Prevention of Delirium
Conditions
Brief summary
The objective of the study is to determine the impact on the frequency of occurrence of delirium of an early inhaled sedation strategy (from induction in rapid sequence if intubation in intensive care, or from admission if intubated in pre -hospital) by Isoflurane using an ANACONDA ™ type system, compared to a conventional intravenous sedation strategy.
Detailed description
Sedation-analgesia is used in most patients treated with mechanical ventilation (MV). The usual benzodiazepine and morphine sedation reduces pain and anxiety and allows tolerance of invasive procedures in intensive care. These molecules, used as part of the sedation titration protocol or the daily sedation stop protocol, have improved patient outcomes. Although necessary, these drugs, by mechanisms still uncertain, would promote the occurrence of resuscitation delirium. Delirium itself responsible for worsening morbidity and mortality (increase in the duration of MV, increase in the length of hospital stay, discussed increase in mortality, long-term cognitive sequelae). This finding favored the use of new drugs in the sedation strategies of patients on MV. Dexmedetomidine has for example reduced the number of days of delirium, the number of days of coma and even mortality in septic patients. Its large-scale use has however been questioned by a recent study. Halogenated gases have been used for a long time in anesthesia. Their pharmacodynamics, their positive and adverse effects, their therapeutic margins are well known. Thanks to technical innovations they can be used on resuscitation respirators. Several studies on targeted populations have shown the feasibility and the benefits of this use, in particular, the absence of accumulation, the absence of tachyphylaxis, the broad therapeutic range, the small interindividual variation, the rapidity of efficacy and the speed of awakening. Safety in use for the staff in charge of the patient is established. In addition, their potential neuroprotective effect would make it an anesthetic of choice in the prevention of resuscitation delirium.
Interventions
DRUGPropofol + analgesic drug
sedation according to a written, standardized Nurse management protocol using at least one sedative drug (propofol) and one analgesic drug. It uses the nurse driven analgesia protocol of each ward involved in the study. It uses a pain assessment score (BPS, VICOMORE, FLACC), local or regional anesthesia, non-opioïd adjuncts (acetaminophen, NSAIDs, nefopam), opioïds (per os opioïds, bolus of sufentanyl followed by continuous infusion if necessary, continuous infusion of remifentanyl
DRUGIsoflurane + analgesic drug
sedation by inhalation of halogenated gas (Isoflurane) delivered by the Anesthetic-Conserving Device (ACD) system ANACONDA ™ associated with the administration of a analgesic drug. It uses the nurse driven analgesia protocol of each ward involved in the study. It uses a pain assessment score (BPS, VICOMORE, FLACC), local or regional anesthesia, non-opioïd adjuncts (acetaminophen, NSAIDs, nefopam), opioïds (per os opioïds, bolus of sufentanyl followed by continuous infusion if necessary, continuous infusion of remifentanyl.
Sponsors
University Hospital, Brest
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Caregiver)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patient aged 18 and over * Patient requiring mechanical ventilation for at least 24 hours * The patient requires continuous and immediate sedation for more comfort, safety and to facilitate the administration of survival measures. * Consent obtained from patient or relative
Exclusion criteria
Patient hospitalized for the following reasons for admission: * Cardiac arrest * State of refractory epilepticus * Head trauma * Stroke * Hearing, visual or aphasia disorders before inclusion making it impossible to take the CAM-ICU * Sedation started more than 24 hours ago * Impairment of cognitive functions and / or dementia * Contraindication to halogenated gases (personal or family history of malignant hyperthermia, acute or chronic neuromuscular disease, hepatocellular insufficiency with PT \<30%) * Severe acute respiratory distress syndrome (ARDS) (Berlin criteria: PaO2 / FiO2 \<100 after ventilatory optimisation)) * PaCO2 at inclusion\> 50 mmHg after ventilatory optimisation * Patient for whom a procedure of "limitation of active therapies" is envisaged at inclusion * Patient under guardianship or curatorship * Minor patient * Pregnant or breastfeeding woman * Patient not affiliated to the social security scheme
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Occurrence of a delirium in intensive care | 28 days | Occurrence of delirium in intensive care will be observed (yes / no) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mortality in intensive care | Throuh exit from the intensive care unit, an average of 28 days | Mortality in intensive care will be observed |
| Mortality at day 28 | 28 days | Mortality at day 28 will be observed |
| Hospital cost per patient | Through study completion, an average of 1 year. | The average cost of hospitalization for each patient will be calculated taking into account their length of hospital stay, examinations carried out and medical treatment taken. |
| Number of days with vasopressors or inotropic agents | Throuh exit from the intensive care unit, an average of 28 days | Number of days with vasopressors or inotropic agents will be observed |
| Number of days with sedation | Throuh exit from the intensive care unit, an average of 28 days | Number of days with sedation will be observed |
| Cumulative dose anesthetics drugs | Throuh exit from the intensive care unit, an average of 28 days | Cumulative dose anesthetics drugs will be observed |
| Duration of anesthetics drugs | Throuh exit from the intensive care unit, an average of 28 days | Duration of anesthetics drugs will be observed |
| Maximum dose of vasopressors or inotropic agents | Throuh exit from the intensive care unit, an average of 28 days | Maximum dose of vasopressors or inotropic agents will be observed |
| Ventilation free days at 28 days following randomisation | 28 days | Ventilation free days at 28 days following randomisation will be observed |
| Incidence of delirium | 28 days | Incidence of delirium will be observed |
| Duration of delirium | 28 days | Duration of delirium will be observed |
| Length of ICU stay | Throuh exit from the intensive care unit, an average of 28 days | Length of ICU stay will be calculated |
| Requirement of patients physical restraints | Throuh exit from the intensive care unit, an average of 28 days | Requirement of physical restraints, of patients with unplanned extubation, unplanned catheter, urinary probe or gastric probe removal will be observed |
| Self aggressive act | Throuh exit from the intensive care unit, an average of 28 days | Self aggressive act will be observed |
| Hetero-aggressive act | Throuh exit from the intensive care unit, an average of 28 days | Hetero-aggressive act will be observed |
| Evaluation of cognitive functions | Through study completion, an average of 1 year. | Cognitive function will be evaluated at discharge, 3- and 12 months using two kinds of score : * Cantab test, combining 6 cognitive evaluations with an iPad during a 45-60 minutes medical consultation * PCLS (Posttraumatic stress disorder Checklist Scale), HADS (Hospital Anxiety and Depression scale), SF36 (medical outcome study short form 36), IADL (instrumental activities of daily living) practised by a clinical research associate |
Countries
France
Contacts
PRINCIPAL_INVESTIGATORPierre Bailly, MD
CHRU BREST
Outcome results
None listed