Critical Care Medicine

Journal Article Annotations
2019, 4th Quarter

Critical Care Medicine

Annotations by O. Joseph Bienvenu, MD PhD and Jordan H. Rosen MD
December 2019

  1. Ramelteon for Prevention of Postoperative Delirium: A Randomized Controlled Trial in Patients Undergoing Elective Pulmonary Thromboendarterectomy.
  2. Nonpharmacologic Interventions to Prevent or Mitigate Adverse Long-Term Outcomes Among ICU Survivors: A Systematic Review and Meta-Analysis.

    PUBLICATION #1 — Critical Care Medicine
    Ramelteon for Prevention of Postoperative Delirium: A Randomized Controlled Trial in Patients Undergoing Elective Pulmonary Thromboendarterectomy.
    Jaiswal SJ, Vyas AD, Heisel AJ, Ackula H, Aggarwal A, Kim NH, Kerr KM, Madani M, Pretorius V, Auger WR, Fernandes TM, Malhotra A, Owens RL.
    Annotation

    The finding:
    In this prospective, randomized, double-blinded placebo-controlled trial, delirium incidence was assessed in patients undergoing elective thromboendarterectomy. No statistical difference in incidence of delirium, duration of delirium, ICU length of stay or hospital mortality was found between those receiving ramelteon 8mg and placebo groups.

    Strength and weaknesses:
    This is a well-controlled trial with a specific patient population that yielded clear results. The study’s relatively uniform population limits its generalizability to prophylactic use in surgical cardiac critical care patients. The study is also limited in its inability to use its original primary outcome, total sleep duration, due to not being able to provide continuous electroencephalography. This lead to using a secondary outcome as the focus of the study.

    Relevance:
    While sleep-wake disturbance in ICUs has been linked with development of delirium in the critically ill, this study adds to the already mixed evidence on the impact of prophylactic melatonergic agents on delirium incidence in critically ill patients. This study does not support global administration of such agents to high risk groups though, given its specificity, does not rule out effect for other populations.

    Type of study:
    Randomized controlled trial

    PUBLICATION #2 — Critical Care Medicine
    Nonpharmacologic Interventions to Prevent or Mitigate Adverse Long-Term Outcomes Among ICU Survivors: A Systematic Review and Meta-Analysis.
    Geense WW, van den Boogaard M, van der Hoeven JG, Vermeulen H, Hannink G, Zegers M.

    Annotation

    The finding:
    This was an extremely ambitious systematic review and meta-analysis, covering all nonpharmacologic interventions to prevent or mitigate adverse long-term outcomes in critical illness survivors-that is, post-intensive care syndrome (PICS).  The results emphasize how little is known about prevention of these common sequelae of critical illness and intensive care.  ICU diaries and exercise interventions both had thin evidence of effectiveness to improve long-term mental health outcomes.  However, this is a young field, and a recent large multisite RCT in France did not show a mental health benefit for patients and families randomized to receive ICU diaries.

    Strength and weaknesses:
    The methodology was rigorous, but the term PICS is less than 10 years old, so the field still has much to learn.

    Relevance:
    C-L psychiatrists should be aware of PICS and be open to helping our general medical colleagues develop more robustly effective interventions.

    Type of study:
    Systematic review and meta-analysis