Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

A prospective, observational feasibility study was conducted at an academic hospital between July 2012

ICU care was offered. Sixty-two patients were seen in the clinic. Median time from hospital discharge to

ICU recovery center visit was 29 days. Cognitive impairment was identified in 64% of patients. Anxiety

and depression were identified in 37% and 27% of patients. One-third of the patients were unable to

ambulate independently. The median 6-minute walk distance was 56% of predicted. Only seven of the

previously working patients (15%) had returned to work. Referral services and case management were

provided 142 times. The median number of pharmacy interventions per patient was four.

Glucose dysregulation: A retrospective study of 74 patients with ARDS found that a blood glucose

value of 153.5 mg/dL resulted in a 2.9 greater chance of developing cognitive impairment. A second

retrospective case-control study of 37 surgical ICU patients with at least one episode of hypoglycemia

found that cognitive impairment was higher in the hypoglycemic group (p<0.01). Intensive insulin

therapy (maintaining blood glucose levels between 80 and 100 mg/dL) in surgical ICU patients

decreased neuropathy from 51.9% to 28.7%, and the prevalence of critical illness polyneuropathy (CIP)

and critical illness myopathy (CIM) from 49% to 25% in surgical ICU patients (p<0.0001) (Neurology

2005;64:1348-53). Intensive insulin therapy also decreased CIP and CIM from 51% to 39% in the medical

ICU (p=0.02) in patients who had an ICU stay of at least 1 week. The percentage of patients needing

mechanical ventilation for at least 2 weeks was reduced from 42% to 32% in the surgical ICU (p=0.04)

and from 47% to 35% in the medical ICU (p=0.01). Subsequently, NICE-SUGAR showed increased

mortality in the intensive insulin group (81 to 108 mg/dL) (27.5%) versus conventional glucose control

(less than 180 mg/dL) (24.5%) (p=0.02). The SCCM guidelines for the use of an insulin infusion for the

management of hyperglycemia in critically ill patients suggests that a blood glucose of 150 mg/dL or

greater initiates interventions to maintain blood glucose less than 180 mgdL and to avoid hypoglycemia

based off the results of NICE-SUGAR.

medications (PIMs) and actually inappropriate medications (AIMs) was evaluated in a single-center

study of 120 older adult ICU survivors. PIMs were defined as potentially harmful on the basis of prior

studies and pharmacologic effects. PIMs could further be classified as AIMs if the benefit of the drug

was considered less than the harm. The 2003 Beers Criteria and medication safety data published since

2003 were used to identify medications (Arch Intern Med. 2011;171:1032-4). Medications were identified

at five points during the hospital stay: admission, ward admission, ICU admission, ICU discharge, and

hospital discharge. The most common categories of PIMs identified at hospital discharge were opioids,

anticholinergic medications, antidepressants, and drugs causing orthostasis. Thirty-six percent of

these PIMs were considered AIMs. The PIM categories at hospital discharge with the highest positive

predictive values for being AIMs were anticholinergics (55%), nonbenzodiazepine hypnotics (67%),

benzodiazepines (67%), atypical antipsychotics (71%), and muscle relaxants (100%). In multivariate

analysis, the number of discharge PIMs was independently predicted by the number of preadmission

PIMs (p<0.001), discharge to somewhere other than home (p=0.03), and discharge from a surgical

service (p<0.001). Almost two-thirds of AIMs were initiated in the ICU.

Not restarting home medications: A large population-based Canadian cohort study of 396,380 patients

evaluated records of hospital and outpatient medications prescribed from at least one of five of the

following groups: (1) statins, (2) antiplatelet/anticoagulant agents, (3) levothyroxine, (4) respiratory

inhalers, and (5) gastric acid–suppressing drugs. Patients were divided into three groups: hospitalization

with an ICU admission, hospitalization without ICU admission, and nonhospitalized patients who

served as the control group. Compared with control patients, those admitted to a hospital without an

ICU stay were more likely to have medications discontinued among all five of the medication groups.