Protocol for a meta-review of interventions to prevent and manage ICU delirium

Introduction Intensive care unit (ICU) delirium is an acute brain dysfunction that affects up to 7 out of 10 patients admitted to ICUs. Patients who develop ICU delirium cannot think clearly, have trouble paying attention, do not understand what is happening around them and may see or hear things that are not there. ICU delirium increases the time patients spend in ICUs and hospitals and therefore healthcare costs. ICU delirium is also associated with increased mortality and dementia in the longer term. ICU delirium prevention and management strategies are likely to include both pharmacological and non-pharmacological components as part of a complex intervention, but it is unclear which components should be included. The objective of this meta-review is to systematically map the quantity and certainty of the available evidence from reviews and meta-analyses of randomised controlled trials (RCTs) of pharmacological and non-pharmacological interventions, which will be used to design a multicomponent intervention to prevent and manage ICU delirium. Methods and analysis A systematic search strategy was performed in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and Web of Science (from inception to 26 September 2023), as well as Epistemonikos (from inception to 19 July 2023). We will include all critically ill adults (aged≥18 years) and any ICU delirium prevention or management intervention (pharmacological or non-pharmacological). For pharmacological interventions, we will include reviews of RCTs. For non-pharmacological interventions, we will consider reviews of RCTs, quasi-experimental and cohort studies. We will use the International Consensus Study (Del-COrS) core outcome set for research evaluating interventions to prevent or manage ICU delirium and synthesise our findings using quantitative data description methods. We will involve our Patient and Public Involvement group of people who experienced ICU delirium to develop and comment on such aspects as the research question, methodology and which outcomes are most important. Ethics and dissemination No ethical approval is required for this study. The results of this meta-review will be disseminated through peer-reviewed publications and conferences. They will also form part of an evidence map and logic model for the prevention and management of ICU delirium. PROSPERO registration number CRD4202347326

Factors contributing to the implementation of interventions to prevent and manage intensive care unit delirium: a systematic review protocol

Introduction: Delirium is a common and serious condition that frequently affects patients in the intensive care unit (ICU). It is characterised by an acute disturbance in cognition, attention and awareness that develops over a short period of time and tends to fluctuate in severity. Patients with ICU delirium (ICUD) may experience confusion, disorientation, difficulty focusing and perceptual disturbances such as hallucinations or delusions. The prevalence of ICUD is high, with estimates suggesting that it can affect up to 70% of ICU patients. The development of ICUD is associated with several adverse outcomes, including prolonged ICU and hospital stays, increased healthcare costs, higher mortality rates and an increased risk of long-term cognitive impairment, including dementia. It is unclear which components should be included in a complex intervention to prevent and manage ICUD. Furthermore, we need to understand how the different components have been implemented and their impact on clinical practice. Methods and analysis: The review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis Protocols (PRISMA-P) and the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) reporting recommendations. We will perform systematic searches to identify relevant interventions and implementation strategies for the prevention or management of ICUD. We will assess primary research, service evaluations and audits for the use of the Standards for QUality Improvement Reporting Excellence (SQUIRE) as a checklist for quality improvement in healthcare. We will extract both qualitative and quantitative data and assess study quality using the Critical Appraisal Skills Programme (CASP) tool. Our findings will be synthesised using a best-fit framework synthesis mapped against the Theoretical Domains Framework (TDF). Our Patient and Public Involvement (PPI) group will contribute to the development of review processes such as the research question and methodology and will help to evaluate which outcomes are most important. Ethics and dissemination: No ethical approval is required for this study. The results of this systematic review of implementation strategies will be disseminated through peer-reviewed publications and conferences. They will also form part of an evidence map and logic model for factors that can improve the implementation of strategies for prevention, identification and management of ICUD. PROSPERO registration number: CRD42024537313

Inequalities in access to and outcomes of cardiac surgery in England: retrospective analysis of Hospital Episode Statistics (2010–2019)

Background We aimed to characterise the variation in access to and outcomes of cardiac surgery for people in England. Methods We included people >18 years of age with hospital admission for ischaemic heart disease (IHD) and heart valve disease (HVD) between 2010 and 2019. Within these populations, we identified people who had coronary artery bypass graft (CABG) and/or valve surgery, respectively. We fitted logistic regression models to examine the effects of age, sex, ethnicity and socioeconomic deprivation on having access to surgery and in-hospital mortality, 1-year mortality and hospital readmission. Results We included 292 140 people, of whom 28% were women, 11% were from an ethnic minority and 17% were from the most deprived areas. Across all types of surgery, one in five people are readmitted to hospital within 1 year, rising to almost one in four for valve surgery. Women, black people and people living in the most deprived areas were less likely to have access to surgery (CABG: 59%, 32% and 35% less likely; valve: 31%, 33% and 39% less likely, respectively) and more likely to die within 1 year of surgery (CABG: 24%, 85% and 18% more likely, respectively; valve: 19% (women) and 10% (people from most deprived areas) more likely). Conclusions Female sex, black ethnicity and economic deprivation are independently associated with limited access to cardiac surgery and higher post-surgery mortality. Actions are required to address these inequalities

Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery The TIGHT K Randomized Clinical Trial

IMPORTANCE Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly. OBJECTIVE To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger. DESIGN, SETTING, AND PARTICIPANTS This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023. INTERVENTIONS Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment. MAIN OUTCOMES AND MEASURES The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm-related events, clinical outcomes, and cost related to the intervention. RESULTS A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, −2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95$103.60-$120.19]; P < .001). CONCLUSIONS AND RELEVANCE For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes