JAMA Online First

Music Therapy for Reducing Anxiety in Critically Ill Patients Music Therapy for Reducing Anxiety in Critically Ill Patients

Azoulay E, Chaize M, Kentish-Barnes N. — Mon, 20 May 2013 00:00:00 GMT

The vast majority of critically ill patients who receive mechanical ventilation now survive, even those with acute lung injury or acute respiratory distress syndrome. Over the past decade, an increasing number of studies have focused not only on survival, but also on the patients' experience of critical care. These studies have evaluated 3 periods: the intensive care unit (ICU) stay (confusion, delirium, acute stress, nightmares, hallucinations, and sleep disorders), the first few weeks or months after ICU discharge (symptoms of posttraumatic stress disorder [PTSD], cognitive impairment, and depression), and the period beyond one year after ICU discharge. Many of these studies have shown a significant association between the amount of ICU sedation and decline in factual memory, presence of delusional memory, and additional PTSD-related symptoms.

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support A Randomized Clinical Trial Patient-Directed Music Intervention

Chlan LL, Weinert CR, Heiderscheit A, et al. — Mon, 20 May 2013 00:00:00 GMT

Importance

Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support.

Objective

To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients.

Design, Setting, and Patients

Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days.

Interventions

Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125).

Main Outcomes and Measures

Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency).

Results

Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, −32.2 to −6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by −0.18 (95% CI, −0.36 to −0.004) points/day (P = .05) and had reduced frequency by −0.21 (95% CI, −0.37 to −0.05) points/day (P = .01). The PDM group had reduced sedation frequency by −0.18 (95% CI, −0.36 to −0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity.

Conclusions and Relevance

Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH.

Trial Registration

clinicaltrials.gov Identifier: NCT00440700

Early Nutrition in Critically Ill Patients Feed Carefully and in Moderation Early Nutrition in Critically Ill Patients

Ochoa Gautier JB, Machado FR. — Mon, 20 May 2013 00:00:00 GMT

Clinicians in intensive care units (ICUs) have to decide whether supplemental parenteral nutrition should be ordered for a critically ill patient who cannot be fed and is kept “nil per os (NPO),” for instance, because of gastrointestinal tract dysfunction. Without early supplemental parenteral nutrition, the patient is temporarily starved, an approach based on the assumption that physiologic compensatory processes are protective and thus there will be no untoward clinical consequences. In contrast, clinicians who order early supplemental parenteral nutrition presumably consider the accumulating caloric deficit to be deleterious for critically ill patients. Although determining the best approach might seem straightforward, a clear answer remains evasive.

Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition A Randomized Controlled Trial Early Parenteral Nutrition in Critically Ill Patients

Doig GS, Simpson F, Sweetman EA, et al. — Mon, 20 May 2013 00:00:00 GMT

Importance

Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission.

Objective

To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes.

Design, Setting, and Participants

Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days.

Interventions

Random allocation to pragmatic standard care or early PN.

Main Outcomes and Measures

Day-60 mortality; quality of life, infections, and body composition.

Results

A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, −1.26%; 95% CI, −6.6 to 4.1; P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, −0.47; 95% CI, −0.82 to −0.11; P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, −0.16; 95% CI, −0.28 to −0.038; P = .01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, −0.13; 95% CI, −0.25 to −0.01; P = .04).

Conclusions and Relevance

The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays.

Trial Registration

anzctr.org.au Identifier: ACTRN012605000704695