In this episode I’ll:
1. Discuss an article about evaluating the presence of pain in patients with ICU delirium
2. Answer the drug information question: “Does quetiapine reduce the duration of ICU delirium?”
3. Share a resource I use to find information about the prevention and treatment of ICU delrium
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Article
Lead author: Salmaan Kanji
Published ahead of print in the journal Critical Care Medicine January 2016
Background
Despite the high incidence of ICU delirium, currently available tools to evaluate the presence of pain in ICU patients have not been validated in patients with delirium.
Purpose
The purpose of the study was to investigate the validity of the Critical Care Pain Observation Tool (CPOT) in patients with ICU delirium.
Methods
The study was a prospective cohort study in two ICUs within a Canadian tertiary healthcare center. The authors enrolled 40 consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU (CAM-ICU).
Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (such as mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points.
Results
The Critical Care Pain Observation Tool demonstrated excellent discriminant validity as evidenced by a highly statistically and clinically significant change in mean Critical Care Pain Observation Tool scores between baseline and painful procedures (mean difference, 3.13 +/- 1.56; p < 0.001; Cohen D, 2.0). Interrater agreement was also excellent ([kappa] > 0.6), and scores between raters were highly correlated (r = 0.957). The Critical Care Pain Observation Tool possessed a high level of internal consistency (overall Cronbach [alpha], 0.778). Percent agreement was found to be greater between the Critical Care Pain Observation Tool and the nurse’s subjective opinion of the presence or absence of pain when compared with that between the Critical Care Pain Observation Tool and physiologic variables (80.5% vs 67.5%, respectively).
Conclusion
The authors concluded that the Critical Care Pain Observation Tool is a valid pain assessment tool in noncomatose, delirious adult ICU patients who are unable to reliably self-report the presence or absence of pain.
Discussion
I found this study to be significant since it is the first to establish that CPOT is a valid pain assessment tool in patients with ICU delirium. My institution’s current assessment for patients unable to verbally communicate pain is the Behavioral Pain Scale. This study makes me want to consider using the CPOT instead to have one scale for patients unable to verbally communicate pain whether they have delirium or not.
Drug information question
Q: Does quetiapine reduce the duration of ICU delirium?
A: Probably not – evidence that suggests quetiapine helps resolve delirium is weak.
In 2010 a pilot study reported quetiapine use was associated with faster delirium resolution. Follow-up analysis did not find that quetiapine use was associated with a faster resolution of either hypoactivity or hyperactivity. The 2013 SCCM Guidelines on Pain, Agitation, and Delirium noted that evidence to use quetiapine as a treatment for delirium was weak.
A retrospective study published in August 2015 in Pharmacotherapy reported that exposure to one or more doses of quetiapine was associated with a significant reduction in the duration of the first delirium episode. However the study is full of known and unknown confounders. In addition the retrospective/uncontrolled nature of the study precludes using it as a basis to recommend the routine use of quetiapine in ICU delirium.
A prospective, randomized, controlled trial examining antipsychotics effect on the duration of delirium is currently recruiting patients.
Resource
The website ICUdelirium.org is managed by Vanderbilt University Medical Center. The website hosts tons of resources on the prevention and treatment of ICU delirium. It offers resources for patient families and medical professionals including videos on implementing an ICU delirium prevention bundle.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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