed tomography images in the transversal plane from two different patients with confirmed ARDS according to the Berlin criteria. C. Driving pressure The lungs in the left image show mostly dorsal collapse of lung tissue, The driving pressure is the difference in alveolar pressure meaning most lung tissue is still able to participate in ventilation. The between end inspiration and end expiration: lungs in the right image are almost completely collapsed, only the right Driving pressure = Pplat – PEEPtot frontal lobe can contribute to ventilation. The driving pressure was found to correlate better with mortality than tidal volume per ideal bodyweight in a large (retrospective multilevel mediation analysis) trial with 3562 ARDS patients.[16] Both patients in this example (figure 3) meet the Berlin criteria If compliance is considered to be a marker for disease severity, for ARDS[15] and have an ideal bodyweight of 70 kg, meaning a driving pressure is essentially tidal volume corrected for disease recommended tidal volume of 6 ml/kg * 70 kg = 420 ml. If this severity: volume is administered to the lungs of the patient on the left, the volume will be distributed rather evenly over the healthy Driving pressure (cmH2O) = tidal volume (ml) / compliance parts of the lung, meaning the ‘stretch’ posed on the lung tissue respiratory system (ml/cmH2O) is low. If the same 420 ml is administered to the lungs of the right patient, all the volume will be transmitted to the small Accordingly, the physiological rationale of driving pressure is part of the lung that is not collapsed, causing a major rise in appealing. local stress and strain. The stress and strain caused by a certain We therefore recommend driving pressure below <15 cmH2O tidal volume can be estimated by measuring two important during controlled mechanical ventilation,[16] although this study pressures: the end-inspiratory plateau pressure and the driving essentially suggested that no threshold value exists: the lower the pressure. driving pressure, the better the outcome. Because the compliance of many patients with COVID-19 remains relatively high, the observed The end-inspiratory plateau pressure estimates the stress posed driving pressures are usually low, especially in L-type patients. on the lung tissue at end-inspiration. It can be measured during an end-inspiratory occlusion, which causes flow to cease and D. Positive end-expiratory pressure (PEEP) consequently causes pressure in the ventilator to equilibrate Setting PEEP at the right level for the individual patients is with alveolar pressure (figure 4). It is recommended to maintain still a point of debate in ARDS. Ideally, specific monitoring [14] the plateau pressure below 28-30 cmH2O. techniques (including electrical impedance tomography,
122 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Mechanical ventilation in COVID-19
oesophageal pressure monitoring or functional residual communication with other centres, it appears that early supine capacity measurements) are used to select the appropriate PEEP position (within 24 hours of prone position) results in rapid and for each patient, but these techniques have not been widely severe deterioration of oxygenation. implemented, nor proven to improve clinical outcome. A few preliminary studies have assessed the influence of PEEP F. Muscle relaxants on oxygenation and respiratory mechanics in patients with Although earlier randomised studies found a survival benefit when COVID-19. Although selection bias is of concern, it seems using muscle relaxants during the early phases of severe respiratory that recruitability with PEEP in many COVID-19 patients is failure,[20] a subsequent larger study did not demonstrate survival limited.[3] In patients with predominantly characteristics of the benefit over light sedation.[21] A more thorough analysis of this L-phenotype (i.e. high compliance), it seems reasonable to use subject falls outside of the scope of this article. lower PEEP. Pragmatically, we suggest using the ‘low PEEP / We suggest using muscle relaxants in the early phase of high FiO2 table’ from the ARDSnet(17): COVID-19 in patients with respiratory effort leading to substantial patient-ventilator asynchronies, despite deep Table 1. Low PEEP/ high FiO 2 sedation. We advise to interrupt muscle relaxants daily to
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 evaluate patient-ventilator interaction. PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 G. Partially supported mechanical ventilation Selecting the appropriate moment to switch from controlled A disadvantage of a lower PEEP strategy is that potentially mechanical ventilation to a partially supported mode is still recruitable lung tissue remains collapsed, especially in patients a major point of debate in ARDS. In the early phase of ARDS with extensive consolidation or a low compliance of the chest respiratory drive may be injuriously high[7,8] and the use of wall (obesity, ascites). In these patients, the ‘high PEEP / low partially supported modes may facilitate the development of [6,22] FiO2 table’ can be used: P-SILI, although firm evidence is lacking.
Table 2. High PEEP/ low FiO 2 We suggest switching to a partially supported mode when the
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 PaO2/FiO2 ratio improves, and arterial pH is >7.35. Each patient PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24 should be evaluated daily to decide whether it is time to switch to a partially supported mode. If a patient is switched to a partially supported mode, we suggest monitoring the respiratory drive The potential disadvantages of a higher PEEP strategy include with the commonly available airway occlusion pressure (P0.1). [23,24] a potential hyperinflation of relatively healthy lung regions, The normal range of P0.1 is between 1.0 and 4.0 cmH2O. and an increased afterload of the right ventricle, which might We suggest increasing the level of sedation if breathing effort hamper circulation. or tidal volumes remain high during partially supported modes, or consider reinstitution of controlled mechanical ventilation. We advise against regularly using recruitment manoeuvres in COVID-19, as the potential for recruitment in these patients H. Weaning from mechanical ventilation seems low and previous studies in ARDS have shown harm in Currently, there is no literature to suggest that weaning from ARDS patients undergoing recruitment manoeuvres.[18] mechanical ventilation in COVID-19 is substantially different from typical ARDS. We therefore refer to the recent guideline E. Prone position ‘weaning from mechanical ventilation’ available from the NVIC Mechanical ventilation in prone position improves the outcome website (see the end of this article for the link). Notably, it is if applied early in the course of moderate-to-severe ARDS (PaO2/ the authors impression that reintubation in COVID-19 is more [19] FiO2 <150 mmHg). Experience by clinicians and preliminary frequent compared with typical ARDS, even after successfully data suggest that oxygenation improves in most COVID-19 passing a spontaneous breathing trial. patients with proning. We advise to ventilate COVID-19 patients with moderate-to-severe ARDS (PaO2/FiO2 <150 I. Miscellaneous mmHg) in prone position. We suggest keeping these patients • There are currently no data available on the percentage in prone position until improvement in respiratory mechanics of patients that develop ‘non-resolving’ ARDS and / or and / or PaO2/FiO2 ratio. Although patients in clinical studies pulmonary fibrosis in response to COVID-19. In case of non- were returned to supine daily,[19] under the current special resolving COVID-19 corticosteroids may be considered, if circumstances it can be advisable to leave patients in the prone active pulmonary infections (including aspergillus) can be position for 2-3 days. In our clinical experience, and personal ruled out. We suggest to discuss this with expert centres.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 123 Netherlands Journal of Critical Care Mechanical ventilation in COVID-19
14 The Acute Respiratory Distress Syndrome Network. Ventilation with Lower Tidal Volumes We recommend against the use of corticosteroids in the as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute early phase of COVID-19, given the adverse outcome after Respiratory Distress Syndrome. N Engl J Med. 2000;342:1301-8. [25] 15 Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: The treatment with corticosteroids in other viral pneumonias. Berlin definition. JAMA. 2012;307:2526-33. • An increasing number of observations suggests that 16 Amato MBP, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2014;372:747-55. COVID-19 patients are more susceptible to developing 17 Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory thrombotic events such as pulmonary embolism. It is pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327-36+411. therefore important to consider pulmonary embolism with 18 Cavalcanti AB, Suzumura ÉA, Laranjeira LN, et al. Effect of lung recruitment and titrated acute respiratory (or haemodynamic) deterioration (especially Positive End-Expiratory Pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome - A randomized clinical trial. JAMA. 2017;318:1335-45. increased dead space) of a ventilated COVID-19 patient. 19 Guérin C, Reignier J, Richard J-C, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2013;368:2159-68. 20 Papazian L, Forel J-M, Gacouin A, et al. Neuromuscular Blockers in Early Acute Respiratory Disclosures Distress Syndrome. N Engl J Med. 2010;363:1107-16. 21 Moss M, Huang DT, Brower RG, et al. Early neuromuscular blockade in the acute All authors declare no conflict of interest. No funding or respiratory distress syndrome. N Engl J Med. 2019;380:1997-2008. financial support was received. 22 Goligher EC, Fan E, Herridge MS, et al. Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort. Am J Respir Crit Care Med. 2015;192:1080-8. 23 Telias I, Damiani F, Brochard L. The airway occlusion pressure (P0.1) to monitor respiratory References drive during mechanical ventilation: increasing awareness of a not-so-new problem. Intensive Care Med. 2018;44:1532-5. 24 de Vries H, Jonkman A, Shi Z-H, Man AS, Heunks L. Assessing breathing effort in 1 Guan W, Ni Z, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N mechanical ventilation: physiology and clinical implications. Ann Transl Med. 2018;6. doi: Engl J Med. 2020; NEJMoa2002032. 10.21037/19953. 2 Wu Z, McGoogan JM. Characteristics of and Important Lessons from the Coronavirus 25 Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases from treatment for 2019-nCoV lung injury. Lancet. 2020;395:473-5. the Chinese Center for Disease Control and Prevention. JAMA. 2020;323:1239. 3 Pan C, Chen L, Lu C, et al. Lung Recruitability in SARS-CoV-2 Associated Acute Respiratory Distress Syndrome: A Single-center, Observational Study. Am J Respir Crit Care Med. 2020; rccm.202003-0527LE. Consult the NVIC website for the latest updates on COVID-19 4 Gattinoni L, Coppola S, Cressoni M, Busana M, Chiumello D. Covid-19 Does Not Lead to a ‘Typical’ Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020; rccm.202003-0817LE. 5 Slutsky AS, Ranieri VM. Ventilator-Induced Lung Injury. N Engl J Med 2013;369: 2126-36. 6 Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195:438-42. 7 Jonkman AH, De Vries HJ, Heunks LMA. Physiology of the Respiratory Drive in ICU Patients: Implications for Diagnosis and Treatment. Crit Care. 2020;24:104. 8 Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory drive in critically ill patients: Pathophysiology and clinical implications. https://nvic.nl/covid-19 Am J Respir Crit Care Med 2020;201:20-32. 9 Oppersma E, Doorduin J, van der Heijden EH, van der Hoeven JG, Heunks LM. Noninvasive ventilation and the upper airway: Should we pay more attention? Crit Care. 2013;17:245. Guideline ‘weaning from mechanical ventilation’ 10 Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Med. 2020. doi:10.1007/s00134-020-06022-5. 11 Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372:2185-96. 12 Rochwerg B, Granton D, Wang DX, et al. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med. 2019;45:563-72. 13 Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of noninvasive ventilation https://nvic.nl/richtlijnen/beademing- delivered by helmet vs face mask on the rate of endotracheal intubation in patients with ontwenning-van-2018 acute respiratory distress syndrome a randomized clinical trial. JAMA. 2016;315:2435-41.
124 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Submitted September 2019; Accepted February 2020
REVIEW
Delirium in the ICU – A structured review of promising diagnostic and therapeutic approaches: Next steps in ICU delirium
L. Smit, M. van der Jagt Department of Intensive Care Adults, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
Correspondence L. Smit - [email protected]
Keywords - delirium, intensive care unit, critical care, critical illness, therapeutics, diagnosis, critical care outcomes
Abstract Screening Checklist (ICDSC),[10] is strongly recommended by Background: The purpose of this review is to provide a the 2018 ICU Pain, Agitation/Sedation, Delirium, Immobility, structured overview of emerging diagnostic and therapeutic and Sleep Disruption in Adult Patients in the ICU (PADIS) modalities for delirium in critically ill patients. guidelines in order to improve the identification of delirium Methods: Literature searches were carried out to identify relevant and delirium management.[11] The accuracy of these two tools, articles for both diagnostic and therapeutic approaches other than however, varies in different ICU populations.[12] Also, in 2013 those included in the 2018 Pain, Agitation/Sedation, Delirium, the Diagnostic and Statistical Manual fourth edition (DSM- Immobility, and Sleep Disruption in Adult Patients in the ICU IV) was revised into DSM-5, along with a change in criteria guidelines, including prospective and retrospective studies. for delirium diagnosis.[13] Consequently, we should explore Results: Regarding diagnostic approaches seven articles were methods for diagnosing delirium in the ICU which are more included. The Neelon and Champagne (NEECHAM) Confusion accurate and easier to administer. Furthermore, evidence on Scale, Stanford Proxy Test for Delirium (S-PTD), and DelApp- effective therapies for delirium is very scarce.[11] Small studies ICU yielded excellent diagnostic performances. We included have been conducted on the efficacy of therapeutic approaches seven articles studying different therapies. Some therapies not discussed in the 2018 PADIS guidelines. In this structured showed potential to decrease the burden of delirium, using review, we aim to provide an overview of potentially new different pathophysiological pathways than antipsychotics. diagnostic and therapeutic approaches for delirium in the ICU. Conclusion: Alternative screening tools may help in ICU delirium detection, either as replacement or combined with Methods the Confusion Assessment Method for ICU (CAM-ICU) This is a structured review aiming to describe alternative and Intensive Care Delirium Screening Checklist (ICDSC), diagnostic and therapeutic approaches to ICU delirium, and other therapies than antipsychotics may reduce delirium compared with those described in the 2013 Pain, Agitation burden, but further studies are required. and Delirium (PAD) and 2018 PADIS guidelines.[11, 14] To that end, two separate literature searches (one aimed at diagnostic Introduction approaches and another one at therapeutic approaches) were Delirium is a common form of acute cerebral dysfunction, carried out by a biomedical information specialist of the occurring in 11% to 80% of critically ill patients.[1,2] It Erasmus Medical Center library in the electronic databases is characterised by an abrupt disturbance of attention, Embase, Medline (Ovid), Web of Science, Cochrane and Google consciousness and either perception or cognition, and has been Scholar until 29 April 2019. The selection of articles was done associated with deleterious long-term outcomes, among which by one of the authors (LS). increased mortality rates and cognitive impairment.[3-7] The reference standard for diagnosing delirium is the Diagnostic Article search and Statistical Manual of Mental Disorders, 5th edition (DSM- Titles and abstracts of the articles were screened for eligibility. 5) criteria as assessed by delirium experts.[8,9] However, due to Subsequently we screened the full text of articles meeting our sedation and mechanical ventilation the detection of delirium in inclusion criteria. For both searches, we included English full the ICU is challenging. Routine delirium screening in the ICU text articles involving adult ICU patients. Both prospective with a valid screening tool, such as the Confusion Assessment and retrospective studies were considered for this review. We Method for ICU (CAM-ICU)[1] or Intensive Care Delirium excluded review articles, meta-analyses, case reports, letters to
126 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Delirium in the ICU
the editor, and abstracts that did not result in original papers. Bedside screening tools We collected information on the authors, journal, year of The Neelon and Champagne (NEECHAM) Confusion Scale has publication, study design, inclusion period, number of patients, good diagnostic accuracy for delirium in non-intubated older numbers of observations, and patient population. surgical ICU and mixed ICU patients, with a reported sensitivity Diagnostic approaches: Search terms included DSM-5, CAM- of 99.2% and 87%, respectively, and a specificity of 95% for both ICU, ICDSC, delirium, ICU and associated free terms (see ICU populations, as compared with the CAM-ICU. It assesses appendix 1 for details). We included articles comparing any information processing, behaviour and physiological condition, diagnostic tool for ICU delirium with DSM-5 as the reference, leading to a numeric score and the ability to classify patients as published after 2013 (publication of the DSM-5 [9]), and articles ‘delirious’ (score below 20), ‘at risk’, ‘mild confusion’ and ‘normal’. assessing diagnostic tools with CAM-ICU or ICDSC as the The NEECHAM Confusion Scale may be an easy to use scale reference standard, published after 2001 (the publication for bedside nurses, taking less than 10 minutes to complete.[20] validation studies of both CAM-ICU and ICDSC[1, 10]). Articles Advantages are that the categories ‘at risk’ and ‘mild confusion’ not mentioning any quantitative data, such as sensitivity, give opportunities for preventive measures as compared with specificity, positive predictive value, area under the curve or CAM-ICU, which is a binary scale. Caution however is warranted receiver operating characteristic curve, were excluded. We for cardiac surgery patients, as its sensitivity is reported to be specifically extracted total number of patients diagnosed with 67%.[19] Another limitation is that its use in ventilated patients is delirium, APACHE score and sensitivity and specificity of the not validated.[19] The Stanford Proxy Test for Delirium (S-PTD) diagnostic tools, when available. on the other hand may be a fitting tool for intubated patients.[21] Therapeutic approaches: Search terms included among Twelve items are assessed, including various cognitive processes, others delirium, ICU, delirium and coma-free days, therapy awareness and alertness, perceptions, visuospatial abilities and and associated free terms (see appendix 2 for details). We sleep pattern. The S-PTD yielded an excellent sensitivity (82.7%) selected original articles assessing therapeutic approaches and specificity (95.3%) for ICU delirium diagnosis as compared for ICU delirium, which had not been discussed in the 2018 with DSM-5 based neuropsychiatric examination.[21] Advantages PADIS guidelines (i.e. we excluded articles on antipsychotics, are that this test takes one minute to administer by an ICU nurse HMG-CoA reductase inhibitors, dexmedetomidine, bright and that no patient interaction is required. light therapy, and multicomponent intervention bundles). We excluded prophylactic or prevention intervention trials, Computerised and smartphone-based tests and studies related to alcohol or substance withdrawal. We The Edinburgh Delirium Test Box (EDTB) for the ICU specifically extracted patient population, delirium and coma- may be able to discriminate between delirious and non- free days, and APACHE score. delirious ICU patients.[22] The EDTB-ICU is a custom-built computerised device which measures arousal and sustained Assessment of risk of bias in included studies visual attention. The DelApp-ICU is a smartphone-based We used the validated Cochrane Risk of Bias Tool to assess test developed to administer the EDTB-ICU.[23] With this the risk of bias for included randomised controlled trials,[15] application, a behavioural assessment is performed initially in and the Quality Assessment of Diagnostic Accuracy Studies order to examine arousal (maximum score of 3) and a visual (QUADAS)-2 tool for included diagnostic studies.[16] For task to identify visual changes. After successful completion, observational studies the Newcastle-Ottawa Quality Assessment the sustained attention test is performed. During nine trials Form was used.[17] We classified the type of research according patients have to indicate the amount of circles shown on the to the algorithm published by Grimes & Schulz.[18] smartphone, leading to a total score from 0 to 9. Hence, the total score obtained during the attention task ranges between 0 Statistics and 12. With the graded measure of attention, it might provide Due to the narrative character of this review, statistical analysis physicians with a degree of delirium severity. A DelApp-ICU was not appropriate for the summary of study data. Meta- score of ≤6 has a delirium detection sensitivity of 100% and a analysis was therefore not attempted or possible, also given the specificity of 96%. The DelApp-ICU requires little training, fact that we focused on articles that did not comply with the can be used in non-ventilated as well as ventilated patients, evidence level aimed at in the PADIS guidelines. and is easy to use, taking 3-8 minutes to administer. Despite its promising diagnostic potential, this was an initial exploratory Results study with a small sample size, and further evaluation and Diagnostic approaches for delirium in the ICU: search results validation is necessary. Limitations of this application and Our literature search into new diagnostic approaches identified other smartphone-based tests include concerns about infection seven articles meeting inclusion criteria (appendix 3). The control, discouragement of using phones on an ICU, and limited characteristics of the included studies can be found in table 1. application in case of visual impairment.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 127 Netherlands Journal of Critical Care Delirium in the ICU
Table 1. Main characteristics of the studies evaluating new diagnostic tools
Study Study Inclusion period Tool studied N No. of ob- Patient Delirious Mean APA- Sensitivity Specificity Risk of design servations population patients (%) CHE II score bias?*
Bedside screening tools
Alosaimi et Cross- June 2016-Oct S-PTD by 135 ICU - ICU and DSM-5: - S-PTD≥2: S-PTD≥2: Yes al. 2018 [21] sectional 2017 nurse vs. patients 3 general 44/135 86.4%; 91.2%; study DSM-5 by (out medical (32.6%) S-PTD≥3: S-PTD≥3: psychiatrist of 288 wards S-PTD: 79.6% 97.8% total) 37/135 (27.4%) Matarese et Cross- 1 Oct 2008-30 NCS vs. 41 164 Surgical ICU 27.3% - Cut-off 25: Cut-off 25: Yes al. 2013 [19] sectional Apr 2009 CAM-ICU 99.19% 95% study Van Cross- July-Aug 2006 & NCS vs. 172 559 Mixed CAM-ICU: 21 Cut-off 20: Cut-off 20: Yes Rompaey et sectional Feb-Mar 2007 CAM-ICU ICU, non- 19.8%; 87% 95% al. 2008 [20] study intubated NEECHAM scale: 20.3% Computerised and smartphone-based tests
Tang et al. Case- - DelApp-ICU 46 89 General ICU 21 (46%) 14 DelApp-ICU DelApp-ICU Yes 2018 [23] control vs. CAM-ICU score 6: score 6: study 100% 96%
Green et al. Case- - EDTB-ICU vs. 30 79 General ICU 38% 18 (median); EDTB-ICU EDTB-ICU Yes 2017, [22] control CAM-ICU delirious: score ≤ 5: score ≤ 5: study 22; non- 100% 92% delirious: 14 Continuous electroencephalography (EEG)
Plaschke et Case- - Bilateral BIS 114 - After 32 (28%) Delirious: 27% 96% Yes al. 2010 [24] control vs. CAM-ICU cardiac 28.5; non- study surgery delirious: 26.5 Chart-based methods
Pisani et al. Cohort 3 Sept 2002-30 Validated 178 1457 Medical ICU, 143 (80%) 23.4 64% 85% Yes 2006 [25] study Sept 2003 chart-based patient patients patients; delirium days ≥60 years 929/1457 method vs. (64%) CAM-ICU patient- days
BIS = Bispectral index; CAM-ICU = Confusion Assessment Method for the ICU; EEG = electroencephalography; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th edition; EDTB-ICU = Edinburgh Delirium Test Box-ICU; NCS = Neelon and Champagne (NEECHAM) Confusion Scale; S-PTD = Stanford Proxy Test for Delirium. * Risk of bias is assessed with the QUADAS-2 tool. Its more extensive assessments may be found in table 4.
Electroencephalography is assessed daily with the CAM-ICU combined with a validated Electroencephalography (EEG) might be promising considering chart review method, in which the patient’s medical record is the limitations of intermittent assessment of bedside screening examined for symptoms of acute confusion.[25] The chart-based tools and the fact that healthcare personnel may find the bedside method had a sensitivity of 64% and a specificity of 85% as tools cumbersome. However, continuous EEG is relatively compared with the CAM-ICU. However, this method is time- expensive, needs time-consuming 16-channel cortical function consuming with 15 to 30 minutes spent per patient. Additionally, monitoring, and requires training for interpreting the obtained while the chart-based method may be effective for research data. Bilateral Bispectral Index (BIS) EEG measurements settings, the CAM-ICU may still be preferred for application in require a four-channel frontotemporal EEG system and hence clinical use due to its better diagnostic performance. may be more practical. In cardiac surgery patients, the BIS EEG data were different for patients who experienced postoperative New treatments for ICU delirium: search results delirium as opposed to non-delirious patients, with a lower Our literature search yielded 6326 articles, of which seven were mean BIS index, relative alpha slowing and increased relative included in this review (appendix 4). Characteristics of the theta activity.[24] Bilateral BIS index as a screening tool for included articles may be found in table 2. postoperative ICU delirium was found to have a sensitivity of 27% and specificity of 96%.[24] Pharmacological management of delirium Other medications than antipsychotics which are already in use Assessment methods based on the patients’ medical record in ICUs might be beneficial for treating ICU delirium. Opioids Pisani et al. described a research algorithm in which delirium are frequently used as analgesic agents in the ICU, but have
128 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Delirium in the ICU
Table 2. Main characteristics of the studies evaluating new therapeutic approaches
Study Study design Intervention Inclusion N No. of ob- Patient popu- Delirium rela- APACHE II Risk of Remarks period servations lation ted outcomes score bias*
Pharmacological management of delirium
Bakri et al. Randomised i.v. 1 µg/kg 2dd 23-month 96 - Postoperative No significant - Low Significantly 2015 [28] controlled dexmedetomidine period delirium difference in more patients trial or 4mg 2dd in trauma mean daily in ondansetron ondansetron patients ICDSC scores group used vs. 5mg 2dd and remaining rescue haloperidol during number of haloperidol in 3 consecutive days delirious higher dose patients at last day of study Bayindir et Descriptive Single dose - 35 - Coronary Significant - High No valid al. 2000 [27] study ondansetron 8mg artery bypass decrease of delirium i.v. graft surgery delirium score screening tool 10 minutes used after gift
Gagnon et Descriptive Valproate; 42% Dec 2012- 53 522 Mixed ICU Incidence Median High Significant al. 2017 [29] study with loading dose; Feb 2015 patient- of delirium APACHE III: 59 reduction in maintenance dose days decreased from agitation and 1500mg/d (23 mg/ valproate day 1 daily amount of kg/d) in 1-4 doses to day 3: 68% vs administered 49%, p=0.012 fentanyl and lorazepam equivalents Atalan et al. Randomised 5mg Morphine i.m. Jan 2010- 53 - Postoperative Delirium hours: 5.69±1.93 High Morphine 2013 [26] controlled vs. 5mg Haldol i.m. July 2012 hyperactive morphine (haldol) vs. group: less trial delirium 31.56, haldol 6.33±1.79 additive in cardiac 33.9 (p=0.607) (morphine), sedative drug surgical p=0.218 (8 vs 1 patient, patients p=0.011), less reintubation (23.1% Haldol vs 3.7%, p=0.050) Thom et al. Cohort study Ramelteon 1 Oct 2015- 322 - Medical ICU DCFH: No 24.5±7.5 Low Ramelteon was 2018, [31] 31 May 2016 ramelteon: 0 (ramelteon) not associated (IQR 0-196), vs. 23.9±8.4 with changes ramelteon: 46 (no in extubation (IQR 0-168), ramelteon), or mortality. p=0.105 p=0.600 Ramelteon more median ventilator-free hours (156 vs. 4.5, p=0.005), but most likely due to administration of ramelteon postextubation Daniels et al. Cohort study No 1 July 2015- 449 - Medical ICU No reduction Median Low Melatonin or 2018 [30] pharmacological 30 June 2016 of delirium APACHE III: antipsychotics treatment, duration Total 75. did not reduce melatonin only, Neither: 73.0; ICU/hospital antipsychotics only, Melatonin: 78; LOS or 28-day both melatonin and Antipsychotic: mortality. antipsychotics 79; Both: 79; Antipsychotic p=0.04 use only associated with longer hospital LOS Non-pharmacological treatment options
Mailhot et Randomised Nursing 2 June 2013- 30 - Post cardiac Mean - High No difference al. 2017 [32] controlled intervention 6 June 2015 surgery ICU delirium days: in delirium trial involving families Intervention: severity. in delirium 1.94; control: Significant management vs 4.14. (no p differences usual care value available) favouring intervention for patients’ psycho- functional recovery
APACHE = Acute Physiology and Chronic Health Evaluation; DCFD = delirium and coma-free days; DCFH = delirium and coma-free hours; DSI = delirium severity index; ICDSC = intensive care delirium screening checklist; i.m. = intramuscularly; i.v. = intravenously; LOS = length of stay *Risk of bias is assessed with either the Cochran Risk of Bias Tool or the Newcastle-Ottawa Quality Assessment Form. Its more extensive assessments may be found in table 3 and table 5.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 129 Netherlands Journal of Critical Care Delirium in the ICU
anxiolytic properties if used in higher dosages.[26] Atalan et al. antipsychotics on ICU delirium duration as compared with no studied the efficacy of morphine for postoperative hyperactive treatment.[30] No other beneficial effects on relevant patient delirium in cardiac surgical patients as compared with outcomes were found, such as ICU and hospital length of stay haloperidol in dosages of 5 mg intramuscularly.[26] They found and mortality. Similarly, another recent retrospective study no differences between the two groups with regard to delirium found no effect of ramelteon, a melatonin receptor agonist, on duration, but did report a lower reintubation rate, less sedative median delirium-and-coma free hours, nor was administration use and more patients with target Richmond Agitation-Sedation of ramelteon associated with length of mechanical ventilation Scale (RASS) scores in the morphine group. Ondansetron, a or mortality rates.[31] selective 5-hydroxytryptamine 3 receptor antagonist involved in the serotonergic system with anxiolytic properties, has also Non-pharmacological treatment options been studied for the treatment of ICU delirium. A prospective Recently the importance of involving family members in routine study in postcardiotomy patients described a decrease in patient care gained more attention. Mailhot et al. conducted a pilot agitation and delirium shortly after a single dose of 8 mg randomised controlled trial studying the feasibility of a nursing intravenous ondansetron was administered.[27] However, this intervention involving family caregivers in delirium management.[32] study was performed without a valid delirium screening tool They found a significant difference in psycho-functional recovery and lacked a control group. The efficacy of ondansetron for in patients who received delirium management interventions by postoperative delirium in a trauma ICU has been studied in family caregivers. Differences in other outcomes favoured the a randomised controlled trial, comparing dexmedetomidine intervention group, among which delirium duration, hospital and ondansetron with haloperidol in 96 patients.[28] No length of stay, and anxiety and self-efficacy experienced by the differences were found between the study groups. However, in caregivers. These results, however, did not reach statistical the ondansetron group more rescue haloperidol was needed to significance as this was a pilot study with a small sample size. obtain the same anti-delirium effects. For dexmedetomidine as well as ondansetron no QTc interval prolongation or serious Risk of bias of included studies adverse events were reported, suggesting their safety in an All included studies evaluating new diagnostic tools have been found ICU setting. Furthermore, another agent with potential anti- to be at risk of bias with the QUADAS-2 tool, as shown in table 3.[16] delirium effects is the antiepileptic drug valproate. In a recent As depicted in table 4 and table 5, most of the studies assessing new descriptive study valproate (1500 mg in 1-4 divided daily treatments for ICU delirium have been judged as having a high risk doses) was associated with significantly reduced incidence of bias. The studies by Bakri et al., Daniels et al. and Thom et al., of delirium from 68% to 49% within 48 hours of initiation. respectively, investigating the effect of ondansetron, melatonin and [29] Additionally, it was associated with reduced incidence of ramelteon, had a low risk of bias.[28, 30, 31] agitation and administration of opioids, dexmedetomidine and quetiapine. However, 19% developed hyperammonaemia Discussion and 13% thrombocytopenia, which might limit the safety of This structured review identified and discussed several this drug. Lastly, melatonin has been studied as a potential potential alternatives regarding the diagnostic tools and delirium treatment. A recent retrospective cohort study found treatments for ICU delirium which, after further study, no effect of melatonin as sole treatment or in combination with may become useful additions to the current diagnostic and
Table 3. Risk of bias assessments for included diagnostic studies using the QUADAS-2 tool
Study Risk of bias Applicability concerns Patient selection Index test Reference Flow and timing Patient selection Index test Reference standard standard Alosaimi et al. - - + - - - - 2018 [21] Matarese et al. - - - + - - - 2013 [19] Van Rompaey et al. + - - + - - - 2008 [20] Tang et al. 2018 [23] ------
Green et al. 2017 [22] - - - + - - -
Plaschke et al. + - - + - - - 2010 [24] Pisani et al. 2006 [25] + - - + - - -
+ = low risk of bias; - = high risk of bias.
130 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Delirium in the ICU
Table 4. Risk of bias assessments for included randomised controlled trials using the Cochrane Risk of Bias Tool
Study Random sequen- Allocation con- Blinding of Blinding of outco- Incomplete Selective Other bias ce generation cealment participants and me assessment outcome data reporting personnel Bakri et al. 2015 [28] - - + - - - -
Atalan et al. 2013 [26] - - - + - - -
Mailhot et al. + - - + - - - 2017 [32]
+ = low risk of bias; - = high risk of bias. therapeutic armamentarium. Diagnostic alternatives with good not account for sedation effects. After adjusting for arousal, BIS diagnostic performance include two bedside screening tools – may have less diagnostic utility in diagnosing ICU delirium.[36] NEECHAM Confusion Scale and S-PTD – and the DelApp- Furthermore, compared with previously published reviews, we ICU smartphone-based test, with reported sensitivities between did not examine biomarkers as a potential diagnostic tool for 82.6% and 100%, and specificities between 95% and 96%. With ICU delirium.[37] Our literature search yielded articles studying regards to treatment options that were not discussed in the biomarkers, but these were excluded as the articles did not PADIS guidelines, we found that valproate and ondansetron mention diagnostic data, such as sensitivity and specificity, yet may constitute potentially beneficial treatments for the burden showed results as biomarkers associated with risk of developing of delirium, if future research provides more high-quality delirium. Similarly, EEG has been hypothesised to be a promising evidence. diagnostic modality.[38] However, due to the lack of data in the The 2018 PADIS guidelines recommend routine delirium identified articles, we have not discussed the potential of EEG screening in critically ill patients with either the CAM-ICU in our review. or ICDSC.[33] Recently these tools have been shown to be less Despite the increasing amount of research on ICU delirium, accurate, possibly due to a trend of less sedation as recommended there is no robust evidence for the efficacy of pharmacological by the 2013 PADIS guidelines.[8,14] This is disconcerting, as or non-pharmacological treatment options. Previous reviews false-positive results may lead to unnecessary and unproven on pharmacological treatment options have mainly focused on treatments, while false-negative results may result in persisting antipsychotics and dexmedetomidine.[34, 39, 40] Our results add to unrecognised delirium, with associated undesirable patient the current literature that melatonin or melatonergic agonists, outcomes. opioids, ondansetron and valproate may require further In the studies included in this review, we identified evaluation in prospective trials. heterogeneous diagnostic modalities. The most used delirium Current evidence supporting non-pharmacological bedside screening tools are the CAM-ICU and ICDSC.[12, 34] Our interventions to treat ICU delirium is also lacking.[41] Our results add to current literature that NEECHAM Confusion results regarding non-pharmacological treatment options are Scale and S-PTD are promising delirium assessment tools with in line with previous research. Based on one identified pilot good diagnostic performance as compared with recent DSM-5 study, involving family in ICU care seems promising, as the criteria, CAM-ICU or ICDSC. These have not been discussed intervention seems to be easy to implement with gain in patient in previous recent systematic reviews involving delirium as well as family outcomes. A recent systematic review also assessment tools.[12, 34, 35] However, NEECHAM Confusion Scale found benefits of a protocolised family support intervention, is not suitable for ventilated patients. Additionally, BIS EEG including shorter ICU and hospital length of stay.[42] Future showed good specificity, but a sensitivity of 27%, in one study research is warranted to study the effect and optimal frequency involving cardiac surgery patients. The authors of this study did of family involvement in delirium management. Limitations of this review include: few eligible articles, especially Table 5. Risk of bias assessments for included observational studies using few randomised controlled trials, restricted search to English the Newcastle-Ottawa Quality Assessment Form articles, and the included studies mostly had small sample sizes, Study Selection Comparability Outcome/ Overall quality and used inconsistent methodologies, primary outcomes and exposure study designs, among which varying study populations and Bayindir et al. 2000 [27] 1 point 0 points 1 point Poor lack of comparison groups, with most studies having a high risk of bias. This limits generalisability and comparability of these Gagnon et al. 2017 [29] 3 points 0 points 2 points Poor diagnostic and therapeutic approaches. Another limitation [31] Thom et al. 2018 4 points 2 points 2 points Good intrinsic to this study is that the diagnostic and therapeutic Daniels et al. 2018 [30] 4 points 2 points 3 points Good approaches discussed were not included in the 2018 PADIS guidelines. Therefore, the level of evidence, or quality, of studies
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 131 Netherlands Journal of Critical Care Delirium in the ICU
included are necessarily lower than in the PADIS guidelines. Hence, therapeutic practices as summarised in the recent 2018 PADIS we would like to emphasise that this structured review is meant to be guidelines. However, it is clear that additional studies are needed to an overview of new possibilities to diagnose or treat ICU delirium, establish whether these new diagnostic and therapeutic approaches for which further research is required, and that recommendations should be implemented for the management of ICU delirium. for their use in clinical practice are not yet appropriate. Furthermore, as mentioned before, the accuracy of the CAM-ICU and ICDSC Conflict of interest has decreased in recent studies. This might imply that the articles All authors declare no conflicts of interest. No funding or presented in this review which compared diagnostic tools with the financial support was received. CAM-ICU or ICDSC instead of the DSM-5 may not be as accurate as well. Even though the CAM-ICU and ICDSC are the most used Acknowledgements delirium bedside screening tools in the ICU, these tools are generally We would like to thank the biomedical information specialist not considered to be the reference standard for the diagnosis of Elise Krabbendam of the Medical Library at the Erasmus delirium. The potential diagnostic modalities, which were compared University Medical Center Rotterdam for her assistance with with the CAM-ICU or ICDSC as the reference, may therefore only be the literature search. considered to be validated diagnostic tools if future studies compare them with the DSM-5. On the other hand, it can be argued that most References studies done with CAM-ICU or ICDSC show strong associations 1. Ely EW, Inouye SK, Bernard GR, Gordon S, et al. Delirium in mechanically ventilated of delirium diagnosed with these instruments with mortality patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286(21):2703-10. (indicating their clinical relevance), whereas for the DSM diagnosis 2. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences this association is less well established. In other words, whether of ICU delirium. Intensive Care Med. 2007;33(1):66-73. 3. Ely EW, Shintani A, Truman B, Speroff T, et al. Delirium as a predictor of mortality in DSM diagnosis or well validated and widely implemented screening mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753-62. 4. Girard TD, Jackson JC, Pandharipande PP, Pun BT, et al. Delirium as a predictor of long-term tools are more justified to diagnose delirium may be amenable to cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513-20. discussion in our view. Additionally, for some intervention studies 5. Pandharipande PP, Girard TD, Jackson JC, Morandi A, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-16. assessing efficacy of drugs, the optimal dose for treatment of ICU 6. Pisani MA, Kong SY, Kasl SV, Murphy TE, et al. Days of delirium are associated with delirium is uncertain. Strengths of this review are its structured 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009;180(11):1092-7. design and comprehensive search with a highly experienced medical 7. van den Boogaard M, Schoonhoven L, Evers AW, van der Hoeven JG, et al. Delirium in information specialist. critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med. 2012;40(1):112-8. We recommend future research to report on the association of the 8. Gusmao-Flores D, Salluh JI, Chalhub RA, Quarantini LC. The confusion assessment diagnostic tool used and the clinical outcomes of the ICU patients. method for the intensive care unit (CAM-ICU) and intensive care delirium screening checklist (ICDSC) for the diagnosis of delirium: a systematic review and meta-analysis of Indeed, aside from the accuracy of the diagnostic tools, it might be clinical studies. Crit Care. 2012;16(4):R115. 9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. of interest to pay attention to the patient outcomes, such as mortality Washington, DC: Arlington, VA, 2013. and length of stay, associated with delirium as diagnosed with these 10. Bergeron N, Dubois MJ, Dumont M, Dial S, et al. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27(5):859-64. different tools. Which new therapeutic approach is suited for which 11. Devlin JW, Skrobik Y, Gélinas C, Needham DM, et al. Clinical Practice Guidelines for the specific ICU population should also be further elucidated. Valproate Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e73. may be a potential therapy, but a large randomised controlled trial to 12. Gelinas C, Berube M, Chevrier A, Pun BT, et al. Delirium Assessment Tools for Use in study its efficacy on delirium duration is recommended. However, Critically Ill Adults: A Psychometric Analysis and Systematic Review. Crit Care Nurse. 2018;38(1):38-49. considering the multifactorial pathway of delirium, it is unlikely 13. Meagher DJ, Morandi A, Inouye SK, Ely W, et al. Concordance between DSM-IV and DSM- that treatment of ICU delirium can be pinned down to one specific 5 criteria for delirium diagnosis in a pooled database of 768 prospectively evaluated patients using the delirium rating scale-revised-98. BMC Med. 2014;12:164. pharmacological agent. 14. Barr J, Fraser GL, Puntillo K, Ely EW, et al. Clinical practice guidelines for the management Alternative bedside screening tools or smartphone based tests may of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. become aids for the ICU physician and nurse in diagnosing delirium 15. Higgins JP, Altman DG, Gotzsche PC, Juni P, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. in critically ill patients by either using these tools as a replacement of 16. Whiting PF, Rutjes AW, Westwood ME, Mallett S, et al. QUADAS-2: a revised tool for the or combined with the CAM-ICU and ICDSC. quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529-36. 17. Wells GA, Shea B, O'Connell D, Peterson J, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses: The Ottawa Hospital; Conclusion 2019 [Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. 18. Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. Due to the adverse patient outcomes associated with delirium 2002;359(9300):57-61. in critically ill patients, it is important to use a reliable and 19. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, et al. A comparison of the CAM-ICU and the NEECHAM Confusion Scale in intensive care delirium assessment: valid delirium screening tool and safe and effective treatments. an observational study in non-intubated patients. Crit Care. 2008;12(1):R16. This structured review has provided an overview of currently 20. Matarese M, Generoso S, Ivziku D, Pedone C, et al. Delirium in older patients: a diagnostic study of NEECHAM Confusion Scale in surgical intensive care unit. J Clin Nurs. 2013;22(19- available and promising alternative diagnostic and therapeutic 20):2849-57. 21. Alosaimi FD, Alghamdi A, Alsuhaibani R, Alhammad G, et al. Validation of the Stanford approaches for delirium in critically ill patients, as an addition and Proxy Test for Delirium (S-PTD) among critical and noncritical patients. J Psychosom Res. future perspective to the current state of the art diagnostic and 2018;114:8-14.
132 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Delirium in the ICU
22. Green C, Hendry K, Wilson ES, Walsh T, et al. A Novel Computerized Test for Detecting 34. Hayhurst CJ, Pandharipande PP, Hughes CG. Intensive Care Unit Delirium: A Review of and Monitoring Visual Attentional Deficits and Delirium in the ICU. Crit Care Med. Diagnosis, Prevention, and Treatment. Anesthesiology. 2016;125(6):1229-41. 2017;45(7):1224-31. 35. Boogaard M, Pickkers P, Schoonhoven L. Assessment of delirium in ICU patients: A 23. Tang E, Laverty M, Weir A, Wilson ES, et al. Development and feasibility of a smartphone- literature review. Netherlands Journal of Critical Care. 2010;14. based test for the objective detection and monitoring of attention impairments in 36. Ely EW, Truman B, Manzi DJ, Sigl JC, et al. Consciousness monitoring in ventilated patients: delirium in the ICU. J Crit Care. 2018;48:104-11. bispectral EEG monitors arousal not delirium. Intensive Care Med. 2004;30(8):1537-43. 24. Plaschke K, Fichtenkamm P, Schramm C, Hauth S, et al. Early postoperative delirium after 37. Khan BA, Zawahiri M, Campbell NL, Boustani MA. Biomarkers for delirium--a review. J Am open-heart cardiac surgery is associated with decreased bispectral EEG and increased Geriatr Soc. 2011;59 Suppl 2:S256-61. cortisol and interleukin-6. Intensive Care Med. 2010;36(12):2081-9. 38. van der Kooi AW, Leijten FS, van der Wekken RJ, Slooter AJ. What are the opportunities 25. Pisani MA, Araujo KL, Van Ness PH, Zhang Y, et al. A research algorithm to improve for EEG-based monitoring of delirium in the ICU? J Neuropsychiatry Clin Neurosci. detection of delirium in the intensive care unit. Crit Care. 2006;10(4):R121. 2012;24(4):472-7. 26. Atalan N, Efe Sevim M, Akgün S, Fazlioğullari O, et al. Morphine is a reasonable alternative 39. Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care. to haloperidol in the treatment of postoperative hyperactive-type delirium after cardiac 2012;2(1):49. surgery. J Cardiothorac Vasc Anesth. 2013;27(5):933-8. 40. Barbateskovic M, Krauss SR, Collet MO, Larsen LK, et al. Pharmacological interventions 27. Bayindir O, Akpinar B, Can E, Guden M, et al. The use of the 5-HT3-receptor antagonist for prevention and management of delirium in intensive care patients: a systematic ondansetron for the treatment of postcardiotomy delirium. J Cardiothorac Vasc Anesth. overview of reviews and meta-analyses. BMJ Open. 2019;9(2):e024562. 2000;14(3):288-92. 41. Bannon L, McGaughey J, Verghis R, Clarke M, et al. The effectiveness of non-pharmacological 28. Bakri MH, Ismail EA, Ibrahim A. Comparison of dexmedetomidine or ondansetron interventions in reducing the incidence and duration of delirium in critically ill patients: a with haloperidol for treatment of postoperative delirium in trauma patients admitted systematic review and meta-analysis. Intensive Care Med. 2019;45(1):1-12. to intensive care unit: Randomized controlled trial. Anaesth Pain Intensive Care. 42. Lee HW, Park Y, Jang EJ, Lee YJ. Intensive care unit length of stay is reduced by protocolized 2015;19(2):118-23. family support intervention: a systematic review and meta-analysis. Intensive Care Med. 29. Gagnon DJ, Fontaine GV, Smith KE, Riker RR, et al. Valproate for agitation in critically ill 2019;45(8):1072-81. patients: A retrospective study. J Crit Care. 2017;37:119-25. 30. Daniels LM, Nelson SB, Frank RD, Park JG. Pharmacologic Treatment of Intensive Care Unit Delirium and the Impact on Duration of Delirium, Length of Intensive Care Unit Stay, Appendix 1 en 2. Literature and search details Length of Hospitalization, and 28-Day Mortality. Mayo Clin Proc. 2018;93(12):1739-48. 31. Thom R, Bui M, Rosner B, Teslyar P, et al. Ramelteon is Not Associated With Improved Outcomes Among Critically Ill Delirious Patients: A Single-Center Retrospective Cohort Study. Psychosomatics. 2018. 32. Mailhot T, Cossette S, Cote J, Bourbonnais A, et al. A post cardiac surgery intervention to manage delirium involving families: a randomized pilot study. Nurs Crit Care. https://njcc.nl/sites/nvic.nl/files/hd%20 2017;22(4):221-8. 33. Devlin JW, Skrobik Y, Gelinas C, Needham DM, et al. Clinical Practice Guidelines for the 19-84%20Smit%20Appendix%201%20 Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e73. en%202%20QR.pdf
Appendix 3. Flowchart literature search: diagnostic approaches Appendix 4. Literature search details: therapeutic approaches Appendix 3. Flowchart literature search: diagnostic approaches Appendix 4. Literature search details: therapeutic approaches
2018 citations from 6326 citations from literature search literature search
1970 citations excluded after screening title and abstract 6292 citations excluded after screening title and abstract
27 excluded after full text screening: 2: prevention trial 48 potentially relevant 34 potentially relevant 14: conference abstract articles for full text 41 excluded after full text screening: articles for full text 3: terminated research review 15: conference abstract review 11: no specific quantitative data reported (clinicaltrials.gov / (sensitivity / specificity) Clinicaltrialsregister.eu) 8: studied factors associated with developing 1: ongoing research (clinicaltrials.gov) delirium, not specifically diagnostic methods 2: recruitment completed but no 4: duplicate. results reported yet (IRCT + ISRCTN) 1: duplicate (clinical trials registration 7 articles meeting 2: not (clearly stated as) ICU patients 7 articles meeting inclusion criteria 1: ongoing research (clinicaltrials.gov) of finished research) inclusion criteria 2: no full text available 1: atypical antipsychotic 1: no delirium data available
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 133 Netherlands Journal of Critical Care Submitted May 2019 Accepted September 2019
ORIGINAL ARTICLE
A Lean approach to improve the organisation of unplanned intensive care admissions: A before-after analysis
I.T. Spaan, A.F. van der Sluijs, A.D. Boelens, J. Binnekade, E-J. van Lieshout, N.P. Juffermans, R. Mudde, P. Bouter, D.A. Dongelmans, A.P.J. Vlaar The first two authors contributed equally Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
Correspondence A.P.J. Vlaar - [email protected]
Keywords - Lean, CRM, crew resource management, organisation, unplanned admissions, SAQ, safety attitudes questionnaire
Abstract to 4.14 million in 2008-2009).[3] Although the organisation of acute Background: Unplanned admissions of intensive care patients hospital care in the US and the Netherlands is not similar, we also demand well-organised team work. Lack of an intensive care unit noticed a more gradual increase in unplanned ICU admissions in (ICU) admission protocol may lead to insufficient preparations Dutch hospitals, both from the ED and general hospital wards.[4] or unclear task allocations. It was hypothesised that using a Because our department is a general ICU we admit patients Lean approach, the organisation and perceived quality of care of with a variety of critical conditions. A substantial number of unplanned ICU admissions could be improved. them are haemodynamically unstable, in respiratory distress, or Methods: Using Lean, the organisation of unplanned admissions both, regardless of the underlying disease. Those patients need was analysed by measuring the perception of the quality of prompt resuscitation after admission. This study evaluated the care amongst physicians and nurses. These results led to a new improvement, using a Lean approach, of the perceived quality of protocol describing logistical and organisational measures. care of the unplanned admissions to the ICU. After six months of implementation, a survey was performed to The Lean method engages the frontline healthcare professionals evaluate the effect using a modified t-test. to improve safety, quality and service.[5] The Lean philosophy Results: After implementation, 27 questionnaires were filled in is derived from the Toyota Production System (TPS) and was and compared with 27 baseline questionnaires. The satisfaction of originally developed as a system to improve quality.[6] One of the nurses with the quality of admission, expressed in the admission main features of Lean is to reduce ‘waste’ and to add ‘value’ in small score (M, on a scale of 1-10) improved (pre: M=7.4; SD=1.3; post: steps, which is easy to understand in a manufacturing process, but M=8.2; SD=0.9; p=0.001). On a scale of 1-5 the score for clear task more difficult when it concerns healthcare. Although there are allocation improved (pre: M=3.3; SD=1.2; post: M=4.3; SD=0.9; examples of successful Lean-based quality improvement projects p < 0.001) as well as the score for effective communication (pre: in healthcare,[7] there is not much supporting evidence for the Lean M=4; SD=0.8; post: M=4.4; SD=0.7; p=0.01). Physicians reported approach in a healthcare setting.[8-10] Because of our own positive an improvement in the score for clarity about task allocation (pre: experiences with Lean as a tool for quality improvement, we decided M=3.2; SD=1.2; post: M=4.1; SD=1.3; p=0.001) and the content of to study the effect of implementing new strategies to improve the task (pre: M=3.6; SD=1.1; post: M=4.1; SD=1; p=0.001). acute care of unplanned ICU admissions.[10] We hypothesised that, Conclusion: By using a Lean approach, the implementation of a using a Lean approach, the organisation and perceived quality of survey-based protocol resulted in a perceived improved quality of unplanned ICU admissions could be improved. unplanned admissions at the ICU. Objective Introduction The objective of this study was to measure the improvement, Worldwide, millions of people are admitted to an intensive care using a Lean approach, of the perceived quality of care of unit (ICU) annually.[1] There are important differences in the rate unplanned admissions to the ICU. of ICU admissions and available ICU beds per capita between the US and European countries.[2] In the past decade, a sharp increase Methods in the number of ICU admissions from the emergency department Setting (ED) was observed in the United States (2.79 million in 2002-2003 Our department is a mixed ICU with in total 32 beds
134 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Improving the organisation of unplanned ICU admissions
during maximum occupancy. It is situated in a tertiary survey consisted of a written questionnaire for nursing staff and care teaching hospital and staffed with intensivists, fellow physicians involved in these admissions measuring quantitative, intensivists, residents and ICU nurses. The intensivists have i.e. duration of admission until stabilisation, and qualitative data, an anaesthesiology, internal medicine, cardiology or neurology i.e. satisfaction and perceived quality of care (see supplement 1 background; the specialties of the residents are equally diverse. for the questionnaire and table 1 for the results). The items in our But next to the aforementioned specialties, there are residents questionnaire were based on the short form of the Self-Assessment from pulmonary medicine and cardiac and non-cardiac surgery. Questionnaire (SAQ), a well-established and validated method to The ICU is known to have a high throughput of new residents. measure teamwork and safety climate.[11] After an acute admission, this questionnaire was offered to the team involved in the admission Lean by staff not involved in the current admission. A rating was given The Lean philosophy is used to improve the quality and efficiency of on different subjects: clear task allocation, clarity about their role, care in our department. In one of the stand-up meetings, concerns clarity about which doctor or nurse to assist, whether or not the about the perceived potential of improvement of quality of care of content of their task was clear, quality of the communication in the unplanned admissions were brought to attention. In response to general and safety of the procedure. All were scored with a Likert this meeting, a project group was formed with the goal to analyse scale ranging from one (strongly disagree) to five (strongly agree). the improvement potential and set up a proposal for possible The overall admission satisfaction was scored on a scale of one to improvement. This proposal was the outcome of several meetings ten. The questionnaire was used to evaluate the perceived quality of the project group and discussions during stand-up meetings. The of care before and after the intervention described below. project group developed and carried out a survey in order to evaluate the perceived quality of care of the unplanned admissions to the ICU. Development and implementation of the new protocol The results of the survey before the intervention were analysed Survey and used to develop a protocol describing both logistical and We performed a survey measuring the perception of the quality organisational measures to improve the perceived quality of the of acute care during unplanned admissions of unstable patients admission of unplanned, unstable patients (supplement 2). In as well as time measurements of the acute care process. The short, the following work flow was implemented. We assigned a bed and a team comprising at least two nurses and two physicians Table 1. Results of the questionnaires of the nursing staff and physicians on one of our units for unplanned emergency admissions. When a Nurses patient was in direct need of respiratory or haemodynamic support Observations N (forms) N = 46 N = 46 it was classified as an emergency admission. Every patient with an Score 1 to 51 Before After Difference (95% CI), p value2 emergency admission either from the ward or from the emergency Clear task allocation 3.3 (1.2) 4.3 (0.9) -0.98 (-1.43 to -0.54), p<0.001 department (ED) could be included in the study. The nurses and Clarity about role 3.5 (1.2) 4.2 (1) -0.65 (-1.11 to -0.2), p=0.01 physicians were assigned to clearly described roles. We composed Clarity on which doctor 3.8 (1.3) 4.4 (0.9) -0.58 (-1.06 to -0.1), p=0.02 to assist a checklist with items necessary for an emergency admission. The Clear content of task 3.6 (1) 4.3 (0.8) -0.61 (-0.98 to -0.25), p=0.001 assigned nurses were responsible for all the necessary items being Good communication 4 (0.8) 4.4 (0.7) -0.44 (-0.76 to -0.13), p=0.01 present and functioning. Just before transport from the ward or Clear which contact 4 (0.8) 4.5 (0.6) -0.51 (-0.81 to -0.21), p=0.001 person ED to the ICU, the attending physician called the supervising Safety of procedure 4.3 (0.7) 4.6 (0.5) -0.3 (-0.56 to -0.03), p=0.03 nurse to announce the arrival of the emergency patient. This Admission score 7.4 (1.3) 8.2 (0.9) -0.8 (-1.28 to -0.33), p=0.001 announcement included the latest vital signs and necessary
Physicians measures to resuscitate the patient. We divided these into Observations N (forms) N = 44 N = 47 haemodynamic measures, respiratory measures or both. Based on Score 1 to 51 Before After Difference (95% CI), p value2 this announcement, the supervising nurse alerted the team, which Clear task allocation 3.2 (1.2) 4.1 (1.3) -0.92 (-1.45 to -0.4), p=0.001 assembled at the designated bed in the ICU. During the admission Clarity about role 3.8 (1) 4.2 (1.1) -0.44 (-0.89 to 0.01), p=0.054 all members of the team performed the tasks belonging to their Role nurses clear 3.4 (1.4) 4.3 (1) -0.93 (-1.46 to -0.41), p=0.001 roles; only the responsible team members were present. Over a Clear content of task 3.6 (1.1) 4.4 (1) -0.77 (-1.19 to -0.34), p=0.001 period of six months the new protocol was implemented; during Good communication 4.1 (0.8) 4.4 (0.9) -0.33 (-0.67 to 0), p=0.051 this period several clinical teaching sessions for both nursing Safety 4.4 (0.6) 4.6 (0.7) -0.21 (-0.48 to 0.06), p=0.131 Admission score 7.5 (1.3) 8.2 (1.5) -0.71 (-1.3 to -0.12), p=0.019 staff and physicians were given, there was a publication of the protocol in our database, multiple notifications in our department 1 Although the data have, strictly speaking, an ordinal measurement level, we assume that the distances between the five item levels are equal, so analysis on newsletter and members of the project group stimulated its use. an interval level is possible. After these six months a new survey was performed using the same 2 p-value modified t-test, known as Welch's t-test that adjusts the number of degrees of freedom when the variances are thought not to be equal to each questionnaire to assess if the interventions had led to the desired other. results.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 135 Netherlands Journal of Critical Care Improving the organisation of unplanned ICU admissions
Clinical data collection Table 2. Demographic data of patients admitted during the two evaluation episodes (before and after intervention) The demographics of patients and of the acute care procedure were collected after completing the admission procedure. The Demographic data Before After admission time was set at the moment that all team members Inclusion period 20-02-2016 26-09-2016 Difference (95% CI), - 06-05-2016 - 08-04-2017 p value agreed that the emergency patient was adequately stabilised. (76 days) (194 days)
Statistics Observations (N) 27 27 (1 patient lost to follow- The results of the questionnaire consisted of data of an ordinal up) measurement level. Most answers were scored on a scale of one Gender: Female 6/27 (22%) 10/27 (37%) -14.81 (-38.08 to 9.89 ), to five. It was assumed that the distances between the five item p 0.37 levels were equal so analysis on an interval level was possible. Male 21/27 (78%) 16/27 (59%) 18.52 (-6.57 to 41.68), Furthermore the p-value modified t-test was used to calculate a p 0.24 95% confidence interval. Age 57.7 (27 – 89) 63.4 (22-83) -9 (-14 – 1), p 0.10 NICE score APACHE IV 72.3 (30-127) 79.8 (35-145) 5.43 (-20 to 9.27), p 0.46 Continuous normally distributed variables were expressed by their Length of stay (days) 7.1 (0 – 37) 8.0 (0-32) 3 (-3.5 to 1), p 0.18 Referring specialisms: p 0.61 mean and standard deviation or when not normally distributed Cardiology 1 (4%) 2 (7%) as medians and their interquartile ranges. Categorical variables Cardiothoracic surgery 0 (0%) 1 (4%) were expressed as n (%). To test groups, Student’s t-test was used, Gynaecology 0 (0%) 2 (7%) if continuous data were not normally distributed the Wilcoxon nternal medicine 10 (37%) 11 (41%) test was used. Categorical variables were compared with the Chi- Neurology 4 (15%) 3 (11%) square test. Appropriate statistical uncertainty was expressed by Neurosurgery 2 (7%) 1 4%) 95% confidence levels. Statistical significance was considered to Orthopaedics 1 (4%) 0 (0%) be at p=0.05. Analyses were performed using R (version 3.4; R Surgery 9 (33%) 6 (22%) Foundation for Statistical Computing, Vienna, Austria).[12] The physicians’ scores varied from 3.2 for the clearness of task Results allocation to 4.4 for the sense of safety during the procedure. Perceived problems during Lean approach The overall admission score was 7.5. The median duration of During the first stand-up meetings it became clear that the the acute care procedure was 45 (18-77) minutes. The median chief complaint was the absence of a clear task allocation during duration of the acute care procedure without delay was 40 (16- unplanned ICU admissions. This was thought to be due to the 60) minutes. In 18% of the admissions, a delay was reported. lack of a protocol, leading to insufficient preparation before Several reasons were reported as a cause for the delay: a non- admission and unclear allocation of tasks during the admission. functioning capnograph, an unclear task description or not Missing equipment was also mentioned as a cause of delay enough personnel because the doctor was needed elsewhere. during admission. Before implementation of the new protocol, an unplanned emergency patient was brought in after notifying After implementation the ICU specialist and nurse in charge on the unit by our rapid After the implementation of the protocol the demographic data response team. Tasks were not further explained nor allocated of the evaluated patient population did not differ, although the in advance to the nurses and doctors involved. Also, equipment inclusion period was 194 days compared with 76 days before was not checked according to a checklist. the implementation. Unfortunately, data for one patient were lost during follow-up. The mean age and APACHE IV score did Baseline measurement not significantly differ from the baseline APACHE IV score. The The baseline measurement was done for 27 unplanned majority of patients admitted were surgical patients (22%) and admissions during a period of four months (table 2). In total 46 internal medicine patients (41%). nurses and 44 physicians filled in the questionnaire. Nurses and physicians were randomly assigned to the emergency admission. Before-after comparison Of the patients, 22% were female. The mean age was 57.7 See table 1 for the before-after comparison. The overall admission (range: 27-89) years. The majority of the patients were referred score of nurses improved (pre: M=7.4; SD=1.3; post: M=8.2; SD=0.9; via internal medicine (37%) and surgery (33%). Results of the on a scale of 10; p=0.001). There was a significant improvement in survey before the intervention were as follows. On a scale of 1 the clarity about their task allocation (pre: M=3.3; SD=1.2; post: to 5 the nurses’ scores varied from 3.3 for the clearness of task M=4.3; SD=0.9; p<0.001) and more clarity about their role (pre: allocation to 4.3 for their sense of safety during the admission. M=3.5; SD=1,2; post: M=4.2; SD =1; p=0.01). The clarity about which Their overall admission score was 7.4 on a scale of 1 to 10. doctor to assist improved (pre: M=3,8; SD=1,3; post: M=4,4; SD=0.9;
136 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Improving the organisation of unplanned ICU admissions
p=0.02) as did what the content was of their task (pre: M=3.6; post: Table 3. Results of the questionnaires about duration and delay M=4.3; SD=0.8; p=0.001). Their communication improved (pre: Data patient and acute care Before After M=4; SD=0.8; post: M=4.4; SD=0.7; p=0.01) as well as clarity on who Inclusion period 20-02-2016 to 06-05- 26-09-2016 to 08-04- their contact person was (pre: M=4; SD=0.8; post: M=4.5; SD-0.6; 2016 (76 days) 2017 (194 days) p=0.001) and an improved sense of safety (pre; M=4.3; SD=0.7; post: Observations (N) 28 (in 27 patients) 27 Duration acute care Median (IQr) 45 (18 to Median (IQr) 60 (30 to M=4.6; SD=0.9; p=0.03). procedure 77) minutes 60) minutes Amongst physicians the overall admission score improved as well Min 15, max 120 Duration acute care Min 6, max 210 Median (IQr) 60 (30 to (pre: M=7.5; SD=1.3; post: M=8.2; SD=1.5; p=0.019). There was procedure without delay 60) minutes improvement in clarity about their task allocation (pre: M=3.2; Min 15, max 120 Delay reported Median (IQr) 40 (16 to 4% (1/24) (2 not SD=1.2; post: M=4.1; SD=1.3; p=0.001), more clarity about their own 60) minutes reported) (p=0.27 compared to role (pre: M=3.8; SD=1; post: M=4.2; SD=1.1; p=0.01) and about the before) role of the nurses (pre: M=3.4; SD=1.4; post: M=4.3; SD=1; p=0.001). Reason of delay 1. Capnograph not 1. Short oxygen meter functioning cable, patient arrived The sense of communication (pre: M=4.1; SD=0.8; post: M=4.4; 2. Unclear task too quickly to activate description the team SD=0.9; p=0.051) and safety improved (pre: M=4.4; SD=0.6; post: 3. Not enough M= 4.6; SD=0.7; p=0.131), although the latter was not significant. personnel because another patient had Additionally, the duration of the admissions was compared an acute problem as well before and after implementation of a more structured admission 4. Not enough protocol. Table 3 shows that, although there was a trend towards a personnel, fellow doctor was at the longer duration of the acute care procedure at the admission (pre: emergency room. 5. Not enough median=40 minutes; post: median=60 minutes), there were less personnel, unclear admissions in which a delay was reported, but this was not significant task description (pre: 18%; post: 4%; p=0.27). Reported reasons for delay were a too short oxygen saturation meter and one patient who was admitted items (a clear task allocation and content of task, clarity about before the team was ready. Shortage of personnel and an unclear task the role or who to assist or to contact) are contributing factors description were no longer given as a reason of delay. to a better team performance, a key component in CRM.
Discussion Our study was a qualitative study about the Lean approach In this study, a Lean approach was used to improve the workflow to the implementation of an admission protocol. Similar to regarding unplanned ICU admissions. The main findings of the that of Kemper et al.[14] this study was implemented after study are 1) the Lean method has led to the implementation of a acknowledgment of a performance gap. A Lean approach protocol which was associated with perceived improvement in was used to improve the workflow regarding unplanned ICU communication and an improved sense of safety of unplanned admissions. This resulted in the development of a protocol ICU admissions; 2) The effect was more obvious among nurses that was implemented, leading to subsequently better compared with physicians; and 3) Implementation of a protocol communication and an improved sense of the safety of the for unplanned ICU admissions resulted in a trend towards a admission procedure. These findings are in line with results from longer duration of acute care in an unplanned admission but a study in which structured communication led to improved with less delay. quality of communication between nurses and physicians.[15]
While Crew Resource Management (CRM) is well known from An important aspect of the Lean method is engaging healthcare the aviation industry, there is increasingly more attention for CRM professionals who are at the frontline, in the process of in healthcare[13] and intensive care medicine in particular.[14,15] In a improving safety, quality and service.[5] After implementation healthcare setting, CRM is applied to improve the cooperation of our protocol, improvement of communication and sense of of professionals leading to a better team performance and thus safety of the procedure was found more among nurses compared patient safety.[16] According to Haerkens et al. implementation of with physicians. Some of the physicians working in our ICU are CRM is associated with a reduction in serious complications and residents. This means they do a rotation of several months. During a decrease in mortality in critically ill patients.[17] This study was an emergency admission, a resident is supervised by a fellow or performed in an ICU of a similar Dutch tertiary care hospital. registrar. At least two nurses, but often more, are involved in the Our study specifically resulted in improved team structure unplanned ICU admissions. The number of professionals, but and communication. This facilitated providing and receiving also the fact that some of them are relatively new to the team, effective feedback, which corresponds with the CRM key can lead to confusion about roles and subsequent tasks. Having subjects of communication and creating and maintaining team a clear task description beforehand, the benefits could even be of structure and climate. In our study the significantly improved more importance for nurses than physicians.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 137 Netherlands Journal of Critical Care Improving the organisation of unplanned ICU admissions
After implementation of the protocol, there was a trend References towards less delay in the acute care of an unplanned emergency 1. Barrett ML, Smith MW, Elixhauser A, et al. Utilization of Intensive Care Services, 2011: admission. This is a relevant factor in the efficiency of an Statistical Brief #185. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-2014 Dec. admission procedure. However, the duration of the total acute 2. Wunsch H, Angus DC, Harrison DA, et al. Comparison of medical admissions to intensive care procedure increased. Whether this longer duration was care units in the United States and United Kingdom. Am J Respir Crit Care Med. 2011;183:1666-73. associated with a better quality of care was not investigated. 3. Mullins PM, Goyal M, Pines JM. National growth in intensive care unit admissions from emergency departments in the United States from 2002 to 2009. Acad Emerg Med. A possible explanation could be a more precise timing of 2013;20:479-86. the procedure, possibly due to better task allocation. Data 4. https://www.stichting-nice.nl/datainbeeld/public [17] 5. Cohen RI. Lean methodology in health care. Chest 2018;154:1448-54. from earlier studies showed an association between CRM 6. Marchwinski C, Shook, J, Schroeder, A. Lean Lexicon. A graphical glossary for Lean thinkers. implementation with clinical tools such as briefings, debriefings Fifth Edition ISBN-10: 0966784367 Lean Enterprise Institute 2006. 7. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve and checklists and a reduction in serious complications and operating room efficiency in a high-volume tertiary-care academic medical center. J Am lower mortality in critically ill patients. In the study of Kemper Coll Surg. 2011;213:83-92. 8. DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean [18] et al. CRM affected the thinking about errors and risks as well in the health care industry. Qual Manag Health Care. 2010;19:211-25. as the safety culture instead of affecting the patient outcomes. 9. Moraros J, Lemstra M, Nwankwo C. Lean interventions in healthcare: do they actually work? A systematic literature review. Int J Qual Health Care. 2016;28:150-65. 10. Van der Sluijs AF, Slobbe-Bijlsma ER, Goossens A et al. Reducing errors in the administration of medication with infusion pumps in the intensive care department: A lean approach. Limitations SAGE Open Med. 2019 Jan 2;7. The number of observations could have been too small given 11. Haerkens MH, van Leeuwen W, Sexton JB et al. Validation of the Dutch language version of the Safety Attitudes Questionnaire (SAQ-NL). BMC Health Serv Res. 2016;16(a):385. the much larger number of personnel working on our ICU. 12. R Core Team (2018). R: A language and environment for statistical computing. R This may have led to a reporting bias. The years of experience Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/ 13. Grogan EL, Stiles RA, France DJ, et al. The impact of aviation-based teamwork training on of the caregivers was not known. This could have been of the attitudes of health-care professionals. J Am Coll Surg. 2004;199:843-8. influence in scoring the items of perceived quality, leading to 14. Kemper PF, van Dyck C, Wagner C, et al. Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units. J Patient Saf. 2017;13:223-31. a reporting bias as well. Also the number of observations was 15. Turkelson C, Aebersold M, Redman R, et al. Improving Nursing Communication Skills small compared with the amount of unplanned admissions. in an Intensive Care Unit Using Simulation and Nursing Crew Resource Management Strategies: An Implementation Project. J Nurs Care Qual. 2017;32:331-9. It is estimated that, after implementation of the protocol, 4% 16. Haerkens MH, Jenkins DH, Van der Hoeven JG. Crew resource management in the ICU: the of unplanned admissions were included in this study. This need for culture change. Ann Intensive Care. 2012;2(1):39. 17. Haerkens MH, Kox M, Lemson J et al. Crew Resource Management in the Intensive Care percentage was thought to be a random sample as staff that were Unit: a prospective 3-year cohort study. Acta Anaesthesiol Scand. 2015;59:1319-29. 18. Kemper PF, de Bruijne M, van Dyck et al. Crew resource management training in the not involved in the admission handed over the questionnaires. intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25:577-87. The low percentage can partially be explained by limitations in collecting evening and night time admissions due to the absence Supplement 1: Questionnaire.pdf of the research team during these moments. Moreover, we do not know whether or not admissions which were, for example, chaotic, were not reported and a well-executed admission was, thus leading to a selection and a (non) response bias. On the https://njcc.nl/sites/nvic.nl/files/hd%2019-56%20 other hand, most physicians involved were rotating physicians Spaan%20Supplement%201%20Questionnaire.pdf thus not aware of the previous situation. Supplement 2a: Role allocation edited IS.pdf Furthermore the study was conducted in an ICU of a large academic centre which might be different from other healthcare settings in which the composition of the team is less variable. https://njcc.nl/sites/nvic.nl/files/hd%2019-56%20 Additional CRM trainings were not implemented which could Spaan%20Supplement%202a%20Role%20 have further improved the results. allocation%20edited%20IS.pdf Supplement 2b: Checklist equipment.pdf Conclusion Unplanned ICU admissions require well-organised team work because of the critical status of the patients. A Lean approach https://njcc.nl/sites/nvic.nl/files/hd%2019-56%20 resulted in an improvement of the logistics, communication Spaan%20Supplement%202b%20Checklist%20 and sense of safety of the unplanned admissions in the ICU in a equipment.pdf tertiary care teaching hospital. Supplement 2c: Checklist patient.pdf
Disclosures https://njcc.nl/sites/nvic.nl/files/hd%2019-56%20 All authors declare no conflict of interest. No funding or Spaan%20Supplement%202c%20Checklist%20 financial support was received. patient.pdf
138 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Submitted: June 2019; Accepted: December 2019
ORIGINAL ARTICLE
POCUS series: E-point septal separation, a quick assessment of reduced left ventricular ejection fraction in a POCUS setting
S.C. Boon1, J.E. López Matta1,2, C.V. Elzo Kraemer1,2, P.R. Tuinman2,3, D.J. van Westerloo1,2 1 Department of Intensive Care, Leiden University Medical Center, Leiden University, Leiden, the Netherlands, 2 Amsterdam Leiden Intensive Care Focused Echography (ALIFE) 3 Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
Correspondence D. van Westerloo - [email protected]
Keywords - ultrasound, EPSS, ejection fraction, heart failure, POCUS
Abstract of these parameters in themselves are diagnostic as to the cause In the last decade ultrasound has found its place in the intensive of shock and therefore ultrasound is frequently used to image care unit. Initially ultrasound was used primarily to increase the heart with the goal to identify patients suffering from heart safety and efficacy of line insertion but now many intensivists failure as a cause for shock. use point-of-care ultrasound (POCUS) to aid in diagnosis, assessment of therapy and therapeutic interventions. In this When performing cardiac ultrasound several measurements series we aim to highlight one specific POCUS technique at a can be performed to roughly estimate LVEF, such as ‘eyeballing’, time, which we believe will prove to be useful in your clinical the Simpson method or measurement of mitral annular plane practice. In this issue our aim is to provide you with a short systolic excursion (MAPSE). Clinicians often ‘eyeball’ the left and practical description of the measurement of E-point septal ventricle in order to estimate the LVEF. Eyeballing has several separation to identify a severely reduced left ventricular ejection important pitfalls since it is known that although it may be a fraction. reliable way of estimating LVEF in trained and experienced observers, such as cardiologists, it is quite unreliable in Introduction inexperienced observers, which intensivists frequently are. Point-of-care ultrasound (POCUS) is increasingly adopted by Eyeballing is not only operator dependent, it is hard to repeat emergency physicians and intensivists to assess cardiac function over time to monitor treatment response and it requires at least in patients admitted to the ICU or emergency department. two views of the heart. And, as we know, in ICU patients it Initially, ultrasound was used primarily to increase safety and can be hard to obtain more than one image due to suboptimal efficacy of line insertions but now many intensivists use POCUS conditions.[2-4] Classic genuine LVEF measurements, such as the to aid in diagnosis, assessment of therapy and therapeutic Simpson method, require training and experience which most interventions.[1] This article is part of the POCUS series in the intensivists lack.[3,4] Nowadays, automatic tracking algorithms Netherlands Journal of Critical Care, in which we aim to highlight are available which automatically define endocardial borders. POCUS techniques that will improve decision-making in daily However, in most of our units such sophisticated machines are clinical practice on the ICU. We aim to provide intensivists with not yet available. MAPSE can be used as a parameter for left an overview of easy, quick and reliable methods which may be ventricular function and subsequently for LVEF. It has shown useful in their practice and in this issue we will focus on a simple, to be a relatively easy, reliable and quick method to assess left albeit quick and dirty technique to assess left ventricular ejection ventricular function and is well worth using in an ICU POCUS fraction (LVEF) in patients admitted to the ICU. setting. MAPSE can be falsely positive in patients with aortic stenosis or hypertension.[5-7] An estimate of LVEF is of great importance in patients admitted Apart from MAPSE, which we may discuss in another part of to the ICU since decreased LVEF directly impacts on clinical the series, intensivists are in need of an additional quick, easy management. Several parameters are readily available to help and reliable method to assess LVEF in order to rapidly identify intensivists determine whether a patient is in shock, such as those patients who have reduced LVEF and would benefit from physical examination, plasma lactate and SvO2. However, none inotropic support.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 139 Netherlands Journal of Critical Care E-point septal separation
E-point septal separation as a crude quick measurement of patients in whom the ejection fraction is significantly reduced LVEF and who may benefit from inotropic treatment. It is a quick and Assessing LVEF by using the E-point septal separation (EPSS) rather dirty method to get an indication of whether significantly method has shown to be a reliable way of objectivising reduced LVEF is present, nothing more and nothing less. It is not (severely) reduced LVEF (<50%).[2,3.8-10] EPSS is a quick and a sophisticated measurement and is not advocated in cardiology easy measurement which we can use to rapidly identify those guidelines, but in a setting of ICU POCUS with a clearly defined question such as ‘is there an indication for significantly reduced LVEF?’ EPSS may well be suitable. In fact, studies have shown that EPSS by an inexperienced operator is just as good as quick eyeballing by an experienced cardiologist.[10] EPSS measures the distance between the most apical point of the anterior leaflet of the mitral valve and the septum at diastole (figure 1, video 1). In healthy individuals, there is a pressure gradient between the left atrium and left ventricle, which results in passive blood flow towards the left ventricle followed by atrial contraction in diastole. In case of reduced LVEF, the diastolic pressure inside the left ventricle increases because Figure 1. Parasternal long axis, location of M-mode placement through top of the mitral valve is shown. RVOT the left ventricle can no longer = right ventricular outflow tract; Ao = aorta; MV = mitral valve; LA = left atrium; LV = left ventricle. eject the same amount of blood during systole. This leads to an increasing end- diastolic volume and therefore end-diastolic pressure. This diminishes the A-V gradient in diastole, and leads to reduced opening of the mitral valve. Also, these ventricles dilate. The combination of less mitral opening because of a diminished gradient, but also because of remodelling of the mitral valve apparatus and tethering forces with left ventricular dilatation as well as the dilatation of the left Figure 2. EPSS measurement in M-mode. The E wave represents early filling of the left ventricle by passive ventricle itself with the septum blood flow from the left atrium. The A wave represents the atrial kick. The distance between the E wave and the moving far from the valve tips, septum is the EPSS and considered to be <7 mm in healthy individuals. In order to meet the criteria for heart leads to low EPSS. EPSS per failure, this distance needs to be over 7 mm. se does not measure function, it is a surrogate measure of
140 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care E-point septal separation
how much a left ventricle remodels in the course of significant not be used to monitor treatment effect but will help in those systolic dysfunction. patients in whom shock is, in part, of cardiac nature and who may benefit from inotropes. EPSS is performed in M-mode (figure 2 and video 1). The operator will be provided with an overview of the distance between the Disclosures mitral valve and septum during diastole and systole over time. All authors declare no conflict of interest. No funding or An EPSS less than 7 mm is considered normal, 7-12 mm suggests financial support was received. decreased LVEF, and >12 mm indicates a low LVEF.[11] An EPSS measurement >7 mm is uniformly sensitive in identifying patients References [11] with LVEF <50%. 1. Malbrain M, Tavernier B, Haverals S, et al. Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU). Anestezjologia Intensywna Terapia. 2014;49. Limitations 2. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of EPSS is not suitable to monitor the effect of a given treatment. left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;135:1416-20. For example: LVEF increases from 20% to 30%, but it still 3. Weekes AJ, Reddy A, Lewis MR, Norton HJ. E-point septal separation compared to fractional shortening measurements of systolic function in emergency department remains severely decreased and an abnormal EPSS will be found. patients. J Ultrasound Med. 2012;31:1891-7. If you want to monitor for fluid responsiveness, for example, 4. Moore CL, Rose GA, Tayal VS. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002;9:186-93. serial measurement of left ventricular outflow tract velocity 5. Rydberg E, Gudmundsson P, Kennedy L, Erhardt L, Willenheimer R. Left atrioventricular time integral is a much better test, as discussed previously. plane displacement but not left ventricular ejection fraction is influenced by the degree of [12] aortic stenosis. Heart. 2004;90:1151-5. In addition, in the presence of some conditions, EPSS may 6. Weidemann F, Herrmann S, Störk S, et al. Impact of Myocardial Fibrosis in Patients With be overestimated or underestimated; valvular diseases which Symptomatic Severe Aortic Stenosis. Circulation. 2009;120:577-84. 7. Xiao HB, Kaleem S, McCarthy C, Rosen SD. Abnormal regional left ventricular mechanics decrease the mobility of the mitral valve leaflets, left ventricular in treated hypertensive patients with ‘normal left ventricular function’. Int Cardiol. hypertrophy or asymmetric septal hypertrophy all may result in 2006;112:316-21. 8. Massie BM, Schiller NB, Ratshin RA, Parmley WW. Mitral-septal separation: New false interpretations concerning LVEF. echocardiographic index of left ventricular function. Am J Cardiol. 1977;39:1008-16. 9. Satılmış Siliv N, Yamanoglu A, Pınar P, Celebi Yamanoglu NG, Torlak F, Parlak I. Estimation of cardiac systolic function based on mitral valve movements: An accurate bedside tool for Instructions for the EPSS measurement combined with emergency physicians in dyspneic patients. J Ultrasound Med. 2019;38:1027-38. M-mode 10. Secko MA, Lazar JM, Salciccioli LA, Stone MB. Can junior emergency physicians use E-point septal separation to accurately estimate left ventricular function in acutely dyspneic An instructional video accompanies this article (video 1) link & patients? Acad Emerg Med. 2011;18:1223-6. 11. McKaigney CJ, Krantz MJ, La Rocque CL, Hurst ND, Buchanan MS, Kendall JL. E-point septal QRcode separation: a bedside tool for emergency physician assessment of left ventricular ejection 1. Obtain a parasternal long-axis view of the heart (figure 1). fraction. Am J Emerg Med. 2014;32:493-7. 12. López Matta JE, Elzo Kraemer CV, Tuinman PR, van Westerloo DJ. The use of velocity time 2. Activate M-mode and place the cursor on the most apical tip integral in assessing cardiac output and fluid responsiveness. Neth J Crit Care. 2019;5:8. of the anterior leaflet of the mitral valve cutting through the septum (figure 1). 3. The M-mode will demonstrate the movement of the anterior leaflet during the heart cycle (figure 2). Video 1. 4. A time/distance graph is shown, where time is on the X-axis and distance on the Y-axis (figure 2).
Conclusion E-point septal separation as part of point-of-care ultrasound https://njcc.nl/sites/nvic.nl/files/19-63%20 may be used in conjunction with other tests in order to quickly Westerloo%20video.mp4 detect reduced LVEF in patients admitted on the ICU. It should
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 141 Netherlands Journal of Critical Care Submitted November 2019; Accepted December 2020
CLINICAL IMAGE
Harm prevented by using ICU ultrasound prior to percutaneous dilatational tracheostomy
M.E. Seubert, M. de Mos Department of Intensive Care, het LangeLand Ziekenhuis, Zoetermeer, the Netherlands
Correspondence M.E. Seubert – [email protected]
Keywords - percutaneous dilatational tracheostomy (PDT), vein, ultrasound neck imaging
A tracheostomy was indicated in a 32-year-old female ICU patient with normal habitus and no significant medical history. She had been on and off mechanical ventilation for 11 days because of acute respiratory distress syndrome after ditch water aspiration and was deemed to require a tracheostomy for further ventilator weaning. Informed consent was obtained from the patient and her family to perform a percutaneous dilatational tracheostomy (PDT). In preparation for this, an ultrasound of the trachea was carried out to locate the optimal insertion site and to determine if there where possible complicating factors. As the images show, there appeared to be an overlying vein covering at least the third and fourth tracheal ring, the usual insertion site for a tracheostomy.
With this information an increased risk for bleeding related to the PDT procedure was anticipated. Therefore it was decided to perform the tracheostomy in the operating theatre, safeguarding the vein. The surgeon tied up the vein and an uneventful Figure 1. Midline transverse view showing cricoid cartilage (lower tracheostomy under bronchoscopic control followed. arrow) and a vein measuring a diameter of 0.31 cm above (top arrow)
Ultrasound screening prior to percutaneous tracheostomy procedures Severe haemorrhage related to PDT may be caused by puncture Performing ultrasound prior to or during a percutaneous or distortion of an nearby artery, vein, or a tracheal-vascular tracheostomy has previously been recommended.[1,2] In a fistula. Risk factors are previous neck surgery or radiotherapy, retrospective, observational study of 343 adults, 41% of patients leading to altered vascular anatomy, and obesity, making it demonstrated a vessel overlying percutaneous tracheostomy difficult to identify the classic landmarks for cannula insertion. insertion sites on computed tomography angiograms. Veins However, congenital variants of normal vascularisation are were more common than arteries.[3] This number does not fit also possible, such as the presence of an anterior jugular vein the low number of haemorrhagic complications experienced. overlying the trachea in this case. CT scanning is probably Possibly tamponade of bleeding from smaller vessels may unsuitable to detect such abnormalities and although MRI account for this. On the other hand, mortality as a result of PDT would provide useful information, this is a ponderous exercise has been described, with one report demonstrating three deaths with an ICU patient on ventilator support. Ultrasound of the in 1187 procedures (0.25%) over a 13-year period due to severe trachea provides a simple and safe method to visualise the haemorrhage.[4] A randomised controlled trial has demonstrated vascularisation around the cannula insertion site. It allows for reduced bleeding with the use of ultrasound guidance.[5] identification of nearby vascular structures and for localisation
142 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care Ultrasound prior to tracheostomy
Disclosures The authors declare no conflict of interest. No funding or financial support was received but the first author (M.E.S) does receive compensation for being an ICU ultrasound instructor at the Dutch Society of Intensive Care (NVIC).
T1 T2 T3 T4 References
1. Alansari M, Alotair H, Al Aseri Z, A Elhoseny M. Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review. Crit Care. 2015;19:229. 2. Lopez Matta JE, Elzo Kraemer CV, van Westerloo DJ. To see or not to see: ultrasound- guided percutaneous tracheostomy. Neth J Crit Care. 2018;26:66-9. 3. Rees J, Haroon Y, Hogan C, Saha S, Derekshani S. The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes. J Intensive Care Soc. 2018;19:107-13. Figure 2. Sagittal view of the trachea showing four tracheal cartilages 4. McCormick B, Manara AR. Mortality from percutaneous dilatational tracheostomy. A (T1-4) with a vein above (longer arrow) and above this the infrahyoid report of three cases. Anaesthesia. 2005;60:490-5. 5. Sarıtas A, Kurnaz MM. Comparison of Bronchoscopy-Guided and Real-Time Ultrasound- muscle (short arrow) Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients. J Intensive Care Med. 2019;34:191-6. of the correct insertion site above the fourth tracheal ring. Performing a PDT below this level may increase the risk of severe bleeding by puncture of the right innominate artery.
Video link to sagittal view of collapsing overlying vein due to Transducer selection is important when evaluating the anatomy slight pressure with probe surrounding the trachea. Higher-frequency linear probes (7.5 MHz) provide the best resolution of superficial structures. Video 1. Importantly, one should be aware not to use any pressure with the probe on the underlying area because venous structures may collapse and thus become invisible (video link).
In line with results of observational studies, precautions should https://njcc.nl/sites/nvic.nl/files/19-87%20 be taken when an overlying vessel is seen. Therefore, we suggest Seubert%20Collapsvene.mp4 performing an ultrasound of the trachea as a standard part of the preparation for PDT.
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 143 Netherlands Journal of Critical Care TitelKlein NVIC CONFERENCE AND COURSE AGENDA
COURSES AND CONFERENCES | NVIC
NVIC Basiscursus echografie NVIC FCCS cursus Tuesday 1 September - Wednesday 2 September 2020 Wednesday 3 June - Thursday 4 June 2020 Tuesday 3 November - Wednesday 4 November 2020 Tuesday 30 June - Wednesday 1 July 2020 Tuesday 1 December - Wednesday 2 December 2020 Tuesday 25 August - Wednesday 26 August 2020 Wednesday 9 September - Thursday 10 September 2020 NVIC Najaarscongres 2020 Thursday 1 October - Friday 1 October 2020 Thursday 17 September 2020 Wednesday 28 October - Thursday 29 October 2020 Tuesday 17 November - Wednesday 18 November 2020 NVIC Cursus Luchtwegmanagement op de IC Wednesday 9 December - Thursday 10 December 2020 Wednesday 11 November - Thursday 12 November 2020 Conferences | Other 40th ISICEM, Brussels Tuesday 15 September – Friday 18 September 2020 CURSUS Luchtwegmanagement op IC
Woensdag 11 november - donderdag 12 november 2020
Hotel Houten / OSG www.nvic.nl Houten
144 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care
Editorial board of the Netherlands Journal of Critical Care Dirk Donker, Editor in Chief Maarten van Eijk, Associate Michael Kuiper, Section Editor Eleonora Swart, Section Editor Dept. of Intensive Care Medicine, Section Editor Anesthesiology Neurology Pharmacology Div. of Anesthesiology, Intensive Dept. of Intensive Care Medicine Dept. of Intensive Care Medicine Dept. of Pharmacy Care and Emergency Medicine University Medical Center Utrecht Medical Center Leeuwarden Amsterdam UMC location AMC University Medical Center Utrecht PO Box 85500 PO Box 888 University of Amsterdam PO Box 85500 3508 GA Utrecht 8901 BR Leeuwarden Meibergdreef 9 3508 GA Utrecht 1105 AZ Amsterdam Nuray Kusadasi, Associate Section Dept. of Clinical Pharmacology and Walter van den Bergh, Section Janneke Horn, Section Editor Editor Hemato-Oncology Pharmacy Editor General General Dept. of Intensive Care Medicine Amsterdam UMC location Vumc Dept. of Critical Care Dept. of Intensive Care University Medical Center Utrecht De Boelelaan 1117 University of Groningen Amsterdam UMC location AMC PO Box 85500 1081 HV Amsterdam Hanzeplein 1 University of Amsterdam 3508 GA Utrecht 9700 RB Groningen Meibergdreef 9 Pieter Roel Tuinman, Section 1105 AZ Amsterdam Christiaan Meuwese, Associate Editor General Dennis Bergmans, Section Editor Section Editor Cardiology Dept. of Intensive Care Medicine Infection and Inflammation Can Ince, Section Editor Physiology Dept. of Intensive Care Medicine Amsterdam UMC location Vumc Dept. of Intensive Care Dept. of Physiology University Medical Center Utrecht PO Box 7057 Maastricht University Medical Amsterdam UMC location AMC PO Box 85500 1007 MB Amsterdam Center+ University of Amsterdam 3508 GA Utrecht P. Debyelaan 25 Meibergdreef 9 David van Westerloo, Section 6229 HX Maastricht 1105 AZ Amsterdam Marike van der Schaaf, Section Editor General Editor Rehabilitation Frank Bosch, Section Editor Evert de Jonge, Section Editor Dept. of Intensive Care Medicine Dept. of Rehabilitation Imaging Scoring and quality assessment Leiden University Medical Center Amsterdam UMC location AMC Dept. of Internal Medicine Dept. of Intensive Care Medicine PO Box 9600 University of Amsterdam Rijnstate Hospital Leiden University Medical Center 2300 RC Leiden Meibergdreef 9 PO Box 9555 PO Box 9600 1105 AZ Amsterdam Job van Woensel, Section Editor 6800 TA Arnhem 2300 RC Leiden Pediatrics Peter Spronk, Section Editor Diederik van Dijk, Section Editor Nicole Juffermans, Section Editor Pediatrics Intensive Care Unit General Cardioanesthesia Hemostasis and Thrombosis Emma children’s hospital Dept. of Intensive Care Medicine Dept. of Intensive Care Medicine, Dept. of Intensive Care Amsterdam UMC location AMC Gelre Hospital, location Lukas Div. of Anesthesiology, Intensive Amsterdam UMC location AMC University of Amsterdam PO Box 9014 Care and Emergency Medicine University of Amsterdam Meibergdreef 9 7300 DS Apeldoorn University Medical Center Utrecht Meibergdreef 9 1105 AZ Amsterdam PO Box 85500 1105 AZ Amsterdam Ilse van Stijn, Managing Editor 3508 GA Utrecht Dept. of Intensive Care Medicine OLVG PO Box 95500 1090 HM Amsterdam
International advisory board Jan Bakker Charles Hinds Paul Marik Xavier Monnet Professor of Intensive Care Professor of Intensive Care Associate Professor Service de réanimation médicale Columbia University Medical Medicine Dept. of Medicine and Medical Centre Hospitalier Universitaire Center, New York University St. Bartholomew’s Hospital Intensive Care Unit de Bicêtre Medical Center, New York, USA West Smithfield, University of Massachusetts Le Kremlin-Bicêtre, France Pontificia Universidad Católica de London, UK St. Vincent’s Hospital, Jean-Charles Preiser Chile, Santiago, Chile Worcester, USA Patrick Honoré Dept. Intensive Care Erasmus MC University Medical Professor of ICU Medicine Greg Martin Erasme University Hospital Center, Rotterdam, Netherlands Director of Critical Care Dept. of Medicine Brussels, Belgium Charles Gomersall Nephrology Platform Division of Pulmonary, Allergy and Yasser Sakr Dept. of Anaesthesia and Intensive ICU department Critical Care Dept. of Anaesthesiology and Care Universitair Ziekenhuis Brussel, Emory University School of Intensive Care The Chinese University of Hong VUB University Medicine Friedrich-Schiller University Kong, Prince of Wales Hospital Brussels, Belgium Atlanta, USA Hospital Hong Kong, China Alun Hughes Ravindra Mehta Jena, Germany Frank van Haren Professor of Clinical Pharmacology Professor of Clinical Medicine Hannah Wunsch A/ Professor, Australian National University College London Associate Chair for Clinical Dept. of Anaesthesia University Medical School London, UK Research New York Presbyterian Columbia Department of Intensive Care Department of Medicine Manu Malbrain New York, USA Medicine UCSD Medical Centre Dept. of Intensive Care Unit The Canberra Hospital San Diego, USA Hospital Netwerk Antwerp PO Box 11, Woden, ACT 2606 Campus Stuivenberg Canberra, Australia Antwerp, Belgium
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 145 Netherlands Journal of Critical Care
Information for authors
The Netherlands Journal of Critical Care (NJCC) is the official journal of Editorials the Dutch Society of Intensive Care (Nederlandse Vereniging voor Intensive Editorials are always commissioned by the Editors and comment on one or Care-NVIC). The journal has a circulation of about 1750 copies bimonthly more articles in the same issue of the Journal or to a subject with high news in the Netherlands and Belgium. value. Editorials should not exceed 1500 words and may include up to 15 High-quality reports of research related to any aspect of intensive care references. Editorials have a maximum of 3 authors and no abstract. Please medicine, whether laboratory, clinical, or epidemiological, will be considered provide 2-3 key words. for publication in the NJCC. This includes original articles, reviews, and meta-analyses. Case reports, clinical images, book reviews, editorials, letters Case reports to the editor, clinical problem solving, research news and correspondence are The text of a case report should include an abstract, introduction, case also welcome. All manuscripts pass through an independent review process report/case history, discussion, tables and figures (2 in total), and references. managed by the editorial board. The journal does not have any publication The main text may be up to 2000 words; the abstract should not exceed 150 fees, and colour figures are reproduced free of charge. words and may be unstructured. Please provide a minimum of 3 keywords The journal is indexed by Embase, Emcare and Scopus. A Medline annotation and a list of not more than 30 references. Please include an informed consent is in preparation. statement from the patient described in the case.
Ethical standards Clinical problem-solving Manuscripts reporting original research must contain a statement that all These manuscripts consider the step-by-step process of clinical decision- human and animal studies have been approved by the appropriate ethics making. Information about a patient is presented to an expert clinician committee and have therefore been performed in accordance with the or clinicians in stages (indicated by boldface type in the manuscript) to ethical standards laid down in the 1964 Declaration of Helsinki and its later simulate the way such information emerges in clinical practice. The clinician amendments. Where appropriate, it should also be stated in the text that all responds (in regular type) as new information is presented, sharing his or her persons gave their informed consent prior to their inclusion in the study. If reasoning with the reader. The text should not exceed 2500 words, and there possible, the Journal aims to also include informed consent of individuals should be no more than 15 references. Please include an informed consent described in case reports. Details that might disclose the identity of the statement from the patient described in the case. subjects under study should be omitted. The editors reserve the right to reject manuscripts that do not comply with Research news the above-mentioned requirements. The author will be held responsible for Research news should be a review of a manuscript which has appeared in the false statements or failure to fulfil the above-mentioned requirements. The past two months. It contains sections on why this study was done, the research editors adhere to the guidelines laid down by the International Committee question, how this was investigated, conclusions and the impact of the study of Medical Journalist Editors (www.icmje.org), concerning authorship and on clinical practice. The text should not exceed 800 words with a maximum scientific conduct. of 5 references. Contributions for this section will be commissioned; however, inquiries about contributions can be sent to [email protected]. Types of papers The following manuscript types are considered for publication: original Clinical images articles, review articles, systematic reviews, meta-analyses, editorials, case A clinical image should contain one or two pictures with a legend and a short reports, clinical images, book reviews, letters to the editor, clinical problem case history, and should preferably not be referenced. The manuscript should solving, research news and correspondence. succinctly present relevant clinical information, including a short description of the patient’s history, relevant physical and laboratory findings, clinical course, Original articles response to treatment (if any), and condition at last follow-up. Please provide a Original articles should not exceed 3000 words (excluding abstract, minimum of 3 keywords. The text should not exceed 500 words. Please include references, tables and legends). The manuscript should be clear in outline an informed consent statement from the patient described in the case. (with subheadings) for maximum clarity. The text should follow the IMRAD format and contain an abstract, introduction, materials (patients) and Photo quiz methods, results, discussion section and references. This should be followed In this section relevant images for critical care medicine (e.g. flow and pressure by tables and figures (maximum of 6 in total) with titles above and legends curves of mechanical ventilation or haemodynamic indices, radiological images below these elements. The abstract should not exceed 250 words and should or laboratory results) will be accompanied by a short introduction of the context. be structured: background, methods, results, conclusions. Do not include The introduction will be followed by ‘what is your diagnosis?’. The answer will references in the abstract. Authors should provide a minimum of 3 keywords, include a brief discussion of the literature. A photo quiz should not exceed 500 a running title, and a list of not more than 30 references. words and contain no more than two figures, and five references conform the Original articles must meet the following criteria: Vancouver style. Abbreviations of measurements should be quoted in SI units. - the manuscript presents the results of primary scientific research; - the results have not been published in full elsewhere; Book reviews - analyses are described in full in the manuscript; A book review should not exceed 300 words. Please mention in the header: - conclusions are presented in a clear and concise manner and are supported title, author, edition and year. Scan the cover in high resolution (300 dpi/1 by the data; mb) and send with the text. With an online review, the cover can usually - the research meets all applicable ethical standards; be downloaded. Details with the cover: title, author, edition, year, publisher, - the article adheres to appropriate reporting guidelines and community number of pages, price and ISBN number. Conclude with the name and standards for full data disclosure; affiliation(s) of the reviewer. - when reporting the results of a randomised controlled trial, author(s) should use the CONSORT statement as a guide to preparing the Letters to the editor manuscript (http://www.consort-statement.org/); Letters to the editor provide an opportunity to present results of scientific - conflicts of interest should be clearly stated in the manuscript (see below). value where a short format is most appropriate. They should not exceed 1000 words, 5 references and 1 figure or table. The authors are encouraged to refer to national and international registries of trials in their papers (such as clinicaltrials.gov), where applicable. Correspondence Correspondence provides an opportunity to debate published articles. Review articles This should not exceed 500 words, 5 references and 1 figure or table. Review articles, systematic reviews and meta-analyses should not exceed Correspondence is sent to the authors for rebuttal, and a final decision on 3000 words (excluding abstract, references, tables and legends). The publication is made at the end of this process, by the editor. manuscript should contain subheadings. A maximum of 6 tables and figures (in total) are allowed. Please provide titles above and legends below General information these elements. The abstract should not exceed 250 words and should be Each manuscript should be accompanied by a cover letter stating the structured: background, methods, results, conclusions, with the exception following: the complete postal address, email address and telephone number of a non-systematic review, which may contain a non-structured abstract. of the corresponding author and, if it is a resubmission, the previous No references should be included in the abstract. Authors should provide Neth J Crit Care number and year. The language of the journal is British a minimum of 3 keywords, a running title, and a list of not more than 70 English. Authors who are unsure of proper English usage should have their references. The authors are encouraged to refer to national and international manuscript checked by someone proficient in the English language. All text registries of trials in their papers (such as clinicaltrials.gov), where applicable. should be double spaced. The manuscript pages, including references and legends, should be sequentially numbered throughout
146 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 Netherlands Journal of Critical Care
General guidelines on house style ownership of the manuscript (title of article) to the Netherlands Journal of - The title of the manuscript should be in typeface Times New Roman, size 20. Critical Care’. Any relevant papers that may be considered as duplicating in With the exception of the first word and proper nouns, initial capitals are not part the current submission should be reported. used in the title. - The names of departments should be in typeface Times New Roman, size 12. References - The names of hospitals should be written in English. Neth J Crit Care uses the Vancouver style of referencing. Only articles cited - Write ‘the Netherlands’, without capitalising the t. in the text are to be listed. They should be arranged in order of appearance - Generally, abbreviations should not be used in the title (see Table of standard in the text and numbered consecutively. Only the reference number should abbreviations for exceptions). appear in the text between brackets. […] Include all author names (unless - The corresponding author only provides his/her email address on the title page. there are more than six, in which case abbreviate to three and add ‘et al.’), and - Please provide a minimum of three keywords and a running title. page numbers. Use the Medline abbreviation for names of journals. - The abstract of original and review articles should be written in a structured format. Article in journals: Calandra T, Cometta A. Antibiotic therapy for Gram - Unstructured abstracts should take the form of a single paragraph. negative bacteremia. Infect Dis Clin North Am. 1991;5:817-34. - Headings must be in bold. Use no more than two levels of headings. Books (sections): Thijs LG. Fluid therapy in septic shock. In: Sibbald WJ, - Paragraphs starting immediately under headings and subheadings should begin Vincent JL (eds). Clinical trials for the treatment of sepsis. (Update in at the left margin. Subsequent paragraphs should be indented. intensive care and emergency medicine, volume 19). Berlin Heidelberg New - Non-standard abbreviations (see table of standard abbreviations) should always York: Springer; 1995, pp 167-90. be explained and their use kept to a minimum. Conference meetings: Rijneveld AW, Lauw FN, te Velde AA, et al. The role - Use British English spelling – except in titles of institutions that have chosen to of interferongamma in murine pneumococcal pneumonia. 38th Interscience use US spelling, e.g. Academic Medical Center, Amsterdam. Examples: anaemia Conference on Antimicrobial Agents and Chemotherapy (ICAAC). San (instead of anemia), oesophagus (instead of esophagus), litre (instead of liter), Diego, Ca.; 1998, pp 290. colour (instead of color), labelling (instead of labeling), practice (noun), and Article/ information on website: Samenwerken aan duurzame zorg, landelijke practise (verb). This should be used consistently. Use the s-form spelling, e.g. monitor proeftuinen: Rijksinstituut voor Volksgezondheid en Milieu, 2015. minimise, randomisation. (Accessed 11 August 2015, at http://www.rijksoverheid.nl/documenten-en- - Do not use full stops in initials, abbreviations and academic titles. publicaties/rapporten/2015/07/10/samen-werken-aan-duurzame-zorg.html.) - References are numbered sequentially in the text and placed in square brackets after the punctuation. [..] How to submit - Genus names should be written in italics, e.g. Staphylococcus aureus, S. aureus. Please submit manuscripts directly to the Editorial Office through our online - Numbers under 10 are spelled out except for measurements with a unit (10 submission system at www.njcc.nl. mmol/l) or age (4 weeks old), or when in a list with other numbers (5 mice, 6 rats, 12 gerbils). Peer review - When referring to tables or figures in the text, use italics; do not use a capital All papers are subject to a peer-review system handled by the editors. Authors are letter, e.g. see table 2. encouraged to resubmit, when invited, the revised paper within two weeks after the editorial decision. The changes made in the revised paper should be highlighted Tables and the manuscript accompanied by a letter with a point-to-point rebuttal. Tables are to be numbered independently of the figures with Arabic numbers and are uploaded as separate documents. Proofs - Tables should be laid out in Word, using the table function. Other tables (e.g. The corresponding author will receive proofs of accepted papers by email. in pdf format or PowerPoint) will not be accepted; Corrected proofs should be returned within 48 hours of receipt. - Do not use internal horizontal or vertical lines; - Do not use spaces, tabs or hard returns in tables; Production process - Each piece of data must be contained in its own cell; Decisions of the editors are final. All material accepted for publication is - Numbers and percentages are presented in the same cell; subject to copyediting. The Neth J Crit Care reserves the right to edit for - Tables should always be cited in the text in consecutive numerical order; house style, clarity, precision of expression, and grammar. Authors review - For each table, please supply a title explaining the components of the table; these changes at the proof stage but must limit their alterations in the proof - Any abbreviations used in the table must be defined in a legend; to correcting errors and to clarifying misleading statements. - Tables should not exceed the printed area of the page (174 x 234 mm). Table of commonly used abbreviations Figures AIDS acquired immunodeficiency syndrome Figures should also be numbered with Arabic numbers and are uploaded in ALI acute lung injury separate documents. Legends should be given in the document that contains the ARDS adult respiratory distress syndrome text, references, and tables. Authors wishing to include figures or tables that have APACHE acute physiology and chronic health evaluation already been published elsewhere are required to obtain permission from the BIPAP biphasic positive airways pressure copyright owner and provide evidence that such permission has been granted CCU coronary care unit when submitting their paper. Colour figures can be published. Short, clear COPD chronic obstructive pulmonary disease legends make additional description in the text unnecessary. Figures should be CPAP continuous positive airway pressure provided in electronic format (TIFF or JPEG). CT computed tomography ECG electrocardiogram Conflict of interest ECMO extracorporeal membrane oxygenation Authors must indicate any conflict of interest. This includes a financial EEG Electroencephalogram relationship with an organisation that sponsored the research (funding, ELISA enzyme-linked immunosorbent assay speakers fee, consultancy fee), management relations with the organisation that ETCO2 end-tidal carbon dioxide sponsored the research (consultant, member of board). All sources of funding HIV human immunodeficiency virus obtained for the research should also be stated. A conflict of interest statement IC intensive care can be downloaded from the website. The completed and signed form should ICU intensive care unit be uploaded as a separate document when submitting the manuscript. If no IM Intramuscular conflict exists, authors should state: All authors declare no conflicts of interest. INR international normalised ratio IPPV intermittent positive pressure ventilation No funding or financial support was received. IV Intravenous Author agreement MAP mean arterial pressure MODS multiorgan dysfunction syndrome All authors must certify they have seen and approved the manuscript being MRI magnetic resonance imaging submitted. All authors warrant that the article is the authors’ original work, has PACU post anaesthesia care unit not been published previously and is not under consideration for publication PEEP positive end expiratory pressure elsewhere. The author agreement form can be downloaded from the website. An PET positron emission tomography article will only be published when this form is completed, signed and returned. SARS severe adult respiratory syndrome SIRS systemic inflammatory response syndrome Copyright SOFA sequential organ failure assessment Copyright ownership is to be transferred in a written statement, which must SPECT single-photon emission computed tomography accompany all manuscript submissions and must be signed by all authors. TIA transient ischaemic attack The agreement should state: ‘The undersigned authors transfer all copyright TRALI transfusion-related acute lung injury
NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 147